TEACHING MEDICAL ETHICS FOR UNDERGRADUATE MEDICAL STUDENTS (BY NON-SPECIALIZED STAFF)TAYBA UNIVERSITY FOM (22-23 MAY 2012)

Ghaiath M. A. HusseinAssistant Professor, Faculty of Medicine King Fahad Medical CityKing Saud Bin Abdulaziz University for Health SciencesContacts: ghaiathme@gmail.com; 00966566511653

Outline of the Workshop

Ethics, bioethics & Professionalism

Teaching Bioethics & Professionalism (Why? What?)

Day 1: Concepts

& Mis-concepts How to teach

bioethics?

How to evaluate?

Day 2: Teaching

& Evaluation

This workshop is… is NOT…

Is aiming to: Introduce the main

concepts related to terminology and taxonomy of ethics;

Discuss the need to teach ethics, what to teach; and

Provide practical hints on how to deliver ethics topics

Is NOT a workshop on:Medical ethics

Professionalism

Medical education

Before we start… Let’s Reflect…Which one would you drink?

What do you think?

Levels of moral response

The expressive level (unanalyzed expressions or feelings that, by themselves, don’t provide reasons or justification)

The pre-reflective level (justification via law, religious tenets, social values, codes of ethics, etc.; accepted uncritically)

The reflective level (reasoned ethical argument/defense based on ethical principles, rules, virtues, values to which we consciously subscribe; justification provided)

Thomas J and Waluchow W, 1998

Ethical/Moral reasoning

It is the process we need to go through to reach a decision about an ethical issue.

It helps us to differentiate:

description of the way the world is; an actual state of affairs (“is”)

judgment about the way things should be (“ought”).

they are meant to guide actions. Key values in bioethics have corresponding (e.g., principle of respect for autonomy)

Don’t judge things on what they first appear to you!

There is always a reason why people do

things?

What is ethics?

What are the branches of ethics?

What is bioethics?

What is medical/clinical ethics?

What is an ethical issue?

How do people resolve ethical issues?

What is professionalism?

What are the professional commitments of the medical doctor/student?

Key definitions and concepts

What is ethics?

A system of moral principles or standards governing conduct.

a system of principles by which human actions and proposals may be judged good or bad, right or wrong;

A set of rules or a standard governing the conduct of a particular class of human action or profession;

Any set of moral principles or values recognized by a particular religion, belief or philosophy;

The principles of right conduct of an individual. (UNESCO/IUBS/Eubios Living Bioethics Dictionary version 1.4)

Ethics

Bioethics

Clinical Ethics

Research ethics

Resource Allocation ethics

Public Health ethics

Nursing ethics

other

Business ethics

Environmental ethics

Social ethics

Organizational ethics

IT ethics

Other

What is bioethics?

It is derived from Greek bio- life and ethicos moral.

The science/art that aims at identification, analysis, and resolution of the ethical issues in almost any field that is related to human life and health.

What is clinical/medical ethics? It is that branch of bioethics that is related to the

identification, analysis, and resolution of moral problems that arise in the healthcare of individualpatients.

Questions answered by Bioethics

deciding what we should do (what decisions are morally right or acceptable); Example: Should patient A or B have the ICU bed?

explaining why we should do it (how do we justify our decision in moral terms); andWhy did we decide to admit A & not B?

describing how we should do it (the method or manner of our response when we act on our decision).What are we going to do for patient B?

Main Western Philosophies

Other philosophies AbrahamicPhilosophies

Oriental philosophies

Utilitarianism African, Asian, etc. Islamic Buddhist

Deontology Human Rights Jewish Confucius

Feminist ethics Catholic Indian

Casuistry

Virtue ethics Protestant Persian

Principlism Jehovah Witnesses

Professionalism

Professionalism in medicine requires the physician to serve the interests of the patient (and community) above his or her self-interest.

Professionalism aspires to altruism, accountability, excellence, duty, honour, integrity, and respect for other. (ABIM, 2000)

Professionalism

• Role of the doctor within the health service– Understanding of the

health care system

– Understanding of clinical responsibilities

– Appreciation of doctor as researcher

– Appreciation of doctor as mentor or teacher

– Appreciation of doctor as manager including quality control

– Team working

• Personal Development– Lifelong Learner

– Self awareness

– Self confidence

– Self regulation

• Self care

• Self control

• Personal time management

– Motivation

• Achievement drive

• Commitment

• initiative

– Career choice

Elements of Professionalism

Altruism is the essence of professionalism. The best interest of the patients, not self-interest, is the rule.

Accountability is required at many levels - to individual patients, society and the profession…

Excellence entails a conscientious effort to exceed normal expectations and make a commitment to life-long learning…

Duty is the free acceptance of a commitment to service.

Honour and integrity are the consistent regard for the highest standards of behaviour and refusal to violate ones personal and professional codes.

Respect for others (patients and their families, other physicians and professional colleagues such as nurses, medical students, residents, subspecialty fellows, and self) is the essence of humanism…"

10 commitments of professional doctor

The Doctor is committed to: Professional competence Honesty with patients Patients’ confidentiality Maintaining appropriate relationships Improving quality of care Improving access to care Just distribution of finite resources Scientific knowledge Maintaining trust by managing COI’s Professional responsibilities

Commitments as a professional Medical Student

The Medical Student is committed to respect for:

professors, preceptors, and peers

guest speakers and visiting patients

cadavers and anatomical specimens in the anatomy lab

the institution of which you are a part

patients and their families at clinical encounters

patient confidentiality

all members of the health care team

administrative and support staff

the core values of professionalism

Lack of Professionalism

Signs and Symptoms (ABIM, 2001)

1- Abuse of power2- Arrogance (offensive display of superiority and self-

importance); 3- Greed (when money becomes the driving force);4- Misrepresentation (lying, and fraud); 5- Impairment (any disability that may prevent the

physician from discharging his/her duties); 6- Lack of conscientiousness (failure to fulfill

responsibilities); 7- Conflicts in interests (self-promotion/ advertising or

unethical collaboration with industry; acceptance of gifts; and misuse of services, etc.).

What do you think?

Ethics… taught or inherited?

How does teaching of E&P works?

Knowledge Attitude Behaviour & Practice

Transient change

Poor role models

What happens with NO E&P formal teaching?

“Sub-ethical doctor”?

Vulnerable patient

‘Dictator’ professor

Strict hierarchy

Sub-ethical researcherSub-ethical clinicianSub-ethical teacher

Sub-ethical…etc.

Poor/No accountability

Poor/No ethics

curriculum

Importance of teaching E&P

Moral reasoning (and not only the medical facts) makes the physician more competent to deal with his patients as a whole (body and soul), and not merely dealing with their sick bodies.

It improves the analytical thinking abilities,

Empower the attachment of the Muslim doctor to the set of the Islamic moral framework

Muslim doctor may be consulted from Scholars (Ulama) about a certain medical issue that he wants to issue a Fatwa about;

Teaching E&P helps in improving the outcome of the healthcare they provide.

E&P… WHAT AND WHEN TO TEACH?

We teach E&P to make our graduates able to:

Constitute, express and sustain professional and efficient relationships with their patients, colleagues, and the resources to the best of the patients and the profession

We do NOT teach them E&P to be:

Virtuous persons

Religious scholars

Our clones…

How to decide what to teach?

Public Health

Laws/ Fatwas

Policies, guidelines

health-allied

personnel

Admin., Resources

Doctor Patient/family

Know when… know what… know howPhase Students’ characteristics

Pre-clinical Fresh from high school

No previous personal exposure to patients

‘Ideal’ figure of the doctor as ‘angel of mercy’

Effect of the personal (good or bad) experiences with the health system

Ethics is inherited from their communities and family (the way they were raised up)

Clinical Students are exposed to and start communicating with patients

Students begin to ‘feel (and maybe act) like doctors’

Students’ imagination becomes more realistic by exposure to the system (how the

system really works?)

Feelings of frustration, shock, confusion, coping, surrender… when what they think

right/ethical doesn’t match what their seniors do

Near-

graduation

(specialized)

Students are technically almost doctors

They feel the direct responsibility towards the patients, colleagues and the system

Main focus and concern on ‘whatever it takes to get graduated’

Personal clinical specialty preferences start to get established

Near-mature clinical style of practice

Students’ mindsets are more towards ‘clinical analysis’ kind of thinking and doing

things

Topics usually given in E&P curriculum

I: Introduction and Basics of Islamic Medical Ethics

Introduction to the concepts of ethics, bioethics, and medical ethics

Comparison between the western and Islamic medical ethics

Professional duties of the doctor towards self, colleagues, patients, and community.

Basic ethical principles and guidelines (national and international)

Overview on patients' rights

II: Practical Aspects of Medical Ethics

Informed consent to treatment

Privacy and confidentiality

Medical Malpractice, Misconduct & Medical Errors

Terminally Incurable Diseases and the End of Life (EOL) Decisions

Financial Aspects in Practice and Conflict of Interests (COI)

How to manage ethical issues in clinical practice?

Resource allocation

Ethics of public health

Islamic Fiqhi Rulings in Major Medical Specialties

Topics usually given in E&P curriculum(2)

III. Professionalism

Concepts of professionalism

Professional duties on the medical student

Professional duties on the doctor (towards self, pt., colleagues, community, and the profession)

Non-professional attitudes and practices

IV: Research Ethics

This section includes the ethical issues that are encountered before, during and after the conduct of research.

Basic concepts in research ethics

The ethical standards of research

The concepts of benefit and harm in research

Informed consent in research

Research on vulnerable groups

Privacy and confidentiality in research

Conflict of interests in research

Ethical review of research

TEACHING METHODS

How to teach what in E&P?

Where Learning Occurs?

Class

• Lectures

• Cases

• SPs

• Movies

• Student activities

Hospital

• Bedside teaching

• Clinical Rounds

• M &M reports

Community

• Student activities

• Research

Class-Based methods

Interactive sessions (lectures) Suitable Topics: Foundation and principles Theoretical (parts of) topics: e.g. Fiqhi & Philosophical

issues

Advantages: Safe learning environment Better control

Disadvantages: Needs interaction to keep students alert Monotonicity and teacher dominance

Class-Based methods (2)

Problem solving and case discussion Suitable Topics: Practical aspects (consent, privacy, confidentiality)

Research ethics

Advantages: Engaging to students

Closer to reality

Disadvantages: Development and suitability of cases

Logistic needs

Class-Based methods (3)

Glossary and debates:Glossary: Students are asked to define an ethics-related terminology. Defined

terms are gathered in a glossary by the end of the course

Debate: Two groups of students are asked to make an argument, and defend it, while the other group tries to provide a counter-argument

Suitable Topics:

New terminology and Provocative topics

E.g. (SOPA), Teaching ethics is needed for medical students? For vs. Against

Advantages:

Engaging

Make students search and reason

Disadvantages:

Good argument for a bad cause!

Class-Based methods (4)

Student seminars How to do it?

Students groups are given topics to summarize & present to their colleagues

Suitable Topics:

Topics that are not covered in the curriculum, e.g. many of the Islamic rulings (Fatwas) and Fiqhi issues

Advantages:

Students remember best what they search and present by themselves

Disadvantages:

Uncontrolled Group dynamics

Inefficient groups (group members)

Credibility and integrity of what the students present (Whatever Google brings can do the job fine )

Class-Based methods (5)

Case studies and case presentation

How to do it?

Students groups are given ethical scenarios (dilemmas), preferably modified from true cases to summarize, analyze & present to their colleagues

Suitable Topics:

Clinical ethics (e.g. consent, confidentiality, EOL, etc.) and research ethics

Advantages:

Students utilize the ethics analysis tools and start ‘resolving’ ethical issues by themselves

Self-confidence

Disadvantages:

Unresolved issues and disagreements may lead to frustration

Inefficient groups (group members)

Heavy reliance on a specific reference (especially religious)

Class-Based methods (6)

True story telling (by patient, patient relative, or a doctor)

How to do it?

A patient, a patient’s relative, or a clinician who has been exposed to a situation with ethical dilemma is invited to give a short talk about his/her experience with receiving or giving medical care

Suitable Topics:

Clinical ethics (e.g. consent, confidentiality, EOL, etc.) and research ethics

Advantages:

Human engagement and reflection

Links theory to practice

Disadvantages:

Hesitance by patients to come and contribute their experiences

Sharing sad stories can be distressing/depressing for the narrator

Confidentiality issues

Class-Based methods (7)

Watching movies or documentaries that discuss ethical issues.

How to do it?

Selected drama movies or documentaries are presented to the students

Suitable Topics:

Clinical ethics (e.g. consent, confidentiality, EOL, etc.) and research ethics

Advantages:

Human engagement and reflection

Many topics are covered in short time

Disadvantages:

Distraction by unrelated events in the film

Approaches to ethical issues in the movies may not match the ILOs

Refusal to watch movies for religious reasons

WIT movie… as an example

Shortcut to Wit.(2001).DVDRiP.XviD.lnk

Hospital-Based methods (1)

Clinical (or Research) Ethics Consultations How to do it?

Students groups are invited to attend a true (or mock) ethics consultation meeting

Suitable Topics: Clinical ethics (e.g. consent, confidentiality, EOL, etc.) and research

ethics

Advantages: Students are exposed to true experience on ‘how things work in real life?’

Matching theory to practice

Disadvantages: Confidentiality issues (hospital policy)

Hard to endorse large number of students

Disagreements among committee members are not educationally structured

Hospital-Based methods (2)

Narrative Ethics (listen to the patients) How to do it?

True (or SPs) patients are invited to share their admission experiences with emphasis on what they (dis)liked about their clinical team

Suitable Topics: Professionalism, consent, privacy

Advantages: Students start communicating humanly (not mechanically) with

patients Matching theory to practice

Disadvantages: Patients’ hesitance to share their stories (SPs as alternative) Confidentiality and COI issues Consent from patients?

Standardized patients (SPs)

This is a more advanced method that is based on making professional actors work on simulating a patient with a given condition.

This SP is then interviewed by the student in front of the other students, and supposed to behave like a real patient.

This could be used in many topics, but it is more efficient in topics that needs direct doctor-patient communications like breaking bad news, or taking consent

Students, facilitators, methods, facilities, etc.

Who do we evaluate in E&P course for what?

Students

• Knowledge

• Understanding

• Reasoning

• Practice

Educators

• Knowledge

• Interaction

• Teaching methods

• Answering questions

Course

• Content

• Objectives

• Coordination

• Accessibility to material

• Meet ILOs & expectations

Tools commonly used to assess students

What does it assess?

MCQs Short essays

Cases/ problems

OSCE Assignments Research Practical

Knowledge + ++ ++ + +++ +++ ++

Understanding + +++ +++ + +++ ++ ++

Reasoning + +++ +++ ++ +++ +++ +

Ethical Analysis - ++ +++ ++ +++ +++ ++

Competencies - - + + - ++ +++

MCQs

How to do it? Either Best Answer or T/F

A stem presents a case scenario followed by choices; one of which only is (most) correct

Suitable Topics: MCQs are suitable for almost all topics

Advantages: easy to mark

Covers many topics

Disadvantages: Abstract (does not reflect the student’s reasoning)

Some choices may be debatable

Example of MCQs

اوه فً حالة احتضار غٍر اوك غٍر متٍقه، فأي مه لكإذا كان لدٌك مرٌض ال ٌرجى برءه وبدااَتً مه المىاقف والقىاعد الفقهٍة هى تصرفك األمثل؟

.Aإعالن َفاتً نالستفادة مه أعضاءي عمال بقاعذة انعادة محكمة

.Bإعالن َفاتً إلخالء سريري نغيري عمال بقاعذة اخف انضرريه

.Cاالوتظار حتى تتيقه مه َفاتً عمال بقاعذة انيقيه ال يزَل بانشك

.D فصم األجٍزة عىً تحقيقا نمقصذ انشريعة بانحفاظ عهى انمال

.Eوقهً نمستشفى تخصصي آخر تحقيقا نقاعذة األمُر بمقاصذٌا

A psychiatrist is conducting a trial on a drug that would (if the trial succeeds) reduce the suicidal tendency in severely depressed patients. They will only use the trial’s medication for 3 months. He took their consent. What is the ethical stand from this trial?

A. Ethically acceptable because it reduces the patients' suffer

B. Ethically acceptable because the consent was taken

C. Ethically unacceptable because of doubtful drug efficiency

D. Ethically unacceptable because of lack of patients' competence

E. Becomes ethical if nobody gets harmed after the trial

Short essays

How to do it? The students are asked to mention/discuss a certain

topic

Suitable Topics: Topics that has more knowledge than analysis (e.g.

Fiqhi Issues)

Advantages: easy to put, assesses topics not covered by MCQs

Disadvantages: Hard to answer (students are not used to write)

Hard to mark, especially in large numbers of students

Example of Short Essay

What are the measures that should be taken by doctors and hospitals to ensure their patients' privacy and the confidentiality of their medical information? (5 Marks)

واقش مقاصد الشرٌعة مه خالل عالقتها بالصحة وبعمل الطبٍب(درجات 5)

Cases/Problems

How to do it?

Select a true case that has ethical aspects to it, modify it then add some questions to it to be answered

Suitable Topics:

Clinical ethics and ethical analysis topics

Advantages:

reflects students ability to analyze ethical issues

Disadvantages:

Not easy to formulate and may be hard to mark

Example of Case Scenario

Parkinson patient case

Dr. Nerve, the famous neurologist used to tell some of the interesting things happened to him along the day while having dinner with his wife, a School Principal. He told her about one of his patients. He told his wife about a poor elderly bus driver who had Parkinson disease and had to take an unusually high dose of medication to suppress the tremors. When she enquired if this affects the patient's ability to drive, he told her that the medication made the patient sleepy all day.

The wife told him that she suspects that she might know this patient; as there is a bus driver at her school who used to come late for the last few weeks. She asked for the name of the patient and realized that the patient was a driver for her school transport company. She dismissed him the next morning.

Mention at least 5 patient rights and discuss whether Dr. Nerve breached any of them. (2 marks)

Was his action of telling his wife ethically justifiable? Why? (1 mark)

Discuss the conditions in which disclosing patient's information is justifiable, and whether this case fulfills these conditions. (2 marks)

Assignments

These assignments are usually about cases with ethical problems guided in each assignment by a set of questions.

They are intended to be a self-reflection on what the student has learnt so far along the course to express his/her understanding, than to focus on reaching a correct answer.

Assessment of assignments:1. Originality of content. 2. Novelty of content. 3. Strength of arguments. 4. Uniform editing. 5. Proper citation

Students should abide to the professional academic conduct, without the abuse of internet. Use software to detect plagiarism. Plagiarism similarity score of 20% or more means that the student’s work will be rejected and will have to resubmit it.

Case Studies

The case study

To assess the student’s ability to define, analyze and be able to use the relevant tools to resolve ethical issues. In a case study the student is asked to find a case with one or more ethical issues around it.

A case study will be typically composed of these sections:

1. The presentation of the case

2. What are the ethical issues in the case?

3. What are the ethical and Fiqhi principles at stake?

4. Ethical case analysis

5. Fiqhi Case analysis

6. Case resolution

Practical Activities

Ethics book review

Public awareness campaign

Producing short film (documentary) on an ethical issue

Ethics education material

Short Play or scene

Movie review

Ethics consultation meeting

Research ethics review meeting

Other activities that the student thinks relevant

Take Home Messages

Teaching of E&P is about the principles and tools that the future doctor can use to manage the ethical issues they will face in healthcare practice

There are many factors that need to be included in curriculum development

Make sure you use the suitable teaching and assessment format.

Feel Free to contact:Ghaiath Mohamed Abas Husseinemail: ghaiathme@gmail.comwebsite: http://sites.google.com/site/medicalethicscourse/

Mobile: +966-566511653