The need for a course related to plagiarism alone is not adequate but there needs to be complete course on different aspects of medical along with the ethical responsibility related issues of medical research and communication.1 The major goal of the ethics theme is to help students think critically about the ethical issues they encounter in medical practice. This approach is distinctly not one of learning ethics per se or becoming an ethical person. Rather it is learning what ethical issues look like in medicine, learning the skills and about the facilities that help in addressing them and to even think in a preventive mode — some ethical issues are best dealt with by not letting them happen. Ethical issues can be among the most disturbing encounters in medicine often leaving a residue of uneasiness or discomfort. But they can also be profoundly meaningful since they are so charged with human value. With some preparation they can positively challenge doctors and become a stimulus for life long learning.1
The case based method is perfectly suited to learning practical ethics because it trains students to think carefully about the details of an individual case, how to apply general knowledge to analyse the case and come up with an explanation or diagnosis and develop a treatment plan. Ethics arises in numerous ways ranging from critical evaluation of the reasoning itself (e.g., was the case analysed thoroughly enough, were there important aspects overlooked) to thinking of ways to involving patients and families in managing the medical problem. By putting the case upfront as the object of learning, ethics naturally gets attention.
Having a Division of Medical Ethics with a group of faculty representing many different specialties like obstetrics and gynaecology as well as paediatrics, primary care and intensive care meaningful ethical analyses could be carried out. 2-5
Abstract discussions of moral theory and fewer concrete examples of difficult medical-ethical decisions; talking about the difference between consequentialist and deontological ethics could address the theoretical values of ethics.
Practical exercises in obtaining informed consent, sessions on genetic counselling, resource allocation (managed care), clinical trials and ethics committees teach medical students the practicality of the subject.
By having a core course like this the Ethics Division could supplement and amplify ethics in other parts of the curriculum including the Patient-Doctor sequence. There is no other place in the curriculum to talk about the ethics of clinical trials. And genetic counselling raises some very important ethical issues which might not be addressed in a course on genetics. The course is needed to be taught in a small group, case-based seminar style so that students come prepared for discussion.
Living with life threatening Illness in Ambulatory Care and Prevention and the Department of Palliative Care could be the area that could teach students to deal with patients with very poor prognosis. It gives students first-hand experience with patients living with life threatening illnesses along with classroom learning about the problems of controlling pain, treating depression, providing family support, etc. Ethical issues like advance directives, direct versus indirect effects and withholding versus withdrawing care are integrated with the communication skills and attitudes needed to implement them. Patient care under these circumstances is often stressful for physicians, patients and families and hence requires the greatest degree of skill and planning. By exposing students early in their education to these challenges we expect them to be more comfortable and capable later in their careers.
Doctor-patient relationship depends on communication, trust, understanding and each of these can go awry. To avoid this learning the skills and attitudes that help foster effective doctor-patient relationships can be undertaken. Discussion of empathy, transference and boundary issues in the doctor-patient relationship is loaded with ethical content. Cases usually serve to discuss ethical issues in the patient workup in the earlier part of the course. The later part of patient-doctor course could include more explicit ethical problems like competency assessments, medical mistakes, and the connection between informed consent and patient-centred decision making. Every encounter between a doctor and a patient raises an ethical issue; sometimes the issues are trivial — like the timing of a return visit — and other times they are momentous like assisting suicide.
Another important venue for the ethics theme can be student organized Ethics Journal Club.
There is a need to start a short-term course for medical students and to develop clinical material as well as challenging psychosocial issues. These cases can incorporate background material from the humanities and social sciences, which helps analyse the case in a more illuminating fashion. These cases will also lead to questions about the social role of the physician in patient advocacy, in clinical trials, as part of hospital committees and in managed care networks.
These would help understand what to do if a patient refuses life saving treatment, how to deal with conflicting family members, how to talk about resuscitation, how to give bad news and how to act as a counsellor as well as a diagnostician and therapist. Setting up an Objective Standardized Clinical Exam for ethics will be essential for assessing our goals.
1. Joe Varghese, Molly Jacob Do medical students require education on issues related to plagiarism? Indian J Med Ethics Nov. 2015; online first
2. Rennie SC, Crosby JR. Are ‘‘tomorrow’s doctors’’ honest? Questionnaire study exploring medical students’ attitudes and reported behaviour on academic misconduct. BMJ 2001;322:274–5.
3. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69:861-71.
4. L, Yin Y, Robertson D, et al. Understanding the clinical dilemmas that shape medical students’ ethical development: questionnaire survey and focus group study. BMJ 2001;322:709-10.
5. Mayer AJ, Gillam LH, Gillett GR, et al. An ethics core curriculum for Australasian medical schools. Med J Aust 2001;175:205-10.
Dr D S Sheriff
Faculty of Medicine
Benghazi University, Benghazi, Libya