Boyd: The first speaker in this session on Bioethics Education is Prof. Meng. Are there any questions?
Leavitt: Korea is recognized as being a pioneer in clinical ethics all over the world. I want to ask you to what extent cheating is a problem in medical schools here? The British Medical Journal published three different news on this subject. I know how to teach them about brain death, but how to teach them to be honest doctors, to be honest researchers; I don't know where to start. Do you have any solutions to this problem?
Meng: I don't know. But we try very hard to teach them to be honest in every area. And in terms of cheating, we deal with the student's specific ethical dilemmas. We encourage medical students to be more honest. Anyway, that's one area we really have to tackle further.
Sahin Aksoy: I think one of the problems of medical ethics education is how to assess the formation and knowledge. If we include these questions in the medical license, what kind of ethical questions do you suggest?
Meng: Well, what I'm thinking is that we have a medical school or declaration from an association in which most of these subjects are mentioned, in very operational definitions. So we might be able to add to this the principles of biomedical ethics. We can ask them to name the principles. Or we can present very short cases, which students can formulate, questions from. So that's one area we have to do research on.
Bagheri: Regarding the course content, you put ethical theory before case presentation? I wonder for medical students, based on my experience in my country and from colleagues in the United States, I wonder whether you have experienced presenting ethical problems in a case first before ethical theory?
Meng: Medical schools have different kinds of system. Some medical schools will introduce the ethical theory at a very early stage. And in the course of the medical curriculum, as cases are encountered, medical students are able to analyze these using the ethical theories they learned. So it's really a matter of integration of these two different things.
Boyd: Thank you. The second presentation is by Darryl Macer. We have five minutes for questions.
Doering: Thanks Darryl for this new idea of yours. I have two questions. The first question is about the finiteness of the ideas. What do you mean by that? I understand that ideas can be phrased in such a way that you can have several data and ways to present that. But we all know about the history of ideas, about subjective perspective on ideas and perception of ideas and so on. So please elaborate more on that. Second is, even if you end up creating a map one day, ultimately, I wonder how you could prevent policy makers from possible misuse - from using this beautiful tool in making a total social engineering.
Macer: The experience that I have in doing surveys and interviews with people in different countries in the world suggests that the number of ideas people raised when it comes to any bioethics dilemma is finite. It's limited to around 50 or 60 ideas for any dilemma. This is all that we will find. Possibly, we could double this if we really push people. So this is finite. For history it is also finite. Different cultures might find one or two linguistic terms which people will think specific. But when we actually look at these ideas, they are often linked to other kinds of things. One of the origins of this therefore, why are cultures so similar, is what if these cultures' social mind is pre-human as it is and developed through and expanded through recent evolution. Still we find this diversity, but it's finite. This hypothesis is open to experiment. So I hope we will work out if it's finite or infinite. If we can't count it all, it's infinite; but I think we can. Secondly, it could be misused; both for control of individuals or for positive means. So we have to be careful. But I think it is important for technology or social policies. That's why we should respect people's values. That each person is different and we have to allow them to be able to identify with their values as human beings when they make their decisions.
Meng: You talked about the diversity in bioethics education. Does that mean that mean diverse methodology or diverse content?
Macer: I think both. Because we do not have data on either about which really works.
Meng: If you vary the content, wouldn't that be a risk of having different kinds of education?
Macer: The main risk of education is that it may do harm to the person seeking education. But I don't think there is enough systematic study on that. So I hope in the education network we will actually research the impact. And the reason I say content, we have some teachers in schools and universities. In Japan we have a 100 teachers in a network for example. They teach in different ways and different goals. This diversity is useful but we have to try to measure it and see what actually goes. But it seems not many people are doing this.
Leavitt: What you say is that in any moral dilemma, there is a finite number of choices. Linguistically dilemma means there are different choices. Anyway, I don't think that it will be finite, because it is often that when we think about all the alternatives, suddenly new alternatives emerge that we haven't thought of before. I don't know if you can prove that the things which you never thought of before are never going to emerge, which you would have to prove in order to prove that it's finite. But I am skeptical about it being finite.
Macer: Actually, I say, a finite number of human ideas not a finite number of choices. It's true we might find new choices, however, I probably doubt that they are infinite also. I'm saying that the ideas are finite does not mean that choices are restricted.
Boyd: Thank you. The third presentation is by Ole Doering. Are there any questions?
Leavitt: You said something before that you wanted to improve the capacity of physicians to do the right thing. Excuse me for being in a slightly skeptical and pessimistic mood, but I don't think we know what the right thing is. And we're supposed to be the bioethicists. What I mean is that, honesty is the right thing, but when it comes to the questions that are usually taught to medical students, brain death, abortion, terminal care, organ donation and so on, I don't think we have a general agreement in this room what the right thing is. Because everyone has his or her own opinion. Consequently, I don't know how we could teach the students how to do the right thing.
Doering: I get your point. I think there are different starting points we should consider. Of what we did. We acknowledged the situation. Nobody knows the truth, and I mentioned that we didn't accept any dogma. But we dreamt it, we named it and the question about it must be addressed by different people in different ways; if we are to find out what are the real problems, why are medical students cheating. Many of them can give absolutely rational reasons why they are cheating. And I don't have to go through all these reasons. But some are more subjective reasons than one. So that's one. Do the right thing. One assumption of that is that everyone who is engaged in medicine should have knowledge of what's good. The problem is nobody knows what is right or wrong in a particular situation. But we can practice; we can learn by making mistakes, we can criticize each other. It is not perfect. These methods might lead to a perfect moral answers, in fact far from the opposite. But we can improve our behavior.
Meng: I don't think we teach students what the right thing is. But we teach them how to find a way to solutions. So we don't tell them absolutely this is right or that is wrong. We just present the cases to them and let them find the end.
Unknown: Do you have any way of measuring the effectiveness of this way of teaching on students?
Doering: We don't have that. But what I can say is that we have a lot of information and evidence that the old system doesn't work. The fact that everyone was highly inspired and encouraged to try something new in the working place indicates that at least there must be something there.
Unknown: I am sure that there should have been some studies on how much impact we are giving to the students.
Manickavel: In response to the students concerns. In the USA there was a survey of students who took medical ethics education, having different attitudes in these dilemmas to those who did not. This was the reason that medical ethics was developed.
Oshima: The next paper is presented by Han Suk. Any questions or comments?
Nurten Aksoy: Did you find any correlation between ethical subjectivity and education levels?
Han: No we did not.
Hsin: I would like to ask about the distribution of religion among the Korean population. It is more religious than in Taiwan. What is the religious background of medical professionals and the patients they serve?
Han: Our country is about 45% Christian, Most of the institutions we surveyed were run by Catholics or other Christians.
Oshima: The last paper in this session is by Young-Moo Koo on on-line medical ethics education. Are there any questions?
Maekawa: What are your criteria for grading? That is, what can a student do in order to get a score of 5? I am particularly interested in this question because I'm a student myself. And my second question is, if this weren't a mandatory class, do you still think that many people would take it?
Koo: If this weren't mandatory, I think very few people would take this course because they are busy and they are tired. So I feel a little bit sympathetic and think that I may be asking too much from those who are burdened already. That's my dilemma. I firmly believe that the young physicians need to be educated on bioethics in order to improve their professional quality. And taking a biomedical ethics course would benefit them. And that's why I'm motivated to offer this course.
Tanida: Thank you for a very interesting talk. I am a doctor from Japan. I have experienced teaching medical ethics to first year students. And from next year we are planning to offer an on-line course for 4-year students. I'm very interested about the effects of using the Internet as a pedagogical method. This reminds me of a paper I read in Lancet wherein they described that the best way of learning would be through direct conversation with an experienced retired doctor or retired nurse. I think there may be a difference in terms of the effects of personal, direct learning and learning from a monitor. I wonder what do you think the implications are?
Koo: I think the best way of learning is through interacting with persons. I think this kind of on-line method is second best but we have many realistic limitations. It is difficult, and I would go as far as to say that it's impossible to get them all together in one class. Like I said before, they are very, very busy and very, very tired. Also the students may do internships in different parts of the country. So this is a kind of compromise between ideal bioethics education and reality.
Leavitt: I want to suggest that you can compromise. I went to this workshop on teaching by the Internet. What I would like to do in the next year is to put my reader and required material and other materials on the Internet in order to save on copying and binding. This will combine the methods but the discussions can be made face to face. What I'm suggesting is combining the two methods.
Hsin: I'm Dena from Taiwan. I totally agree with both. Bioethics can be taught by both. From my experience working in a 2000-bed hospital, it is very useful to have discussions on issues of bioethics in a busy hospital. Ethics grand rounds for half a year are held. In this way, doctors are able to express their dilemmas and nurses are able to voice out their concerns. Thus also contributes to good relations in the hospital. Maybe once every two months is useful to have such a meeting.
Koo: I would just like to mention that I don't work for Seoul National University. My affiliation is with the University of Ulsan. I am just helping.
Unknown: I am a pediatrician working in a university hospital in Korea. Let me give you one example in pediatric clinic. For one doctor who was giving medications to children, but only half were medically indicated. There was great pressure from families to give drugs. This is a real dilemma. Also many persons cannot attend a conference like this, as they are busy with patients. Giving proper medical care does not mean only medication.
Hwang Sang-Ik: I think this education for residents could be considered as part of post-graduate education. It is very important because ethical behavior is determined in the training period. And in my hospital, residents discuss ethical issues for the ethics grand rounds and they then present the results of their case analysis to a general meeting attended by hospital staff and officials. This is followed by active discussion. I think it is very impressive since they can learn different opinions from different people. So I think that this kind of method is a powerful tool for learning.
Oshima: Thank you very much for your attention.