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8.3. Consideration of medical ethics education in China from the comparison between China and the United States

- Yali Cong, Ph.D.
Associate professor, Department of Medical Ethics, 
Teaching and research office of medical ethics
Department of Medical Humanities
Peking University Health Science Center,
Peking, 100083, China

Based on the different response to a case between different students from China and the United States, the article compares the difference of medical ethics education from four aspects--- the arrangement of the course of medical ethics, the content of the curriculum, the team of medical ethics professors, the organizations of hospital ethics committee and IRB. In one word, the mechanism of how to integrate medical ethics education into the clinical practice is the aim we concern.

1. Case of Blood Transfusion

QWL, a female patient, aged 42 years, because of abdominal pain, be sent to GD commune hospital (GJ county of Jiangsu Province in south China) one evening. The physicians thought maybe massive abdominal cavity hemorrhage, most possibility is "ectopic pregnancy or rupture of spleen", and it was suggested to cut open the abdomen for exploration. At 8.50 pm, hospital telephoned the Yangzhou blood donor center and asked them to take 1,200 ml blood type A. At 9.30 pm, during the examining, physicians found that it was the base of the spleen broken, the loss of blood was about 4,000~4,500ml, and then urged the donor center come quickly. The answer of the blood donor center was that the blood was already on the road. At 10.00pm, the splenectomy was started, and at 10.20pm the blood came, at 10.25pm, QWL's heart stopped beating, 10.30pm transfusion began, and 11.30 pm QWL died finally.

Before the operation, the family members asked the hospital to draw family member's blood, but the hospital said: the County health bureau had just transmitted a file of blood transfusion, one point of the file was: hospital can't take blood by themselves, who takes who in charge. [the related laws:
1.<<The blood transfusion law of People's Republic of China>>, Clause 15: in case of urgency, hospitals can take blood temporarily, but should make sure the safety of blood.
2. <<the regulation of clinical use of blood >> (try-out), Clause 19: if the following demands are met, the hospitals can take blood for emergency use: a. There is no blood donor center in remote district; b. Only by blood transfusion can save the patient's life, other methods are futile; c. Have medical facilities to do blood cross matching examination, can examine HIV, Hepatitis B surface antigen (hbsag) (and Hepatitis C virus antibody). ]

The column of law of The Beijing Youth Newspaper invited 10 lawyers and hospital managers discuss this case on September 19, 2000, and most of them thought: hospital is not responsible to the death of QWL. A month later, the Beijing Youth Newspaper reported: the family member of QWL decided not to sue the hospital, the reason not disclosed.

To response to the newspaper, our medical students (47) also discussed the case, and the conclusion was:
13 students thought the behavior of hospital is legal and moral;
34 students thought the behavior of hospital is legal, but immoral, 11 of 34 students will take family member's blood to save patients, regardless of risk of breaking law.

While being a visiting scholar in the University of Chicago, I had a chance to discuss the same case with the medical students. The result of the students' response was: almost all the students (total number was 14) would draw the family member's blood to save the patient.

Now the question occurs: do Chinese medical students have low sympathy and responsibility to patient? If that is the case, how we medical ethics professors can do to help medical students to realize their medical morality? If not the case, then what is the obstacle for students to reach their ideal? The follows will analyses from several aspects.

1. The arrangement of the course of medical ethics

The study of medicine can be divided into two phases, the first two and half years and the second two and half years. After the basic science study, students will go to the teaching hospitals to begin the second phase study; they will study "bridge courses" (it takes 15 weeks to study physical diagnosis, chemical diagnosis, radio medicine, laboratory medicine, general introduction of surgery, etc.), "systematic courses"(it takes half year to study intern medicine, surgery, pediatrics, obstetrics and gynecology) and clinical practice. Usually, the course of medical ethics is arranged in the second phase, either during the bridge courses, or systematic courses.

In China, different universities provide different class hours from 40 to 20 for the course of medical ethics. It is required in most medical universities, only few as selective course.

2. What the students study from the curriculum

The Oath for Medical Students In China (1991, Ministry of Education)

Patient's health and life rest on us.
I solemnly swear upon enrolling in holy medical school:
I'll pledge myself to medical profession; I'll love my country and loyal to my people; I'll obey medical morality; I'll give my teachers the respect and gratitude which is their due; I'll practice my profession and advance medical science continuously and diligently.
I'll do my best to relieve pain of humankind, realize the perfection of health, maintain the honor and the noble traditions of the medical profession by all means in my power. I'll help all those who need medical service, regardless of difficulties and dangers, and dedicate all my life to the development of medical profession of our country and the health of mind and body of humankind.

Medical students swear this oath just after the entrance to medical school. Whenever they think of the oath afterwards, the medical students say the feeling of solemn occurs naturally.

The content of medical ethics is similar in different medical schools. Generally, medical ethics professors will offer the following knowledge: the introduction of the subject, history of Chinese and foreign medical morality, doctor-patient relationship, general theories, principles, moral standards in clinical practice, research and prevention ethics, bioethics topics, such as abortion, artificial assisted technology, euthanasia, organ transplantation, allocation of medical resource, etc.

Unlike the United States where medical professors have different teaching way and offer different kind of knowledge, we do similar job in the field of medical ethics, the difference lies in the teaching level and knowledge level.

We can consider what students learn from their clinician professors. Currently, the doctor-patient relationship (DPR) is not good in China, many disputes happened and court cases occurred since last decade, and more and more physicians are afraid being sued by patients. The result of bad DPR is the high sense of self-protection of physician and which is taught to medical students while they teach medical knowledge in class and in practice. So, before becoming a formal physician, many students have formed an idea that most patients are difficult to make contact with.

Being on the same side of DPR, it is very easy for medical students to accept any advice from their clinician professors, including unethical ones. The students are usually told how to protect themselves, or avoid being sued or getting into troubles. All these form an adverse effect to medical ethics education. In comparison with clinical professors, medical ethics professors are not regarded as interest community, and students will not like to accept what medical ethics requires, especially when what medical ethics professors teach is different with clinician professors.

3. The team of medical ethics professors

Most medical ethics teachers are full-time; we have no clinical medical ethics course, which is different with American style. To much extent, part-time medical ethics teachers who are physicians at same time have much advantage in medical ethics education, not only because they can use clinical language, which is more close to the practice, but also more easily accepted by students.

It was surveyed several years ago in China that 3/5 of medical ethics teachers had the background of philosophy, education, psychology or other humanities, and 2/5 had the background of medicine. But for those who had medicine background, they usually don't practice medicine, and don't have license, that means they only know more medicine knowledge, but are non-physicians.

We didn't have master degree and PH.D of medical ethics before last decade. Nowadays, we have more and more professors and universities to train master degree students of medical ethics, and also the PH.D students. Now we have reason to believe that we can contribute to the field of medical ethics education with a team of high quality professors.

4. The ethics committees

Divorce of medical ethics theory and practice is a serious problem in the field of medical ethics in China. With the development of research ethics and publishing of some medical laws, more and more hospitals and researchers have come to know the importance of medical ethics committee. On August 1, 2001, the Ministry of Health of People's Republic of China passed and put into effect a law of administration of sperm bank and artificial assisted reproduction technology, in which hospital ethics committee is needed to do good management. One point here in reality is that the members of ethics committee are usually clinical staff, and ethicists are seldom involved now.

About the hospital ethics committee and IRB, it has been a routine organization and has regular activities in almost all American hospitals. E.g., in the University of Chicago, every Wednesday's case conference can not only enlarge doctor, nurse's vision, but also an very good chance of education for other medical staff, sometimes for fellows, visiting scholars, and especially for medical students who are interested in it. By this way, can make the medical students have a sense that ethics committee is such an institution which can resolve ethical problem. Nowadays in China, ethics committee has just begun, and students have not come to know the real function of ethics in their future medical practice, which is also an obstacle for their acceptance of some ethical points.

5. Conclusions

Now, let's back to the case. From the brief analysis of four aspects of medical ethics education, we can know that students worry a little about breaking the law, even though most of them know the result of only obeying the law is immoral to patient. The problem reflected from the case is not special but common among medical students, especially when there is conflict between ethics and law or other regulations. But the serious issue is that, in current China, the system of law is not developed yet, and many aspects lack law or regulation. Another, even there is some law, with the time going, some content of law cannot fit the new circumstances. On the condition of current DPR, medical students and clinicians both hold an idea to protect themselves, which will worsen the DPR if there is not enough ethical laws to make them safety.

Truly speaking, most students have high moral and emotional bases, especially when their role has not changed into the medical community. But affected by the big environment, medical students can't identify what is ethical or not totally. Such problem can not be resolved only by medical ethics education, in the long run, we should improve the education based the Chinese special condition. The beginning of medical education is just after high school, that means many students don't have enough preparation for the medical profession, e.g. students usually don't consider why they study medicine, what is aim of their study, etc. While they face the ethical issues in clinical practice, students lack sense and ability to resolve problems, especially lack the knowledge of humanities. So, in personal life, it is whole life education, but in society's life, it is an engineer project.

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