- Atsushi Asai, MD, MBioeth., Shizuko
Nagata, MD, & Tsuguya Fukui, MD, MPH
Department of General Medicine and Clinical Epidemiology,
Kyoto University School of Medicine, Kyoto, 606-8507 Japan
Various ethical problems have been concerning medical professionals and general public in Japan. Many of them remain controversial and people sharply disagree about what act is ethically justifiable. For instance, intense arguments has never ceased with regard to definition of death, euthanasia, and truth telling. The significance of ethical discussion about various issues in clinical settings has gradually been recognized in medical societies as well as society as a whole, and medical professionals, especially physicians, are expected to be capable to make sound judgments about difficult ethical dilemmas encountered in the clinical setting. Under these circumstances, what kind of ethics education should be done for medical students and physicians under clinical training? Consensus has not been reached, however, regarding teaching formats in which health care ethics (HCE) is taught, including what, when, how, to whom, and by whom it ought to be educated. In this article, We would like to consider a desirable form of HCE education for undergraduate medical students.
The first section will concern
current situations with regard to teaching practice of ethics
teaching in under-graduate education in medical schools. We will
review several surveys published recently and discuss what we
know and what consensus exist in this regard. Some examples will
also be mentioned. In the second section, what we do not know
about education in HCE will be identified and considered. In
the third part, we will focus on skepticism against ethics education
and refute some arguments against the importance of ethics teaching
in medical schools. Cultural relativism will also be rejected.
The fourth section will discuss what should be done in ethics
teaching in medical schools. What, when, how, to whom, and by
whom ought HCE to be educated? Each issue will be answered.
The fifth section will concern whether or not educators in health
car ethics should present their own normative attitudes about
ethical issues to their students. We will defend the claim that
the educators should explicitly present their attitudes in normative
ethics about every single ethical issue. In conclusions, we will
argue that case-based, problem-solving, and small group teaching
is a preferable teaching format. It will also be argued that
it is essential and urgent to develop a qualified physician-ethicist
as a coordinator of HCE education.
1. What we know about teaching practice of health care ethics
In 1990s, various clinical studies has been conducted with regard to current teaching practice in HCE in Japanese medical schools. The deans of medical schools, undergraduate medical students, and postgraduate medical residents have been asked about what kind of HCE is being given in their schools or clinical training. Based on the findings of these studies, it is possible to summarize what is going on about HCE education in Japan.
First, most medical schools (80% and more) in Japan have been offering or will offer undergraduate HCE education as compulsory basis, and the majority of the medical schools teach it before bedside teaching. Less than one-fifth of all schools reported that they teach HCE both before and in the middle of undergraduate clinical training. The average length of teaching is between 6 and 9 hours a year. Specialties of educators in HCE vary and interdisciplinary staff collaborate HCE teaching. Both small group case discussion and lectures are used as teaching formats (1, 2, 3, 4). Second, as opposed to many other countries, quality and quantity of medical ethics education in Japan could be relatively poor and the intensity and frequency of education in medical ethics in Japan vary widely (2). Third, regarding attitudes of medical students and deans towards HCE education, both recognize the significance of it teaching and both regard informed consent, brain death, and medical end-of-life decisions as major issues in Japanese clinical settings (1, 5, 6).
There remains considerable disagreement, however, about necessity of medical ethics specialists and HCE itself. Finally, the majority of medical students and residents perceive that HCE should be taught as part of clinical training and case discussion should be central. Ethics education give by interdisciplinary staff is considered desirable as opposed to its teaching given solely by physicians. Furthermore, postgraduate ethics education has not been established and medical residents' satisfaction with undergraduate HCE education they had in undergraduate education was very low. On the other hand, exposure to ethical dilemmas seemed to motivate medical trainees to learn medical ethics affirmatively (5, 7).
2. What we do not know about HCE education in Japan
Our review on several recent papers about HCE in Japan gave us the outline of actual situations in HCE and attitudes of those who involved in this regard. However, the review of the papers also reveals that many important problems remain unknown. Seven issues, at least, are identified and listed on Table 1.
These unknown issues partially
concern what is actually going on in a class room or seminar discussion.
For instance, we do not know how teachers from various academic
backgrounds join and collaborate in ethics teaching and discussion
and who are taking initiatives. What happen when they disagree
with the final judgment? More serious issues are about whether
or not normative conclusions that the educators reach should present
to medical students and how to do so. Furthermore, whether or
not present educators in charge of HCE are all qualified to teach
ethics to medical students? How can we evaluate the qualification
of educators? These basic and fundamental problems will be thought
through in the fourth sections.
3 Skepticism and cultural Relativism
to providing sufficient HCE education have already been identified
(1, 3, 6, 7). We think that deep-rooted skepticism agasinst ethics
and its education is one of the most powerful obstacles. Bernard
Lo described skepticism about clinical ethics in detail as in
the Table 2 (8). There are also meta-ethical problems including
cultural relativism and ethical subjectivism. Now, how can we
refute these claims? We would argue against both claims briefly
Is ethics just a matter of character?
The goal of HCE education is to help health care professionals make sound ethical decisions and, as a consequence, to satisfy patient's rational wishes. At the same time, it aims to benefit patient's family and society as a whole. If we are right, ethics is a matter of decision making, not exclusively about agents' character or human nature. As Lo claims, even a good physician would experience difficult ethical conflicts and sufficient knowledge regarding ethical issues and discussion are helpful. Systematic principles are necessary if we want to make universally-accepted and impartial decisions in clinical settings.
According to definition made by
James Rachels, the conscientious moral agent is someone who is
concerned impartially with interests with everyone affected by
what he or she does; who is willing to listen to reason even when
it means that his or her earlier convictions may have to be revised;
and who, finally, is willing to act on the results of this deliberation
(9). Thus, our ethics can be revised by sound reasoning even
if our ethics or that of medical students have already been set.
Table 1: Unknown issues in health care ethics education
(1) How do teachers from various academic backgrounds join and collaborate in ethics teaching?
(2) How often is case discussion used and what kind of case is presented to discuss ethical issues?
(3) How does case discussion and didactic lectures combine?
(4) How should be medical student's competency in health care ethics assessed?
(5) How can we motivate medical students to affirmatively learn health care ethics?
(6) Are present educators in charge all qualified to teach medical ethics to students?
(7) What kind of reasoning and conclusions
do educators in ethics present to medical students?
Table 2: Various skeptical attitudes against health care ethics education
ETHICS IS A MATTER OF CHARACTER
Only unethical persons have ethical problems
Ethics is being a good person, not a system of rules
By the time you are a doctor, your ethics are set.
WE ALREADY KNOW HOW TO HANDLE ETHICAL ISSUES
Ethics is common sense and clinical experience
Ethics is following the Hippocratic oath
Ethics is following the law
TEACHING ON MEDICAL ETHICS IS NOT USEFUL
Every case is unique, so guidelines are impossible
Lo B: Resolving Ethical Dilemmas A Guide for Clinicians, Williams
and Wilkins, Baltimore, 1995.
Do we already know how to handle ethics issues?
In modern medicine
and clinical practice, we always have unique and new ethical dilemmas.
It is quite unlikely that common sense and experiences without
reasoning or deliberation can work well in novel and unfamiliar
situations. Furthermore, as Helga Kuhse argues, ethics is not
a matter of religion or a matter of obedience to authority. It
is not either what comes naturally or social practice. Finally,
ethics is not just a matter of feelings (10). Although we cannot
discuss justification about Dr. Kuhse's arguments fully here,
blind obedience to traditional oaths, laws, or traditional moral
fabric does not mean being ethical at all.
Is teaching on medical ethics not useful?
is unique in details, but it can be argued that, despite its uniqueness,
every problems in each case can be reduced to dilemmas raised
between two and more normative ethical principles in medicine.
For example, although an issue about truth telling in Japan may
be regarded as complicated, problems caused in the issue can be
reduced to dilemmas raised among a principle of respect for autonomy,
nonmaleficence, and confidentiality.
How can we deal with meta-ethical problems inherited in ethics itself? Cultural relativism is probably one of the most popular theory used when opponents of HCE try to disregard its significance in Japan. For example, one would claim like the following: "We are practicing in Japan, therefore, we should prolong patient's life regardless of its quality or patient's suffering" or "We should withhold a true diagnosis of cancer because we are Japanese." Are these statements ethically sound or defensible? We would say that cultural relativism is untenable .
Does morality completely differ in every society? Is it a convenient term for socially approved habits? It can be fair to argue that each separate moral principle may be universal in most societies although it does not mean such principle is objectively right. For example, almost all societies seem to accept that parents have to take care of their infants and children carefully. Most societies would agree that killing an innocent people who wishes to survive is never permissive. Promise keeping is also one of widely shared moral principles from one society to another. This is also the case in major principles in HCE. Professional ethical principles in most societies may include beneficence (the duty to promote good and prevent harms to patients), nonmaleficence (the duty to do no harm to patients), and respect for a patient's preferences for autonomy (the duty to protect and foster an individuals free and non-coerced choices as long as he or she wishes it. No medical society or no ordinary health care workers would reject each of them as pointless or meaningless. Despite their origin in western societies, these ethical norms have been accepted in almost all societies including Asian countries such as Japan.
What happen when two or more ethical
principles conflict? Each culture could have different solutions.
For example, traditionally in Japan, wishes of a patient's family
can be prioritized over preferences of the patients and the value
of family unity is highly prized. Can we argue that we should
ignore the patient's wishes in order to respect those of the family
because it is culturally and traditionally accepted in our country?
What if such disregard for patient's wishes suffer him or her
seriously? Cultural relativist would say yes. We would answer
it wrong. It can be argued that even if a certain moral norm
has been accepted in a particular society, it is wrong to maintain
the norm at the cost of individual happiness or preferences-satisfaction.
The fact that a certain moral norm has been accepted in a particular
society do not justify its automatic application for decision
making. If culture-specific ethical principles suffered people
in the culture, we should abandon it. If traditional human relationship
in the clinical setting is suffering patients, it should be criticized
and revised. The value of ethical principles should be judged
based on whether or not it makes patient's preferences satisfy,
not based on whether or not it has been traditionally accepted
in a particular culture.
4 What we ought to do about health care ethics education
consideration available information and unknown issues, we would
like to make some recommendation about how to build appropriate
undergraduate HCE education in medical schools.
What medical ethics should be taught?
As mentioned previously, informed consent, medical end-of-life decisions, and brain death are regarded as very important issues in HCE education by all involved. We think that to make ethics education more comprehensive and make student's decision making more universally acceptable, ethical issues regarding justice, that is to say, fair allocation of medical resources and ethical problems concerning heath care decisions for society as a whole should be extensively discussed. Issues including medical futility, abortion, personhood, quality and value of life should be explicitly referred. Along with these individual problems, underlying ethical principles and theories can be briefly mentioned. To make ethics teaching deeper, relevant cases and history should be taught.
When and to whom should medical ethics be taught?
It is preferable for us to teach medical students who have already had some clinical experiences. This is because they are more likely to be motivated to learn ethics. Therefore, it is possible to argue that HCE should be educated to students in clinical year as part of clinical training rather than before bedside teaching.
How should medical ethics be taught?
It seems that
some agreement have been reached in this problem. Case-oriented,
small group seminars or tutorials with extensive discussion may
be the most preferable teaching format. We think that we can
add some brief didactic lectures before or after small group teaching
as supplements. We can use historical cases for discussions.
In order to motivate medical students to learn medical ethics,
they should be asked to make a certain ethical decision in case
How should students' competence in ethical decision making be assessed?
It is often
mentioned that ability to identify, analyze, and to make decisions
are crucial in competence in HCE. Basic knowledge should also
be regarded as important. However, the assessment of capacity
to identify and list up ethical problems and knowledge may not
be sufficient. This is because knowledge and sensitivity may
not necessarily relate to student's motivation to make more sound
ethical decisions when they identify ethical dilemmas in this
regard. Therefore, it is not certain about what is the best method
to assess their competence in HCE. Probably, writing essays in
which medical students are asked to make a certain decision can
be used and they should be asked to rigorously defend their own
choices in the essay.
By whom should medical ethics be taught?
It may be fair to say that there is a certain consensus that both health care workers and philosopher/ethicists should join and collaborate in HCE teaching. But, in reality, as mentioned before, there are many unresolved questions in this regard (Table 1). We think that health care workers who are educated by philosopher/ethicists or bioethics should take initiatives in preparing case discussion and didactic lectures and leading them. It is very hard to define a qualified teacher in HCE. But, undoubtedly more physicians should be systematically educated in ethics/bioethics and should actively take responsibilities to establish effective and interesting medical ethics as decision making in the clinical setting with assistance of moral philosophers and other interdisciplinary staff.
5 Presenting conclusions and reasoning
What kind of reasoning and conclusions should educators in HCE present to medical students? This final and the most important question is difficult to answer. What ethical principle should they primarily rely on when two or more "prima facie" ethical principles are in conflict? Let us divide this question into three inquires.
In the first place, should we even present normative decisions made by educators to medical students? We would argue that the educators ought to express their normative decisions and attitudes explicitly because ethics is, as discussed previously, about what should be done and the main concern of ethics in the clinical setting is what act is right or wrong. Therefore, presenting reasons and conclusions is the essential part of ethics teaching in health care.
The second inquiry is whether physicians
are qualified as people able to make sound judgments about the
value or futility in health care. It can be argued that a physician
can be an effective judge in value under certain conditions.
Physicians or health care workers constitute a unique population
because they have had substantial exposure to patients who are
comatose, terminally ill, demented, or very elderly. They also
have direct experiences caring for patients receiving hemodialysis,
CPR, and the other intervention (12). In this sense, their value
judgments are well informed and based on a certain tendency of
fact. Physicians' training and experiences would tell them that
a miracle is just a miracle in almost all cases. Of course, physicians
may not know very much about a patient's personal value or their
desired goals of medicine. Nevertheless, they know what patients
in a similar situation are like in general. They know a group
of patients in similar circumstances. The facts on which physicians
base their value judgments are more realistic than those of patients
or their family, although there might be some exceptions. If
sufficient information and psychological calmness can make value
judgments more appropriate, physicians' value judgments about
general states of patients in a certain situation can be as good
as those of the patient, family, and other people (13). Of course,
we should always be aware that imposing one's value on others
is one thing and having a certain position about value is quite
another. Value judgments of physicians can be sound only when
physicians are aware that they are making value judgments, not
Table 3: What should educators in health care ethics do?
Finally, the hardest and the most important inquiry is what kind of normative decisions should be made in a given ethical question. Even in Japan which is often perceived as homogeneous as opposed to some other western countries, a lot of ethical questions are, at best, controversial. Under these circumstances, what should educators in medical ethics do as an educator, not simply as an individual?
We would argue that teachers in
HCE should firmly settle their own normative ethical attitudes
towards every single ethical issue though thorough rational consideration
backed by good reasoning; distinguish descriptive ethics from
normative ethics, and present data of research regarding descriptive
ethics as a fact; abandon cultural relativism and ethical subjectivism;
not impose their value judgments on students, but try to persuade
students that the conclusions reached is ethically justifiable
with sound arguments, and finally, whatever conclusions the teachers
express, they ought to justify them by rational arguments and
sincerely discuss about them with their students (Table 3) .
we would argue that , first, more comprehensive medical ethics
education is necessary, second, case-based, problem-solving, and
small group teaching is preferable, third, further research is
needed to reveal what is actually going on in a class room or
clinical conference in medical schools. Finally, it is essential
and urgent to develop a qualified physician-ethicist as a coordinator
of HCE education and help students make sound normative decisions
about ethics issues based on rational arguments and reasoning.
1. Akabayashi A, et al.: Survey
of Medical Ethics Education in Japanese Medical Schools. Medical
Education (Japan) 1999; 30: 47-53.
2. Miyasaka M: Jittai wo motanai wagakuni no igakubu, ikadaigaku no rinrikyouiku. Medical Asahi 1995 December 35-40.
3. Shirahama M: Clinical Ethics Education using case studies of dilemmas faced by students. Journal of Japanese Association for Bioethics 1998; 8: 81-88.
4. Miyasaka M, et al.: Bioethics Education at Niigata University School of Medicine: Toward the improvement of Medical Ethics Education in Japan. Journal of Japanese Association for Bioethics 1998; 8: 75-9.
5. Akabayashi A, et al.: Study of 5th-Year Medical Students Interest in Medical Ethics and Related Factors. Medical education (Japan) 1999; 30: 77-81.
6. Asai A, et al.: Attitudes and Opinions of Medical Students in Clinical Years towards Ethical Issues in Japan. Medical Education 1998; 29: 221-5.
7 Asai A, et al.: Postgraduate Education in Medical ethics in Japan. Medical Education (UK) 1998; 32: 100-4.
8 Lo B: Resolving Ethical Dilemmas A Guide for Clinicians, Williams and Wilkins, Baltimore, 1995.
9. James Rachels: The Element of Moral Philosophy. 2nd edition. McGraw-Hill, NY 1995
10. Helga Kuhse Caring: Nurses, Women and Ethics, Blackwell Publishers, Oxford 1997
11. Catherine Myser: How bioethics taught: a critical review chapter 485-97, in A companion to Bioethics edited by Peter Singer and Helga Kuhse, Blackwell, Oxford, UK 1998
12 Gillick MR et. al. Medical technology at the end of life. Arch Intern Med. 1993; 153: 2542 - 2547.
13 Asai A: Should physicians make value judgments regarding medical futility? EJAIB 8 (1998), 141-3.