Implementation of Medical Ethics Education


Journal: J. Medical Education 2, 138-44.
Author: Darryl R. J. Macer
This paper will discuss several aspects of the issue of bioethics education, focusing especially on medical ethics education. There are several fundamental issues that need to be discussed, especially what is bioethics?, can it be taught?, where is it learnt?, who should be taught?, how and when can this be accomplished?, and who should teach?

"Bioethics" means the study of ethical issues arising from human involvement with life, and could be called simply the "love of life". Love is a broad term, but includes the concepts of balancing benefits and risks. Love is the desire to do good and the need to avoid doing harm. It includes love of others as oneself, the respecting of autonomy. It also includes the idea of justice, loving others and sharing what we have - distributive justice. Bioethics includes both medical and environmental ethics. Balancing the ideals of doing good / not doing harm; and individual autonomy / justice to all. It includes technology assessment in the biological sciences, and issues that are new and old.

There are three ways to think of "bioethics":

1. Descriptive bioethics - The way people view life, their moral interactions and responsibilities with living organisms in life.

2. Prescriptive bioethics - To tell others what is good or bad, what principles are most important; or to say something/someone has rights, & others have duties to them.

3. Interactive bioethics - Discussion and debate between people, groups within society, and communities about 1 and 2 above.

There are several bioethical worldviews in a descriptive meaning of bioethics including:

Anthropocentric - individualistic, family-centred, nationalistic, racial or communitarian

Biocentric - biological organisms, hierarchy?

Ecocentric - ecosystem or biosphere as unit

Why teach bioethics?

We allow people to make choices in many parts of their life, such as activities, marriage, occupation, and religious belief, so we should also allow them choice in their medical treatment. It is a challenge for us to respect all human beings as people with the same status but expressing different values. Moral education aims to teach respect for others and nature, and whenever we hear of ethics scandals, be it political, business or crime, we comment that it is a deficit in our education. Whether education is to blame or not, is not scientifically proven, though it seems to be one of the causative factors. Is medical ethics also the result of incomplete or misdirected education?

We can ask the question whether we can teach a person how to be ethical? Probably we can, but there is one caution that should be noted - the principle of do no harm tells us that if we implement a medical ethics curriculum we need to be sure we are not doing harm. Therefore this question, "Can it be taught?" is important to assess with ongoing trials.

Next we can ask what are we trying to teach? For example, communication skills, love of others, respect for persons, to consider the family context, to be non-directive, to be at an equal level to patients, to be a good example to others, to be able to apply knowledge in the proper place and at the proper time, and to know when to let go. We may all have some further ideal attributes of an ideal physician, but if we are going to measure the effectiveness of the education we will have to decide upon which measure. Furthermore, will it be evaluation from the patient, or the family, self-evaluation, evaluation of colleagues in the medical team, or an exam or test format?

Bioethics education is a growing concern internationally. The 1993 International Bioethics Survey was conducted by mail response surveys among the general public and medical students in Australia, Hong Kong, India, Israel, Japan, New Zealand, The Philippines, Russia, Singapore and Thailand, with collaborators (Macer, 1994). That International Bioethics Survey was performed in order to look at how people think about life, nature, and selected issues of science and technology, biotechnology, genetic engineering, and genetic technology. In all countries of the International Bioethics Survey there is 90+% support for "including discussion of social issues associated with science and technology in school, so that students can participate in contemporary debates". It therefore appears that there is very widespread support for inclusion of bioethics teaching in schools.

Also in 1993 the International Bioethics Education Survey was conducted in Australia, New Zealand and Japan, and the results together with many comments from teachers in these countries are available on-line (Macer et al., 1996). The International Bioethics Education Survey found that more Japanese teachers tended to view bioethics as respect for life, whereas more Australian and New Zealand teachers viewed it as developing practical responses to the issues which students face, brought about by modern science and technology. In 1996 the International Bioethics Education Survey was also conducted in India (Pandian and Macer, 1997) and Singapore, and Indian teachers followed the Japanese responses whereas those in Singapore followed more the Australian or New Zealand responses. What we think is that respect for life is essential, but we need to move on to practical approaches to develop decision-making.

This need has been recognised universally by its inclusion in the Universal Declaration on the Human Genome and Human Rights which was adopted unanimously by 186 member countries of UNESCO on 11 November, 1997. The UNESCO International Bioethics Committee which I am a member of since its founding in 1993, includes 55 members from 40 countries of the world. The Committee tries to stimulating bioethics around the world, in local/regional meetings and by reports on various subjects. In the Declaration several articles call for education:

20. States should take appropriate measures to promote the principles set out in the Declaration, through education and relevant means, inter alia through the conduct of research and training in interdisciplinary fields and through the promotion of education in bioethics, at all levels, in particular for those responsible for science policies.

21. States should take appropriate measures to encourage other forms of research, training and information dissemination conducive to raising the awareness of society and all of its members of their responsibilities regarding the fundamental issues relating to the defense of human dignity which may be raised by research in biology, in genetics and in medicine, and its applications. They should also undertake to facilitate on this subject an open international discussion, ensuring the free expression of various socio-cultural, religious and philosophical opinions.

What to teach

Perhaps we can all agree there is a need for bioethics education. The next question is what should be included? What is common sense to one person may not be to another, so even the basics need to be taught. The four ideals I mentioned above, autonomy, justice, beneficence (to do good) and non-maleficence (not to do harm) are universal, though the way they are balanced can vary. Some practical examples of bioethics can be given to make students understand these principles, for example the Tuskegee syphilis experiments, the radiation experiments on unconsenting persons, Nazi or Japanese war crimes, or local examples of medical injustice.

Bioethics not only considers decision-making, but the relationships in which the decisions are made. The principle of harmony is important. Any relationship requires communication, like teacher - student; politician - people; and doctor-patient. In medicine the healing situation requires special morals as it involves a sick person with a healer who is required to help, and not to exploit the vulnerability (weakness) of the patient.

One type of relationship is where both are equal, sometimes with friends or husband/wife, though not always. In medicine the relationship could have the doctor higher than the patient; equal, or the patient higher than the doctor (like a supermarket). Where is the right balance between the two? We can also think of relationships within the health care team; nurses, doctors, medical students, administrative staff, cleaners, volunteers, and patient supporters like the family and friends.

The behaviour most characteristic of many doctors in Asia can be called paternalism. Paternal means coming from the father, and paternalism means behaving as a father would to his children. The sick patient is vulnerable, like a child, and seeks the care of a doctor. The doctor may know what is physically best for the patient, but this may not always be what is best for the patient given the patient's life values. For example, anyone in authority in Japan is called a teacher, "sensei", and they may feel their authority is challenged if anyone debates their decision. Doctors, politicians, or others in authority, should not be concerned about being questioned, rather this should be normal.

Another basic is informed consent, which is that for every procedure the patient should be offered an explanation of the problem and possible solutions, and then their consent asked. This is called informed consent. The doctrine of informed consent, simply stated, is that before a patient is asked to consent to any treatment or procedure that has risks, alternatives, or low success rates, the patient must be provided with certain information. This information includes at least the following, which must of course, be presented in language the patient can understand.

1. A description of the recommended treatment or procedure

2. A description of the risks and benefits of the recommended procedure, with special emphasis on risks of death or serious bodily disability

3. A description of the alternatives, including other treatments or procedures, together with the risks and benefits of these alternatives

4. The likely results of no treatment

5. The probability of success, and what the physician means by success

6. The major problems anticipated in recuperation, and the time period during which the patient will not be able to resume his or her normal activities

7. Any other information generally provided to patients in this situation by other qualified physicians

Health care workers need to make patients make decisions, we must find the best way to do this. It will involve some time. Health care workers should have good counseling skills. Health care workers should be decision facilitators, the patients should make the decisions. Therefore we need to teach communication skills to enable decisions to be made.

When to teach

If we are going to teach young student doctors and nurses to have equal relationships to patients, but they enter a hospital where the older staff are very paternalistic or demanding to the younger staff, it is difficult to expect the young medical staff to maintain equal relationships with patients. You must be strong to break with tradition at the encounter with the patient, while also respecting the establishment. Therefore we need to have teaching of senior staff, who will be the mentors of the younger staff. I think this is very important especially in the traditional Asian societies. This way they can also share their experience. This may include conferences like this one, and congratulations on holding the First National Conference on Medical Ethics Education.

Inside medical schools there are a range of options. Generally we could say more is better than less, but only if spread throughout the training course. Undergraduate level lectures allow some introduction to the philosophical background, the sociology of the healing situation, and the legal aspects. For example up to 25 hours in the first three years is considered a good level, but at some schools it is much less, or only focuses on medical law not ethics. As an addition to lectures, writing reports that involve some literature research will enable the student to realize that ethics is an academic discipline in its own right, and there is a vast wealth of papers and books on the subject. Not many medical school libraries have medical ethics journals, but some materials are on the Internet.

In the absence of clinical practice, lecture knowledge will be eventually lost. Therefore some case studies and ethics discussion in the early clinical rounds is considered necessary to allow students to learn how to apply ethics. This form of teaching can include some refresher lectures, but is generally done in seminars or small groups of students with the doctor. In some schools, nurses and doctors are taught together, which reflects the way medicine is practiced and has some advantages.

Not only the health care worker needs training. The patient or family also needs to want to communicate, communication is a two way process. This is the same for any expert-public relationship. Education should start in the home, and it may even be in our genes. Let us hope that ethics education and respect for life does reach all people in both these ways, but there is still a need to reinforce it, and to develop this feeling for bioethics as respect for life into something which can help us make value choices in the difficult questions that we face in our life, and we face from biology and biotechnology. There are already some practical measures for environmental education that are included in most countries of the world, from green day, to recycling. The spirit of minimum consumption and avoiding waste is also central to a practical bioethic of behaviour.

In school there is some inclusion of science in the curriculum, and also of environmental education. However there is a range of subjects in which bioethics can be included. A general way to survey the teaching of these issues is textbook analysis. In Japan we have surveyed the textbooks used by high school, junior high and primary school students for a number of key words related to bioethics in 1996 (Macer et al. 1996). What is interesting is that there is similar coverage of these ideas in non-science or social studies books, such as history, Japanese language, English language, for example. Therefore we should not be fixed in the subject that we think of. Several pages of high school ethics texts introduce brain death and bioethics, though generally the ethics discussion is less than in Australasia for example.

One of the reasons to focus on school education is that almost everyone goes to school, whereas only a few, 10-30% of the population go on to college or university. Therefore if we focus on the university level we will miss the majority of people who do not attend. Public education is also necessary for covering all those in our society who have no further contact with the formal education system of schools and colleges. School education also means the students take the interesting subjects back to their homes in discussion, and in this way the whole of society can have bioethics education.

In Japan my major focus on bioethics education has been at the high school level. This is because during these years students may be at the right age to consider bioethics issues. The main problem is the exam system at the end of school may restrict time and attention given to these issues, however, in some countries bioethics is part of the formal examined curriculum for biology. As mentioned above, an International Bioethics Education Survey was conducted. Open questions looked at images of bioethics, and found the views of teachers varied with some differences apparent between practical concerns and vague ones, the former could represent progress towards bioethical maturity. Open comments were also given for the reasons why about 90% of teachers thought bioethics was needed in education. However they were short of teaching materials, and since 1994 teaching materials have been developed and placed on the Internet in English <http://eubios.info/TM.htm">, and Japanese (Asada & Macer, 1997). Since the first edition, pictures and illustrations have joined questions, as a basis for the materials to be more interesting for students. The revised teaching materials were then announced by sending a fax to all high schools in Japan (5000+). Over 800 replies were received requesting materials, which were sent free of charge to the teachers. We do receive some comment sheets from students who used these sheets, but not very much feedback.

In addition to the advertisement for receiving teaching materials we announced the establishment of a bioethics education network. There are currently 50 members of this network, from both biology and social studies backgrounds, and we meet every 1-2 months, since 1996. One of the basic purposes of the network is that isolated teachers will be encouraged by exchanging ideas and information with each other, and it has been found to be effective. I am now moving on to test various teaching strategies, as partners with teachers.

When people are asked what is their source of information about science and technology, the major source is the mass media. In particular newspapers and television. Therefore journalists have an important and very responsible role in providing information in a balanced and correct manner. On the next level there is radio talk-back, and magazines for women or men, which provide other information.

Education in University of Tsukuba

To provide some concrete information on university level courses, I will mention the courses I have developed over the past 8 years at the University of Tsukuba. There are two formal courses that I teach in the University of Tsukuba to undergraduates and one to postgraduates. Each course is ten lectures. In addition in a weekly class of 30 lectures the topics of bioethics, research ethics and genetics are discussed with reference to recent scientific papers and news stories from Nature, New Scientist or Science journal.

The undergraduate bioethics lectures that are given are: Introduction to ethics, autonomy, justice, bioethics; animal rights; environmental ethics; informed consent; euthanasia and terminal care; brain death and persistent vegetative state; organ transplants; human embryo status and abortion; fetal tissue transplants and reproduction; assisted reproductive technology; cross cultural bioethics (with visiting lectures and attendance at conferences); release of transgenic organisms and dangers of genetic engineering; Human Genome Project; Life and economics, and patenting of genetic material; Genetic diversity; Genetic screening; Genetic information and privacy; AIDS testing; Eugenics; Human gene therapy; Human genetic engineering and our future. The courses look at bioethics as the study of the ethical issues of life. Also at the bioethical issues raised by the use of genetic technology in medicine and agriculture. We will discuss the science, ethics and legal aspects from an international perspective. The courses focuses on making decisions in a balanced and rational way.

The postgraduate course in the Master's Program in Environmental Sciences looks at human relationships with the environment, and the lessons we can learn for a sustainable coexistence. Some of the bioethical issues raised by the use of technology in the environment are a major focus. We will discuss the science, aesthetics, ethics and legal aspects from an international perspective. How can we make balanced decisions preserving the harmony of nature and life in a modern age dominated by economic forces? The lectures include: 1. Introduction to bioethics and environmental ethics; 2. What can we learn from relationships with nature?; 3. Sustaining biodiversity, patents on life and genes, economics; 4. Animal rights; 5. Dangers of genetic engineering; release of transgenic organisms. 6. Cross cultural bioethics and international regulation; 7. Science, technology and environmental risk assessment; 8. Pollution, disease and the environment. 9.A sustainable environment in the technological age; 10. Discussion. It is also open to Ph.D. students, but their seminar in bioethics is more informal.

I am currently writing a specific textbook and introduction to bioethics. I have used some of my previous books for the courses, but a specific and concise textbook is needed.

The Future and Education of Professionals

Bioethics is a multidisciplinary subject, therefore cross-professional education is even more essential than in other fields. In addition to lay members of medical ethics committees and hospital boards that interact with nurses and doctors, there may also be academics from other specialties, such as philosophy, sociology, religion, biology, etc.

Most professionals were educated at a time when ethics was taught less, and there was less general consciousness of the broader environmental, ethical and social consequences of choices people make in use of technology. Also there is a tendency to become over-specialized and focus on a particular research area, perhaps blind to broader issues. Some academic societies have enacted codes of ethics to give practical guidance on some common problems, the same as the way some medical doctors have followed a Hippocratic Oath or a related medical code for many centuries. However there does need to be some additional discussion or training, as ethics codes alone are not sufficient for practical life.

Information from different fields is also essential and that is one of the functions of the Eubios Journal of Asian and International Bioethics, published by the Eubios Ethics Institute. It is on-line, and the news files on 31 topics of environmental and medical ethics are updated since 1990, together with a number of books published by the Eubios Ethics Institute <http://eubios.info/index.htm">. There are various networks, and the recently founded Asian Bioethics Association has made this journal its official journal.

Around the world there are people trained in many specialties who teach medical ethics. I started as a molecular biologist, others enter bioethics from law, philosophy, medicine, sociology. In medical schools there can be non-medical staff employed, though there is resistance to this idea in Japan. In the USA it is popular to have a philosopher in a medical school. Medical sociology and law have a little older roots. I do not think the background is important, but rather that it should not be left to one person or one class. Ethics is something inseparable from practice, therefore we need to have all staff being teachers. In one medical school in Japan, Fukui Medical School, the students in nursing and medicine all visit homes for the handicapped and learn from the patients there about respect for life. One's mind should be open to learn in every chance, not only in a formal program that is called "medical ethics". If we can teach people to teach themselves this is what I consider successful education.

Education is important both for students, professionals and the public. The balancing of benefits and risks of scientific advances is a sign of bioethical maturity and essential for a healthy society in the technological age. Let us work towards a common goal, testing different methods and levels of interaction.


References

Asada, Y., Akiyama, S., Tsuzuki, M., Macer, N.Y. & Macer, D.R.J. (1996) High school teaching of bioethics in New Zealand, Australia, and Japan. Journal of Moral Education , 25, 401-420.

Asada, Y & Macer, D. (1997) Establishment of High School Bioethics Education Network, EJAIB 7 (1997), 73-7.

Macer, D.R.J., Bioethics for the People by the People, (Christchurch: Eubios Ethics Institute, 1994).

Macer, D.R.J., Asada, Y., Tsuzuki, M., Akiyama, S., & Macer, N.Y. Bioethics in high schools in Australia, New Zealand and Japan, (Christchurch: Eubios Ethics Institute, 1996).

Pandian, C. & Macer, D. "Bioethics Education in High Schools: An Investigation in Tamil Nadu with Comparisons to Australia, Japan and New Zealand", pp 390-400 in Azariah J., Azariah H., & Macer DRJ., eds, Bioethics in India (Eubios Ethics Institute 1997).


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