A Qualitative Evaluation of Ethics Educational Program in Health Science

Abstract

This paper originates from a panel discussion on the evaluation of “Ethics Educational Program in Health Sciences” held during the IAEE Conference 2014 Ankara, Turkey. The participants of the panel had consultations to solidify the concepts about the topic. The qualitative data out of these antecedent discussions became mature with the contributions in the panel. The outcome of this qualitative study mainly focuses on the examples of two current curricula; one from PhD on History of Medicine and Medical Ethics, the other one from an elective course on medical ethics as a part of a PhD program on Pharmacy Management and History, followed by the major challenges the trainees face during their education, their expectations and whether the program was satisfactory, the aspects of the programs which are prone to improvement and their overall evaluations of the programs.

Historic Background

The very first medical education in the lands of Ottoman Empire was initiated at “Fatih Külliyesi”⁵ established in 1470 after the conquest of Istanbul in 1457. “Fatih Külliyesi” was not dedicated only to medical education, but still medicine was one of the key components of the curriculum with other disciplines such as mathematics, law and theological education. (Gürkan, 1953) The establishment of Tıphane-i Amire in 1827 is followed by the foundation of Mektb-i Tıbbiye-i Şahane⁶ in 1832; both are considered as the landmarks of modern medical education in Istanbul. In 1859 the first courses on medical ethics were presented by Charles Edwards, a British physician, at the Mektb-i Tıbbiye-i Şahane. Charles Edwards was a member of the Academy in 1861-1864. Dr.Rusinyan and Dr. Nurican were his successors from 1876 to 1881. (Yıldırım, 1993) Dr.Nurican was also the author of a book which had divisions on primary medical ethical issues such as the rights and obligations of the physicians, anti-discriminatory act, and the deontological aspects of the relationship of physicians with her colleagues and patients. Nevertheless the first curriculum on medical ethics and deontology is Zoeroş Pasha’s lectures at the Mektb-i Tıbbiye-i Şahane which took place from 1991 to 1913. His curriculum included the definition of basic deontological terms, the necessary qualifications of a physician, the tasks and moral duties of a physician during war, the privacy of medical records and the deontological rules of autopsy. (Yıldırım, 1994)

In 1856-1857 Academic year the courses on History of Medicine was initiated and in 1876 the two courses on Medical Ethics and History of Medicine were merged within the same curriculum. Today, the combined curriculum of Medical Ethics and History of Medicine approach is adhered by most of the medical faculties in Turkey. (Yıldırım, 1993)

Medical Faculty of Ankara University, was established in 1945 and is one of the very first medical faculties of Turkish Republic. Right after the establishment of the faculty, in 1946, “The Institute of History of Medicine” was founded, and is currently named as the “Department of History of Medicine and Medical Ethics”. In this department PhD program on History of Medicine and Medical Ethics started in 1988 and is still going on as one of the most prestigious PhD programs of the field. Other than this PhD program, Medical Ethics courses are involved in Masters and PhD programs of other Faculties of Ankara University such as, Faculty of Pharmacy, Faculty of Dentistry and Faculty of Veterinary Medicine.

In Turkey pharmacy education and training was started at Ottoman Empire Period with 6 schools: “Mekteb-i Tıbbiye-i Adliye-i Şahane (Military Medical School)-1839”, “Mekteb-i Tıbbiye-i Mülkiye-i Şahane (Civil Medical School)-1867”, “Haydarpaşa Askeri Sağlık Okulu (Haydarpaşa Military Health School)-1876”, “Merkezi Türkiye Koleji (Central Turkey College), Gaziantep,1876”, “Şam Tıbbiye Okulu (Şam Medical School)-1903”, “Eczacı Yüksek Okulu (Pharmacy Collegiate School), İstanbul-1908”. After Ottoman Empire Period, at Republican Period Ankara University Faculty of Pharmacy was established in 16.12.1960, İstanbul University Faculty of Pharmacy was established in 15.01.1962. The first faculty of Republican Period is Ankara University Faculty of Pharmacy. In the initial years of Republican Period there was a pharmacy education institution committed to Medical School with the name of “Eczacılık Yüksek Okulu (Pharmacy Collegiate)”. This collegiate was committed to Medical School till University Reform (1933). In 1933 this collegiate departed from Medical School and committed to Faculty of Science, continued with this way till 1944 and then committed again to Medical School. The basis of present-day İstanbul University Faculty of Pharmacy was generated. After that special pharmacy collegiates were established to ensure the country needs of graduated pharmacists: “İstanbul Eczacılık Özel Yüksek Okulu (İstanbul Special Pharmacy Collegiate)-1964”, “Karataş Eczacılık Özel Yüksek Okulu (Karataş Special Pharmacy Collegiate-İzmir)- 1967”, “Anadolu Eczacılık Özel Yüksek Okulu (Anadolu Special Pharmacy Collegiate-Ankara)- 1968”, “Ankara Eczacılık Özel Yüksek Okulu (Ankara Special Pharmacy Collegiate)- 1968”, “Efse Eczacılık Özel Yüksek Okulu (Efes Special Pharmacy Collegiate-İzmir)- 1967”, “Yakındoğu Eczacılık Özel Yüksek Okulu (Yakındoğu Special Pharmacy Collegiate-İzmir)- 1968”, “Hastaş Eczacılık Özel Yüksek Okulu (Hastaş Special Pharmacy Collegiate-Eskişehir)- 1968”, “Galatasaray Eczacılık Özel Yüksek Okulu (Galatasaray Special Pharmacy Collegiate-İstanbul)- 1969”. These special pharmacy collegiates were turned into pharmacy faculties (Özçelikay, 2013). Today, there are many faculties of pharmacy in Turkey.

The Curriculum of the PhD Program on History of Medicine and Medical Ethics in the Ankara University Faculty of Medicine

The aim of the program is developing ethical sensitivities and awareneess, increasing the knowledge and abilities to solve ethical dilemmas and ethical problems and guiding the participants to take the right action in related professional areas. The PhD program is a 2 year program consisting of 4 semesters. The ultimate requirement is to gather 36 credits throughout the whole period. Class discussions, lectures, seminars and case studies are used mainly as the methodology of teaching. The course evaluations are based on attendance, assignments, term papers and/or final exams for each student. The content consists of compulsory and elective courses both on ethics and history. The compulsory courses on Medical Ethics are; Medical Ethics and Health Legislation, General and Special issues in Medical Ethics, Ethics and Methodology, Introduction to Philosophy and Research ethics. Ethics of Science and History, Methodology in History and History of Medicine are the compulsory courses regarding the History of Medicine. The elective courses consist of; Introduction to Law (Application),Health Ethics, Social History of Medicine, Ottoman Paleography, Scientific Research Methods in Medical Ethics and Introduction to the Humanities in Medicine.

The ethics courses in the Pharmacy Management and History PhD program in the Pharmacy Management Department of Ankara University Institute of Health Sciences

Aim of this program is to train pharmacists to be able to apply ethical principles in their practices, to be able to identify the ethical problems arising in daily practice of the profession and developing the ability to solve these ethical problems. The program is a one semester course which takes 28 hours in total. The methodology is interactive and mainly depends on student presentations and class discussions under the supervision of professor. Generally each student adds their own perspectives to the releated subject. During the presentation and at the end the professor makes contributions about the topic. The content of the course covers the declarations of The World Medical Association, ethical principles, solving ethical problems, ethical committees, research ethics, ethics education, patients’ rights, children’s rights and ethic, clinical ethics, plastic surgery and ethics, psychiatry and ethics, environmental ethics.

The challenges

The foremost challenge mentioned is the need to change the paradigm of the way of thinking and reasoning from the quantitative positive science oriented to qualitative social science oriented one. Most of the attendees of the medical ethics courses and PhD programs in Institute of Health Sciences are physicians, pharmacists or dentists who have a positive science background. This background develops a concrete vision which relies on positive sciences. The visible, tangible, measurable one is the real data for these professionals. The difference in the way of thinking of a medical doctor who is coming from the clinics with patients made of flesh and blood and a social scientist, a historian, a philosopher; whose mind is well trained to think about transcendental/ abstract concepts is intense. This intense divergence creates the challenge of learning to think in another way than the trainees are used to which is to alter the paradigm of the methodology of thinking and reasoning from a result oriented and evidence based concrete pattern to a flexible, comprehensive, transcendental status. The trainees have to remember that achieving a result with the available data may not always be enough for ethical reasoning. Thus this requires lots of brain exercise to learn to see as many aspects of a case as possible and make judgment by taking in consideration all of them.

The unified nature of the curricula which includes the courses on medical ethics and history of medicine is the second significant challenge for the trainees. Although it is a great advantage to have classes on as many disciplines as possible, some practical problems exist because of the unification of two different comprehensive disciplines like history and ethics. The divergence of the subjects, the different nature of the methods of the two disciplines makes it hard to concentrate. Besides, this divergence may be quite challenging in another sense such as the requirement to study in both subjects even the trainee has very little interest in one of the two disciplines. Both disciplines are evolving and improving enormously, the amount of knowledge is increasing way so much and that urges the curricula to require more time and more classes to cope with the vast progress in the field.

Expectations from the program and whether it was satisfactory

The main expectations from the ethics education programs are; to understand and internalize the key concepts of ethics such as; informed consent, capacity to consent, privacy and confidentiality equality, justice, equity, non-discrimination and non-stigmatization; respect for cultural diversity and pluralism, individual and social responsibility in health; protecting future generations, environment, the biosphere and biodiversity; human dignity and human rights; autonomy; human vulnerability and personal integrity are stated as the major expectations form ethical courses. The other expectations are; to gain the ability to recognize the ethical issues in medicine, pharmacy, health care and life sciences and distinguish an ethical issue from other issues, to conceive the principles of bioethics and learn how to balance these principles in practice, to identify harms and benefits in health care and be able to justify decisions by taking harms and benefits into account and to be able to reflect the theory of ethics to practice.

Regarding the satisfaction of the trainees, the main emphasis is on the dynamics of adult education. (Arda, 2014) Ethics education has many diversities concerning the context, training hours, training methods and ways of evaluation but one feature is common for all the programs; it is adult education. Although adult education has many aspects, the primary one for the participants is that it is personally driven. The involvement and motivation of the trainee is very much depending on the trainee’s personal characteristics. Thus, the overall satisfaction evaluation is in fact an evaluation of the trainee’s performance of following the clues given by the instructor. In this context, the satisfaction rate very much depends on if the instructors were very good at giving the hints to the trainees’ further exploration. (JHPIEGO, 2009)

Points of improvements for the programs

The foremost point for improvement is to reconsider the unified nature of the programs which embodies history of medicine and ethics under the same program. Although this implementation bases on the traditional approach which was launched in the beginning on 1900’s the current state of improvement in both of these disciplines make it harder to qualify in both of them in one PhD program.

Improving the practical aspect of the curricula is also mentioned as a point in need for improvement. To observe a professional while she is doing what the trainees are expected to learn is an archaic method proven to be effective. This method has its philosophical reflection in the words of Aristotle, who defined ethics as a virtue gained through practice. As Aristotle says;

“it takes education and practice in order to become virtuous. It does not just happen, like growing taller…..education is a matter of drawing out a ‘latent’ potential, at least in the best people.”

One of the trainees articulated the need and importance of practice and observation of the professionals with the following words;

“In some topics of the educational program if it is possible to learn directly from the professionals, it will be better to internalize that topic. In some cases we could only be informed theoretically, so the practical part of the topics remains incomplete.”

Another trainee who had the chance to attend the ethical committee meetings in Boston Children’s Hospital as an observer during her PhD, referred to this requirement as follows;

“To observe how the ethical committee works was a great experience. It was like observing a surgeon during surgery instead of reading how to do it from a text. I felt I would be absent from my skills like a surgeon who has never seen and observed an operation but read it from the books would be”

Advancing the plurality of teaching methodology is another way of enhancing the opportunities to practice. The trainees would be able to diagnose and cure the ethical problems they face during their professional performances in case they exercise by interactive methods of learning such as case studies, role plays etc. Thus, evolving the methodology to enclose more interactive and participatory approaches of teaching would set forward the outcomes of the programs. (Honan, Sternman Rule, 2002) To encourage the trainees to participate in ethics courses or programs held in Universities, international or supranational organizations other than the ones in their countries would help to evolve the integration of the trainees as well. Short time student exchange programs would be a very handy mechanism to achieve this result.

The other issue which is prone to improvement is the integration of the content of the curricula with international core curricula. Because of the plurality and inconsistency of the many ethics curricula around the world, it became a necessity to ensure that the current content of the curricula is in line with the core curricula which is advised by international organizations such as UNESCO. This would ease the integration of the trainees with their colleagues from other parts of the world, and take forward the impact of their research and studies in the global world. (UNESCO, 2011) In addition to these, increasing the number of international conferences like IAEE will reflect the global prespectives about ethics education and make contributions.

Another feature that should be improved is about the number of academic staff in the field of ethics education at pharmacy faculties in Turkey. In very limited pharmacy faculties in Turkey ethics education is provided by fundamentally ethics and pharmacy management academicians. However in the vast majority of the remaining pharmacy faculties in Turkey, academicians from different departments lecture topics related with ethics; this is a negative point because these academicians can not focus on ethical topics as fundamentally ethics and pharmacy management academicians do. This is a major problem of ethics educational programs on the aspect of pharmacy in Turkey. The norm staff related with ethics education at pharmacy faculties must be increased as quickly as possible in Turkey.

To establish a feedback mechanism to further evolve the programs is a proposal to improve the effectiveness and quality of the programs. The concept which considers ethics training as an instructor led one-way teaching leaves out the main principles of adult learning which bases on mutual interaction between the professors and the trainees. This understanding values a constant, well established communication in between which leads to continuous evaluation of the curricula, teaching methods and techniques. This approach would have a concrete positive impact on the quality of the program. Besides it would serve as a wholesome tool for trainees and instructors to develop a critical outsider view on their work.

Discussion

The archaic discussion about the difference between “teaching about ethics” and “teaching ethics” drives us back to the questions such as; “What is the ultimate goal of ethics education? Why do we need to be good? Why do we need to act ethical?”

The modeling and construction of the ethics programs under discussion is compatible with the goal of “teaching about ethics”. The main consideration of the trainees is to learn about the ethical tools they should be able to use while performing their profession and the legislations which bind them from ethical aspects. The discussion among the participants reveal that the in the current state of play, many medical ethics and bioethics courses are heading this way. The emerge of practical ethical problems in profession and scientific research such as the increase of scientific misconduct cases and ethical problems concerning financial conflicts of interest are the main causes of the limited and pragmatic goal of ethics education which is; to teach ethics as a way of learning skills for diagnosing and solving ethical dilemmas in everyday practice. This approach focuses on the practical and measurable outcomes thus; it is easier to set learning/teaching goals and asses the outcomes. However, ethics is not a pure quantitatively measurable topic. In fact what we can measure is if the acts of the professionals are in line with the legislations, such as if they acquired informed consents properly or if they obey the rules of property rights etc… ıt is obvious for the participants that the ethics education in Ankara University is very well established for this purpose. The binding legislations, the ethical codes of the profession; the universal declarations are incorporated in a comprehensive frame of ethics. The trainees agree that, the combination of teaching the essentials of primary ethical theories and explication of the current legislation and implementations of profession on this ground is a fertile way of leaning about ethics.

Nevertheless, as mentioned above ethics is not a branch of quantitative science which has formulas to apply to a particular problem and find out the exact right answer. Ethics is a branch of philosophy which is far away from the relieving concrete results. It needs practice and raising the virtue to be able to do the right thing under the particular circumstances which may be unique to the actual case. This evaluation brings the discussion of “being ethical and acting ethical” to the table. The limited applied ethics training view has considerations on acting ethical which is very valuable indeed, but not enough regarding the ultimate goal of ethics. (Have, Gordjin, 2012)

The trainees mostly agreed on the idea that; the pragmatic and limited goal of learning/teaching ethics should proceed towards the broader view on the goal of bioethics education which considers bioethics education as a tool to counteract the dehumanizing and objectifying tendencies in contemporary medicine and technology. In this broad view, bioethics education is not defined as means only to facilitate decision making but also contribute to make the innovations in the related fields more humane. This is why, bioethics education is considered as a broad spectrum including humanities, liberal arts, social sciences and philosophy. On these grounds bioethics education is regarded as a long term ethical training with the ultimate goal of creating virtuous professionals.

This view of ethics education aims to change the manners and attitudes of professionals to a virtuous state. In this view the education of ethics is supposed to cultivate an introspective orientation to personal values and chance them towards the good and ethical ones. Nevertheless, this is a quite ambitious definition of goal for a course on medical ethics or any other kind of practical ethics. But for people who are determined to take “bioethics/medical ethics” as their primary focus; this broader view should be valid so that they are no more people who show what is to be done to act ethical, they themselves be ethical people not only in their professional life but in all aspects of life which they are ethical agents. This is the way to fulfill what Aristotle mentioned about drawing out the latent potential to become better persons. Regarding ethics education, we may consider this state as becoming a “role-model” for young professionals and trainees. In adult education it is critical for trainees to have a role model to guide them in their academic works.

Conclusion

Since the establishment of the first medical school in Turkey, ethics education is on the agenda of the academic curricula. The initial context, which focused on deontology, evolved by time and turned out to be a combination of History of Medicine and Medical Ethics lately. This combined form of ethics education is approved by most of the faculties which are related to medical sciences such as, clinical medicine, veterinary medicine, pharmacy and dentistry. Like medical schools, ethics education at pharmacy faculties started with deontology education and in the course of time began to take place basically within Pharmacy Management and History educational programmes. In this paper two curricula one from the medical faculty and the other from the faculty of pharmacy, on medical ethics is mentioned. The attendees of the two programs discussed about the challenges, expectations, points prone to improvement and the ultimate goal of the ethics education. The qualitative data out of these discussions revealed that the combined nature of the curricula is one of the main aspects of the ethics education which is subject to reconsideration. The other prominent topics are the scarce number of academicians who have ethics as their main subject of specialty, the need to improve the methodology towards interactive adult learning techniques and, the absence of sustainable and continuous feedback mechanism between the professors and trainees. The archaic debate on the ultimate goal of medical ethics education manifested itself during the discussions. The idea that ‘ethics education is supposed to form an introspective orientation to personal values and chance them towards the good rather than only referring to practical ethics and ethical principles’ is favored by the participants. However they were chary of the far too ambitious nature of this goal for a course on medical ethics. Nevertheless, the participants agreed that, for people who are determined to take “bioethics/medical ethics” as their primary focus; the ambitious goal which demands the evolution of the personal ethical values towards the good should be valid.