MEDICAL ETHICS EDUCATION IN TURKEY; STATE OF PLAY AND CHALLENGES

Abstract

Medical ethics can be traced back to Hippocratic Oath in antiquity. Last decade witnessed improvements in science and technology which attracted attention to the ethical impacts of the innovations in medicine. The need to combine medical innovations with a preservation of human values and to cultivate ethical competencies required by professionalism conceived medical ethics education in various levels in medical schools. Despite the diversities regarding teaching hours, methodology and content of the courses, medical ethics became a fundamental part of medical education around the world. In Turkey medical ethics education is given both in undergraduate and postgraduate levels. The high increase in the number of medical schools and shortfall of instructors who have medical ethics as their primary academic focus creates a big challenge in medical ethics education in both levels. Currently there are 89 medical schools in Turkey and only six medical schools are giving postgraduate medical ethics education. In 2010 only 33 of all medical schools could establish a separate department dedicated to medical ethics. There are no medical ethics courses embedded in residency programs. The quality and standardization of undergraduate medical ethics education has started but there are no initiatives to do so in postgraduate level.

1. Introduction

In 1971 when Potter wrote his book “Bioethics, the bridge to the future”, he defined bioethics as “…a new discipline to contribute the future of human species…” by enabling “two cultures, science and humanities that seem unable to speak to each other..” to communicate and find common grounds to contribute the development of human kind. Since then, bioethics has evolved as an umbrella concept composed of the three pillars; medical ethics, environmental ethics and animal ethics. The vast improvement in medical sciences and technology made medical ethics a crucial concept which medical professionals and researchers must be aware of. Thus the need for medical ethics education is realized and this awareness led to the generation of medical ethics education programs to build the bridges Potter defined. (Potter 1971, Ekmekci, Arda 2014)

The first traces of medical ethics can be found in Hippocratic Oath (500 B.C.E.) in antiquity. In medieval times and early modern period Islamic medicine had the lead and the book “Conduct of a Physician” by Ishaq ibn Ali al-Ruhawi was a step forward for the development of the medical ethics concept. In 18th and 19th centuries the attention of the medicinal society was more drawn to this newly flourishing concept. Thomas Percival’s book named “Medical Ethics” is considered as a corner stone in this regard. (Güven 2000, Davis 2003) Depending mainly on the principles of this book American Medical Society approved the first code of ethics in 1847. However recognition of the fundamental importance of medical ethics depends on the tragic implementations during Second World War. The torturous researches of Nazi camps led to the first widely accepted medical ethics code called the Nuremberg Code in 1947. Tuskegee Syphilis Study, Willowbrook Hepatitis Experiments are examples of scientific misconduct which were recognized lately and ironically contributed to the formation of the contemporary discourse of medical ethics.

Apart from the researches carried out in medicine, rapid developments in technology changed the “possibilities of innovations” in medicine. Gene therapy, cloning, cell, tissue and organ transplantations have become a reality that each and every human being may be subject to. This new set of possibilities led to emerge of many ethical problems which did not exist in the conventional way of being a medical doctor and reckoned the scientific and ethical communities to reconsider the importance of medical ethics. (Ekmekci, Arda 2014)

Hence the role of a physician changed from a simple healer to an ethical agent who has to find out the “right thing to do” in a variety of situations with ethical dilemmas such as allocation of resources, deciding about the issues related to the beginning and end of life problems and research on human subjects.

2. Medical Ethics Education

The evolution of medical ethics concept created the need for medical ethics education. The increase of scientific misconduct cases and ethical problems concerning financial conflicts of interest were other motives to create a curriculum for bioethics education. The pragmatic goal of medical ethics is to teach ethics as a way of learning skills for diagnosing and solving ethical dilemmas in everyday practice. Beyond this pragmatic goal there exists a broader view for the goal of medical ethics education. This view refers to medical ethics education as a main branch of bioethics education to counteract the dehumanizing and objectifying tendencies in contemporary medicine and technology. In this broad view, medical ethics education is not defined as means only to facilitate decision making but also contribute to make the innovations in the related fields more humane. (Have, Gordjin 2012) (Ekmekci, Arda 2014)

Medical ethics education applies to undergraduate medical faculty students or postgraduate medical doctors who are already performing their professions. Undergraduate medical ethics education has flourished in the last decades in most developed countries. In 1972 only %4 of US medical schools had a separate, formal required course on medical ethics. By 1989 the proportion of medical schools with separate required medical ethics education had risen to %34 and medical ethics education became a part of all medical schools’ curricula in 1995. (Fox et al, 1995) However not all medical schools around the world followed this rapid improvement. There is a variety regarding the existence of required courses as well as teaching and assessment methodology of medical ethics courses in medical schools in different parts of the world. (Mijaljica 2014)

A survey reviewing the teaching of ethics in the European Union Schools of Medicine exposes the great variety by declaring that 11 out of 25 schools of medicine from 18 European Union Member States uses vertical teaching method, and only 2 out of 14 South East European countries had transversal teaching method in their curricula. (Claudot et al 2006) A survey by Mattick and Bligh showed that shortfall in compatencies in medical ethics did not preclude graduation from medical schools in UK. (Mattick 2006)

The situation in Asia is in concordance with the results of the surveys of Europe. The study conducted in 206 medical schools in Asia showed that medical ethics education has a widespread feature of medical curricula and the kinds of programs, especially with regard to integration into clinical teaching, were greatly diverse throughout the study area. (Miyasaka et al 1999) (Ekmekci, Arda 2014) Likewise Medical Council of India does not have medical ethics in any of courses and neither requires a separate course on medical ethics. (Ravindran 2008)

According to UNESCO Observatory Data, currently there are 235 teaching programs from 43 countries in Central and Eastern Europe, the Arab region, the Mediterranean region and Africa are identified and described in this data base. (UNESCO 2015)

Researches reveal the shortcomings existing in the literature of medical ethics regarding theoretical work done on overall goals of medical ethics education, empirical studies attempting to examine the outcomes of the education, studies examining teaching methods in medical ethics education and evaluating the effectiveness of teaching methods. (Eckles et al 2005).

2.1 Medical Ethics Education in Turkey

Medical school of Ankara University was the first medical school launched after the establishment of Turkish Republic in 1945. There has been a constant increase in the number of medical schools since then and the increase in number made a peak in the last three decades. Number of medical schools rose from 19 in 1980 to 74 in 2010. Together with that, the quota of medical school students per year peaked from 2409 in 1980 to 8090 in 2010. (Turkish medical Association Undergraduate Medical Education Report 2010) Today the number of medical schools reached to 89 and the total number of students in undergraduate training became 67197. (Turkish Student Assessment Evaluation and Placement Center 2015)

2.1.1 Undergraduate medical ethics education

The increase in number of medical faculties raised concerns about the quality and created a need for standardization of the medical education. Council of Higher Education started an initiative to determine the core competencies of the medical school graduates and published “National Core Education Program” in 2002 and updated in 2014. Medical schools are required to set their curricula in coherence with the core program. (Turkish Council for High Education 2014)

National Core Education Program refers to medical ethics and states that “one of the aims of undergraduate medical education is to embed humanitarian and professional values in the students and enable them to perform their profession in coherence with ethical values”. In the Program the core competencies of a medical school graduate related to medical ethics are listed as follows;

• “Advanced ability to consider the humanitarian, cultural and social ethical values and human rights during decision making process with respect to disparities.”

• “Developed professional identity with the awareness of ethical values emerging from history of medicine and philosophy of science, and acting in compliance with these values in every procedure and implementation of their profession, able to combat with unethical behaviors.”

• “Enhanced professional and legal responsibility and protect and defend patient and medical doctors’ rights…”

• “Internalized rights based approach to health and work together with partners to provide equal opportunity to health and to remove barriers to health services.” (Turkish Council for high Education 2014)

Depending on this theoretical basis National Core Education Program listed the minimum requirements of the curricula content of medical schools. The requirements about medical ethics education takes place under the section of “education for professional values and behaviors” and are as follows;

• Rights based approach to health

• History of medicine and philosophy

• Medical ethics, ethical values and obligations of a medical doctor, humanitarian, social and cultural values and responsibilities

• Patient rights, physician responsibility, physician patient relationship

• Ethical dilemmas in medicine

• Research ethics

• Inequalities in health and gender mainstreaming

Most medical schools updated their curricula in compliance with the National Core Education Program. In Turkish medical schools, medical ethics and history of medicine studies are merged in the same department called “History of Medicine and Ethics”. Hence the courses and curricula of medical ethics departments include both subjects. Most of the medical schools have required history of medicine course in the first term and required medical ethics course in the second term of first year curricula. History of medicine course gives the general information to form a baseline for the medical students regarding health related concepts in the historic discourse. Medical ethics courses constitute of the following topics;

• Concepts of ethics, bioethics, medical ethics

• Basic ethical theories

• Principals of medical ethics

• Paternalism, informed consent and respect for autonomy

• Ethical dilemmas and ethical decision making process

• Confidentiality and patient privacy

• Physician patient relationships

The general inclination of medical schools is to insert another required medical ethics course in the third or fifth year of medical education which is dedicated to clinical ethics and research ethics. The aim is to draw the attention to special topics of medical ethics which future physicians are most likely to face during their profession. These courses focus on the listed topic below;

• Euthanasia and other ethical issues about the end of life

• Personhood and ethical issues about the beginning of life

• Genetics and ethics

• Ethical dilemmas regarding tissue and organ transplantation

• Research ethics

• Patient rights, telling the truth

• Futile treatment

• Informed consent

• Ethical dilemmas regarding research or care choosing process.

The most common methodologies are lectures, group discussions and case studies. Evaluations are mainly done by written exams. (Turkish Medical Association Undergraduate Medical Education Report, 2010)

2.1.2 Postgraduate medical ethics education programs

In Turkey medical ethics has been excluded from postgraduate medical residency programs. Therefore the only means for postgraduate training in this area are masters and PhD programs. There are four masters programs in ethics. Three of these programs are run by medical schools and one is run by the Faculty of Science and Letters. (UNESCO 2015)

PhD Programs are run by five well established medical schools. Four of these programs are considering medical ethics and history of medicine in the same program while one is particularly focusing in medical ethics and bioethics. (UNESCO 2015) The main topics of the PhD programs are as follows;

• History of science

• Philosophy of Science, sociology and law

• Philosophical ethics, Axiology

• Medical deontology

• Clinical ethics

• Research ethics

• Legal and forensic medicine

Lectures and seminars are the basic education methods to give an overview of the legislation on medical ethics and the philosophical and theoretical background of the ethic norms. Role plays, personal reflection presentations, case-study analysis, peer presentations and peer-education methods are the means to be used for the training of PhD candidates. Every student is asked to present seminars on particular topics of medical ethics. Collaborative classes with pharmacy school and forensic medicine as well as law school is commonly arranged to ensure a holistic and integrated view for the students.

3. Discussion

The vast increase in the number of medical schools and the quantity of medical students is the main challenge for medical ethics education in Turkey since the increase in number of lecturers and professors of medical ethics did not soar in parallel. The percentage of increase in the number of all medical school teaching staff has been %8 from 2008 to 2010 while number of students in medical schools grew by %14 in the same period. Basic medical sciences, especially newly developing specialties such as medical ethics, find it very hard to cope with the increase in demand. As a consequence of that in 2010, of 74 medical schools only 33 had a separate department for medical ethics and half of these departments did not have any professors recruited. (Turkish Medical Association Undergraduate Medical Education Report, 2010)

The well established medical schools in main cities of Turkey have developed their capacities to some extent thus they are in better situation compared to new medical schools in remote cities. Most medical schools without separate departments of medical ethics recruit visiting professors or professors from other basic or clinical sciences departments are compensating for the deficit. (Turkish medical Association Undergraduate Medical Education Report, 2010)

This shortage in teaching staff creates concerns about the quality, competence and sufficiency of the medical ethics education both in undergraduate and postgraduate levels. The theoretical work to standardize and determine core competencies of medical education encounters high risk of failure because of deficiencies in the newly established schools. The interdisciplinary nature of medical ethics gives the chance to lecturers from other medical specialties to teach medical ethics all through the world. Ten Have and Gordjin remarks that not even half of the bioethics instructors in the U.S. have published an article in bioethics and that most of the teachers involved in bioethics education do not have ethics as their primary academic focus. (Have, Gordjin 2012) Although medical schools are using this advantage to solve the problem this is only a temporary solution which carries risk of its own. The crucial point is the educators’ competency level and the quality of the education. Besides the lack of deficiency of specialized medical ethics specialists not only creates failure in medical ethics education but also leads to weakness regarding clinical ethical committees, institutional review boards, ethical consultations and researches.

The exclusion of medical ethics from residency programs in 2005 has been a breakpoint for the medical ethics departments in Turkey. With the new regulation, postgraduate medical ethics education became limited to only PhD programs hence the number of the new lecturers and professors could not be increased in parallel with the demand. (Civaner 2014) Besides, Council for Higher Education has published a new legislation regarding PhD educations and banned medical schools’ departments with less than five professors from giving PhD education. The new legislation will be in force from 2016 and it will possibly have a devastating impact on medical ethics education and limit the postgraduate medical ethics education even to a worse state.

Other challenges regarding medical ethics education exists apart from the shortage in training staff. Standardization of medical ethics education and determining the core competencies is a common problem which has been recognized by most institutions globally. (Soleymani et al 2004 Although National Core Education Program has succeeded in standardization to some extend this is only for undergraduate education. Regarding the post graduate masters and PhD programs there has been a growing consensus among the academicians about the need for the determination of minimum competencies however no concrete action is taken up-to-date. (Turkish Bioethics Association 2013)

Recent literature shows the growing consensus about the insufficiency of current medical school ethics education to answer the needs of professionals and informs us about the benefits of embedding medical ethics education into residency programs curricula. (Manson 2008) Diagnosing and solving ethical dilemmas emerging from clinical practices or research with human subjects, gaining competencies stipulated by professional and accreditation agencies, developing medical professionalism are among the needs to the medical ethics education in residency programs. (Jocobson et al 1989, Alfandre Rhodes 2009, Carrese et al 2015, Braddock et al 2012) Despite the growing tendency to support residence education by established medical ethics courses we see no intention for that in Turkish medical schools. Most residency programs neither have medical ethics education in their formal programs nor have plans to do so in near future.

4. Conclusion

Since the importance of medical ethics is realized by the scientific and professional community, medical ethics education is embedded in the curricula of both undergraduate and postgraduate curricula of medical schools. Despite the current diversities and shortfalls in many medical schools around the world, significant improvements such as standardization of curricula and determining core competencies of medical education are taking place. Turkey faces great challenges in this regard. The huge increase in the number of medical schools and the inadequacy in number of instructors with medical ethics as their primary focus as academic work has been the Achilles hill for medical ethics education in Turkey. Furthermore the lack of medical ethics courses in residency programs and shortage of separate medical ethics departments create a risk for having medical professionals with ethical competency in the near future.

Table 1.

Number of medical schools and quota of medical schools

Years	Number of medical schools	Quota of medical schools
1980	19	2409
1990	25	4847
2000	47	4176
2010	74	8090

Table 2.

Masters Programs in Medical Ethics

Title of masters program	University	Area of ethics	Faculty
Bioethics and women	Ankara University	Bioethics
Ethics	Maltepe University	Philosophical ethics	Science and Letters
History of Medicine and Medical Ethics	Kocaeli University	Medical ethics	Medicine
Medical Ethics and Deontology	Marmara University	Medical ethics	Medicine

Table 3.

Medical Ethics PhD Programs

Title of Course	University	Faculty	Area of Ethics
Ethics of Science and History of Science	Ankara University	Health sciences Institute of Health Sciences Medicine	Science ethics
History of Medicine and Medical Ethics	Kocaeli University	Medicine	Medical ethics
History of Medicine, Medical Ethics and Deontology	Marmara University	Medicine	Medical ethics
Medical Ethics and History of Medicine	Ankara University	Medicine	Medical ethics
Medical Ethics and Bioethics	Istanbul University	Cerrahpasa Medical School Medicine	Bioethics
Medical Ethics and History of Medicine	Hacettepe University	Institute of Health Sciences Medicine	Medical ethics

Biography

Perihan Elif Ekmekci is medical doctor and PhD in History of Medicine and Ethics. She has masters in research ethics. Currently she is teaching history of medicine and ethics at Medical faculty of TOBB University. Her main areas of interest are right to health of vulnerable populations, research ethics, bioethics education and health legislation.