Knowledge and practices of bioethics – Need for periodic assessment and reinstatement for budding family physicians

Abstract

Objective:

The study has been designed to assess the knowledge of ethics amongst young students and professionals, and practices of health care ethics among medical professionals in a government teaching hospital in India.

Methodology:

A cross-sectional study was carried out at one of the teaching hospitals in Southern India with a sample size of 84 among fresh medical graduates, post-graduate trainees, and young consultants with work experience of 6 months to 8 years. The data were collected by means of a structured and validated questionnaire, and the questionnaire was administered before and after a lecture/seminar on ethical principles, and results were analyzed using SPSS software.

Results:

The maximum participants were in the age group of 20 to 24 years with 0–2 years of clinical experience. The basic awareness and practices before the workshop were quite less when compared to after the workshop which showed a very good improvement in the correct responses to the questions. The maximum change seen, reflected in curiosity to learn bioethics. The workshop was an eye-opener for many participants in terms of the Nuremberg Code and its origin. The ethics committee was an alien concept to many participants, and it was reflected in the response postworkshop. The students felt a strong need to discuss ethics and implement them postworkshop. The segment on attitudes in clinical practice showed an impact on autonomy and truth-telling (32% to 50%). The segment on ethical practices reflected a confused audience. The increase in sensitivity to police information, and the concept of error of judgment and negligence were positive. The fact that medical practitioners are legally bound to help accident victims showed a positive response.

Conclusion:

Based on the assessment of pre-and post-workshop, there is a strong need to stress the ethical principles and revision of these ideas from time to time. Workshops and interactive sessions are a good way for periodic assessment and reinstatement of these values in our research and clinical practice. Thus, these should be part of the curriculum across all educational institutions for budding primary care providers and family physicians.

Introduction

The participation of human subjects in medical research has raised ethical concerns from time to time. After the gross exploitation of human subjects by the Nazi regime under the guise of medical research, the international community was bound to think in the direction of ethical regulations, so a number of guidelines, declarations, and codes and reports were prepared.[1] However, in spite of all these guidelines, there are still a number of reported incidents of unethical behavior of medical students and health practitioners with patients as well as colleagues.[2,3,4] This may be partly due to a lack of practical ethical guidance during the learning phase. Recently, in India, as the medical profession has been brought under the “Consumer Protection Act,”[5] there have been increasing complaints of poor ethical conduct against health care practitioners. This may be due to increased public awareness and inappropriate practices by health care professionals.

After graduating from the medical course and entering into the practical field, the sudden exposure to various challenges makes it very difficult to take decisions encompassing the broader aspect of both scientific knowledge and human values. Medicine is holistic in nature, and patient–physician relationship is its backbone.[6,7]

Clinical knowledge alone is not sufficient to solve medical problems. Patients are more inclined to consult those physicians who have expert clinical knowledge, are well aware of patients’ needs and values, able to effectively engage in dialogue, communicate clinical knowledge with empathy and understanding, and embrace their broader concerns. With the information explosion and increasing public awareness, physicians must be competent and compassionate.

Future doctors and medical students must be provided excellent scientific knowledge within the context of the moral basis of their relationship with the patients, and they must understand how human values are embedded in clinical decision making. Though the current curriculum includes topics related to ethics, and there are studies stressing the importance of incorporating ethical and legal issues into medical curricula,[8,9] still the traditional medical training offers little help in resolving practical ethical problems encountered by health care professionals. There are opinions and debate on the subject of inclusion of formal education of practical ethics in medical curricula[10] as it has been found that ethics teaching has a profound influence on medical professionals’ attitudes and decision making.[11,12] Moreover, some institutions have developed guidelines for ethics in clinical teaching and surgical residency programs.[13,14] But the initial step in this direction is to determine the prevailing knowledge and attitude of health care professionals in the concerned region. In this regard, some studies have been done in the past in different regions.[15,16,17,18,19] The study has been designed to assess the knowledge of ethics and practices of health care ethics among young medical students and professionals, who are our budding family physicians. The knowledge and practical aspects of bioethics are very much essential for primary care providers and family physicians so as to carry out ethical practice and research activities.

Materials and Methods

A cross-sectional study was carried out as part of the course on bioethics conducted at one of the teaching hospitals in Southern India. We included a sample size of 84, the size being decided based on availability and voluntary participation (Convenient sampling). Fresh medical graduates, postgraduate trainees, and young consultants with work experience of 6 months to 8 years were included in the study after taking informed consent. The data were collected by means of a 27-item self-administered structured and validated questionnaire about knowledge, beliefs, and attitudes towards principles and practice of bioethics in clinical research. The questionnaire was administered before and after a lecture/seminar on ethical principles, and the results were analyzed using SPSS software. Institutional ethical clearance was taken, and confidentiality was maintained.

Results

This workshop was attended enthusiastically by post-graduate trainees and was well received by the audience. The maximum participants were in the age group of 20 to 24 years with 0–2 years of clinical experience [Table 1]. The response to the workshop showed a very good improvement in the correct responses to the questions. The maximum change seen, reflected in curiosity to learn bioethics. Response of participants towards knowledge and practices of health care ethics is shown in Tables 2 and 3.

Table 1.

Basic parameters of participants (n=84)

	No of participants	Percentage
Age
20-24 Year	58	69.04%
25-29 Year	22	26.19%
30-34 Year	04	4.76%
Years of clinical experience
0-2 Year	68	80.95%
3-5 Year	14	16.66%
6-8 Year	Nil	Nil
More than 8 Year	02	2.38

Table 2.

Response of Participants towards knowledge of healthcare ethics

Question	Response Pre-work shop (%age stating yes)	Response Post-work shop (%age stating yes)
Do you Know the main contents of Hippocratic oath?	83.3	93.3
Do you know the main contents of Nuremberg code?	8.33	73.33
Do you know the main contents of ICMR guidelines?	15.38	26.66
Are you aware of Bioethics as a specialty?	46.15	86.67
How important is knowledge of ethics to you in your work? (Extremely important)	100	100
Would you be interested in educating yourself in bioethics?	76.0	97.6
Would you like to become member of bioethics group?	68.0	88.9
How important are ethical issues in your Profession?	60.0	95.2
Is there an ethics committee in your institution?	48	97.6

Table 3.

Distribution of response to practices of healthcare ethics

Question	Response Pre-work shop (%)	Response Post-work shop (%)
During clinical rounds along with clinical aspects of a patient’s care. It is also essential to discuss ethical, social and legal issues of the patient-yes	92.0	90.4
The patient should always be told if something goes wrong - Yes	80.0	83.33
Close relatives must always be told about the patient’s condition -Yes	92.0	83.33
Children (except in emergency) I should never be treated without the consent of their parents or guardian- Yes	88.0	81.0
Doctors and nurses should refuse to treat patient who behave violently - No	48.0	69.04
A patient who wishes to die should be assisted in doing so, no matter what his/her illness -No	80.0	90.47
Patients who refuse to be treated on religious or other grounds, should be told that they need to find another doctor with their beliefs or accept the treatment offered ? -No	64.0	57.14
In an emergency unit are you obliged to give information to the local police inquiry? - Yes	60.0	57.14
Does the spouse need to give simultaneous consent for sterilization or termination of pregnancy?- No	44.0	42.85
Is it necessary by law to inform a spouse of the other’s venereal disease, hepatitis or HIV status? -No	88.0	95.2
Are “error of clinical judgement” and “negligence” synonymous ?- No	88.0	85.7
In a road traffic accident are medical practitioners legally bound to help the victim on the roadside ? - No	40.0	50.0

Discussion

Bioethics as we understand it today originated in the United States and Europe and the values, language, content, and thought processes behind ethical discourses are strongly influenced by the culture and technological advances of the western, developed world. While ethics is discussed in developing countries such as Nigeria, Thailand, Sri Lanka, India, and Bangladesh, these efforts are few and far between. Bioethics education needs to be developed in these countries. Bioethics groups play a role in this process, especially for faculty who are role models and mentors for the new generation of doctors. Ethics are therefore an integral part of clinical practice and teaching institutions need to stress on them from time to time. The workshop was an eye-opener for many participants in terms of the Nuremberg Code and its origin. The ethics committee was an alien concept to many participants, and it was reflected in the response postworkshop. The students felt a strong need to discuss ethics and implement them postworkshop. The segment on attitudes in clinical practice showed an impact on autonomy and truth-telling (32 to 50%). The segment on ethical practices reflects a confused audience. The increase in sensitivity to police information, and the concept of error of judgment and negligence were positive. The fact that medical practitioners are legally bound to help accident victims showed a positive response. It was this segment that the participants had a good prior knowledge of. The first segment of knowledge and attitude showed a positive impact from the workshop.

In a study carried out by Ashfaq T et al.,[20] students from the public sector had lesser awareness and perception as compared to students of private sectors, emphasizing the need for regular bioethics workshops, lectures, and inclusion of bioethics syllabus in their curriculum as done by private sector colleges. Similarly, studies conducted by Hsu LL et al.[21] and AlMahmoud T et al.[22] in India and Iran also suggested that formal bioethics education was the need of the hour and should be part of the medical educational system as inferred by our study too.

Our study had a majority of participants as young medical graduates with less than 2 years of experience. This would be the reason for low awareness as compared to post-workshop awareness. These young professionals usually work under senior consultants, and the majority of patients-related bioethical decisions are been taken by senior consultants and passed on to the juniors. Similar findings were also seen by Ashfaq T et al.[20] in their study, depicting duration of clinical practice and seniority as a strong predictor for adequate knowledge. However, there are also other studies like one carried out by Chatterjee et al.[23] in Bangalore, wherein more medical years’ experience had no influence on awareness and perceptions on study participants. However, studies carried out by Ngan et al.[24] and D’Souza et al.[25] made it clear that with constant and repeated exposure to bioethics principles in different forums like mass media, case-based discussions, and other innovative modalities favoring patient–doctor relationship would definitely have an impact on bioethics practice by medical students. One more study carried out in Nepal by Sharma S et al.[26] emphasized the need for awareness of bioethics among medical graduates and constant training in different ways should be carried out. Such awareness about bioethics is thus very much essential for budding primary care providers and family physicians so that they do not face any issues while carrying out ethical practice and research activities.

Conclusion

Based on the assessment of pre- and postworkshop, there is a strong need to stress ethical principles and revision of these ideas from time to time. Workshops and interactive sessions are a good way for periodic assessment and reinstatement of these values in our research and clinical practice. Thus, these should be part of the curriculum across all educational institutions to prepare our budding primary care providers and family physicians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.