J Acad Ethics (2010) 8:85–93 DOI 10.1007/s10805-010-9110-3
Medical Ethics Education: A Survey of Opinion of Medical Students in a Nigerian University Temidayo O. Ogundiran & Clement A. Adebamowo
Published online: 31 July 2010 # Springer Science+Business Media B.V. 2010
Abstract In Nigeria, medical education remains focused on the traditional clinical and basic medical science components, leaving students to develop moral attitudes passively through observation and intuition. In order to ascertain the adequacy of this method of moral formations, we studied the opinions of medical students in a Nigerian university towards medical ethics training. Self administered semi-structured questionnaires were completed by final year medical students of the College of Medicine, University of Ibadan, Nigeria. There were 82 (64.1%) male and 44 (34.4%) female respondents. The median age was 26 years. Most students (80.5%) responded that they did not receive enough training in medical ethics. The ethics instructions they received did not sufficiently prepare them for the ethical challenges they came across as medical students. Though inadequate, the few hours of lecture and discussion on human values and professional etiquette which they received positively influenced their moral reasoning. They identified end-of-life issues, dealing with financial issues and handling socio-cultural beliefs of patients and relations as some challenges that medical doctors are ill-prepared for by their current training. Most, 85.9% believed that formal medical ethics education would be worthwhile as it would enhance the making of complete and better doctors. They recommended incorporating bioethics as a course in the medical school curriculum. Nigerian medical students encounter ethical challenges for which they have not been adequately trained to resolve. They recommended formal medical ethics training in their curriculum and a uniform bioethics programme in the country. T. O. Ogundiran (*) Division of Oncology, Department of Surgery, University College Hospital, University of Ibadan, PMB 5116 Ibadan, Nigeria e-mail:
[email protected] T. O. Ogundiran : C. A. Adebamowo West African Bioethics Programme, University of Ibadan, Ibadan, Nigeria C. A. Adebamowo Institute of Human Virology, Abuja, Nigeria C. A. Adebamowo Department of Epidemiology and Preventive Medicine, University of Maryland, College Park, MD, USA
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Keywords Medical ethics education . Students’ opinions . Nigeria
Introduction Medical ethics is as old as medical practice but remained the “hidden” curriculum of medical education until recently (Hafferty and Franks 1994). Though it appeared as a recognizable academic discipline in the 19th century as a professional ethic (Widdows et al. 2003), formal medical ethics curriculum and training in many medical schools were a recent development. For example, it became a compulsory part of medical curriculum in the United Kingdom in 1993 (Widdows et al. 2003). The wave of medical ethics renaissance in medical schools across the globe began with the heightened awareness about research ethics which resulted partly from the well documented scandalous events in the history of medical research. The foundation of medical ethics was laid at the Hippocratic School of 400-300 B.C. and, since then, it has gone through many phases. At the beginning it was concerned with the decorum, qualities and duties of a good physician. A more society oriented paradigm ensued by the middle ages when the medical profession paid close attention to the education and practice of members. Contributing to this social tilt were Thomas Percival’s book titled “Medical Ethics” in 1803 and the ethics codes of the American Medical Association which was established in 1847. The history of contemporary medical ethics and its all inclusive metamorphosis, called bioethics today, began following the second world war as a result of contemptible issues in medical research and advances in medical science and medical interventions (Jonsen 1998; Irving 2000). The ethics movement became further strengthened by the increasing recognition of ethical, legal, socio-economic and cultural issues that attend modern, largely technology driven medical care especially in the developed parts of the world. With these events came the birth of bioethics and the development of a new set of professionals that are drawn from both within and without the medical disciplines (Andre 2002). These professionals now provide training, service and research in contemporary bioethics and are also well suited to complement the medical faculty to provide necessary formal training in traditional medical ethics to medical students and resident doctors. The core issues in medical ethics are the ethics of the doctor-patient relationship, the duty to maintain patient confidentiality and the need to obtain informed consent, whereas bioethics deals with all encompassing moral issues in medicine and biomedical sciences (Widdows et al . 2003; Andre 2002). Where already established, undergraduate bioethics training programs are aimed at developing skills in ethical reasoning and improving medical decision making. Besides, formal teaching of ethics lays the background for inter-disciplinary collaboration that is often needed for result-oriented biomedical research (Ogundiran and Omotade 2009). In Nigeria, medical education remains focused on the traditional basic and clinical medical science components, leaving students to develop moral attitudes passively through observation and intuition. In order to ascertain the adequacy of the current method of moral formations, we studied the opinions of medical students in a Nigerian university towards medical ethics training.
Materials and Methods The study took place among medical students of College of Medicine, University of Ibadan, Nigeria. The University of Ibadan was established in 1948 with the College of Medicine as
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one of its foundation faculties. Following preliminary studies in applied basic sciences, the undergraduate medical training stretches over a 5-year programme. The students spend the first one year and half learning anatomy, physiology and biochemistry and the last three and half years in pathology, pharmacology and the clinical disciplines. Usually, the students in a class or year of entry are divided into four to six groups and each group rotates through the postings at different times in batches throughout the entire training period. In the entire duration of training, medical ethics is an informal non-structured component of the curriculum. An observational cross-sectional survey of opinions of final year medical students of the College of Medicine, University of Ibadan was conducted between January and April 2006 using self-administered questionnaires containing semi-structured and open ended questions. All the final year students received a copy of the questionnaire. The questions were meant to assess the content of medical ethics in their training and elicit their opinion about the value of formal introduction of medical ethics into the medical curriculum. Prior to commencement, approval for the study was granted by the university’s ethics review committee. We developed a 51 item questionnaire which was organized under four broad subheadings. The first part dealt with essential demographic information. The second section explored issues about relevance of medical ethics to the Nigerian health system, adequacy of current medical curriculum in meeting the ethical challenges of medical practice in Nigeria and whether or not formal medical ethics education would be worthwhile in the Nigerian medical curriculum. The third set of questions focused on the content, the adequacy and the effects of medical ethics in the University of Ibadan medical curriculum. The final set of questions sought the respondents’ opinion about what should constitute a medical ethics curriculum, how it should be run and what body should oversee medical ethics education in Nigeria. The questionnaires were given to all the students as they rotated in batches through their last surgical posting preparatory to their final examinations. The students waited behind after a surgical grand round to complete the questionnaires. All of them were encouraged to answer all the questions and to return the completed questionnaires to the pool. Data analysis was done with SPSS software version 15 using simple descriptive analysis.
Results There were 271students in the final class of 2006 (Table 1). Of these, 128 students returned the completed questionnaires making a response rate of 46.5%. The majority (125) were in their sixth year of training while three of them had repeated a year once and were in their seventh year. Most respondents, 64.1% (82/128), were males and 34.4% (44/126) were females. Two respondents did not state their sex. Their ages ranged between 22 and 35 years with a mean of 25.9 years. Their responses to the issues raised in the questionnaire have been grouped under four subheadings and are presented below. Medical Ethics in the Nigerian Health System Majority of the students were of the opinion that medical ethics teaching in Nigerian medical schools was inadequate. 80.5% of them responded “no” to the question about whether medical students in Nigeria receive adequate instructions in medical ethics. The inadequacy, according to them, stemmed from the wrong perception that medical students
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Table 1 Characteristics of respondents Characteristic
n
Total number of final year students
271
Number of respondents
128
Gender
Age (yr)
(%)
(47.2)
Male
82
(64.1)
Female Gender not stated
44 2
(34.4) (1.5)
Range
22–35
Mean
25.9
Median
26
should develop their own ethics during training, that ethics was intangible and that there were no serious ethical issues in medical practice in Nigeria (Table 2). Judging by their own training, some of them (39.8%) were of the notion that Nigerian doctors face distinct ethical challenges for which their training does not prepare them. They identified end-of-life issues, dealing with financial and litigation issues and handling religious, cultural and traditional beliefs of patients and relations, among others, as challenges that they envisaged practicing medical doctors were ill-prepared for by their current training (Box 1). The solutions they proffered to address those challenges included incorporating formal ethics teaching into the curriculum (52.9%), stressing ethical issues during clinical postings (23.5%) and complimenting ethics teaching with practical examples (14.7%). Box 1: Ethical issues identified by medical students as challenges that Nigerian medical doctors face and for which their training does not prepare them Dealing with end-of-life issues Payment and financial issues Patients care decisions Legal issues and litigation Religion, culture and tradition Communicating bad news
Medical Ethics in Present Curriculum Though the Ibadan medical school does not run a course designated as medical ethics, 80.9% of the students remembered receiving some instructions in medical ethics. 58.6% of the respondents identified some postings during which they received instructions on human values, moral reasoning, professional etiquettes or ethical codes in the medical curriculum. The teaching occurred during introduction to the clinical sciences and subsequently during postings in community medicine, psychiatry, medicine and surgery. The mode of teaching was mainly a few hours of didactic lectures (average of 2 h) and discussion of clinical cases. The teaching was not structured, not mandatory, was taught mainly during clinical years and focused mainly on physician-patient relationship. Asked about its effect on them, 82% of the responders claimed that the teaching had at least some influence on their moral development while 18% claimed that the teaching had no influence on them. On the effects of this teaching on their clinical activities as students, 65.3% thought it had effects, while
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Table 2 Medical students’ reasons why medical ethics education is inadequate in their curriculum (in decreasing order of importance) 1. Perception that students should develop their own ethic during their training 2. Perception that ethics is intangible, cannot be taught, it rubs on students naturally during training 3. Perception that there are no serious ethical issues in medical practice in Nigeria 4. Faculty staff are not disposed or committed to teaching ethics 5. Medical ethics is undervalued in the medical curriculum 6. Staff falls short morally
16.3% thought otherwise and 18.4% did not know if it had any effect. A minor (12.2%) of the overall respondents thought that there was discordance between what the staff taught and what they practiced. 9% of the students responded that their medical ethics teaching provided some information on conduct of research and research ethics. Asked “how often have you come across ethical and social issues in clinical medicine for which you think your clinical training has not prepared you fully?” the response was “sometimes” and “commonly” in 73.8% and 12.3% respectively. Incorporating Formal Medical Ethics or Bioethics Program in the Medical Curriculum in Nigeria At the time of this survey, majority (87.5%) of the students had heard about bioethics though a few (10.9%) claimed ignorance about it. Moreover, most of them (85.9%) believed that formal medical ethics or bioethics education would be worthwhile for medical students in Nigeria. According to them, such education would enhance the making of complete and better doctors who would be equipped to face and handle ethico-legal challenges, appreciate human values, prevent exploitation of patients and be prepared for global challenges. 60.2% would welcome medical ethics or bioethics as a new course in their own medical school curriculum. The leading issues that they would like to see feature in the new ethics curriculum were morality, physician professionalism, medical abuse and legal issues, end-of-life issues and research ethics (Table 3). The teaching methods proposed include didactic lectures, seminars and grand rounds and as part of general studies. Some of the problems they envisaged that the introduction of such new course would face included resistance, time constraints, implementation and resources. Uniform Bioethics Program in the Medical Curriculum in Nigeria The students recommended that there should be a uniform bioethics curriculum for medical schools in the country. Listed as the foreseeable benefits of such formal approach are uniform and standard medical practice, well trained professionals and improved quality Table 3 Top five issues that medical students would like to see included in their medical ethics curriculum 1. Morality, doctor-patient relationship and respect for persons 2. Physician professionalism 3. Medical abuse and legal issues 4. End of life issues, euthanasia and sanctity of life 5. Ethics of medical research
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health care delivery among others (Table 4). While 38.5% of them were of the opinion that medical ethics or bioethics is best introduced in the pre-clinical school, almost half respondents (45.3%) would rather it is taught during clinical postings. Most of them (84.7%) however, suggested that it should be taught as an integral part of clinical sciences and not as a separate stand-alone course. More than half of respondents (51.6%) suggested that the Nigerian Medical and Dental Council, which is the umbrella body that regulates medical and dental education and practice in the country, should be saddled with the responsibility of regulating ethics education in Nigerian medical schools. Other bodies suggested included the Nigerian Medical Association, a trade union organization of practicing medical and dental doctors, and the government’s Ministry of Health. A few of them (7%) recommended an independent national bioethics body to oversee ethics education in the country while some others suggested a combination of some of these agencies (Box 2). Box 2: Organizations suggested by medical students to oversee bioethics education in medical schools in Nigeria Nigerian Medical and Dental Council Nigerian Medical Association Individual Medical Schools Ministry of Health An Independent National Bioethics Body
Discussion This study among final year medical students of the University of Ibadan, Nigeria explored the medical ethics programme in their school curriculum. It showed their perceptions about the ethics content in their curriculum, the gaps that are left unfilled by the current system of ethics acculturation and their desirability of and expectations from a formal bioethics programme. A vast majority of them opined that medical ethics in the Nigeria health system and in the medical schools was undervalued, and as such, medical students do not receive adequate tutelage to cope with the ethical challenges that they encounter during training and post qualification. For example, the present curriculum is deficient in preparing them to deal with issues at the end of life, money matter, and culture and tradition which are germane to health care process especially in a developing country like Nigeria. These and Table 4 Medical students’ list of benefits of formal bioethics programme in medical schools in Nigeria 1. Uniform and standard medical practice 2. Better medical professionals 3. Improved quality of health care 4. Better patient-doctor relationship 5. Safeguard of patients’ interests 6. Knowledge and enlightenment 7. Tools for dealing with challenges 8. Preparation for medical research
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many issues like them are non-technical, non-scientific and yet important determinants of healthcare practices and outcomes in any society. To them, the non-prominence of medical ethics in their current programme was not only a reflection of its apparent non-importance, but also a manifestation of the insensitivity of the system to recognize that doctors encounter challenging ethical issues in routine medical activities. That the present medical curriculum in Ibadan is not completely bereft of teachings in medical ethics is borne out by the identification of some clinical rotations that provide avenue for discussing ethics related issues albeit not to a great detail. It is not surprising that the students received some ethical orientation in community medicine and core clinical specialties like internal medicine, surgery and psychiatry. Traditionally, these are key areas where issues such as physician-patient relationship, informed consent, patients’ confidentiality and individual person’s rights versus community interests have always been frontline concerns. Some attention seemed to have been given to these in the “hidden curriculum”. The issue that remains is the veracity by which such issues have been handled and the impact such discussions have had on students’ moral perception and upbringing. In a previous study among the staff of an urban hospital, Gross (1999) surmised that ethics education had little or no effects on moral development and ethical confidence of trainees. Earlier reports, though, had suggested that ethics education had positive impacts on students’ moral development and practice (Pellegrino et al. 1990; Price et al. 1998). The self reported positive effects of ethics teaching on the moral reasoning and clinical activities of the students in this study attest to the usefulness of whatever ethics training they have received from the present structure however rudimentary that might seem in light of today’s burst of knowledge in bioethics. Perhaps, it also demonstrates the need for re-structuring the curriculum to facilitate the introduction of a more comprehensive ethics training module in the training of future doctors. However, the extent of the positive effects attested to and whether or not they were cognitive, attitudinal or behavioural or a combination remains to be explored in future studies. In line with feedbacks from similar studies in the past (Olukoya 1983; Shelp et al. 1981; Delaney and Kean 1988), most students agreed with the idea to make ethics more visible in the medical curriculum. The integration of ethics as a mainstream course would enhance the development of skills that are necessary to appreciate and negotiate ethical challenges or at least refer them to those who have the training and expertise to analyse and resolve them appropriately. It is unknown from this present study whether medical ethics should be a compulsory, required or elective course. In the survey by Shelp et al (1981), while most students indicated desire for more ethics content in their training, 82% of them supported it as an elective course and another 59% of them wanted it at all levels of the curriculum. The curriculum at the University of Ibadan makes all medical courses compulsory and one could reasonably assume that the students remembered this point in indicating their desire for a formal medical ethics course. However, supplementary online and additional elective courses should be encouraged to enhance learning and promote further self development (Iramaneerat 2006). The preference by majority of the students for introducing the course during clinical postings and for making it an integral component of the clinical sciences perhaps illustrates the narrow view of these students about medical ethics being important only to the doctorpatient relationship at the clinical level. The lack of mention by these students of anything on genetics, organ donation and transplantation, and reproductive technology might be a reflection of the lack of awareness of the ethical issues that these phenomena engender in modern medicine. On the other hand, it could be that either little work is being done in these areas in their institution or that the students were not being directly involved in these activities in their training. Whichever way, there is need for concerted efforts to draw due
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attention of the students to these emerging issues before they become enmeshed in them. Worthwhile ethics training in the medical school should begin with the fundamentals of ethical decision making and analysis and continue with the application of these theories to ethical issues in clinical medicine. Such training, spread over the entire medical curriculum, provides ample opportunities for trainees to bridge theory with practice and assists them to discover their professional role, responsibility, and identity (Shelp et al. 1981). A formal bioethics module in the medical school, even at the very basic levels, offers a more comprehensive programme that includes medical ethics, research ethics, clinical ethics and organizational ethics among others.
Conclusion In this survey of opinions of medical students in a Nigerian medical school, it has been shown that students do not generally receive sufficient ethics training in medical schools. Medical ethics is integrated into clinical and community medicine discussions and focuses mainly on doctor-patient relationship. The training is deficient in preparing them to address ethical challenges of daily medical practice. They expressed desire for formal medical ethics training in their curriculum and recommended a uniform bioethics programme integrated into the clinical sciences in the country. This study has many limitations. One, the information in this report is from students in only one of several medical schools in Nigeria and might not possibly represent the opinions of all medical students in the country. Besides, the medical ethics content of the curriculum may differ from school to school though medical training in Nigeria is fairly uniform across schools. Second, the sample size is small as the response rate was below half of all the final year medical students. This rate, however, was similar to the trend in most literature. Third, the opinions represented in this study were from medical students only, with no feedbacks from their teachers. The perceptions of the medical faculty about the issues raised in the study would have provided balanced information from which to make more apt conclusions. Fourth, the design of the study leaves many issues unexplored fully. Perhaps it is pertinent to mention that this was the first in a series of nation-wide multi-step study that includes qualitative methods and focus on both students and staff of medical schools in Nigeria. Acknowledgements The authors thank the house officers and resident doctors in the Department of Surgery, University College Hospital, Ibadan who assisted in distributing and collecting the questionnaires. The study was partly supported by funds from Fogarty re-entry grant from the Joint Centre for Bioethics, University of Toronto, Ontario, Canada.
References Andre, J. (2002). Bioethics as practice. The University of North Carolina Press. Delaney, B., & Kean, L. (1988). Attitudes of medical students to the teaching of medical ethics. Medical Education, 22(1), 8–10. Gross, M. L. (1999). Ethics education and physician morality. Social Science & Medicine, 49(3), 329–342. Hafferty, F. W., & Franks, R. (1994). The hidden curriculum, ethics teaching and the structure of medical education. Academic Medicine, 69, 861–871. Iramaneerat, C. (2006). Moral education in medical schools. Journal of the Medical Association of Thailand, 89(11), 1987–1993. Irving, D. N. (2000). What is bioethics? At: http://www.lifeissues.net/writers/irv/irv_36whatisbioethics01.html.
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Jonsen, A. R. (1998). The birth of bioethics. New York: Oxford University Press. Ogundiran, T. O., & Omotade, O. O. (2009). Bioethics in the medical curriculum in Africa. African Journal of Medicine and Medical Sciences, 38(1), 87–92. Olukoya, A. A. (1983). Attitudes of medical students to medical ethics in their curriculum. Medical Education, 17(2), 83–86. Pellegrino, E. D., Siegler, M., & Singer, P. A. (1990). Teaching clinical ethics. Journal of Clinical Ethics, 1(3), 175–180. Price, J., Price, D., Williams, G., & Hoffenberg, R. (1998). Changes in medical student attitudes as they progress through a medical course. Journal of Medical Ethics, 24(2), 110–117. Shelp, E. E., Russell, M. L., & Grose, N. P. (1981). Students’ attitudes to ethics in the medical school curriculum. Journal of Medical Ethics, I98I(7), 70–73. Widdows, H., Dickenson, D., & Hellsten, S. (2003). Global bioethics. New Review of Bioethics, 1(1), 101– 116.