Teaching of Medical Ethics: Students’ perception in different periods of the course �

ARTÍCULO DE INVESTIGACIÓN
Rev Med Chile 2011; 139: 36-44

Teaching of Medical Ethics: Students' perception in different periods of the course
􀀀




 ABSTRACT
Background: Medical Ethics is structured to guide doctors towards a better
professional practice. However, its teaching in medical schools seems to be neglected.
Aim: To evaluate the perception of Federal University of Sergipe medical students
about ethical confl icts during their academic practice, in two different periods of a
medical course. Material and Methods: A cross-sectional, analytic and observational
study. Using a qualitative approach, analytic categories were identifi ed using an
open questionnaire answered by two groups of students, before and after attending
the medical ethics course. Results: In everyday practice, the participants referred
embarrassment in front of patients. When considering the relationship with the
professional/professor, they identifi ed negligence and confl icts of interests in their
practice. The students also detected bad infrastructure and professional relationship
in public services, when compared to private ones. The confl icts experienced by
the students in their own practice were insecurity, inability to cope with patients'
problems and inadequate perception of medical confi dentiality limits. According to
the respondents, contribution of ethics teaching varied from adequate, when it was
effective to orient their practice and provide confi dence, to inadequate or absent because
of an overall superfi cial approach. Conclusions: Major defi ciencies related to
the teaching of medical ethics were identifi ed, pointing to the need to change current
medical education model.
(Rev Med Chile 2010; 139: 36-44).
Key words: Education, medical, undergraduate; Ethics, medical; Students,
medical.
Percepciones de los estudiantes acerca
de la enseñanza de ética médica
Antecedentes: La ética médica debería guiar a los médicos hacia una mejor práctica
profesional. Sin embargo, se enseña defi cientemente en las escuelas de medicina.
Objetivo: Identifi car las percepciones de un grupo de estudiantes de medicina acerca
de los confl ictos éticos durante su práctica profesional en dos períodos distintos de
un curso de medicina. Material y Métodos: Se efectuó un estudio transversal con
un grupo de estudiantes de medicina que habían recibido el curso de bioética y otro
grupo que no había recibido el curso. Ambos grupos respondieron un cuestionario
abierto acerca de los confl ictos que vivieron al enfrentar pacientes. Resultados: En
la práctica diaria, los alumnos relataron sentir vergüenza al enfrentar pacientes.
1Departamento de Medicina
da Universidade Federal de
Sergipe.
2Núcleo de Pós Graduação
em Medicina da Universidade
Federal de Sergipe
aNurse, PhD.
Recibido el 23 de noviembre
de 2009, aceptado el 29 de
noviembre de 2010.
Correspondência:
Dra. Déborah Pimentel.
Praça Tobias Barreto 510-1208,
bairro São José,
Aracaju-Sergipe-Brazil.
CEP 49015-130.
Phone: 55 79 3214 1948. Fax:
55 79 32318372
E-mail: deborah@infonet.
com.br
37
ARTÍCULO DE INVESTIGACIÓN
The problem
Human behavior is a complex entity, and
regulations and laws have always been
conceived to guide men's behavior in
accordance to what is expected for one specifi c
society. Since Hippocrates, medicine practice has
expressed formal concern about moral procedures
and respect for life. These were the beginnings of
Medical Ethics.
The medical professional is subjected to preestablished
ethical standards that guide his/her
conduct in the different activities he/she may be
exposed, and ethical discussions have been included
as a specifi c discipline in the medical course
curriculum in some, but not all universities1,2.
Ethics and moral are complementary terms.
Ethics, from the Greek ethos, means "way of being",
"character" and moral, from the Latin mor
or moris, means "usual", i.e., a set of standards or
rules acquired by man by ordinary use3,4.
Professional Ethics or Deontology includes
the guiding principles for professionals when
interacting with patients, other professionals and
the institutions where they work. These principles
are limited to professional environment and have
specifi c standards, such as the Brazilian Medical
Ethics Code, established from discussions between
doctors and society and approved by the Federal
Council of Medicine2,5,6.
For some authors1, the concept of Medical
Ethics should prioritize medical practice. They
understand that the Medical Ethics Code is no
longer enough to guide the physician behavior. In
an increasingly complex society, medical decisions
go beyond purely cognitive aspects, so overrated
in academia. It seems crucial to focus on medical
education for ethics topics inclusion, inserting
most of the problems students will potentially face
during professional life7. Technical skills must be
accompanied by ethical values early in medical
education.
It is known that in many universities in Brazil,
in their traditional medical course curriculum,
Bioethics is not yet included as a discipline to guide
the acquisition of abilities that allow the student
to identify and analyze ethical problems yet. Only
some of these themes are included in the subject of
Forensic Medicine and Deontology, which prioritizes
the Medical Ethics Code and the legal aspects
of medical practice. Perhaps these contents are not
suffi cient to fulfi ll the needs of students relating
to the ethical confl icts in their academic practice.
Therefore, a research was made to identify how
medical students deal with ethical confl icts before
and after the formal teaching about Medical Ethics
at the discipline of Forensic Medicine and Deontology;
to identify situations of ethical confl icts
during the academic practice and to verify the
contribution of Ethics formal courses to dealing
with these confl icts.
As well, this paper, as a clipping of this research,
aims only to identify the perception of Federal
University of Sergipe medical students about
ethical confl icts during their academic practice,
in two different periods of the course.
The method
This is a cross-sectional study in regard to the
Medical Ethics teaching at the Medical School of
Federal University of Sergipe (UFS), in Aracaju,
Brazil. An open questionnaire was used, with 19
questions regarding subjects of students' studies,
motivations, methodology, disciplines that contributed
to the practice experience, and ethical
dilemmas they could have experienced during
the course.
Acerca de su relación con los profesores, notaron negligencia y confl ictos de intereses
en su práctica. Los alumnos también detectaron una mala infraestructura y relación
entre profesionales en servicios públicos, al ser comparados con clínicas privadas. Los
confl ictos que relataron los alumnos fueron inseguridad, incapacidad de enfrentar
con los problemas de los pacientes y una percepción inadecuada de la confi dencialidad
médica. Los alumnos consideraron que la contribución de enseñar ética fl uctuó
desde ser adecuada cuando orientó su práctica profesional y les dio confi anza hasta
inadecuada o ausente, debido a ser enseñada en forma superfi cial. Conclusiones: Se
identifi caron las principales defi ciencias en la enseñanza de ética médica, señalando
la necesidad de cambiar el modelo educacional utilizado actualmente.
Teaching of medical ethics - D. Pimentel et al
Rev Med Chile 2011; 139: 36-44
38
ARTÍCULO DE INVESTIGACIÓN
The study was performed with two groups of
students, corresponding to two different context
units: the fi rst one, attending the 5th and 6th semesters,
with students who had not studied the Forensic
Medicine and Deontology, and the second
one, attending the 9th and 10th semesters with
students who had just fi nished that course. The
same questionnaire was applied to both groups.
The discipline Forensic Medicine and Deontology
was used as a landmark for the division of
the groups, since it is the only one that formally
approaches ethical contents.
The students participated in the classroom,
where they received the questionnair, and those
who agreed to participate in the research returned
it to a predetermined local.
The present article used data from a single
question that asked the students to write a brief
story about the most important ethical confl icts
perceived in their academic practice.
This study was approved by the Research Ethics
Committee of the Federal University of Sergipe
and all respondents were informed about the
purposes of the research and about their rights,
in accordance to the regulations for research in
human beings8.
The total number of questionnaires returned
was 110 (71.4%): 56 from the fi rst group and 54
from the second.
The fi rst group of students was formed by 24
women and 32 men, with an age range of 19 to
27 years and mean age of 22.3 years. The second
group was formed by 22 women, 31 men and one
respondent who did not declare the gender, with
an age range of 20 to 41 years and mean age of
24.47 years.
Data was analyzed using a technique of categorical
approach of content analysis9. Individual
analysis was blinded by using a strategy in which
each questionnaire was coded as A or B for the fi rst
and second groups respectively and a sequential
number for the students in each group. Content
analysis was performed9, and each sense nucleus
was identifi ed at the registry units (words, clips of
speeches), leading to the analytical pre-categories.
The resulting categories were grouped by similarity
and registered with their sense nucleus,
regarding to those categories presence in different
contexts and not to their frequency of occurrence.
Results
In view of the ethical confl icts identifi ed by the
student of both groups, the results were organized
into four analysis sub-categories:
1. Confl icts involving the patient (Table 1);
2. Confl icts involving the professional / professor
(Table 2);
3. Confl icts involving the structure of services
(Table 3);
4. Confl icts involving their condition as students
(Table 4).
Table 1. Ethical conflicts involving the patient identified by students, during the medical course
Sub-category Sense nucleus
The first context unit
(5th/6th periods)
The second context unit
(9th/10th periods)
Embarrassment in front of
the patient
Physical examination/anamnesis
Feeling of patient privacy invasion
Request the patient to undress himself
Exhibition of the patient in front of others
Feeling of patient privacy invasion
Exhibition of the patient in front of others
The using of the patient as an
object of study
The feeling of patient usage,
Feeling of bothering the patient
Many students examined few patients
The feeling of patient usage
Care dehumanization
Violence against the student The threat from dissatisfied patients
Patient who attack doctors or students
Patient shocked by the treatment
Aggressive patient
Patient who attack doctors or students
Teaching of medical ethics - D. Pimentel et al
Rev Med Chile 2011; 139: 36-44
39
ARTÍCULO DE INVESTIGACIÓN
Table 2. Ethical conflicts involving the professional/professor identified by students,
during the medical course
Sub-category Sense nucleus
The first context unit
(5th/6th periods)
The second context unit
(9th/10th periods)
Neglect/
Disrespect from
professionals
Lack of communication from doctors
and professionals to the patient
Neglect from professionals for the
patients
Neglect of patients signs and symptoms
Disrespect to the patient
Disrespect for patients individuality
Indifference to patients suffering
Disrespect to patient autonomy
Failure in front of fellow doctors
Conflicts of
interest
Professional deviating patients from public service to
private clinic
Doctors who receive privileges from laboratories
Professional competition
Use of the profession as a mean of achieving political
interests
Inadequate
professor
attitudes
Bad treatment of the patient
Bad treatment of the student
Arrogance
Lack of humanization
Embarrassment to patients by professors
Lack of commitment to the teachinglearning
process
Lack of commitment to the patient
Lack of interest for the profession
Inadequate clinical discussion with medical students in
front of patients
Bad mood of teachers
Arrogance
Bad treatment of the patient
Discouragement with the choice of specialty
Critical of colleagues in front of patient
Table 3. Ethical Conflicts identified by students, during the Medical course,
involving the structure of services
Sub-category Sense nucleus
The first context unit
(5th/6th periods)
The second context unit
(9th/10th periods)
Disruption of
health services
Lack of organization of care.
Lack of material.
Defective equipment.
Lack of supplies necessary for treatment of needy patients
Services that do not meet the demand
Services where the patients' care is done by students
without monitoring
Lack of compliment of working hours
Lack of material
Defective equipment
Bureaucracy
Attendance
at public and
private services
Difficult relationship with public service
and private health enterprise
Poor attendance at the public service when compared to
the private services
Teaching of medical ethics - D. Pimentel et al
Rev Med Chile 2011; 139: 36-44
40
ARTÍCULO DE INVESTIGACIÓN
Discussion
Frequently the relationship student-patient
has been considered merely technical, depersonalized
and sometimes troubled, bringing negative
stress to the student. It was observed (Table 1) a
similarity between the two groups regarding these
confl icts, either with the student´s acts invading
the patient´s privacy or when they are victims of
patient´s violence or harassment.
The results of the present research are, most of
the time, coincident with the ones of other authors
cited in literature.
In these two context units, the contact with
patients resulted in confl icts at some point during
medical training. Students demonstrated a variety
of fears while relating to the patient, probably due
to lack of experience and insecurity in medical
practice10-12.
For students in the 5th and 6th semesters, it
seems to be more signifi cant, for collecting the fi rst
medical history and performing the fi rst physical
examination usually awake emotional reactions in
students and make them anxious12,13:
Feeling of bothering the patient, insecurity and
diffi culty to examine the patient when it is necessary
to undress him (A11, 5).
The feeling of using the patient as an object for
study is also named as a nuisance to the students,
creating feelings of being invasive or abusive to
their fellow-being11-14:
Patients were also a source of confl ict for
having hostile attitudes when facing different
situations. It seems to refl ect changes in society,
where patients are not as "patient" as before15.
Real life shows that the patient out of the books is
a human being who suffers, complains, does not
always cooperate and requires a quick and effective
solution for his/her problems16:
I was threatened by a patient for delaying to
attend him. I was almost beaten (A8, 6).
The results show that the interaction with
various professionals allows having experiences
in many types of confl icts, particularly as mutual
respect, which is missing in medical education.
In the two contexts units we found an inadequate
attitude of professional/ professor, regarding to the
relationship with patients. In second unit, however,
students made it clearer, perhaps because they have
already been exposed to specifi c discussions about
that topic (Table 2).
Overcoming these diffi culties relies on the
professor's aid, because it is during academic background
that the students must obtain the resources
Table 4. Ethical Conflicts identified by students, during the Medical course,
involving their condition as students
Sub-category Sense nucleus
The first context unit
(5th/6th periods)
The second context unit
(9th/10th periods)
Insecurity Students inexperience
Students shyness
Do not know what to do due to
ignorance
Students inability to help the patient
Students shyness
Fear of dealing with the unknown
Fear of making mistakes.
Inability to help the patient.
Do not know what to do in the practice
In regard to the issuing of medical certificates.
Medical secrecy Students, difficulty in dealing with
patients' secrets
Students difficulty in dealing with patients' secrets
Lack of skills in
relationship/
communication
Lack of guidance from professors to
students
Difficulty of patient communication
Differing of opinions among professionals.
Controversial therapy
Difficulty in communicating bad news.
Difficulty in approaching the patient.
Do not understand the patient's language.
Difficulties in relationships with patient's relatives.
Difficulty with colleagues and professor relationships.
Teaching of medical ethics - D. Pimentel et al
Rev Med Chile 2011; 139: 36-44
41
ARTÍCULO DE INVESTIGACIÓN
they need to deal with human dimension of therapeutic
relationship. A professor's example seems
to be essential in building up professional identity,
which enhances the patient-doctor relationship (10).
However, important confl icts involving professors
were observed. There are unethical and
inhuman attitudes by health professionals in
general and by professors, and these models are
incorporated into the student's practices as a standard
for their professional behavior7,15.
Some professors do not consider patient autonomy17,18
and do not act within recommended
ethical and humanistic approaches:
In the investigation of certain conditions, it is
not questioned whether the patient wants to be
submitted to that procedure (A11, 9).
... professors seem to forget that they are facing
the patients and talk about the disease (...) without
caring about the human being in front of them
(A22, 10).
In regard to that situation, some authors18-20
report patient perceptions about the treatment
received at the University Hospitals and reveal
that the visits at the bedside are the only negative
aspect, once they feel themselves like subjects
under study. There must be ways to teach new
doctors without embarrassing the patient. On
the other hand, there are researches in which the
patients relate they accept the student's presence in
anamnesis as well as in the physical examination,
as long as they do not participate in the decisions
at diagnosis and treatment11.
Situations of abuse, defi ned as "negative actions
or words, unnecessary and avoidable, infl icted by
one person to another or others" (21) were indirectly
referred, but such circumstances are very common,
and literature21,22 refers that many students reported
abuse at some time point at the course.
... the occurrence of maltreatment of patients
and students from professors (A1, 5).
Teachers` lack of compromise is also referred
by students. They identify professors without updated
teaching material, showing uncommitment
to teaching process and frustrating student expectations
about school contribution to their medical
career with interesting and motivating teaching
situations10, 23:
Some (professors) were arrogant, pretending they
were almighty, without compromise with education
(A3, 9).
... arrived late or missed the clinic (A 21.9).
The relationship within the workplace was
perceived as unethical and marked by a spirit of
competition (24):
Authoritarian personality towards other professionals
(A18, 5 ).
Professors do not miss any opportunity to lower
a workfellow's image (A7, 9).
Interest conflict was identified by second
unit students, referring to the infl uence of nontechnical
factors in medical prescriptions (25-27) and
mercantilist attitude of some professionals (28):
Doctors prescribe only one type of medicine and
receive privileges from laboratories, like free travel
to medical conventions, help in job dispute between
professionals, patient referral to their private offi ces
... (A19, 9).
In this context, learning motivation can be
infl uenced by the professor and the existence of
confl icts in this relationship may cause depression
and discouragement to studying and having a good
relationship with patients13:
My doctor ideal, as a person who is concerned
about others' suffering, does not exist here. Doctors
are insensitive. Patients are treated in an inhuman
way. I see ethics as respecting the patient as a human
being, and not as legal principles. Medicine has become
a profession like any other (A32, 6).
The authors21 remind us that when the professor
gives some freedom, security and confi dence
to the students, they feel more stimulated, while
the aggressive response from him would be an
obstacle to learning.
The students point out the lack of physical and
organizational structure observed in public services
and their anxieties about the quality of learning,
considering the usual shortage of conditions
for implementing knowledge. Also here, students
of second unit relate problems more clearly, even
identifying the care provided by unsupervised
students (Table 3).
Medical schools should provide an infrastructure
with adequate materials and professors committed
to guide, encourage and foster students'
learning based on humanism and ethics23. The overall
situation is, inversely, the lack of commitment
of professors and of hospital infrastructure to face
student needs and aspirations29:
In addition, the respondents have confl icts with
their role as a student.
As medical students, they may fear specifi c
responsibilities that they are not prepared to deal
Teaching of medical ethics - D. Pimentel et al
Rev Med Chile 2011; 139: 36-44
42
ARTÍCULO DE INVESTIGACIÓN
with. This may be a matter of lack of experience
or technical skills, or it may happen because of
shyness (Table 4).
The expectation to be a good doctor stumbles
on the frightening prospect of increasing responsibility
associated with the fear of making mistakes
or not knowing what to do in the face of several
situations12, 23:
The relationship with patients' relatives is
sometimes interpreted as an obstacle to a good
relationship with the patient:
When the accompanist does not allow the patient
to express by him/herself or when he/she inquires us
about what the patient told us (A12, 9).
Facing death brings suffering, the students
become aware or discover that it cannot always
be avoided. The contact with chronic or terminal
patients awakens in students a sense of impotence,
and they realize that they do not really know how
to deal with these situations12,13,30:
... to learn how to deal with children suffering
from cancer and poor prognosis (A21, 10).
Doubts about the confi dentiality, body of character
substantive in the doctor-patient relation (24),
created discomfort for some students:
Patient who refuses medical recommendations
and I did not know whether to inform the doctor, as
the patient only told me secretly. (A1, 6).
Patient with AIDS accompanied by the husband,
whom doesn't know about it (A5, 9).
The current individualistic vision discourages
a listening attitude in daily relationships and
makes doctors less prepared to work with subjectivity,
and to develop a healthy doctor-patient
relationship31.
... knowing to what extent we may/must get
involved with patients' problems (A26, 9).
There are also diffi culties in understanding
the patient, and it is important for the doctor to
try to translate their language, sometimes full of
primitive signs31,32.
Finally, the results also show how some subjects,
according to the students, clarifi ed some
ethical points, and were able to solve problems
during the course33.
In general, for the fi rst group important relief
could be felt in knowing that they are not the
only ones with confl icts, that some confl icts are
expected, indeed.
For the other group the guidelines are more
detailed according to each situation, with some
theoretical deepening missing, and some practical
skills also.
There were students who did not feel assisted,
in any way, by the institution with the confl icts
they had to deal with, describing the school's contributions
as insuffi cient or nonexistent.
It was observed that the teaching of ethics, as
from the point of view purely deontological or
understood as a guideline for dealing with moral
confl icts of medical practice, constitutes a little
explored fi eld within the university, despite its
great importance.
Meanwhile, society requires more and more
that doctors should have ethical attitudes and a
holistic view of the patient, beyond the technical
training so stimulated during their course.
The failing in the ethics formation within the
university brings confl icts of the magnitude previously
reported. The relationships in all fi elds, are
worn, and students, most of the time, feel helpless.
The results show major defi ciencies in many
respects, although a more sharp ethical conscience
was evident in students from the second group,
who studied Forensic Medicine and Deontology.
They more often felt that they were more skilled
to manage confl icts after having studied this discipline,
also considering that different levels, age,
and other variables must give different perceptions
and experiences.
It is important to consider that the drawing of
the study with different groups does not follow the
maturation of the pupils throughout the course.
As well, despite it is known that the students of the
fi rst group were younger and less mature than the
ones of the second group, and that these factors
can infl uence their perception and administration
of confl icts, what is argued in this paper is that
there is no preparation of the pupils of the fi rst
group about ethical considerations to face academic
practice and patients contact, and this contact
happens before they are prepared for this.
As for the second group, neither the subject
Forensic Medicine and Deontology fulfi ls the students
needs, because it is not a Bioethics specifi c
matter, pointing to the need of Medicines courses,
which have that matter as the only possibility of
study of ethical subjects, to try to adjust its courses
of study to contribute to the formation of the
pupils and their future practice.
It is in progress another stage of the same research
to identify, with the medical professionals,
Teaching of medical ethics - D. Pimentel et al
Rev Med Chile 2011; 139: 36-44
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ARTÍCULO DE INVESTIGACIÓN
the confl icts in their practice and the contribution
that the university education had to dealing with
these confl icts.
Ahead of the results presented in this research,
it is strengthened that there is an urgent need for
greater commitment with education focused on
the humanization of medical practice, with more
prepared professors, better infrastructure and a
curriculum reform that will prioritize the teaching
of ethics.
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