Khurram Niaz  ( Department of Surgery, Quaid-e-Azam Medical College/ Bahawal Victoria Hospital, Bahawalpur, Pakistan )
Usman Mahboob  ( Medical Education, Institute of Health Professions Education and Research, Khyber Medical University, Peshawar, Pakistan )

Teaching ethics to undergraduates is no more a part of hidden curriculum rather it is a norm to be incorporated in the formal curriculum. Regarding instructional strategies, the consensus is stagerry and mainly based on the institutional choices. To develop moral reasoning and address the social value system, Cognitive part is delivered through lecturing while affection part is discussed via reflective practices in small group settings through deliberate moral case teachings and portfolio note book writings. However the outcome of such practices is yet to be known. However we suggest that the ethical curriculum should base on the reflective practices, social constructivism and experiential learning. Further customization could be done assessing potential ethical conflicts and legal accountability specific to our profession. We cannot merely focus on student preparation but also must focus on the organizational culture to be conducive for ethical practice and quality to match with what is being preached.

 

Keywords: Clinical ethics, Experiential learning, Portfolio, Constructivism.

 

DOI: https://doi.org/10.47391/JPMA.3407

 

Introduction

 

Ethics is a practical discipline that guides one how to live and what actions one ought to perform in life. Clinical ethics enables the health professionals in recognizing, analysing and managing the ethical issues while practicing the clinical acumen.¹ It provides a structured yardstick which is contextual of clinical practice and social values. Growing awareness of the patients' rights and more accountability in the healthcare delivery systems has compounded the ethical dilemmas of clinical Management (Figure-1). Teaching ethics in clinical context to undergraduate students is demanding and needs formal incorporation in curriculum. The pedagogical challenge is the role shifting from informal ethical framework to new context of joining respective interpretive communities to provide professional services. Some believe it is part of hidden curriculum and can be learnt only by observing faculty or Role Modeling.² Despite inclusion in curriculum there is staggering consensus about the learning theories that forms the basis of ethical curriculum.

 

 

So far Ethical dilemmas have changed the environment of medical education in terms of complexity and learning. Students encountering the complicated diversities of clinical ethics every day and they are facing the twin pitfalls of moral relativism and moral imperialism.³ There are no absolute moral principles rather every society set their own in context of customs, benefits and practices. Knowledge and competencies formed the core curriculum but professionalism and ethical conduct are the foundation stones of future undergraduates. Medical ethics becomes an essential component of undergraduate and postgraduate clinical training in many countries. Literature is either severely deficient of theoretical perspective of ethical education or unable to find educational philosophy and objectives of teaching ethics. Since much of the health care is provided as sole practitioner, behind closed doors or in non-institutional setups so undergraduate training in clinical settings is considered as sole opportunity to teach and learn ethical dimensions.^3,4 These social, psychological and humanistic encounters will enrich the trainee with new ethical persona with amalgamation of emotions, thoughts and actions.

Establishing an effective module or programme for teaching ethics to undergraduates is of utmost importance. Touchstones for learning include the problem encountered by the trainees and then probing these cases for ones feelings and thoughts.  No integrated theoretical or practical model of teaching ethics and professionalism exists yet but reflective practice encourages informal ethical thinking and gives insight to learning.⁵ With regard to teaching and learning in clinical context, case presentations, grand rounds, interactive lecturing and small group discussions on spiritual aspect of care can be helpful. Many studies supported these instructional strategies when lead by a knowledgeable clinician. Small group teaching is a preferred strategy in comparison to didactics in terms of developing moral reasoning and recognizing the value systems of diverse cultures. Special activities can be organized in terms of orientation like white coat ceremony etc. The four topics - medical indications, patient preferences, quality of life, and contextual features — provide a framework that can be used with any case.⁶ Quality of Life is the individual perception of their position in life in context of their culture and value systems.

Real time clinical cases are preferred but preplanned vignettes to signify particular ethical issues are also effective. First teaching strategy is moral case deliberate practice as depicted by Stopler et al (2016).⁷ He claimed that dilemma method is effective in teaching ethics in clinical settings with advantage of autonomous learning. It presumes that moral wisdom is based on reflections of learner's experiences in practice. In moral deliberation, one is invited to share the experience of cases and other is invited to reflect upon the situation and do brain storming to find solutions.² Reflection and feedback are the ethical skills to cope with the ethical dilemmas.⁴ Literature mentioned the use of sharing stories and perspectives for constructing moral convictions. The humanistic and ethical dilemmas are best dealt by the physicians who write short reflective stories.

Portfolio-workbook is innovation in teaching ethics in clinical settings. Portfolio is effective usage of reflections. Students reflect about the yield of ethical knowledge learnt in ethical modules and they gather evidences from clinical or nonclinical experiences. Shamim et al (2016) used various tools in conjunction to the workbook like video demonstrations, role plays and small group discussions to enhance the learning experiences.⁸ This strategy can be less time consuming.

Ethical education is imperative in both undergraduate and postgraduate education, as have already been commented on. However ethics is not something which lends itself well to didactic teaching. It is much effective for the students to be presented with ethical dilemmas and allow them to develop their reasoning and arguments.^7,9

 

Conclusion

 

Amid the existing shortcomings, Ethical curriculum for undergraduates should be taught based on the reflections, social constructivism and experiential learning theories. Therefore its inclusion as a subject in the health care curriculum is suggested. Further customization could be done assessing potential ethical conflicts and legal accountability specific to our profession. We cannot merely focus on student preparation but also must focus on the organizational culture to be conducive for ethical practice and quality to match with what is being preached.

 

Disclaimer: Article is neither published earlier nor is a part of PHD thesis.

Conflict of Interest: None to declare.

Funding Disclosure: None to declare.

 

References

 

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2.       Molewijk AC, Abma T, Stolper M, Widdershoven G. Teaching ethics in the clinic. The theory and practice of moral case deliberation. J Med Ethics. 2008;  34:120–4.

3.       Shamim MS. A contextually relevant ethics education model. Int J Ethics Educ. 2020; 5:97–100.

4.       Dexter S, Mann K. Enhancing learners’ attitudes toward reflective practice. Med Teach. 2013; 35:422–3.

5.       Fisher P, Chew K, Leow YJ. Clinical psychologists’ use of reflection and reflective practice within clinical work. Reflective Pract. 2015; 16:731–43.

6.       Fox E, Arnold RM, Brody B. Medical ethics education: Past, present, and future. J Assoc Am Med Coll. 1995; 70:761–8.

7.       Stolper M, Molewijk B, Widdershoven G. Learning by Doing. Training Health Care Professionals to Become Facilitator of Moral Case Deliberation. HEC Forum. 2014; 27:47-59.

8.       Shamim MS, Baig L, Zubairi N, Torda A. Review of ethics teaching in undergraduate medical education. J Pak Med Assoc. 2020; 70:1056–62.

9.       Beauchamp T, Childress J. Principles of Biomedical Ethics: Marking Its Fortieth Anniversary.Am J Bioeth. 2019; 19:9-12.