Muhammad Shahid Shamim  ( Dow University of Health Sciences, Karachi. )
Lubna Baig  ( APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan )
Nadeem Zubairi  ( King Abdulaziz University, Jeddah, Saudi Arabia. )
Adrienne Torda  ( Prince of Wales Clinical School, Sydney, Australia University of New South Wales, Sydney, Australia )

Objectives: To provide an overview of existing literature regarding ethics in undergraduate medical education around the world, and to identify gaps in literature for recommending areas for future research.

Methods: The scoping review was conducted in March 2016. PubMed and Web of Science search engines were used to identify English language literature on ethics in undergraduate medical education published over the preceding 20 years. Google search was used for grey literature. Two reviewers independently screened eligible studies for final study selection and review. Descriptive analysis of data was performed with mutual consensus.

Results: Of the 199 items located, 56(28%) were included; 37(33%) of 112 studies, and 19(22%) of 87 pieces of grey literature. Papers covered almost all regions of the world, including North and South America, Europe, Africa, and different Asian regions like Middle East, central, south-east and far east. The analysis identified several curriculum designs and teaching methods used for ethics education.

Conclusion: The review identified gaps in evidence that required further research. These areas include theoretical underpinning of ethics curriculum, role of educators, standardisation and validation of teaching and learning strategies, and relevance to cultural context in the development and delivery of ethics curriculum, especially in Asian regions.

Keywords: Ethics education, Undergraduate, Medical education, Review.

DOI: https://doi.org/10.5455/JPMA.21013

 

Introduction

 

Only few decades ago ethics was considered a part of the undefined, implicit curriculum which students were expected to learn "on their way" to graduation through peers and role-models.¹ This learning was, at best, opportunistic, sporadic, poorly calibrated and difficult to assess. Recent evidence shows that ethics is now a component of the formal curriculum in most medical institutions, with empirical reports from different parts of the world on the use of variable methods for content delivery.^2-10 However, there is limited evidence on the effectiveness of the methods in achieving outcomes required of ethics courses.^11,12 Practising medical ethics is now considered an essential core competency for medical graduates¹³ and has become part of the formal curriculum in almost all healthcare education institutions.^6,12

In 2000, Goldie stated that there is general agreement among educationists to apply adult education principles to ethics teaching.¹⁴ However, Singer argued for consensus on underlying educational philosophies and their implementation for ethics in undergraduate medical education.¹⁵ Their concerns for linking ethics education with theoretical underpinning have been consistently echoed by subsequent educationists.^16,17

To add to the complexities of ethics education, the socio-cultural context of a region or country often influences the content and delivery of such educational endeavours. These complexities are especially notable in reports coming from countries like Saudi Arabia and Pakistan.^6,10 Such countries have their own moral value systems, different from the Western secular social system. The Western system has given rise to most of the details published regarding contemporary ethics education, including the underlying moral philosophy, content, methods of delivery and contextuality.¹⁸ In this context, there is a severe dearth of substantial evidence for developing a thoughtfully designed and contextually tailored educational approach.^14,18

The current systematic review was planned to provide an overview of existing literature regarding ethics education in medical institutions in different parts of the world. The paper identifies areas in undergraduate medical ethics education where further research is required to inform the educators. The review also examines evidence coming from differing regions and its implications for ethics education.

 

Methods

 

The systematic review of literature on undergraduate medical ethics education was conducted in March 2016. A scoping review methodology framework.¹⁹ was considered appropriate because it is particularly useful for exploring the literature for identifying gaps in specific areas, such as ethics education. The framework outlines a five-stage approach, and each stage of the framework was considered during the current research (Table-1).

Relevant data was extracted from each study (Table-2).

PubMed and Web of Science electronic databases were searched for studies, while Google was searched for grey literature.  Combinations of "Ethics", "Medical Education" and "Undergraduate" were used as key words for the preliminary search. Publication titles from the initial search were reviewed by two authors for refinement of key words, where "Healthcare" and "Teaching" were added in the list. The filtering methods included the date range (within the preceding 20 years), English language, and a search string to further narrow the results to full-text articles. Boolean term 'and' was used between each of the key words.

The scoping review of published articles did not require ethical approval.

 

Results

 

Of the 199 items located, 56(28%) were included; 37(33%) of 112 studies, and 19(22%) of 87 pieces of grey literature (Figure).

Overall, 23(41%) papers were published from 1996 to 2005, and 18(32%) were published from 2011 to 2015. The studies related to almost all global regions, including Asia, Africa, Australia, Europe as well as North and South America. Publication and journal types were also noted (Table-3).

The review found only 2(3.6%) articles relating to the theoretical or philosophical basis of ethics education; 1(50%) mentioned the theoretical approach while explaining the curriculum design, and 1(50%) referred to the deficiency of a theoretical approach in relevant literature. Local context was mentioned in 22(40%) papers. None of the reviewed articles explored the theoretical basis or effect of cultural context on ethics education in significant depth. The findings of all the studies were summarised in five categories (Table-4).

 

Discussion

 

The primary purpose of this review was to identify areas in undergraduate ethics education where more research is required. This scoping review identifies the gaps in the literature on undergraduate ethics education and tries to provide an overview of the situation through geographically mapping the gaps. Thereby, the review identifies not only what the deficiencies are, but also where the deficiencies are.

 

Need for ethics education

 

A significant number of publications have supported the need for thoughtfully structured curriculum for motivation of those involved in, and need for evaluation of, undergraduate medical ethics education. Also discussed in articles published between 2011 and 2015 coming from countries like Brazil, India and Pakistan where ethics education is a relatively recent development (Table-4). On the other hand, articles published from countries like Australia, Japan, South Korea, Singapore, Taiwan, United Kingdom (UK) and United States of America (USA), where ethics education has been part of formal curriculum for some time, discussed the use of innovative teaching/ learning strategies, role of facilitators, and standards and validation (Table-4). This distinction reflects the level of development of ethics education in different world regions. Stakeholders, like statuary bodies, universities and community stakeholders, in countries which responded to the need are now advancing on the way to improving ethics education, while others are still struggling to commence their journey.

 

Teaching and learning strategies and the role of facilitators

 

The reviewed publications discussed different teaching and learning methods and the role of facilitators/teachers in ethics education. The publications discussed a range of teaching and learning strategies being used including ethical dilemmas in small group sessions, standardised patients, ward round model, team-based learning (TBL) and problem-based learning (PBL). They identify the need to clearly articulate standards for effective ethics education while using the strategies. Among the different strategies used, the review shows emphasis on small group teaching (SGT) with the use of ethical dilemmas and case scenarios for eliciting dialogue with students. In this regard, Goldie¹⁴ showed the enhanced effectiveness of SGT compared to large-group lecture-based learning (LBL) methods in ethics education. He evaluated the process of ethics education and concluded the importance of effective facilitation during the process of SGT. Onge²⁰ and Miyasaka et. al.²¹ suggested narrative approach, using stories, ethical dilemmas, conversations and life experiences, in small groups. Parker et al.²² and Yu-Chih Lin²³ evaluated this approach by conducting pilot studies in their respective institutions. Both pilot studies showed effectiveness in providing opportunities to students for discussing relevant issues in a safe environment. A study²⁴ supported a similar method in student-led seminars, while another²⁵ suggested peer-based ethics teaching along with narrative approach. Chung et al.²⁶ studied the application of TBL, and reported improved student performance, especially that of academically weaker students, and increased student engagement and satisfaction. Although a number of studies and review articles have described the use of different methods for ethics education, none of the published works provide substantial evidence for guiding validation and standardisation of teaching and learning methods.

 

Theoretical basis

 

Another area of concern was theoretical underpinning of ethics education. The review identified only two publications, from UK14 and USA.¹⁶ which considered the theoretical basis for developing ethics curricula in their manuscripts. Among these, Goldie used the Harden et al.'s SPICES (Student cantered, Problem-based, Integrated, Community based, Electives and Systematic) model¹⁴ while reviewing the design of ethics curriculum, and Eckles et al.¹⁶ reported the need for theoretical work for developing core content, processes and skills relevant to medical ethics. The paucity of evidence on theoretical underpinning in ethics education found in this review should be seen as a matter of unease for educators.

 

Contextual bias in publications

 

Significant disparity was also found between articles published from different regions compared to the number of medical schools in the regions. The large number of medical schools in different areas (Table-5) do not correspond to the number of published articles on ethics education.

Less than 20% of world medical schools are in the UK and the USA combined. Nevertheless, 52% of literature on ethics education has originated from the two countries. Hardly any publication from regions with large number of medical schools in Asia were found discussing issues like theoretical basis of core content, teaching and learning strategies, standards, validation, and role of educators in the educational process. A number of possible reasons, like limited resources for evaluation and/or lack of technical and financial support for publications, can be assumed for this finding. However, the situation cannot be improved unless there is evidence available on the cause. Hence, there is a need for further research in this area.

 

Cultural relevance

 

Ethics curriculum is generally relevant to cultural norms in the region. The articles originating in Australia, Canada, UK and USA have reflected on issues of polarisation of students and cross-cultural ethics (Table-4). Their primary concern is to develop an ethics curriculum for students coming from different cultures and backgrounds. On the other hand, students in most of middle-eastern and southern Asian regions are from similar cultural backgrounds, as also reflected in this review's findings. However, there is little published research, particularly from Asian countries, and, therefore, it is impossible to know whether a shared set of moral principles govern medicine in these similar cultures or is this a form of cultural imperialism. Literature from these regions stress upon the need for ethics curriculum that is relevant to cultural needs and societal norms.^18,27,28 The reviewed publications that have mentioned the issues of cultural context include personal opinion²⁹ and description of innovation in ethics education in one institute.⁷ These isolated publications cannot be considered sufficient to establish evidence in this matter. Hence, this review identified a major gap in the medical education literature regarding the importance of cultural factors in ethics education in different parts of the world and the validation of culturally relevant ethics curricula. Future studies may also explore whether the issues of cultural diversity and pluralism are influences in Asian countries or not.

 

Significance of evidence

 

There are different levels of evidence in scientific educational research. Although all levels of evidence are important, they cannot be considered of equal value. The impact factor of a journal measures citation frequencies and is used to assess relative importance of a scientific journal.³⁰ The impact factor of a journal may not be the best measure of the quality of articles but it is readily available and universally accepted.³¹ In this review, the majority of studies published in peer-reviewed journals with impact factor are from relatively developed countries of different regions, like Australia, Brazil, Denmark, South Korea, Singapore, South Africa, Taiwan, UK and the USA. The deficiency of publications in journals with impact and impact factor from regions which host the largest number of schools graduating healthcare professionals reflects an area of concern that needs further exploration.

 

Limitation

 

This review identified overall gaps in literature on ethics in undergraduate medical education rather than the quality or level of research data and scientific evidence. The review looked for evidence published in English language only. There may surely be data in other languages that is completely missed in this work. The discussion is, therefore, predominantly revolves around ethics education in countries and regions where English language is the medium of medical education.

 

Conclusion

 

There is a dearth of evidence in literature relating to different aspects of ethics education in medical and academic institutes. The review identifies areas with gaps in evidence that require further research. These areas include theoretical underpinning of ethics curriculum, role of educators, standardisation and validation of teaching and learning methods, and relevance to cultural context in the development and delivery of ethics curriculum, especially in Asian regions. The review also identifies disparity in number of research publications from regions which host a large number of medical schools, which is food for thought for researchers and journal editors.

 

Disclaimer: The text is part of a PhD thesis.

Conflict of Interest: None.

Source of Funding: None.

 

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