Medical Ethic & Bio-Ethic In Undergraduate And Postgraduate Radiology Teaching*

Dr.Nurul Azman Ahmad Alias
School of Medical Sciences
Universiti Sains Malaysia Kubang Kerian
Kepada anda yang ingin membuat komen/pembetulan e-mail kepada :

The definition of health is a state of complete physical, mental, social, and spiritual (emotion) well-being. It is not merely the absence of disease or infirmity. In the context of health-care delivery system, we as teachers in medical school, our role to apply these principles in a holistic approach to to the care of our patients and impart these knowledge to our student.

Little has been established regarding instruction in medical ethics and bioethical issues. Is it because it is not important or since it lies outside the familiar technical aspect of the radiologic sciences? Educators may also lack confidence in presenting the subject. We have to address the importance of adequate instruction and presents it in a systematic, holistic and philosophical approach teaching medical ethics to our students, be it undergraduate or postgraduate.

We are now more concerned on the aspects of mental, social and spiritual well-being of our patients. These are closely related to ethics, moral and behaviour of our health-care staffs, the doctor's relationship with patients, colleagues, and society. On the whole, the issues on moral, role of values, philosophical, social, legal, ethics and communication and interpersonal skills are not widely taught nor discussed adequately in most university curriculum. Training in medical ethics helps physicians to be familiar with moral values, patient’s right and recognize ethical issues in patient care and resolve those issues wisely base on methodology of ethical reasoning. Education on ethics may alter the physician clinical practices and improve the quality of patient care.

The doctor-patient relationship has always required patients to entrust their bodies and even their lives to the physician. Medical ethics provides the basis for this trust. We also have to communicate effectively and have the right professional conduct and social accountability.

Morality and religion are inter-related but nevertheless quite distinct from each other. All the great living religions of the world teach broadly comparable moralities. In all of them there is general acceptance of the fundamental worth of the human personality and honour. Moral principles are indispensable for the assessment of sciences. A conflict of interest may occurs when a specialist places personal or financial interest ahead of the welfare and health of a patient. Medicine is one of those sciences in need of the guidance of ethics.

We as staffs in radiology department play an important role in patient’s care and diagnosis of diseases. Almost all patients are referred to us for at least one diagnostic examination. We also performed a growing number of therapeutic procedures. Patients are often apprehensive, frightened and uncertain by what we are going to do, often they are surrounded by heavy equipments and im

personal place. Thus for optimal care of our patients, the health-care staffs must be sensitive to the concerns and right of patients, their spiritual needs and their family needs.

Medical decisions should be freely and jointly formulated by the patient and the specialist with awareness to matters such as mental competence, relevant medical information and standards of care, allocation of health care, sufficient time for contemplation, informed consent and refusal of treatment, truthfulness, confidentiality and the right of patient and physician to seek consultation or additional opinions.

Medical ethics, medical jurisprudence and medical economics is an integral part of the practice of medicine, its study should parallel that of the study of medicine. It should proceed in an orderly fashion from undergraduate into postgraduate levels, starting with an understanding the principal moral values governing medical ethics. Student should subsequently expose and develop awareness of the existence of ethical issues and dilemmas, acquire the capability for resolution of these issues through ethical reasoning. Clinical real life situations and case studies should be extensively used as an educational tool.

Teachers of ethics have obligations not just to teach the subject matter but also to help create an academic environment in which well motivated students will reinforced their inherent good qualities. Personal humility on the part of teachers as role model can help set a good example for students to follow. Emphasis should be placed on the ethical aspects of daily medical practice and not just on the dramatic dilemmas raised by modern technology. Interdisciplinary teaching should be encouraged and teaching should span the entire duration of medical studies. Attention should be paid particularly to ethical problems faced by the students themselves, preferably at the time when the problems are most on the students' minds. A high level of academic commitment, including critical examination of students' progress is recommended.

We, in PPSP USMKCK have embarked on a new curriculum on medical ethic, bioethic and communication skills for undergraduate teaching. Medical students should be educated in the ideals and practicalities of the new mission. This will equip the student with strong foundation before they venture out into the world and grapple with the problems of society, where they will take actual responsibility for the health of their local populations. The teaching program on ethics are mainly carried out as problem-base learning (PBL) and student seminar on an interdisciplinary , approach. PBL encourage and stimulate students to develop a critical faculty and an ability to handle conflicting data and attitudes. They will also appreciate the importance of accountability (through group learning activities) and to be aware of the impact of community concerns on the practice of medicine.

In PPSP, which practice integrated curriculum, an innovative medical curriculum, has been guided by educational principles of problem-orientation, continuous assessment, student initiative and attitude development. It is student-centred approach and students are guided to determine their own moral viewpoints on common controversial issues and provide a framework for managing common ethical dilemmas.

The teaching was designed early in the curriculum, while student are still fresh, young and eager to learn, ie. phase 2 (year 2 & 3) on a global (all disciplines block posting) integrated teaching of medical ethics, bioethical issues and communication skills. We believe such training has its maximum impact during the formative years of undergraduate training. For the full clinical years, reinforcement is needed and effort has been made to extend the philosophy to this more or less traditional part of medical education. This has been done in year 4 radiology teaching.

In the structured educational objectives curriculum of phase 2, students are expose to designated reading materials followed by problem-base learning (problem-solving) and seminars. Topics are presented along with sample case scenarios to be used in a small group discussion format. Learning process in PPSP USMKCK has been to one of student input, questioning, learning to cope with uncertainty and taking responsibility for one's education. The passive “facts-oriented” teaching and spoon-feeding teaching process is thing of the pass.

Meanwhile, in the undergraduate radiology posting, which is undertaken in year 4, for two weeks, we took the opportunity integrate ethics in our program through case presentation and student seminar, and again in final year 5 posting, integrated into student case presentations.

When the department of radiology set-up it Master program in radiology, it has the following ethical curriculum included.

2.10.1. Falsafah perubatandan perawatan
2.10.2. Etika Perubatan barat dan Islam- satu perbandingan 
2.10.3.  Pendidikan dan rehabilitasi jasmani dan rohani pesakit
2.10.4.  Konsep dan moral perawat terhadap pesakit dan penyakit 
2.10.5.  Pembinaan keperibadian perawat yang sempurna 
In a reviewed article , 44.7% of the student preferred case presentations as their learning format and 30.7% ranked seminars as their first choice. Informal discussions and rounds were less popular, and lectures were considered least appropriate by 69.3%. In a another reviewed article , a major topics for example, informed consent are taught in a seminar format by one or more of the three members of the multidisciplinary ethics faculty (a philosopher, an internist, and a communications specialist) and an experienced physicians.

At the end, some form of examination and evaluation of the whole course should be a standard feature of all teaching programs of medical ethics integrated across discipline.

The course in PPSP was designed by a multidisciplinary and multidepartmental planning group; the format and content of the course were instrumental to its success. Significant difficulties involved in establishing and maintaining the program is to be expected, due to uninformed and negative attitudes of some students and faculty toward ethical teaching. Training clinical faculty in clinical ethics issues has to be persued.

From experiences, the success of training in ethics depends on strong commitments from the school policy and philosophy and every departmental staffs on recruitment of several dedicated persons on planning the PBL. What are the ethical concepts students should know? These include knowing how to obtain informed consent, knowing what to do about incompetent patients, knowing when to withhold or disclose clinical information, and knowing how to use resources efficiently. Radiation protection and hazards, values and limitations of investigations, overfilming of patients, appropriate radiological studies, financial implication and cost effective of procedures are amongst the topics discuss for efficient integration in patients health-care management.

Other topics such as informing patients of their disease using three basic styles; 'telling what the patients want to know', ‘telling what patients need to know’ and ‘translating information into terms that patients can take’. But it has to be supported by five basic principles; 'respect the truth', 'patients rights', 'doctors duty to inform', 'preserve hope' and 'individual contract between patients and doctors'. Doctors has to adhere to the recent trends of medical ethics based on informed consent doctrine and give the impression that patients have control over obtaining information. Ethics issue and education should focus on health promotion and preventive medicine, respect to patient, humanistic role of the doctor with added understanding to diverse cultures and religious background; all these have alway play a minor role in our quest for optimal health-care delivery system. Not surprisingly, many students and clinicians experience considerable difficulty in making competent ethical decisions in their day-to-day clinical practice.

Judging and evaluating ethical ideas without regard for these aspects of cultures, social and religious perspective means diminishing and limiting our scope of health care.

The three objective of the curriculum are::

(1) to enable student to recognize the ethical implications of both inpatient and outpatient clinical cases,
(2) to teach student to recognize ethics issues and alternatives in order to arrive at a well-rounded clinical strategy, and
(3) to help them learn to communicate sensitively with patients and others, about these ethics issues and be able to propose management plans.

A majority of student expressed concern and felt that their understanding on the subject was only "fair" or "poor" regarding ethics as a whole. Factors recognised to influence the student ethical decision-making process, includes in the majority indicated the influence of family views, other through viewpoint of teaching staff, peer attitudes, mass media, general reading and religious background. In conclusion, the results from a small survey revealed that, the students' perceptions and feeling of ethical issues identified were of professional conduct, respect toward patients, medical confidentiality, involvement of patient and family in health-care management, appropriate use of costly technology, the limits of intervention, resource allocation and consideration of cost implications in clinical decision making, level of care (under- or over-treatment) and effective communication skills.

* This paper was presented at the Malaysian Radiological Society 19th Annual General Meeting/Scientific Meeting 16th-18th August, 1996. Langkawi, Malaysia