Medicine is one of the few professions that sets a code of behaviour for its practitioners. In the past the relationship between the doctor and patient was paternalistic. Today this has changed. Advancement of medical science and technology has made a tremendous impact on medical practice. Rising costs of medical care and scarce resources pose dilemmas to the practitioner of medicine.
Since the late 1950s there has been an explosion in the field of bioethics. Gone are the days when problems were resolved by emulating seniors in the profession. Writing in The National Medical Journal of India, Dr SK Pandya laments that today “unfortunately the number of role models in the medical colleges is diminishing as unethical practices flourish and this adds to the frustration of students for they see a divergence between what is preached and what is practised” (1).
The Medical Council of India (MCI) regulations on undergraduate medical courses emphasise that medical graduates become exemplary citizens by the observation of medical ethics, and fulfilling social and professional obligations, so as to respond to national aspirations (2). This is one of the objectives of medical education. Students need to develop a rational approach to solve medical dilemmas that they will face in the future. Just as they learn various subjects to tackle medical problems, they also need ethics to solve the moral quandaries that they are likely to face in their practice in the future.
The application of the Consumer Protection Act to the medical profession has stimulated professional bodies to consider medical ethics in their annual deliberations. Media reports of patients faced with questions regarding transplants, medical negligence, end-of-life issues, etc highlight the ethical dilemmas of the medical profession as well as those of the public. Reports of misconduct in research, and the Indian Council of Medical Research (ICMR) guidelines on clinical trials, have stimulated a keen interest in the study of ethics in the country.
Medical ethics teaching in India: the current scenario
The MCI curriculum does not have medical ethics as a separate subject in any of its courses. In the curriculum of forensic medicine, the student is expected to “observe the principles of medical ethics in the practice of his profession” (2). The St John's National Academy of Health Sciences is one of the few medical colleges with ethics as a separate subject for training of undergraduates (3). Many universities and medical colleges are making efforts to introduce it in the curriculum. Since 2004 the ICMR has been conducting sensitisation workshops for students as well faculty throughout the country. This has created a tremendous interest in medical ethics. Therefore, we need to act now to fulfil aspirations.
A few law schools have started distance education courses in medical law and bioethics in the country. These courses are more tuned to law than to ethics. Moreover all of these are certificate or diploma courses. At present there is also a dearth of teachers and resources for teaching medical ethics.
Challenges faced in teaching medical ethics
1. At present the MCI curriculum does not have medical ethics as a subject. Only when it is made a separate subject by the MCI will all the medical colleges and universities in the country implement it. We need to lobby to implement it.
2. Medical ethics should be made a compulsory course with requisite attendance for the award of medical degrees. Studies have shown that making ethics an optional course in medical colleges does not serve its purpose (4).
3. Medical ethics need to be structured in such a way that the student is exposed through out the medical training period.
4. Evaluation of the course should be left to the faculty teaching the course. Students should have to be certified by the college, stating that they have successfully completed the course with the requisite attendance. In my opinion, making medical ethics a university examination subject adds to the burden of the student and reduces the classroom interactions.
A structured curriculum is necessary for the teaching of medical ethics. The St John's curriculum has been modified by many universities. The ICMR is in the process of formulating a curriculum for bioethics in the country. The MCI should develop its curriculum by adopting one of these curricula. Care must be taken that it is not overloaded with legal issues.
A handful of trained bioethics teachers (postgraduates) are available in the country, but only a few of them work in medical colleges. There is a need to increase this pool. Many medical teachers have diplomas in medical ethics. There is an acute shortage of trained medical ethics faculty in the country. There is an urgent need to train staff if medical ethics is to be introduced as a subject.
What can be done?
1. Organise advanced programmes urgently for teachers who have undergone diploma/certificate courses in medical ethics.
2. Start master's degrees in medical ethics. Encourage more clinicians to become ethics teachers. This will, hopefully, improve the standard of ethics practice and there will be better role models for students to follow.
3. Redress the lack of faculties of law, philosophy and social sciences in medical universities in the country. Faculty in these disciplines who are working in the regular universities must be given a dual appointment in medical colleges and they should be actively involved in teaching.
4. Provide additional incentives for faculty who are involved in teaching ethics either in monetary terms or in terms of career advancement.
5. Encourage medical universities to establish chairs and departments of medical ethics to develop the subject in the country.
Resources for teaching ethics
There are few Indian textbooks on medical ethics. Most deal with the legal aspects of medicine rather than ethical ones. Some books are even factually incorrect and misleading. There is a dire need to have good textbooks on medical ethics in an Indian context.
There is a dearth of articles on medical ethics from the point of view of Indian philosophy. Research has to be undertaken to identify and interpret Indian philosophy as it relates to medical ethics.
Writing on ethics in the Indian context is negligible. General medical journals rarely carry articles on medical ethics. Even if they are written, they deal more with malpractice and legal issues rather than ethical thought.
Throughout the ethics discourse we need to remember that India is a secular and multicultural society. Resource materials on medical ethics must incorporate this unique aspect.
Hope for ethics teaching
At present there is a tremendous interest in medical ethics in the country. Many universities are actively working on developing an ethics curriculum. The ICMR is taking a lead to introduce a certificate as well as a master's course in medical ethics. It is also in the process of publishing a book on medical ethics. The response of the medical community to the first national bioethics conference is another hopeful sign that medical ethics teaching will become important in the near future. One hopes that the MCI will take the lead and make ethics a part of medical education.
- Pandya SK. Clinical ethics: A practical approach. Natl Med J India 2006; 19: 340-1.
- Medical Council of India. Salient features of regulations on graduate medical education, Gazette of India. 1997 May 17; part III, section 4.
- Ravindran G, Kalam T, Lewin S, Pais P. Teaching medical ethics in a medical college in India. Natl Med J India 1997; 10: 288-9.
- Burling SJ, Lumley JS, McCarthy LS, Mytton JA, Nolan JA, Sissou P, Williams DG, Wright LJ. Review of the teaching of medical ethics in London medical schools. J Med Ethics 1985; 2: 22-4.
Professor of Medicine and Medical Ethics, St John's Medical College, Bangalore
iNDIAN JOURNAL OF MEDICAL ETHICS JANUARY TO MARCH 2008