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The apartheid ideology in South Africa had a pervasive influence on all levels of education including medical undergraduate training. The role of the health sector in human rights abuses during the apartheid era was highlighted in 1997 during the Truth and Reconciliation Commission hearings. The Health Professions Council of South Africa (HPCSA) subsequently realised the importance of medical ethics education and encouraged the introduction of such teaching in all medical schools in the country. Curricular reform at the University of Stellenbosch in 1999 presented an unparalleled opportunity to formally introduce ethics teaching to undergraduate students. This paper outlines the introduction of a medical ethics programme at the Faculty of Health Sciences from 2003 to 2006, with special emphasis on the challenges encountered. It remains one of the most comprehensive undergraduate medical ethics programmes in South Africa. However, there is scope for expanding the curricular time allocated to medical ethics. Integrating the curriculum both horizontally and vertically is imperative. Implementing a core curriculum for all medical schools in South Africa would significantly enhance the goals of medical education in the country.
Knowledge of medical ethics and moral reasoning skills are crucial to good patient care in much the same way as biomedical knowledge and technology are to diagnosis and management of disease. Globally, the teaching of medical ethics in the health sciences has been subjugated to scientific and clinical teaching. In 1999, the World Medical Association “strongly recommended” to medical schools around the world that the teaching of ethics and human rights should be compulsory in their curricula.1
The teaching of medical ethics in South African medical schools has lagged behind that of clinical and scientific courses. In 1997, the Truth and Reconciliation Commission Hearings revealed the role of the health sector in human rights abuses.2 It became evident that violations of human rights were not limited to political and socioeconomic spheres of life but had pervaded the medical profession as well.3 It was clear that the clinical independence of healthcare professionals had been compromised by security forces and that gross violations of human rights had occurred, as in the case of the death of the political prisoner Steve Biko.4,5 Furthermore, various transgressions of professional ethics had occurred, including the allocation of separate waiting rooms to patients of colour. The training of black medical students had been based on apartheid principles that had pervaded academic institutions to the extent that black students were not permitted to examine white patients, alive or dead. In pathology teaching where postmortems were conducted on white bodies, black students had to wait outside the morgue and view the organs after their white colleagues had received teaching.6 The need to train doctors who would be morally sensitive and ethically accountable to their patients and colleagues became apparent. Soon after the hearings, the Health Professions Council of South Africa (HPCSA) introduced compulsory ethics training as part of the continuous professional development programme for qualified doctors. The teaching of medical ethics at medical schools in the country was also strongly encouraged.
The Faculty of Health Sciences at the University of Stellenbosch, South Africa, has been conducting undergraduate training of predominantly white, Afrikaans‐speaking medical students for the past 50 years. The teaching of medical ethics was historically limited to two didactic lectures during the fifth year of study. In 1999, a new undergraduate health science curriculum was implemented. This process of curricular reform presented an unparalleled opportunity to formalise ethics teaching in the first and fifth years of training. Formal training in medical ethics was implemented for the first time in 2003. This paper highlights the challenges encountered in the teaching of medical ethics over the course of 6 years, with an emphasis on the programme that is presented to the medical students in their fifth year.
In South Africa, medical students begin their undergraduate training immediately after high school. On average, they are 18 years old in their first year of study when they begin basic science training. Clinical exposure to patient care in the hospital occurs after the first 18 months and escalates during the subsequent years. At the University of Stellenbosch, curriculum development has been guided by the clinical exposure of students. However, medical ethics teaching has also been limited, as it competes with traditional scientific and clinical disciplines for curricular time. The concentration of medical ethics teaching in the fifth year of study has hence been motivated by space in the curriculum as well as clinical exposure of students. The gap between the first and fifth years is bridged in the second year by a short module and in the third and fourth years in the family medicine rotation. Details of the 6‐year curriculum are outlined in table 11.
At the start of the curriculum, four lectures are presented to introduce students to medical ethics, medical law, logic, critical thinking and scientific integrity. These lectures are intended to sensitise students to the ethical dimension of their further work in the medical field and to form a foundation for future ethics teaching. By the end of the 18‐month basic science rotation, further lectures and group work are presented on ethical theories and principles.
During this module, fifth‐year students experience 1½ weeks of intensive teaching and learning in ethics, medical law and human rights. The ethics course material is presented in the form of interactive lectures, small group discussions and group assignments. In deciding on the content of the module, we used the General Medical Council core curriculum as a guide.7 Topics relevant to healthcare in South Africa and other developing countries were incorporated (box 1).
1 A place for bioethics in medicine
2 Theories in bioethics
3 Respect for patient autonomy
7 Justice incorporating human rights and the law
8 Human reproduction
9 End of life issues
10 Research ethics
11 HIV/AIDS—the ethical issues
12 Genetics & ethics
13 Practice management
Hence, we have an emphasis on the ethics relating to HIV/AIDS and other infectious diseases (multi‐drug‐resistant tuberculosis), resource allocation, termination of pregnancy, human rights violations8 and communal personhood.9 Students are provided with a bilingual study guide (in English and Afrikaans) and a student manual (in English) and are referred to relevant texts.10,11,12 Provision of English texts is usually a source of much concern to students who have predominantly been educated in their home language (Afrikaans) since the apartheid era in South Africa.
Group discussions typically involve groups of 40 students, in subgroups of 10. During these sessions, students develop skills in identifying conflicting ethical values, building arguments and reaching consensus when challenged with an ethical conflict. Student groups are allocated various tasks such as role‐playing a hospital ethics committee that must deliberate over a 60‐year‐old diabetic patient who refuses amputation of his gangrenous foot. Controversial topics such as suicide and end‐of‐life issues are subject to a debate in which two teams present opposing arguments. The challenge of HIV‐positive pregnant and non‐pregnant patients refusing antiretroviral treatment is also discussed. The first group discussion of the module has consistently been emotionally challenging and cathartic for the students. For many, this is their first opportunity to discuss ethical dilemmas they have experienced during their clinical training in the preceding 3 years in hospital settings. One of the most emotive presentations concerned the lack of compassion and respect shown by healthcare workers towards women in labour.
A special focus of this ethics module is the application of theoretical ethics knowledge in the various healthcare environments that are used for student training—the tertiary academic hospital attached to our medical school as well as private and state primary healthcare and research facilities. In their fifth year of training, it is imperative that students can link the ethical theory they have been taught in the preceding years to the clinical context of the medical profession.13,14 Students work in 15 groups of 10. Each group is assigned a topic on which a literature search is conducted and a small research project is conducted in a hospital or clinic (see box 2).
1 The Jehovah's Witness and blood transfusions
2 Human reproduction and the Choice on Termination of Pregnancy Act
3 Paediatrics and ethics
4 Resource allocation
5 Health and human rights
8 Research ethics
9 Informed decision‐making
11 Ethics pertaining to students
12 Ethics pertaining to doctors
13 Mental disorders and disabilities
14 The ethics of HIV/AIDS
15 The ethics of circumcision
The groups then present their findings to the full class during the second week of the module. A similar approach has been documented by Roff and Preece in Australia, where second‐ and third‐year graduate students research ethical dilemmas they have experienced and present their findings to their colleagues. In their programme, however, only 20 students are admitted to the course at any one time. Nevertheless, their course is perceived to be extremely effective as a teaching and learning method by the students who attend the programme.15
To illustrate the content of the projects that students conduct, I will describe a few in detail. One of the assignments examines ethical issues that pertain to medical students. Inclusion of this topic in the programme is supported by other studies.16,17 The group is advised to interview fellow students in their class and elicit their opinions on performing procedures that they are not confident to perform, obtaining informed consent from patients for procedures they are not going to perform, challenging medical routine or orders from superiors and witnessing unprofessional behaviour by colleagues and superiors. Other issues covered include substance use by students and dress codes during training.
As HIV/AIDS currently poses enormous ethical challenges in South Africa, a group is advised to visit the HIV clinic at the academic hospital and establish its policy on confidentiality, informed decision‐making and counselling. An examination of the Tarasoff case10 is required to assess whether it provides justification for breach of confidentiality in HIV/AIDS. Students must also examine the South African Medical Association guidelines to establish the circumstances under which confidentiality can be breached and under which HIV testing can be performed without consent. In the event of a needle‐stick injury, what should healthcare professionals do if the patient declines consent for testing? The dilemma of HIV‐positive doctors continuing with medical practice is explored.
The group with the best presentation in 2006 explored informed consent in the surgical and orthopaedic wards at a tertiary hospital. Their research found that 30% of the 15 stable postoperative patients surveyed did not understand the procedure that they were subjected to. Half of these patients were not given an explanation of the procedure in a language of their choice. Patients were uncertain whether consent had been obtained by a student or a doctor. The students discovered that the consent form being used in the hospital mentions that blood will be tested for HIV if a healthcare worker sustains a needle‐stick injury. This appears in very small print and is not easily readable by prospective patients.
While the practical assignments are an extremely valuable teaching experience, they are fraught with ethical concerns in and of themselves. First, clinicians in the hospital setting have felt threatened by students conducting ethics projects, as there is a perception that clinicians are being judged. In an attempt to pre‐empt this, an explanatory letter is sent out to all heads of departments and hospital superintendents before the module is begun. However, on occasion the message does not reach all clinicians in the hospital. Second, students must be carefully trained to conduct all interviews with consent, ensuring privacy. Third, students fear reprisal after presenting data that may expose unethical practices in a particular department. One of the groups in 2006 voiced these opinions. This required a deliberate process of discussion with the relevant department and reassurance of the students. The phenomenon of fear of reprisal against students who witness unethical patient care in the clinical setting has been documented in other teaching programmes on ethics.18 Fourth, the intensive nature of ethical enquiry can be emotionally demanding. Students are often disturbed by the gulf between the ethical theory they have been taught and what is encountered in regular practice in clinical settings. At an informal level, tutors conduct ad hoc debriefing. The class presentation of the assignment presents another opportunity to debrief and discuss emotional and controversial issues. The role of the tutor during these sessions is crucial. It often becomes essential for tutors to maintain a position of neutrality while allowing all aspects of the debate to emerge in a safe environment for the students. One of the most controversial presentations relates to termination of pregnancy—largely because South Africa has relatively liberal legislation regarding termination of pregnancy and because of the changing demographics of the student profile at the university over the past 2 years. Students hold a wide range of religious views, most of which are strongly opposed to abortion. Finally, tutors may be significantly burdened with information that emerges during ethics programmes based on students' experiences in the clinical setting. The question of how best to resolve unethical practices within one's own institution without exposing students to victimisation remains a challenge.
One of the most striking features of the ethics curriculum in its current state is the enormous gap between teaching in the first and fifth years. In 2003, student feedback reflected this deficiency after the first group of fifth‐year students had completed the ethics module for the first time. The fifth‐year class in 2003 comprised 156 students, of whom 107 completed feedback questionnaires, yielding a response rate of 69%. In assessing the link between the first and fifth years of teaching, it was noted that 65% (70/107) of students responding could not recall the first‐year ethics lectures. In 2004, the first‐year lectures were repeated in the fifth year in an attempt to bridge the gap.
Another attempt to bridge the gap took the form of a training programme in ethics for faculty members: “Train the Trainers”. The concept of teaching ethics as a “golden thread” such that ethics is included in all undergraduate medical training modules—in the lecture halls and at the bedside—has been described. To achieve this goal, it was necessary to expose faculty in other clinical disciplines to ethics theory. Hence, “Train the Trainers” was established in 2004 and continues to date. Monthly meetings are held, where a range of different topics in medical ethics as well as case studies are presented to clinical staff. Attendance at these meetings has grown rapidly over the past 3 years, from five per meeting in 2004 to 22 in 2006.
In 2005, an external review of the module was conducted by ethics and human rights experts not affiliated with the faculty. Among other comments, the gap between the first and fifth years was highlighted. To intensify efforts to reduce this gap, an ethics logbook will be introduced in 2007. This will require students to document ethical dilemmas as they arise during their training in the various disciplines during their third and fourth years of clinical work. This logbook will be reviewed during the fifth year ethics module in group sessions.
Although ethics, medical law and human rights are distinct fields of study, they overlap considerably in medical practice, and they are intertwined in the curriculum. Over the course of 6 years, approximately 70 hours of formal ethics teaching is conducted. Most of this time is devoted to the teaching of medical ethics, with much less time being allocated to medical law and human rights. The limited amount of teaching on medical law is incorporated under the theme of justice, where legal justice is explored. Medical law as it applies in South Africa is introduced. The various statutory laws that relate to healthcare are elaborated. Of these, the National Health Care Act of 2003, which was signed off by the State President in May 2005, is prioritised.19
The subject of human rights in healthcare is introduced in the third year of study as part of the family medicine and primary healthcare rotation. In the fifth year, human rights are discussed under the theory of liberal individualism and as part of the theme of justice. In this respect, concepts such as rights and responsibilities, the South African Constitution and Bill of Rights, the Patients' Health Rights Charter and the Universal Declaration on Human Rights is explored.
The Steve Biko story is used as a case study to illustrate the role that South African doctors played in the treatment of political prisoners under apartheid in South Africa. Doctors Ivor Lang and Benjamin Tucker were required to examine Steve Biko after he sustained head injuries during interrogation by security police. Over a 5‐day period, both doctors failed to examine him correctly and allowed police to be present during their examination. Most importantly, they allowed the police to influence their diagnosis and management and hence colluded with the apartheid regime in power. Although the Biko case was widely publicised in South Africa and internationally,4,5 most of our fifth‐year students, every year over the past 4 years, had not heard of it before the ethics module. The case study is an excellent example of the link between health and human rights, as the students learn the importance of adequately examining all patients, including prisoners, in a humane and independent manner. Human rights violations in the context of rural health in South Africa are also included in the readings.8
While this approach to human rights teaching in the healthcare environment is controversial and inadequate, it is the only way that we were able to integrate it into the current ethics module, given the curricular time constraints. Simply including human rights content under the theory of liberal individualism has the potential to minimise the importance and the depth of the subject. Another reason for the reduced human rights content relates to the objection students voiced in the first year this programme was introduced at the faculty. Discussions on human rights and past injustices within the healthcare setting made many of the students extremely uncomfortable and defensive. One of the reasons for this could have been related to the composition of the class of 2003, which was 74% white, mainly Afrikaans‐speaking, students. The remaining 34% of the class comprised “coloured” (of mixed ethnicity) and Indian students. Given this context, there is bound to be resistance to discussions on human rights, especially when the tutor is a person of colour. In the student feedback for that year (2003), students complained about the discussions that referred to human rights abuses during the apartheid era, and there was a call to leave the past behind us.
In 2004, an invited lecturer, Dr Wendy Orr, delivered an outstanding talk on health and human rights in South Africa. Dr Orr is a well‐known white South African medical doctor who demonstrated immense moral courage when she voiced her objections to inhumane treatment of prisoners at the height of the apartheid era.20 Her talk, based on her personal experiences in the medical profession, highlighted the tension created when apartheid laws conflicted with her ethical principles as a prison doctor. In contrast to 2003, in 2004 students were more accepting of a discussion on human rights in the health sector. Since then we have been trying to increase the human rights content incrementally. With the transition of South Africa to democracy, the racial profile of classes has also changed, such that the 2005 fifth‐year class comprised 58% white students and 42% students of colour, where discussions on human rights in the health sector are tolerated. To students of colour, these discussions are also cathartic.
The goal of training in medical ethics is a source of much controversy.21 On the one hand, one could aim to develop a virtuous physician. On the other hand, one could aim to equip students with skills that will enable them to resolve their own ethical dilemmas as they arise in the course of their medical careers. These two goals are not mutually exclusive. The goal of our course incorporates both elements as we aim to contribute to the ethical profile of the Stellenbosch doctor. This profile has been developed by the university so that all teaching can be measured against specific outcomes in terms of knowledge, attitudes and skills that should be inculcated in all doctors graduating from our institution. In terms of ethics training, we provide basic knowledge of ethics and legal aspects applicable to medicine. The test and the examination in the fifth year of study test knowledge. We attempt to inculcate respect for person and life, a loyal and ethically accountable disposition towards the profession, patients and community and an acknowledgement of the limitations of knowledge and skills. Ethical skills development should involve the ability to integrate, interpret and apply knowledge. The ability to think and act in a problem‐solving fashion is an important outcome. We aim primarily to equip students to be able to identify ethical dilemmas as they arise in practice and to be able to attempt to resolve them. These skills are taught in the first 5 years and are tested in the fifth‐year ethics examination, the group assignments and the final‐year ethics case report, which incorporates a problem‐solving method. In all these areas, our students have so far demonstrated good problem‐solving skills.
If, in the process of skills development, we also succeed in creating virtuous physicians, that would be rewarding and worthwhile. To date, we have not measured whether the latter goal has been achieved; that may be an outcome that is in any event very difficult to assess in most undergraduate teaching programmes. One of the practical challenges to measuring such an outcome relates to the geographical scattering of students after graduation as they embark on internship training and community service in urban, rural and semirural areas.
Since its inception, the module has been updated annually. The comments emanating from the 2005 review will be considered for the 2007 course. In particular, the volume of teaching on ethical theories will be reviewed. A lecture on dual loyalties will be added. Another lecture and group discussion on health and human rights will be added. The resource allocation chapter in the student manual will be revisited and the discussion on fairness will be expanded. All case studies will be reviewed to assess the balance in primary, secondary and tertiary healthcare level examples. As mentioned earlier, we will add an ethics logbook, in which individual students can record all ethical dilemmas encountered in earlier years of study. This will assist with development of the “golden thread”. Mentorship is available via the Bioethics Unit. We have an ethics hotmail (email), which is accessed by our students even after they graduate. During the fifth year of study, there are student electives, and some students may choose an ethics elective that is supervised by the Bioethics Unit.
Ideally, more time is required to teach the ethics module in order to incorporate some of the suggestions elicited by the external review. There is room for expansion to teach medical law and health and human rights and to demonstrate links between the three disciplines to a larger degree. Developing ethics as a “golden thread” that must be woven through all disciplines and departments within the faculty of health sciences requires enhanced awareness and skill in teaching ethics by other clinicians at the bedside. This approach of integration is supported by the literature.21 The development of the “Train‐the Trainers” programme was intended to achieve this end. However, the introduction of an ethics logbook will make it mandatory for clinicians in all disciplines to at least start thinking about ethical issues in their various disciplines and to share them with students. An elective in ethics is supported by existing literature22 and will be marketed more effectively by the Bioethics Unit.
Finally, ethics teaching at medical schools in South Africa is inconsistent and variable. The HPCSA is attempting to develop a core curriculum that can be implemented at all institutions. This will further the goals of medical education in South Africa in a significant way.
The author would like to acknowledge the contribution of all part time lecturers to the module: Professor Anton van Niekerk, Professor Willie Pienaar, Dr Lyn Horn, Dr Sharon Kling, Dr Daniel Sidler, Dr Malcolm de Roubaix and Nico Nortje. The following invited lecturers have made significant contributions to teaching on this module: Dr Wendy Orr, Dr Mohamed Dada, Dr Ames Dhai, Mrs Anita Kleinsmidt, Professor Pierre de Villiers, Professor Marietjie de Villiers and Dr Manie de Klerk.
HPCSA - Health Professions Council of South Africa
Competing interests: None declared.
Professor Moodley is a family physician who currently heads the Tygerberg division of the Bioethics Unit, Centre for Applied Ethics & Faculty of Health Sciences, University of Stellenbosch, South Africa. She has been teaching medical ethics to undergraduate students since 1997 and to postgraduate students since 1999.