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To carry out an appropriate overview and inventory of the teaching of ethics within the European Union Schools of Medicine.
A questionnaire was sent by email to 45 randomly selected medical schools from each of 23 countries in the European Union in February 2006.
25 schools of medicine from 18 European countries were included (response rate=56%). In 21 of 25 medical schools, there was at least one ethics module. In 11 of 25 medical schools, the teaching of ethics was transversal. Only one of the responding schools did not teach ethics. The mean time invested in ethics teaching was 44 h during the overall curriculum.
Ethics now has an established place within the medical curriculum throughout the European Union. However, there is a notable disparity in programme characteristics among schools of medicine.
At the time of the World Medical Associations assembly (WMA) in 1999, a resolution was passed recommending that all schools of medicine should include teaching of medical ethics and human rights as an obligatory course in their curricula.1 Major developments in the sciences, particularly advances in medical care, medical knowledge and techniques and recent societal changes, have made ethics an essential element in daily medical decisions. How have the medical schools of the European Union applied this recommendation? To date, to the best of our knowledge, no comprehensive study has been published with regard to the implementation of this new core curriculum in the medical schools of the European Union, in particular, since its expansion in 2004.
This study aims to carry out an appropriate overview and an inventory of the teaching of ethics within the medical schools of the European Union.
Participating medical schools were selected from the International Medical Education Directory listing, which contains 468 European medical schools (http://imed.ecfmg.org/) and this list was compiled with an internet search (using the key words: medical school or faculty of medicine). Two medical schools were randomly selected from each of the member countries, except Slovenia and Malta (which only have one medical school registered), and Luxemburg and Cyprus (which do not have any registered medical school with a complete curriculum). For countries from where no medical school replied, a third school was randomly selected.
A questionnaire was emailed to the dean of each of the 45 selected schools in February 2006. Email and postal reminder questionnaires were sent 1 month later. This questionnaire included two parts: Form A, which was general, and Form(s) B, of which one form was to be completed for each module that included an ethics element (Appendix A).
Descriptive statistics were used to characterise each item. As requested by certain medical schools, the results are presented anonymously.
From 18 European countries, 25 medical schools were included in the study (response rate=56%). No medical school replied in five countries to the mails (Austria, Czech Republic, Greece, Poland and Portugal) and for Hungary, three medical schools eventually replied (table 11).).
All these medical schools taught a complete medical curriculum. The medical school curriculum of the respondents was between 5 and 8 years in duration (6 years in 18 of 25 medical schools).
All the medical schools except one had one or more local or regional ethics committees. These committees were located within the school of medicine (n=15), within a hospital (n=14) and/or elsewhere (n=7). The ethics committee played a role in teaching in 8 of 24 medical schools concerned. This role seemed to be related to the location of the committee (7 of 8 committees involved in teaching were located within the school of medicine).
What was an integral part of the teaching of ethics? Among the items proposed, 24 of 25 respondents included professional ethics, 22 medical morals/ethics, 22 bioethics, 20 patients' rights, 19 human rights, 18 morality, 20 deontology, 16 philosophy and 8 included religion (table 11).
In 21 of 25 medical schools, ethics modules existed (7 with one module, 14 with more than one modules). In 11 of 25 medical schools, the teaching of ethics was transversal (taught throughout course work in different subject areas), including nine medical schools with both forms of teaching (modular and transversal). Only one of the respondents did not teach ethics (they desired to, but “[d]espite many efforts the Faculty Board and the Faculty's Curriculum Committee have not been allocated the necessary resources to conduct the proposed programme”).
When is ethics taught during the curriculum? During the first 3 years of studies (preclinical level, n=7), later (clinical clerkship level, n=4) and at both preclinical and clinical clerkship levels (n=9). Among these latter nine medical schools, two replied that ethics was distributed throughout the entire medical curriculum (“integrated into the scenarios studied by students throughout the five‐year programme; thus, it is difficult to disentangle the time specifically spent on medical ethics, which is integrated into other teaching and learning activities”).
The mean time invested in ethics was 44 h over the course of the entire curriculum. Seven medical schools could not specify the amount of time: “It is impossible to give any exact amount of time invested in medical ethics”.
Among the 45 identified modules, 35 could be analysed (presence of sufficient information) and among those 35, 30 were part of an obligatory core programme course (table 22).). The mean duration of the modules was 38.9 h, of which 16.8 were devoted to ethics (43%).
The educational methods used for teaching were lectures (n=30), practical case studies (discussion of clinical cases; n=27), individual work, student papers and presentations (n=24), directed study (n=15), clinical examination/hospital rounds (n=8), computer‐assisted teaching (n=5) and others (n=6). Only two medical schools used World Health Organization/WMA course materials.
Instructors who participated in the modules were generally doctors (n=30), ethics/bio‐ethics specialists (n=20) or philosophers (n=16). Other professionals such as healthcare professionals from other disciplines (n=9), scientists/researchers (n=9), lawyers (n=4), theologians (n=4), sociologists/anthropologists (n=3), psychologists (n=3), politicians (n=1), patient representatives/self‐help group leaders (n=1) and others (non‐specified, n=1) were less frequently involved.
The learning process in ethics is generally evaluated (22 of the 26 responses positive for this section of questionnaire). When present, validation methods included a written examination (n=20), an oral examination (n=9) or others (n=2). Examinations consisted of course‐related questions (n=17), analysis of a clinical situation (n=15), short‐answer open‐ended questions (n=12), personal work (eg, reports, thesis) and experience (n=4).
This study presents the interest of being, to the best of our knowledge, the first regarding the teaching of ethics throughout the countries of the European Union since its expansion in 2004.
It was conducted via 23 randomly selected medical schools in the European Union and allowed us to show that a teaching programme in ethics existed in almost all of the responding medical schools. The recommendations of the WMA1 thus mostly seem, to be implemented in the prior European countries as well as in the 10 that recently joined. However, a large disparity was reported regarding the modalities and the duration of the teaching programme.
In our investigation, the mean number of hours devoted to teaching ethics in responding European medical schools was 44 h. This result is similar to that of a prior study carried out in 32 medical schools from 18 European countries,2 where it was 51 h.
In general, European, as well as American, studies are in agreement in emphasising the notable disparity that exists in the number of hours devoted to the teaching of ethics by various institutions (ranging from 0 to 107 h in the present study, from 0 to 140 h in a Croatian study2 and from 5 to 200 h in an American study.3
A few medical schools thus teach little or no coursework in ethics. In addition, we could pose questions regarding the characteristics of non‐responders to this study. They could be less interested and less involved in this field.
Previous inquiries have shown that common barriers to medical ethics instruction were stated to be: a lack of time within the curriculum, a lack of qualified teachers, and a lack of time in teaching‐faculty schedules.4 However, at the same time, the importance of introducing ethics into the medical curriculum has been established by a number of national medical institutions/committees.5,6 The acceptability to administrators of arguments regarding the lack of resources calls into question the true willingness (of medical schools) to implement a teaching programme in ethics. No medical school would allow itself not to offer a course in anatomy or physiology on the pretext of lack of resources or time. One can only hope that, concomitant with international recommendations, all medical schools will progressively grant the importance to ethics instruction that it deserves.
Most of the European medical schools that replied to this survey reported modular teaching (a structured, separate and distinct programme). Nearly half of the medical schools reported transversal teaching (integrated into the curriculum, combined with other courses). Silverberg3 reported similar results in the US.
The development of teaching ethics in a modular format presents several advantages: the time devoted to ethics is greater; it allows for the elaboration of the basics and fundamental notions of ethics; it allows for an approach to ethics that is at the same time theoretical and practical; the learning of ethics is more detailed. However, it presupposes a genuine willingness on the part of medical schools, with a policy and consensus regarding the time to be allocated to ethics teaching, the quality and content of instruction, and the quality of the teaching staff. However, modular teaching is also subject to several critiques. Modular teaching is by nature more concentrated and could not leave sufficient time for the maturation of the student's process of reflection.3
Transversal teaching, on the other hand, may allow for better integration of ethics into future practice, through the acquisition of knowledge pertinent to the specialty in question and through the adaptation of learning to different clinical situations. However, this pedagogical modality presents the risk of reducing the teaching of ethics to a smattering, thereby impoverishing it.
The association of the two modalities, as is the practice in one‐fourth of the respondents in this study, seems thus to be the best compromise. According to some authors,4 ethics education should be integrated vertically and horizontally throughout preclinical and clinical training.7,8,9,10
Although the teaching of the theoretical basis of ethics can have its place in the first years of the curriculum, one can imagine, on the other hand, that practical teaching requires specific medical knowledge and consequently has its place in the clinical clerkship years. Both are thus necessary and the approaches are complementary.
The preference for lecture courses could be explained by the fact that the teaching of ethics took place mainly at the preclinical level.
Nonetheless, in our study, the pedagogical methods did not, a priori, vary according to the level of teaching, which could be unfortunate. Although lecture courses allow for the acquisition of knowledge, the capacity for reflection and the development of practical capabilities, they are unable to deliver outcomes such as “[e]nabling students to think critically about ethical issues in medicine, to reflect upon their own beliefs about ethics, to understand and appreciate alternative and sometimes competing approaches and to be able to argue and counterargue in order to contribute to informed discussion and debate”.11
In a previous study,12 we showed that 65% of the instances, the use of clinical cases allowed one to consider, nonetheless, that the process of learning ethical questioning required discussion and reasoned application of ethical principles. This correlates with the study carried out in 1999, funded by the John Conley Foundation for Ethics and Philosophy in Medicine, in which medical students were asked to submit answers to the question “How can medical students best develop ethical thinking and behaviour?”13 In all, 100 medical students responded. Many students did not want lecture courses to be the primary teaching method for ethics. Most students wanted small‐group discussions in which they could freely discuss the ethical issues that arose in practice. They did not want to treat ethics as a black‐and‐white discipline.13,14 Most students disliked the lecture component, preferring the opportunity, when provided, for small group work. The lectures were viewed by students as being complementary to the small group sessions.
A crucial question is that of knowing to which teaching staff the task of ethics instruction is to be entrusted in schools of medicine. In most medical schools, and in a manner that corresponds with results from the US,3 ethics teaching is initially conducted by doctors or ethics specialists—But are these specialists, doctors trained in ethics or are they “ethicists”? Other professions are little involved.
We can only regret this lack of true multidisciplinarity (eg, a lack of human sciences and social sciences input),5 which would allow for a confrontation of different points of view, offering future doctors the possibility of treating dilemmas through the medico‐scientific‐technical angle, and in a more global manner. This multidisciplinarity could be created by means of better involvement of ethics committees in the teaching of ethics. This involvement is rare at the present time, and according to the results of our investigation, is limited to committees within the university setting.
Although the involvement of doctors is to be expected and even necessary, they must, nonetheless, have both competencies, that is to say, have received high‐level and specific training in ethics.5 Nonetheless, while ethics teaching must call upon persons trained in ethics, this teaching must not result in the pitfall of over‐specialisation, of scientism, of technocratic jargon and must remain close to the clinical context.15
The principal limitation of this study is related to the response rate, which was only 56%. Although low, it is higher than that found in recent international studies on the same subject (eg, 27%12 and 37%16). Generally, only in national studies there has been a better response rate (eg, 66%3 and 79%17). The non‐responding medical schools may be less committed to ethics (teaching), and thus the extrapolation of the results to the totality of European universities must be made with reserve.
Ethics has now an established place within the medical curriculum. However, in Europe, as in the US, there is a notable disparity among schools of medicine in their programmes as well as in the number of hours and in the different categories of teachers. These differences do not seem to arise from national directives but rather from the medical schools themselves, which sometimes suffer from lack of time and lack of means in the implementation of ethics instruction. In a rather acute manner, this poses a problem of the modalities of teaching and seems to favour a transversal mode of teaching which does not require a staff with relevant expertise.
Although the goal of the WMA has not yet been attained in the European Union, we can nevertheless note an awareness of the importance of such teaching. One must, however, regret the inadequacy of, or even deficiency in, utilisation of recommendations and ethics teaching tools such as those made available by the WMA, for instance (only two responding European medical schools stated that they used these course materials).
Medical ethics play a part in everyday practice. On the one hand, medical ethics is necessary to uphold a relationship of solidarity between the art of medicine and the values that are essential to society, and, on the other hand, it is fundamental in the current context of the emergence of new biomedical technologies and exigencies related to the rights of patients. Consequently, the time has now come to organise an effort to improve and validate this important area of medical education.
We thank the respondents of this study.
WMA - World Medical Association
Questionnaire usd in this study
Form A‐General information and Teaching of ethics
Form B‐Ethics modules (one Form B per module containing a specific ethics element)
Competing interests: None.