Teaching Medical Ethics

Srivieng PairojkulDepartment of Pediatrics

Faculty of MedicineKhon Kaen University

Why Ethic Teaching?

Ethics is now regarded as an essential component of medical education

Scott et al, 1991

Most U.S. medical schools had separate or covered medical ethics within required courses

Miles et al, 1990

All 16 Canadian medical schools now offer courses on medical ethics

Baylis and Downie, 1990

The American Board of Internal Medicinerequires “humanistic qualities” evaluation

in residency training program

The Royal College of Physicians and Surgeons of Canada requires bioethics teaching as a condition of accreditation

for post-graduate training programs

Ethic TeachingHow?

ProfessionalismCode of Medical Ethics

DECLARATION OF GENEVA, 1948

AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION:I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;I WILL GIVE to my teachers the respect and gratitude that is their due;I WILL PRACTISE my profession with conscience and dignity;THE HEALTH OF MY PATIENT will be my first consideration;I WILL RESPECT the secrets that are confided in me, even after the patient has died;I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession;MY COLLEAGUES will be my sisters and brothers;I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, politicalaffiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;I WILL MAINTAIN the utmost respect for human life;I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;I MAKE THESE PROMISES solemnly, freely and upon my honour.

AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION:I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;I WILL GIVE to my teachers the respect and gratitude that is their due;I WILL PRACTISE my profession with conscience and dignity;THE HEALTH OF MY PATIENT will be my first consideration;I WILL RESPECT the secrets that are confided in me, even after the patient has died;I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession;MY COLLEAGUES will be my sisters and brothers;I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, politicalaffiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;I WILL MAINTAIN the utmost respect for human life;I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;I MAKE THESE PROMISES solemnly, freely and upon my honour.

How student learn professional values

Bring some to medical school with them

Learn some through the formal curriculum

Learn some from role models

Formal curriculumLectures Seminars Reading

Passive reading, listening,thinking

Hafferty and Franks. Academic Medicine 1994

Informal curriculum(Hidden curriculum)

General clinical experience Peer interactions Ward rounds Multi disciplinary teamsRole model

Powerful embedded in action

Hafferty and Franks. Academic Medicine 1994

Teaching the Hidden Curriculum

Consciously Role ModelingUse Deliberate ReflectionTell the StoriesProvide Humanistic ProblemsInvolve Your PatientsInvolve Your StaffInvolve Your Community

Richard Smith, 2006

Core Curriculum of Medical Ethics• Ethical theory• Physician-patient relationship

- Physicians’ obligations and virtues- Patient autonomy- Truth telling- Informed consent- Determination of competence- Conflict of interest

Core Curriculum of Medical Ethics• Confidentiality• Death and decisions regarding life-

sustaining treatment- Definition & determination of death- Refusal of life-sustaining treatment- DNR orders and medical futility- Advance directives- Euthanasia

Core Curriculum of Medical Ethics• Abortion and maternal-fetal conflicts• Genetics and human reproduction

- Reproduction risk- Reproductive technologies- Gamete donation and surrogacy- Human cloning- Genetic engineering

Core Curriculum of Medical Ethics• Social justice and health care policy

- Justice, rights, and social obligations- Resource allocation- Manage care

• Children issues• Mental health issues

Teaching Methodsfor Medical Ethics

Whole class lectureSeminarCase-based analysisDebate Write-up

Interactive Class RoomAudience Response System

The brain-dead patient and the family’s dilemma

A 15-year old patient, suffered major injuries is now brain dead. The parents have been explained everything. They do not want to let their loved one go, and want to continue treatment.

Can physicians take a decision to switch off the ventilator if it is needed by

another patient?

The brain-dead patient and the family’s dilemma

Can physicians take a decision to switch off the ventilator if it is needed by another patient ?

จากจํานวนผูโหวต 114 คน

52%48%

40%

45%

50%

55%

60%

1. Yes, continue treatment is medical futility. The resource should be allocate toother patients. 2. No, the parents’ autonomy should be respect.

The terminal cancer patientA 50-year old man with metastatic cancer. You know that another trial of chemotherapy may prolong his life for several months, but he will suffer enormous pain. The family had already spent 100,000 Bahts for the treatment. He is poor and has 3 children with a wife who does not earn.

Will you offer this treatment to the family ?

The terminal cancer patientWill you offer this treatment to the family ?

จากจํานวนผูโหวต 116 คน

0%20%40%60%80%100%

1 2

1. Yes, family have rights to receive information regarding treatment options.

2. No, the family could not effort it.

Baby Theresa

Theresa Ann Campo Pearson Anencephalic infant born in Florida in 1992

Parents volunteered her organs for transplantIs it justify to remove the infant’s organs,

causing her immediate death to help other children?

Baby Theresa

Is it justify to remove the infant’s organs,causing her immediate death to help other children?

จากจํานวนผูโหวต 114 คน

61%

39%

0%

20%

40%

60%

80%

1 21. Yes, according to Utilitarian theory2. No, according to Kantian theory

Please Let Me Die!

Dax’s Case

The Case of Dax Cowart• Due to a propane gas Dax was critically injured.• Suffers 2nd and 3rd degree burns on more than

68%. Both eyes, ears and hands are damaged beyond repair.

• Large doses of narcotics are required to reduce the excruciating pain.

Repeatedly wishes he had died in the explosion. Continually begs that treatment be discontinued

and that he be allowed to die.

The Case of Dax CowartShould Dax ‘s request be responded ?

50% 50%

0%

20%

40%

60%

1 21. Yes, because of his suffering and poor quality of life.

2. No, he may make wrong decision because of his pain.

Theresa Marie "Terri" Schiavo

She collapsed, and experienced cardiac arrest leading to 15 years of institutionalization and a diagnosis of persistent vegetative state.

In 1998, her husband and guardian, petitioned the Court to remove her feeding tube. Her parents, opposed this.

Theresa Marie "Terri" SchiavoSchiavo’s feeding tube…..

จากจํานวนผูโหวต 114 คน

34%

66%

0%

50%

100%

1 2

1. Should be removed according to her wish before theincident2. Should not be removed because she is still alive

Feed Back จากนักศึกษา• ดีมากๆ ใหเรามองหลายแงมุมและไดแสดงความคิดเห็นใน case ตางๆ ทําใหรูวาตอไปถาเราเจอเราจะทําอยางไร ตองตัดสินใจอยางไร อยากใหมีการเรียนแบบนี้อีก

• ดีมาก เรียนเขาใจ

• สนุก นาสนใจ ไมมีขอตองปรับปรุง

• ไดฝกคิดอยางมาก ดีกวา lecture อยางเดียว

• เหมือนคุยกันแบบแสดงความคิดเห็นถา lecture คงนาเบื่อ

• อยากใหอาจารยแสดงความคิดเห็นของตนเองดวย

KKU Ethic Teaching

Goals of Ethics teachingKKU

• To incorporate ethics teaching into medical curriculum

• To provide students with knowledge, skills, and attitudes in medical ethics

• To prepare students to be able to make ethically-informed medical decision

Implementation: • Integrate both formal and informal

curriculum• Expose to major ethical principles• Provide knowledge/approach to common

ethical problems in medicine • Include ethical concerns in all aspects of

medical training

Ethics – year 1• History of Medicine

- Ethics- Medical professionalism- Death & dying, evolution of palliative care

• Behavior science- ชีวิตแพทย และจรยิธรรม- ความสัมพันธเชิงแพทยและผูปวย - เทคนิคการสื่อสารกับผูปวย- การแจงผลการตรวจโรคราย- ความตายและผูทีก่าํลังจะตาย

Ethics – Year 2• Anatomy - Memorial service• Small group learning

- Breast cancer with metastasisBreaking bad newsPalliative care

- ThalassemiaPrenatal diagnosisAbortion, pre-abortion counseling

- Child abuseLegal issues

Ethics – Year3• Medical ethics:

- Principles of ethics, decision making in medical dilemmas- Physician-patient relationship- Inform consent- Research ethics - Social justice and health care policy- Medical professionalism- Truth telling and confidentiality- EOL issues and euthanasia- Palliative care- The art in medical practice

• Small group learning• White coat ceremony and preparation

for clinical years

Medicine Surgery Obstetrics-Gynecology

Orthopedics Community Medicine

Forensic Medicine

RehabMed

Physical examPDM Med4: CVSPDM Med5: RSPDM Med6: NSPDM Med7:

AbdomenPDM Med8: Joint

& MusclesProcedural skills

PDM Med1: Universal precaution and specimen handling

PDM Med2- Venepuncture- Sample collection- Fluid analysisPDM Med3: Basic bedside labs

PDM Med11:Blood smear interpretationOthers:

PDM Med9:Report writing

PDM Med10:Learning in clinical yearsCommunication & Ethico-legal issues:

PDM Med12: Clinical reasoning and ethical decision

Procedural skillsPDM Surg1: Hand

scrubbing, Gowning, grooving, scrubbing, and painting operative field

PDM Surg2:- NG tube- Foley’s catheterization- Per rectalexamination.

PDM Surg3:- Ostomy care- ICD- Bandage:stump, arm, leg, headPDM Surg4:- Infiltration andsuture, surgical tie- Short drain, off drain- Wound dressing

PDM Surg5:Pre-post op care

(Surg-Anes)Communication & Ethico-legal issues

PDM Surg6:Consent form for procedure & medicolegal case (Surg & Anes)

Procedural skills: PDM OB-Gyn1:

- Leopold- PV, knotting- Catheterization

PDM OB-Gyn2: - NL- Repair episiotomy woundCommunication & Ethico-legal issues:

PDM OB-Gyn3: -- Professional values- Physician charter

PDM OB-Gyn4: - Counseling forgenetic diseases, HIV- Confidentiality- Unwantedpregnancy- Reproductivedilemmas

PDM Ob-gyn5: Communication with

colleagues, team, patients, & relatives.

PDM Ob-gyn6: …………………Others:

PDM OB-Gyn2EBM

History and physical exam.

PDM Ortho1:History taking and report writing

PDM Ortho2:lower limbs

PDM Ortho4:upper limbs

PDM Ortho5:spines & neurological examProcedural skills

PDM Ortho3 : - Closed reduction of fracture and dislocation- Joint aspiration

PDM Ortho6 : - Traction PDM Ortho7 : - Joint aspiration PDM Ortho8: - CastingCommunication

& Ethico-legal issues::

PDM Ortho9:History taking of OPD cases PDM Ortho10:

Giving information for health promotion

Communication & Ethico-legal issues:

PDM CM1: Communication with patientPDM CM2: พฤติกรรม

การสื่อสาร-

LawsPDM FM1:

กฏหมายที่เกี่ยวของกับแพทย PDM FM2: พ.ร.บ.

วิชาชพีเวชกรรมและขอบังคับ

แพทยสภาวาดวยการรกัษา

จรยิธรรมแหงวชิาชพีเวชกรรม PDM FM3: กฏหมายที่เกี่ยวของกับการชันสูตรพลิกศพ PDM FM4: ความผิดทางเพศPDM FM5: ฝกเขียนใบชันสตูรบาดแผล

Procedural skills: PDM Rehab1: Manual muscle testing PDM Rehab2: Stretching exercise PDM Rehab3: Stump bandagingPDM Rehab4: Mobility training and gait aids PDM Rehab5: Therapeutic exercisePDM Rehab6: Chest physical therapy

Pediatrics Medicine Surgery Community Medicine

Psychiatry Eye/ENT Anesth ForensicMed

Radiology

Procedural skills: PDM Ped1:

- Restraint techniques- IM, IV injection - Arterial puncture - ET intubation- Iinter-osseous infusionCommunication skill, ethico-legal issuesPDM Ped2:

Family centered communication & communication with adolescents

PDM Ped3: Pediatric ethic conference PDM Ped4: Parent’s self-help group PDM Ped5: Psychosocial holistic roundPDM Ped6: Palliative care case conference PDM Ped7: - Play activities for children

Physical examPDM Med12:

CVSCommunication skill, ethico-legal issuesPDM Med13:

Holistic case approach

Procedural skills

PDM Surg7: - Proctoscopy- FNA digital nerve block - Suturing and desuturing

PDM Surg8: - Biopsy superficial mass- Incision and drainage- Debridement of wound PDM Surg9: - Dressing gastroschisis- Excision and incisions - Biopsy- Excision of benign tumor and cyst of skin and subcut. tissue

Communication skill & Ethico-legal issues

PDM CM3: Ethical consideration

Procedural skillsPDM Psy1:

Mental status examinationCommunication skill, ethico-legal issues

PDM Psy2:Counseling skills

EyeProcedural skillsPDM Eye1:

Occular examPDM Eye2:

Direct ophthalmoscopeHealth promotion:

PDM Eye3:Preventive ophthalmology

ENTPhysical exam

PDM ENT1:ENT examProcedural skills:

PDM ENT3:FB removal

PDM ENT4:Nasal packing

PDM ENT5:TracheostomyCommunication skill, ethico-legal issues

PDM ENT2:Communication skills in Medicine

Procedural skills: PDM Anes1Endotracheal intubationPDM Anes2Spinal block

Procedural skills:

PDM FM9: AutopsyLaws

PDM FM6 : ผูปวยคดีPDM FM7: งานนิติเวชกับพนักงานสอบสวนPDM FM8: ตรวจศพสถานที่เกิดเหตุPDM

FM10: ดงูานพิจารณาคดทีี่ศาลPDM

FM11: พยานทางการแพทยPDM

FM13: Case study-บาดแผลPDM FM14

: Medical malpracticePDM FM15

: จรยิธรรมทางการแพทย

PDM FM16: ผูปวยคดี 2

Procedural skills PDM Radio1Clinical

radiology skillsCommunication skills & Ethico-legal issuesPDM Radio2- Writing radiologic request - Medical reports - Information giving

Medicine Surgery Obstetrics-Gynecology

Pediatrics Orthopedics

Communication & Ethico-legal issuesPDM Med : - Writing prescription

PDM Med : Breaking bad news, truth telling

PDM Med : Palliative careOthers

PDM Med :Information IT searching

Procedural skillsPDM Surg10:

- Incision and drainagePDM Surg11:

- Suture- ICD- Circumcision

PDM Surg12: - Venesection- Appendectomy

PDM Surg14: Evaluation of trauma, evaluation of severity and complication

Communication & Ethico-legal issues

PDM Surg13: Asking for organ transplantation PDM Surg15:

Malpractice and negligence

Procedural skillsPDM OB-Gyn8:

Pap smear, cervical Bx, vaginal packing, IUD, TR implant contraception

PDM OB-Gyn9: Ultrasonography

Communication skills, ethico-legal issuesPDM Ped3:

Pediatric ethic conference PDM Ped6:

Palliative care case conference PDM Ped8: Identification of child abuse and child protection lawPDM Ped9: Child protection case conference

Physical examPDM Ortho 8:

upper limbs PDM Ortho 11:

Spine

Procedural skillsPDM Ortho 7:

Emergency in orthopedics

PDM Ortho 9:Reduction and casting technique

PDM Ortho 10:Cadaveric workshop: closed reduction of common dislocation, joint aspiration and debridement

Ethic-medico-legal Conference2006

• Introduction to Bioethics• Truth telling• End-of-life issues• Medical malpractice• Medical futility• Ethic approach to abortion• ขอบงัคับแพทยสภาวาดวยหลักเกณฑการปฏิบัติเกี่ยวกับการยุติการตั้งครรภทางการแพทย

• Research ethics• Medico-legal report

• Principles of bioethics and decision making

• Surrogate decision making• Ethics at beginning of life• สิทธิบัตรยา• พระราชบัญญัติสุขภาพแหงชาติ• Ethico-legal issues in psychiatry

Ethic-medico-legal Conference2007

The Hiddened Curriculum• Training workshops for teachers:

- Communication skills- Clinical teaching- Other medical education trainings- Medical professionalism

• Training workshops for residents- Communication skills- Clinical teaching- Medical professionalism

Topics HoursLecture Practice

1. Clinical reasoning2. Principle of bioethics4. Patient centered care5. Patient safety5. Quality improvement6. Leadership7. Palliative care: Why and how?

111111

1.58. Advance communication skills in Medicine9. Clinical teaching10. Defining professionalism 11. Ethic conference (3 hours x 3 sessions)12. Medical laws13. Supervision and feedback

33393

1.5 Total 7.5 22.5

Post-grad curriculum - Medical Professionalism

New KKU Medical Curriculum• Module 1 - How to learn

* Principles of ethics• Module 2 - Life and life cycle

* Ethics in early life issues• Module 3 - Life and environment

* Public health issues• Module 4 - Human society and culture

* Resource allocation• Module 5 – Gen. principles for med science

* Inform consent

• Module 6 - Skin and connective tissues • Module 7 - Hemato & lymphoreticular

* Truth telling• Module 8 - MS 6wk

* ALS and physician assisted suicide• Module 9 - Neuroscience

* Brain death & EOL issues• Module 10 Endocrine and metabolism• Module 11 - GI and nutrition

* Termination of life support

New KKU Medical Curriculum

• Module 12 - RP * Artificial reproductive technologies

• Module 13 – KUB* Organ transplant

• Module 14 - RS • Module 15 - CVS

* CPR and DNR orders• Module 16 - Correlated basic & clinical science • Module 17 - Intro to clinical

* Physician-patient relationship* Patient-centered care

New KKU Medical Curriculum

What Should be Assessed?

Actions

Assessment method

Habituation

Knowledge

Learning outcome• OSCE• 360 feedback

• Portfolio• Vignettes

• MCQ• EMQ• Essays• MEQ• Case study• Vignettes

• Ethical and clinical competency

• Moral development• Values, attitudes and beliefs

• Knowledge and understanding ofethical principles,medical guidelines

• Critical thinking skills and ethical awareness/sensitivity