Teaching of medical ethics in Faculties of Medicine

From a competent student to a responsible physician

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Foreword for ethics

ethics is not a prejudice, but a reflection

So ethics is not by itself a science

ethics is inspired by the philosophical reflection about « the person » The person being either « individual » (autonomy,

personal needs) or « citizen » (relationship, solidarity, collective needs)

Medical ethics is a reflection about medical acts through the patient-physician relationship

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« at first, not to harm »

A precursor… Hippocrates

Foreword for medical ethics

medical ethics is political too : it differs from society, collectivity. It is influenced by social, legal, biological reflections. It cannot provide for each issue an universal answer.

medical ethics evolves following the technics : age for surgery, death criteria, assisted conception…

medical ethics is a self-evaluation of their practices by the physicians, open to other professionals

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Why a new need for medical ethics ?

the medical specialization moves the doctor closer to the ill organ and moves him away from the « person » (body mechanization)

technical progress reduces the importance of physical examination (are we treating a person… or a picture ?)

the law is not suitable to the new fields of the bioethics and medical advances

growth of the health cost is leading, in a medium term, to cares decrease

the frequent confusion(and confrontation) between the « feasible » coming from the medical technologies, and the « desirable » for the patient

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(report Alain Cordier)

State of the teaching of ethics in the frenchspeaking universities (1)

Out of 45 Faculties(study of G.Llorca, CIDMEF) : Specific teaching : 36 (80%) Obligatory teaching : 32 (71%) Average : 29 h (maximum, Strasbourg 123 h)

Pedagogical methods : Lectures / 33 (73%) Reflection groups : 14 (32%) Cases analysis : 19 (43%) Special meetings in the hospital : 9 (20%) Integrated in medical specialties: 22 (50%)

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(2)

Evaluation : Assiduity : 16 (36%) Oral examination : 8 (18%) Written examination : 25 (56%) Reports of cases : 10 (23%) MCQ : 4 (9%) ECOS : 2 (4%)

Teachers : Physicians with ethical leaning : 36 (80%) Teachers of Philosophy : 27 (60%) others: 7 (16%)

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A strategy for the teaching of medical ethics

1. providing the basic theories for a reflection1. medical

2. philosophical

3. sociological

2. leading the student to become aware of ethical reflection by collective studies of practical cases

3. obtaining an individual involvement : follow-up of patients, presentation of actual cases, reports, thesis.

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Three steps

Before the teaching

The ethical formation will begin usefully only after the selection for admission, to avoid huge numbers of students

It would be a wish to get an awakening to ethics before the admission into the Faculty, for instance by the philosophy teachers in the last year of the secondary school.

as we discuss about ethics it’s a paradox that, in most of the Faculties, the humanist qualities of the candidates are not taken into consideration for the students selection.

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Don’t forget the density of our curriculum…

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First part of the curriculum: basic theories

Some thought steps (outside religious aspects)

Immanuel Kant : autonomy , duty to others(1788)

Jean-Jacques Rousseau : social contract, solidarity between citizens(1762)

John Rawls (theory of justice, 1971)

Hans Tristan Engelhardt : compassion principle (1986)

Paul Ricoeur : otherness (1990)

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Towards the medical values…

objectives

understand the ethical norms and assimilate theorical and practical knowledge definition of a person, citizen, patient,

vulnerability…) public health, solidarity human rights, health rights health system and its actors

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• find immediate applications in subjects with specific ethics

• anatomy (dissection)• biology (research)

objectives

make the student understand elements concerning the confidence of the patient and duties of the physicians (code of ethics or deontology, science of duties),

assimilate the values of the physicians keep up the clinical competence be honest with the patient. Provide him an adapted information to

his understanding respect the professional secrecy pay attention to the patient. Let him receive a secund advice understand and accept the principles of solidarity

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Secund part of the curriculum: ethics in medical practice

The professional competence is the first and primordial value of medical ethics : then evidence based medicine is an ethical part of the training

The details of patient-physician relation Patient’s trends : degree of the illness, confidence or doupt,

degree of understanding, importance of the near social circle Doctor’s trends : competence, ability to explain, to convince,

ethical sense

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First level

ethics in medical practice

Let the student be aware of the usual ethical problems : difficulties of medical decision, of communication Disagreement between the nearest of a patient about a decision Legal or practical difficulties for application of an ethical advice Potential danger for somebody of keeping a professional secret Conflict between two ethical principles for the same case. ….

Special situations : announcement of a bad prognosis, end of life patient, hurting words

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This teaching to the ethical questioning requires a special training: small groups with tutors, with hand-outs provided, and followed by reports

second level objectives

in the hospital the exemple value

In the hospital activity, we must work about : Relation student / nurses Relation student / patient

Clinical examination Given explanations

Ethical behaviour of all the members of the staff

The seniors’ counter-exemples are disastrous !

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Third part of the curriculum & specialties cycle

Personal involvement into ethical problems : charge of practical cases, reports, presentation of specific difficulties in the ethical field of the specialty

Most concerned Specialties, Cancerology Geriatrics Emergency, intensive care Pediatrics, gynecology Infectious diseases …

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From the student-doctor to the responsible physician

Organisation of common seminars with continuous medical education

Education for ethics in human research

Two possibilities : Master of research in ethics

Master 1 : initiation to methods in ethics research Master 2 : specialty in ethics research

Or the presence of a chapter devoted to ethics in each medical research master.

obligations for a student, describe the ethical issues when designing a

research with humans obtain specialized training devoted to protection of persons

undergoing research

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the foreseeable risks must not outweight the potential benefits to the patients

Choice of the teachers

A requirement : coexistence of physicians, other health professionals, and nonhealth professionals…

In the case of physicians : no professionnal in ethics, but practised in ethics

For the nonhealth professional : philosophers, anthropologists, sociologists…

All must have obtained a PhD in ethics… ideally…

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Structures of ethics in Faculty of medecine and universitary hospital

Ethics laboratory in the Faculties which aims : organization of teaching organization of research Continuing education in connection with hospital

Ethical space in universitary hospitals reflection and answers to the daily problems participation of all the health professionals continuing education in connection with the Faculty

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Conclusion

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A good doctor

ought learn and keep

the balance

Clinical competence

Ethical competence

Bibliography

Conseil européen des Ordres des médecins : « Charte européenne d’éthique médicale ». www.ceom-ecmo.eu/charte-europeenne-dethique-medicale-51

Comité Consultatif National d’éthique pour les sciences de la vie et de la santé : avis n°84 : « avis sur la formation à l’éthique médicale », 2004. www.ccne-ethique.fr

A Cordier : « Rapport » . www.sante.gouv.fr/htm/actu/cordier

Ch Hervé et al : « Visions éthiques de la personne ». L’Harmattan ed, 2001.

P La Marne : « Réflexion éthique et formation médicale », ADSP, 1999. www.hcsp.fr/explore.cgi/ad285456.pdf

M Parker et al : « introducing medical ethics » The ethox centre, University of Oxford, sept 2011.

World Medical Association : « WMA ethics manual ». www.wma.net

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