The Medicine and Human Rights special studymodule: a Physicians for Human Rights (UK) initiative

R.S. MAXWELL & D.J. POUNDERDepartment of Forensic Medicine, University of Dundee, Scotland, UK

SUMM AR Y Human rights have been much neglected in medical

education. An attempt to ® ll this gap was made by introducing a

`Medicine and Human Rights’ special study module into the

undergraduate programme at Dundee. It covers issues such as

physician participation in torture and the death penalty, rape in

war, and the physical and psychological results of torture. Var ious

teaching methods were used, with an emphasis on self-directed

learning. Assessment was by students’ par ticipation in the

programme, including a formal presentation to the class. An

evaluation of the programme showed it to be appreciated by

tutors and students. As a subject, human rights is worthy of

in-depth study by medical students; its study also helps them

acquire a variety of important generic competences. Some aspects

of human rights may merit inclusion in the core programme,

`Man in Society’ .

Introduction

The General Medical Council (1993) published a key docu-

ment: Tomorrow’s Doctors: Recommendations on Undergraduate

Medical Education. This lays out a series of recommended

changes in basic medical education. The recommendations

were designed to solve two problems: they would reduce

curriculum overload and allow courses to adapt to recent

changesÐ social, cultural and technological. A key feature

of the GMC document is the creation of a core curriculum

de® ning the ª requirements that must be satis® ed before a

newly quali® ed doctor can assume the responsibilities of a

pre-registration house officerº . It was recognized that the

diversity among medical schools might be lost with the

introduction of a more stringent core course. To maintain

that diversity, the core curriculum was reduced by 33%.

That time was given over to special study modules (SSMs)

which allow students ª to study in depth in areas of particular

interest to themº .

The GMC recommendations have prompted medical

schools throughout the UK to create SSMs and introduce

them into the MB ChB curriculum. The University of

Dundee introduced a new curriculum in the academic year

1995± 96; since then, SSMs have been playing an important

part in the course (Harden et al., 1997).

In Phase 2 of Dundee’s new curriculum (academicYears

2 and 3), SSMs account for 23% of teaching time. The

relationship between core and options is sequential (Harden

& Davis, 1995). Students proceed to the modules only after

mastering the core. This arrangement caters for differences

in learning speeds. Modules last 2 weeks or 4 weeks.

This paper describes the introduction of an SSM on a

previously neglected subject: the interactions between

medicine and human rights.

Why a special study module on medicine and human

rights?

Respect for human rights is generally agreed to be desir-

able. It is also a vital aspect of international social and

economic development. Medicine has a multifaceted

interface with human rights.Their special skills, their role in

society and their ethical standards make doctors particularly

well placed to promote respect for human rights. Through

lack of a clear awareness of the issues, doctors are also at

risk of being drawn into human rights abuses. Violations

can and do occur in western societies. We are just as guilty

as some countries in the Middle East or the Third World.

Prior to the new Dundee medical curriculum, the subject

had not been studied. However, it had become increasingly

apparent that human rights was an important topic and

merited study. Students could now do so by choosing this

SSM, to enhance their awareness and appreciation of human

rights in medicine.

In keeping with the GMC recommendations, the module

was designed to help students acquire various generic compe-

tences. In particular, the GMC stated that, on completion

of their degrees, medical students should possess a know-

ledge of and understanding of ª ethical and legal issues

relevant to the practice of medicineº ; an ª awareness of the

moral and ethical responsibilities involved in individual

patient careº and should develop an attitude which

recognizes patients’ rights in all respects (GMC, 1993).

Pressure for teaching on human rights to be included in

the medical curriculum has existed throughout the world

for many years. In the UK, a non-governmental organiza-

tion, PHR (UK), lists among its objectives a desire to educate

health professionals about human rights. Until recently, this

had been impossible owing to competition for curriculum

space. However, a statement in Tomorrow’s Doctors provided

the long-awaited opportunity: the extent and range of

modules offered should closely re¯ ect and depend upon the

ª interests, resources and individual enthusiasms of medical

school staff and . . . the wider range of opportunities within

their universitiesº .The implementation of the new Dundee

curriculum built on pre-existing links between PHR (UK)

and the Department of Forensic Medicine, where PHR

(UK) is based. Dundee medical students can now enhance

their knowledge of human rights and widen their perspec-

tive.

Correspondence: Professor D.J. Pounder, Department of Forensic Medicine,

University of Dundee, Dundee DD1 4HN, Scotland, UK.Tel: 44 1382 348020.

Fax: 44 1382 348021. Email: forensicmed@dundee.ac.uk

Medical Teacher, Vol. 21, No. 3, 1999

0142-159X/99/030294-05 ½ 1999 Taylor & Francis Ltd294

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Module organization

External funding from PHR (UK) allowed the authors to

develop a medicine and human rights module. Develop-

ment took 8 months. At the end of academic year 1995± 96

the SSM was ® rst taught to 27 Phase 1 students.

Initially, we concentrated on aspects of human rights

with which PHR (UK) were already involved. However, as

the course was developed, this extended. Contact was made

with over 100 national and international organizations. Over

700 resources were collected: medical journals, legal texts,

textbooks, news reports and publications and videos from

non-governmental organizations. Only some were actively

employed on the course.

Aims and objectives

The Medicine and Human Rights SSM had six aims:

· to provide students with a knowledge of human rights

standards as expressed in internationally agreed texts; the

supervisory mechanisms which encourage compliance;

and the ways in which practical respect for human rights

is ensured;

· to encourage in students an appreciation of the ways in

which medical personnel can be drawn unwittingly into

human rights abuses;

· to help students develop a knowledge of how medical

personnel and their professional organizations can protect

and respect human rights;

· to assist students to develop the capability of working

efficiently and effectively in groups.

· to assist students to develop the capability of communi-

cating through seminar presentations and discussions;

· to assist students to develop an attitude which views respect

for human rights as an integral part of medical practice.

These aims are in the course guide given to students on

starting the module.

Structure and content

The module (see Figure 1) is divided into nine roughly

equal sections. Each addresses one key issue. Sections build

upon, and make use of, knowledge gained earlier in the

module. A number of underlying themes pervade the course.

These range from potential social and legal responses to

violations of human rights, through documentation of

injuries, to treatment and rehabilitation of victims.

The ® rst day’s general introductory lecture-based session

and series of class exercises provides students with the main

legal and human rights knowledge needed for their work on

the course. The issues in the remainder of Week 1 mainly

follow sequentially. In Week 2 the topics are less connected,

but still have a natural progression. The key areas are:

diagnosis and rehabilitation of torture victims, as well as

medical involvement in torture and the death penalty; the

need to respect human rights within public health pro-

grammes such as AIDS control; women’s rights and rape in

war; and seeking asylum from the point of view of the

psychological aspects of torture. Mechanisms of redress for

human rights abuses are explored throughout the two weeks.

Teaching and learning strategies

In line with the GMC recommendations, the Medicine and

Human Rights module moved away from traditional teaching

methods and adopted approaches that enhance self-

directed learning.This is particularly appropriate in human

rights: the individual must, within the objective framework

provided by human rights law, make a decision based on

interactions among a variety of personal and professional

factors. The SSM featured directed group discussions

(Figure 2). These allowed a wide range of sub-topics to be

studied in the short time available.

Each topic commenced with a br ief introductory

presentation to outline the educational approach. The class

divided into three large groups that each researched, using

pre-selected written material, a different aspect of the topic’s

background. Guidance on groupwork skills was offered if

the course lecturers felt a group was having difficulty in

functioning effectively. Each group was free to decide how

best to approach the task in hand. It could, for example,

sub-divide the issues and work in pairs or individually.

Sub-groups then reported back to the whole group in time

to prepare a presentation on major issues.This presentation

was made to the whole class, in sufficient detail to provide

a review of the literature.

Figure 1. Weekly overview of the Medicine and Human Rights special study module.

The Medicine and Human Rights special study module

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This newly acquired knowledge was then applied to

human rights issues. New groups were formed of approxi-

mately six students to introduce students to the idea of

teamwork and changing team composition. Groups received

a series of ® ctionalized case studies or a number of relevant

questions. Unlike the parallel research session, these smaller

groups all worked on the same tasks. They tried to agree

about the issues raised before a whole-class discussion.

Student assessment

At the start, students were told what assessment procedures

would be employed by tutors. This information was also

printed in the course guide. Because the module is highly

participatory, every student who attended and actively

contributed was likely to pass. However, to gain more than a

mere pass students had to contribute signi® cantly in the group

exercises and presentations. Groups were monitored for how

well they worked together and for whether they achieved their

tasks efficiently and effectively. This was possible, despite the

constant ¯ ux in group composition, simply by observing the

strategies adopted by the group and how well the group

responded to available guidance. Being vocal was not the only

pro® ciency in groupworking; involving all group members

and listening actively were of equal importance.

Knowing that assessment depended so heavily on

presentations made to the class, some of the more confident

members spoke at the ® rst opportunity.Towards the end of

the module, those who had not yet presented began to push

themselves more. As they gained con® dence, they sought to

improve their grading. Guidance in presentation skills was

offered to all students.

Assessment of student presentations was based on a form

obtained from Richard Ellis, an Edinburgh-based trainer

and consultant in communication. The form assessed

presentations under ® ve headings:

· verbal skills, e.g. audibility, clarity and pronunciation;

· non-verbal skills such as eye contact and use of gestures;

· content and structure of the presentation;

· strengths (according to the examiner);

· areas requiring attention.

Under each heading, the examiner put the presentation into

one of three categories. For example, under audibilityÐ the

® rst verbal skill to be assessedÐ the choices were:

· volume well suited to room;

· reasonable, occasional difficulty in hearing;

· poor, difficult to hear, under-projected.

Every student was given a copy of the assessment form in

advance so that they all knew the criteria. They were told

that con® dential feedback on their presentation would be

available, if requested. Every aspect of a presentation was

transferred directly to a numerical scale. These numbers

were totalled, then combined with the tutors’ assessment of

that individual’s contribution to group exercises and to class

discussions. When overall student gradings for the module

were being decided, the forms gave some objective guidance

in classifying students against each other.

Evaluation

The Medicine and Human Rights module was assessed

with a standard feedback questionnaire from the Curriculum

Development Section of Dundee’s Medical Faculty. Students

also completed a questionnaire from the Department of

Forensic Medicine that examined the SSM as a complete

unit and assessed different aspects of individual topics.The

departmental questionnaire gave students space to make

free-text responses: these were later combined with vocal

comments made during the two weeks. Finally, the tutors

themselves assessed the course.

Tables 1 and 2 contain quantitative data from the 26

completed Curriculum Development feedback forms. That

form listed a number of statements concerning module

organization (Statements 1.1 ± 1.5), and delivery (State-

ments 2.1± 2.18). Each was evaluated on a ® ve-point scale,

ranging from 1 (strongly disagree) to 5 (strongly agree).

Figure 2. Typical educational strategy employed in the Medicine and Human Rights SSM.

Table 1. Student opinions of the Medicine and Human Rights SSM organization.

Statement Responsea

Blank

/invalid

1 2 3 4 5 Mean

valueb

1.1 The course was well organized 0 0 0 0 3 23 4.9

1.2 The study/course guide was useful 1 0 0 1 10 14 4.5

1.3 I always knew where I should be 1 0 0 0 7 18 4.7

1.4 I chose this module 1 0 0 0 5 20 4.8

1.5 The process for allocating modules was

appropriate

0 0 1 5 11 9 4.1

a 1 = strongly disagree; 2 = disagree; 3 = uncertain; 4 = agree; 5 = strongly agreeb

Excludes blank/invalid entries

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The success of the course is obvious from the responses

to all but two of the statements. Question 2.14 asked students

whether they had been able to decide the area of study.

Their responses had a mean of 3.6, signi® cantly lower than

that for most other questions. However, this merely re¯ ects

the highly de® ned module structure, in terms of areas of

study and time per subject. The subjects for group discus-

sion were largely determined by what material was avail-

able.To aid digestion of a large volume of material, guidance

was given on which documents would be of most use.

The lowest mean value (2.5) came in response to ques-

tion 2.16, which asked whether students would have liked

more time to study. In contrast with all other questions, this

low value is actually positive. It states that students were

satis® ed with the time allocated to speci® c tasks, within the

topic and to the whole topic.

Of the 21 participants who completed the Department

of Forensic Medicine questionnaire, 15 rated the course

`excellent’ and the remaining six `very good’ . Many students

stated how enlightening they had found their studies; they

wished to continue learning about the issues they had

touched upon. It was evident that most enjoyed having had

the chance to look at these important issues.

The course provided ample opportunity for individuals

to assess and to question their own attitudes and perspec-

tive towards many issues. Contentious topics, such as the

death penalty and physician participation in torture,

provoked many lively discussions, especially with participants

whose life experiences differed from those of most students.

Class members found themselves continuing to discuss

issues during lunchtimes and at the end of the day with

peers who had selected different modules. The grasping of

essential legal knowledge proved an exciting challenge to

many, widening their perspective and intellectual abilities

through comprehension of a different academic discipline

and teaching style.

Comments and observations from staff and students led

to slight modi® cations of the course material. Primarily

these adjusted the time allocated to certain subjects and,

during the initial sessions, offered guidance on groupwork

skills and presentation skills.

From a teaching perspective, the course was highly

successful, drawing a great deal of active participation from

class members.The inherently ¯ exible nature of the module

allowed progress to be matched to class needs. Sub-issues

were included or omitted as time permitted. Groupworking

and the reconstitution of groups permitted dissemination of

a large quantity of material and the discussion of a wide

range of issues.

The free-text responses were encouraging. Additional

Table 2. Student opinions of the Medicine and Human Rights SSM.

Statement Responsea

Blank

/invalid

1 2 3 4 5 Mean

valueb

2.1 I understood the objectives of the module 0 0 0 0 8 18 4.7

2.2 The structured events of the module were

well delivered

0 0 0 0 7 19 4.7

2.3 There was adequate time available for

private study

1 0 0 3 6 16 4.5

2.4 There was adequate time to re¯ ect on what

I learnt

0 0 0 3 8 15 4.5

2.5 I explored in depth the subject material 0 0 0 5 7 14 4.4

2.6 The course was exciting 1 0 0 0 8 17 4.7

2.7 I felt I had responsibility for my learning 0 0 0 1 11 14 4.5

2.8 I felt able to in¯ uence the running of the

module

0 0 1 4 10 11 4.2

2.9 The module gave me new insight into

medicine

0 0 0 0 6 20 4.8

2.10 I was able to explore the material at my

own pace

0 0 1 5 11 9 4.1

2.11 There was appropriate guidance and

direction

0 0 0 0 9 17 4.7

2.12 The module helped me consider my future

career development

1 0 0 2 9 14 4.5

2.13 The assessment allowed me to express the

work I had done

0 0 1 2 11 12 4.3

2.14 I was able to decide the speci® c area of

study

0 1 1 11 8 5 3.6

2.15 A range of learning materials were used 0 0 0 1 8 17 4.6

2.16 I would have liked more time to study 3 6 6 6 4 1 2.5

2.17 I found this module challenging 0 0 0 0 8 18 4.7

2.18 I enjoyed the module 0 0 0 0 2 24 5.0

a1 = strongly disagree; 2 = disagree; 3 = uncertain; 4 = agree; 5 = strongly agree

bExcludes blank / invalid entries

The Medicine and Human Rights special study module

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module strengths outlined by students included: organiza-

tion and structure, range of content, provision of all relevant

material, logical nature, success of self-directed learning

mechanisms, learning how to review literature, immediate

application of acquired knowledge.

In contrast, concerns about information overload led to

a few calls for issues to be summarized rather than asking

students to extract the important aspects themselves. In

response, it was explained that one purpose of the course

was for students to learn the skill of selective information

retrieval for themselves. Indeed, certain students considered

information availability to be one of the module’s strengths.

There were also calls for additional time to be spent on the

issues, perhaps by making the SSM a three-week or four-

week module, thereby enabling a more complete picture to

be gained.

Discussion and conclusion

Lessons to be learnt from this module are signi® cant to

those who implement change in medical education as well

as those interested in human rights. A signi® cant majority of

students felt human rights was both important and useful: it

deserved a place in the medical curriculum. Inclusion of the

topic as a special study module allowed human rights to

enter the medical curriculum.

The SSM educated students on how to avoid becoming

ensnared in situations where violations are allowed to occur. It

provided them with information about how to respond,

individually or collectively, should abuses be brought to their

attention. Evaluation revealed secondary bene® ts in develop-

ment of generic competences and skills, all of which are

essential to the wider practice of medicine. Approaches that

gave students more responsibility for their own learning were

successful. Directed small-group teaching and self-learning,

while requiring more active participation from students,

facilitated understanding and appreciation. Students were

eager to become more personally involved in the issues they

were studying.The Medicine and Human Rights SSM success-

fully encouraged an alternative approach to learning, where

personal transferable skills are developed and actively applied.

Issues debated in the module can be applied to most

core courses. The course fostered an attitude that viewed

respect for human rights as an integral part of medical

practice. This attitude should remain with students forever.

Although originally designed to run for 2 weeks, the SSM’s

modular structure allows topics to be selected at will then

studied to the required or desired depth. If run in full, there is

material for a full 3 weeks. Careful use of groups made it

possible, within the 2 weeks, for a sufficiently comprehensive

understanding of the background information to be obtained

prior to application of the principles. The modular structure,

chosen deliberately, also allows the material to be used in a

variety of medical settings, in various cultures and within

differing traditions. Timetabling can be adjusted to ® t the

considered priorities of any given teaching environment.

How best, then, can the success of an individual module

spread beyond its creating institution? Not every medical

school in the UK has an organization like PHR (UK) within

its walls. Can special study material be exchanged or shared?

The GMC (1993) recognized the additional workload

created by introducing an optional element into the

curriculum; it encouraged medical schools not only to share

their ideas on development of special studies, but also to

make the necessary teaching and learning materials avail-

able to one another. PHR (UK) and the Department of

Forensic Medicine have done this. They both intend to

continue helping medical undergraduates develop an attitude

of respect for human rights protection. The Medicine and

Human Rights SSM is now freely available on the World

Wide Web for any interested parties to download and use as

required. The address is: http://www.dundee.ac.uk/

med&humanrights/SSM/welcome.html

In considering the practical details of the shift to the new

curriculum, the GMC (1993) was concerned that material

removed from the core should not resurface disguised as an

SSM , thereby perpetuating information overload and

preventing re® nement of core teaching. A unique initiative

such as this module makes consideration of the classi® ca-

tion of `core’ a pertinent debate. Traditionally, the content

of elective periods has been dictated by material already

included in core studies. However, our students have said

that all medical undergraduates should receive education

on human rights issues. Some Medicine and Human Rights

material would enhance core teaching on ethics. It may thus

open avenues revising what is classi® ed as `core.’

Acknowledgement

We gratefully acknowledge external funding from Physi-

cians for Human Rights (UK). That ® nancial help enabled

the creation of the Medicine and Human Rights special

study module.

Notes on contributors

MR S RACH EL MAXWELL obtained her LL.B law degree from the

University of Warwick in 1995. Since moving to Dundee and creating

this education module, she is presently writing her doctoral thesis

evaluating whether human rights law and medical ethics provide

sufficient regulation for the medical profession with respect to torture.

PROFESSOR DERR ICK J POUNDER has been head of the Department of

Forensic Medicine at the University of Dundee, Scotland since 1987 .

As founder member and past chairman of Physicians for Human

Rights (UK), he acts as consultant for a range of human rights agen-

cies internationally.

References

GENERAL M EDICAL COUNCIL (1993) Tomorrow’s Doctors: Recommenda-

tion on Underg raduate Medical Education (London, GMC).

HARDEN , R.M. & DAVIS, M.H. (1995) AMEE Medical Education

Guide No. 5. The core curriculum with options or special study

modules, Medica l Teacher, 17(2), pp. 125 ± 148. [Also available as a

booklet from: Association for Medical Education in Europe,

University of Dundee, Tay Park House, 484 Perth Road, Dundee,

DD2 1LR, Scotland, UK.]

HARDEN , R.M ., DAVIS, M.H. & CROSBY, J.R. (1997) The New Dundee

Medical Curriculum: AWhole that is Greater than the Sum of the Parts

Medical Education, 31, pp. 264 ± 271.

Bibliography

DOWDING , T.J. (1993) The application of a spiral curriculum model to

technical training curricula, Educational Technology, July, pp. 18± 28.

HARDEN , R.M. (1986) Ten questions to ask when planning a course

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