A Continuous and All-Level Educational Activity in Medical Ethics: “Problem Discussions”

Introduction
The Importance of Problem Solving in the Teaching of Ethics
From both a methodological and pragmatic point of view, every human activity, can be seen as a “problem-solving” endeavor. Be it basically conceptual (philosophy), cognitive (basic science), applied health sciences (engineering), technical (technology), and other. To appreciate the problems, of a given academically based activity, we must see it in the light of its main methodogical aspects, including its subject matter, purpose(s)/aim(s) and method(s). Medicine, for instance, is an applied science, or science-based applied activity, with basic science being its necessary condition (or sine qua non), and man’s health problems constituting its subject matter. The essential and overall purpose or aim of medicine is to find ways to cope with these problems. Its methods vary according to the medical discipline in question.^1,2 This is also necessary for an analysis of the related moral issues, as in the case of ethical discussions and research on morality — we must inevitably be in a position to know the factual states of affairs, empirical context, in which the moral problems regarding medicine or its main, secondary, or tertiary divisions take place.

The ethical or moral issues in medicine, are dependent upon, if not directly derivable from, the properties of this activity’s specific, scientific-technical methodologies, the characteristics of its main divisions — basic medical sciences, preventive medicine/public health, clinical/therapeutic medicine, and their subdivisions, each having its own kind of submethods or techniques applied in the course of their realization. Furthermore, Medical Ethics as an academic discipline can be regarded as an interdisciplinary field, an intersection between medicine and ethics or moral philosophy. Understandably, however, as a subfield and in the last methodological analysis it is ethics and not medicine. It may thus be regarded as a “differentiated extension” of ethics into the medical area. The corollary is that the subject matter, purpose, methods/techniques involved in the activity of medical ethics are those of moral philosophy in principle, and, in accordance with the current more comprehensive use of the term “medical ethics”, additionally those of human/social sciences involved in moral values and moral problems in medicine. There have been other^3,4,5,6 who also considered medicine from such an academic-methodological perspective.

In the context of the present article, we discuss the methodology of “Medical Ethics” from a pedagogical as well as methodological perspective. It must be stressed that although moral discussions (and judgments) are open-ended, which means that there would be no unanimity of opinion among discussants in a given case or set of cases, what matters in (Ethics and) Medical Ethics pedagogically is that the teacher in this field must be in a position to express his or her own stance in moral matters in a logically (coherent and) rationally sound way.⁷ Although there can in principle be no definite answers to be given to moral problems, and the teacher, as an individual as well as moral thinker, must express his/her own ethical decision making (as well as his/her moral views and judgments), giving, as far as it is possible in the moral sphere, his/her rationales.⁸ Contrary to what we might call “neutrality thesis” as a generally held attitude in different areas of ethics education in our time, we believe that our approach represents good pedagogics, provided that he/she discusses moral issues sincerely and open mindedly with the students. For teachers as well as for learners, and generally speaking, education involves, a complex set of relationships which form a life-long, process^7,9 and this is an institutional and/or individual setting. This temporality involved in the educational process is one of the main aspects of this article as reflected in its title.

The importance of all-level academic discussions and interaction in medical ethics and the related areas
In this section we consider, the rationale(s) of the activity, which has taken place in our Department regularly as monthly presentations during the academic year for 14 years under the general title of “Medical Ethics Problem Discussions”. Understandably, what such a title could signify would not at all be foreign to the reader of the Journal. Regardless it seems to be necessary to explain what we mean by the terms “all-level”, “academic interaction” and “related areas” in connection with a series of activities on medical ethics in a related and “dynamic” university department.^10,11 First, the meaning of “all-level” is three-fold: the great variety in the age, academic title and the professional status of the presenters and participants; the variety of the specialties involved so far as their degree or level of academic technicality is concerned (pediatric surgery, forensic medicine, clinical psychology, and so on); and a variety in the subject matter of their presentations. Secondly, “academic interaction” means that as an established attitude in our meetings, we expect the participants and the presenters, to give their rationales in whatever they claim, be it (basic) scientific, logical, moral…and to whatever extent any one of them would be possible. Thirdly, the expression “related areas”, or areas related to medical ethics may refer to dental, nursing and veterinary ethics, medical education, different aspects of academic life such as one’s observations as a university administrator or the problems of women academicians; the relation of each one of academic fields or topics may differ from a methodological point of view.

Medicine is evidently not just a sum total of scientific knowledge and technical skill, but also includes, as a sui generis activity perhaps, inherent moral values. The latter is closely related to what has been known in our time as the “doctor’s identity”. This is understandable, because the doctor is “a (professional) moral agent”. The acquisition of this identity is explained in two ways: the affect of the moral atmosphere in which the student finds herself/himself during medical education, and the observations of students as regards the attitudes and actions of the teaching staff, in other words, the latter’s overall role-playing. Judging by the variety of the participants so far as their field, academic status, professional experience and so on are concerned, however, it may be said that it is oriented, to the acquisition of identity in other academic professions as well. In our time, where the “mechanization” and even “dehumanization” of medicine are not infrequently mentioned expressions, the doctor is visualized as a professional who would not listen to, does not care much about, the patient, and who has alienated himself/herself from the society at large. This is certainly a justifiable observation, and to whatever extent it may be true, many determinants / factors seem to have been involved in it. In the present context, however, it may suffice for us to indicate that this state of affairs strongly implies a new shaping of medical education from the viewpoint of the future physician’s moral values and communication skills, with an effective emphasis on an awareness and consciousness in ethics / medical ethics.

Table 1. Systemization of the presentations made at Medical Ethics Problem Dicussions

a.General, Methodological, Philosophical Aspects of Medical Ethics

• “The ethical aspects of arriving at a diagnosis” (Physicotherapy)
• “The problems of medical aesthetics from an ethical point of view” (Deontology)
• “The distress created by the passive role in interdisciplinary work, with special reference to pathology” (Pathology)
• “To be a woman: as a scientist, as a spouse, and as a mother” (Pharmacology)

b.Research and Publication Ethics in Medicine

• General Aspects: “The ethical dimension of writing medical articles” (General Surgery).

c.Basically Socially / Publicly Oriented Topics in Medicine, and in Medical and Health Ethics

• “The society and the tuberculosis patient with drug resistance: Whose responsibility?” (Chest Diseases)
• “Ethical issues in family planning” (Medical Anthropology)
• “Transsexuality from the viewpoint of Forensic Medicine” (Forensic Medicine).

d.Genetics and Ethics

• “Medical ethics and the use of human gametes and embryos” (Family Medicine);
• “The Lysenko case from the viewpoint of science ethics” (Deontology).

e.Clinical Ethics – Presentations Related to Different Clinical Branches and Topics

• “Ethical issues in the application of radiodiagnostic visualizing methods” (Diagnostic Radiology).)
• Psychiatric Ethics: “Alternative Medicine” in modern psychiatry and the related ethical questions” (Psychiatry)
• “Psychiatry, torture and the physician’s responsibility” (Psychiatry).)
• The Ethical Aspects of Organ Transplantation

f.Various Ethical Issues in Medicine

• “Physical Medicine and Psychiatry as two Clinical Branches Where Indeterminacy is Frequent” (Physical Medicine and Psychiatry).)
• The Dead Body: “Ethical questions related to dead body from the viewpoint of psychiatry and forensic medicine” (Psychiatry and Forensic Medicine – two speakers.)
• Death and Suicide as Topics of Medico-Ethical Interest: “The patient-doctor relationship vis-à-vis death” (Cardiology); “The impact of the media upon suicide attempts” (Clinical Psychology).)

g.Ethics and Medical Education

• “Education of the physician and his responsibility in renewing himself, (Deontology).
• “The teaching responsibility of the teaching staff” (Neurology).
• “The education and identity of the life scientist” (Pharmacology)

h.Ethics and the History of Medicine as a Discipline

• “Ethical issues in medical history, with the beginning of modern anesthesia as a case in point” (Anesthesiology).)

i.Other Subjects, Directly or Indirectly Related to Medical Ethics

• Dental Ethics: “The three E’s in dental medicine: Ethics, Esthetics, and Economics” (Dental Medicine and Deontology).
• Nursing Ethics: “The ethical aspects of the care of the prisoner as a patient” (Pediatric Nursing)

j.Presentations as regards Personal Experience and Observations on Topics of Medico-Ethical Interest

• “Being an academic administrator in a medical faculty and its problems” (General Surgery).
• “The Physician Couple: The Ethical Dimension of Their Working Together” (Cardiology – two speakers -)

What has so far been considered is certainly a universal problem concerning in principle the institutions of medical education and the medical profession in all the societies. So far as our Faculty is concerned, we have recently begun to give graduate medical ethics courses to specialty and/or doctoral students in different departments, notably in psychiatry and pharmacology. Our regular monthly discussions on the ethical problems in medicine and related areas, as mentioned above and which we will consider in some detail below, may be regarded as a complementary activity in this regard, with its expected common “appeal” to participants of different categories.

A systematization of the topics presented
Here, we give an informative and sufficiently illuminatory systematics from the material at hand, with certain characteristic titles in most sets / subsets given as typical or “not so typical” representatives of them, together with the specialties of the presenters. In those cases where no example has been found worth mentioning in this context, the title of the set and/or the subset, would extent “speak for themselves” so far as the related ethical questions are concerned. We have formed the systematics by beginning with the most general subjects and ending with the basically special if not too specific ones. In any case, we cannot say that our overall outline of the topics / subjects of our program here could be the only and “ideal” systematics which one could create out of the material we had “at our disposal”.

The presentations in question have not been ad hoc; instead, there occur weekly and often as “brown-bag” talks of certain academic circles in medical/biomedical ethics as informal if not necessarily unacademic interactions.

One might say that Table 1, together with the examples accompanying each item / set, would give a basic idea on the conceptual-academic scope and boundaries of the presentations made in the course of our regular monthly program (Table 1).

Conclusion
Critical Observations on the Activity from Academic and Psycho-social Standpoints
The qualification “all-level” in the title signifies the presence or active participation of the “representatives” of different generations of academic / professional life, with differences in their experience, understanding and approach, such as graduate students and research assistants, assistant and associate professors, professors, and other academic people with or without an academic title or degree. Mainly with the overall academic circles of Ankara University School of Medicine in mind, it has possibly had an audience of over 900 potential participants, who would be informed in time by a circular, in principle, about our regular activity taking place on a definite day of the month during the academic year (altogether seven meetings). In the course of time, more and more speakers have been invited from the academic, mainly medical circles outside our Faculty (but as a rule in Ankara). From the very beginning the overall participation in our activity has not been so high as we think it should, possibly with no more than 15 participants as an overall mean number per meeting, changing between a minimum of six and a maximum of 25 (not taking account the extreme cases on both ends). Undergraduate students have only occasionally taken part in the activity as participant, because we invited them, knowing their interest in certain topics of medico-ethical or social, or methodological interest.

Since its beginning in January 1989, the program has been prepared, first, on a monthly, and then semester basis; and for some years now, at the end of the previous academic year and announced in the beginning of the next. As for their actualization, there has been two gaps during the whole course of the meetings which have otherwise taken place regularly or without interruption, with such excuses as “forgetting” in one and “to have to do the clinical routine (surgical operation)” in the other. Interestingly, a rather young professor of psychiatry, who would speak on “the Ethical Aspects of Psychotherapies” according to the program, began his presentation with the question, “What should I really speak about now?”

A great majority of the speakers or presenters have been academicians from different branches of medicine and the related fields. In most cases, the speaker has made a presentation on a subject directly related to his/her specialty. In cases where a more general topic beyond the scope of his/her own limited field was presented, his/her role was that of a teacher, medical thinker, or an experienced academician with his/her different roles. Some presentations were made by more than one speaker, and it may perhaps be interesting to learn that in two cases the speakers were three young sister physicians.

A psychologically interesting and academically significant point arises from our observations on how some of the speaker candidates’ reactions to our proposals to them, to make a presentation in the following academic year’s program in the medical ethics problem discussions. When the choice was of a candidate from among the “frequent guests” or “loyal participants” of our activity, he/she would normally accept our invitation with no or little, if any, hesitation. For some of those candidates who had little experience with presentations, discussions and the literature in medical ethics, and ethics in general, to think of themselves sitting in the presenter’s chair could apparently give them a feeling of responsibility somehow hard to bear. Such candidates would try to give the excuse that they had no academic experience with the subject, and that, accordingly, “they did not know” ethics. When we tried to explain to them that for us ethical discussion, even in an academic milieu, would involve, rather than knowing, the expression of impressions and sharing of feelings and concern in moral issues which should be discussed on a case or set basis, with a clarification of ethical decision-making and moral reasoning in very different professional and/or academic situations, they would mostly be convinced and “accept the invitation”. As we emphasized, the speakers did not at all need to speak in an academically technical language; what we expected from them could be very briefly put as “the sharing of concern in interhuman relationships in their respective areas of academic and/or professional life.

In spite of the fact that the overall academic and social atmosphere during the presentations in our program was apparently not a “formal” one, it was not “informal” either, using both of these words in their usual senses. Most speakers took their expected “jobs” or “missions” seriously from an academic-scientific point of view; and this even when, during the activity itself, humor was a significant component of their presentation and the following discussions. Furthermore, in recent years more and more speakers took their presentations even more academically, with some having a very successful systematics and content which appeared to be texts almost ready as manuscripts to be considered for publication in scientific/academic journals.

We wonder if a possible comparison of such non-routine academic activities between different educational and/or research institutions and countries could be realized in future studies, taking into consideration the different social, cultural, specifically institutional, and possibly other aspects.

References

1. Berns KI. Preventing academic medical center from becoming an oxymoron. Academic Medicine. 1996; 71: 117-20.
2. Korn D. Re-engineering academic medical centers: re-engineering academic values? Academic Medicine. 1996; 71: 1033- 43.
3. Fox E, Arnold RM, Brody B. Medical ethics education: Past, present, future. Academic Medicine. 1995; 70: 761- 769.
4. Gillon R. Thinking about a medical school core curriculum for medical ethics and law. Journal of Medical Ethics. 1996; 22: 323 – 324.
5. Warren KS. The humanities in medical education. Annals of Internal Medicine. 1984; 101; 697- 701.
6. Consensus Statement – Teaching medical ethics and law within medical education: A model for the UK core curriculum. Journal of Medical Ethics. 1998; 24, 188 – 192.
7. Arda B, Örs Y. Teaching medical ethics with an ethics to teach. Bulletin of Medical Ethics. 1996; 116: 19 – 22.
8. Örs Y. Teaching medical ethics in the subjonctive mood. Bulletin of Medical Ethics. 1993; 93: 31 – 36.
9. Arda B. A model from Turkey on the history of the health sciences as seen from the point of view of scientific societies and their contributions- The Guest House Society. Vesalius. 2003; IX(1):28-40.
10. Örs Y. Medical evolution and methodology: On the activities of a university department in Ankara. Clio Medica. 1983; 17(4): 240 – 242.
11. Örs Y. Medicine and ethics: The changing activities of an academic unit. Clio Medica. 1983; 18(1-4): 230 – 231.