Human rights (HR) is important in medicine; violations in HR not only result in health problems but some kinds of HR violations are possible in treatment by medical professionals themselves. Therefore in medical education, awareness of HR, their reflections in the community and in treatment approaches are essential. This article is devoted to HR in medical ethics as a different educational perspective. The pilot study was carried out in our medical ethics course with a class of third year students at Ankara University School of Medicine during Spring 2000 semester. The study focused on the superiority of an interactive education over a classical education in medical ethics through the problems related to HR. The data reflects that role-playing as one of the interactive learning experiences is the best suited to help medical students achieve the curriculum’s educational objectives.
Human rights (HR) is defined as a relationship between the public authority and citizens. It is important in medicine since violations in HR not only result in health problems but may result from the aid of medical professionals in some instances. Furthermore, HR violations can be regarded as epidemic diseases influencing the overall community. Therefore in medical education, awareness of HR, their reflections in community and treatment approaches are essential.
This research article is devoted to HR in medical ethics as a different educational perspective. In 1999, the World Medical Association declared that medical ethics and human rights must be an important component of medical education. In accordance with this declaration, and owing to the fact that HR is an especially critical issue in Turkey,1, 2,3 some hot HR issues such as “torture, “hunger striking”, “capital punishment” and “hymen examination” have been included in the syllabus of a medical ethics course offered at Ankara University School of Medicine since 1993. Physicians play a critical professional role in the field of HR and should be well informed of their ethical responsibilities and should absolutely develop an occupational identity related to HR.
How do we learn attitudes that contain such responsibilities? Learning of attitudes is realized as follows:4
1. Society and culture: Most of the attitudes are learned this way.
2. Role modeling: Moral atmosphere is important.
3. Interactive education: Case discussions, role playing, and simulations help to obtain attitudes with interactive methods. Practice intensifies learning.
Despite agreement on the necessity to adapt adult education principles to medical ethics teaching, there are some difficulties with curriculum integration, experimental learning, and assessment methods. Student assessment is a quite important component of medical ethics education. Most of the authors have emphasized the lack of information regarding evaluation. The perceived difficulty of objectively evaluating intangibles such as human values and prejudices and the lack of suitable and valid assessment techniques are the main reasons of the lack of evaluation. 5,6,7, 8, 9, 10
Despite problems about the nature of the “humane attitude” and whether it can be taught or not, the humane attitude has an ethical component. Could these courses give students the opportunity to stand outside their extremely narrow focused, “pure” medical activities and look on them from a different viewpoint? The final aims encourage a critical and questioning attitude to professional identity, including human rights subjects. Integration has been accepted as an important educational strategy in medical education. Harden describes eleven points on a continuum between the two polarized debates in favor and against integrated teaching. These points are stressed as isolation, awareness, harmonization, nesting, temporal co-ordination, sharing, correlation, complementary, multi-disciplinary, inter-disciplinary, trans-disciplinary by Harden. Didactics and seminars will be taught as part of the curriculum inevitably but all of them must not be lectures.11,12 Interactive learning experiences are best suited to help medical students achieve the curriculum’s educational objectives.13
MATERIAL AND METHODS
This study is concerned with HR as a tool to express the importance of proposed interactive education in the material. Therefore, the study focuses on the superiority of an interactive education over a classical one in medical ethics through the problems related to HR.
This pilot study was carried out in the medical ethics course with a class of third year students at Ankara University School of Medicine during spring 2000 semester. The students were divided into Group A and Group B and following the presentation of some theoretical information by the course instructor, were provided with two cases reflecting different HR issues in medical practice. They were then asked to discuss the issues, and following a role distribution, to act out the cases. The role-play was followed by a feedback session in which the students not only expressed how they personally felt about the issues but also assessed the session itself. Finally, a written examination was taken and results were analyzed.
Case 1: Dr. A works in a state hospital as a practitioner. The hospital is defined as a reference one and is responsible for providing medical services to detainees. One day while Dr. A is working in the out-patient clinic, two armed gendarmes come in with a man handcuffed. The man is a prisoner and is suffering from nausea and vomiting. The patient is taken into the examination room and the gendarmes are asked to stay out the room, but they refuse to do so and insist on staying in the same room during the medical examination. Dr. A says that they have to wait in front of the door, but they don’t accept. If you were Dr. A, what would you do and why? If you were the patient how would you feel?
Case 2: Dr. B. is a practitioner and works in a primary health care unit. One day two young girls and two men come to his office. The girls are crying and the men look quite angry. One of the men introduces himself as the director of a dormitory for girls. He then complains about the girls’ close relations with the boys. He requests that you perform hymen examination. If you were Dr. B. what would you do? Would you perform hymen examination or not? Discuss your occupational responsibility on this case considering the emotional status of the young girls. Think about the importance of the “informed consent” concept in physician-patient relationships.
DISCUSSION AND CONCLUSIONS
Instead of applying traditional assessment techniques and relying solely on statistical results, I prefer to focus more on educational experience. The feelings of the medical students after the interactive lecture were so impressive. They noted that this “drama” approach in teaching made it possible for them to understand the perspective of the patients and to think and feel like them. Generally they agreed that this method is better than having it in the form of a lecture. Their feelings with their words are as follows…. “I feel deep anxiety when I act the patient”, “I think this (writing a medical report) is not my job”, “I feel despair myself”, “I want to escape”, “I’ll never forget this experience”, “A different kind of learning”…
The students reported that they know the Declarations of the World Medical Association and the other basic international documents, but they wanted to apply the ethical approach in their medical practice. They emphasized that feelings and emotions are similar to those in the real world and this method is more impressive than traditional lectures.
Medical ethics must be an indispensable part of the medical education. As generally accepted it should be spread to all periods of education and it should be student-centered, integrated and population oriented. Population orientation is also of importance. For example, Yehova witnesses is not a good case for educational discussions in Turkey because it has no connection with the real life practices of our population. Students want to know whether various cases are realistic or not; their preference is always for real cases such as the two already mentioned. For that reason, Yehova witnesses are difficult to understand and too “fantastic” in the students’ point of view.
When incorporating such a method into classroom teaching, certain limitations and difficulties should be taken into consideration. For instance, the instructor needs to allocate more time. He or she should be ready to cope with tasks such as scenario writing and developing assessment tasks. The number of students is also a concern. However, it should be noted that the advantages and educational outcomes far outweigh these limitations and difficulties. This method greatly contributes to attitude education, persistent effect, and the students’ development of emphatic mindedness, awareness, sensitivity to case discussions on ethics education, as mentioned in the literature.14, 10
Lecturing is not the only appropriate method fordeveloping attitudes in medical education; an integrated and interactive method may be preferred, however unfavorable the conditions are. We are responsible for implementing a social and population-based curriculum. This is our primary responsibility both for our students and our society.
- Iacapino, V., Heisler, M., Pishevar, S., Kischner, R. Physician complicity in misrepresentation and omission of evidence of torture in postdetention medical examinations in Turkey. Journal of the American Medical Association. 1996; 276 (5): 396 – 402.
- Istanbul Protocol; manual on the effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment. Professional Training Series No. 8, United Nations, Office of the High Commissioner for Human Rights, Geneva, 2001.
- Arda, B. How should physicians approach a hunger strike? Bulletin of Medical Ethics. 2002; 181: 13- 8.
- Steinert, Y., Snell, L.S. Interactive lecturing; strategies for increasing participation in large group presentation. Medical Teacher. 1999; 21 (1): 37 – 42.
- Goldie, J. Review of ethics curricula in undergraduate medical education. Medical Education. 2000; 34: 108- 119.
- Hebert, P.C., Meslin, E.M., Dunn, E.V., Byrne, N., Reid, S.R. Measuring ethical sensitivity of medical students: A study at the University of Toronto. Journal of Medical Ethics. 1992; 18: 142 – 147.
- Rezler, A.G., Schwartz, R.L., Obenshain, S.S., Lambert, P., Gibson, J.M., Bennahum, D.A. Assessment of ethical decisions and values. Medical Education. 1992; 26: 7 – 16.
- Self, D.J., Wolinsky, F.D., Baldwin, D.C. The effect of teaching medical ethics on medical students’ moral reasoning. Academic Medicine. 1989; 64: 755 – 759.
- Self, D.J., Baldwin, D.C., Wolinsky, F.D. Evaluation of teaching medical ethics by an assessment of moral reasoning. Medical Education. 1992; 26: 178 – 184.
- Shorr, A.F., Hayes, R.P., Finnerty J.F. The effect of a class in medical ethics on first year medical students. Academic Medicine. 1994; 69: 998- 1000.
- Gillon, R. Case studies and medical education. Journal of Medical Ethics. 1996; 22: 2-4.
Ors, Y. Ethico-drama and education in bioethics. Eubios Journal of Asian and International Bioethics. 1995; 5:154.
- Harden, R.M. The integration ladder: A tool for curriculum planning and evaluation. Medical Education. 2000; 34: 551 – 557.
- Gillon, R. Thinking about a medical school core curriculum for medical ethics and law. Journal of Medical Ethics. 1996; 22: 323- 4.