Teaching BioethicsTeaching BioethicsArnuparp Lekhakula M.D., M.S.Department of Internal MedicineFaculty of MedicinePrince of Songkla UniversityHat Yai, Songkhla, Thailand

Plan of Presentation

Why should we teach?Who should we teach?What should we teach?How should we teach?How should we evaluate?

Why should we teach?

Performance PerformancePerformance

(and quality)(and moral distress)

Why should we teach?

Minimizes complaints and ligitation Improves patient satisfaction Improves treatment complicance Improves clinical outcome Lowers cost Builds trust and mutual respect

Who should we teach?

Medical studentsResidentsFellowsPracticing physiciansHealth care teams

What should we teach?

Depends on profession level of

“student” specialty

What should we teach?Critical issues

Formal vs informal curriculumTheory vs practicePrinciples vs decision tools vs paradigm cases

What should we teach?Medical students

Integrated curriculumStudent-specific ethical dilemmas (Hicks et al) conflict between medical education

and patient care responsibility beyond one's

capabilities perceived substandard patient care

I should call thestaff back...

An intern and clinical clerk are asked to close a surgical wound; staff then leaves the OR. Neither the intern or the clerk has performed this procedure before.

Is this being done incorrectly?

Will this affect the clinical outcome?

Intern attempts to close the incision,appears to be having difficulty.

How can I call my staff without humiliating

my resident?

Intern now clearly has difficulty. Patientbeginning to rouse from anesthetic.

Clerk decides not to call staff. Internfinishes closing.

If I call for help, I’ll look incompetent, get less opportunities and it may affect my mark.

Wound infection

How should we teach?

LectureTeacher’s cases Paper Video Standardized patientLearner’s casesBedside encounter

Undergraduate Medical Ethics University of Toronto Medical School

1Year Structure & Function

- - 2Ethics decision procedure two hr whole class ssssssss

-2Care of newborns with hr multidisciplinary s sssss ssssssssss panel Genetic testing & treatment 1-hr whole class session

Metabolism & Nutrition sssssss sss ssssssss s -ss s ssss sssss sssssss1 sssssssssssss sssssss s s ssss s ss ss s -ss ss sss sssss sss ssss2 Truth telling in Medicine

Undergraduate Medical Ethics University of Toronto Medical School

11 Brain & Behaviour

Brain death 1-hr whole class presentation

2YearPathobiology s ss sss ssssss - 2 hr small group,

- case based semi nar Foundation to Medical Practice

ssssssss sss sss s -ss sssss sssss sssssss1 - 2 hr small group with SP

The end of life -ss sssss sssss sssssss1

Undergraduate Medical Ethics University of Toronto Medical School

Informed consent - 2 hr small group seminar ssssss ss sssssssssss - 2 hr small group seminar -Euthanasia and Physician ssssssss sssss - 2 hr small group seminar -34Year (Clerkship) ssss ss ssssssss s -ss ss sss sssss sss ssss( ) 1 Informed consent & -substitute decision making (Surgery) - 1 hr small group seminar - Ethical problems (Paediatrics)1 hr small group seminar - 4 4Medical jurisprudence (Yr ) three hr whole class

Undergraduate Medical Ethics University of Toronto Medical School

Adjunct curriculum sss s s s s& ( 1 & 2 )

- Patient doctor relationship weekly small group Health, Illness and the Community (Yr 1 & 2 )

Social aspects of illness - 3 .5 hr symposium Social justice -ss ss sss sssss ssssssss4

3Determinants of Health (Yr ) sssssss ssssss ss ssssssss - 2 hr seminar Health care expenditure & heal t h economi cs -ss sssssss1

Undergraduate Medical Ethics University of Toronto Medical School

Adjunct curriculum -Costs and cost effectiveness ss ssssss ssss - 2 hr workshop ssssssss sssssssss s& sssssss sssssssss -ss sssssss1 Developing & implementing CPG’s -ss sssssss1

Teaching Medical Ethics the University of Chicago

Program Concepts (“5 C’s”) Program Concepts (“5 C’s”)• Teaching should be C linically cased• Real patient C ases should serve as the teaching focus• Teaching should be C ontinuous• Ethics teaching should be C oordinated with the students’ other learning objectives• C linicians should be participate actively in the teaching effort both as instructors and as role models

Teaching Medical Ethics the University of Chicago

1 2Year &- Doctor patient relationship

Social and ethical issues in Medicin

s (Philosophical bioethics, euthanasia

, researchethics, health& economi cs, ssssss)

ss sss ss sssss sssssss sssssss,

ng, HIV issues, human experimentation

Cognitively impaired patients

• sssss sssss ssssssssssss• -Team taught sssssss• Small group ssssssssss• Demonstration• Seminar• Independent s ssssssss&

Teaching Medical Ethics the University of Chicago

3 4Year & - 1420Medicine ( hr)

Care of terminal illness, consent, - truth telling, HIV issues, health csss economics, confidentiality, legal issues, st udent r ol es

- 816Surgery ( hr) Consent, HIV issues, ethical issuss in breast surgery, trauma surgery, poor out come

• ssss ssssssssssss• ssss ssssssssss• sssssss• Lecture

Teaching Medical Ethics the University of Chicago

3 4Year &- - sss( 2 6 )

Reproductive ethics, terminal illness, treatmentof mi nor s, soci oeconomi c i ssues i n heal t h care, HIV issues

- Pediatrics (4 6 hr) Care of infants and children, -reproductive ethics, socio economi c i ssues i n heal t h care, legal issuesElective

• ssss ssssssssssss• ssss ssssssssss• Reading• Lecture

Teaching Medical Ethics the University of Newcastle

11 : 6 9seminars ( hr) Theories of moral reasoning Information disclosure Patient competence -Truth telling Refusal of treatment - Doctor patient relationship 12 : 4 6seminars ( hr) sssssss sss sssssss sss Acts and omission Active and passive euthanasia Doctrine of double effects s ssssssssss sss s sssssss ss

• Tutor inputs including ssssss• sssssssss-sss ssss sssss ssssssss• Selected reading• Small group ssssssssss• sssss ssssss

Teaching Medical Ethics the University of Newcastle

13 : 3 45seminars ( . hr) Obligatory beneficence Paternalism Autonomy vs beneficence sssssssss sssssssssss sss ssss sssssssssss

• Tutor inputs including ssssss• sssssssss-sss ssss sssss ssssssss• Selected reading• Small group ssssssssss• sssss ssssss

Teaching Medical Ethics the University of Newcastle

14 : 9 seminars (13.5 hr) Medical negligence Reproductive technologies - Selective non treatment of ssssssss Terminating medical care Allocation of health resources sssssss ss ssssssss Rights and duties Medical and social utility Cost containment Beneficence vs justice conflicts

• Tutor inputs including ssssss• Ward rounds• Patient care team• sssssssss-sss ssss sssss ssssssss• Selected reading• Small group ssssssssss• sssss ssssss

Teaching Medical Ethics the University of Newcastle

5Year : 7 ( 1 0 .5 ) - Medico legal issues Risk management Solicitors’ letters and courts s sssssssss Human experimentation Termination of medical care Transplantation Drug use and abuse AI DS s sssssss

• Tutor inputs including ssssss• Ward rounds• Patient care team• sssssssss-sss ssss sssss ssssssss• Selected reading• Small group ssssssssss• sssss ssssss

Teaching Bioethics Faculty of Medicine, PSU

11 : General Philosophy 12 : 135. hours Foundation to Clinical Practice and Medical Ethics I

Introduction to Ethics-Meta ethics

Ethical reasoning I Foundation to Clinical Practice and Medical Ethics II

- Doctor patient relationship Ethical reasoning II Ethical reasoning III

Teaching Bioethics Faculty of Medicine, PSU

13 : 18 hours Foundation to Clinical Practice and Medical Ethics III

Principles of BioethicsAutonomy

-Beneficence and Non maleficence Foundation to Clinical Practice and Medical Ethics IV

Difficult patients Justice and resource allocation

Breaking bad news Difficult of life and death Medical codes of ethics

Teaching Bioethics Faculty of Medicine, PSU

14 : 12 hours Health and Diseases of Adults and Elderly

ssssssssssssssssssssss

-Substitute decision making- Doctor patient relationship

Preoperative to Postoperative Caresssssss

Truth telling and withholding information Conflict of interest (student issue)

Family and Community Medicine Public health ethics

Teaching Bioethics Faculty of Medicine, PSU

15 : 15 hours Health and Diseases of Adults and Elderly

s ssssss sss-ss-ssss ssss Preoperative to Postoperative Care

Refusal of treatment Medical negligence Health and Diseases from Conception to Adolescence

Involving children in decision making Resource allocation

Health and Diseases of Women- Maternal fetal dilemma

Medical futility Reproductive technology

RCPSC Bioethics Requirements

“The academic program must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to the specialty” “That the Royal College extend evaluation of bioethics in all of its current methods of evaluation of programs and residents”

RCPSC Bioethics ProjectGoals

To integrate bioethical knowledge and skills into the clinical practice of residents To assist Canadian post-graduate program directors to teach bioethicsTo develop model curricula in medicine, surgery, OBGYN, and psychiatryTo develop evaluation strategies

RCPSC Bioethics ProjectMedicine Curriculum Topics

truth tellingconsentcapacitysubstitute decision makingconfidentiality

conflict of interestappropriate use of life-sustaining treatmenteuthanasia / assisted suicideresource allocationresearch ethics

How shall we evaluate?

Knowledge Mutliple choice, true / falseAnalysis Essay questionPerformance Chart review OSCE In-training evaluation