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Teaching Bioethics

Teaching Bioethics. Arnuparp Lekhakula M.D., M.S. Department of Internal Medicine Faculty of Medicine Prince of Songkla University Hat Yai, Songkhla, Thailand. Plan of Presentation. Why should we teach? Who should we teach? What should we teach? How should we teach?

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Teaching Bioethics

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  1. Teaching Bioethics Arnuparp Lekhakula M.D., M.S. Department of Internal Medicine Faculty of Medicine Prince of Songkla University Hat Yai, Songkhla, Thailand

  2. Plan of Presentation • Why should we teach? • Who should we teach? • What should we teach? • How should we teach? • How should we evaluate?

  3. Why should we teach? • Performance • Performance • Performance • (and quality) • (and moral distress)

  4. Why should we teach? • Minimizes complaints and ligitation • Improves patient satisfaction • Improves treatment complicance • Improves clinical outcome • Lowers cost • Builds trust and mutual respect

  5. Who should we teach? • Medical students • Residents • Fellows • Practicing physicians • Health care teams

  6. What should we teach? Depends on • profession • level of “student” • specialty

  7. What should we teach?Critical issues • Formal vs informal curriculum • Theory vs practice • Principles vs decision tools vs paradigm cases

  8. What should we teach?Medical students • Integrated curriculum • Student-specific ethical dilemmas (Hicks et al) • conflict between medical education and patient care • responsibility beyond one's capabilities • perceived substandard patient care

  9. I should call the staff 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.

  10. Is this being done incorrectly? Will this affect the clinical outcome? Intern attempts to close the incision, appears to be having difficulty.

  11. How can I call my staff without humiliating my resident? Intern now clearly has difficulty. Patient beginning to rouse from anesthetic.

  12. If I call for help, I’ll look incompetent, get less opportunities and it may affect my mark. Wound infection Clerk decides not to call staff. Intern finishes closing.

  13. How should we teach? • Lecture • Teacher’s cases • Paper • Video • Standardized patient • Learner’s cases • Bedside encounter

  14. Undergraduate Medical Ethics University of Toronto Medical School Year 1 Structure & Function Ethics decision-procedure 2 two-hr whole class sessions Care of newborns with 2-hr multidisciplinary myelomeningocele panel Genetic testing & treatment 1-hr whole class session Metabolism & Nutrition Truth telling and androgen 1-hr whole class session insensitivity syndrome Ethical Dilemmas of 2-hr small group seminar Truth telling in Medicine

  15. Undergraduate Medical Ethics University of Toronto Medical School Year 1 Brain & Behaviour Brain death 1-hr whole class presentation Year 2 Pathobiology HIV and Ethics 2-hr small group, case-based seminar Foundation to Medical Practice Breaking bad news 1-hr whole class session 2-hr small group with SP The end of life 1-hr whole class lecture

  16. Undergraduate Medical Ethics University of Toronto Medical School Informed consent 2-hr small group seminar Ethics in Paediatrics 2-hr small group seminar Euthanasia and Physician- assisted death 2-hr small group seminar Year 3-4(Clerkship) End of life care (Medicine) 1-hr small group seminar Informed consent & substitute decision-making (Surgery) 1-hr small group seminar Ethical problems (Paediatrics)1-hr small group seminar Medical jurisprudence (Yr 4) 4 three-hr whole class

  17. Undergraduate Medical Ethics University of Toronto Medical School Adjunct curriculum Art & Science of Clinical Medicine (Yr 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 4-hr small group tutorial Determinants of Health (Yr 3) Ethical issues in research 2-hr seminar Health care expenditure & health economics 1-hr lecture

  18. Undergraduate Medical Ethics University of Toronto Medical School Adjunct curriculum Costs and cost-effectiveness of health care 2-hr workshop Clinical practice guideline & quality assurance 1-hr lecture Developing & implementing CPG’s 1-hr lecture

  19. Teaching Medical Ethics the University of Chicago 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

  20. Teaching Medical Ethics the University of Chicago Year 1 & 2 Doctor-patient relationship Social and ethical issues in Medicine (Philosophical bioethics, euthanasia, research ethics, health & economics, legal issue) Use of human body, genetic screening, HIV issues, human experimentation Cognitively impaired patients • Large group • presentation • Team-taught • lecture • Small group • discussion • Demonstration • Seminar • Independent • study & research

  21. Teaching Medical Ethics the University of Chicago Year 3 & 4 Medicine (14-20 hr) Care of terminal illness, consent, truth-telling, HIV issues, health care economics, confidentiality, legal issues, student roles Surgery (8-16 hr) Consent, HIV issues, ethical issues in breast surgery, trauma surgery, poor outcome • Case • presentation • Case discussion • Reading • Lecture

  22. Teaching Medical Ethics the University of Chicago Year 3 & 4 Obstetrics-Gynecology (2-6 hr) Reproductive ethics, terminal illness, treatment of minors, socioeconomic issues in health care, HIV issues Pediatrics (4-6 hr) Care of infants and children, reproductive ethics, socio- economic issues in health care, legal issues Elective • Case • presentation • Case discussion • Reading • Lecture

  23. Teaching Medical Ethics the University of Newcastle Year 1 : 6 seminars (9 hr) Theories of moral reasoning Information disclosure Patient competence Truth-telling Refusal of treatment Doctor-patient relationship Year 2 : 4 seminars (6 hr) Killing and letting die Acts and omission Active and passive euthanasia Doctrine of double effects Withholding and withdrawal • Tutor inputs including • lawyer • Clinician-led case • study analyses • Selected reading • Small group • discussion • Class debate

  24. Teaching Medical Ethics the University of Newcastle Year 3 : 3 seminars (4.5 hr) Obligatory beneficence Paternalism Autonomy vs beneficence conflicts Contractual and role obligations • Tutor inputs including • lawyer • Clinician-led case • study analyses • Selected reading • Small group • discussion • Class debate

  25. Teaching Medical Ethics the University of Newcastle Year 4: 9 seminars (13.5 hr) Medical negligence Reproductive technologies Selective non-treatment of newborns Terminating medical care Allocation of health resources Justice as fairness Rights and duties Medical and social utility Cost containment Beneficence vs justice conflicts • Tutor inputs including • lawyer • Ward rounds • Patient care team • Clinician-led case • study analyses • Selected reading • Small group • discussion • Class debate

  26. Teaching Medical Ethics the University of Newcastle Year 5 : 7 seminars (10.5 hr) Medico-legal issues Risk management Solicitors’ letters and courts Negligence Human experimentation Termination of medical care Transplantation Drug use and abuse AIDS Genetics • Tutor inputs including • lawyer • Ward rounds • Patient care team • Clinician-led case • study analyses • Selected reading • Small group • discussion • Class debate

  27. Teaching Bioethics Faculty of Medicine, PSU Year 1 : General Philosophy Year 2 : 13.5 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

  28. Teaching Bioethics Faculty of Medicine, PSU Year 3 : 18 hours Foundation to Clinical Practice and Medical Ethics III Principles of Bioethics Autonomy 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

  29. Teaching Bioethics Faculty of Medicine, PSU Year 4 : 12 hours Health and Diseases of Adults and Elderly Consent Confidentiality Substitute decision-making Doctor-patient relationship Preoperative to Postoperative Care Consent Truth telling and withholding information Conflict of interest (student issue) Family and Community Medicine Public health ethics

  30. Teaching Bioethics Faculty of Medicine, PSU Year 5 : 15 hours Health and Diseases of Adults and Elderly Quality end-of-life care 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

  31. 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”

  32. RCPSC Bioethics ProjectGoals • To integrate bioethical knowledge and skills into the clinical practice of residents • To assist Canadian post-graduate program directors to teach bioethics • To develop model curricula in medicine, surgery, OBGYN, and psychiatry • To develop evaluation strategies

  33. truth telling consent capacity substitute decision making confidentiality conflict of interest appropriate use of life-sustaining treatment euthanasia / assisted suicide resource allocation research ethics RCPSC Bioethics ProjectMedicine Curriculum Topics

  34. How shall we evaluate? • Knowledge • Mutliple choice, true / false • Analysis • Essay question • Performance • Chart review • OSCE • In-training evaluation

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