Open Journal Systems

ETHICS AND BIOETHICS

Received: May 25^th 2015

Accepted: December 10^th 2015

The perception of ethics from the point of view of medical students

José Alberto García-Mangas,^a José Luis García-Vigil,^b Alberto Lifshitz^c

^aMaestro en Ciencias de la Educación

^bMaestro en Ciencias Médicas, Diplomado en Investigación Educativa

^cSecretario de Enseñanza Clínica e Internado Médico, Facultad de Medicina, Universidad Nacional Autónoma de México

Distrito Federal, México

Communication with: José Alberto García-Mangas

Telephone: (55) 5582 8629

Email: mangas3357759@gmail.com

Background: The present study was conducted to characterize the ethical environment in which medical students and internal are trained. The aim of this article is to identify the perception of ethics in medical students.

Methods: The instrument was constructed by pairs: the socially desirable and socially undesirable exploring 10 principles and 24 ethical values. Through rounds of experts the instrument was validated with 35 pairs with 70 statements. The internal consistency of the instrument with the coefficient of determination “r2” reached a “p” value of < 0.025.

Results: In the overall analysis to compare means, students gave higher scores than interns with “p” value of < 0.002. A comparison of the principal differences was found in seven of the ten principles explored and in three (freedom, honesty and solidarity) no differences were noted in the rate of perception of the ethics (RPE). The were statistically significant differences between groups with a “p” value of < 0.04 in which students perceive higher scores with interns.

Conclusions: We conclude that learning environments are not prone to ethical reflection and changes depending on the degree in training in medical school, with a worse perception in greater degrees.

Keywords: Education, medical; medical students; Codes of ethics; Professional ethics

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Ethics describes and reflects on the conscious, free, and voluntary acts that are based on principles and are expressed in practice through values. The ethics of education, therefore, addresses virtue, duty, happiness, and good living for those involved in promoting learning and the development of knowledge in medicine, i.e., teachers, health professionals, and students.

Aristotle said: "It depends on the man himself if he is or is not happy; because it depends only on him to do what is good or bad. Man can act randomly or routinely, but can also act reflectively, with understanding of the self with the self, the self with others, and self with the context. In the case of "doing", this deals with technical and productive knowledge; in the case of "working" it is doing what is moral."¹

There is interest, for purposes of this paper, to distinguish between ethics and morality, because it is important to emphasize that moral theory means custom and, as such, changes depending on the characteristics of human groups, such as the imposition of a certain social group against another. These are rules that are imposed from the outside, from the social context and not from within the individual. This justifies a series of dogmas which, as such, are considered unquestionable; the adjective "moral" is not synonymous with "good", but indicates that an action can be morally good or bad, according to what is in force at the time. The moral individual loses their ability to regulate themselves and the conviction that emerges with self-questioning, from reflection on what is vital and important, for authentic individual and collective deliberation and free action arise out of this.²

For this study we chose ethical thought as an invitation to delve deep into our being. Ethics arise from reflection that mediates between the individual and the rule. The relationship with the norm is no longer immediate, but is mediated by reflection, by the critical capacities of the individual, and it implies that the subject already has the capacity and courage needed to be authentic and self-regulated. The ethically "good" or "bad" individual is one who has come to this preference through their own conviction, imposing on their person a principle of autonomy, considering the risks, benefits, and limitations involved in any action. In the same vein, ethical thought is an invitation to choose, through reflection, the maximum values ​​and principles that enrich the human being, with the advantage that this can avoid impulsive or automatic obedience, in addition to enhancing the development of rational thoughts tinged with emotion, as a way to make the most appropriate choice. Therefore, freedom is the essence of all ethical thought and behavior.³

For its relevance, it is important to distinguish between principles and values. Ethical principles are natural laws that ultimately control the consequences of our actions. Values ​​(or counter-values as appropriate) are internal and subjective, and represent what we feel most strongly and what guides our action. For the purposes of this study we clarified that ethical principles are higher values; we decided also that ethical values ​​arise from ethical principles, that the two have different hierarchical levels, and that their value is relative. Ethics, principles, and the values ​​that emanate from them, can lead to more or less broad consensus, on the understanding that acceptable ethics in the performance of a profession do not usually bear discussion. Ethical values are conceived as ​​essentially interrelated in a hierarchical order that Rangordnung called nature a priori and emotionally accessible. It is therefore a hierarchy ranging in rating systems and resulting in a scale of values: the values ​​are organized into two categories, acceptable or unacceptable, the unacceptable may also be referred to as counter. In conclusion, it may seem that values ​​are merely relative, but in reality this relativity concerns only the awareness that every person has them.

Teaching practice and the formation of ethical values ​​in medicine have different scopes and implications; training and practice in a dignified axiological conception of being honest is often challenging. According to Max Scheler, Kant made two mistakes: confusing the a priori with the formal, and arguing that everything a priori necessarily has the status of rational, because the values ​​are apprehended by an emotional intuition other than mere psychological apprehension. In other words, values ​​are perceived a priori, but not necessarily linked with the formal, and their apprehension is not only done from intellectual knowledge, but also emotionally, through “intentional sentimental perception."

The quality of our spirit that we call "preference", taking as an example the student that is influenced by the environment, shows us that values ​​are a strict hierarchy of rankings that is transmitted through the image. We may be mistaken in our preferences, putting the inferior before the superior, switching acceptable and unacceptable ranges of values. When this is becomes constitutive of a person, and a "certain error of preferences" becomes habitual, then we are facing a socially undesirable ethical conception.

According to Kohlberg, in his proposal for moral reasoning, youths 13 years and older are at level III (autonomous moral principles); starting at this time and for the first time, the person recognizes the possibility of conflict between two patterns and tries to decide between them. The correct action tends to be defended in terms of the rights of the individual.⁴

The population to be studied is medical students and residents who, thanks to their level of education, are old enough to be able to distinguish between socially acceptable values ​​of those that are not. The student of medicine and medical specialties is usually an adult who has reached moral reasoning and therefore the capacity for choice.

This proposed measure is based on the interest in understanding and knowing more about the occurrence of certain principles that are not only intellectual, but also ethical for medical practice, which would allow, if necessary, timely and appropriate decisions for one’s own and others’ benefit (fellow students, teachers, and patients). With the study results, we hope to clarify some of the impact and events of ethical connotation that may impact on the dignity and the lives of all involved in the process of medical training and professional practice.⁵

This instrument is intended to assess ethics objectively. The measurements try to investigate the scope and limitations of behaviors and medical practices that have ethical connotations, with the intention of seeking the most promising alternatives for education to gain a sense of ethical reflection, and for learning and training to be significant in life.

Students’ perceptions are the starting point for measurement, and the observations of them that emanate from specific situations are "valid" to understand daily action.

The proposed instrument considers ethical assertions that, as arguments, "require no validity or demonstration". This instrument can be applied to a wide variety of actors with the role of students in the medical career, with the prerequisite that the examinees’ answers should be as sincere as possible about how they perceive or "live" ethical principles and values that are explored during the teaching event.^6,7

With this assessment tool we aim to move beyond subjectivity and the prevailing self-complacency; its design is not centered on dogma or Manichaeism that everything is good or bad. It is about using the pairs in the instrument to appropriately weigh observations of what is acceptable and unacceptable in ethical experiences that are a source of experience that students are exposed to, and that can be expressed through responding to the instrument; that is, how they experienced the ethical event in the daily practice of medicine and medical education. We are interested in pertinently characterizing and clarifying how ethics happens in daily practice, under certain conditions and circumstances, and assessing the scope of the environments that influence and determine it.

What motivates us to explore ethics is the growing idea that there is a sub-optimal quality in health care, represented among other things by medical errors; factors associated with medical error translate into formal and informal complaints (malpractice, neglect, recklessness, or deviations, intentional or not) and other indications that make us think that decent and humane treatment has lost ground.^8-10

It is therefore necessary to examine medical students in training to identify their experiences and achieve a proper understanding of the ethical phenomenon. We also propose a process of "evaluation of ethics", whose results facilitate reflection on the different actors in medicine in their actions and their relationship with the environment. It is important to have a vision of ethics, what it is like in the practice of medicine and the teaching process, and how it can lead to results where different forms of action are discussed, such as acting regarding values ​​and decision-making, in order to integrate those who have "lost their way", changed or diverted their course, thus strengthening the path to perception, strengthening, and assimilation of socially acceptable principles and ethical values ​​in medicine.

Justification

Ethics is not sufficiently considered as a criterion for assessing the performance of teachers of medicine as an example for new generations, so it is important to have means of observation to propose evaluation criteria for ethical principles and values. There is insufficient evidence of how ethics is expressed, what features it has, and how it manifests in daily practice.^11,12

Most research results published in the literature related to evaluation in education, have been linked to the assessment of skill, aptitude, and performance standards of clinical competency, either through analogous practice or equivalent practice during the doctor-patient relationship, in addition to assessment of teacher performance, and there is insufficient evidence of what medical ethics is like, what features it has, and how it is manifested in the field of certain concrete reality.^13,14

In evaluating students, what prevails are some proposals to implement guidelines for the purpose of evaluating teachers promoting learning. There have been very few studies making statements about the humanistic dimension of medicine, the ethical dimension of the medical act, and the effects on doctors’ training.^15-17

Problem statement

It is assumed that there is insufficient reflection on interpersonal relations and ethical commitment for the training of doctors and specialists (hidden curriculum), mainly because it is given as a fact already known or understood. In the explicit curriculum, we tend to forget or ignore ethical training while solving clinical problems. Quite often what is observed is the lack of reflection and forgetting the ethical implications during training, a situation with a scope still undetermined.

The experiences that students have during their formation is that health care staff, particularly teachers, are a very strong role model that students learn from and quite often imitate. These models are an example to follow that can both strengthen and degrade their spiritual, moral, and ethical development, whether or not they are aware of a certain theoretical and practical code in the subject.¹⁸

Goals

Characterize ethics from a hypothetical deductive epistemological perspective. Design, develop, validate, and apply a measuring instrument. Assess the scope of medical and teaching ethics from the perspective of students.

Methods

Design

For the design and validation of the measuring instrument, a deductive hypothetical, epistemological stance was followed that goes from the general to the particular, from the abstract to the concrete, from the concept to the data (Appendix 1). Similarly, definitions were developed that clearly helped to determine ethics as the object of study, specifying three dimensions and establishing in each the conceptual meaning of the terms.¹⁹ 

Definition and selection of content

• Conceptual dimension. This Includes 5 general concepts about ethics seen as relevant for study, understanding, and interpretation: bioethics, ethical, morals, ethical principles, and ethical values. All were defined to avoid the semantic confusion that often accompanies them (Annex 2).
• Abstract, theoretical, or nominal dimension. Nine ethical principles that literature accepts as socially desirable were selected and defined conceptually.^20,21 Another relevant ethical principle was added because of its importance, as it usually relates to the ethical management of patients during medical practice, so in the end 10 ethical principles were included. Moreover, the ethical principles as manifest variables were translated into indicators, which were deduced from the general concepts. This is the axis dimension and the object of study. For this research, the ethical principles proposed by the Academia Nacional de Educación Médica were taken as the basis, among others (Annex 3).   
• Operational dimension. Based on the 10 ethical principles, different values​​ were selected and defined that can reasonably be deduced from the "indicator" ethical principle, and that conveniently represent every ethical principle. This dimension contains ethical values ​​that allow indirect observation of the phenomenon, and are the basis of the instrument’s statements or assertions. The conceptual definitions are also the empirical reference values ​​representing the variables to be measured. On the other hand, the derivation of the ethical values ​​from each ethical principle was relevant for purposes of measurement, because it increased consistency between the statement and the defined value, increased the possible number of statements, and also facilitated the writing. This dimension represents the "interlocking" between ethics and a true social value system (Annex 4).

Variables according to study methodology and design

• Dependent Variable (DV):
  • Ethics
• Independent variables (IV):
  • Gender
  • 3^rd year students and medical interns
• Design:
  • Transversal, prospective, and comparative
• Population:
  • 20 third-year medical students and 30 interns
• Sampling:
  • Convenience
• Criteria:
  • Inclusion. Third-year students and medical interns rotating in a health institution
  • Exclusion. Refusing to participate
  • Elimination. Incomplete data in the questionnaire
  • 10% or more of answers considered totally contradictory.

Statistical analysis

Pearson R and determination coefficient "r²" to assess the internal consistency of the instrument.

Student’s t-test used for comparison between two groups.²²

Development

The instrument was developed with pairs, i.e. two statements that explore the same value from two different perspectives: the socially desirable, plausible vision, and the socially undesirable vision or counter-value.

Each pair explores an everyday situation using a value and a counter-value representing ten principles (indicators) of ethical events. To develop the statement pairs, we wrote statements describing everyday ethical situations that students had to answer. Two phases were used to do this:

• Phase 1. Based on each value, we wrote the plausible socially desirable or undesirable statements that emerge from the previously defined ethical value.
• Phase 2. Statements were written describing everyday situations contrary to the value or socially undesirable, properly representing the counter-value, i.e., undesirable meanings of the same value explored by the pair.

Validation of the measuring instrument

To validate the measurement criteria, we asked a group of experts for their opinions on the principles, values, ​​and statement pairs. This process served as external criterion for subjecting the instrument to their considerations, modifications and changes, which were incorporated in perfecting the instrument.

6 professionals were selected to validate the instrument: two bioethicists; two researchers from the education area​​, and two educators. All were medical specialists with teaching experience who regularly research and publish. Two belong to the Sistema Nacional de Investigadores in the humanities area.

The instrument underwent three rounds of expert review to seek independent consensus on the relevance of the selection and conceptual definition of the principles and values; they were also asked whether they thought the statements appropriately emerged from the values, ​​and if they are situations that realistically happen with some frequency, which helped give the instrument empirical adequacy. They were also asked to indicate whether the statements of the pairs were diametrically opposed, contrasting, or mutually exclusive, to correct or delete the statements in points of disagreement.²³

Results

The instrument called Acontecer de la Ética Médica (AEM, Medical Ethics Events) was composed of 10 principles that properly represent ethics, 24 values derived pertinently from the principles, 35 pairs, and 70 statements that conveniently represent the values ​​(Annex 1). 

Drawing

For the final version, a drawing was made of the statements, and the socially undesirable situations were described in order to assign them different places, keeping the place of the socially desirable statements so that the student could not easily identify the pairs. For example, statement 2 was in place 14 and 4 was in place 42.

Pilot

A pilot was performed with 20 medical students to identify the internal consistency of the instrument, improve empirical adequacy, and evaluate its applicability.

Applicability

The time was recorded from the students starting the questionnaire until the first and the last student finished. The time it took students to answer 70 statements was 15 to 30 minutes.

Internal consistency

As for internal validity, of the 35 pairs 10 were selected (20 statements), which were developed with the same value, but with different wording, to later find correlation between the double pairs made on purpose. These 10 pairs and 20 statements were compared using the Pearson correlation coefficient, yielding r = 0.48, and with the coefficient determination test "r²" was p < 0.025.

Scale to assess students’ ethical perception

The following levels of acceptability were assigned according to the scale shown.

• Highly socially unacceptable 0-19
• Socially unacceptable 20-39
• Socially confused, vague, or ambiguous 40-59
• Socially acceptable 60-79
• Highly socially acceptable 80-100

The frequency scale to respond and the ethical perception scale showed that the level of measurement has intervals, it can show us exactly what the distance is between one score and another, understanding that 0 is relative, as it does not involve the lack of ethics. The form of scoring allows for appropriate comparisons between different principles.

The range of the index of ethical perception was 51-92 with an average of 66 in students and 42-81 with an average of 54 in interns. In the overall analysis, comparing the averages obtained according to academic level, it was observed that in the index of ethical perception, the averages showed significant differences in favor of students with better perception than the interns (Table I).

For socially acceptable and unacceptable perception, there were statistically significant differences between students and interns. In the case of what is socially acceptable, students had a higher score than the interns. In the perception of what is ethical socially unacceptable, the score was higher in favor of the interns (Table II).

In the analysis of principle (indicator), for the purposes of comparison perception was ranked high to low based on the third-year students, obtaining the lowest scores in the principles of respect, solidarity, and honesty. In the case of the interns it was courage, respect, and dignity that had the lowest score. There were significant differences between the two groups in 7 of the 10 principles. In both, the principle that earned the highest score was the so-called bioethical principle, even though there were significant differences between them (Table III).

No differences were found comparing the rate of perception among students according to gender, and no differences were found in interns. Significant differences were found in both sexes in favor of students with better perception (Table IV).

Considering the two groups, the score obtained for the socially unacceptable was 8%, the socially confused, vague, or ambiguous was 50%, the socially acceptable 34%, and the very acceptable 8% (Table V).

Discussion

This way of evaluating ethics using pairs gives a theoretical and practical linkage to appreciate what is done and how ethics happens in practice, with their strengths and weaknesses. This idea of ​​evaluation comes close to assessing specific situations of ethics in practice, and the results advance awareness of action.

The results of this type of evaluation can guide students, teachers, and doctors to improve ethics in solving specific ethical cases.

The validation process with expert rounds was a laborious but necessary activity as it lent criterion, construct, and content validity.

The independent consensus (the decision that each expert makes in the construction of the instrument without knowledge of the others’ responses) provided an appropriate procedure for interobserver consistency, the reviewers helped to give theoretical and empirical adequacy by proposing, deleting, and modifying values ​​and statements that represent everyday ethical situations.

The pilot helped to assess the internal consistency and improved the instrument’s empirical adequacy, as it let us assess whether the information in the instrument relates (connects) to a certain concrete reality, which led to greater bonding of the construct with reality.

The convenience sample is a point that undermines the validity of the results, but does not invalidate them. Cross-sectional studies are not the strongest, but in this case the design is. Making a longitudinal study would not be appropriate since at the beginning of the study, students would only be speculating on what ethics is like in an environment unknown at the time.

The instrument provides valuable information about the ethical conditions of a certain reality and links the data to that reality.

The results suggest inauspicious academic environments for ethical reflection, questioning, and inquiry.

The prevailing conditions of the environment, education, and ethics training positively or negatively influence the results. Probabilistic studies are needed to clearly determine the scope of the ethical perception of students.

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