|ORIGINAL RESEARCH ARTICLE
|Year : 2017 | Volume
| Issue : 1 | Page : 35-43
Medical ethics education in China: Lessons from three schools
Renslow Sherer1, Hongmei Dong1, Yali Cong2, Jing Wan3, Hua Chen4, Yanxia Wang5, Zhiying Ma6, Brian Cooper1, Ivy Jiang1, Hannah Roth1, Mark Siegler1
1 Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
2 Department of Health Science Center, Peking University, Beijing Shi, China
3 Department of Cardiology, Zhongnan Hospital, Wuhan University, Wuhan, China
4 Institute of Humanities and Social Science, Guangzhou Medical University, Guangdong Sheng, China
5 Department of Resource and Environmental Science, Renmin Hospital, Wuhan University, Wuhan, China
6 Department of Anthropology, University of Chicago, Chicago, Illinois, USA
|Date of Web Publication||13-Jul-2017|
Department of Medicine, University of Chicago, 5841, S. Maryland Avenue, MC 5065, Chicago, IL 60637
Source of Support: None, Conflict of Interest: None
Background: Ethics teaching is a relatively new area of medical education in China, with ethics curricula at different levels of development. This study examined ethics education at three medical schools in China to understand their curricular content, teaching and learning methods, forms of assessments, changes over time, and what changes are needed for further improvement. Methods: We used student and faculty surveys to obtain information about the ethics courses' content, teaching methods, and revisions over time. The surveys also included five realistic cases and asked participants whether each would be appropriate to use for discussion in ethics courses. Students rated the cases on a scale and gave written comments. Finally, participants were asked to indicate how much they would agree with the statement that medical professionalism is about putting the interests of patients and society above one's own. Results: There were both similarities and differences among these schools with regard to course topics, teaching and assessment methods, and course faculty compositions, suggesting their courses are at different levels of development. Areas of improvement for the schools' courses were identified based on this study's findings and available literature. A model of the evolution of medical ethics education in China was proposed to guide reform in medical ethics instruction in China. Analysis identified characteristics of appropriate cases and participants' attitudes toward the ideal of professionalism. Discussion: We conclude that the development of medical ethics education in China is promising while much improvement is needed. In addition, ethics education is not confined to the walls of medical schools; the society at large can have significant influence on the formation of students' professional values.
Keywords: China, clinical ethics education, medical education, medical education reform, medical ethics education
|How to cite this article:|
Sherer R, Dong H, Cong Y, Wan J, Chen H, Wang Y, Ma Z, Cooper B, Jiang I, Roth H, Siegler M. Medical ethics education in China: Lessons from three schools. Educ Health 2017;30:35-43
|How to cite this URL:|
Sherer R, Dong H, Cong Y, Wan J, Chen H, Wang Y, Ma Z, Cooper B, Jiang I, Roth H, Siegler M. Medical ethics education in China: Lessons from three schools. Educ Health [serial online] 2017 [cited 2020 Aug 8];30:35-43. Available from: http://www.educationforhealth.net/text.asp?2017/30/1/35/210501
| Background|| |
A global trend in medical education is the inclusion of ethics teaching in the required curriculum of medical schools. For example, ethical values and behavior are among the core competencies defined by the global minimum essential requirements and by the World Federation for Medical Education., Standards for accreditation in the USA require a medical school curriculum which includes instruction for students in medical ethics both before and during their participation in patient care. In China, medical ethics had gained significant attention since the 1980s when some schools started to offer the first medical ethics courses in the country., In 2008, China issued new standards for medical education that specified requirements for ethics.
Medical ethics courses are now taught in almost all medical schools in China. Pedagogically, the dominant teaching method is didactic lecture  though other methods are being used to varied degrees including group case discussions, a problem-based learning approach to engage students and foster independent thinking, bedside teaching, and scenario simulations where clinical cases are represented by students in role play. However, the majority of teachers of medical ethics have background in social sciences or humanities rather than medicine, and the majority of schools' teaching still leans heavily toward ethics theories, with inadequate relevance to clinical practice. There is an urgent need for faculty training, for a faculty team that is knowledgeable in both ethical theories and clinical practice, and for the use of multiple teaching methods and the reduction of didactic lecture time. Ethics courses' clinical applicability needs to be increased, and ethics education is yet to be integrated throughout the curriculum.
We studied three medical schools in China to understand their ethics education. Findings were compared with available literature, and areas of improvement for the Chinese schools' courses were identified. We also aimed at filling a gap in the English-language literature on medical ethics education in China.
This study was approved by Wuhan University Health Science Center Ethics Committee, Guangzhou Medical University (GMU) Ethics Committee, Peking University Health Science Center Ethics Committee, and Institutional Review Board of Biological Science Division of the University of Chicago.
| Methods|| |
Study sites and data collection
An ethics course survey was administered at the end of the spring semester in 2014 to clinical medicine students of three Chinese medical schools – Wuhan University School of Medicine (WU), GMU, and Peking University School of Medicine (PKU). The Chinese schools were chosen because they are among the prominent medical schools in China. Located in Central China, WU is a prestigious educational institution in the nation. In 2009, it launched medical education reform by adapting the University of Chicago's medical curriculum and has since achieved positive results. GMU is in South China and is among the nation's top-tier schools for undergraduate medical education. PKU, one of the China's best universities, is located in the national capital, rich in resources and talents, well-funded by the central and municipal governments and has extensive exchange with renowned medical schools in the world. We assumed that these three schools' curricula would somewhat reflect the current trends in medical ethics education in China.
The First part of the survey asked students to provide information about features of their ethics courses and their satisfaction with the course. The second part of the survey included five realistic cases and asked students whether each was appropriate to use for discussion in ethics courses. Students expressed their opinion on a 10-point scale where 1 means “inappropriate” and 10 means “appropriate.” The final question of the survey invited participants to indicate how much they would agree with Reynolds' statement: “Medical professionalism is a set of values, attitudes, and behaviors that results in serving the interests of patients and society before one's own.” A 10-point rating scale was used, where 1 means “disagree” and 10 means “agree.” At the center of Reynolds' position is the belief in an altruistic dedication to serving patients. Broadly defined, “professionalism” includes a code of ethics and a body of knowledge and skills, among other things. Reynolds' statement highlights the ethical imperative of the profession. Through participants' response, we hoped to understand their perceptions on this ethical position.
The survey, after minor modifications in content and wording, was administered to the medical ethics course faculty of the schools.
In addition to the survey, we asked the schools' medical ethics course directors to fill in a multidimensional form to provide up-to-date information about their respective courses and describe how the courses changed since inception. The dimensions covered main aspects of a course, including faculty team composition, course hours, course content, and teaching and assessments methods.
Target participants of the survey were all students in clinical medicine programs who had recently completed their ethics course and the courses' teaching faculty. WU 5-year program students consisted of two groups: one in the traditional curriculum (about 200) and the other in a reform curriculum (about 50). Each year, since 2009, first-year students volunteered to join the reform program, fifty of whom were randomly selected by the medical school. All targeted students were invited through E-mail to take the survey – 404 students in GMU, 200 in PKU, and 270 in WU. Faculty members were invited as well – four in GMU, four in PKU, and 14 in WU. The invitation letter promised anonymity of the study. The survey instrument included instructions explaining the study's purpose and emphasizing confidentiality and voluntariness of participation. The paper survey was distributed to all students and then collected after completion.
Descriptive analyses were applied to arrive at percentages of students' answers. Where appropriate, comparisons were made between the response of students from the traditional and reform curricula at WU. Data collected through the multidimensional form were analyzed using qualitative methods.
| Results|| |
Altogether, 232 GMU students, 99 PKU students, and 76 WU students (forty from the traditional curriculum and 36 from the reform) responded to the survey, with response rates of 57.4%, 49.5%, and 28.1%, respectively. At WU, 18% of the traditional curriculum students and 72% of the reform curriculum students participated in the survey. Students at GMU, PKU, and WU were in the year 2, 5, and 4 of their school career, respectively. Seven of the 13 WU faculty members who taught the reform curriculum responded so did two of the four PKU teachers. None of the GMU faculty members answered the survey. The year-4 students at WU were in clinical rotations in two teaching hospitals and thus not easily accessible. As a result, only 76 students were available to answer the survey. Each course director from the schools filled in the multidimensional form that collected information on his or her respective course.
The three schools' ethics courses
[Table 1], [Table 2], [Table 3], [Table 4] summarize the key features of the ethics courses of the schools. All the courses are compulsory. At WU, all students (traditional and reform curricula) take their first ethics class in their 2nd year taught by a professor of philosophy [course 1 in [Table 1]. Then, the reform curriculum students take a second ethics class during clerkships in their 4th year. The reform students at Zhongnan Hospital and the reform students at Renmin Hospital are offered different courses, each developed and taught by physicians at their respective teaching hospitals. Thus, the reform curriculum has two parallel ethics courses. Of the physician teachers, only Zhongnan Hospital's course director received formal training in ethics education. In this article, we will not describe in detail all the three courses offered at WU but focus on the course taught to the reform students at Zhongnan Hospital [course 3 in [Table 1], due to constraint in space.
|Table 1: Basic information of the ethics courses at the three medical schools|
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|Table 2: Course topics (for Wuhan University, only Zhongnan Hospital's reform curriculum course is represented here)|
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|Table 3: Course topics (for Wuhan University, only Zhongnan Hospital's reform curriculum course is represented here)|
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GMU is one of the first medical schools in China to offer a course in medical ethics, now taught by four professors of philosophy. PKU has 8-year program students only, and their ethics course, first established in 1988, is now co-taught by one physician and three philosophy professors. Detailed information on the schools' courses is found in [Table 1].
The three schools addressed five overlapping topics: research ethics, end-of-life care, informed consent, organ transplant, and reproductive ethics. WU and PKU both covered pediatrics ethics, WU and GMU had introduction to ethics, and PKU and GMU have no additional topic in common. Overall, there seems to be no overwhelming consensus as to what should constitute the common core of an ethics curriculum. Complete lists of topics are shown in [Table 2].
Regarding teaching methods, all three schools used lecture, case-based discussions, and role play though time devoted to each type of activities differed from school to school. Assessments in the PKU course put greater emphasis on student scholarship than GMU or WU. [Table 3] summarizes their details.
The ethics courses at these schools, especially WU and PKU, have undergone considerable changes since inception [Table 4]. WU added physicians to the teaching force and increased instruction time for reform students by 50%. PKU increased course hours by 100%, included a physician–teacher, and added student research projects as a learning and assessment method. All the schools used student feedback to improve their courses.
Participants' satisfaction with their courses
Students and faculty were somewhat satisfied with their respective schools' ethics education. On a 5-point scale, students' mean ratings were 3.45 (GMU), 3.15 (PKU), 3.19 (WU traditional curriculum), and 3.34 (WU reform curriculum). No significant difference was found between WU's traditional and reform curricula. Faculty members' ratings were similar –3.00 by two PKU teachers and 3.29 by seven WU reform course teachers.
Cases appropriate for discussion
On a 10-point scale, all the cases received a 5.9 or above, except case 2 [Table 5]. The majority of the students agreed that the remaining four cases would be appropriate for discussion in an ethics course. PKU faculty members' scores appeared to be outliers perhaps because only two teachers answered this question.
Only PKU students, WU students, and WU faculty participants gave explanations as to why the cases would be appropriate to use in an ethics course (other participants chose not to do so). According to these participants' comments, a case would be appropriate when it:
- Involves a real-world medical ethics issue, such as doctor–patient conflict, economic interests, personal interests, informed consent, or conflict between patients' preferences and doctors' professional standards
- Is controversial, where people will tend to disagree with one another
- Is realistic, that is, commonly encountered in clinical practice
- Is representative and reflects current health care issues in China
- Is complicated enough with issues worth exploring
- Involves issues in health insurance, healthcare reform, and care for the vulnerable
- Involves issues of public interest.
Characteristics that would make a case inappropriate were the opposite of the above. In addition, a case would also be inappropriate if it involved subject matters that students have not yet been exposed to, such as laws or particular topics in medical sciences, or if it could enhance students' dissatisfaction with the practice of medicine in China.
Views on Reynolds' statement
Students were inclined to agree with Reynolds' position. Mean ratings were 6.71, 6.97, 7.0, and 7.92 by GMU, PKU, WU reform curriculum, and WU traditional curriculum students, respectively. PKU faculty members' mean rating was 8.5 and WU faculty members' mean rating was 8.43.
Students' takes on Reynolds' definition fell into two categories. Some totally agreed with Reynolds without reservation that the interest of patients should be placed above the interest of the physician or hospital as one student wrote, “This is the spirit of the medical profession. The doctors' fundamental purpose is to serve patients.” Another group of students focused on the tension between the professional ideal and the reality in which physicians must work. They seemed to think that the current healthcare environment in China was not conducive to the practice of such ideal belief in professionalism. One student wrote, “Most doctors originally have this ideal. But as China's healthcare environment is deteriorating continuously, even doctors' most basic wellbeing is not protected. Doctors must first protect themselves before they can bring benefit to patients.” This remark might refer to patients' violence toward doctors in China that has occurred now and then. Another student commented, “I agree with Reynolds' view. However, the general public and the government lay the burden of healthcare on hospitals. In order to generate revenues to withstand the pressure, hospitals have no choice but value monetary income.” Here, respondents pointed out two types of societal factors impacting physicians' ethical choices – tension in hospital–patient relationship and the hospital's burden to generate income to sustain financially.
| Discussion|| |
The three medical schools' ethics education share some common features: (a) The courses all started in the 1980s and are compulsory; (b) course topics overlap somewhat; (c) instruction hours are at or above 36, beyond the level recommended by research (20 h or more); (d) faculty includes professors of humanities; (e) teaching methods include lecture, small-group discussions, and independent readings.
Differences are also apparent. First, WU offers two courses at the undergraduate level for students in the reform, with total instruction time of 54 h. GMU and PKU each offer one course for 36 h. Second, the relatively small overlap among curricular contents indicates the lack of a consensus as to what topics should be taught. Third, different emphasis is placed on ethical theories; for GMU, course devotes a session to ethical theories while the other schools do not. Fourth, faculty team composition differs. WU undergraduate students'first ethics course is taught by a philosopher while the other courses by physicians and a forensics professor. PKU's course is cotaught by a team of philosophers and one physician, and GMU faculty team has philosophers only.
The above similarities suggest that educators in China share some common beliefs about medical ethics, such as its significance in the formation of doctors, what topics should be covered, the imperative to make it relevant to clinical practice, and the need for multiple teaching methods. These notions are consistent with what literature tells us about how the subject is taught in the West ,, as well as in China.,
The differences perhaps indicate that medical ethics education is in its formative stage in China, with Chinese educators still exploring the field and experimenting with new approaches, sometimes by learning from the West. For example, WU physicians established a new course by adapting the University of Chicago's medical ethics course structure, and PKU, which had a course director trained at the University of Chicago, added a physician to its teaching team.
These schools' ethics education shares a few apparent shortcomings. First, faculty teams are relatively small compared to the large number of students they serve. The faculty teams are not multidisciplinary – WU has a PhD and several MDs involved in ethics education, but they teach different courses rather than coteach. Another issue is that ethics education is through standalone courses only neither as a longitudinal thread throughout the curricula nor is it well integrated into basic science or clinical courses. Finally, there is little training for clinical faculty in ethics theories, pedagogy, and research.
Student and faculty satisfaction with their respective courses are similar across the schools, suggesting that participants are somewhat satisfied with the courses and that there is much room for improvement.
Participants' views on the cases
Four of the five clinical cases were believed to be appropriate or somewhat appropriate to be used for discussion in an ethics course. With the participants identified criteria in mind, it is easy to see why case 2 was considered inappropriate: Its topic was not in regard with healthcare or clinical ethics or clinical practice and therefore failed to meet the criteria mentioned earlier. These criteria can guide teachers' selection of clinical cases. Because students indicated that clinical cases for discussion should be relevant to healthcare issues in China, it is important for faculty to study those issues as they prepare for teaching. Students did not go into detail what those issues consist of, but literature reveals that main issues include care for the poor and for vulnerable populations such as migrant workers, relatively low patient satisfaction, distorted incentives in the form of profits from overprescribing drugs and tests, and how to remove these incentives without disrupting healthcare institutions' financial viability. Although China has made big strides in recent years toward providing its population with basic healthcare and has achieved nearly universal insurance coverage, it still needs to further reform the healthcare governance so that providers put the public interest first. Ethics-related issues in healthcare offer many opportunities for teaching students.
Participants' views on Reynolds' position
Participants' ratings suggest that they tend to agree with Reynolds' view. Their reservation about the ideal of professionalism may suggest the limited effect of teaching ethics in the medical school curriculum alone. Hafferty and Franks maintain that any attempt to develop a comprehensive ethics curriculum must acknowledge the broader cultural milieu within which that curriculum must function as most of the critical determinants of physician identity operate in a hidden curriculum. As opposed to the formal curriculum, which explicitly communicates knowledge and values through such mechanisms as lectures and texts, the hidden medical curriculum is revealed through the words, behaviors, and attitudes of faculty and others in various contexts. Phillips and Clarke also wrote that curricular content is always embedded in a context and learning environment. Through observing the hidden curriculum in educational institutions and other societal settings, students tacitly acquire what is valued in clinical practice and what are considered acceptable professional norms.
The hidden curriculum is not confined to the medical school or even the teaching hospitals. It is found in a country's healthcare culture as well. Government's healthcare policies, doctor–patient relationships as observed by students outside of medical school training, and media stories about hospital–patient conflicts also help shape medical students' beliefs about the medical profession. Indeed, school learning is situated in and impacted by the larger societal environment.
The evolution of medical ethics education in China
Based on our findings and literature, we propose the following four-level model [Table 6] that shows the development of medical ethics education in China. At level 1, no ethics course is taught in the medical curriculum, which was the case for all medical schools before the 1980s. Some schools reached level 2 in the early 1980s, and this is still a prevalent model in China nowadays. Level 3 is also found in China now, and its most obvious difference from level 2 is that it involves physicians or the collaboration between physicians and philosophers. To the best of our knowledge, there is no indication in published literature that level 4 approaches are used in China though it is common in leading medical schools in the West. We hope that this model can help medical schools assess their ethics education by locating where they are right now and determine where they want to be through innovations.
|Table 6: Evolution of medical ethics education in China: A developmental model|
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Recommendations for medical schools in China
Based on the current literature and our findings, we would like to offer the following suggestions for improving medical ethics education in China.
Faculty and teaching methods
First, clinical faculty training is badly needed in the areas of ethics theories, teaching methods, healthcare system, and other topics relevant to medical ethics.,, Medical school faculty often believe they are incapable of teaching the subject because they have no formal training in ethics instruction, so development programs should provide clinical faculty with formal training to better prepare them for teaching.,
Second, it is necessary to build a larger course faculty team consisting of mostly physicians but also including professors of humanities to reflect the multidisciplinary nature of the subject. Scholars have long argued that a multidisciplinary team of ethicist – philosophers and physicians – should teach medical ethics.,,
Finally, didactic lectures as the predominant method need to give way to a combination of teaching and learning strategies. Teacher-centered lectures must be balanced by venues that require active learning on the part of students, such as small-group work and independent assignments. Assessment of students should measure not only students' knowledge of ethics topics but also their ability to explore ethical issues through projects.
The ethics curriculum
First, in making decisions about course content, consider both international standards and Chinese characteristics including students' needs. Ethics course should cover important topics as per the international standards, for example, those given in the American College of Physicians Ethics Manual. Equally important is the inclusion of topics that pertain to healthcare in China by taking into consideration Chinese characteristics and culture. Besides standards, part of the common core should be related to students' needs. Such a core should include topics critical in healthcare today, such as healthcare reform and conflict between hospital and patients.
Second, find an appropriate balance between ethics theories and practical skills ,, as both are essential components of medical ethics. Part of the solution to this issue is in the formation of a multidisciplinary teaching team and in faculty training.
Third, integrate medical education and ethics education throughout school training., Wang and Li gave the following suggestions on how ethics teaching can be incorporated into all stages of the medical curriculum: (a) into the overall educational objectives; (b) into basic science and medical science courses by including elements of ethics and ethical decision-making in clinical case discussions; (c) into clerkships where ethics can be taught during teaching rounds, patient care rounds, “ethics rounds,” and case analyses; (d) into other activities such as seminars or talks on special topics.
Addressing the “hidden curriculum”
Participants' reservations about Reynolds' statement suggest the urgency of improving teachers' role models and the culture of healthcare to make them more conducive to ethical thinking and decision-making. Chinese scholars introduced the concept of hidden curriculum to China in the 1980s. They are not only investigating the nature of the hidden curriculum but also exploring approaches to conscientiously shaping a desirable hidden curriculum by enhancing positive elements in the school culture. Yu and Liu argue that it is not sufficient to offer an ethics course, and that attention must be given to the construction of a positive hidden curriculum as it plays a more significant role in training ethical physicians.
Research and scholarship
China's research work in medical ethics needs much development to address what approaches to medical ethics education are being used, what works, and what directions to go in the future. Chinese scholars can learn from the West while exploring possibilities of establishing frameworks that suit China. Such frameworks should simultaneously contain universal values and culturally significant values to help Chinese educators keep abreast of global advances while serving the needs of Chinese students in their social and cultural contexts.
| Conclusion|| |
The development of medical ethics education in China is encouraging and promising, and the directions of further innovations are rather clear. As Eckles et al. concluded in their review of ethics education in the USA, ethics education should be coherent, integrated through preclinical and clinical training, and multidisciplinary, and ethical development should be viewed as a process throughout all years of medical school. Furthermore, ethics education is not confined to the walls of classrooms or wards; the society at large can have unintended influences on the formation of students' professional values.
This study's limitations
This study does not explain the process through which the ethics curricula in China's medical schools have evolved through drawing on Chinese traditions and through learning from the West. A second limitation is in the small sample size – only three medical schools participated in this study. Especially small is the number of faculty participants. Finally, there is a very small body of Chinese literature on this subject, making it hard for us to gain a thorough view of this topic. To the best of our knowledge, there is no English literature on Chinese medical schools' ethics education. Thus, our study is situated in a limited body of literature. We hope that it will help inform this area of medical education in China as well as abroad.
Financial support and sponsorship
Alphawood Foundation, Chicago, USA, supported the study.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]