An international survey of medical ethics curricula in Asia.

Abstract

Medical ethics education has become common, and the integrated ethics curriculum has been recommended in Western countries. It should be questioned whether there is one, universal method of teaching ethics applicable worldwide to medical schools, especially those in non-Western developing countries.
To characterise the medical ethics curricula at Asian medical schools.
Mailed survey of 206 medical schools in China, Hong Kong, Taiwan, Korea, Mongolia, Philippines, Thailand, Malaysia, Singapore, Indonesia, Sri Lanka, Australia and New Zealand.
A total of 100 medical schools responded, a response rate of 49%, ranging from 23%-100% by country.
The degree of integration of the ethics programme into the formal medical curriculum was measured by lecture time; whether compulsory or elective; whether separate courses or unit of other courses; number of courses; schedule; total length, and diversity of teachers' specialties.
A total of 89 medical schools (89%) reported offering some courses in which ethical topics were taught. Separate medical ethics courses were mostly offered in all countries, and the structure of vertical integration was divided into four patterns. Most deans reported that physicians' obligations and patients' rights were the most important topics for their students. However, the evaluation was diverse for more concrete topics.
Offering formal medical ethics education is a widespread feature of medical curricula throughout the study area. However, the kinds of programmes, especially with regard to integration into clinical teaching, were greatly diverse.

Full text

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Journal ofMedical Ethics 1999;25:514-521
Teaching medical ethics
An international survey ofmedical ethics
curricula in Asia
Michio Miyasaka, Akira Akabayashi, Ichiro Kai and Gen Ohi Niigata University, Niigata City, The University
of Tokyo, Tokyo and The National Institute for Environmental Studies, Tsukuba City,Japan
Abstract
Setting
common, and the integrated ethics curriculum has
been recommended in Western countries. It should be
questioned whether there is one, universal method of
teaching ethics applicable worldwide to medical
schools, especially those in non-Western developing
countries.
Objective-To characterise the medical ethics
curricula atAsian medical schools.
Design-Mailed survey of206 medical schools in
China, Hong Kong, Taiwan, Korea, Mongolia,
Philippines, Thailand, Malaysia, Singapore,
Indonesia, Sri Lanka, Australia and New Zealand.
Participants-A total of 100 medical schools
responded, a response rate of49%, rangingfrom 23%
- 100% by country.
Main outcome measures
integration ofthe ethics programme into theformal
medical curriculum was measured by lecture time;
whether compulsory or elective; whether separate
courses or unit ofother courses; number ofcourses;
schedule; total length, and diversity ofteachers'
specialties.
Results A total of89 medical schools (89%)
reported offering some courses in which ethical topics
were taught. Separate medical ethics courses were
mostly offered in all countries, and the structure of
vertical integration was divided intofour patterns.
Most deans reported that physicians' obligations and
patients' rights were the most important topicsfor
their students. However, the evaluation was diverse
for more concrete topics.
Conclusion-Offeringformal medical ethics
education is a widespreadfeature ofmedical curricula
throughout the study area. However, the kinds of
programmes, especially with regard to integration into
clinical teaching, were greatly diverse.
(7ournal ofMedical Ethics 1999;25:514-521)
Keywords: Medical ethics education; curriculum survey;
medical school; Asia
Medical ethics education has become
The degree of
Introduction
In the last two decades, formal ethics education
has become one of the common features ofmedi-
cal curricula in many Western countries.'
formation of a formal programme led to a general
empirical understanding of how medical ethics
should be taught. In the United Kingdom the
Institute of Medical Ethics recommended that
medical ethics teaching should recur at regular
intervals throughout medical teaching, and that
time should be set aside within existing teaching
for ethical reflection relevant to each stage of a
student's experience.2 Miles and colleagues in the
USA argued similarly that ethics education should
be conceptually coherent, vertically and horizon-
tally integrated through preclinical and clinical
training, multidisciplinary, academically rigorous,
and should demonstrate humane and value-
conscious medical practice.3 Thus, the integration
of ethics into the formal curriculum has become
the standard recommended programme design of
medical ethics education.
However, examples of well-integrated ethics
programmes, quite often found in the literature,
are mostly limited to Western industrialised coun-
tries. Few have questioned whether this standard
programme design is universal, applicable world-
wide to all medical schools, especially to those in
non-Western developing countries. The funda-
mental changes in medical ethics are usually
attributed to social factors common to Western
developed countries, namely the novel moral view
of respect for patient's autonomy; the develop-
ment of high-tech medical technology, and the
shift of major causes of death from acute curable
diseases to chronic incurable ones, which have
forced physicians to think of therapeutic options
concerning patients' quality of life.'0`14 In many
developing countries,
acute
killing many people, and therapeutic options con-
cerning comfortable quality of life are not realistic
for many people. Furthermore, individualistic
The
diseases
are
still

Page 2

Miyasaka, Akabayashi, Kai, et al
515
patient choice in clinical settings is not usual
in non-Western
countries, even today. Some
Japanese scholars have criticised Western bioethics
as placing too much weight on the principle of
respect for autonomy that poorly fits the East-
Asian ethos, which appreciates human interaction
and communitarian empathy.'5 16
If Western individualistic ethics has promoted
formal medical ethics education, and if it is really
unacceptable for the South and the East, it could
be assumed that formal medical ethics education
is neither common, nor even needed in most
Asian countries. On the other hand, taking into
account that most issues in medical ethics, such as
organ transplantation and termination of life sup-
port, are now faced in Asian countries, and that
the worldwide trade of medical technology has
created a greater disparity in the distribution of
health care resources, even within countries, it
could be argued that Asian medical schools
should prepare their students for ethical dilem-
mas, and indeed, for ethical dilemmas that could
be much more complicated than in the West.
This study was designed to survey the medical
ethics programmes ofmedical schools in the East,
South-east, South Asia, and Oceania. The pur-
pose of the study is to analyze how much ethics
education is formally given, and how much is
integrated into the medical curriculum.
Methods
SUBJECTS
We included all medical schools of the area which
appeared in the World Health Organisation's
World Directory of Medical Schools.'7 Medical
schools which specified they taught only tra-
ditional medicine were excluded. A four-page
questionnaire was developed and sent to the dean
or the president of the medical school. The initial
mailing was made in November 1994, and four
months later, a follow-up mailing was sent to
non-respondents. The last response was received
in October
1995. The mailing included an
introductory letter. The letter and the question-
naire were
in English.
Japanese data were collected using a Japanese
translation of the questionnaire used in
survey, and were submitted elsewhere.'8 Part of
the Japanese data was used to make statistical
comparisons in this report. In Taiwan, where no
data were cited in the directory, Dr Tai-Yuan
Chiou ofTaiwan University kindly informed us of
the mailing addresses of all of the ten medical
schools at that time.
In
a separate
study,
this
QUESTIONNAIRE AND ANALYTIC TECHNIQUES
The questionnaire consisted of two parts. One
addressed the programme of medical ethics or
similar courses. Deans were asked to fill in the
name of the course, school years in which the
course was offered, the length of the course,
whether it was compulsory or elective, and teach-
ers'
specialties. The second
personal opinion ofthe dean on: ethics education;
the degree of satisfaction with ethics education at
his/her school; the importance of ethics education
compared with other subjects; what kind of
programme he/she would like to see and what
kind ofbackgrounds he/she would prefer teachers
to have, and what lecture topics he/she regarded as
desirable for students. Respondents were required
to
note
their
nationality,
specialty, the number of students in a school year,
the number of full-time teachers, total school
years (duration of medical degree course), and
during which school years bed-side teaching was
scheduled.
A "separate medical ethics course" was defined
as a course whose title contained both (1) words
representing medicine/medical care, ie "medi-
cine", "health", "physician", "patient", "clinic",
and (2) words representing ethics/moral philos-
ophy, ie "ethics", "moral", "rule", "value". Other
courses were categorised as "medicine related
courses"; these were courses whose title contained
only
medicine-related
courses"; these were courses whose titles included
no medicine-related words.
We separated the medical degree course into
three segments: before, during, and after bed-side
teaching (BST) school years. The "BST school
years" were defined as including school years at
the beginning and end ofBST, and all school years
in between. Therefore, if BST was offered in the
second and the fourth years, the third year was
also regarded as "during BST".
Teachers' specialties were categorised into four
categories; (1) physician/health professional; (2)
philosopher/ethicist; (3) theologian/priest/monk,
and (4) lawyer/ jurist/social scientist. Interdiscipli-
nary backgrounds were identified by combination
of the four categories. For instance, "medical eth-
ics" was coded as "(1) and (2)". We didn't distin-
guish between the following two cases: (A) where
one teacher had two or more backgrounds, and
(B) where two or more teachers took part, but
each
of them
had
one-but
background.
With regard to Singapore and Mongolia, both
ofwhich had only one medical school, the country
data are not shown in this report.
part
asked
the
sex,
age,
religion,
words,
or
as
"other
a
different-

Page 3

516Teaching medical ethics:An international survey ofmedical ethics curricula in Asia
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Results
MEDICAL ETHICS PROGRAMMES
We did notanalyze countries from which fewer
than tenpercent ofquestionnaires were retrieved.
Theresponse rate of the remaining 13 countries
(China, Hong Kong,TheRepublic ofKorea, Tai-
wan, Indonesia, Malaysia, thePhilippines, Singa-
pore, Thailand, Sri Lanka, Australia, New Zea-
land, Mongolia), was 48.5%o (100/206), ranging
from 23% - 100%by country.
Table
summarises
courses which had lectures on ethical topics.
Eighty-nine percent(89/100) of medical schools
had some courses. Seven schools did not have a
course, but said they would have in the near
future. One Thai school answered that they did
not have acourse, and did notexpect to haveany
course in the near future. Adiversity of allocated
lecture
time
was
found
However, inChina, Taiwan and thePhilippines,
60% or more medical schools allocated more than
20 hours to ethics courses, while in Hong Kong,
Korea, Indonesia, Malaysia, Thailand and Sri
Lanka,this ratio was below40'%O. Ineverycountry,
most of the courses were compulsory. Seventy-
ninepercent ofmedical schools required students
to take all courses, and three per cent offered
elective courses in addition to required ones. Four
percent of medical schools which responded said
theyhad elective coursesonly.
The
number
of medical
separatemedical ethics courses was 8 1 % (8 /1 00)
of all respondents. The majority of theseparate
courses were referred
to
"bioethics", or "clinical ethics".
The longitudinal schedule, reflected
number and the schedule of the course, was as
diverse as any other aspect of the curriculum. In
China, Taiwan and Malaysia, more than 60% of
medical schools reported one course, while in
Hong Kong, the Philippines, Thailand, SriLanka,
Australia and New Zealand, two or more courses
were more common than one course. Inparticu-
lar,
in
the
Philippines,
Zealand, 60% or more replied that they offered
three or more courses. The schedule of ethics
teachings was found to differwidely by country. In
China, Korea, and Indonesia, the number of
medical schools offering ethics courses during
BST schoolyears was less than half. In contrast, in
Taiwan, Hong Kong, Malaysia, the Philippines,
Sri Lanka, and Australia, ethics courses were
scheduled during BST school years in 60% of
schools, or more. Medical schools offering ethics
both before and during BST school years were
found in most countries. In the Philippines, Thai-
land, Sri Lanka, Australia, and New Zealand,30%o
1
the
characteristics
of
in
most
countries.
schools
offering
as "medical ethics",
in the
Australia
and New
7)
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