Zooming in to health ethics: an action to promote ethics.

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17 Vol. 41, No. 1
Literature and the Arts in Medical Education
Johanna Shapiro, PhD
Feature Editor
Dean Gianakos, MD
Associate Editor
Editor’s Note: In this column, teachers who are currently using literary and artistic materials as part of
their curricula will briefly summarize specific works, delineate their purposes and goals in using these
media, describe their audience and teaching strategies, discuss their methods of evaluation, and speculate
about the impact of these teaching tools on learners (and teachers).
Submissions should be three to five double-spaced pages with a minimum of references. Send your
submissions to me at University of California, Irvine, Department of Family Medicine, 101 City Drive
South, Building 200, Room 512, Route 81, Orange, CA 92868-3298. 949-824-3748. Fax: 714-456-7984.
jfshapir@uci.edu.
A recent survey of 1,662 medi-
cal doctors in the United States
revealed that a substantial percent-
age of physicians’ behavior does
not reflect ethical guidelines.1 The
Accreditation Council for Graduate
Medical Education (ACGME) in the
United States requires residents to
follow ethical principles.2 Teaching
of medical ethics (ME) is usually
carried out by didactic lectures or
case presentations. Even in schools
where ME education is well estab-
lished, there is skepticism about the
value of such teaching.3 Liaschenko
et al also criticized overemphasis of
the use of “the tragic case” to teach
ME since this does not reflect real
everyday practice.4 In the same
paper, Liaschenko et al stressed the
importance of emotions in human
relationships.
Of the five medical schools in
Lebanon, only two teach ME. In
1992, the American University
of Beirut (AUB) started a 3-day
course on ME. The course, which
was coordinated by the Department
of Family Medicine, was based on
discussing cases, mainly “tragic
cases.” This course was a big leap
forward; however, some educators
questioned its impact. A brain-
storming session identified several
ways to promote ethical conduct.
The importance of good role mod-
els and continuous emphasis on ME
were highlighted.
The Zooming in to Health Ethics
committee (ZIHE) was founded in
autumn of 2005 by a team of health
professionals and students in the
health field. Its main objective is to
shed light on ethical issues pertain-
ing to medicine on a continuous ba-
sis. Societies/departments involved
in this project at the time of writing
this paper are the Family Medicine
Department; the Resident Staff Or-
ganization; the Internal Medicine
Resident Society-Ciné Club Com-
mittee; the Lebanese Exchange
Medical Students International
Committee, represented by the
Standing Committee on Medical
Education; the School of Nursing;
the Nursing Services Department;
and the Nursing Student’s Society.
The dean of the medical school and
the chief of staff of the American
University of Beirut Medical Cen-
ter (AUBMC) supported ZIHE. The
Department of Family Medicine at
AUB committed itself to finance
ZIHE activities as needed.
A poster announced each activ-
ity, and subsequent reminders were
sent on pagers and by e-mail. The
(Fam Med 2009;41(1):17-21.)
Zooming in to Health Ethics:
An Action to Promote Ethics
Basem-Roberto Saab, MD; Nisrine Sidani, MSN; Marie Merheb, MD;
Dina Mahmassani; Fatima Ghaddar; Ghassen Hamadeh, MD
From the Department of Family Medicine,
American University of Beirut.

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18 January 2009Family Medicine
activities started at 5 pm. An at-
tendance sheet was available at the
entrance of the projection hall. In
addition to the name, the participant
was asked to write his/her profes-
sion/title, and phone number/e-
mail. The first activity, the film
“Wit,” was launched in January
2006 after a press conference that
was covered by the major news-
papers in Lebanon. Between that
time and May 2007, the committee
projected five other films (see Table
1 for titles and suggested clips).
Selected faculty with special
interest in the topic discussed were
invited to moderate each session.
The moderators answered the au-
dience’s questions. At the end of
the activity, an anonymous evalu-
ation form was distributed to the
audience. The form consisted of
two parts. In the first section the
respondent was asked to rate, us-
ing a 5-point Likert scale, her/his
interest in the subject, suitability of
the activity for teaching, relevance
to own practice, how realistic is
the material, and to what extent he/
she benefited from the session. The
second part of the questionnaire
included open-ended questions,
namely what did he/she like most
and least and to state how such
sessions can be improved.
Attendance varied between 56
and 143 people. The number of
those who filled out an evaluation
form ranged from 98 (67.6%) to 17
(16.2%). On average, 32.5% of the
attendance were medical students
and doctors; the rest were mainly
from the nursing school and nurs-
ing services. Females were more
likely to attend this activity (56.1%).
The discussion lasted between 35
minutes to 1 hour. The budget of
each activity was on average $325.
The feedback on the six activities is
shown in Tables 1 and 2. Selected
comments are shown in Table 3.
The activities coordinated by
ZIHE were well received by health
professionals at AUBMC. This was
expected, since there is now posi-
tive rich experience in using clips
from films as a teaching tool in
Lebanon and other countries.5-6 The
World Medical Association, in its
Medical Ethics Manual published
in 2005, stated “Indeed, ethics it-
self is enriched by the insights and
data of these other disciplines; for
Table 1
Summary, Themes Raised, and Time Counter of the Suggested Movie Clips
Film
“Wit”
Summary
An English professor with end-stage cancer is a
subject of interest for research.
Opportunities for Discussion
Informed consent, autonomy, ethics of
research, physicians and other health
professionals
Autonomy, religion, law, and euthanasia
Time Counter
0:00:00–0:04:06
0:57:45–1:11:40
1:26:00–1:30:30
0:04:48–00:08:06
0:43:25–00:49:52
0:54:37–1:07:25
1:25:40–1:28:15
1:48:30–1:52:30
0:05:25–0:07:34
0:19:05–0:23:55
0:51:20–0:56:12
0:59:20–1:03:10
1:32:40–1:35:06
1:50:40–1:54:00
“The Sea Inside” A quadriplegic young man wants to put an end to his
life. Religion and law stand against his wish.
“The Doctor”The attitude of a surgeon who teaches residents to
distance themselves from emotions and makes fun of
his patients changes once he develops a tumor.
Confidentiality, truth telling, health
systems, medical error, whistle blowing,
organ donation, cultural differences,
receiving gifts from patients
“Side Effects”A political science graduate works as a drug
representative. She has to choose between a lucrative
life and concealing the side effect of a new drug.
Truth telling, malfeasance, research
ethics, gifts from the drug industry
0:02:10–0:11:10
0:15:35–0:17:36
0:18:34–0:20:20
0:36:45–0:40:44
0:51:26–0:57:33
0:59:24–1:05:23
1:14:16–1:16:37
1:20:37–1:26:04
0:13:34–0:16:50
0:22:06–0:33:40
0:36:30–0:39:19
0:45:24–0:51:57
1:14:40–1:20:50
1:49:00–1:52:57
0:01:21–0:07:10
0:37:15–0:39:40
0:55:24–01:06:15
1:14:22–1:18:48
“The Constant Gardener” An activist discovers that a pharmaceutical company
is trying a new drug on poor African human beings.
She and her husband pay with their lives to reveal the
truth.
Research ethics, justice, physicians and
society, malfeasance
“Talk to Her”A nurse falls in love with a ballerina. The ballerina is in
deep coma. The nurse rapes his patient.
Boundary setting, malfeasance

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19 Vol. 41, No. 1
Literature and the Arts in Medical Education
Table 2
Evaluation of Activities Using the Likert Questionnaire*
Activity (Evaluation Number, Percentage)
“Wit” (98, 67.6%)
“The Sea Inside” (62)
“The Doctor” (45)
“Side Effects” (25, 44.6%)
“The Constant Gardener” (22, 29.3%)
“Talk to Her” (17, 16.2%)
Average for all activities
Interest in
Subject
4.7
4.6
4.6
4.1
4.6
4.0
4.4
Suitable for
Teaching
4.3
3.8
4.4
3.5
4.3
3.8
4.0
Relevancy to
Practice
4.4
3.5
4.4
2.8
3.9
3.3
3.7
Realistic
4.3
4.0
4.5
3.6
4.5
3.6
4.1
Benefit
4.4
4.5
4.0
3.1
4.3
3.3
3.9
* 1=strongly disagree, 5=strongly agree
Table 3
Selected Comments of the Audience
“Wit”
1. “Makes us think and hopefully act.”
“Puts reality in our face.”
“The initiative is important since medical ethics should be discussed throughout a medical education and not only med III (I’m a med I student).”
“As a med student I think I learned many things (how not to treat patients...).”
“The movie replaced a lecture”
“It is an attempt to change an attitude, to change the way we are used to do things.”
2. “Timing; medical students busy preparing for their exams.”
“Discussion is difficult in a large group.”
“Medical workers are not that monstrous.”
“The Sea Inside” (Spanish movie)
1. “That you brought a priest and a sheikh.”
“Good film, informative message, and everlasting conflict to be solved.”
“Factual example.”
2. “Euthanasia is reflected as legal and inevitable in terminal illness, which is very far from all religions.”
“Language of film in Spanish.”
“The discussion that relies on direct scientific logical compassion versus ideas that are like wood; religious and non-logical.”
“The Doctor”
1. Triggers thoughts and questions, “Am I like this as well?”
“It makes me realize that doctors are busy and not hard.”
“It enables health care team to see how medical ethics affect quality of care.”
“Shows the pressure put by insurance companies.”
2. “The film sometimes exaggerates.”
“None of the insurance companies were present.”
“Need more oriented discussions.”
“Side Effects”
1. “Highlights very important subject; relationship between drug reps and physicians.”
“Raises issues for discussion.”
“Simple, clear, and sweet.”
“Doctors should refuse gifts that are beyond ‘token value’—pen, lunches OK—holidays not OK.”
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20January 2009Family Medicine
example, a theatrical presentation
of a clinical dilemma can be more
powerful stimulus for ethical reflec-
tion and analysis than a simple case
description.”7
The films were all relevant to
the practice of those who attended.
“Side Effects,” which tackles the
issue of drug representatives, had
the lowest score when compared to
the other five films. This is because
the majority of the attendees were
nurses who do not get exposed to
drug representatives.
The depicted films did not simply
present a “tragic case.” All of them
stressed emotions—patient-doctor,
and/or inter-health professional,
and/or institution-patient/family
relationships—facts neglected by
several modules that teach medi-
cal education.4 This was clearly
reflected in several of the audience
comments. The films cited also
showed negative role models. Por-
trayal of negative qualities in health
professionals was advocated to be a
helpful teaching tool.8
The continuous involvement of
students and faculty, mainly the
nurses, over 17 months indicates
the need for emphasizing ethical is-
sues. Nurses spend more time with
patients than physicians and are
more likely to observe the interac-
tion between the caretaker and the
caregiver. Attendance by medical
students, residents, and doctors
was low. This could be due to their
busy schedule and to the fact that
this activity is not part of the formal
curriculum. They also may think
that this is not an important topic.
Evaluations were filled out by a low
percentage of those who attended
some of the activities. This is attrib-
uted to the fact that many left at the
time of the discussion and did not
complete the evaluation form.
ZIHE is lobbying for having the
selected clips incorporated within
the curricula of the nursing and
medical schools. At the time this
paper was written, the assistant
dean for medical education agreed
to work on incorporating all ZIHE
activities into the 4-year medi-
cal school program. Other future
plans for ZIHE are to transform
it from a committee to a club that
will be led by students in different
health specialties. The faculty on
the committee will act as advisors
to ZIHE and as a liaison between
ZIHE and the ethical committee at
the AUBMC.
In summary, using clips from
selected films looks to be a promis-
ing way of teaching medical ethics.
The various films used cover the
main principles of medical ethics
without neglecting emotions and
relationships between caretakers
and caregivers. This initiative,
2. “Bias against the pharmaceutical industry although some aspects may be realistic.”
“Teach ethics to drug promoters.”
“Invite medical reps from all medical companies.”
“Not applicable to nursing.”
“The Constant Gardener”
1. “Exposure to important reality.”
“Perfect activity.”
“Humanistic touch of the film.”
“Discussion after the film.”
“Very relevant to current power misuse in the world.”
“Really showed ethical views on research conduction.”
2. “Further advertisement needed.”
“Choose panelists who are versed in ethical issues.”
“Audio was poor.”
“We should give solutions; how we can help those people.”
Talk to Her (Spanish film)
1. “It provides awareness to health ethics in an enjoyable method rather than sitting in a class listening to a lecture.”
“Discussions after the film.”
“It is a daring film.”
“Relevance to clinical life.”
“It involves (the activity) diverse audience.”
2. “The language of the film; prefer films to be in English.”
“Open Moodle forum online for further discussion.”
“Different timing (earlier).”
1—Liked most about activity, 2—Liked least about activity and suggestions for improvement
Table 3
(continued)

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21 Vol. 41, No. 1
Literature and the Arts in Medical Education
which was facilitated by faculty at
AUBMC, became more a students’
concern.
Acknowledgments: We would like to acknowl-
edge the support of the dean and the chief of staff
of the AUBMC. This continuous activity would
not have been possible without the help of ZIHE
committee members and the efforts of those who
moderated the several sessions.
Corresponding Author: Address correspondence
to Dr Saab, American University of Beirut, De-
partment of Family Medicine, PO Box 11-0-236,
Beirut, Lebanon. brsaab @aub.edu.lb.
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