ethics in the curriculum of ethics in the curriculum of biomedical & related programs biomedical & related programs

in africa: past, present and in africa: past, present and future future

Omotade O. O.Omotade O. O.College of MedicineCollege of MedicineUniversity of Ibadan,University of Ibadan,

Ibadan, NigeriaIbadan, Nigeria

Which biomedical and related Which biomedical and related programs?programs?

• Faculties and Departments of Sciences in Faculties and Departments of Sciences in Universities, Polytechnics and Research Universities, Polytechnics and Research Institutes.Institutes.

• Faculties and Departments of Social Faculties and Departments of Social SciencesSciences

• Colleges of MedicineColleges of Medicine• Schools and Colleges of Nursing and Schools and Colleges of Nursing and

Allied health professionalsAllied health professionals• Other tertiary educational and research Other tertiary educational and research

establishments who carry out research or establishments who carry out research or interaction with humans……..interaction with humans……..

Curriculum (and ethics) in Curriculum (and ethics) in the pastthe past• Certain things typified curriculum in Certain things typified curriculum in

the past and these are:-the past and these are:-Based on colonial templates and not Based on colonial templates and not

transferable to non-related coloniestransferable to non-related coloniesNon uniform curriculum for Africa per seNon uniform curriculum for Africa per seIt’s easier to access the colonial overlords It’s easier to access the colonial overlords

than next door neighbour hence than next door neighbour hence harmonization of curriculum was hardly harmonization of curriculum was hardly practicable.practicable.

Whatever principles of ethics (legal Whatever principles of ethics (legal codes) operated in the individual codes) operated in the individual countries were either direct transfer from countries were either direct transfer from colonial programs or modifications of colonial programs or modifications of samesame

Curriculum and ethics in Curriculum and ethics in the nowthe nowNot much change (as the map of Not much change (as the map of

Africa)Africa)Whatever changes are being pushed Whatever changes are being pushed

from outside the continentfrom outside the continentColonial allegiance much more than Colonial allegiance much more than

languagelanguage differences still a major differences still a major barrier barrier

Collaborations (rays of hope) are Collaborations (rays of hope) are subject/project/donor driven and not subject/project/donor driven and not ethics or curriculum drivenethics or curriculum driven

Current diversity is welcomed but Current diversity is welcomed but there must be unity in the diversity there must be unity in the diversity (way forward!)(way forward!)

Curriculum and ethics in Curriculum and ethics in the futurethe future Whatever is promoting people talking Whatever is promoting people talking

together should be continued and together should be continued and intensified!intensified!

Recommendations and communiqués Recommendations and communiqués should be acted upon!should be acted upon!Some of the expected major actorsSome of the expected major actors Africans! Africans!! and Africans!!!Africans! Africans!! and Africans!!! African Union (both political and scientific African Union (both political and scientific

machinery)machinery) International Communities, Bodies and International Communities, Bodies and

InstitutionsInstitutions Universities and Colleges on Africa (AAU)Universities and Colleges on Africa (AAU) Lovers of AfricaLovers of Africa Etc etc………Etc etc………

Practical suggestions of Practical suggestions of how to include ethics in the how to include ethics in the

curriculum curriculum

case study:-case study:-

Medical schools, and Universities !Medical schools, and Universities !

Justification:-Justification:-

Though medicine is based on empirical and Though medicine is based on empirical and scientific principles, doctor-patient scientific principles, doctor-patient relationship and the practice of medicine is a relationship and the practice of medicine is a profoundly human endeavour.profoundly human endeavour.

Critical thinking skills and analytical Critical thinking skills and analytical techniques from various humanities techniques from various humanities disciplines is known to help physicians and disciplines is known to help physicians and future physicians understand the future physicians understand the implications and context of their actions.implications and context of their actions.

Patients’ views and perceptions on illness and Patients’ views and perceptions on illness and treatment (often irrational to physicians and students) treatment (often irrational to physicians and students) have a bearing on their outcome.have a bearing on their outcome.

Introduction of medical humanities and ethics can Introduction of medical humanities and ethics can provide insight into such concepts as professionalism, provide insight into such concepts as professionalism, communication, empathy and a critical evaluation of communication, empathy and a critical evaluation of biomedical research and policybiomedical research and policy

Skills in ethical reasoning, improvement in medical Skills in ethical reasoning, improvement in medical decision making, easier recognition of ethical issues decision making, easier recognition of ethical issues in day-today practice.in day-today practice.

Handling dilemmas daily encountered in practice Handling dilemmas daily encountered in practice while in training and afterwardswhile in training and afterwards

Laying the background for inter-disciplinary Laying the background for inter-disciplinary collaboration often needed for result-oriented collaboration often needed for result-oriented biomedical research biomedical research

Guiding principles:-Guiding principles:-Ethics contribute to high quality patient care and Ethics contribute to high quality patient care and professional behaviourprofessional behaviour

Knowledge of ethics could allow medical trainees Knowledge of ethics could allow medical trainees to become better practitioners of medicineto become better practitioners of medicine

Ethics taught, learned and evaluated along with Ethics taught, learned and evaluated along with the general medical knowledge is better the general medical knowledge is better incorporated into practice.incorporated into practice.

Ethics is better taught and retained when Ethics is better taught and retained when students are still impressionable and malleable.students are still impressionable and malleable.

Goals:-Goals:-

To incorporate ethical concerns and To incorporate ethical concerns and issues into all phases of the education of issues into all phases of the education of medical studentsmedical studentsTo help prepare students to understand To help prepare students to understand their own values and be ethically aware their own values and be ethically aware medical practitionersmedical practitionersTo provide students with the knowledge, To provide students with the knowledge, skills and attitudes required to be able skills and attitudes required to be able to make ethically-informed decisionsto make ethically-informed decisionsReflect on their own beliefs about ethics Reflect on their own beliefs about ethics and consider and challenge opposing and consider and challenge opposing beliefsbeliefs

Goals in briefGoals in brief

Improve the quality of patient careImprove the quality of patient careTeaching should focus on cognitive Teaching should focus on cognitive skills , behavioural skills and character skills , behavioural skills and character developmentdevelopmentTeaching should be integrated into all Teaching should be integrated into all stages of a physicians education, stages of a physicians education, including medical schools, residency and including medical schools, residency and continuing educationcontinuing education

But can ethics be taught?But can ethics be taught?Can character or virtue be taught?Can character or virtue be taught?Are there enough people to teach?Are there enough people to teach?Will teaching ethics make any difference?Will teaching ethics make any difference?

Implementation Implementation

Taking into account the different Taking into account the different curriculum in Africa’s medical schools, curriculum in Africa’s medical schools, introducing formal training in ethics would introducing formal training in ethics would highlight principles for general discussion.highlight principles for general discussion.

Formal training in ethics should be Formal training in ethics should be undertaken throughout the period of study in undertaken throughout the period of study in the medical school (from the pre-clinical the medical school (from the pre-clinical years till graduation)years till graduation)

Training format should include didactic Training format should include didactic lectures, seminar presentations, case lectures, seminar presentations, case presentations and attendance at IRBs and presentations and attendance at IRBs and cERC meetingscERC meetings

Implementation (contd.)Implementation (contd.)

To ensure that courses are taken seriously, To ensure that courses are taken seriously, there must be compulsory, elective and there must be compulsory, elective and required courses should have their required courses should have their examinations and scores that count towards examinations and scores that count towards graduation. Individual or group projects graduation. Individual or group projects should be part of graduation requirements.should be part of graduation requirements.Clinical ethical teaching should be started Clinical ethical teaching should be started from the first year right through to the from the first year right through to the graduating years.graduating years.Non-medical students who intend to Non-medical students who intend to undertake research with human subjects undertake research with human subjects should be allowed to participate in the should be allowed to participate in the programmeprogramme

Implementation (contd.)Implementation (contd.)

Students groups should be given Students groups should be given advisors drawn from a multidisciplinary advisors drawn from a multidisciplinary pool of appropriately trained staff pool of appropriately trained staff members from Law, Social sciences, members from Law, Social sciences, Medicine, Medical Humanities, Nursing, Medicine, Medical Humanities, Nursing, and other interested faculties.and other interested faculties.

Provision should be made for those who Provision should be made for those who would ultimate specialize in medical would ultimate specialize in medical ethics by a gradual build up of facilities ethics by a gradual build up of facilities and faculty members capable of and faculty members capable of imparting postgraduate level training in imparting postgraduate level training in Biomedical ethics.Biomedical ethics.

Suggested input into curriculum Suggested input into curriculum

First yearFirst year:- type of courses and no of units :- type of courses and no of units to be determined by each institution to be determined by each institution - The nature of man in health and in sickness - The nature of man in health and in sickness - Differences between the sexes and between the - Differences between the sexes and between the

ages ages - History and development of biomedical ethics- History and development of biomedical ethics- Introduction to the principles of biomedical - Introduction to the principles of biomedical

ethics including patient confidentiality, ethics including patient confidentiality, informed consent, privacy, autonomy, non-informed consent, privacy, autonomy, non-maleficence, beneficence and justice.maleficence, beneficence and justice.

- Case studies of situations expressing adherence - Case studies of situations expressing adherence or non-adherence to these principles.or non-adherence to these principles.

- Term papers and assignments - Term papers and assignments

Second yearSecond year

- Rights and responsibilities (patients and health Rights and responsibilities (patients and health workers) in health care workers) in health care

- Practical application of reasoning skills to some Practical application of reasoning skills to some of the clinical cases discussed in the first year.of the clinical cases discussed in the first year.

- International and national guidelines directing International and national guidelines directing research and clinical practice.research and clinical practice.

- Case studies of situations expressing adherence Case studies of situations expressing adherence or non-adherence to ethical principles.or non-adherence to ethical principles.

- Being a good doctorBeing a good doctor- Dealing with drug company promotionsDealing with drug company promotions- Term papers and assignmentsTerm papers and assignments

Third yearThird year

- Medicine and the LawMedicine and the Law- Conflict of interestsConflict of interests- Medical mistakesMedical mistakes- Malpractices Malpractices - ProfessionalismProfessionalism- Informed consent (revisited)Informed consent (revisited)- Patient participation in researchPatient participation in research- Vulnerable subjectsVulnerable subjects- Breaking bad news (I)Breaking bad news (I)- Ethics in paediatricsEthics in paediatrics

Fourth yearFourth year

• - breaking bad news (II)- breaking bad news (II)• - do-not-resuscitate orders- do-not-resuscitate orders• - withholding and withdrawing treatments- withholding and withdrawing treatments• - end of life decisions, advance directives etc.- end of life decisions, advance directives etc.• - legalising abortions (seminar forum, for and - legalising abortions (seminar forum, for and

against)against)• - care of the elderly- care of the elderly• - care of the disabled- care of the disabled• - ethics, law and the child.- ethics, law and the child.• - confidentiality revisited (STIs and Family planning)- confidentiality revisited (STIs and Family planning)• - case follow up in Paediatric and/Obstetric unit for - case follow up in Paediatric and/Obstetric unit for

write upwrite up

Fifth yearFifth year

• - breaking bad news (III)- breaking bad news (III)• - informed consent in surgery and invasive procedures- informed consent in surgery and invasive procedures• - patient participation in research- patient participation in research• - involving children and other vulnerable subjects in - involving children and other vulnerable subjects in

researchresearch• - ethical issues in research, randomization, placebo - ethical issues in research, randomization, placebo

controlled trials controlled trials • - ethics and the law in mental health- ethics and the law in mental health• - community consent how culturally appropriate and - community consent how culturally appropriate and

how legalhow legal• - project- project• - seminars - seminars

Additional facilities and resources needed Additional facilities and resources needed for appropriate establishment of this for appropriate establishment of this programme in the Medical schoolsprogramme in the Medical schools

On-going staff development in the area of On-going staff development in the area of biomedical ethics biomedical ethics

Establishment of Centres for Biomedical EthicsEstablishment of Centres for Biomedical Ethics Provision of resources materials by way of Provision of resources materials by way of

journals, books and virtual librariesjournals, books and virtual libraries Possibility of a combined degree in medicine Possibility of a combined degree in medicine

and bioethics for excellent students.and bioethics for excellent students. Collaboration with other establishments with Collaboration with other establishments with

and outside Africa for appropriate development and outside Africa for appropriate development of ethics in our medical schoolsof ethics in our medical schools

Postgraduate programme in biomedical ethics.Postgraduate programme in biomedical ethics.

Thank you for listeningThank you for listening

•Meanwhile let’s Meanwhile let’s discuss discuss