A.M.Jafarey  ( Department of General Surgery, The Aga Khan University, Karachi. )

Over the past few years bioethics has become an integral part of medical education worldwide. In the early seventies, only 4% of American medical colleges taught bioethics as a formal course. By 1994, all medical colleges in the United States had bioethics as a required part of the medical curriculum.1 Even though Pakistan Medical and Dental Council code of ethics stipulates that medical ethics be taught in medical colleges in Pakistan2, unfortunately bioethics has still not found its way into formal medical curricula. To the best to the authors' knowledge, bioethics is not a formal part of the medical syllabus of any undergraduate or post graduate medical institution with the exception of one private medical college.
Why is there a need for ethics education to medical students and graduates? Inculcation of moral values in an individual starts from the cradle. By the time an individual starts medical schooling, basic values are assumed to be firmly and unshakably entrenched. But is this really the case? Evidence from across the world indicates that students have felt their ethical values challenged in the hospital environment. According to Feudtner et al surveying third and fourth year medical students in six medical colleges of eastern Pennsylvania, USA, 58% students reported doing something they considered unethical and 62% believed that at least some of their ethical principles had been eroded or lost.3 Another study indicated that students exposed to unethical situations within clinical environment may feel encouraged to maintain two separate codes of ethics, one personal and one as a physician.4 In this same study, fewer students felt that their code of ethics as residents would improve and more indicated that it would actually decline.
The situation is no different in Pakistan. In a study conducted by Syed et al in Karachi, Pakistan, on junior doctors, 74% felt their teaching of medical ethics had been unsatisfactory. Fifty three percent respondents felt that their senior's medical practice was unethical and 65% felt that a majority of the patients suffered because of the unethical practices of the senior medical staff.5 Witnessing unethical behavior predictably leads to an erosion of the noble ideals that young men and women entering medical college bring with them as they begin their training. This is highlighted in a questionnaire based study of medical students from three different medical colleges in Karachi, Pakistan to different ethically challenging situations presented to them.6 Disillusionment is an expected consequence.
This unfortunate disillusionment with the medical culture and tradition has been called traumatic deidealization7 and emphasizes the importance of creating an environment that fosters ethical clinical practice. Inclusion of bioethics into medical curricula is an attempt to stem this decay and salvage the sanctity of this profession.
As the objective of teaching surgery or obstetrics at the undergraduate level is not to create specialist surgeons or obstetricians but to produce at the end of the prescribed course a well rounded and mature medical graduate who is adequately equipped to recognize a variety of medical problems and treat them within limits of his expertise and refer those beyond his capacity of intervention to appropriate healthcare facilities. Similarly the objective of teaching bioethics is not to create bioethicists but to equip the graduate with adequate reasoning skills to be able to identify ethical dilemmas as they occur in his practice and attempt judicious resolution using the knowledge and experience imparted to him during the training years.
Even in the US where bioethics training had been described several years ago as 'coming of age'8 there are several issues still being widely debated. These include: what to teach, how to teach, when to teach and who should teach.
Regarding the issue of what to teach, there is still no 'ideal' curriculum identified and wide variation exists from institution to institution.9 This variance would perhaps be even more pronounced when looking at courses in the different regions of the world with widely different value systems and cultures.
A significant part of ethics education occurs passively through osmosis, in the true spirit of the apprenticeship mode of medical education. To strengthen this informal mode of indoctrination, more formal tools have also been applied with success like formal didactic lectures, small group discussions, standardized patients, ethics rounds and so on. It is generally agreed by most bioethics educators that realistic case based discussions are the best way of imparting bioethics education.10 Here again, the best possible mode of instruction will depend upon the resources and manpower available to conduct the course.
It is well documented that students start facing ethical challenges right from the first year of medical education.3,11 It is therefore imperative that bioethics education starts in the first year. In order to be effective, ethics education has to be seamlessly integrated into the existing medical curriculum so that its relevance is brought out and it does not assume the role of just another series of lectures that have to be endured. Ideally this integration should not only be horizontal but also vertical throughout the five years of medical schooling.1
Regarding the question of who should teach medical ethics, an interdisciplinary group of teachers has been shown to be an effective model.1 Philosophers can be rightly expected to have a greater command over ethics but medical practitioners with knowledge of medical ethics, the upcoming breed of medical ethicists, are perhaps best suited to teach medical students and postgraduates. They have first hand experience of the issues at hand and are also armed with the know how of ethics to be able to deal with the real problems faced in the clinical environment by the students and clinicians.
The need for including bioethics in Pakistani medical curricula is unquestionable. One major hurdle is in the lack of personnel who can actually create and implement culturally and regionally relevant bioethics curricula in the various Pakistani medical institutions. Bioethics education programs can realistically only be expected to take off if there is a core faculty that can make this happen. The need of the hour is the training of faculty in this budding field who are willing to spearhead this bioethics revolution in Pakistan.

1. Fox E, Arnold RM, Brody B. Medical ethics education: Past Present and Future. Acad Med 1995;70:761-68.

2. Pakistan Medical and Dental Council Code of Ethics. http://www.pmdc.org.pk/ethics.htm

3. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students perceptions of their ethical environment and personal development. Acad Med 1994;69:670-67.

4. Satterwhite RC, Satterwhite III WM, Enarson C. An ethical paradox: the effect of unethical conduct on medical students' values. J Med Ethics 2000;26:462-65.

5. Syed SS, John A, Hussain S. Attitudes and perceptions of current ethical practices. Pak J of Med Ethics 1996;1: 5-6.

6. Jafarey AM, Farooqui F. Ethical dilemmas and the moral reasoning of medical students. J Pak Med Assoc 2003;53:210-14.

7. Kay J. Traumatic deidealization and the future of medicine. JAMA 1991; 263:572-73.

8. Miles SH, Lane LW, Bickel J, et al. Medical ethics education: coming of age. Acad Med 1989;64:705-14.

9. DuBois JM, Burkemper J. Ethics education in US medical schools: a study of syllabi. Acad Med 2000;77:432-37.

10. Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993;68:249-54.

11. Yamey G, Roach J. Witnessing conduct: the effects. West J Med 2001;
174:355-56.