Healthy curriculum: medical ethics

One of the significant announcements by the newly appointed Board of Governors of the Medical Council of India in November this year is an overhaul of undergraduate medical curriculum to revitalise and contextualise medical education, keeping abreast of evolving healthcare challenges and needs. It is 21 years since a revamp of this scale, and colleges are preparing to introduce these changes from 2019.

Significantly, teaching of ethics has finally been mandated, a much-awaited move that will orient students to ethical norms and social expectations in professional life. The World Medical Association ‘Resolution on the inclusion of medical ethics and human rights in the curriculum of medical schools world-wide’, adopted in 1999, urged that “teaching of medical ethics should become and obligatory and examined part of the medical curriculum in every medical school’”.

This did not materialise in India where, with very few exceptions, ethics did not find a place in formal medical training. The Medical Council of India itself is facing an existential crisis following allegations of mismanagement and is due to be replaced by a National Medical Commission through a Bill introduced in the Lok Sabha in December 2017.

With falling standards of ethical practice and calls for regulation and accountability in healthcare, medical faculty acknowledge the need to introduce ethics but cite an overcrowded curriculum and absence of trained faculty as hurdles in this regard. In the absence of a mandate, colleges produce graduates and specialists who may be technically competent but remain insensitive to the ethical obligations owed to their patients.

The direct impact of this lapse over the last few decades may be hard to quantify, but we are painfully conscious of the gradual erosion of trust in the medical profession, the commercialisation of medicine, and violence against doctors.

Despite technical advances in medicine, it is still an inexact science, with newer insights shaping the evolution of practice. The art of medicine, however, like the empathic touch, the listening ear and the voice of concern, remains a constant feature; particularly relevant today in an age of dehumanising treatments and techno-diagnosis. Patients rightfully expect from the doctor a respectful attitude and sensitive communication.

Further, sickness is a state of extreme vulnerability where trust in the doctor, and confidence in his ethical standards, can provide a great measure of comfort. However, there is little emphasis on these aspects of care, leaving patients disenchanted with the transactional attitude encountered in reality.

An ethical code of conduct is a social contract between the profession and society, based on principles and values that apply to the practice of medicine. If students were merely skilled to diagnose and cure, without emphasis on moral conduct and respect for human rights, their formation would be incomplete. Engagement with ethics and medical humanities is essential to sensitise doctors to the human condition, social and cultural needs, and the rights and dignity of individuals.

The draft of the ‘Patients’ Charter’ prepared by the National Human Rights Commission and circulated by the Ministry of Health and Family Welfare in August 2018 for public comment, is based on human rights, and provides an understanding of the expectations of patients in healthcare settings. It highlights the need to protect patients and their autonomy in medical decisions, clearly setting the standards in patient-provider interactions.

In this context, the mandate to include ethics, clearly expressed in the new ‘Competency based Undergraduate Curriculum for the Indian Medical Graduate’ is the appropriate response to a long-felt need. Not only does the new curriculum envision a “Professional, who is committed to excellence, is ethical, responsive and accountable to patients, community and profession”, but it also expects that clinicians will be able to “demonstrate knowledge of medico-legal, societal, ethical and humanitarian principles that influence healthcare”.

It describes a special course named ‘Attitude, Ethics and Communication’ (ATECOM) that will run across all years of training, using lectures, case discussions, reflections and evaluations in training modules designed to familiarise students with values in medicine, the role of the doctor, ethics, communication skills and social expectations.

At its heart, the medical profession addresses a profound human need. Teaching medical ethics, communication skills and professionalism with good role-modelling, will form doctors with a ‘medical conscience’ who recognise vulnerability in patients and the importance of upholding their trust.

Integrating ethics into every subject of the curriculum will help students recognise the ethical dimensions in the use of new medical technologies and complex clinical situations and equip them to make ethical as well as clinical decisions, in the best interest of the patient.

(The writer is Adjunct Faculty, Division of Health and Humanities, St Johns Research Institute, Bengaluru)