An international survey ofmedical curricula in AsiaKeywords: Medical ethics education; curriculum survey; medical school; Asia Introduction In the last two decades, formal ethics education

Journal ofMedical Ethics 1999;25:514-521

Teaching medical ethics

An international survey ofmedical ethicscurricula in AsiaMichio Miyasaka, Akira Akabayashi, Ichiro Kai and Gen Ohi Niigata University, Niigata City, The Universityof Tokyo, Tokyo and The National Institute for Environmental Studies, Tsukuba City, Japan

AbstractSetting Medical ethics education has becomecommon, and the integrated ethics curriculum hasbeen recommended in Western countries. It should bequestioned whether there is one, universal method ofteaching ethics applicable worldwide to medicalschools, especially those in non-Western developingcountries.Objective-To characterise the medical ethicscurricula at Asian medical schools.Design-Mailed survey of206 medical schools inChina, Hong Kong, Taiwan, Korea, Mongolia,Philippines, Thailand, Malaysia, Singapore,Indonesia, Sri Lanka, Australia and New Zealand.Participants-A total of 100 medical schoolsresponded, a response rate of 49%, rangingfrom 23%- 100% by country.Main outcome measures The degree ofintegration of the ethics programme into the formalmedical curriculum was measured by lecture time;whether compulsory or elective; whether separatecourses or unit of other courses; number of courses;schedule; total length, and diversity of teachers'specialties.Results A total of 89 medical schools (89%)reported offering some courses in which ethical topicswere taught. Separate medical ethics courses weremostly offered in all countries, and the structure ofvertical integration was divided into four patterns.Most deans reported that physicians' obligations andpatients' rights were the most important topics fortheir students. However, the evaluation was diversefor more concrete topics.Conclusion-Offeringformal medical ethicseducation is a widespreadfeature ofmedical curriculathroughout the study area. However, the kinds ofprogrammes, especially with regard to integration intoclinical teaching, were greatly diverse.(7ournal ofMedical Ethics 1999;25:514-521)Keywords: Medical ethics education; curriculum survey;medical school; Asia

IntroductionIn the last two decades, formal ethics educationhas become one of the common features of medi-cal curricula in many Western countries.' Theformation of a formal programme led to a generalempirical understanding of how medical ethicsshould be taught. In the United Kingdom theInstitute of Medical Ethics recommended thatmedical ethics teaching should recur at regularintervals throughout medical teaching, and thattime should be set aside within existing teachingfor ethical reflection relevant to each stage of astudent's experience.2 Miles and colleagues in theUSA argued similarly that ethics education shouldbe conceptually coherent, vertically and horizon-tally integrated through preclinical and clinicaltraining, multidisciplinary, academically rigorous,and should demonstrate humane and value-conscious medical practice.3 Thus, the integrationof ethics into the formal curriculum has becomethe standard recommended programme design ofmedical 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 standardprogramme design is universal, applicable world-wide to all medical schools, especially to those innon-Western developing countries. The funda-mental changes in medical ethics are usuallyattributed to social factors common to Westerndeveloped countries, namely the novel moral viewof respect for patient's autonomy; the develop-ment of high-tech medical technology, and theshift of major causes of death from acute curablediseases to chronic incurable ones, which haveforced physicians to think of therapeutic optionsconcerning patients' quality of life.'0`14 In manydeveloping countries, acute diseases are stillkilling many people, and therapeutic options con-cerning comfortable quality of life are not realisticfor many people. Furthermore, individualistic

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patient choice in clinical settings is not usualin non-Western countries, even today. SomeJapanese scholars have criticised Western bioethicsas placing too much weight on the principle ofrespect for autonomy that poorly fits the East-Asian ethos, which appreciates human interactionand communitarian empathy.'5 16

If Western individualistic ethics has promotedformal medical ethics education, and if it is reallyunacceptable for the South and the East, it couldbe assumed that formal medical ethics educationis neither common, nor even needed in mostAsian countries. On the other hand, taking intoaccount that most issues in medical ethics, such asorgan transplantation and termination of life sup-port, are now faced in Asian countries, and thatthe worldwide trade of medical technology hascreated a greater disparity in the distribution ofhealth care resources, even within countries, itcould be argued that Asian medical schoolsshould prepare their students for ethical dilem-mas, and indeed, for ethical dilemmas that couldbe much more complicated than in the West.

This study was designed to survey the medicalethics programmes of medical schools in the East,South-east, South Asia, and Oceania. The pur-pose of the study is to analyze how much ethicseducation is formally given, and how much isintegrated into the medical curriculum.

MethodsSUBJECTSWe included all medical schools of the area whichappeared in the World Health Organisation'sWorld Directory of Medical Schools.'7 Medicalschools which specified they taught only tra-ditional medicine were excluded. A four-pagequestionnaire was developed and sent to the deanor the president of the medical school. The initialmailing was made in November 1994, and fourmonths later, a follow-up mailing was sent tonon-respondents. The last response was receivedin October 1995. The mailing included anintroductory letter. The letter and the question-naire were in English. In a separate study,Japanese data were collected using a Japanesetranslation of the questionnaire used in thissurvey, and were submitted elsewhere.'8 Part ofthe Japanese data was used to make statisticalcomparisons in this report. In Taiwan, where nodata were cited in the directory, Dr Tai-YuanChiou ofTaiwan University kindly informed us ofthe mailing addresses of all of the ten medicalschools at that time.

QUESTIONNAIRE AND ANALYTIC TECHNIQUES

The questionnaire consisted of two parts. Oneaddressed the programme of medical ethics orsimilar courses. Deans were asked to fill in thename of the course, school years in which thecourse was offered, the length of the course,whether it was compulsory or elective, and teach-ers' specialties. The second part asked thepersonal opinion of the dean on: ethics education;the degree of satisfaction with ethics education athis/her school; the importance of ethics educationcompared with other subjects; what kind ofprogramme he/she would like to see and whatkind of backgrounds he/she would prefer teachersto have, and what lecture topics he/she regarded asdesirable for students. Respondents were requiredto note their nationality, sex, age, religion,specialty, the number of students in a school year,the number of full-time teachers, total schoolyears (duration of medical degree course), andduring which school years bed-side teaching wasscheduled.A "separate medical ethics course" was defined

as a course whose title contained both (1) wordsrepresenting medicine/medical care, ie "medi-cine", "health", "physician", "patient", "clinic",and (2) words representing ethics/moral philos-ophy, ie "ethics", "moral", "rule", "value". Othercourses were categorised as "medicine relatedcourses"; these were courses whose title containedonly medicine-related words, or as "othercourses"; these were courses whose titles includedno medicine-related words.We separated the medical degree course into

three segments: before, during, and after bed-sideteaching (BST) school years. The "BST schoolyears" were defined as including school years atthe beginning and end ofBST, and all school yearsin between. Therefore, if BST was offered in thesecond and the fourth years, the third year wasalso regarded as "during BST".

Teachers' specialties were categorised into fourcategories; (1) physician/health professional; (2)philosopher/ethicist; (3) theologian/priest/monk,and (4) lawyer/ jurist/social scientist. Interdiscipli-nary backgrounds were identified by combinationof 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) whereone teacher had two or more backgrounds, and(B) where two or more teachers took part, buteach of them had one-but a different-background.With regard to Singapore and Mongolia, both

of which had only one medical school, the countrydata are not shown in this report.


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516 Teaching medical ethics:An international survey of medical ethics curricula in Asia

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ResultsMEDICAL ETHICS PROGRAMMESWe did not analyze countries from which fewerthan ten per cent of questionnaires were retrieved.The response rate of the remaining 13 countries(China, Hong Kong, The Republic of Korea, Tai-wan, Indonesia, Malaysia, the Philippines, Singa-pore, Thailand, Sri Lanka, Australia, New Zea-land, Mongolia), was 48.5%o (100/206), rangingfrom 23% - 100% by country.

Table 1 summarises the characteristics ofcourses which had lectures on ethical topics.Eighty-nine per cent (89/100) of medical schoolshad some courses. Seven schools did not have acourse, but said they would have in the nearfuture. One Thai school answered that they didnot have a course, and did not expect to have anycourse in the near future. A diversity of allocatedlecture time was found in most countries.However, in China, Taiwan and the Philippines,60% or more medical schools allocated more than20 hours to ethics courses, while in Hong Kong,Korea, Indonesia, Malaysia, Thailand and SriLanka, this ratio was below 40'%O. In every country,most of the courses were compulsory. Seventy-nine per cent of medical schools required studentsto take all courses, and three per cent offeredelective courses in addition to required ones. Fourper cent of medical schools which responded saidthey had elective courses only.The number of medical schools offering

separate medical ethics courses was 8 1 % (8 /1 00)of all respondents. The majority of the separatecourses were referred to as "medical ethics","bioethics", or "clinical ethics".The longitudinal schedule, reflected in the

number and the schedule of the course, was asdiverse as any other aspect of the curriculum. InChina, Taiwan and Malaysia, more than 60% ofmedical schools reported one course, while inHong Kong, the Philippines, Thailand, Sri Lanka,Australia and New Zealand, two or more courseswere more common than one course. In particu-lar, in the Philippines, Australia and NewZealand, 60% or more replied that they offeredthree or more courses. The schedule of ethicsteachings was found to differ widely by country. InChina, Korea, and Indonesia, the number ofmedical schools offering ethics courses duringBST school years was less than half. In contrast, inTaiwan, Hong Kong, Malaysia, the Philippines,Sri Lanka, and Australia, ethics courses werescheduled during BST school years in 60% ofschools, or more. Medical schools offering ethicsboth before and during BST school years werefound in most countries. In the Philippines, Thai-land, Sri Lanka, Australia, and New Zealand, 30%o

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or more of schools had this kind of multi-steppedschedule.The analysis of diversity in teacher specialty was

limited to cases in which specialties could beidentified concretely enough to be categorisedinto four groups. Fifty-eight per cent of medicalschools reported that persons with medical back-grounds were teaching ethics. The proportion ofmedical schools featuring philosopher/ethicist,theologian priest/monk, and lawyer/jurist/socialscientist, were 27%, 11%, and 10%, respectively.Theologian/priest/monk, and/or lawyer/jurist werereported to be teaching medical ethics in a limitednumber of countries.

ATTITUDE OF RESPONDENTS TO ETHICS EDUCATIONWe mailed the questionnaire to deans andrequested them to express their personal opinions.However, it should be noted that we could notcorrectly identify the person(s) who directlyanswered the questionnaire. Therefore, we do notdescribe the attitude of respondents as that of"deans".The number of respondents who were "satis-

fied" or "moderately satisfied" reached 80% inChina, Taiwan, the Philippines, Thailand andAustralia, while in Korea and Malaysia, this ratiowas 50 to 60% or lower (table 1). Eighty-three percent of all respondents considered ethics educa-tion to be "very important" compared with othersubjects (not shown in the tables). However, fewerrespondents thought more time should be allo-cated to ethics courses.

Table 2 shows which topics the respondentsthought ought to be covered in lectures duringmedical ethics courses at their schools. "Physi-cians' obligations/etiquette" was evaluated as themost important topic by 64% of all respondents."Patient's right/autonomy," "informed consent,"and "patient's privacy/confidentiality", were allhighly evaluated, but the ratio of respondents whochose these as "most important" decreased to40%, 24%, and 15% respectively. On the otherhand, the evaluation was diverse and may reflectsome difference between countries for specificitems. "Artificial abortion" was considered as"most important" or "very important" by 78% ofFilipino respondents and 73% of Indonesianrespondents. However, in China, Thailand, andAustralia the figure did not reach 30%. "Popula-tion control" was highly evaluated in China. "Thecare of children, the rights of children" receivedhigh evaluation in Thailand, Malaysia, the Philip-pines and Sri Lanka.

DiscussionOur survey has shed some light on both similari-ties and differences in medical ethics education inAsian countries. It is obvious that medical ethicseducation has become a universal component ofundergraduate formal medical training in mostcountries. Except for Japan, where many schoolswere not teaching medical ethics in separatecourses, and China, where the data of non-respondents might significantly alter the results,medical ethics was commonly taught in requiredseparate courses. We could not obtain detaileddata which would illustrate how the ethicsprogramme had been developed in each schoolreported herein. Nevertheless, the developmentappears to have occurred in the last twodecades,'9-21 as in many Western medical schools.It should be noted that the spread of formal medi-cal ethics education is not limited to industrialisedcountries, where high-tech medicine forces physi-cians to face new ethical dilemmas which arefamiliar in the literature of bioethics. Also, indeveloping countries, where physicians are re-quired to cover a large population, with high-techmedicine usually beyond their reach, medicalschools are becoming aware of ethical dilemmasunique to their own medical and socioculturalcontext, and that students should be prepared forthese dilemmas.On the other hand, there were many different

sorts of medical ethics teaching programmes. Oneof the most conspicuous differences was foundbetween Japan and other countries. In allcountries except Japan, courses dealing with ethi-cal topics were separate ones, mostly with explicittitles such as "medical ethics" or "bioethics".However, the majority of Japanese medicalschools were teaching medical ethics as a unit of"introduction to medicine" or similar courses.This was not likely to be due to the matter ofwording or translation. The original Japanese for"introduction to medicine," igaku gairon, has beendefined and translated in various ways (ie "thephilosophy of medicine"22 or "medicalhumanities"23) since its establishment in 1942. Byany definition, it aims to cover a broad spectrumof humanities and social sciences which will forma foundation for the study of medicine. Thus, thegoal of "introduction to medicine" is similar tothat of the medical humanities. However, quite afew Japanese medical schools seemed to allocateonly a short time to ethical topics in theircourses,24 and most Japanese deans did not feeltheir ethics teaching was well organised.29 In theJapanese survey,'8 the number ofJapanese medicalschools offering separate medical ethics courseswas 14 (22% of 64 schools responded), but this


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520 Teaching medical ethics: An international survey of medical ethics curricula in Asia

figure was a leap from 7 (9% of 80 respondents) in1990.24 Furthermore, Japanese respondents werethe least satisfied with their ethics education.Putting all accounts together, offering medicalethics in separate courses is becoming a commonfeature of Asian medical schools, includingJapanese ones.From the standpoint of vertical integration,

medical ethics should be taught step by stepthroughout preclinical and clinical education. Theresults suggest that the structure of verticalintegration in this area was divided into fourstages. Medical ethics is given as either: (1) a sin-gle course before BST school years (dominant inChina and Korea; (2) a single course during BSTschool years (dominant in Taiwan and Malaysia);(3) multiple courses during BST school years andother years (dominant in the Philippines and Aus-tralia), or (4) a unit of courses not specified formedical ethics before BST school years (domi-nant in Japan). Judging from the longitudinalstructure of the programme, the third patternappears to be the most explicit mode of the verti-cally integrated programme, in which medicalethics literally recurs through preclinical andclinical training, as recommended by Westernobservers.2 3 Medical ethics curricula categorisedin other groups seemed to be suffering from theabsence of either preclinical or clinical ethics edu-cation. It can be argued that preclinical and clini-cal ethics education have different goals from eachother, and that both are indispensable. Thisstandpoint appears to be becoming accepted inmany Asian countries, because the vertically inte-grated programme was found in most countriessurveyed herein. At the same time, the wide rangeof differences in the patterns within countriessuggested that the longitudinal cohesiveness ofethics education is still of less concern to medicaleducators in this area. The importance of longitu-dinal cohesiveness has only been recognised veryrecently, and it might be a hard task for medicalschools where the curriculum is overcrowded, tointroduce another set of courses throughout mul-tiple school years.Our results indicated that, on the one hand,

interdisciplinary teaching was popular in manyschools, but on the other hand, that teachers withreligious backgrounds only took a modest part inthe teaching of medical ethics. Modern academicmedical ethics, or bioethics, has been developed asa secular discipline, dominantly influenced by theAnglo-American social context, even though therehas been a significant contribution by theologiansto its development. Our data suggest that medicalethics teaching at Asian medical schools has asecular character. However, the dominance of

secular teachers raised questions about educationon sensitive ethical issues such as abortion andeuthanasia where there can be conflicts betweenmedical conduct and religious beliefs. Most Asiancountries maintain diverse, and sometimes con-flicting, traditional religious beliefs or socialhabits. Furthermore, the conflict between modernmedicine and traditional values is very often hardto mediate. The diversity observed in therespondents' evaluation of ethical topics suggeststhe contents of medical ethics education candiffer, perhaps reflecting the sociocultural andhistorical context in which the medical schoolstands. Therefore, in the educational setting,teachers need carefully to address this conflict,especially when no one from the religious camp isparticipating in the programme. In this regard,interdisciplinary teaching was highly appreciatedby deans; respondents expected more diversitythan the current teachers had. The recruiting ofmore lecturers can be done without a drastic ref-ormation of the curriculum, without needing tohire full-time teachers, and without having toestablish an independent department or pro-gramme. However, the successful institutionalisa-tion of medical ethics education would be hard toachieve without a core responsible organisation.The form of the core organisation could varyaccording to the availability of multidisciplinaryteachers, and the support of the dean and the col-lege. Therefore, the most serious weaknesses ofAsian medical ethics education may be that only afew countries have centres for training teachers,'6and that the standardisation or qualification ofmedical ethics teachers is still poorly developed.

Exchanging experiencesOn the basis of our survey we can say that theteaching of medical ethics is obviously widespreadin the South and the East. Therefore, it may not betrue to describe modern medical ethics as a disci-pline unique to the industrialised West. Rather,medical ethics education, like other disciplines,should be taken to be an essential part of medicaleducation that is mandated to meet society's needfor a supply of competent practitioners. On theother hand, the diversity in vertical integration ofthe programmes suggested a difference of contentsor goals of medical ethics teachings. The rec-ommendation for an integrated programme, as putforward by Western observers, seems grounded inthe practical character of medical ethics, and thebelief that it should be incorporated as a unit ofclinical education. In countries like Japan, whichhas traditionally taken medical ethics education asa unit of medical humanities, and given it acharacter resembling liberal education, it is not yet


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certain how medical ethics will be given a practicalcharacter, and integrated into clinical education.Although setting goals, designing programmes,and recruiting appropriate teachers are left foreach country and each medical school to decide,these tasks would be harder to achieve without theaccumulation of empirical study in the field.Therefore, exchanging experiences may be themost feasible method for Asian medical schools toestablish well-organised programmes of medicalethics education.

AcknowledgementsThe authors wish to thank all participants whowere involved in the studies, and Dr Darryl MacerofTsukuba University, for his critical review of thequestionnaire and this manuscript. This study waspartly supported by the TOYOTA foundation,and by grant-in-aid for scientific research No07672437 by the Ministry of Education, Science,Sport and Culture, Japan.

Michio Miyasaka, PhD, (corresponding author), isLecturer in the School of Health Sciences, Faculty ofMedicine, Niigata University, Niigata City, Japan.Akira Akabayashi, MD, PhD, is Lecturer in TheSchool of Health Sciences and Nursing, The Univer-sity of Tokyo, Tokyo, J7apan. Ichiro Kai, MD, PhD,MPH, is Professor in The School of Health Sciencesand Nursing, The University of Tokyo, Tokyo. GenOhi, MD, PhD, MPH, is Director General of TheNational Institute for Environmental Studies, Tsu-kuba City, Japan.

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An international survey ofmedical curricula in AsiaKeywords: Medical ethics education; curriculum survey; medical school; Asia Introduction In the last two decades, formal ethics education