Teaching ethics and medical humanities to medical students in Sri Lanka:

a multi-cultural approach

ANOJA FERNANDOFaculty of Medicine

University of RuhunaSri Lanka

8th Asian Bioethics Conference, Bangkok, Thailand19 - 23 March 2007

THE FACULTY OF MEDICINE, UNIVERSITY OF RUHUNA (GALLE)

Established 1980

At inception, in 1981, ethics teaching was in

• Forensic Medicine course (professional, legal)

• History of Medicine lecture• Code of Hammurabi 2000 BCE

• Lord Buddha, Vinaya Mahavagga 1st century CE (500 years after Buddha)

• Hippocratic Oath 5th century BCE

• Declaration of Geneva, W M A 1948

Lord Buddha (Vinaya Mahavagga)

5 characteristics of a good “caregiver”• To be capable of prescribing the proper

medicine

• To administer what is suitable

• To nurse the patient out of charity and not out of greed

• Not to be squeamish about removal of excrement, vomit etc

• To teach the patient, to be able to cheer him and comfort him

• Formal Medical Ethics course 1995

• Medical Humanities introduced 2005

Formal course on Medical Ethics

1995

Traditional Curriculum - Ruhuna

1 2 3 4 5

Pre-clinical

Para-clinical

Clinical

ETHICS

Medical Ethics Course

At entry tomedical school

Medical Students’ Oath (2001)Introductory lecture

At entry to clinical course in 3rd year

7 lectures and one seminar on ethical scenarios

Forensic Medicine

Pharmacology

Professional and legal ethics

Research ethics

3rd to 5th year Specialised topicsClinical ethics discussions

• During Professorial Appointments (5th YR)

• Students identify and present ethical issues in ward patients

• Discussion in the wards• Guidelines provided

Assessment• Simple student assessment

• Final course evaluation

Clinical Ethics Discussions

Formative assessment of students at end of

course

1998* 2005

Question 1 93 % 91 %

Question 2 75 % 99 %

Question 3 71 % 75 %

Question 4 81 % 84 %

Question 5 83 % 83 %

Question 6 63 % 80 %

Evaluation of ME Course by students

1998 2005

Interesting 90 % 90 %

Useful/relevant 86 % 98 %

Continue during internship

85 % 97 %

Input excessive 25 % 16 %

Reduce lectures 50 % 14 %

Increase discussions 80 % 76 %

Innovations in 2005

• Use of Asian sources for teaching medical ethics

• Introduction of Medical Humanities into the Ethics Course

“Drawing on Asian literature may lead to greater cultural relevance in teaching and

acceptance of medical ethics in Sri Lanka.”

Prof S N Arseculeratne

Medical Ethics of Susruta and Charaka

Medical Ethics of Arab physicians eg Rhazes

Buddhist Jataka Tales

Comparison of Hippocratic Oath with Charaka’s Code of Conduct

• Hippocratic oath more about doctor-patient relationship, while Charaka’s Code stresses personal morals also. (more difficult as well)

• About 25% thought Charaka’s Code better and more relevant to Sri Lanka (Asia), while about 8 % thought Hippocratic Oath better.

(n=114)

Medical Humanities

2005

In favour of introducing Medical Humanities

YES NO

Teachers 76 % 24 %

Students 98 % 02 %

2005

Introduction of Medical Humanities in 2005

• Course of short optional lectures from October to December 2005.

• First time in a medical faculty in Sri Lanka.

• Experimental in nature

MEDICAL HUMANITIESArts subjects related to Medicine

OBJECTIVES:

To promote• Reflective practice and personal

development• Empathy with patients • Compassionate understanding of

individuals in society

METHOD

• Ten half hour lectures• Fourth year students• Handouts• Western and Asian sources• Optional • No assessments • Lecturer: qualified in med +

humanities • Evaluation of course

This was voted the most popular lecture by the students

Students’ comments

“It made me feel special to be a doctor in the future and an impulse to do good.”

“It touches our deep emotions and makes us think back - do we practice real medicine at present?”

“I liked the painting because I have never related to one so before. It was really interesting to actually UNDERSTAND a painting.”

EXAMPLE

• 99 students (out of 135) responded

• 96% wanted course continued

• Enjoyed the lectures (80%-97%)

• Agreed on relevance to objectives (80%-88%)

• Preference: half-hour (69%) lectures (71%)

• Comments were positive and appreciative, indicating that lectures were effective.

Preliminary evaluation of course

STUDENT COMMENTS ON COURSE

• “Talks on humanities are a very good approach to create a better doctor.”

• “This is a really good idea to introduce this kind of thing to medical students.”

• “This series should be continued.”• “It makes our life a little relaxed and

also some at least can think about our patients in a different way, more empathetically, and emotionally, and care for their feelings in the future.”

CONCLUSIONS

Short, didactic lectures are feasible, acceptable to students, and effective as a method of introducing medical humanities to undergraduates, in a developing Asian country with limited resources.

2nd course of lectures – October 2006

• Lecture duration 1 hour

• External lecturers

• Simple assessments

Lecture topics

• Evolution of ethics during the 20th century (hist)• The doctor-patient encounter in western art (art)• Anatomical drawings of Leonardo da Vinci (art)• The history of the Nuremberg Code (hist)• Anatomy lesson by Jack Coulehan (poetry)• Use of Jataka stories in psychotherapy (lit)• Tapestry art depicting end of life (art)• Medicine and hospitals in ancient Sri Lanka (arch)• Ethical Codes in Medicine: East and West (hist of

med)• Racism in medicine : some examples (hist of med)• Alternative systems of medicine (hist of med)• The music of Mozart (music)

ACKNOWLEDGEMENTS

My thanks are due to Dr A A G Abeysinghe, Dr K K R P Kodituwakku and Dr P G D Tharanganee for collection and entry of data from questionnaires.