Teaching of medical ethics in Faculties of Medicine From a competent student to a responsible...
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Transcript of Teaching of medical ethics in Faculties of Medicine From a competent student to a responsible...
Teaching of medical ethics in Faculties of Medicine
From a competent student to a responsible physician
Moscou, avril 2012 1
Foreword for ethics
ethics is not a prejudice, but a reflection
So ethics is not by itself a science
ethics is inspired by the philosophical reflection about « the person » The person being either « individual » (autonomy,
personal needs) or « citizen » (relationship, solidarity, collective needs)
Medical ethics is a reflection about medical acts through the patient-physician relationship
Moscou, avril 2012 2
« at first, not to harm »
A precursor… Hippocrates
Foreword for medical ethics
medical ethics is political too : it differs from society, collectivity. It is influenced by social, legal, biological reflections. It cannot provide for each issue an universal answer.
medical ethics evolves following the technics : age for surgery, death criteria, assisted conception…
medical ethics is a self-evaluation of their practices by the physicians, open to other professionals
Moscou, avril 2012 3
Why a new need for medical ethics ?
the medical specialization moves the doctor closer to the ill organ and moves him away from the « person » (body mechanization)
technical progress reduces the importance of physical examination (are we treating a person… or a picture ?)
the law is not suitable to the new fields of the bioethics and medical advances
growth of the health cost is leading, in a medium term, to cares decrease
the frequent confusion(and confrontation) between the « feasible » coming from the medical technologies, and the « desirable » for the patient
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(report Alain Cordier)
State of the teaching of ethics in the frenchspeaking universities (1)
Out of 45 Faculties(study of G.Llorca, CIDMEF) : Specific teaching : 36 (80%) Obligatory teaching : 32 (71%) Average : 29 h (maximum, Strasbourg 123 h)
Pedagogical methods : Lectures / 33 (73%) Reflection groups : 14 (32%) Cases analysis : 19 (43%) Special meetings in the hospital : 9 (20%) Integrated in medical specialties: 22 (50%)
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(2)
Evaluation : Assiduity : 16 (36%) Oral examination : 8 (18%) Written examination : 25 (56%) Reports of cases : 10 (23%) MCQ : 4 (9%) ECOS : 2 (4%)
Teachers : Physicians with ethical leaning : 36 (80%) Teachers of Philosophy : 27 (60%) others: 7 (16%)
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A strategy for the teaching of medical ethics
1. providing the basic theories for a reflection1. medical
2. philosophical
3. sociological
2. leading the student to become aware of ethical reflection by collective studies of practical cases
3. obtaining an individual involvement : follow-up of patients, presentation of actual cases, reports, thesis.
Moscou, avril 2012 7
Three steps
Before the teaching
The ethical formation will begin usefully only after the selection for admission, to avoid huge numbers of students
It would be a wish to get an awakening to ethics before the admission into the Faculty, for instance by the philosophy teachers in the last year of the secondary school.
as we discuss about ethics it’s a paradox that, in most of the Faculties, the humanist qualities of the candidates are not taken into consideration for the students selection.
8
.
Don’t forget the density of our curriculum…
9
First part of the curriculum: basic theories
Some thought steps (outside religious aspects)
Immanuel Kant : autonomy , duty to others(1788)
Jean-Jacques Rousseau : social contract, solidarity between citizens(1762)
John Rawls (theory of justice, 1971)
Hans Tristan Engelhardt : compassion principle (1986)
Paul Ricoeur : otherness (1990)
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Towards the medical values…
objectives
understand the ethical norms and assimilate theorical and practical knowledge definition of a person, citizen, patient,
vulnerability…) public health, solidarity human rights, health rights health system and its actors
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• find immediate applications in subjects with specific ethics
• anatomy (dissection)• biology (research)
objectives
make the student understand elements concerning the confidence of the patient and duties of the physicians (code of ethics or deontology, science of duties),
assimilate the values of the physicians keep up the clinical competence be honest with the patient. Provide him an adapted information to
his understanding respect the professional secrecy pay attention to the patient. Let him receive a secund advice understand and accept the principles of solidarity
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Secund part of the curriculum: ethics in medical practice
The professional competence is the first and primordial value of medical ethics : then evidence based medicine is an ethical part of the training
The details of patient-physician relation Patient’s trends : degree of the illness, confidence or doupt,
degree of understanding, importance of the near social circle Doctor’s trends : competence, ability to explain, to convince,
ethical sense
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First level
ethics in medical practice
Let the student be aware of the usual ethical problems : difficulties of medical decision, of communication Disagreement between the nearest of a patient about a decision Legal or practical difficulties for application of an ethical advice Potential danger for somebody of keeping a professional secret Conflict between two ethical principles for the same case. ….
Special situations : announcement of a bad prognosis, end of life patient, hurting words
Moscou, avril 2012 14
This teaching to the ethical questioning requires a special training: small groups with tutors, with hand-outs provided, and followed by reports
second level objectives
in the hospital the exemple value
In the hospital activity, we must work about : Relation student / nurses Relation student / patient
Clinical examination Given explanations
Ethical behaviour of all the members of the staff
The seniors’ counter-exemples are disastrous !
Moscou, avril 201215
Third part of the curriculum & specialties cycle
Personal involvement into ethical problems : charge of practical cases, reports, presentation of specific difficulties in the ethical field of the specialty
Most concerned Specialties, Cancerology Geriatrics Emergency, intensive care Pediatrics, gynecology Infectious diseases …
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From the student-doctor to the responsible physician
Organisation of common seminars with continuous medical education
Education for ethics in human research
Two possibilities : Master of research in ethics
Master 1 : initiation to methods in ethics research Master 2 : specialty in ethics research
Or the presence of a chapter devoted to ethics in each medical research master.
obligations for a student, describe the ethical issues when designing a
research with humans obtain specialized training devoted to protection of persons
undergoing research
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the foreseeable risks must not outweight the potential benefits to the patients
Choice of the teachers
A requirement : coexistence of physicians, other health professionals, and nonhealth professionals…
In the case of physicians : no professionnal in ethics, but practised in ethics
For the nonhealth professional : philosophers, anthropologists, sociologists…
All must have obtained a PhD in ethics… ideally…
Moscou, avril 201218
Structures of ethics in Faculty of medecine and universitary hospital
Ethics laboratory in the Faculties which aims : organization of teaching organization of research Continuing education in connection with hospital
Ethical space in universitary hospitals reflection and answers to the daily problems participation of all the health professionals continuing education in connection with the Faculty
Moscou, avril 201219
Conclusion
Moscou, avril 201220
A good doctor
ought learn and keep
the balance
Clinical competence
Ethical competence
Bibliography
Conseil européen des Ordres des médecins : « Charte européenne d’éthique médicale ». www.ceom-ecmo.eu/charte-europeenne-dethique-medicale-51
Comité Consultatif National d’éthique pour les sciences de la vie et de la santé : avis n°84 : « avis sur la formation à l’éthique médicale », 2004. www.ccne-ethique.fr
A Cordier : « Rapport » . www.sante.gouv.fr/htm/actu/cordier
Ch Hervé et al : « Visions éthiques de la personne ». L’Harmattan ed, 2001.
P La Marne : « Réflexion éthique et formation médicale », ADSP, 1999. www.hcsp.fr/explore.cgi/ad285456.pdf
M Parker et al : « introducing medical ethics » The ethox centre, University of Oxford, sept 2011.
World Medical Association : « WMA ethics manual ». www.wma.net
Moscou, avril 201221