Teaching of medical ethics in Faculties of Medicine

1. Teaching of medicalethics in Faculties of Medicine From a competentstudent to a responsiblephysician Moscou, avril 2012

2. 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 Foreword for ethics A precursor… Hippocrates « at first, not to harm » Moscou, avril 2012

3. 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 Foreword for medical ethics Moscou, avril 2012

4. 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 Why a new need for medicalethics ? (report Alain Cordier) Moscou, avril 2012

5. Out of 45 Faculties(study of G.Llorca, CIDMEF) : • Specificteaching : 36 (80%) • Obligatoryteaching : 32 (71%) • Average : 29 h (maximum, Strasbourg 123 h) • Pedagogicalmethods : • Lectures / 33 (73%) • Reflection groups : 14 (32%) • Cases analysis : 19 (43%) • Special meetings in the hospital : 9 (20%) • Integrated in medicalspecialties: 22 (50%) State of the teaching of ethics in the frenchspeakinguniversities (1) Moscou, avril 2012

6. 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%) (2) Moscou, avril 2012

7. providing the basic theories for a reflection • medical • philosophical • sociological • leading the student to become aware of ethical reflection by collective studies of practical cases • obtaining an individual involvement : follow-up of patients, presentation of actual cases, reports, thesis. A strategy for the teaching of medicalethics Three steps Moscou, avril 2012

8. 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. Before the teaching .

9. 1 2 3 Don’t forget the density of our curriculum…

10. Somethoughtsteps(outsidereligious aspects) Immanuel Kant : autonomy , duty to others(1788) Jean-Jacques Rousseau : social contract, solidaritybetweencitizens(1762) John Rawls(theory of justice, 1971) Hans Tristan Engelhardt : compassion principle (1986) Paul Ricoeur : otherness (1990) 1 First part of the curriculum: basic theories Towards the medical values… Moscou, avril 2012

11. 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 1 objectives • find immediate applications in subjects with specific ethics • anatomy (dissection) • biology (research) Moscou, avril 2012

12. 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 objectives 1 Moscou, avril 2012

13. 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 2 Secund part of the curriculum: ethics in medical practice First level Moscou, avril 2012

14. 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 ethics in medical practice 2 second level objectives This teaching to the ethical questioning requires a special training: small groups with tutors, with hand-outs provided, and followed by reports Moscou, avril 2012

15. 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 ! in the hospital the exemple value 2 Moscou, avril 2012

16. 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 • … Third part of the curriculum & specialties cycle 3 From the student-doctor to the responsible physician Organisation of common seminars with continuous medical education Moscou, avril 2012

17. Twopossibilities : • Master of research in ethics • Master 1 : initiation to methods in ethicsresearch • Master 2 : specialty in ethicsresearch • Or the presence of a chapterdevoted to ethics in eachmedicalresearch master. • obligations • for a student,describe the ethical issues whendesigning a researchwithhumans • obtainspecialized training devoted to protection of personsundergoingresearch Education for ethics in human research 3 the foreseeablerisks must not outweight the potential benefits to the patients Moscou, avril 2012

18. 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… Choice of the teachers Moscou, avril 2012

19. 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 Structures of ethics in Faculty of medecine and universitaryhospital Moscou, avril 2012

20. Conclusion Clinical competence Ethical competence A good doctor ought learn and keep the balance Moscou, avril 2012

21. 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 Bibliography Moscou, avril 2012