Views of Indian Medical Students on Bioethics and the Teaching of Ethics

- Pushpa Dhar, M.D.
Dept. of Anatomy, All India Institute of Medical Sciences,

Ansari Nagar, New Delhi, 110 029, India
Email: dhpush@medinst.ernet.in

- Darryl Macer, Ph.D.
Institute of Biological Sciences, University of Tsukuba, Tsukuba Science City, Japan.

Eubios Journal of Asian and International Bioethics 11 (2001), 78-82.


Abstract

The present study was aimed at gaining a broad opinion regarding bioethical reasoning amongst student fraternity. These students had been admitted to medical schools after completion of their high school (10+2). Ethnically all the students were of Indian origin though they belonged to a diverse socio-economic-cultural background. The mean age of students was 18 years and a total of 125 first year medical students were questioned in 1998 (Session August 1997 to July 1998), using the questionnaire designed by Macer with some modifications. The observations revealed the fact that even though fair amount of awareness regarding the wide perspectives of bioethics did prevail amongst many, yet some sense of ignorance was reflected as well. However, the respondents were divided on various sensitive issues like cloning, in vitro fertilisation etc. The results suggest enforcement of both individual and collective efforts to arouse the consciousness of students regarding bioethics and application of bioethical decision making to dilemmas posed by science and technology.

Key words: Bioethics, biotechnology, genetic engineering, India, education, public opinion

Introduction

A vast country like India has been documented to have enjoyed a peculiar but an aromatic socio - ethical bondage over the years. The equilibrium between the unknown forces of nature on the one hand and reasoning (scientific knowledge) on the other hand has been considered as the binding force holding societies together. However the recent past has been a key witness to a steep decline in the socio - ethical bondage. A significant amount of philosophical and experimental pursuit has been undertaken to explain the phenomenon of the steep decline. Various explanations have been invoked to get a plausible answer to this burning problem. The swift, uncontrolled and unending scientific advancements that are perceived by some to fiddle with nature raise a number of concerns.

It is being argued that tilt in the balance might be the underlying cause responsible for uprooting the basic values that once glorified the huge entity - India - that is known to have enjoyed a special status in the whole world with diversities of religion, culture, heritage etc. as its inseparable components. The extreme importance of human behaviour is known from time immemorial. Indian epics, the mythology and even the history are great witness to the same. In Mahabharata (a well known epic) Lord Krishna while briefing Arjuna about the sanctity of war stresses upon the supremacy of humans as according to His version, humans, along the entire evolutionary pathway, alone are bestowed with the power of judgement between the right and the wrong. The appropriate and timely incorporation of this supreme blessing determines the human attitude. Accordingly, it becomes imperative to address these scientific advances under the aegis of religious and philosophical values as an attempt to better understand the crux of the problem.

Being an enormous socio-economic-cultural amalgam, India is subject to a number of strains. Firstly, India harbours the largest illiterate population in the 15-plus age group (291 million) with a literacy rate of only 52% and having 32% males and 62% females as illiterates. This does reflect neglect of educational sector in the country not only in terms of quantity but in terms of quality as well. With a huge population of over one billion, one fifth of its structural components is contributed by young adults (13-21 years). Hence it is this component in their tender age-period of 13-21 years that is vulnerable to innumerable societal atrocities. In spite of the various operations and schemes launched by the government the system of school education even at present provides the most practical example of socio-economic disparities in India with children from higher socio- economic families affiliated to economically sound public schools that ensure a relatively superior and expensive education and invokes in them the competitive spirit whereras children from lower socioeconomic groups crowd at schools with extremely poor environment to offer. This highlights the lack of political will on the part of country's leadership and it is the same disparity that is the root cause of huge number of school dropouts in this county. This exponential number of dropouts is forcibly pushed towards unethical thinking and doing. The sudden exposure to various challenges and dilemmas induces a state of shock where it becomes really difficult to carry ahead unless and until there are certain guidelines to guide them along a proper direction.

Another additional and important factor overpowering young adults in India, and other small and/or developing countries, is the brain drain phenomenon. According to a recent survey, India stands at number three in a huge list of thirty two countries in terms of brain drain and it is six of every ten well educated young adults who are on the look out to emigrate. The young minds get swayed over by external influences and then many prove to be misfits in their own society and it is the society which has ultimately to face the resulting repercussions in turn. At such junctures the role of ethics is often questioned as one of the basic important rectifying measures. Considerable debate is going on the subject of formal education of ethics. Whereas one school of thought strongly believes that the formal education (ethics) is the mentor for moral enculturation of the society, the other school strongly denies the same.

The survey

The present survey was conducted amongst first year students (N=125) who had made their way into medical school at the All India Institute of Medical Sciences (AIIMS) and University College of Medical Sciences (UCMS) in the academic session, August 1997 to July 1998. The academic level of these students is very high when compared to general high school graduates in India. The mean age of the students was 18 years, and high school completion (10+2 years) was their educational status. The educational status was kept in mind with the idea of obtaining their perspective with regard to general ethics as such and not the special ethics. Of the 125, only 25 were females. They all were unmarried and 95% of the students belonged to urban areas whereas 5% of them were of rural origin. The questionnaires for the International Bioethics Survey and the International Bioethics Education Surveys designed by Macer (1994; Macer et al. 1996) with appropriate changes were given to these students and collected after completion. The data thus obtained was statistically analyzed.

Keeping the famous lines of Bosk in mind, "tend to be tolerant and forgiving of technical error and intolerant and unforgiving of moral errors" the theme presently was centred around 'bioethics'. There have been efforts in university medical schools to develop medical ethics education, and we believe it is important (Macer, 1998). There are signs from high school text books that ethics should be well known by Indian university students, so we also wanted to examine this (Bhardwaj and Macer, 1999). In order to find the student's viewpoint - more stress was laid on the following issues: understanding the term of bioethics, inclusion of ethics in curriculum, the importance of ethics as such, the time period for teaching of ethics.

What is bioethics?

To a simple question 'what do you think bioethics is' there was a varied response. Of the male students, more than half (58%) could define 'bioethics' in one way or another whereas one third (36%) did not write anything. Of the female students, a smaller proportion (39%) responded with some definition of 'bioethics' and more than half (57%) did not respond at all. This points towards the unawareness that exists amongst the younger generation. Blunt admissions like 'hearing this term for the first time' were encountered, however, some meaningful definitions were given as well. To quote a few:

However, 32% of students responded to the question 'Do you think that bioethics is needed in education' by saying it is very much needed, with a further 32% saying it is somewhat needed. No response was invoked from 30% respondents, reflecting either their unawareness of the term or of the need. If we compare these results to those of biology teachers in Tamil Nadu, which is a different area of India, we see less enthusiasm for bioethics among the students (Pandian and Macer, 1998). Among the teachers in the 1996 survey, 25% did not write anything when asked what is bioethics, but 60% of teachers said bioethics was needed very much, and 36% said it was somewhat needed.

There was a uniform agreement among the student respondents regarding the time from when 'ethics' should be a part of the curriculum. Almost all were in favour of standard grades at the end of schooling, years IX-XII, which might justify their relevant concern and positive attitude towards learning when they are mature enough to understand the values of life.

Table 1: Knowledge of selected areas of science, technology and bioethics

%*

Not heard

Heard of

Could explain

No class

Yes class

Sample**

T96

S98

T96

S98

T96

S98

T96

S98

T96

S98

Ag. pesticides

6

0

35

27

59

73

6

29

94

71

IVF

11

2

61

29

28

69

41

30

59

70

Prenatal diagnosis

5

3

39

40

56

57

57

34

43

66

Biol. pest control

7

2

36

28

57

70

7

21

93

79

Eugenics

9

5

64

52

27

43

12

50

88

50

Computers

6

1

69

46

25

53

60

43

40

57

Biotechnology

10

2

40

34

50

64

10

27

90

73

Nuclear power

7

1

60

25

33

74

14

13

86

87

AIDS

8

0

38

23

54

77

5

14

95

86

Human gene therapy

17

4

50

71

33

25

31

63

69

37

Fibre optics

28

13

61

55

11

32

50

76

50

24

Bioethics

19

37

67

57

14

6

47

95

53

5

*The total of the knowledge question (first three columns) is 100%, and the total of the teaching question (Yes or No - class) who have discussed in class is 100%.

**Sample - T96 = biology teachers from Pandian and Macer (1996; N=100); S98 = Medical students in this survey.

Table 2: Acceptance of gene therapy

Q9. How do you feel about scientists changing the genetic makeup of human cells to:

%

Strongly approve

Somewhat approve

Somewhat disapprove

Strongly disapprove

Don't know

Sample*

S93

S98

S93

S98

S93

S98

S93

S98

S93

S98

a. Cure a usually fatal disease, such as cancer

62

67

27

26

2

3

2

3

7

1

b. Reduce the risk of developing a fatal disease later in life

53

64

32

27

5

8

2

1

8

0

c. Prevent children from inheriting a usually fatal disease

86

72

12

24

1

1

1

3

0.4

0

d. Prevent children from inheriting a non-fatal disease, such as diabetes

59

53

34

32

4

7

3

6

0.4

2

e. Improve the physical characteristics that children would inherit

36

23

31

33

13

31

14

10

6

3

f. Improve the intelligence level that children would inherit

40

30

28

15

12

27

11

13

9

15

*Sample - S93 = university biology students from Azariah and Macer (1993; N=325); S98 = Medical students in this survey.

Awareness of science and technology terms

One of the questions was to explore knowledge of different areas in science and whether these had been discussed in class. For comparison in India there was a survey of 100 biology teachers in Tamil Nadu in 1996 (Pandian and Macer, 1998), but not for students. The responses are summarized in Table 1. They show that AIDS has been well discussed in schools, as is reflected in the results of text book analysis (Bhardwaj and Macer, 1999), whereas bioethics as a subject had only been discussed by 3% of respondents.

Positive support for scientific research and genetic engineering

Several other questions were asked in the survey, and we present results of only some of these. Table 2 shows that still a majority of students approved with enhancement use of gene therapy, although there was more rejection of this than in the 1993 Indian public and biology student surveys (Azariah and Macer, 1994). If we compare support for enhancement of physical characteristics in children there was 56% support among medical students in 1999 compared to 67% support by biology students in 1993. There was less support for enhancement of intelligence, supported by 45% of medical students compared to 68% of biology students. However the support for example a, to cure a fatal disease remained the same in both samples. We can therefore say that there is some greater degree of questioning of the application of science and technology in the medical student sample. One factor which cannot be determined is whether the teachers influenced the students in the conducting of this survey.

Table 3 shows that there is positive support among medical students for all areas of science and technology, including nuclear power. Agricultural pesticides elicited the most concern among these students, with 19% saying they did not think it was worthwhile, compared to only 7% for nuclear power. This is different to most other countries surveyed, and suggests that there is much positive support for the Indian nuclear policy among these students. India still suffers power blackouts so energy supply is seen to be important. However in the 1996 survey of biology teachers in Tamil Nadu, the preference was reversed, and one third did not see a benefit of nuclear power, (Pandian and Macer, 1996). Both biotechnology and gene tic engineering are seen in a very positive light in all Indian surveys.

Table 3: Worthwhile science and technology

Q3. Do you personally believe each of these scientific discoveries and developments is a worthwhile area for scientific research? (%)

Example

Yes

No

DK

In vitro fertilization

90

2

8

Computers

97

0

3

Biotechnology

88

0

4

Nuclear power

89

7

4

Ag. pesticides

75

19

6

Fibre optics

80

1

19

Genetic engineering

98

0

2

Table 4 presents the results of case examples of the release of GMOs, and here we find a greater degree of rejection of the specific applications for larger sports fish or tastier tomatoes than in other surveys. This is a sign that despite the positive support for enhancement gene therapy, there is a sizeable proportion who want to limit the application of science and technology beyond what is perceived to be necessary. This distinction between disease resistant crops, the most positively supported example, and the sports fish, the least, is higher than earlier Indian survey samples, suggesting some developing sense of bioethical maturity. On the other hand the medical students are almost unanimous in supporting GM disease resistant crops and cows which produce more milk, with few people questioning this. It is a matter of debate in all societies how much food should be dependent upon GMOs, on the other hand nutritionally there is a need for greater food security in India.

Comparisons with other samples

India is known for its rich ancient culture and heritage and religion has always enjoyed a supreme position in the lives of Indians from time immemorial even when industrialisation and scientific progress is known to have weakened the traditional religious sensitivity all over the globe (Morioka, 1999). Since a number of factors ranging from personal experience to religious affiliation help to determine an individual's beliefs about ethics and morality, an attempt was made to obtain student's perspective on this issue and the query about the importance of religion in life was included. While 16% at one extreme did not consider religion important at all, 25%, a bigger fraction were at the other end saying it was very important, which expresses a strong faith in religion. In between 40% considered religion somewhat important and 19% did not consider it very important. The medical students were slightly less religious than the 1993 samples of the public and the biology students, however, there is no indication that this affected the views to the bioethical dilemmas given in the survey.

Table 4: Approval of environmental release of GMOs

Q10. If there was no direct risk to humans and only very remote risks to the environment, would you approve or disapprove of the environmental use of genetically engineered organisms designed to produce...? (%)

Example

Yes

No

DK

Tomatoes with better taste

Medical students (125)

61

32

7

Biology teachers (100)

76

20

4

Biology students (325)

77

17

6

General public (568)

73

20

7

Healthier meat (e.g. less fat)

Medical students

86

16

8

Biology teachers

72

16

12

Biology students

68

18

4

General public

66

22

12

Larger sports fish

Medical students

24

42

34

Biology teachers

56

20

24

Biology students

50

31

19

General public

48

27

25

Bacteria to clean oil spills

Medical students

91

6

3

Biology teachers

68

16

16

Biology students

74

13

13

General public

74

14

12

Disease resistant crops

Medical students

97

3

0

Biology teachers

84

8

8

Biology students

81

11

8

General public

78

13

9

Cows which produce more milk

Medical students

97

3

0

Biology teachers

80

16

4

Biology students

72

19

9

General public

75

19

6

These observations of the survey carried out do indicate the eagerness of students to imbibe at least, certain aspects of value based education for an appropriate behavior. At this crucial moment when we have stepped into the new millennium it is extremely important that high priority is accorded to education both quantitatively as well as qualitatively. This is also emphasized in the Indian school curriculum, and these students will have seen some debate of these issues in high school (Bhardwaj and Macer, 1999), before reaching medical school.

Strategies have to be drawn towards formulating steps for reframing the present university curriculum whereby moral enculturation is given greater consideration. The first and the foremost step needs to be directed towards identification of target groups as in the young-adult age group, these are encountered at various levels: school going children, school dropouts, college going children, college dropouts etc. At the same time it has to be re-emphasized that newly framed policies need to be launched with sincerity and dedication and not to follow the past routine, where major policies like Operation Blackboard launched in 1987 suffered a major setback as only 50% of the goals were reached after 14 years of its launch. As is quite obvious, the values need to be inculcated not only within the core of our inner-self but within the entire society as well. Hence relevant practical measures are to be adopted in order to 'catch them young', and to develop mature citizens. It is also apparent that bioethics education is required in universities and professional schools, because still many students are not comfortable with the concepts that are very important for the development of professional health care workers and scientists who will be faced with moral dilemmas in their daily work after graduation.

Acknowledgment

We are thankful to Dr. Madhur Gupta, Professor of Anatomy, UCMS (Delhi) for her immense help.

References

Azariah, J., Azariah, H. and Macer, DRJ. "Bioethical reasoning in India", pp. 157-160 in Macer, DRJ. Bioethics for the People by the People. Christchurch: Eubios Ethics Institute 1994.
Bhardwaj, M. and Macer, DRJ. "A comparison of bioethics in school text books in India and Japan", Eubios Journal of Asian and International Bioethics 9 (1999), 56-9.
Bosk: Textbook of Surgery.
Macer, DRJ. Bioethics for the People by the People. Christchurch: Eubios Ethics Institute 1994.
Macer, D.R.J., Asada Y., Akiyama,S., Tsuzuki,M. and Macer, NY. Bioethics in High Schools in New Zealand, Australia and Japan. Christchurch: Eubios Ethics Institute 1996.
Macer, DRJ. "Implementation of medical ethics education", J. Medical Education 2 (1998), 138-44.
Morioka, M. "Commentary on Siti Nurani Mohd. Nor", Eubios Journal of Asian and International Bioethics 9 (1999), 169.
Pandian, C. and Macer, DRJ. "Bioethics education in high schools: An investigation in Tamil Nadu with comparisons to Australia, Japan and New Zealand", pp. 390-400 in Azariah, J, Azariah, H. and Macer, DRJ., eds., Bioethics in India. Christchurch: Eubios Ethics Institute 1998.

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