Methods of Bioethics Education Research Paper

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Abstract

The improvements in science and technology attracted attention to the ethical impact of these innovations on humans, the environment, and animals. The need to combine the science of biology with the preservation of human values and to make living being’s future come up to what it could conceivably be became an important issue. Bioethics education came developed to meet this challenge. The popularity of bioethics education grew parallel with the ﬂourishing of the “bioethics concept.” Universities, international organizations, and companies incorporated bioethics education into their curricula in various levels from undergraduate, graduate, to postgraduate. These initiatives as well as short-term courses and short-range programs focusing on particular aspects of bioethics became available. A variety of methods are used to teach bioethics education. Seminars, lectures, and tutorials are the most frequent conventional methodology of bioethics education. More interactive and participatory methods such as case studies, role-plays, out-of-class writing assignments, personal reﬂection presentations, peer presentations, and peer education became more popular with improvements in the ﬁeld of adult education. With the emergence of Internet networks, distance learning, web-based learning, and computer-assisted learning methods appear to be new methods with the dual advantage of eliminating obstacles arising from students living in remote geographical areas and limiting ﬁnancial constraints on the trainees. Although there have been substantial improvements in bioethics education, challenges still exist. The diversity and controversy in approaches to bioethics education regarding objectives, methods, content, and evaluation of teaching are major challenges for bioethics education. Despite this diversity in approaches, there are some well-established bioethics education programs which may serve as examples. The COMEST report 2003 has listed some well-established bioethics education programs. The UNESCO Observatory database holds detailed information about bioethics courses worldwide, in ﬁve different languages. The UNESCO database provides the opportunity to compare these courses on several factors such as level of education, context of courses, entry requirements for trainees, course languages, total number of teaching hours, and methodology of the programs.

Introduction

In 1971 when Potter wrote his book Bioethics: The Bridge to the Future, he deﬁned bioethics as “… a new discipline to contribute the future of human species.. .” by enabling “two cultures, science and humanities that seem unable to speak to each other.. .” to communicate and ﬁnd common ground to contribute to the development of humankind. Since then, bioethics has evolved as an umbrella concept composed of three pillars: medical ethics, environmental ethics, and animal ethics. The vast improvement in science and technology and the effects of innovations on human, environment, and animals make bioethics a crucial concept to which professionals and researchers must be made aware. The need for bioethics education is now realized by the scientiﬁc community, and this awareness has led to the generation of bioethics education programs to build the bridges Potter deﬁned.

Evaluation Of The Bioethics Term And Educational Initiatives/Efforts In The Light Of Historical Background

Although the ﬁrst reference to the term “medical ethics” may be traced back to the Hippocratic Oath in Antiquity (500 B.C.E.), emergence of this new concept in the near future was inﬂuenced by Thomas Percival in 1803. In the beginning bioethics and medical ethics were considered to be identical concepts. Tragic examples from history such as the trials on human subjects during Nazi period and the Tuskegee Syphilis Study led to vast developments in the medical ethics concept and the creation of international medical ethics norms such as National Institute of Health (1949) and the Declaration of Helsinki (1964).

Environmental ethics became a robust ﬁeld as the possible threats attached to technological developments are increasingly recognized. The sensitivity to the protection of the environment grew parallel to the recognition of the crucial role of nature in the survival of humankind and the predictable devastating impact of some technological innovations which were stripped from the notion of protecting the environment.

The third pillar of bioethics, animal ethics, ﬁnds its beginning in the words of Bentham who stated that “what matters morally is not that animals can reason but that they can suffer.” This preliminary seed in the utilitarian grounds grew to Peter Singer’s well-known arguments about the moral value of animals and the animal rights (Singer 1989).

The term “bioethics” was ﬁrst introduced to literature by Fritz Jahr, a German teacher and theologian, in the article he published in 1927. In his article he deﬁned bioethics as “Respect every living being, in principle, as an end in itself and treat it accordingly wherever it is possible,” which may be considered as an extension of Kantian categorical imperative onto animals and plants (Muzur et al. 2011).

The two following articles by Potter “Bioethics, the Science of Survival” (Potter 1970) and by Callahan “Bioethics as a Discipline” (Callahan 1973) are milestones in deﬁning the context of this new concept. In his paper Potter envisioned bioethics as “.. .the attempt to generate wisdom, the knowledge of how to use knowledge for social good from a realistic knowledge of man’s biological nature and of the biological world.” Potter also refers to the viewpoints of Chardin and states that the aim of bioethics is “to combine the science of biology with a preservation of human values and to make man’s future come up to what it could conceivably be” (Potter 1970).

Callahan asks questions about the place of an ethicist in medicine and if he has anything to contribute as a proxy to ﬁnd the margins of the newly developing term bioethics and proceeds with determining the tasks of a bioethicist (Callahan 1973). His overall aim in this pioneering paper is to deﬁne bioethics as a new academic discipline.

Rapid developments in technology changed the “possibilities of innovations” in medicine, engineering, and other disciplines. Innovations such as gene therapy, cloning, cell, tissue, and organ transplantations have become a reality that each and every human being may experience. This new set of possibilities led to the emergence of many ethical problems, which did not exist in the conventional way of performing that profession. Furthermore, the vast development in technology and science grew parallel with the need for more research on human and animal subjects, which presented new ethical problems and dilemmas. In addition, the tragic examples of scientiﬁc misconduct and lack of ethical precision caused the scientiﬁc community to reconsider the importance of bioethics in science.

This new environment of science changed the role of a physician from a simple healer to an ethical agent who has to ﬁnd out the “right thing to do” in a variety of situations with ethical dilemmas such as allocation of resources, deciding about the issues related to the beginning and end of life problems, and research on human subjects. Professions, other than medical doctors, which have a bioethical impact, went through a similar change. This has resulted in a big shift in the paradigm of many professions such as medical physicians, veterinary doctors, engineers, scientists, and others.

The Ultimate Goals Of Bioethics Education

This shift in the paradigm created the need for bioethics education for these professions. Other motives to create a curriculum for bioethics education were the increase in scientiﬁc misconduct cases and ethical problems concerning ﬁnancial conﬂicts of interest. Gradually bioethics education has become a priority in the curricula of the professions, which are closely related to bioethics. The emergence of daily practical ethical problems in professions and research serves as a ground for the limited and pragmatic goal of bioethics education which is to teach ethics as a way of learning skills for diagnosing and solving ethical dilemmas in everyday practice. The limited view focuses on the practical and measurable outcomes.

Beyond this limited goal, there exists a broader view for the goal of bioethics education, which considers bioethics education as a tool to counteract the dehumanizing and objectifying tendencies in contemporary medicine and technology. In this broad view, bioethics education is deﬁned not only as a means to facilitate decision-making but also contributes to making the innovations in related ﬁelds more humane. This is why bioethics education is considered in a broad spectrum and includes humanities, liberal arts, social sciences, and philosophy. On these grounds bioethics education is regarded as a long-term ethical training with the ultimate goal of creating virtuous professionals (Have and Gordijn 2012).

Methods Of Bioethics Education

Bioethics education is designed for adults who are already performing in their professions or candidates for future professions. That’s why the general principles of adult education are valid in bioethics education. The trainees should be regarded as independent unique personalities with experiences and knowledge peculiar to individuals. The trainees should be informed about the goals of the educational process, as learning is more effective when the learners are aware of what they need to learn. Variety in teaching methods and techniques makes learning easier. The content of the education should be in compliance with the target group’s abilities, environmental conditions, and cultural codes. Also it is essential for skill acquisition and development of skill competency for adult trainees to apply what they learn and practice it in controlled or simulated conditions. Furthermore, repetition, a realistic learning environment, and immediate, positive, and nonjudgmental feedback are other essentials to nurture effective learning (JHPIEGO 2009). The planning process of bioethics education curricula should consider all characteristics of adult education to ensure permanent retention (Arda 2014).

The target group of bioethics education has a heterogeneous pattern apart from being adult. A spectrum of undergraduate, graduate, and postgraduate students, acting professionals, clinicians, researchers, and managerial staff constitutes the heterogeneous trainee groups. Besides, the diversity of cultural codes within and between target groups contributes to the heterogeneity. The cultural codes of different nationalities affect both the value systems and ethical reasoning procedures of professionals. The codes of different professions have signiﬁcant effect on their value judgments. These differences should be taken into account when determining the content and methods of the bioethical education.

The actual situation in bioethics education reﬂects this diversity. A survey conducted in Southeast Europe regarding biomedical education revealed notable differences in teaching hours, content, and teaching methods (Mijaljica 2014). Another survey reviewing the teaching of ethics in the European Union Schools of Medicine exposes great variation in teaching by declaring that 11 out of 25 schools of medicine from 18 European Union Member States used vertical teaching method, and only 2 out of 14 Southeast European countries had transversal teaching method in their curricula (Claudot et al. 2006). The situation in Asia is in concordance with the results of the surveys of Europe. The study conducted in 206 medical schools in Asia showed that medical ethics education is a widespread feature of medical curricula, while the kinds of programs, especially with regard to integration into clinical teaching, were very diverse throughout the study area (Miyasaka et al. 1999).

United Nations Educational, Scientiﬁc and Cultural Organization (UNESCO), an agency with the genuine global perspective on ethics, drew proper attention to the moral dimensions of scientiﬁc and technological developments. UNESCO also addressed the need to unify the diversity in bioethics education methods. In 2004, UNESCO launched its Ethics Education Program (EEP) to reinforce and increase the capacities of Member States of the United Nations in the area of ethics education, using the Framework for Action of the 1999 World Conference on Science and the declarations in the 32nd UNESCO General Conference 2003. EEP established a committee with the members from World Commission on the Ethics of Scientiﬁc Knowledge and Technology (COMEST), the International Bioethics Committee (IBC), the Academy of Sciences for the Developing World (TWAS), and the World Medical Association (WMA). In 2008 this committee launched the Bioethics Core Curriculum. The Bioethics Core Curriculum provides both an incentive to start introducing bioethics education in the countries in which bioethics education is absent and also provides a guide to set the minimum requirements for bioethics education. UNESCO’s Bioethics Core Curricula’s “.. . content does not impose a particular model for speciﬁc view of bioethics, but articulates ethical principles that are shared by scientiﬁc experts, policy-makers and health professionals from various countries with different cultural, historical and religious backgrounds.” In 2011 UNESCO launched the UNESCO Core Curriculum Casebook Series to reinforce the introduction of bioethics education curricula (UNESCO 2011).

Relying on the initiative to strengthen the teaching of ethics in 1999 World Conference on Science, COMEST released a report on the teaching of ethics in 2003. This report recommended establishing bioethics teaching at three levels. The ﬁrst level is an elementary ethics course for all students. More advanced courses that are part of Ph.D. requirements in various sciences and courses that lead to a Ph.D. in ethics, suitable for people who already have a Ph.D. in some other ﬁelds, are the second and third levels, respectively (UNESCO 2003).

The COMEST report has selected a few courses and programs in bioethics education as examples of high-quality programs. These programs may serve as a common ground to expel the disadvantages of the regional and national differences in quality, content, and methodology of the courses. Although the emphasis in this report is on the content, aims, and evaluation of the programs, there is signiﬁcant information about the methods to be used (UNESCO 2003).

The most common methods used for bioethics education are lectures, seminars, workshops, movies and videos, websites, small and large group discussions, review of legislations, codes of conduct and guidelines, problem-based learning techniques such as case studies, role-plays, out-of-class writing assignments, personal reﬂection presentations, case study analysis, peer presentations, and peer education (Eisen and Parker 2004).

Lectures and seminars are the basic education methods that provide an overview of the legislation on bioethics. This legislation consists of the international, national, and institutional norms about ethics. The philosophical and theoretical background of the ethical norms and the legislation may also be taught through lectures. The crucial point regarding the success of lectures is the educators’ competency level. Have and Gordjin remark that not even half of the bioethics instructors in the United States have published an article in bioethics and that most of the teachers involved in bioethics education do not have ethics as their primary academic focus (Have and Gordijn 2012).

Some educators prefer case-based learning than conventional lectures, believing in the idea that “.. .case studies can serve as the basis and focal point for productive learning oriented conversations of .. .many problems and issues confronting higher education leaders.” The potential beneﬁts of case-based learning are building conﬁdence in the diagnosis and generating alternative responses to dilemmas of a particular problem, the possibility to learn from the other trainees, and “transferring the trainee from a passive observer to an active participant” (Honan and Rule 2002). The case study method gives the trainees a comprehensive understanding about the need, goals, and practical beneﬁts of the bioethics education. In this sense, case study method may be considered as a unique tool to be used as a proxy to the legislative background of the ethical dimensions of the case.

Mc Kneally and Singer are in favor of “bedside training” which is a particular case-based learning method. They put forth the idea that bioethics education which is designed for clinicians should be linked to patient care, and for this reason, it should ideally be thought out at bedside or clinic. Bedside education involves methods such as case-based conferences, presenting clinical cases at small group conferences. These methods have the advantage of teaching both the theoretical and practical aspects of bioethics as “.. .they provide a broader exposition of pertinent theory and empirical evidence” (Mc Kneally and Singer 2001). On the other hand, bedside training method lacks a systematic evaluation of effectiveness, and the “uneven and hectic pattern of clinical medicine” creates limitations for the predictability of the method (Mc Kneally and Singer 2001).

Small and large group discussions and roleplays are another method in common use within bioethics education. Case studies followed by group discussions help the trainees to evaluate various aspects of the situation including ethical dilemmas, ethical principles, professional ethical codes, and the limits of legislative substructure.

Bioethics education aims to develop and improve a trustworthy and responsible behavioral pattern for professionals. Petra Gelhaus, in a sequel of three articles, demonstrates the crucial role of the concepts of empathy, compassion, and care in developing the desired attitude of health personnel. Gelhaus states that expertise in medical practice needs more than ingenuity and knowhow. Ultimate good conduct of a physician is conduct, which can be achieved by a professional attitude deﬁned in terms of “emphatic compassionate care” (Gelhaus 2012).

The methods Gelhaus suggests include roleplays, personal reﬂection presentations, case study analysis, peer presentations, and peer education.

In the role-play method, the trainee has the opportunity to develop a sense of empathy while evaluating the case. The procedure of role-playing exposes personal values which affect the ethical reasoning process and gives the chance to experience ethical decision-making as a moral agent who has the conscience of responsibility to face the consequences of the ethical decision. In addition, role-play method enhances the ability to improve the insight of the trainee which contributes to the ultimate goal of constituting the desired moral attitude.

The personal reﬂection presentation method shares similar advantages regarding the personal involvement of the trainee who, instead of being an outsider observer, obliges the learners to evaluate the case from different perspectives and urges them to make ethical reasoning within the inclusion of their respective values.

In case studies texts are used to deﬁne the situation. The context of the text should deﬁne the case clearly emphasizing the learning objectives of the particular session. The focus should be on the outstanding aspects of the learning objectives, and unrelated arguments should be avoided.

Movies and short video clips are used for more comprehensive discussions on wider concepts of ethical dilemmas. The plurality and subjectivity of human ethical values, the core function of empathy, and the effects of variables such as culture, religion, gender, age, ethnicity, and socioeconomic and political background are exposed during consideration, reasoning, and discussions on the movies.

With the emergence of technological advancement all throughout the world, distance learning became a rapidly growing method for bioethics education. The limitations raised by time, geographic remoteness, and ﬁnancial constraints are avoided with the use of distance learning. Seminars, lectures, and tutorials are most common methods to be used for distance learning. The presence of a sturdy Internet network brings with it the opportunity for online sessions where all the attendants can communicate. This setting makes interactive teaching methods such as case studies and group discussions possible. Web-based training and computer-assisted learning are considered as subcategories of distance learning. Bioethics courses with special focus on signiﬁcant topics such as research ethics, biosafety and bio-security, and good clinical practice use web-based training or computer-assisted learning effectively.

Examples Of Existing Bioethics Education Programs

Within the scope of the Ethics Education Program of UNESCO, a comprehensive database for the dispersed bioethics education programs is constructed. UNESCO Observatory database not only provides detailed information about bioethics courses worldwide but also provides the opportunity to compare programs regarding several properties such as level of education, context of courses, entry requirements for trainees, course languages, total number of teaching hours, and methodology of the programs in ﬁve different languages. Currently, 235 teaching programs from 43 countries in Central and Eastern Europe, the Arab region, the Mediterranean region, and Africa are identiﬁed and described in this database (http://www.unesco.org/new/en/social-andhuman-sciences/themes/global-ethics-observatory/ access-geobs/).

COMEST has selected some programs in bioethics education that can serve as examples of high-quality programs. The two programs from China existing in this list are “Course in Engineering Ethics” offered by the Institute of Science, Technology and Society at the Tsinghua University and “Course in Biological Ethics” at Beijing University, China. “Harvard University Center for Ethics” and “Professions Harvard Graduate School of Business Administration” are selected as the two outstanding ethics programs from the United States. “Association for Practical and Professional Ethics” in Bloomington is the example from India. Master program in “Health, Human Rights and Ethics,” Andrija Stampar School of Public Health in Croatia, run by the Council of Europe, is selected as a good example of ethics program from Europe. The Norwegian Research Council’s Ethics Program and Master’s in Applied Ethics at Utrecht University are other examples of good practice selected by COMEST.

Challenges Of Bioethics Education

In the beginning of the 1990s, in parallel with the raise of popularity of bioethics concept, many institutions such as universities, international organizations, companies, and NGOs started to establish bioethics teaching programs. Since then there have been signiﬁcant improvement in the quality and quantity of these programs. Nevertheless, challenges regarding bioethics education still exist. Persad et al. (2008) point out that in the United States, bioethics education together with health law and health economics comprises less than 2 % of the total hours in American medical curriculum (Have and Gordijn 2012).

A survey by Mijaljica reveals similar data regarding bioethics education in Europe. In Southeast Europe, the teaching hours vary between 60 and 10 h. Medical schools in Southeast Europe have far fewer vertical courses than European Union; only two medical schools have vertical courses (Mijaljica 2014). Considering the legislative requirements about bioethics education in the United States and European Union, this low percentage blows a whistle for the rest of the world.

The diversity and controversy in approaches to bioethics education regarding objectives, methods, content, and evaluation of teaching stands as a major challenge for bioethics education. The lack of speciﬁed educators of bioethics is another big challenge. Although there have been signiﬁcant steps forward in this ﬁeld, there still remains a big gap to be ﬁlled by future studies.

Conclusion

The importance of acquiring a bioethics education is now accepted by different disciplines within the scientiﬁc and professional community. The number of institutions that incorporate bioethics education into their curricula has been increasing. The common ground for bioethics education independent from the delivering institution is that bioethics education is designed for adults who are already performing in their professions or for future professional candidates. That’s why the general principles of adult education are valid in the case of bioethics education. Apart from this common ground, there exists a huge diversity in the ﬁeld of bioethics education. Although the plurality of methodology being used by instructors is an advantage for adult education, the diversity regarding the goals, teaching hours, content, and evaluation methods may be considered as an Achilles heel for the universality of the bioethics education. The conventional methods for bioethics education are seminars, tutorials, and lectures. Bioethics education is inevitably application oriented. The inevitably application-oriented characteristic of bioethics education generated the need for more interactive and participatory learning methods. Case studies, role-plays, out-of-class writing assignments, personal reﬂection presentations, peer presentations, and peer education became more frequent techniques utilized.

The latest inventory methods used in bioethics education are computer-assisted learning and distance learning methods. The vast dissemination of the access to sturdy Internet networks enhances the popularity of technology-based learning methods.

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