1. Brewin TB (Lancet 1993) "How much ethics is needed to make a good doctor?" 3 qualities of a good doctor; motivation: "put yourself in the patient's place" judgment: sound judgment rapport: all aspects of communication Can we teach these qualities to students? "Yes, through thorough discussion of the pros and cons of difficult dilemmas " (not through academic ethics) Bioethics Education in Medical School

2. Compulsory for first-year students Term: 14 to 15 school hours Content: group discussion & lectures Clinical cases: truth disclosure and Jehovahs witnesses Whole-class session after group discussion Evaluation: ethical test, reports submitted after group discussions, the course attendance rate Medical Ethics Course in HCM The aim of this paper: to introduce our 3 year-experience in bioethics education though teachers, students and tutors eyes

3. 2000 2001 2002 Number 100 98 99 male 53 58 60 female 47 40 39 Age (years) 19.8 19.2 20.1 Attendance rate (%) 86 96 99 Final comments (No) 23 52 21 Backgrounds of Students (continuous variables: average)

4. 1 informed consent in children 2 immunity to malpractice at admission 3 truth: first to the family, then to the patient 4 familys consent is enough in cancer 5 best treatment is done without patient consent 6 patients privacy (health information) 7 patients privacy (document) 8 blood transfusion without patients consent 9 patients right to know 10 emergency medicine without consent Ethical Tests on the First and Last Day Maximum 10 points

5. Ethical Tests on the First and Last Day first test final test 2000 7.1 (6.8 - 7.4) 7.4 (7.1 - 7.6)* 2001 7.6 (7.3 - 7.9) 7.5 (7.2 - 7.7) 2002 5.6 (5.3 - 5.8) 7.7 (7.5 - 8.0)** mean (95% confidence interval), statistically significant between the first and final test (*P<0.01, ** P<0.001)

6. Evaluation of Students Reports Counting number of key words in their reports e.g. patients right 1, informed consent 1 patients right based on Lisbon Declaration 2 informed consent based on patients right 2 * In-depth description can attain higher scores ! Example Ethical issues in truth disclosure 2000 58 (51 - 65) 2001 62 (56 - 68)* 2002 55 (52 - 58)* mean (95% confidence interval), *p<0.050

7. Factors Contributing to Evaluation of Students (2000) odds ratio 95% C.I. p value Age 1.08 0.67 - 2.00 0.52 Gender (male=1.00 0.64 0.03 - 4.31 0.42 Attendance rate 1.22 1.16 - 2.15 0.0001 Ethical test, first 1.14 0.59 - 3.04 0.47 last 2.14 1.53 - 22.22 0.009 Report score Case 1, 1st group discussion 0.97 0.83 - 1.06 0.37 2nd group discussion 1.00 0.91 - 1.10 0.90 Case 2, 1st group discussion 0.95 0.63 - 1.25 0.51 2nd group discussion 1.00 0.95 - 1.05 0.95 Separate analysis regarding tests First test 0.84 0.33 - 1.37 0.27 Last test 1.80 1.44 - 10.3 0.006

8. 1 Clinical case-based discussion is possible in first-year students. 2 Group discussion is functioning. 3 Report score correlated with the last ethical test, but not with the first test. 4 The last test was a contributing factor to the acceptance level. 5 Conclusion: the ethics course was useful for the students to increase reflectiveness regarding ethical thinking. Summary of Evaluation by Teacher (2000)

9. Questionnaire regarding Course by Students (2000&2001) Guidance: Understandable? Understood the method of case analysis? Case discussion: Were issues classified? Presented well? Was evaluation method fair? Was Case 1 appropriate? Was Case 2 appropriate? Were two cases too many? Lecture: Basis of clinical ethics? Bioethical thinking? Death/brain death/organ transplant? Were topics appropriate? Debate: Understood the method? Were issues classified? Was your thinking altered? Whole course: Understood the method of case analysis? Were lectures useful? Was debate useful? Was the course useful? Was group size appropriate? Were teachers active? Was the course too long?

10. Originally a five-point Likert scale. Summarized to 3 point, negative/middle/positive answer by percentages. Response of Students (2000&2001) Questions 2000 2001 χ p value Analysis method 28/38/34 13/22/65 14.948 0.0006 Lectures 15/40/45 4/27/69 12.058 0.0024 Debate 22/49/29 15/31/55 11.377 0.0034 Course 16/35/50 10/24/67 5.145 0.0763 Group size 42/33/25 64/19/17 8.179 0.0167 Teacher 5/26/68 6/20/76 1.188 0.5521 Length 26/43/31 53/38/9 18.946 <0.0001

11. 1Medical ethics course 2000: group size 10 students 2001: group size 7 to 8 students, tutorial method 2 A majority showed positive attitudes to the course 3 2001 students showed more affirmative answers in more than half of evaluated items than the 2000 students 4 The difference appears to stem from more lively discussion by the introduction of tutorial system and reducing the number of students in discussion groups in the latter-year course. Summary of Students Response (2000&2001)

12. Questionnaire on Students Performance (2001&2002) 2001: Group-based manner, 8 items Understood the method, All participated in discussion, Discussed multi- dimensionally, Used own knowledge Role was decided soon, Discussion was active Summarized in time, Reduce the group size 2002: individual-based manner, 2 items Discussed actively, Responded flexibly Answer 2001: a 5-point Likert scale 2002: 5 degrees

13. Correlation of Students Performance in Discussion Understood All participated Discussed Use own Role was Discussion Summarized the method in discussion multi-dimensionally knowledge decided soon was active in time All participated.734 in discussion (.003) Discussed.604.734 multi-dimensionally (.022) (003) Used own.669.698.739 knowledge (.009) (.005) (.003) Role was.684.608.368.429 decided soon (.007) (.021) (.196) (.126) Discussion.569.865.517.563.525 was active (.034) (.000) (.058) (.036) (.054) Summarized.796.708.473.528.529.480 in time (.001) (.005) (.088) (.053) (.052) (.082) Reduce the -.570 -.723 -.421 -.574 -.360 -.624 -.405 group size (.033) (.003) (.134) (.032) (.206) (.017) (.151) More lively discussion correlated with more active participation of students to discussion by tutors eyes. (2001)

14. Correlation of Students Performance with Evaluation Case: discussion on truth disclosure Discussed actively 1.000.802 (.000) Responded flexibly.802 (.000) 1.000 Report score.341 (.001).323 (.003) Final assessment.270 (.007).230 (.038) Discussed actively Responded flexibly correlation coefficient (p value) (2002)

15. Odds ratio (95%CI) of regression analysis. As students started and discussed PBL without tutors order or intervention, odds ratios would increase. *Statistically significant. NC: not calculated. Students Performance and Tutors Intervention Started as Intervention instructed unnecessary First discussion, discussed actively 0.49 (0.02 - 1.72) NC responded flexibly 9.09 (5.26 - 500) * NC Second discussion, discussed actively NC 1.23 (0.20 - 12.7) responded flexibly NC 2.71 (1.26 - 78.1)* Third discussion, discussed actively 0.41 (0.005 - 500) 0.49 (0.01 - 3.31) responded flexibly 0.60 (0.01 - 6.71) 0.68 (0.02 - 6.88)

16. Students Comments on the Course 1Most answers were affirmative to this bioethics course e.g., discussed subjects never thought about knowing different opinion is fruitful difficult to discuss problems without right answer personal growth, changed my view toward themes 2 Some students wanted to learn knowledge of ethics 3A few students claimed discussion not based on proper answer is useless or non-sense.

17. Bioethics Education in Medical School 1 Clinical case-based group discussion is functioning well. 2 The ethics course was useful for the students to increase reflectiveness regarding ethical thinking. 3 To enhance discussion, tutorial system is useful. 4 There were some students who wanted more knowledge. 5Tutors rated flexibility in response to other opinions as an important factor in discussion. 6Need to establish reasonable assessment method.

18. Bioethics Education in Medical School Bioethics Education vs Medical Ethics Education Bioethics education = more patient-centered Medical ethics education = more clinically centered (Miles SH et al, Acad Med 1989) Question: when doctors awareness on ethics are improved, then will doctors become more ethical? Answer: ? Clues to the answer The current medicine: based on belief in limitless advance Reality: life expectancy cannot be extended any longer by medical science. Example: Japan has sent sophisticated incubators to improve neonatology in Afghanistan.