Since the Flexner Report of 1910, instruction in the natural sciences and clinical arts has become standardized and medical training has been based on scientific and clinical advances.1 Unfortunately, this is not been the case with bioethics.* Some suggest that instruction in these disciplines resembles the pre-Flexner status of the natural and clinical sciences.3 The importance of this undisciplined approach to instruction in bioethics cannot be overstated. Medicine will undergo profound changes over the next decades, and professionals skilled in bioethics will dramatically affect those changes.4 It is critical, therefore, that the medical profession be conversant with the issues behind the changes. Methods for teaching bioethics in medical school have been the focus of numerous articles in the literature, but no systematic review of bioethics education in osteopathic medical schools' curricula has been undertaken. Since the socialization process during medical school is profound, instilling an understanding of bioethics at this early stage of osteopathic physicians' education seems intuitively preferable. The goal of many allopathic medical educators is to have medical school graduates be conversant in the major bioethics issues, and to have instilled in those graduates certain values.5
Bioethics instruction has been shown to improve empathy and clinical ethical reasoning skills,6,7,8 and the literature suggests that it can improve clinical diagnostic decision making.9 Credentialing requirements for both osteopathic and allopathic medical schools indicate a general consensus that bioethics should be part of a medical school's curriculum and that the process of developing bioethics knowledge should begin in medical school.11,12,13 Which instructional processes should be used and how those processes will be structured are not well defined. Nor is there consensus on what should be included in that curriculum. Some medical schools prefer small-group discussion, others prefer large-group lectures, and still others prefer approaches such as objective structured clinical examinations (OSCEs), standardized patient assessment laboratories (SPALs), and problem-based learning (PBL).14 Topics taught in bioethics range from euthanasia and abortion to the ethical issues faced by medical students on a daily basis.
How many hours of instruction in bioethics should be offered? When and where should these hours be in the curriculum? Should the instruction in bioethics continue into the clinical years? What instructional strategies should be implemented? What should be the credentials of those facilitating the instruction? The goals of this study were to determine the resources in bioethics at the 19 osteopathic medical schools in the United States (a small group that can be easily surveyed) and access experts' opinions regarding bioethics curricula.11
From 1999 to 2000, we conducted a qualitative study using a repeated-measures design. Individuals responsible for bioethics instruction at all 19 U.S. osteopathic medical schools were identified by direct phone contact with the deans' offices. We contacted them directly and asked them to identify others who provided instruction in bioethics. Surveys were also sent to these individuals.
We used a modified reactive Delphi approach for this study.15–17 The Delphi technique is often used when a validation instrument or method cannot be located to identify or measure the variable(s) of interest as well as in pursuing information that may generate a consensus from a respondent group. The modified Delphi differs from the conventional Delphi in that the primary investigator asks the respondents to react to previously prepared information rather than generating a list of items from the first questionnaire.17 As demonstrated by Stritter and McKenna, this technique has been successfully used in medical school curriculum development.16,18
Using a nominal-group process, local professionals with an interest in bioethics were asked to define priorities for the teaching of bioethics, essential elements for curriculum development, and an initial topic list.15 In the first survey, the respondents were asked to react to the nominal group's list of topics and questions by identifying each topic as either important or not important. In addition, each question was left open-ended so that respondents could generate additional items they felt were important. The first Delphi round gave respondents the opportunity to list the bioethics contents of their medical school curricula.
A report of results from the first survey along with a second round of questions was then sent to the respondents. The second Delphi round asked the respondents to rank the identified topics (over 50 various topics generated by the nominal group and additions from the respondents) for their importance in a bioethics curriculum using an arbitrary 1–20 scale. Unfortunately, ranking of these topics yielded poorly differentiated results because it is difficult for respondents to rank order more than eight to ten items.19
The third round of the Delphi process further differentiated this topic list by asking respondents the importance of a bioethics curriculum for each topic individually. The investigators asked the respondents to determine what topics were essential, foundational, or peripheral to the bioethics curriculum. These terms were defined operationally:
* Essential for the core curriculum: absolutely essential to a curriculum in medical humanities and bioethics; the curriculum could not be covered effectively without this topic
* Foundational to the core curriculum: foundational to the understanding of medical humanities and bioethics
* Peripheral to the core curriculum: could be eliminated from the curriculum without damaging understanding of the field of medical humanities and bioethics. If time were available this would be good to include in/as an elective
To enhance the return rate, the principal investigator called the non-respondents during each of the Delphi rounds. Statistical analysis was performed on all responses using straight percentages.
The response rates were 96% for the first iteration, 75% for the second iteration, and 83% for the third iteration. The mean number of hours of bioethics instruction taught overall in osteopathic medical schools was 27.58, although the range was very great for all four years (0–40 hours in the fourth year).
Only 42% of responding schools had full-time faculty specifically devoted to the instruction of bioethics, and 39% of the respondent schools had no full-time faculty members instructing in bioethics. The bioethics backgrounds for the faculty teaching bioethics appeared to be quite diverse, with only 29% indicating a PhD in bioethics and an additional 29% finishing fellowships in bioethics. Of all the respondents who indicated their backgrounds and training in bioethics, 43% had learned through other means, including home study and “common sense.” Among the professional designations for adjunct or part-time faculty were DOs (46%), PhDs (32%), MDs (7%), and JDs (7%). Full-time faculty reported to various departments and supervisors. Bioethics instruction was most commonly supervised through departments of family practice. The remainder of the responding schools reported supervision across the professions, including the department of basic sciences and a center for ethics.
While most of the respondents indicated that bioethics lectures were interspersed into a variety of other systems and courses within the medical school, no standardized methods or specific times were designated within the curricula for bioethics topics. Only one respondent indicated a specific course or system for bioethics, a “Medical Humanities and Bioethics” course.
Respondents ranked small-group discussion the highest as an instructional strategy throughout the four years of medical school (1.41, 1.47, 1.29, and 1.53, respectively) and for internship and residency (1.12). The rankings for all other instructional strategies fell between 3.12 for standardized-patient format for fourth-year students to 5.88 for term papers in the first year. Interestingly, grand rounds in the fourth year was ranked very highly (1.12).
A total of 26% of the responding schools offered electives in bioethics. None of those had more than one elective in bioethics. Of those who responded in the first iteration, 63% felt that osteopathic medicine offered unique perspectives and views in bioethics.20
Table 1 lists the topics, both those generated by the nominal group and those added by respondents from the first iteration, and their rankings as essential, foundational, or peripheral. Results showed no differentiation between responses in the first and second iterations. A total of 16 topics are ranked above 50% as “essential” for a bioethics curriculum. The topics considered “foundational” and “peripheral” for a bioethics curriculum had only six topics ≥50% ranked either foundational or peripheral.
To date, there has been no concerted effort to define what constitutes a “proper” osteopathic curriculum in bioethics. This is one of the first surveys to explore bioethics in the osteopathic medical school curriculum. Some of our findings were surprising. For example, the average number of hours of instruction over the four years of the curriculum was more than 20, although the range was great. We expected much fewer hours devoted to bioethics in the curriculum.
Furthermore, only ten schools had individuals specified as full-time faculty in the instruction of bioethics. The respondents may have been confused with respect to some of these questions because “full time” could have been interpreted as full time in some other discipline where bioethics was only a partial instructional assignment. So, in actuality, this number may be much smaller. In addition, those teaching bioethics had minimal formal training in bioethics. Only a small percentage of full-time faculty members were osteopathic physicians, and only a few had even a rudimentary background in bioethics. The schools varied tremendously in how and who supervised full- and part-time faculty, and there was no consistency in reporting schemes. This finding presents a significant problem because without a clear reporting strategy and organizational structure little direction for building a bioethics curriculum can be forthcoming.
How bioethics was included in a medical school's curriculum varied tremendously. Bioethics was a separate course in only one osteopathic school; in all others, bioethics was contained within other courses. Again, these results are troubling. Without experience in an established regular bioethics course, can a clear curriculum be determined by researchers? We believe bioethics should be made a separate course supervised by a department that is responsible for only the bioethics aspects of the curriculum.
Another noteworthy finding was the respondents' perspectives on their administrative support. Although a majority of respondents felt that their schools' administrations were strongly sympathetic to bioethics instruction (85%), exactly how much support for this instruction was forthcoming in concrete terms (i.e., dollars) was beyond the scope of this study. Future studies should determine the attitudes and knowledge of administrators concerning actual financial support for bioethics instruction. Administrators tend to drive the curriculum, providing either the needed support or lack of support for a bioethics program.
The data we generated indicating a topic's importance (essential, foundational, or peripheral) to a bioethics curriculum are not especially helpful for schools establishing or changing their curricula. This report is the first effort at tapping into experts' opinions of bioethics instruction and the first step towards building any kind of consensus. The results of this survey are not meant to be a definitive statement on how a curriculum should be designed, but are meant to be both a guide and a platform for discussion. It has been possible to define standardized curricula in many disciplines similar to bioethics, e.g., sociology, psychology, and philosophy. Therefore, we feel this is an achievable goal for bioethics.
It is easy to demonstrate the relevance of biochemistry or anatomy in the medical school curriculum, but showing the relevance of bioethics is more problematic. Medicine is a moral enterprise, and medical students and physicians are confronted with ethical issues on a daily basis. Therefore, instruction in the discipline of bioethics is critical. Not only must the profession codify and standardize bioethics instruction, but also it must support an investing tradition in bioethics.
The osteopathic medical profession must begin a serious investigation of the discipline of bioethics. Andrew Taylor Still was outspoken in his defense of a moral code he felt essential for the practicing physician, e.g., his views on abortion,20 which were the historical foundation of the moral aspect of osteopathic medicine and the perceived contribution of an osteopathic philosophy. This tradition requires support of indepth scholarly investigation of bioethics.
As previously discussed, the literature suggests that bioethics instruction improves empathy, compassion, and clinical acumen among medical students. Additionally, health care will drastically change in the future. Many in the allopathic profession have realized that professionals in bioethics will profoundly affect those changes.21 While it is true that only a disjointed approach to bioethics has been forthcoming from allopathic institutions, osteopathic institutions are without even rudimentary knowledge of what and how these disciplines are to be taught, as is demonstrated by the results of this survey.
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*The term “bioethics” is used inclusively, for the sake of brevity, throughout this paper to refer to issues in medical ethics as well as medicine and literature, medical history, and similar disciplines. It is understood by the authors that defining the term “bioethics” “is not an easy task with a field that is still evolving and whose borders are hazy.”2 Cited Here...