del Pozo, Pablo Rodríguez MD, JD, PhD; Fins, Joseph J. MD
While the importance of the humanities in producing more humane, scientifically curious doctors is widely recognized, its relevance as medical education goes global has been less explored.1–3 When Cornell University inaugurated a full branch of its Weill Cornell Medical College in the Arabian Gulf emirate of Qatar in 2002, the Division of Medical Ethics was asked to define what role medical humanities would play in this cross-cultural educational venture.
The eight time zones between New York and Doha, Qatar, pose many logistical challenges, especially when the mandate is to provide a North American version of medical education to a predominantly Middle Eastern student body. The difficulty of “exporting” medical education4 across national borders suggested an even greater need to “import” medical ethics and humanities into the curriculum to optimize our efforts.
This role for medical humanities and ethics was anticipated by Edmund Pellegrino, who noted that
the ethics of medicine offers a fruitful point for beginning a larger cultural dialogue between and among the world's major cultures…. As the transcultural dialogue in medical ethics continues, it should serve as an encouraging prototype for the larger dialogue between and among all ethical systems…. Let us hope the dialogue continues and that medical ethics will serve to reemphasize our shared fate as humans.5
In this article, we discuss the role of medical ethics and humanities in this transnational project and discuss our first premedical course on these subjects at the Weill Cornell Medical College in Qatar. Below, we provide the context and main features of the project and our pedagogical strategy and offer a preliminary evaluation of this seven-week course first offered in the fall of 2003. We conclude with general comments on the place of the humanities in Weill–Qatar's evolving curriculum, and its broader impact as medical education globalizes.
The College in Qatar
The Weill Cornell Medical College in Qatar (hereafter, “the College”) has completed the second premedical year of an anticipated six-year program offering an MD from Cornell University. The program combines strong preparation in basic medical sciences with intense clinical training. Students are admitted to the premedical years and the subsequent four years of medical education through independent admission processes that include the Medical College Admission Test. Students who have completed their undergraduate degrees in U.S. universities or accredited universities abroad also can be admitted into the final four years. There are currently 50 students in the first two years. Enrollment is expected to expand to 50 students per class over the next several years.
The College is coeducational, making it one of the pioneers in the region. Approximately two-thirds of the students are women. Most students are Middle Eastern, with about one-third from Qatar. There are also Arab-American and Bosnian students, and individuals from Nigeria and India. The vast majority are Muslims.
Unique cross-cultural challenges
As with any premedical curriculum, the overarching goal of the medical ethics course is to prepare students for the four-year medical school experience. This involves the cultivation of both scientific and humanistic skills. Unlike most premed programs, however, the College faced cross-cultural differences that were likely to come to the fore when considering ethical issues in clinical practice and research. There was concern that the autonomy-based ethics so prevalent in Western medicine would be alien to, or even discordant with, our students’ traditions and professional values.6–8
Given these unique challenges, we needed to devise a course that would cultivate the knowledge, skills, and attitudes to prepare our students to address ethical dilemmas in clinical practice from their own cultural perspectives and also from a North American perspective. And while asking students to consider ethics from a Western perspective, we would have to avoid the impression that we were attempting to engage in indoctrination. As we were designing the course, we hoped that our students would become more aware of differing ethical perspectives and begin to appreciate the universal aspects of a life in medicine, no matter where one practices.
Meeting these challenges required specific early steps: exposing students to the medical humanities as a vehicle for developing a broader humanistic sensitivity; stimulating their curiosity and helping them develop analytical skills in the field of the social sciences; fostering an open attitude toward the nonscientific dimensions of medicine; bolstering students’ confidence in their own inner values and beliefs by presenting them with a cross-cultural vision; and nurturing an open and tolerant attitude towards the plurality of views on a given issue. We hoped to promote dialogue and debate rather than to impose a particular point of view. In addition, we wanted to develop the verbal and written skills in our undergraduate students—many of whom come to English as a second language—so that they could explain and articulately defend their own opinions.
We were concerned that the success of this early offering in medical ethics and humanities would hinge on the selection of an appropriate faculty member to teach the course. We felt that it would be counterproductive to have this introduction to North American bioethics taught by a faculty member who came directly from this Western tradition. We were concerned that this might lead to defensiveness on the part of the faculty member or engender criticism from the students, given the underlying political tensions in the region.
To foster more collegial discourse and to attempt to bridge the distance between North American and Middle Eastern perspectives on medicine and ethics, we sought to recruit a faculty member who was familiar with North American medical ethics but not a product of it. Moreover, we sought to identify someone who was experienced in translating the nuances of modern medical ethics across cultures and was comfortable in this role. One of us (PRP) was chosen to lead this course. He came to this position with an extensive international experience in studying and teaching bioethics in Spain and Latin America and bringing North American perspectives on bioethics to the Spanish-speaking world.9,10
Beyond selecting an appropriate faculty member, we felt it critical that he spend a significant amount of time in Qatar in order to build trust with the students and to absorb the local cultural particularities. This would be complimented by several months in New York to teach and engage in scholarly collaboration. This time-sharing arrangement also helped to build relationships between faculty in New York and Doha and helped to optimize the use of distance learning and video conferencing when New York-based faculty “visited” the class over the Internet. As expected, establishing relationships beforehand between faculty members made for a hospitable and academically successful virtual visit.
To design a course that would be appropriate for the students’ abilities and skills, we asked for input from College faculty already teaching in Doha and also reviewed students’ written work. We identified a range of abilities would need to be accommodated in course design and difficulty. Ultimately, we decided upon a curriculum that would utilize readings in literature and philosophy to introduce the students to ethical reasoning, while building their verbal skills.
The course centers on seven thematic areas ranging from nature to the law:
▪ Nature and biology
▪ The patient
▪ The physician
▪ The family
▪ The hospital
▪ Resource allocation
▪ The law
Our objective was to start with the place of biology in medicine and move toward potentially more contentious questions like the role of secular law in ethical deliberations. In this progression we sought to emulate curricular evolution from the basic to clinical sciences and avoid potentially controversial issues before trust could be firmly established in the classroom. It would have been impolitic and inconceivable to start the class discussing the place of secular law in a country governed by Islamic law. We hoped that by the end of the course, such dialogue would be possible.
To address these issues we chose an assortment of selections that were predominantly from European and North American authors, but also included works from Arabic literature. Authors ranged from Sophocles11 and Hippocrates12–14 to Lewis Thomas,15,16 Naguib Mahfouz,17 Albert Camus,18 and Edmund Pellegrino.19 Each was chosen to complement the week's theme (see List 1).
Nature and biology.
We began with a consideration of nature, biology, and the human body, and how science understands them. Using a selection of essays by physician–scientist and essayist Lewis Thomas, we wanted to introduce students to the power of the biological metaphor and the limits of biological reductionism. We also sought to demonstrate that even basic science can present ethical choices, as exemplified by cloning or defining the moral status of the embryo.
By staying in the familiar territory of scientific method, students showed their acceptance of science, and, tacitly, of its accompanying values—despite their strict religious traditions. Leaving that paradox aside, or perhaps because of it, making their implicit philosophy explicit appeared to be a firm step towards the kind of personal growth the course was meant to encourage. This affirmation of science would prove to be the underpinning of a more critical inquiry of more challenging issues. But respect for scientific method also came with its own orthodoxy. Students initially were unable to move beyond the manifest content of Thomas's words to their latent meanings. They were unable to challenge science the way the author had, or ask deeper questions about the lives of a cell, because to do so would be to question accepted authority. Encouraging such defiance was necessary to promote students’ intellectual engagement, much needed for their growth.
We began to see evidence of critical inquiry by the end of the first week, when some students were emboldened to question the text. One male student offhandedly dismissed Thomas's essays as “pure melodrama,” a reaction that put into words the initial uneasiness we perceived among some male students. For men, reflecting on ethics and aesthetics seemed to stray uncomfortably out of their perceived gender role and the relative safety afforded by scientific discourse.
This area explored the psychosocial elements and narratives of the patient's experience, using Leo Tolstoy's The Death of Ivan Ilyich20 and Joseph Fins’ “Voices at the End of Life,”21 a subjective-narrator tale of a terminal cancer patient. We wanted students to look at the universal experience of illness, to understand the complex web of relationships patients encounter in their immediate environment, and provide a glimpse into the often separate worlds of doctors and patients. That was our expectation, but the readings led to a response that we did not anticipate. Students brought their own narratives to the texts, echoing the view of the Argentine writer Jorge Luis Borges that a book is not simply the characters on the page but also their embodiment in the mind of the reader.22 This illustrates what has been described as a “Shakespeare-in-the-bush” phenomenon. Here readers bring their cultural perspectives to bear on the text, which is never understood in a cultural vacuum.23
Our students’ interpretation of the readings said more about their own development than about the actual text. For example, in Tolstoy's novel, students, given their youth and health, were more likely to identify with Ivan Ilyich's survivors than with the main character himself, and even had a touch of survivor's guilt.
Students read Fins’ parable as a doctor's story and not as a patient's narrative. They were enchanted by a character named Dr. Kramer, an aggressive oncologist who approached the protagonist's cancer as an enemy deserving annihilation and for whom palliative care was an unknown concept. “Dr. Kramer was perfect in managing his patient…. I wish he had been the one who proposed to send him to a hospice,” wrote one student. The compassionate clinician who substituted for Dr. Kramer—and actually referred the patient to palliative care—got no credit from the class, although the author of the piece (JJF) intended him to be viewed as the hero of the parable. Instead, our students identified with the mythic, superhero doctor they aspired to become. Their reaction, besides reflecting their youth, may have mirrored some of their culturally-rooted expectations of physicians as optimistic miracle workers.
Relying on The Metamorphosis24 by Franz Kafka, we sought to introduce the family into the discussion of health and disease. We wanted students to appreciate how sickness frequently becomes a family affair. The module also was meant to introduce the use of metaphor as a vehicle for presenting ethical issues in medicine, and Gregor Samsa's awakening as a cockroach provided us with an apt metaphor for a terrible illness in the family.
“I first thought of Gregor's story as a badly written fiction. However, now and after all the discussions we've had in class, I realize that this is a story that happens every day in real life. The vermin seemed to symbolize a fatal disease and the rest of the story illustrates what could be some families’ response to such event,” wrote a student. Wielding newly discovered analytical skills, students easily spotted the allegory of the story. Albeit timidly, students defined stages to describe what happens to the patient's family (shock, helpfulness, tiredness, anger, relief) throughout the story, echoing E. Kübler-Ross.25
Students came down hard on patients’ families in the framework of modern medicine. Nevertheless it was clear that negative comments were directed at European or American families and societies, not at their own. Perhaps there is a factual basis for the cultural stereotype. “Islam highly encourages and demands intense care for our family members and relatives,” one student wrote.
In this thematic area we aimed at making students familiar with the personal and social dimensions of being a doctor, stressing professionalism as both technical mastery and the adherence to the virtues that inform clinical practice.26 We also wanted to highlight the singularities of the student-patient and the doctor-in-training–patient relationship. We drew extensively on the writing of Hippocrates. To create a learning environment befitting the topic, we introduced this module with a solemn lesson on the venerable master.
We could have saved ourselves the trouble. The students had already succumbed to Hippocrates’ name and creed. We believe that reading Hippocrates was a rite of passage that converted the group from lay students into medical students now identified with their future profession. Wrapped in their emerging professional identity, students embraced the wisdom and relevance of the doctor of Cos, and used his teachings to justify physicians’ paternalism. To demonstrate the role of the physician as the patient's advocate, we used Fins’ “Vowing to Care,”27 a modern invocation of the oath in the face of market forces. Students identified the doctor's struggle with an HMO as the epitome of a modern-day Hippocrates.
But this module was also meant to foster a nascent sense of pluralism. Inadvertently, students discussed and praised a secular ethics that they found meaningful and current. Students seemed comfortable with notions of good, virtue, and duty that exist outside purely religious traditions and principles, at least in the realm of medicine. In the context of a culture where religion and morality constitute an inseparable unit, such tolerance was for us an indication of the journey towards intellectual pluralism.
This week we aimed at understanding the life and ethical problems of the hospital, the microenvironment where medicine is learned. We used Sir William Osler's “The Hospital as College”28 and contemporary readings29–31 on the hospital experience of students and physicians-in-training. The idea of hospital-based learning was meant to intrigue students while highlighting the vulnerability of patients in a teaching hospital. Again, their bias was as physicians, illustrating the impact of their emerging professional identity. With more than a nod to paternalism, students minimized the role of the patient and autonomy.
Resource allocation in health care.
In this session we sought to introduce students to today's health care systems, and the societal problems of justice and efficiency in the use of medical resources. We used George Bernard Shaw's The Doctor's Dilemma32 and Edmund Pellegrino's “Medical Morality and Medical Economics,” to cover problems of justice in both the micro- and macroallocative contexts.
Macroallocative problems were recognized by students, but they were more curious about microallocative issues than broader questions of justice in health care. The role of doctors in selecting patients who may benefit from scarce lifesaving resources was an irresistible magnet that overshadowed most other topics. From their growing identity as future doctors, they seemingly couldn't help but to identify themselves with those who have such personal power over life and death. Students could not transcend the doctor–patient context they had recently embraced, to consider broader questions of distributive justice. Perhaps the hierarchical rigidities of their culture played a role in making the issues about personal power more visible than abstract questions of justice.
With this last thematic area we hoped to help students understand the relationship between morality and the law, and stressed how the law is open to different, contradictory interpretations. We relied on a celebrated 1949 theory of law reading, “The Case of the Speluncean Explorers,”33 by Harvard's Lon Fuller, in which different judges make diverse rulings on a well-constructed case of homicide and cannibalism in extreme circumstances. That we could discuss secular law was a clear sign of a developing tolerance, given that the prevailing culture views the Islamic Shariah34 as the only law; the distinction between law and morality is simply nonexistent.
In this context, leaving aside the vehemence of the debate, the strictness of religious arguments, and the irreducibility of one or two students’ positions, we were comfortably discussing secular law and its properties, including its prevalence over unwritten law, with a group of students that was not the same as the one we met seven weeks earlier.
Our early impressions and feedback from students are encouraging. Students ranked this course better than their overall educational experience in other classes. Using a five-point Likert scale, with 5 being the most favorable rating, the course received mean ratings of 4.2 in problem-solving applicability, 3.8 in the appropriateness of the readings, and 4.2 in pedagogic format. The principal instructor in Doha received a mean rating of 4.4 for helpfulness, and most thematic areas were rated above 4.0. However, the appropriateness of the readings were given a mean score of 3.8. Although not a significant difference, this lower rating may suggest difficulty with language, concerns about workload, or, ultimately, students’ perceptions about the selections themselves. The course was also viewed by students as being as relevant as their basic science courses. Not surprisingly, most students complained about the workload—two weekly written assignments for a one-credit course—and others asked for more lectures and less discussion. Nonetheless, students seemed comfortable with our choice of texts and with those texts being mostly from Western literature. Course offerings engendered curiosity and did not prompt concerns about a Western bias.
Subjectively, the course was regarded as a window on new horizons and ways of thinking. “A very new type of thinking,” “broadened my horizons,” “I started to see things from different angles,” and “[never before had] they taught me to imagine, to see things in different ways and perspectives, or even link what I study to nature,” were some of the students’ comments. It also struck some students as a new way of exchanging ideas. One student observed, “I have the opportunity to say what is in my mind whether it is right or wrong.” Class discussions were frequently mentioned as what students liked most about the course, though some were upset by the lack of a final dogma set by the instructor. They also appreciated that “there is more understanding and discussion than memorizing.” Others saw it as a course “which really helped me improve my writing skills.”
The scope of student interests also was broad. This is evidenced by the wide range of themes that they addressed in their final papers. When asked to come up with a topic on their own, these premedical students chose a wide swatch of topics in clinical, research, and public health ethics, including breaking bad news, physician-assisted suicide, confidentiality, assisted reproduction, animals in research, and the Tuskeegee Syphilis Study. Only one student wrote on Islamic medical ethics.
Students were challenged by this “new type of thinking” and tentative with their embrace of more secular modes of inquiry. For example, in the final session, one student who had previously taken an unorthodox position asked for class time to recant her views, explaining she had sought the advice of religious authorities in her community. While she acknowledged that her analysis was correct, she had been informed that her conclusion was wrong.
The student's comments can inform our evaluation of the course in several ways. If we were seeking to indoctrinate the class with Western views, it could be seen as a setback. After all, the student embraced a rational analysis only to recant it because of theocentric pressures. But to view her actions in this way would be to mistake our intent, which was and is to promote engagement with new ideas and authentic intellectual struggle. Her actions—both the embrace of rational analysis and the need to remain true to her faith—indicate that the course had caused her to reflect on themes that were personally meaningful and also point to the need for caution and humility in the early evaluation of our endeavor.
Finally, throughout our experience we have been reminded that we can sometimes misconstrue the meaning of our perceptions in this cross-cultural setting. For example, our perceptions that male students were initially less interactive than their female counterparts was initially seen as a sort of disinterest in these softer topics or as outright detachment. We were reminded about the importance of distinguishing motivation from observed behavior when one male student shared excellent observations with the instructor after class and was asked why he had been so quiet in class. His silence was not disinterest but the product of a tradition that keeps men and women apart and prompts self-censorship, lest he be embarrassed by what he might say.
The Course's Effect So Far
At this early juncture, we are pleased by our first offering in medical ethics and humanities and its impact on our students and the learning environment at the College.
In our view, the course has fostered reciprocal understanding and trust, and has mitigated potential cross-cultural frictions. Students have shown an increased readiness to respect a plurality of opinions and moral traditions.
We believe that the course has broadened students’ perspectives and promoted intellectual maturation. Students have begun to engage texts and form well-considered opinions. They are less passive receptacles of accepted knowledge and more active intellectually. During the course we have also seen an evolution of initially gender-stereotyped roles.
The course has also provided students with a nascent professional identity. 35,36 The sessions on the physician were a transformative experience. After reading Hippocrates they began to embrace their emerging professional identities, albeit as novices. We believe that our course has helped connect the art and science of medicine and has brought our students closer to the experience of doctoring. It has given undergraduates the experience of becoming medical students.
We feel that the emergence of a professional identity is a positive development. However, students assigned their new professional identity a rather disproportionately paternalistic role in healing power and authority. This is consistent with our previous experience with doctors who graduated from universities outside the United States.37 Nonetheless, we are convinced that this power dynamic, coupled with a traditional vision of faith and morality as a single unit, could undermine students’ inclination to respect patients’ preferences. It is too early to say whether this tendency towards paternalism is simply a developmental stage in the progression to a professional identity or an indication that empathy may be culturally mediated. This is a question that will inform our observation of our students as they progress in their training.
The proclivity to invest the physician with unilateral authority also confined their understanding of doctoring to the doctor–patient relationship, at the expense of the broader social aspects of medicine. A more ample vision of medicine as a social science, in which doctors have obligations to the public health, needs to be fostered.
Beyond the course's impact on individual students, it has influenced the broader curriculum and the learning environment at the College. Besides encouraging trust and tolerance, it has enhanced the students’ verbal skills and given the class new skills in critical thinking. This is key for a medical school curriculum so heavily predicated upon reflective practice.38 It also has helped develop students’ writing dexterity.
We also hope that this course will influence the broader Cornell University community. With the advent of video-conferencing technology, we are currently considering whether medical students in New York or undergraduates in Ithaca might partake of this course offering.
Beyond the walls of Cornell, we hope that our nascent efforts have helped lay the foundation for improved health care in the Middle East by giving its future doctors the knowledge, skills, and attitudes necessary to link their local context of care with the broader global medical community. If history vindicates this experiment in medical education, the Weill Cornell Medical College in Qatar will be, as Cornell's President Jeffrey S. Lehman noted, “a shining and hopeful example of the future of higher education worldwide.”39
The authors thank the Qatar Foundation for its support for this project, Daniel R. Alonso, MD, for helping us conceptualize this educational program, and Joseph H. Habboushe for his insights.
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