Teaching ethics and medical humanities to medical students in Sri Lanka: a multi-cultural approach ANOJA FERNANDO Faculty of Medicine University of Ruhuna Sri Lanka 8 th Asian Bioethics Conference, Bangkok, Thailand March 2007

THE FACULTY OF MEDICINE, UNIVERSITY OF RUHUNA (GALLE) Established 1980

At inception, in 1981, ethics teaching was in Forensic Medicine course (professional, legal) History of Medicine lecture Code of Hammurabi 2000 BCE Lord Buddha, Vinaya Mahavagga 1st century CE (500 years after Buddha) Hippocratic Oath 5th century BCE Declaration of Geneva, W M A 1948

Lord Buddha (Vinaya Mahavagga) 5 characteristics of a good “caregiver” To be capable of prescribing the proper medicine To administer what is suitable To nurse the patient out of charity and not out of greed Not to be squeamish about removal of excrement, vomit etc To teach the patient, to be able to cheer him and comfort him

Formal Medical Ethics course 1995 Medical Humanities introduced 2005

Formal course on Medical Ethics 1995

Traditional Curriculum - Ruhuna Pre-clinical Para-clinical Clinical ETHICS

Medical Ethics Course At entry to medical school Medical Students’ Oath (2001) Introductory lecture At entry to clinical course in 3 rd year 7 lectures and one seminar on ethical scenarios Forensic Medicine Pharmacology Professional and legal ethics Research ethics 3 rd to 5 th year Specialised topics Clinical ethics discussions

During Professorial Appointments (5 th YR) Students identify and present ethical issues in ward patients Discussion in the wards Guidelines provided Assessment Simple student assessment Final course evaluation Clinical Ethics Discussions

Formative assessment of students at end of course 1998 * 2005 Question 193 %91 % Question 275 %99 % Question 371 %75 % Question 481 %84 % Question 583 % Question 663 %80 %

Evaluation of ME Course by students Interesting 90 % Useful/relevant 86 % 98 % Continue during internship 85 % 97 % Input excessive 25 % 16 % Reduce lectures 50 % 14 % Increase discussions 80 % 76 %

Innovations in 2005 Use of Asian sources for teaching medical ethics Introduction of Medical Humanities into the Ethics Course

“Drawing on Asian literature may lead to greater cultural relevance in teaching and acceptance of medical ethics in Sri Lanka.” Prof S N Arseculeratne

Medical Ethics of Susruta and Charaka Medical Ethics of Arab physicians eg Rhazes Buddhist Jataka Tales

Comparison of Hippocratic Oath with Charaka’s Code of Conduct Hippocratic oath more about doctor- patient relationship, while Charaka’s Code stresses personal morals also. (more difficult as well) About 25% thought Charaka’s Code better and more relevant to Sri Lanka (Asia), while about 8 % thought Hippocratic Oath better. (n=114 )

Medical Humanities 2005

In favour of introducing Medical Humanities YESNO Teachers76 %24 % Students98 %02 % 2005

Introduction of Medical Humanities in 2005 Course of short optional lectures from October to December First time in a medical faculty in Sri Lanka. Experimental in nature

MEDICAL HUMANITIES Arts subjects related to Medicine OBJECTIVES: To promote Reflective practice and personal development Empathy with patients Compassionate understanding of individuals in society

METHOD Ten half hour lectures Fourth year students Handouts Western and Asian sources Optional No assessments Lecturer: qualified in med + humanities Evaluation of course

This was voted the most popular lecture by the students Students’ comments “It made me feel special to be a doctor in the future and an impulse to do good.” “It touches our deep emotions and makes us think back - do we practice real medicine at present?” “ I liked the painting because I have never related to one so before. It was really interesting to actually UNDERSTAND a painting.” EXAMPLE

99 students (out of 135) responded 96% wanted course continued Enjoyed the lectures (80%-97%) Agreed on relevance to objectives (80%-88%) Preference: half-hour (69%) lectures (71%) Comments were positive and appreciative, indicating that lectures were effective. Preliminary evaluation of course

STUDENT COMMENTS ON COURSE “Talks on humanities are a very good approach to create a better doctor.” “This is a really good idea to introduce this kind of thing to medical students.” “This series should be continued.” “It makes our life a little relaxed and also some at least can think about our patients in a different way, more empathetically, and emotionally, and care for their feelings in the future.”

CONCLUSIONS Short, didactic lectures are feasible, acceptable to students, and effective as a method of introducing medical humanities to undergraduates, in a developing Asian country with limited resources.

2 nd course of lectures – October 2006 Lecture duration 1 hour External lecturers Simple assessments

Lecture topics Evolution of ethics during the 20th century (hist) The doctor-patient encounter in western art (art) Anatomical drawings of Leonardo da Vinci (art) The history of the Nuremberg Code (hist) Anatomy lesson by Jack Coulehan (poetry) Use of Jataka stories in psychotherapy (lit) Tapestry art depicting end of life (art) Medicine and hospitals in ancient Sri Lanka (arch) Ethical Codes in Medicine: East and West (hist of med) Racism in medicine : some examples (hist of med) Alternative systems of medicine (hist of med) The music of Mozart (music)

ACKNOWLEDGEMENTS My thanks are due to Dr A A G Abeysinghe, Dr K K R P Kodituwakku and Dr P G D Tharanganee for collection and entry of data from questionnaires.