Indian Journal of Medical Ethics Vol XI No 2 April-June

2014
Available from: http://www.nature.com/news/editor-s-move- 37. Williams N. To the heart of a clinical matter. The Guardian. 1991
sparks- backlash-1.10068 Apr 17: 21.
35. Smith WJ. Culture of death: The assault on medical ethics in 38. Rothman DJ. Strangers at the bedside: a history of how law
America. San Francisco, CA: Enterprise Books;2000. and bioethics transformed medical decision making. New York:
36. Culliton BJ, Waterfall WK. Flowering of American bioethics. BMJ. Basic Books; 1992.
1978 Nov 4;2(6147):1270–1. 39. Jafarey AM, Iqbal SP, Hassan M. Ethical review in Pakistan: The
credibility gap. J Pak Med Assoc. 2012; Dec;62(12):1354–7.

Knowledge, attitudes and practices related to healthcare

ethics among medical and dental postgraduate students in
south India

CHANDRASHEKAR JANAKIRAM1, SEBY J GARDENS2

1
Professor, Bioethics, Amrita School of Dentistry, Cochin INDIA 2 Assistant Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Cochin INDIA
Author for correspondence: Chandrashekhar Janakiram e-mail: sekarcandra@gmail.com

Abstract medical counterparts. The incorporation of a bioethics curriculum

Background: Conventional medical training offers students little in the initial period of the postgraduate programme would be
help in resolving the ethical dilemmas they will encounter as beneficial.
healthcare professionals. Objective: This article aims to assess
the knowledge of, practices in and attitudes to healthcare ethics
among postgraduate medical and dental students. Methodology:
A questionnaire-based, cross-sectional study was carried out
at two medical and dental schools in south India. A total of 209
medical and dental students were contacted and at least three
were selected from each subspecialty of medicine and dentistry.
One hundred and ninety-nine consented to participate and 172
returned the questionnaire (response rate 83%). The
questionnaire, which was a 35-item pre-tested, self-administered
questionnaire, included both closed and open-ended questions.
The proposal for the study was approved by the institutional
review board (IRB) and the permission of the respective heads
of department was obtained. Written consent was obtained
from each participant. The returned questionnaires were
analysed using SPSS version
11.5. Descriptive analysis was carried out for all the data. The
attitudes of the postgraduates of different courses towards
practical ethical problems were compared using a Chi square
test. Results: Medical and dental postgraduates had obtained
their knowledge of bioethics from “other sources such as the
Internet, newspapers, etc”, followed by their “undergraduate
training” and “experience at work”. Nearly 68% of the
postgraduates had not undergone any bioethics training.
Nearly 98% of the medical postgraduates, as compared to 79%
of the dental postgraduates, knew that their institution had an
ethics committee. There was a difference between the medical
and dental students in terms of their attitude to and knowledge
of healthcare ethics, with the former having a superior
knowledge of the subject and a better attitude. Conclusions:
The medical and dental postgraduates come across ethical
issues during their training, but are not equipped to resolve the
ethical dilemmas they encounter. The dental postgraduates
have less of an appreciation of healthcare ethics than their

[
 Indian Journal of Medical Ethics Vol XI No 2 April-

Introduction
Doctors attending to patients in an emergency
health situation have often had to face assaults
on account of the recent increase in the
awareness of patients’ rights in India (1,2,3).
These may be due to the paternalistic attitude of
the doctor or a lack of understanding, or may
simply be emotional outbursts. Advances in
biomedical technologies such as life support and
artificial reproductive technologies have brought
new ethical dilemmas in their wake and have
exacerbated the problem. Ethical dilemmas are
usually encountered in areas such as abortion,
contraception, treatment of a patient with a
terminal illness, professional misconduct,
maintaining a patient’s confidentiality, the
doctor’s professional relationship with the
patient’s relatives, religion, traditional medicine,
and conflict of interests. The conventional medical
course offers students little help in resolving the
ethical dilemmas they will encounter as
healthcare professionals. Training in medical ethics
has been made mandatory in the undergraduate
curriculum by the regulatory body of medical
education, the Medical Council of India (MCI); but it
has been placed under forensic medicine (4). There
are very few medical colleges in India with a
standardised ethics curriculum, and with provisions
for evaluation (5). The dental curriculum makes
merely a passing mention of the principles of
ethics (6).
Medical and dental postgraduate students
undergo intensive training in their specialties
and their focus is chiefly on organ specialisation.
Postgraduates need intensive training in
bioethics so that they have an appreciation of
the patients’ rights, cultural differences and
research ethics, and are equipped to resolve
ethical dilemmas.

There are varied views on strategising the teaching

of bioethics. Most of them emphasise the
importance of tailoring the teaching of the
subject to the needs of the society concerned
(7). The teaching of bioethics should also be
holistic. For example, students could be taught
about the value of the “heart” over the “mind”,
of the system of values and beliefs in a
community, and of the need to understand the
lived experiences of patients; while also
incorporating various ethical approaches (8).

[
 Indian Journal of Medical Ethics Vol XI No 2 April-June
2014

The dearth of specialists in bioethics and a lack of student was studying, and his/her specialty, age and
organised human resources has led to lack of gender, were included in the questionnaire.
appreciation of the urgent need to include bioethics in
The second part of the questionnaire consisted of
medical education in India. Further, there are
questions regarding the importance of a knowledge
concerns that teaching bioethics as an organised
of ethics, the source of this knowledge and the
science might be problematic and would not be
source of consultation in case an ethical problem
feasible (9). In India, due to the cultural mosaic (10),
arises. The respondents were asked whether they
the teaching of bioethics needs to encompass the
were aware of the presence of an ethics committee
various perceptions of morality and ethics unique to
in their institution, and about the role of these
people from different cultural, socioeconomic and
committees. The
geographical backgrounds (9). The training in this
subject should be integrated with the local social and
cultural values.
The first step in formulating an ethics curriculum
may be to determine the level of the basic
knowledge and attitudes of the postgraduates in the
region. Few standard yardsticks have been designed
to measure what is known and practised so as to
ensure that educational efforts are better targeted
(11). The objective of this study was to assess the
knowledge of, attitude to and practices in healthcare
ethics among medical and dental postgraduates.
Methodology The study was approved by the
institutional review committee of the Amrita
Institute of Medical Sciences, Cochin, India.
Permission was obtained from the deans of all the four
institutions that participated in the study.

Study settings A cross-sectional, questionnaire-based

study was conducted in two medical colleges in
Kerala and two dental colleges. The medical colleges
were the Amrita School of Medicine and the
Government Medical College, Calicut, while the dental
colleges were the RV Dental College, Bangalore and the
Government Dental College, Trivandrum. These
institutions were selected since, at the time of the
study (2010–11), they were offering postgraduate
courses in all medical, surgical and dental specialties.

Study population Postgraduate students who had

enrolled in the MD, MS, MDS and DNB courses in these
institutions were selected. A sampling frame of all
postgraduate students in each institution was
developed and three from each specialty were
selected randomly. For example, three out of 10 were
selected from the MD course. In the case of the dental
postgraduates, all of them were selected since there
were fewer subjects for each specialty. A total of 209
subjects were selected.
Questionnaire We adapted the questionnaire of a
previous study (7) to make it suitable to our
objectives. The 35-item questionnaire was a self-
administered, semi-structured one with both open and
close-ended questions, designed to assess the
students’ knowledge, attitudes and practices in the
sphere of healthcare ethics. The content of the
questionnaire was validated before the study. The
demographic variables, such as the year in which the
[
 Indian Journal of Medical Ethics Vol XI No 2 April-
questionnaire mentioned eight roles that ethics their dental counterparts. The dental postgraduates
committees might play and the respondents were had encountered questions related to ethics from
asked to indicate whether they thought the their patients less frequently than had the medical
committees played these roles by choosing between postgraduates. Most often, it was the medical
“yes”,“no” and “not sure”. rather than the dental postgraduates whom
patients asked questions regarding the diagnosis.
In the final part of the questionnaire, the
Of the medical postgraduates, 59.5% always
respondents were asked to answer questions on
discussed their daily cases with their colleagues,
everyday ethical issues. They were asked if they
compared to 47.5% of their dental counterparts.
agreed or disagreed with certain statements
concerning ethical conduct, autonomy, paternalism,
confidentiality, informing patients about wrongdoing
and informing relatives about the patient’s
condition, informed consent, and the influence of
religious beliefs on the treatment. The respondents
were required to grade their responses on a Likert
scale ranging from 1 to 5.

Informed consent All the participants selected were

given the participant information sheet, which
explained the details of the study, and written
informed consent was obtained from those who agreed
to participate in the study.

Statistical analysis The data were analysed using

Statistical Package for Social Sciences (SPSS) – version
11.5. Descriptive analyses were carried out for all the
data. The attitudes of the dental and medical
postgraduates towards practical ethical problems
were compared using a Chi-square test. Statistical
significance was fixed at the level of p<0.05. In
Table 3, the category of “not sure” was merged with
that of “disagree” as the responses in the “not sure”
category were less than five or zero. Also, the former
category is likely to veer towards the category of
“disagree” rather than “agree”.

Results
We contacted 209 postgraduates, of whom 199
consented to participate. A total of 172 subjects
returned the completed questionnaire. Thus, the
response rate was 83%. The mean age of the medical
and dental students was 28.1±1.7 and 29.9±3.6 years,
respectively. As many as 83.8% of the participants in the
study were males. Table 1 presents the characteristics
of the study participants.

Nearly all the medical postgraduates had knowledge

of the Hippocratic Oath, but surprisingly, only 23.4%
of them had knowledge of the Indian Council of
Medical Research (ICMR) guidelines on ethics for
research, the Nuremberg Code and the World Medical
Association’s Helsinki Declaration. Very few dental
graduates knew about these guidelines. Table 2
presents the responses of the medical and dental
postgraduates to questions on their knowledge of
healthcare ethics.

More medical postgraduates considered knowledge

of bioethics important in their daily practice than

[
 Indian Journal of Medical Ethics Vol XI No 2 April-June
2014
Table 1 not make any significant difference to their knowledge of
Characteristics of study participants ethics.
Specialties Medical Dental
Forty-eight per cent of the medical respondents reported
N % n %
that they would respect the decision of their patients
Number 111 64.5 61 35.5 to refuse
Gender
Female 21 18.9 7 11.5
Male 88 79.2 54 88.5
Year of study
First 42 37.8 29 47.5
Second 42 37.8 12 19.7
Third 27 24.4 20 32.8
Mean age in years 28.1± 29.9±
2.7 3.6

The postgraduates had obtained their knowledge of

bioethics from sources such as the Internet and
newspapers, followed by their undergraduate
training and experience at work. Nearly 68% of
them had not attended any bioethics training
during their postgraduation.

Nearly 98% of the medical postgraduates knew that

their institution had an ethics committee, whereas
only 79% of the dental postgraduates were aware
of this. Most of the postgraduates were not sure if
there was a separate ethics committee for animal
and human research. As for the various roles of ethics
committees, 76.6% and 75.4 % of medical and dental
postgraduates, respectively, felt that the role of
ethics committees is to conduct bioethics
conferences. Nearly the same percentages thought
that the role of these committees is to teach
bioethics to students. Table 3 shows the students’
responses regarding the role of ethics committees.

Nearly 46.9% and 80.3% of medical and dental

postgraduates, respectively, believed that they knew
best, irrespective of the patients’ opinion (Table 4). In
case of any wrongdoing in treatment, 80.2% of
medical and 62.3% of dental postgraduates informed
their patients.

Nearly 83.8% of the medical postgraduates agreed

that informed consent was required for treatment such
as surgery, but did not feel it was necessary for
investigations. The corresponding figure for the
dental postgraduates was 77.1%. Of the medical
postgraduates, 11.7% agreed that ethical conduct is
required to avoid legal issues. The corresponding
figure for dental postgraduates was 16.4%. Overall,
92.7% of the participants had obtained informed
consent for their research thesis. Thirty-five per cent
of the postgraduates correctly expanded the
abbreviations IRB, ERB (ethical review board) and IEC
(institutional ethics committee), while 51% provided
the wrong answers, and 14% reported that they had
not heard of these terms.

The seniority of the students and their gender did

[
 Indian Journal of Medical Ethics Vol XI No 2 April-
Table 2 Lectures/ 6 5.4 2 3.3
Participants’ knowledge of healthcare Seminar
ethics One’s own 16 14.5 1 1.6
reading
Do the participants Medical Dental
know the main Others 50 45 39 64
contents of: N % n % (internet, court
reports,
Hippocratic oath Yes 111 100 54 88.5
newspapers,
Nuremburg code Yes 26 23.4 1 1.6 etc)
ICMR guidelines Yes 26 23.4 13 21.3 Have you attended Yes 36 32.4 20 32.8
Helsinki Declaration Yes 26 23.4 5 8.2 training in bioethics
No 75 67.6 41 67.2
How important is Very 2 1.8 4 6.6
knowledge of ethics Moderately 25 22.5 15 24.5 Have you taken No 3 2.7 5 8.2
to you in your work? informed consent? Verbal 20 18 10 16.4
A little 82 73.9 42 68.9
Signed 88 79.3 46 75.4
Not at all 2 1.8 0 0
Is there an ethics Yes 108 97.3 48 78.7
Do you entertain Yes 94 84.7 56 91.8
committee in your No 0 0 7 11.5
patients’ questions No 17 15.5 5 8 institution? Not sure 3 2.7 6 9.8
during their visits?
How often do you Daily 22 19.8 0 0 Does your institute have Yes 15 13.5 0 0
come across any Weekly 13 11.7 7 11.5 separate committees No 26 23.4 29 47.5
ethical issues? Monthly 15 13.5 15 24.6 for reviewing animal
Not sure 70 63.1 32 52.5
and human research
Yearly 30 27 16 26.2
projects?
Never 31 28 23 37.7
How often do patients Never 5 4.5 0 0 faced with ethical dilemmas, it was the heads of
ask you about their Seldom 39 35.1 17 27.9 departments who were consulted most often (by
diagnosis? Always 67 60.4 44 72.1 62.2% of medical and 55.7% of dental
How often do you Seldom 45 40.5 32 52.5
postgraduates), followed by the students’
discuss your daily supervisors. The ethics committee was the third choice
cases with your Always 66 59.5 29 47.5 (9% of medical and 1% of dental respondents).
colleagues?
How did you acquire During training 29 26.1 14 23
your knowledge of Experience at 10 9 5 8.1
Discussion
bioethics? work
treatment, whereas the corresponding figure for This is probably the first study to assess the
the dental postgraduates was only 27.5%. As can be knowledge, practices and attitudes related to
seen in Table 5, when healthcare ethics among

[
 Indian Journal of Medical Ethics Vol XI No 2 April-June
2014
Table 3 Table 4
Responses regarding ethics committees Attitudes of participants towards healthcare ethics

What do you think an ethics MedicalDental Attitudes Medical Dental p value

committee’s role is? N % N %
n%n%
101 90.75996.7 Doctors know the Agree 52 46.9 49 80.3 0.001
To ensure standard ethical Yes
0023.3 best irrespective of Disagree 59 53.1 12 19.7
practices among healthcare personnel
No Not sure
patients’ opinion
109.300 problems
To advise healthcare personnel
Yeswhen
No they encounter ethical/legal
To advise the administration Not
on ethics 85 76.63862.3 Patient should always Agree 89 80.2 38 62.3 0.011
sure and rules in the institution
To approve and guide research 54.51524.6 be informed of Disagree 22 19.8 23 37.7
21 18.9813.1 wrongdoing 55 49.6 31 50.8 0.87
Agree
Patients’ wishes Disagree 56 50.4 30 49.2
should always be 10 9 9 14.7 0.25
Yes102 91.95285.2 Agree
adhered to 101 91 52 85.3
No0000 Disagree
Not sure98.1914.8 Confidentiality cannot
Yes98 88.35488.5 be maintained in
modern care and 18 16.2 14 22.9 0.27
No0023.3 Agree
Not sure1311.758.2 should be abandoned 93 83.8 47 77.1
Disagree
Yes49 44.12947.5 Consent is required
No18 16.21727.9 only in case of
To settle conflicts between 28 25.2 15 24.6 0.92
Not sure44 39.71524.6 operations and not
professionals Agree
Yes59 53.23455.7 for tests and 83 74.8 46 75.4
No1311.71219.7 Disagree
medications
To settle conflicts between Not sure39 35.11524.6 Certain medical
Yes9081.14980.3
professionals and patients’ relatives practitioners charge
No54.523.3
To teach medical ethics to students more from rich
Not sure16 14.41016.4
patients to 13 11.7 10 16.4 0.38
Yes85 76.64675.4 Agree
To conduct bioethics conferences compensate for 98 85.3 51 83.6
No0023.3
treating the poor Disagree
Not sure26 23.41321.3
Do you agree with
this?
Ethical conduct is
important only
for avoiding legal
action
The “Not sure” category was merged with the “Disagree” category
A p value <0.05 was considered significant

[
Indian Journal of Medical Ethics Vol XI No 2 April-

postgraduates in medicine and dentistry in India. and Dental Council of India, do not prescribe
While the results of the study show that there is a evaluation either by a written or oral examination (4–
difference between the dental and medical 6). Unless such evaluation is incorporated, medical
postgraduates’ knowledge and attitudes, it is not teaching institutions and students will not feel that the
significant. The responses are reflective of categories learning of bioethics is important.
such as different subspecialties, ie medical, surgical,
preclinical and dental, year of study and gender. Bioethics or medical ethics has to be taught by a
specialist in medical ethics. At present, the forensic
Dental postgraduates encounter ethical dilemmas and community medicine faculties teach medical
less frequently than their medical counterparts. ethics and they focus more on medical jurisprudence
This probably explains the difference between the two (4,5). There is a need to encourage training of medical
as far as appreciation of ethical issues is concerned. faculty in ethics or bioethics and eventually, to create
a separate and independent department of medical
The respondents had obtained their knowledge of
ethics or bioethics. Bioethicists from different
ethics from various sources. Though it appeared that
backgrounds, such as the social sciences, philosophy
their postgraduate training was a key source of
and medical sciences, could be faculty members in the
knowledge, it did not contribute more than their
department of bioethics.
experience at work, their own reading and what
they learnt by attending seminars. One reason for It is interesting to note that though both the
the difference in knowledge between the medical medical and dental postgraduates were aware of
and dental postgraduates could be that perhaps the difference between animal and human research
only those who had encountered ethical issues may ethics committees, they did not know about the
have explored other sources of knowledge, such as functions of the ethics committee in their
continuing medical education or workshops. The institution. A similar observation has been made by
undergraduate ethics training does not adequately studies conducted elsewhere (7,13,14). This could
equip postgraduates to deal with the complex be due to the committees’ limited role, which perhaps
ethical issues they encounter in their daily work, which relates only to research ethics and not to clinical
involves direct and often crucial intervention in ethics training.
others’ lives (12). A separate module for bioethics, Most of the research carried out in dentistry is by
accompanied by evaluation, needs to be postgraduates and very few studies are carried out
incorporated into the medical and dental curricula. The by independent researchers or faculty members (15–
present medical and dental curricula, drawn up by the 18). Most ethics committees review the research
MCI proposals, unless the study is funded. Sometimes, a
subcommittee of the main IRB

[
 Indian Journal of Medical Ethics Vol XI No 2 April-June
2014
Table 5 Most of the bioethics expertise in India is
Responses regarding the practice of healthcare ethics concentrated in research ethics, which is different
Attitudes Medical Dental from clinical ethics. The majority of the ethics
n % n % committees focus on the ethical protection of human
When people holding certain beings in research settings. The existence of clinical
religious beliefs refuse to take
ethics committees in hospitals is very important for
blood, undergo surgery or
accept treatment, what is your
stand?
Respect the patient’s 53 47.8 17 27.9
decision
Try to perform the 0 0 2 3.3
procedure
forcibly
Refer to a doctor who 49 44.1 20 32.8
shares
the patient’s beliefs
Any other (specify) 9 8.1 22 36
If you encounter any ethical
problem, who will you
approach?
Colleague 1 0.9 5 8.2
Supervisor 10 9 12 19.7
Head of department 69 62.2 34 55.7
Hospital administrator 5 4.5 2 3.3
Ethics committee 10 9 1 1.6
Professional association 3 2.7 1 1.6
Priest 6 5.4 2 3.3
Textbooks, the Internet 5 4.5 2 3.3
Close friend/family 2 1.8 2 3.3

is formed to review postgraduate research. The data

available in 2003 showed that only 3% of dental
teaching institutions in India (n=292) had effective
research ethics committees (19). This is bound to
result in a lack of knowledge of the functions of
ethics committees among postgraduates. The
master’s programme in dentistry does not have a
mandatory module on bioethics or research ethics (6).
Unlike the dental postgraduates, the medical
postgraduates knew about most of the issues
pertaining to the practice of ethics. The difference
in their responses to issues such as adherence to
the patient’s wishes, confidentiality, the
paternalistic attitude of doctors and the need to
obtain consent for procedures can be traced to
differential training in bioethics.
The majority of the respondents chose to consult
their head of department to resolve their ethical
dilemmas, while the thesis supervisor was the next
preferred option. Another study (7), too, found that
most students preferred to resolve ethical issues with
the help of their departmental heads rather than by
approaching the ethics committee or bioethicist
consultations. The expertise of the heads of
department and thesis supervisors on ethical issues
is uncertain, and it is doubtful whether they would
consult the ethics committee to resolve ethical
dilemmas.

[
 Indian Journal of Medical Ethics Vol XI No 2 April-
moral deliberation on clinical cases. We suggest and law among doctors and nurses in Barbados. BMC Med Ethics.
that healthcare personnel be trained to use 2006;7:E7.
8. Coulehan J. Today’s professionalism: Engaging the mind but
different methods of deliberation on the moral not the heart [Viewpoint] Acad Med. 2005 Oct;80(10):892–8.
issues (20) involved in clinical cases – a standard 9. Cowley C. The dangers of medical ethics. J Med Ethics. 2005
practice in western medical training. These Dec 1;31(12):739–42. doi: 10.1136/jme.2005.011908
methods need the expertise of clinical 10. How did India remain a cultural mosaic? [Internet]. [cited
2014 Mar 9]. Available from:
bioethicists who can form a part of http://wiki.answers.com/Q/How_did_India_remain_a_
comprehensive training in bioethics for healthcare cultural_mosaic
personnel. 11. Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI.
Understanding the clinical dilemmas that shape medical
We could assess the basic knowledge and students’ ethical development: questionnaire survey and
attitudes of postgraduate medical and dental focus group study. BMJ. 2001 Mar 24;322(7288):709–10.
students regarding healthcare ethics in order to
obtain basic information for the framing of a
bioethics course in the medical curriculum. This
study has the limitation that it does not cover a
wider range of postgraduates, as well as the fact
that it is only descriptive in nature.

Conclusion
Medical and dental postgraduates frequently
encounter ethical issues in their training, but lack
the sensitivity to resolve these dilemmas. The
dental postgraduates have less knowledge of
healthcare ethics and the practices related to it,
compared to their medical counterparts. The
incorporation of a bioethics curriculum in the
initial period of the graduation and post
graduation programmes would be beneficial.

Acknowledgements: This study was conducted as part of a

long- term training programme on bioethics (CJ) by the ICMR,
New Delhi and the NIH, USA.
References
1. AIIMS doctor assaulted by patient’s attendants. Times of
India [Internet]. 2012 Jul 19[cited 2014 Mar 9].Available
from:http://articles.timesofindia. indiatimes.com/2012-
07-19/delhi/32745932_1_aiims-doctor-sudipto- ranjan-
singh-attendants
2. Comments. Five junior doctors held for assaulting
patient’s kin. The Indian Express [Internet]. 2010 Sep
28[cited 2014 Mar 9]. Available from:
http://www.indianexpress.com/comments/five-junior-
doctors-held- for-assaulting-patient-s-kin/689199/
3. Now, Delhi hospital hires bouncers to deter attacks.
Indian Express [Internet]. 2012 Sep 10[cited 2014 Mar
9]. Available from: http://m.
indianexpress.com/news/now-delhi-hospital-hires-
bouncers-to-deter- attacks/1000461/
4. Code of Medical Ethics Regulations, 2002. Medical Council of
India
– Notification. [Internet]. New Delhi: MCI;2002 Mar
11[cited 2014 Mar 9]. Available from:
http://www.mciindia.org/RulesandRegulations/
CodeofMedicalEthicsRegulations2002.aspx
5. Ravindran GD. Medical ethics education in India [Internet].
Indian J Med Ethics.2008 Jan-Mar; 5(1):18-19.
6. MDS Course Regulation 2007. Dental Council of India
[Internet]. New Delhi: Dental Council of India; 2007[cited
2014 Mar 9]. Available from:
http://www.dciindia.org/dciregulation_2006_pages/MDS-
Course_ Regulation_2007.htm
7. Hariharan S, Jonnalagadda R, Walrond E, Moseley H.
Knowledge, attitudes and practice of healthcare ethics

[
 Indian Journal of Medical Ethics Vol XI No 2 April-June
2014
12. Aarons DE. Issues in bioethics. Teaching medical ethics to J Dent Res. 2012 Mar-Apr;23(2):293-4. doi: 10.4103/0970-
health professionals. West Indian Med J. 2002 Jun;51(2):59–63. 9290.100447
13. Brogen AS, Rajkumari B, Laishram J, Joy A. Knowledge and 17. Rooban T, Madan Kumar PD, Ramachandran S. Contribution of
attitudes of doctors on medical ethics in a teaching hospital, Indian dental research to the ScimagoTM Database during
Manipur. Indian J Med Ethics. 2009 Oct–Dec;6(4):194–7. 1996–2007: A preliminary report. Chron Young Sci. 2010 Jul
14. Hern HG Jr. Ethics and human values committee survey: (AMI 1;1(3):16–21.
Denver Hospitals: Saint Luke’s, Presbyterian Denver, 18. Dental research in India needs improvements [Internet].
Presbyterian Aurora: Summer 1989). A study of physician [cited 2012 Oct 16]. Available from:
attitudes and perceptions of a hospital ethics committee. http://dental.healthimaginghub.com/portals/ dental-health-
HEC Forum. 1990;2(2):105–25. news-article/articles/2263-dental-research-in-india- needs-
15. Indian Council of Medical Research [Internet]. New Delhi: improvements.html
ICMR;2012 Jun[cited 2012 Oct 16]. Available from: 19. Bioethics Cell at Indian Council of Medical Research. New Delhi:
http://www.icmr.nic.in/ ICMR; date unknown[cited 2014 Mar 9]. Available from:
16. Madan C, Kruger E,Tennant M. 30 Years of dental research in http://icmr.nic.in/ bioethics cell/index.htm
Australia and India: A comparative analysis of published peer 20. Steinkamp NL. European debates on ethical case
review literature. Indian deliberation. Med Health Care Philos. 2003;6(3):225–6.

Publication misconduct among medical professionals in India

DHULIKA DHINGRA1, DEVENDRA MISHRA2

1
Assistant Professor, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, Connaught Place, New Delhi 110 001 INDIA 2 Associate Professor,
Maulana Azad Medical College and Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi 110 002 INDIA. Author for correspondence: Dhulika Dhingra e-
mail: drdhulika@yahoo.co.in

Abstract medical fraternity. With this desire to further

This study was planned as an exploratory study to determine the professional aspirations, misconduct has crept into
extent of occurrence of misconduct in publication (gift-authorship, medical research in different forms. Research
ghost-authorship, falsification of data, fabrication of data, misconduct has been defined as: “fabrication,
plagiarism, and duplication) amongst biomedical researchers. falsification, or
It was a questionnaire-based study, conducted at 9
institutions; 6 medical colleges (4 government-run and 2
private), 1 non- teaching government hospital, and 2 corporate
hospitals, located in northern, central and southern India. The
study was conducted between August 2012 and March 2013. 155
senior residents (<3 years after post-graduation) and young
faculty members (<10 years after post-graduation) with at least
five previous publications were administered a structured
questionnaire, in which no identifying information was
collected. In addition to personal characteristics, the information
collected included their knowledge of publication ethics, their
opinions about the prevalence of these practices among their
colleagues, and details of any first-hand information on
publication misconduct. 155 responses were included for
analysis. 141 (91%) respondents agreed that they had some
knowledge of publication ethics; but only 29% believed it was
adequate. The most commonly observed misconduct was
offering gift authorship, reported by 101 (65%); followed by
alteration of data reported by 88 (56%). Plagiarism was observed
by 83 respondents (53%); while 52 (33.5%) respondents had
observed a colleague’s name being omitted from a paper to which
she/he had significantly contributed. A majority of respondents
in the present study reported witnessing publication misconduct,
thereby revealing the common occurrence of this problem among
Indian biomedical researchers.

Introduction
Publishing research studies has become an important
aspect of career advancement and promotion for the

[
 Indian Journal of Medical Ethics Vol XI No 2 April-
plagiarism in proposing, performing, or reviewing
research, or in reporting research results; fabrication is
making up results and reporting them; falsification is
manipulating research results, equipment, or
changing or withholding data or results such that the
research is not accurately represented in the research
record; plagiarism is the presentation of another
person’s ideas, processes, results, or words without
giving appropriate credit” (1). Research misconduct
does not include honest error or differences of
opinion (1), and implies wilful acts. Apart from this,
misconduct may also be manifested in not
conforming to the authors’ guidelines of a particular
journal and hence offering “gift authorship”
(inclusion among the authors of an individual who
does not fulfil the requirements for authorship), “ghost
authorship“ (non-inclusion of individuals as authors
who played an effective part in the work and were
qualified for authorship), ”duplication“ (publication of
the same paper in different journals with little or no
change at all in its content) (2). It may also involve
“salami”publishing, where authors slice up their
research, carving multiple papers from a single study
with the sole aim of having multiple publications
credited to them
There is paucity of data from India on the
prevalence of misconduct in publication among
researchers. This study was planned to assess the
prevalence of misconduct as observed by young
medical professionals.

Methods
The study was conducted from August 2012 to
March 2013. Initially, detailed discussions on
publication misconduct were held with a few senior
faculty members of medical colleges, having
experience in the field of biomedical publishing. Based
on these discussions, a structured questionnaire was
prepared to elicit responses on publication
misconduct from among researchers. It was pre-
tested on 10 medical researchers and modified where
necessary. The final version was used for