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Indian Journal of Medical Ethics Vol VI No 2 April-June 2009

COMMENT

Teaching ethics in an unethical setting: “doing nothing” is neither


good nor right
SUBRATA CHATTOPADHYAY
Departmento di Filosofia, Universita Degli Studi di Padova, Piazza Capitaniato 3, 35100 Padova, ITALY email: linkdrsc@yahoo.com

Abstract educators may be sceptical about the need to teach


Does it make sense to teach ethics in an unethical setting? ethics. The problem is not about how to develop an
Should teachers who work in morally compromised ethics curriculum, because to develop an ethics
institutions make an effort to introduce biomedical curriculum may be challenging but it is certainly
ethics to the curriculum? Using the medical establishment doable. So, what is so special about ethics education?
in contemporary India as a window to understanding the Why does the teaching of ethics in an unethical setting
challenge of teaching ethics in an unethical setting, this appear to be so problematic? And, more
article attempts to discuss issues pertaining to ethics
education in institutions with a weak ethical climate.
Putting ethics into practice is the essence of ethics
education and in this the integrity of the teacher and the
moral environment of the institution play significant
roles. The choice or decision to “do nothing” is not
necessarily value neutral; rather, given the deteriorating
ethos in medical establishments, it goes directly against
the principles of “doing good” and “avoiding harm”.
Practitioners of the art of healing have a moral
obligation to protect, uphold and nurture the cause of
ethics in medicine. Teaching and learning ethics
should be initiatednot pushed asideeven in unethical
institutional settings.

Introduction
Does it make sense to teach ethics in an unethical
setting? Should one ignore or foster ethics in an
unjust environment? Why bother about ethics or
morality when the medical establishment does not
care much about them?

These are important questions for conscientious


medical teachers and practitioners who work in
morally compromised institutions. In an international
meeting on bioethics, the issue of teaching
bioethics in an unethical setting came up for
informal discussion among participants from some
Asian countries (1). Of course, it would be nice to be
engaged in ethics education if biomedical ethics
was given due recognition and the moral
environment of the institution was something to be
proud of. Unfortunately, that is not the case at
present in several countries, including India, where
medical establishments often tarred by published reports
of corruption neither encourage nor take pride in good
ethical practices of medicine. Worse, they seem to
have lost their moral compass (2, 3). In this complex
web of unwelcome realities, even well meaning
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importantly, what should be our vision in such a
situation? This article delves into some concrete
realities of the Indian scenario and attempts to
address the question of why teaching and
learning of ethics should be initiatednot pushed
asidein an unethical institutional setting.

Medical ethics in contemporary Indiabetrayal of


moral heritage
In ancient times, India had developed her own
indigenous traditional system of medicine,
Ayurveda, and had an elaborate code of medical
ethics that surpassed the Hippocratic Oath in
both “eloquence and moral idealism” (4). Modern
western medicine was introduced into the Indian
sub-continent in the early 19th century by the
British colonialists (5). For socio- political reasons,
Ayurveda was segregated from modern western
medicine during the British era and, significantly,
that colonial legacy continued even after India’s
independence in 1947 (6). Notwithstanding
considerable progress in socio- economic
conditions and the quality of healthcare facilities,
gross disparity continues to exist in health status
indices and in access to healthcare between rural
and urban areas of India (7). With the private
sector contributing 75% of the total health
expenditure and a well-developed system of
modern medicine in cosmopolitan cities, India has
been a destination for “medical tourism” that is
forecast to become a $2.3 billion business by 2012,
while India’s poor continue to suffer second-rate
healthcare (8).

For many Indian physicians, medicine is a vocationa


callingto serve the needy and vulnerable in
resource-poor settings, particularly in remote
areas. The ethos of the Indian medical
establishment, however, has changed for the
worse in recent decades. Medicine, historically
considered a noble profession, has become a
moneymaking enterprise capitalising on human
suffering. Sadly, reports of academic dishonesty,
gross professional misconduct, moral decay and
corruption are commonplace in Indian medicine
(3, 9-11). Statutory bodies and professional
organisations have not only failed to promote a
culture of humane medicine, they lack moral
vision, positive will, and effective mechanisms to
regulate unethical practices in medicine which now
fall under the purview of the Consumer Protection
Act, 1986. The extent of moral degeneration and
abuse of power can be gauged by the fact that the
president of the Medical Council of India (MCI, the
Indian equivalent of the General Medical Council,
UK) was removed from his post by an order of the
high court on charges of corruption (10,11).

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Indian Journal of Medical Ethics Vol VI No 2 April-June 2009
with a myriad life issues.
Few will disagree with the statement that the Third, who will be the preferred teachers in ethics
curriculum of Indian medical colleges is out of touch education? Apart from the uniqueness of ethics as a
with the reality of healthcare needs of the Indian discipline or field of study, the role of teachers in
people. Bioethics is virtually non-existent in India, ethics educationeither as role models or as
both as a subject of academic pursuit and as a mentorsseems to be of paramount importance.
platform for public debate on science and medicine. While attributes like conscience, integrity, and
In the land that gave birth to the Vedas and character of the teacher are undoubtedly important
Upanishads, there is no place for philosophy, spirituality, in education, these qualities are required for
ethics, or the humanities in the medical curriculum. Thus, instruction of ethics. For example, it is
except for a very few religious minority institutions,
medical students in India get almost no exposure to
humanistic, philosophical or spiritual worldviews
during medical education and training. For all
practical purposes, ethics education in Indian medical
colleges is limited to learning bedside manners and a
few neglected lectures as part of medical
jurisprudence.

Ethics is not like differential calculus


Perhaps the first issue to address is the rationale
behind the teaching of ethics: can ethics be taught?
The philosopher Socrates argued in favour of
teaching ethics. His argument was unequivocal: we
need the knowledge of what we ought to do.
Knowledge can be taught, thus the knowledge of
what we ought to do - ethics - can also be taught.
Buddha not only taught ethics to his disciples, but
also inspired them to live ethics. For millennia, in the
Indian sub-continent, the satguru or acharya (the
master) gave lessons to their pupils in all spheres of
life to live ethically. Since theories of moral
development were formulated in the early part of the
last century, educators mostly have agreed that
ethics can be taughtmaybe to varying extentwith
moral development taking place in successive
stages (12).
Second, is ethics like any other subject of study? In
what ways is ethics different from other subjects?
The teaching and learning of ethics has some
unique characteristics that deserve thoughtful
consideration. Morality is intertwined with what makes
us humanmoral development is not necessarily
always related to formal school or college education.
Thus, a person without any formal education may
have sound moral judgements about right and
wrong and live perfectly well as a moral person. The
purpose of ethics education in healthcare institutions
is to emphasise the moral nature of the art and
science of medicine and sensitise the learner to
ethical issues. Ethics is not something like, for
example, differential calculus that one may learn in
school or college only to forget it in later years while
doing an office job. Moreover, learning the subject
matter of ethics does not end in good grades in
transcripts or college graduation; rather, the essence
of learning ethics lies with ethical practicebeing
ethicalapplying ethical reflection and analysis to deal
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nothing amidst an outbreak of an epidemic, is, in
difficult to imagine that a teacher with a proven track fact, doing something that kills human beings.
record of unscrupulous activities can teach ethics. To Similarly, doing nothing when ethics in medicine is
teach ethics you need teachers who value and care for needed perhaps more than ever kills the moral
ethics in individual and collective life, practise ethics in nature of medicine.
their academic and professional worlds, and in a way act
as role models or mentors for the learners. Ethics education, wherever it occurs, necessarily takes
place in a less-than-ideal context, for there is no need for
ethics education
The ethical climate and the hidden
curriculum of the institution
What about the context in ethics instruction? Does
the workplaceor, more specifically, its moral
environmentplay any role in the teaching and
learning of ethics? If yes, how?

Education is a human praxis and thus quite naturally


ethics education takes place not in a vacuum but in
the thick of concrete realities. Ethics curricula in
healthcare professions may thus differ in aims and
methodology of instruction, depending on context
and needs (13). The importance of the ethical climate
of the institution can best be understood if we ask
ourselves whether an ethics department can be funded
by “black” money or patronised by an institution that is
part of the illegal “kidney bazaar”. I doubt it. It is very
unlikely that future healthcare professionals will take a
serious interest in ethical reflection and analysis if the
workplace reflects such an immoral environment. Thus,
the morally lax atmosphere of an institution would be a
deterrent in learning ethical behaviour and practice.
Educators have also drawn attention to a
phenomenon called the “hidden curriculum” in which
students learn more about acceptable and
unacceptable behaviour from institutional
arrangements and non-verbal cues in the classroom
and on the ward (14). The hidden curriculum, more so
in an institution of questionable moral integrity, may
pose a serious challenge to ethics education. It is not
surprising, therefore, that some well- meaning teachers
will be sceptical about the rationale behind instruction
of ethics in an unethical institutional set-up. Does this
mean that we should stop thinking and “do nothing”
in so far as ethics education is concerned? Is doing
nothing a morally sound choice?
While the lack of attention to ethics education in
India is understandableafter all, what good does it do
to teach ethics in a setting marked by corrupt
behaviour and injustice?it is unjustified and a
terrible mistake for medical educators to resign
themselves to morally questionable practices in
healthcare, for a number of reasons.

Doing nothing is an active decision


of moral significance
The choice to do nothing is not necessarily a value-neutral
one; it also has a moral dimension, more so when
doing something is needed to do good and avoid
harm. The apparently harmless position of doing

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Mara, the Evil, Buddha replied, “There will be some who


in an ideal society, whatever that may mean. It is will understand.” The spirit of this powerful saying gives
also true that the noble aspiration of medicineto do one endless hope. When a clinician starts managing a
good and serve human beingsinfluences the mental patient, there is hope that the patient will recover. Hope
landscape of learners in myriad ways. Thus, an is something that keeps us moving when things are not
institution marked with moral integrity is certainly all right. Historically, medicine is considered the art of
preferable, but not absolutely required, for teaching healing and hope has justifiably been treated as a
ethics in medicine. Further, the role of the hidden cardinal
curriculum must be acknowledged, but need not be
exaggerated, because in an unethical setting there
may not be anything that is actually hidden.
The choice of doing nothing is also unrealistic and
impractical. It meansin realityleaving things as they
are in medical education and practice. On the face
of it, this means that no educator would take any
serious interest or initiative in ethics education and
nobody would put the agenda of ethical values and
principles on the table of academic medicine. In
that scenario, either we will all be united in
hopeless misery, or we will hope that things will get
better in the future, without knowing how and why.
The first option of endless darkness does not merit
any comment. The second, more hopeful, option is
wishful thinking, if not daydreaming, that our
students will somehow be gifted with moral values
and principles and they will simply be inspired to
practise medicine ethically even in a morally
compromised institution. It means that in the absence
of any ethics education, our future healthcare
professionals will value, appreciate, and learn ethics in
medicine - presumably from nowhere and nobody.
The future in that scenario, not very arguably, will
be horrendous. With nothing to counterbalance the
unethical tilt, and practically no agency to safeguard
the moral premise of medicine within the profession,
medical educators and practitioners will
increasingly behave like merchants of immorality.
Professors of medicine will stock black money,
surgeons will be involved in organ trade, doctors
will keep on taking kickbacks (“percentage” or “cut-
money”), and yet, amidst all these medical maladies
plaguing the profession, our students, the future
healthcare professionals, will remain “pure in character”
as promulgated by the MCI code of ethics (15). This kind
of pure in character product, manufactured in the process
of doing nothing, will perhaps increasingly appear in
persons like the former head of the MCI who was
stripped of his post for corruption. Doing nothing is
potentially - no, not potentially but actually - the
prescription for doom, crafted by inaction on our part
and approved by the apathy of our medical council
and professional associations.

There will be some who will understand


What is the point of telling people the noble truth
when they seem not to care and are busy with
mundane things? Faced with this question from
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Indian Journal of Medical Ethics Vol VI No 2 April-June
2009
formulate guidelines, set the framework and
foundation of ethics education, and push for its
virtue of medicine (16). The same is true for ethics inclusion as part of the medical curriculum. There are
education. No matter what the nature of ethics many possibilities we can explore once we are
practised in an institution, the possibility always convinced that it is necessary to pursue ethics
exists that there are people who are concerned education in spite of, and amidst, unethical
about ethical lapses and who would like to see a institutional settings.
change in the less-than-ideal ethical climate. The
humble but spirited efforts of these Let us not mince words. The point issimplysmall
conscientious physicians and educators may things also count, and what we do also matters.
gain momentum and may make a difference to Whether one believes in the doctrine of Karma, or
the ethos of medicine. These medical the western philosophy of consequentialism, the fruits
practitioners and educators may not necessarily of our thoughts, words, and actions
articulate their thoughts and ideas in bioethical
jargon like “deontology” or “utilitarianism”, but
they have the potential to pioneer a positive
change in the moral environment of institutional
medicine. This author is respectfully aware of a few
medical teachers who did not draw black money as
part of their salary, refused to fabricate patient
records to “fool” the MCI inspectors, and declined
the request of the management to pass unworthy
students in professional examinations. Spirited and
not inconsequential efforts by such people may go
a long way in sensitising students to issues of
ethical significance and pave the way for ethics
education.

Educators need not wait for significant structural


change in the medical curriculum. They can use
existing opportunities such as tutorials, seminars,
journal clubs, and clinical grand rounds to touch
upon important ethical issues in medicine and
engage students in ethical reflection and
analysis. For example, the problem of cheating
in medical school can be raised for discussion with
students. A basic science teacher can touch upon
ethical issues arising out of biomedical research
with stem cells. A pharmacologist can discuss
ethical concerns with reference to drug trials.
During clinical rounds, ethical- social-legal issues
can be discussed along with clinical aspects of
patient care. A specialist in critical care medicine
may also engage students in discussions on
ethical decision-making in end-of-life care.
Neuroethicsthe neural basis of ethical
behaviourmay be on the agenda of seminars on
recent advances in neurosciences. Organising and
attending seminars, clinical meetings, and journal
clubs gives an opportunity to raise important
issues pertaining to ethics in medicine. In an
unethical setting even a small number of
committed individuals may thus function as the
nucleus of a core group to further the ethics
agenda. Many senior faculty members or those
working in administrative posts can also walk the
extra mile to put ethics back on the agenda of
academic medicine. Sustained initiatives of this
nature are likely to gain momentum in due course.
The Indian Journal of Medical Ethics, for example, can
organise a platform for interaction and exchange
of ideas among educators interested in ethics
education. The National Bioethics Conference can
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Indian Journal of Medical Ethics Vol VI No 2 April-June 2009

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University

opportunities for internships in ethics


Centre for Studies in Ethics and Rights (CSER) was set up in January 2005 by the Anusandhan Trust (AT) to
undertake research in ethics and human rights.
CSER is engaged in research and training in ethics, rights and capacity building of voluntary organisations/NGOs.
It organises training programmes in various fields, including bioethics, ethics in clinical trials and programme
management. Our priority areas include professional ethics, research bioethics, public heath ethics, development
ethics, law, human rights and ethics, comparative ethics, and exploring linkages between the discourses in
ethics and rights in the Indian context.
CSER faculty members include social scientists, medical professionals, bioethicists and public health
practitioners. These include Dr Amar Jesani, Dr Nobhojit Roy, Dr Padma Prakash, Ms Padma Deosthali,
Ms Sandhya Srinivasan, Ms Pranoti Chirmuley and Ms Neha Madhiwalla.
CSER offers internships to graduate, postgraduate and doctoral students from the fields of medicine, law, social
work, social sciences and others who are interested in these areas of study. Faculty at CSER offers mentorship
through out the internship period and resources like; libraries and documentations centres of CSER and
CEHAT in Mumbai can be accessed by the intern. Interns will be expected to do a time-bound project or
assignment to the satisfaction of CSER faculty. Certificates of experience will be provided to the students.
The internships are for a minimum of six weeks and can extend to six months. An intern from Mumbai
and outstation who has an accommodation facility in Mumbai will get Rs. 8000/- as stipend. Any Intern from
outstation who does not have any accommodation in Mumbai will get Rs.12, 000/- as stipend. CSER will
offer partial support. CSER will cover the costs of any local travel and related expenses incurred by the
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intern while doing project-related work.
Interested applicants can email Mr Shinde [mahendra.cser@gmail.com or (call +91-22-2668 1568)], with
updated resumes, areas of interest and contact details. A faculty member will follow up with the applicant.
Interns will be selected based on their interests, skills, experience and requirement of the centre.

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