Medical Ethics Education in the U.S. and Around the World
Exploring the status of global bioethics standards
by Shari Falkenheimer, MA (Bioethics), MD, MPH
Today's Christian Doctor - Spring 2014
Do you feel prepared to discuss bioethical issues in conversations with your colleagues? I don’t recall receiving any bioethics training in medical school. Indeed, I first heard the Hippocratic Oath at graduation and chose not to take it since I thought it would require me to swear an oath to the Greek gods! Later I felt woefully unprepared for end-of-life decisions in my internship. This led me to eventually seek formal education in bioethics.
Education in bioethics is something all healthcare professionals need as the rapid development of new technologies in the last century poses new challenges and questions with respect to human research and patient care. The ability to transplant organs and the inadequacy of the supply to meet the demand required ways to decide who would get the limited number of solid organs available. The legalization of abortion in several countries challenged the value of human life in the womb and raised the new concept of "personhood" and who warranted it. Pressures to assist infertile couples changed the process of conception for many and often brought additional persons in the form of egg and sperm donors and/or surrogates into the process of birthing a child. The mapping of the human genome and advancing genetic techniques brought the hope of re-engineering defective genes and enabling parents to select the characteristics of their children. As a result, children are increasingly viewed as something to be designed, rather than gifts to be received and welcomed with gratitude. And those with genetic abnormalities, such as Down’s Syndrome, are increasingly judged unworthy of birth. The desire to enhance human capabilities and extend human life on earth through artificial means has led to articulation of a Transhumanist Manifesto1 and the desire to free human intelligence from the "limitations" of embodiment. The ability of humans to control a computer cursor through a direct brain-computer interface is a move in this direction as is the desire to find a way to be continually connected to the internet.
Films, television shows, video games and the media have long explored these issues. They are likely the most influential educators on bioethics both in the U.S. and internationally as they communicate values directly to the emotions, often without conscious evaluation of their validity. At times, thoughtful productions have educated people on important considerations and risks of this technology, but others have advocated their uncritical application and desensitized viewers to their downsides. For example, Intelligence, a new television series which premiered in January, revolves around a human with an implanted, super-computer memory chip keeping him continually connected to all parts of the information grid.2
Why is bioethics education important?
Many U.S. universities responded to the onslaught of bioethical issues late in the last century by establishing courses and graduate degree programs in bioethics. Master’s and/or doctoral degrees in bioethics are offered in the United States, Canada,3 Australia,4 New Zealand,5 Pakistan6 and the Netherlands.7 In the rest of the world, bioethics programs appear to be rare. However, many nations, including the U.S., integrate courses in bioethics into healthcare professional training and/or offer certificate, diploma and bachelor’s level training.
For more than two millennia, the tenets of the Hippocratic Oath have been the foundation of Western medicine. The Oath is the basis for the trust relationship between the doctor and the patient. Before Hippocrates, a healer might help or kill a patient. Doctors who took the Oath swore to work only for their patients’ best interests and never to harm them. In it, the doctor forswears participation in abortion and euthanasia, even if requested. Since World War II, the foundational values of the Oath are increasingly being challenged and violated.8 CMDA CEO Dr. David Stevens believes, "Our cherished and proven bioethical principles are being eroded and discarded and we need, as Christian doctors, to stand in the gap and be voices of righteousness ... To do that, people need training and experience." That’s where bioethics education comes in.
Of course, as believers, we cannot take all that we read and are taught in bioethics programs at face value. Like the Bereans, we must examine them in light of scriptural teachings and principles, discarding those things that violate God’s Word. And Christian bioethics programs play an important role in helping us do that.
How is Christianity influencing bioethics education around the world?
Christian organizations have been active in bioethics education nationally and internationally. The Roman Catholic Church has a long history of well-thought-through social doctrine9 and positions on issues related to human life. The most well-known are the writings of Pope John Paul II, such as Evangelium Vitae (The Gospel of Life). The Catholic Church also has many universities which teach on these positions. Its Georgetown University is one of the leaders in bioethics education in the United States with both its MA and PhD programs in the field. Until his recent death, its highly respected and widely published physician and faculty member Dr. Edmund Pellegrino, who also taught in the bioethics program at Trinity International University (TIU), stood firmly for Hippocratic ethics.
In 1993, CMDA leaders participated along with leaders of other Christian organizations and universities in a meeting called by Trinity Evangelical Divinity School professors Nigel Cameron and Harold O.J. Brown to discuss forming what became the Center for Bioethics & Human Dignity at TIU. It also led to the establishment of its master of arts in bioethics. TIU remains the first and only evangelical university in the U.S. to offer this degree. No protestant university offers a bioethics PhD, although some grant PhDs in philosophy or theology which could be completed with concentrations in bioethics. CMDA leaders, including CMDA’s CEO Dr. David Stevens and Ethics Committee Chair Dr. William Cheshire, were among the early graduates of the TIU master’s in bioethics program. In addition, to increase the availability of bioethics education to CMDA members, TIU partners with CMDA each year to offer a master’s level bioethics course at the CMDA National Convention. CMDA has also been a co-sponsor of the annual CBHD bioethics conference, which can be taken for master’s credit or CME. Two additional bioethics centers, the Center for Bioethics and Culture in California and the Tennessee Center for Bioethics and Culture, were started by graduates from the TIU program.
Over the years, numerous CMDA physicians and at least one dentist have completed TIU’s master’s in bioethics, allowing them to effectively put their knowledge into practice on clinical ethics committees and by teaching, speaking and writing on bioethical topics from a biblical perspective. CMDA members also teach bioethics at medical schools and universities such as Cedarville University, Loma Linda University, TIU and other secular universities.
A few international colleagues have been part of the TIU residential master’s in bioethics, but recent initiatives are making biblically-based bioethics education more available to Christians internationally. In 2013, the TIU program became available almost completely online, which should greatly facilitate its accessibility to Christians worldwide. CBHD’s visiting scholar program of scholarships for international colleagues enables them to participate in its summer bioethics conference and courses, as well as to consult with bioethics leaders in the U.S. The Center has also co-taught master’s level bioethics courses in partnership with Emmanuel Hospital Association in India. EHA recently established the first bioethics center in its nation of 1.3 billion people, where female feticide, unethical medical practices and commodification of healthcare are on the rise.10 The Centre is the result of a joint effort by 15 Chris-tian organizations from throughout the country and is working to educate Christian healthcare professionals and ethicists to promote the sanctity of life and ethical healthcare practices in India.
Another Christian bioethics teaching effort is the work of Partners in International Medical Education (PRIME) in the UK. PRIME brings Christian teaching teams to other nations and focuses on the teaching of whole-person medicine.11 It has developed an excellent teaching resource based on biblical values as well as an international network of teachers to bring this knowledge to many other nations with the goal of increasing physicians’ practice of compassionate and spiritual care of patients.
U.S. CMDA members are also making valuable contributions to bioethics education in-ternationally. CMDA Trustee Dr. Robert Orr of Loma Linda University is internationally recognized in bioethics and has taught in many countries. He believes, "Teaching bioethics internationally provides many opportunities to discuss issues that may be viewed differently in different cultures (e.g., autonomy, professionalism) and those that have a scriptural basis for uniformity (e.g., the sanctity of human life, compassion)." Many CMDA members have taken their training to other parts of the world through speaking at and participation in international conferences, meetings with Christian Medical Fellowships in other nations and through Medical Education International’s (MEI) teaching teams.
MEI teams have taught on bioethical issues in places such as Ch*na, Eg*pt, Ind*nesia, Jamaica, Kaz*khstan, Kenya, Kos*vo, Mace*onia, Moldova, Mongolia, Se*bia, the Ukraine and the United A*ab Emir*tes. For three years, MEI furnished keynote speakers for the Jamaican CMDA’s bioethics conference. This conference also attracts non-Christian healthcare professionals who seek to fulfill their bioethics CME requirements. Dr. Doreen Brady West who invited the MEI speakers to Jamaica said, "These visits have increased the awareness of doctors and medical students to the Christian perspective on current contentious ethical issues, have served as outreach to the Buddhist doctors (their medical association officially approved the CMA ethics meetings) and definitely provided the impetus for [her] to begin studies towards a master’s degree in bioethics." She hopes to use this training not only to teach medical students and residents but "to start a Caribbean Bioethics Coalition to provide advocacy and education on sanctity of life and defense of traditional family which are the pressure points of secularism in our region."
MEI educators have taught on a wide range of topics including: Hippocratic ethics, clinical medical and dental ethics, professionalism, ethical issues in science, the patient-physician relationship, healthcare delivery, human subject research, genetic screening, maternal-fetal medicine, reproduction and artificial reproductive technologies, human enhancement technologies, allocation of limited resources, mandatory vaccination, end-of-life and contrasts between Eastern and Western medical ethics. MEI educators have also taught on biblical principles related to and medical identification of victims of human trafficking and on the benefits of using questions in teaching bioethics.12
As Dr. Orr’s comment alluded to above, in other nations, we often find quite different views on bioethical issues than in the U.S., even among believers. Dr. Christine Toevs, a trauma surgeon who spoke on informed consent in Mongolia commented, "There is a huge difference between Western and Eastern Medicine ... application of paternalism and how much we tell patients. I emphasized everyone is made in the image of God and each person has inherent value and needs to be included in discussions of procedures and what will happen to them. Although the audience was Christian, they had not thought about the application of Christian principles to talking with and informing their patients."
Bioethics can also open opportunities to discuss the underlying reasons we believe something is or is not ethical. An MEI team leader who has taught ethics in four Muslim nations learned that, "In all of [these] countries no one would turn off a respirator once it had been started ... in Egypt it was actually against the law ... It did make an opening where one could present ... Judeo-Christian views without being confrontative." Just last fall, an MEI team member gave a plenary session on Hippocratic ethics and its prohibition of participation in abortion at a conference for international students studying medicine in the Ukraine. Later in the conference, the speaker was approached by two students from Muslim countries for counsel on how to balance this knowledge with the risk of honor killing of an unmarried pregnant woman in their culture. MEI teaching in Jamaica and S*rbia is helping them stand against the pressures of abortion and physician-assisted suicide. In another part of the world, the dean of a national medical school expressed a desire for bioethics education to help improve professionalism in the face of unacceptable on-duty behavior by medical personnel.
Much more needs to be done to increase the depth and extent of bioethics education worldwide in this constantly changing field and to be sure the Christian and Hippocratic perspectives are heard and respected. But much has been and continues to be accomplished by Christian healthcare professionals in the U.S. and abroad to spread biblical principles of bioethics, preserve the Hippocratic ethos and model Christ and whole person medicine, whether teaching bioethics or living it out in the clinical care they provide.
1 http://www.singularityweblog.com/a-transhumanist-manifesto; accessed December 19, 2013.
2 http://www.cbs.com/shows/intelligence/video/DF87B5F4-64C1- 3C3B-0CC75E476D73390E/intelligence-prepare-to-upgrade/; accessed December 20, 2013.
3 http://www.gradschools.com/program-details/universit-de-montral/ programmes-de-biothique-bioethics-programmes-248240_1?pos=21; accessed January 4, 2014.
4 http://www.gradschools.com/program-details/university-of-sydney/ sydney-bioethics-program-247068_2?pos=12, http://www.gradschools. com/program-details/monash-university/bioethics-212048_2?pos=42, http://artsonline.monash.edu.au/bioethics/phd-in bioethics/; accessed January 4, 2014.
5 http://www.otago.ac.nz/bioethics/postgraduate/qualifications/index. html and http://www.gradschools.com/program-details/university-of-otago/bioethics-and-health-law-233351_1?pos=10; accessed January 4, 2014.
6 http://www.gradschools.com/program-details/aga-khan-university/ bioethics-250984_1?pos=22; accessed January 4, 2013.
7 http://www.gradschools.com/program-details/radboud-universiteit-nijmegen/bioethics-234446_1?pos=39; accessed January 4, 2014.
8 Cameron, Nigel M. de S. New Medicine: Life and Death after Hippocrates. Wheaton, IL: Crossway Books, 1991.; May, William F. The Physician’s Covenant: Images of the Healer in Medical Ethics The Physician’s Covenant. Presbyterian Pub Corp, 2000.
9 http://www.vatican.va/roman_curia/pontifical_councils/justpeace/ documents/ rc_pc_justpeace_doc_20060526_compendio-dot-soc_en.html; accessed December 20, 2013.
10 http://www.eha-health.org/services/thematic-services/research-bioethics.html; accessed January 4, 2013.
11 http://www.prime-international.org.uk/home.htm; accessed December 20, 2013.
12 Falkenheimer, Sharon A. Effective Engagement in Global Bioethics: The Benefits of Questions. Ethics & Medicine 28(1), Spring 2012, 19-33.