Medical ethics, a branch of professional applied ethics and bioethics, is aimed at practically importing ethics into the scope of practice of doctors and medical staff as well as ethical decision making [1]. Medical ethics is a highly structured system towards provision of suitable solutions for ethical problems existing in medicine [2]. Educated people may encounter different demands that should be met through decisions proportional to one’s conditions. A substantial portion of these decisions is based on moral principles learned on one’s path to growth. For instance, students are exposed to situations and demands in various forms in the environment of universities that incline them to display various moral and immoral behaviours. In such areas, collegiate ethics refer to the extent to which one displays one’s actions based on values, such as honesty, relying on personal efforts, lack of abusing the efforts of others, altruistic conduct, and showing respect for others [3,4]. One of the existing views of modern medical ethics is based on four established principles and two subsidiary principles for ethical decision making: autonomy (respecting one’s right to self-determination as well as creating the conditions necessary for autonomous choice), beneficence (actions done for the benefit of others), non-maleficence (non-harming or inflicting the least harm possible to reach a beneficial outcome), justice (social distribution of benefits and burdens), veracity (truth-telling), fidelity (do as you say you will do and respect confidentiality) [5]. To educate doctors and medical staff, such as nurses and midwives, on these principles is of the essence [6].
Having completed their education, it seems that university students adopt certain behaviour and beliefs that diminish their ethical sensitivity to various issues, thereby making decisions difficult for them [7]. In recent years, with the increasing cases of complications about medical ethics, promotion of professional ethics among the medical students, especially those who are in direct contact with patients, has been attached great importance [8,9]. From the viewpoint of Larijani B [10], the neglect of basic education and lack of attention to some necessities in the field of medical ethics have caused concerns in societies, whereby the dignity of the medical profession is distorted and the trust that societies are placing in physicians’ merit and honesty is lessened. That’s why medical ethics are considered an integral component of the medical science, and its recommendations are tailored towards directing conduct and professional methods of the practice of medicine among students [11-13]. Given the importance of the subject and lack of knowledge about the students’ attitude towards medical ethics at Kermanshah University of medical sciences, the present study was conducted. The aim of this study was to investigate the attitude of medical students regarding principles of medical ethics.
Materials and Methods
In this descriptive-correlational study, the statistical population consisted of 380 medical, nursing and midwifery students of Kermanshah University of Medical Sciences in the second semester of the academic year 2014-2015. A sample of 380 subjects [medical students=180 (47.3%), nursing students=113 (29.7%), and midwifery students=87 (22.9%)] was calculated through Cochran’s sample size formula and selected using quota sampling. The inclusion criteria were the subjects’ prior consent to participate in the study, studying in the second semester of academic year 2014-2015. Being in the first year to the fourth year of university for medical students and incomplete questionnaires were excluded from the study. For data collection, a demographic information questionnaire and an attitude measuring scale developed by Motamed-Jahromi M and Dehghani SL in the year 2014, were used [5]. The demographic information questionnaire consisted of questions about gender, age, marital status, and education. Moreover, the validity and reliability of the questionnaire were tested and then confirmed by content analysis and Cronbach’s alpha (α=0.75) [5]. In the present study, the validity and reliability of the attitude instrument were retested. As for validity, the content analysis was applied. The questionnaires were distributed among 12 faculty members, and their corrective feedback was then included. To determine the reliability of the questionnaire, the Cronbach’s alpha was calculated (α=0.82).
The 18-item attitude measuring scale consisted of six principles (three items for each principle): autonomy, beneficence, non-maleficence, justice, veracity, and fidelity, with five-point Likert Scaling (1=Strongly disagree, 2=somewhat disagree, 3=neutral, 4=somewhat agree, 5=strongly agree).
The students could get a score between one to five from each of the questions. To determine the students’ attitude towards each of the principles of medical ethics, the scores on the questions of each principle were summed up and their average was calculated. The score range for each of the principles was between 3 and 15. To determine the students’ total attitude towards the principles of medical ethics, the scores of all questions were summed up and their average was obtained.
To commence the study, the required permits were obtained from the Vice Chancellery for the Department of Research and Technology at Kermanshah University of Medical Sciences. Then, the questionnaires were distributed among the target samples from the schools of medicine, nursing and midwifery. To this end, the objectives of the present study were explained to the target subjects, and they were assured that their information would be kept confidential. Additionally, their informed consent was obtained, too.
Statistical Analysis
Data were analysed through descriptive (frequency distribution, mean, and standard deviation) and inferential statistics (independent t-test and One-way ANOVA). Further, the SPSS Statistics 21.0 version was utilised for data analysis. To compare the scores of attitudes towards medical ethics in terms of the two-faceted qualitative variables, including gender and marital status, the Independent t-test was used, and in terms of the multi-faceted qualitative variables, one-way ANOVA was utilised. Moreover, the intended significance level was less than 0.05 in the present study.
Results
The results showed that 288 (75.7%) students got the highest scores on the principles of medical ethics. The highest and lowest values of attitude towards medical ethics belonged to the principle of beneficence (with a mean and standard deviation of 4.62±0.67) and the principle of justice (with a mean and standard deviation of 4.29±0.80), respectively [Table/Fig-1].
Mean, standard deviation, minimum score, maximum score and respondents’ ranks in terms of the medical ethics principles.
| Statistical indicator variables | Mean±SD | Minimum | Maximum | Rank |
|---|
| Components | Beneficence | 4.62±0.67 | 1 | 5 | First |
| Non-maleficence | 4.57±0.71 | 1 | 5 | Second |
| Veracity | 4.54±0.76 | 1 | 5 | Third |
| Autonomy | 4.52±0.69 | 1 | 5 | Fourth |
| Fidelity | 4.49±0.71 | 2 | 5 | Fifth |
| Justice | 4.29±0.80 | 1 | 5 | Sixth |
The Independent t-test showed a statistically significant difference between the mean scores of students’ attitudes in terms of gender, indicating that the male students’ attitude was better than those among the female students (p<0.05). According to this test, there was a statistically significant difference between the single and married students’ attitudes, indicating that the single students held better attitudes (p<0.05). On the other hand, the students aged under 20 had better attitudes than those aged over 20 (p<0.05). Further, the mean score of students’ attitudes in terms of education was significantly higher in medical student than those among nursing and midwifery students (p<0.05) [Table/Fig-2].
Frequency, percentage, and comparing the students’ mean scores in terms of the demographic characteristics.
| Variables | Groups | Number (%) | Mean±SD | Test Result |
|---|
| Gender | Male | 180 (47.7) | 4.57±0.33 | t=3.132p<0.001 |
| Female | 200 (52.6) | 4.45±0.40 |
| Age (years) | 20≥ | 116 (30.5) | 4.64±0.34 | t=4.667p<0.017 |
| 20≤ | 264 (69.5) | 4.45±0.37 |
| Marriage | Single | 293 (77.1) | 4.51±0.26 | t=173.3p<0.010 |
| Married | 87 (9.22) | 4.47±0.41 |
| Education | Medical | 180 (47.4) | 4.57±0.33 | F=4.991p<0.001 |
| Nursing | 113 (29.7) | 4.43±0.38 |
| Midwifery | 87 (22.9) | 4.47±0.41 |
p-value <0.05 is significant
Discussion
The present work was the first comprehensive study dealing with the students’ attitude towards medical ethics at Kermanshah University of Medical Sciences, as the medical education hub in western Iran. The results of the present study showed that the students of Kermanshah University of Medical Sciences had positive attitude towards medical ethics. From the viewpoints of the authors of this study, this optimum situation causes students to respect medical ethics, and in practice they will be displayed in their conduct. In a study conducted by Motamed-Jahromi M and Dehghani SL, the students’ overall attitudes were reported as positive [5]. In another study done by Osingada CP et al., on Ugandan nurses and midwives, the results indicated that they were in need of training in nursing ethics, and 93% of them held positive attitudes towards continuing education in the field of nursing ethics [6]. According to Laabs C, 89% of Chinese nurses believed that educating all medical personnel on medical ethics was necessary [14]. Buyx A et al., concluded that specialists in medical ethics should shoulder the responsibility of educating students on moral virtues and ethics [15]. The results of a study conducted by Goldie J et al., showed that educating university freshmen about medical ethics was more efficacious in coping with problems than in later years of study [16]. Hariharan S et al., concluded that physicians had more awareness about medical ethics than nurses [17]. However, the results of a study conducted on Nigerian physicians were indicative of their low levels of knowledge of medical ethics [18]. Bazrafcan L et al., showed that there was not a significant difference between the mean scores of nursing students and nursing staff at Shiraz University of Medical Sciences; whereas the nursing students held more awareness in this regard [19]. It seems to the authors of the present article that this positive attitude acts as an important asset for the clinical environment, and all the officials should do their utmost to maintain and strengthen students’ positive attitudes towards professional ethics through various ways, including retraining courses, and they should be prepared in the face of numerous ethical challenges in the future. The highest mean of attitudes towards medical ethics was related to the principle of beneficence. This finding was consistent with the results of studies conducted by Motamed-Jahromi M and Dehghani SL, Reddy RS et al., and Shah N [5,20,21]. Accordingly, any action causing harm to patients should be avoided by physicians and health staff.
Our findings indicated that the lowest mean of attitudes towards the medical ethics was related to the principle of justice. It should be noted that the students had a positive attitude towards this principle, but the score of their attitudes was lower than that of other principles of medical ethics. The students expressed that all patients were treated equally, no distinction was made between them, and the rights of patients were respected in any circumstance. This finding was consistent with the results of studies performed by Motamed-Jahromi M and Dehghani SL, Mallela KK et al., and Deolia SG et al., [5,22,23]. More attention should be paid to the principles of professional ethics, and the importance of following this principle should be emphasised among medical students, especially in public hospitals [7].
Further, the mean score of students’ attitude was significantly higher in medical students than among nursing and midwifery students. This finding was consistent with the results of studies conducted by Motamed-Jahromi M and Dehghani SL [5], Hariharan S et al., Yousuf R et al., Rai JJ et al., Elder R et al., and Zirak M et al., [5,17,24-27]. It is highly probable that a rise in the number of hours spent on the clinical training programs would be efficacious in increasing the medical students’ attitude score.
In the present study, the mean score of attitude among the male students was better than that among the female students. This finding was consistent with the results of studies performed by Motamed-Jahromi M and Dehghani SL [5], Mallela KK et al., Gupta VV et al., and Kandeel N et al., [5,22,28,29]. It seems that male students are more committed with sticking to the principles of medical ethics.
In the present study, the results indicated that the mean score of the married students’ attitudes was higher than that of the single students. This finding was consistent with the results of a study conducted by Motamed-Jahromi M and Dehghani SL [5], whereas it was inconsistent with the results of a study done by Karampourian A et al., [30]. In our view, marriage can cause law orientation and strengthening one’s attitude towards following the ethical principles.
On the other hand, the students aged under 20 had better attitudes than those aged above 20. This finding was inconsistent with the results of studies conducted by Motamed-Jahromi M and Dehghani SL, Hariharan S et al., Deolia SG et al., and Rai JJ et al., [5,17,23,25].
Limitation
The main limitation of the present study was the data collection method, i.e., self-report, which may have affected the results.
Conclusion
All students held positive attitudes towards medical ethics principles. Given the significance of medical ethics, it is suggested that the medical, nursing and midwifery students should be educated on the general principles of medical ethics by means of short-term training programs or workshops.
p-value <0.05 is significant