Ethics and Attitude- From Seed to Sapling: Perspective from India

Ethics and attitude are important attributes in one’s life. These values have to be taught from the childhood in schools and should be reinforced during the adolescent phase in college life. Methods to impart these values can vary in different phases of life and in different professions, but it is mandatory that these values have to be given paramount importance in the curriculum of primary education in schools and in the medical undergraduate curriculum. Parents, teachers have to be the role models for the young children to imbibe the right attitude and ethical principles. Two professions (among others) i.e., teachers and doctors require the values of empathy, compassion, kindness and humility. School teachers and medical college faculty have to be the role models for their students. If the former sows the seeds, the latter converts the seeds to saplings. Hence it is important to have structured program in the school curriculum and medical undergraduate and postgraduate curriculum for imparting the ethical principles, values and the right attitude. Realising this need for transformation, Samsidh Group of Schools based at Karnataka state has introduced a structured Character Development Programme intertwined with Academics. MCI has now introduced into its revised competency based undergraduate MBBS curriculum, an AETCOM (Attitude, Ethics and Communication) module where Ethics is taught using several case scenarios. This review article highlights the importance and need of incorporation of Ethics education in school and college curriculum.

Ethical values and attitudes are the principles or standards of behaviour and one’s judgments of what is important in life. They are the non-negotiable reference points in life. The world has always believed that values need to be caught and cannot be taught. All of us are born with certain values and acquire many more from the society as we grow. But that perception has changed now as we have realised that values too can be taught as a skill. Values can be learnt and we need to teach the same for the Gen Next.

When we look at all the professions in the world the only two professions which are called ‘NOBLE’ are ‘TEACHING’ and ‘MEDICAL CARE’. While the teachers take care of the growth and development of mind and emotions-mental growth and well-being, the Doctors take care of our physical growth and physiological well-being. Both Teachers and Doctors require the values of empathy, compassion, kindness and humility. But unfortunately the power they wield over the other lives seems to have made them feel extremely omnipotent and thus lose over that personal connect with those who come to them seeking solace. If the former SOWS THE SEEDS, the latter converts THE SEEDS TO SAPLINGS. Over a period of time, we seem to have forgotten that thought.

After home, the place where the children can be groomed to develop right values/ethics and have a right attitude towards work, others, life etc., is the School. Children enter the portals of the educational institutions at a tender age of three when their minds are in a very malleable state. In the ancient style of learning, the Gurukula system, the children of various social status lived with their teacher, learnt the curriculum along with ethics and values- equality, humility, empathy. There were no separate Moral Science classes like how we find today in the institutions. Somewhere down the line, educational institutions forgot the need for imparting ethics and values, only taught curriculum, appreciated and awarded only the grades. The teachers too became mere content facilitators and score givers rather than care givers. The personal connect seems to be missing now. Parents also expect only academic delivery from school and do not give any importance to the value education. Thus, the value education classes in the schools are given the least priority. Trampling on someone to go higher has become the order of the day. This has led to a lot of disillusionment and disenchantment in the children and we find so many capable youngsters go into depression. Since in the Indian education system children spend 15 years of their impressionable age in schools, the Schools/teachers should look into the Social and Emotional well-being of their students. Ethics can be taught as a way of life by including it as part of the curriculum. Simple practices like showing gratitude to at least one person daily, thanking someone for the help rendered, finding positives in daily activities, treating their peers with empathy, compassion and humility to name a few.

Realising this need for transformation, Samsidh Group of Schools based in Karnataka, India, is doing their bit in inculcating the ethics and values as a way of life. This Samsidh Group of Schools of CBSE schools established in 2009 have classes from kindergarden to high school; have included value based program for all the classes as part of the school curriculum. Every single individual in these schools follow ethical living of ‘Clean and Healthy Mind in a Clean and Healthy Body’. Samsidh group Schools do not believe in mere academic pursuit sans ethics as their vision is ‘Creating 21^st Century Ethical and Happy Leaders.’ These schools have a structured Character Development Programme intertwined with academics. As a first step the schools have identified three main values to instill in children whenever they can, wherever they can and in all ways they can. The values that the schools have chosen are ‘Compassion’, ‘Humility’ and ‘Creativity’. These values have a lot of sub-values in them. They are interlinked too. Humility makes a person polite and kind. Humility practised over a period of time makes one compassionate and a compassionate person will automatically turn into a creative one as the person’s mind is free of unnecessary thoughts.

The schools do not have separate Moral Science classes for the inculcation of these. These are taught through the lessons in every period. The lessons are planned by the teachers in such a way that these values are the also the learning outcomes along with the concept understanding. In addition to the lessons being planned with the value mapping, the schools have their indigenously developed life skill books for children, every day the children recite the Value Anthem during their morning assembly [1], there are value boards on all floors on which they adorn the pictures and writing about the eminent personalities who embody those values, the schools have their value flags, all the assembly programmes are value based exhibiting self-compassion, compassion to others and compassion to nature.

Both the teaching faculty and the student body do a Loving-Kindness meditation for 15 minutes every day and the students are led through a five minute activity at the beginning of every class to become mindful. Loving-Kindness, a well-established meditation practice is known to promote positive attitudinal changes and emotions [2]. The teaching faculty cooks and brings lunch for the support staff every Saturday. Everyone is so vigilant to observe an excellent behaviour of student or a staff and those who exhibit the same are felicitated in the assembly mentioning the kindness act of that individual. Every floor has a value wall where the invaluable value based acts of the children and the teachers are recognised and exhibited. Each one has a Happiness Book in which everyone records: 1) An Act of Gratitude shown to someone daily; 2) The kindness act performed by one daily; and 3) Recording three good things that happens to one daily.

When we look at the other noble profession i.e., the medical field, it has advanced so rapidly that many people in that field are struggling to keep abreast with these revolutionary changes. In the melee, they forget the psycho-social emotions of their patients. The patients have become ‘case studies’ rather than ‘human beings’. Efficiency has taken over empathy and focus has moved from psychological support to physiological support. Here empathy should not be misinterpreted as sympathy. Empathy is to have an understanding of what the person is going through and provide support to that person with understanding. A welcome smile by the doctor can cure half the illness of the patient who is already in a petrified state after undergoing a battery of tests in technologically advanced laboratories. The ominous looking testing machines bring in worry and even panic in the patient. This can be alleviated by the doctors with their compassion and empathy.

Medical profession is the most sought after profession and getting into it and cruising through it is quite strenuous for both mind and purse. The Hippocratic Oath taken upon the completion of the course should always be kept in mind. However, that does not seem to be the case most often than not. This makes one feel the need of having a course on ethics and values even in the medical curriculum. Studies have shown teaching medical ethics to medical students to be effective in improving the level of competency regarding the ethical principles, critical thinking [3,4]. The three domains of learning are Knowledge (cognitive), Skills (psychomotor) and Attitudes (affective); but the third component has been somehow lost out during the instruction. Thus medical ethics should be brought into the forefront and taught to the medical students. There is a need for the medical specialists to become that benevolent locum who used to cure all our ills with a mere smile and a pat on the head.

India has approximately 450 Medical colleges producing the largest number of doctors in the world. The Medical Council of India (MCI), the regulatory body, publishes the graduate medical regulations periodically. Curricular reforms have to be done periodically depending on the needs of the community. Realising the need to reawaken the nobility of the profession, the MCI has introduced into its revised competency based undergraduate MBBS curriculum, an AETCOM (Attitude, Ethics and Communication) module where ethics is taught using several case scenarios [5].

Professionalism is one of the five roles (clinician, leader, lifelong learner, communicator and professional) identified by MCI for an Indian Medical Graduate (IMG) as per the revised Graduate Medical Regulations 2018 (GMR) [6]. In addition to being a competent physician, the IMG needs to be professional described by MCI as the one who is committed to excellence, is ethical, responsive and accountable to patients, community and profession. To impart the values and ethics, MCI has introduced in this new GMR, a structured longitudinal program on AETCOM which is a hybrid problem based learning method. MCI has provided a facilitator guide for implementation of AETCOM in the medical colleges in an uniform and structured way and at the same time giving the flexibility to medical institutions on developing their own approaches based on the criticality and feasibility. Few sample case scenarios on several topics like autonomy, doctor-patient relationship, confidentiality etc., are provided in the facilitator guide. There is also both formative and summative assessment at the end of each professional year as assessment is known to drive learning. MCI has also introduced an early foundation course for a period of one month as soon as the student joins the medical college where all the students are sensitised regarding the five roles of an IMG before embarking on the technical journey.

Ethics education improves the affective domain of learning among the undergraduate medical students. Hence integration of ethics education in the curriculum of schools is to weave a firm moral fibre in the student’s personality to ensure that the students become confident, caring young people. Hope that the proposed incorporation of AETCOM modules in the Competency based undergraduate medical curriculum by MCI will reinforce the ethical values and principles for the students to become caring, empathetic medical professionals.

[1]. http://www.samsidhmlzs.com/about-us/#ourphilosophy  [Google Scholar]

[2]. Zeng X, Chiu CP, Wang R, Oei TP, Leung FY, The effect of loving-kindness meditation on positive emotions: A meta-analytic review Front Psychol 2015 6:1-14.10.3389/fpsyg.2015.0169326579061  [Google Scholar]  [CrossRef]  [PubMed]

[3]. Chin JJ, Voo TC, Karim SA, Chan YH, Campbell AV, Evaluating the effects of an integrated medical ethics curriculum on first-year students Ann Acad Med Singapore 2011 40:4-18.  [Google Scholar]

[4]. Burling SJ, Lumley JS, McCarthy LS, Mytton JA, Nolan JA, Sissou P, Review of the teaching of medical ethics in London medical schools J Med Ethics 1990 16:206-09.10.1136/jme.16.4.206  [Google Scholar]  [CrossRef]

[5]. https://www.mciindia.org/CMS/wp-content/uploads/2019/01/AETCOM_book.pdf  [Google Scholar]

[6]. https://www.mciindia.org/CMS/information-desk/for-colleges/ug-curriculum  [Google Scholar]