National pecularities of teaching bioethics in the medical university

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Modernization of the system of professional national education provides for the graduate the formation of an optimal set of professional competencies that meet modern requirements, including international standards, aimed at minimizing the risks of social and professional maladjustment. Despite general trends, medical education is characterized by certain specificity due to the peculiarity of professional activity [1, 2]. It is no coincidence that one of the modern trends in the development of professions, according to Western sociologists, is the phenomenon of the «closure of professional groups», which represents the strong power of the expert group of professionals. The creation of professional communities of doctors according to the criterion of specialization (the Association of Obstetricians, Gynecologists, Pediatricians, Dentists, etc.) indicates the appearance of such a trend in Russia. At the same time, the growth of legal conflicts in medicine is being observed in Russia. It is a negative marker of patients' dissatisfaction with the quality of medical care [3, 4]. Thus, there is a paradoxical situation in the field of health protection: technical equipment and qualifications of specialists are growing, and the number of complaints about medical organizations is not decreasing. At the same time, an analysis of judicial practice on the problem under consideration confirms the opinion of researchers that most legal conflicts in medicine are of an ethical nature [3]. Indifference, rudeness, inattention, lack of compassion and arrogance of a doctor are the starting mechanisms of conflicts, formalized into complaints, claims, lawsuits. In this regard, there is an increasing need for optimizing the bioethical education of doctors, starting with the educational environment of the university, where the formation of both specialized (operational) and socio-psychological competencies determines the starting position of a doctor’s career path. Another aspect of the relevance of ethical education in a medical higher school is the orientation towards international standards of professional education. The integration of bioethical education has long ceased to be a European trend. Currently, the International Network of Bioethics Departments of UNESCO has more than 200 branches, which in addition to Europe and the USA includes the Bioethics Departments of medical higher schools in India, 2 (24) 2019 ФЕДЕРАЛЬНЫЙ НАУЧНО-ПРАКТИЧЕСКИЙ ЖУРНАЛ China, Malaysia, Africa and the Middle East. The UNESCO Social Sector conducts regular workshops to train UNESCO faculty members the bioethics curriculum. The goal of our work is to demonstrate the European experience of teaching ethical values of the profession on a fragment of the UNESCO training course in favor of arguing the need to optimize the bioethical education of medical students in Russia. The main method of the basic course of Bioethics is the method developed by the Chairman of the International Network of Bioethics Departments of UNESCO, the Head of the Department of Bioethics at the Medical University in Haifa (Israel), Professor A. Karmi, for seminars - «YES / NO». In its essence it is the case study which is widely used in Russian pedagogical practice. To demonstrate it, we chose an ambiguous, perhaps, ahead of Russian reality in its relevance, case from European practice on the problem of treating underage patients [5]. Students are invited to discuss the following case: «A 16-year-old S. is diagnosed with bilateral gynecomastia (enlarged breast tissue). To avoid embarrassment and psychological distress caused by the ridicule of his peers, he has never swum, gone to the beach, and he has never played any sports that could expose his problem. Physical education lessons were especially difficult for S. S. exhausted himself with diets that allowed him to lose weight, but the problem of gynecomastia persisted. Thus, S. continued to avoid situations where his condition would have been obvious to others. Moreover, although he was admitted to college, he decided not to attend it, because he did not want to live in a dormitory, where, he expected, he would be mocked. Dr. G., the pediatrician of the boy, recommended an operation to correct the "deformation" of S. and to reduce the patient's emotional discomfort. According to Dr. G., "the procedure was a medical necessity"». Students are asked to answer the question: «Should S. be subjected to surgery to correct a cosmetic defect?» The following answers / arguments are suggested: «No» - Patient S.'s age is still minor, and he does not have to undergo a surgical procedure with certain medical risks; it is not a medical necessity. His difficulties in dealing with his discomfort can be treated with the help of psychological methods. «YES» - The operation is indicated to the patient. This will not only improve his appearance, but also will allow him to return to the life characteristic of a teenager. Students need to discuss and offer other possible answers, determine ethical issues and decide which answer is most appropriate, explaining the reasons. Since the professional activity of a doctor is governed by national law, students are guided to a primary assessment of the legality of a doctor’s actions, and they also predict possible legal conflicts. In particular, a real decision of the national court on the claim related to this case is proposed. The court’s decision: «This case took place in the Civil Court of XXX District, where the patient S.’ father requested compensation from the insurance company for the surgical procedure performed for S. to remove the enlarged breast tissue. The court noted that, although the mastectomy was aimed primarily at improving the appearance, this improvement was not an end in itself. Rather, it was a means to allow S. to live like an ordinary teenager. Analytical determination of whether the operation was optional and cosmetic depends on the size of any "functional defect" caused by patient’s anomaly. The impairment noted in S. took the form of fear of any situation that would lead to the exposure of his physical defect by others. Because of his fear, C avoided many activities related to normal adolescence. While many adolescents avoid activities due to emotional turmoil caused by existing or imagined abnormalities, S.’s gynecomastia was an objective, tangible and unusual source of emotional discomfort comparable to such defects as clubfoot or cleft palate rather than the typical adolescent psychological problems associated with the "big nose" or acne. Recent examples are also objective and relatively common and often lead to cosmetic treatments. The psychological health of anadolescent plays a significant role in determining the extent of the adolescent's reaction to the perceived anomaly. Thus, there may be cases where an anomaly is insignificant (no functional disorders), and for psychological reasons the adolescent’s reaction is serious and irrational. In such cases, psychological treatment should be prescribed, but not surgery. On the contrary, S.'s anomaly was significant, and his reaction to it was rational; apparently, there was no psychological reason for S.'s emotional disturbances. The medical expert acknowledged that "the operation was a treatment that was medically necessary to correct the S.’s anomaly and malfunctioning"». Of course, further discussion on the case under consideration should be managed by a teacher. In particular, a teacher reminds students that, in general, the purpose of cosmetic surgery is to improve the appearance of a person, and not to save his (her) life. However, improved appearance can significantly improve the quality of life and benefit the patient on an emotional level. In the case of a minor cosmetic surgery for underage, it is necessary to examine carefully whether this medical intervention will benefit the child or adolescent, since any operation carries certain medical risks. Quite often, patients, including minors, feel disadvantaged because of defects in appearance, and cosmetic procedures can be beneficial to them, e specially if the potential damage and risks of injury are small. 27 федеральный научно-практическии журнал 2 (24) 2019 The patient is 16 years old in this case, and there is no doubt that he is mentally mature enough to understand the procedures that are offered to him and he cant assess the consequences of such treatment. In this case, the views of the patient are extremely important. In this case there is no description of a specialist’s consultation or the patient’s opinion about undergoing mastectomy, however it is difficult to believe that this was done against his wishes. The problem of providing care to minors is complicated by psychological content, and it is necessary to take into account age, lack of life experience, emotional lability of adolescents. It is necessary to understand the importance that he (she) attaches to his (her) condition (illness), in accordance with his (her) values and feelings. If a minor is old enough to assess his (her) condition fully, and he (she) is aware of the risks of surgery and wants this medical procedure, because his (her) condition (defect) significantly reduces the quality of life, interferes with his (her) daily life and the ability to communicate with his peers -the appointment and performing cosmetic surgery can be considered quite ethical. Despite the fact that at first glance the problem seems far-fetched, and it is unlikely to be often encountered in the Russian medical practice of a pediatrician, discussion of this case raises a number of ethical problems of the doctor’s professional activities, such as the concept of benefit and risk, decision-making autonomy, etc. According to the current Russian legislation, the age of the legal capacity of the patient in the field of health care is 15 years (Federal Law «On the protection of public health in the Russian Federation, № 323 Federal Law 2011»). Thus, a 15-year-old teenager (if he (she) is not registered with a narcologist) can independently give consent to medical intervention. It is the early age of the patient’s capacity that causes a number of ethical problems. We conducted a sociological study of students in the higher medical school on the model of 2nd year students of the pediatric faculty [n = 92, average age (19,2 ± 1,01) years]. The survey was anonymous, while respecting all the privacy standards of the respondents. The goal of the study is to determine the possible ethical risks of professional work of pediatricians associated with the complexity and peculiarity of the patient's age in pediatrics. Students were asked indirect questions. So, the students gave ambiguous answers to the question about the ability of the patient-child to accept their condition and perceive medical intervention. Students are divided into approximately equal groups of 15-27 % of respondents (p > 0,5), fig. 1. Fig. 1. The structure of the views of medical students about the age of availability of medical information* The abscissa is the number of respondents (in%); the ordinate is the estimated age groups of patients. 28 According to the results, students believe that patients-children are able to be aware of their condition (at their level) and should be familiar with treatment tactics already at 6 years old (14,2 %), and only at 16 years old (21,2 %). The obtained data are explainable by the specifics of the patient's age in pediatric practice. Future pediatricians are aware of the need to respect the patient as a person, at any age, and an emotional trauma for the child, which he (she) can have when receives medical information. At the same time, all students are already familiar with the current legislation (the legal basis for the activity was studied in the previous training course), they know the age of the patient’s capacity, but already having little 2 (24) 2019 ФЕДЕРАЛЬНЫЙ НАУЧНО-ПРАКТИЧЕСКИЙ ЖУРНАЛ experience of visiting pediatric departments, they admit that the legal norms are lagging behind modern medical technologies and practices. Thus, students were asked to assess the adequacy of the legal capacity of 15-year-old patients to give written consent to a number of medical procedures (for example plastic surgery). The data obtained are characterized by sufficient student solidarity (Fig. 2). Fig. 2. The structure of the views of medical students about the age of consent of 15-year-old patients to medical intervention in the field of cosmetic surgery* * The abscissa is the number of respondents (in%); the ordinate is the answer options. Despite the fact that 54,3 % of respondents (more than a half) believe that a 15-year-old patient cannot give consent to cosmetic surgery on their own, 27,5 % of students find it difficult to answer (the option «I don't know»), i.e. doubt the possibility of making such decisions at the age of 15. The data obtained demonstrate common ethical problems raised by the case-problem proposed by UNESCO in the course of bioethics. Despite possible discrepancies between the legal norms of national laws, cultural, confessional or atheistic peculiarities of countries, ethical problems of professional activity are of a general nature. Thus, in our opinion, the integration of international bioethics programs in medical higher schools into the national educational practice is necessary. This will allow, within the educational environment of a medical higher school, to form a specialist doctor who is ready to make mature ethical decisions, based on international experience within the framework of Russian reality [6]. The programs on bioethics developed by the International Network of UNESCO Bioethics Chairs are constantly discussed and modernized in the framework of international congresses and conferences on bioethics and health law (14th World Conference on Bioethics, Medical Ethics and Health Law, November 21-24, Jerusalem; 23rd Annual of World Association for Medical Law Congress, July 10-13, 2017 Baku, Azerbaijan) [7, 8].

About the authors

V. V. Shkarin

Volgograd State Medical University

Email: biosoc2008@yandex.ru

A. D. Donika

Volgograd State Medical University

Email: addonika@yndex.ru

M. V. Reymer

Volgograd State Medical University

Email: mashaliru@yandex.ru

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