ETHICAL PROBLEMS OCCUPATIONAL GROUPS: VALUE ORIENTATIONS OF THE FUTURE DOCTOR

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Introduction. At the present stage of advancement in medicine and healthcare the topicality of forming a bioethical outlook of the Russian medical workers and the relevance of elaboration on its basis of practical skills of making moral decisions has significantly increased. A number of authors write about it. Siluyanova I.V. [9, 10, 11], Sedova N.N., Sergeeva N.V. [7], Svetlichnaya T.G., Chumakova G.N., Stepanov E.S., Larionova N.S. [6], Bermant - Polyakova O.V. [1], Donika A.D. [2, 3] et al. are among them. The adoption of moral decisions represent the intellectual phase of moral choice, a rational procedure of moral consciousness of the person performing the selection of action on the basis of moral norms and values. Successful mastery of the abilities to the implementation of moral actions and relations is an indispensable condition of formation of professionally significant competences at undergraduate stage of learning basic educational programs of higher medical education. The foundation of morally responsible actions and relationships is a moral consciousness that can be implemented in bioethical worldview. A bioethical worldview refers to a person's attitude toward nature on the basis of universally recognized rules and norms of morality. The formation and development of bioethical worldview occurs throughout the undergraduate stage of professional preparation of future physicians, starting with their mastering of educational material of the discipline of "Bioethics". This is because "today it is important not only creating new regulations, how much harmonization and clear interpretation of the already existing" [12]. The urgent 29 need for deliberate creation of bioethical worldview of the doctor, "which will combine a professional and moral components of his personality" [4], justifies the need for the explication of the initial moral views of students in medical school. Their study was conducted for the purpose of us medical sociological research. Methods. The subject of study was the moral and ethical views of students before and after the development of the discipline of "Bioethics". The study tool provided the statistical map "Questionnaire for the study of bioethical views of students in medical school", developed on the basis of the methodology proposed in 2002 by Lyaush L. B., Saburova, V. I., Siluyanova I. V. and Sushko N. A. - the employees of the Department of biomedical ethics of the Russian state medical University in Moscow [5]. This study tool was validated during the pilot study, while the results confirmed its test - retest reliability and relative stability in time. The questionnaire consisted of three main parts and a final (passport) part and characterized the status of the respondents (11 questions). The first part of the questionnaire was devoted to the moral and ethical characteristics of students (18 questions), the second - to their relationship to biomedical technology (19 questions), a third - to detailed formulation of three of the most cherished dreams and the three main concerns in life (2 questions). The total number of questions was equal to 50. The moral views of the first and second year students of the faculty of General medicine of the Northern State Medical University (Arkhangelsk) before and after passing "Bioethics" discipline were studied by means of continuous method using questionnaires in March, June 2014. In the structure of the curriculum of the "General medicine" specialty the "Bioethics" discipline is included in the humanitarian, social and economic cycle and in 2014 it was taught in the second semester of the 1 course in the fourth semester of the 2nd year. After checking the completeness and quality of filling all the points of the program 298 and 213 research profiles accordingly obtained before and after passing the academic subject were included in the study, which accounted for 83.0 per cent and 59.3 % of the total number of students in these courses. Quantitative and qualitative variables were applied for statistical data analysis. Dynamic shifts in the moral and ethical characteristics of students were determined on the basis of statistically significant differences in their perceptions before and after mastering of educational material by Chi - square test of Pearson. Pairwise comparison of variables was carried out by using the correction of Bonferroni. The critical level of significance was equal to 0.05. The calculation of the 95% confidential intervals (CI) were performed by the method of Fisher. Processing of statistical data was carried out using the software package SPSS ver. 21 and WinPEPI. Results and discussion. Contradictory nature of the "public" bioethical issues necessitated the use of bioethical discourse in the multitude of scientific approaches. At the same time, specialists [7, 8, 9] understood the impossibility of the formation and further development of bioethical outlook based only on rationality that led to the recognition of the desirability of engaging in the process of formation of norms of religious morality, produced in the process of implementing interfaith dialogue. Interfaith dialogue, especially given the content of different religions, aims to establish universal morality beginnings in their relationship with existential values as the basis of planetary consciousness and the humanization of society. Modern bioethical dialogue is developing in two main areas: the ideological and practically - applied. The ideological aspect of bioethical discourse is associated with the presence of moral consciousness, a certain contribution to the development of which promotes the recognition of attachment to a particular religious denomination [11]. Practically - applied aspect involves the implementation of actions and relations based on moral norms, that is, bioethical decisions. The basis of moral choice in case of aforementioned aspeats adoption is phronesis, which is the practical wisdom implemented through judgements in individual situations of medical practice [6]. In medicine the rules of morality historically appeared first as regulators of professional conduct and traditionally have always been much stricter than in other spheres of society, being the determining factors of the development and acting as the main culture - forming phenomenon [8]. The successful formation of bioethical outlook in future doctors requires the initial set of moral views. Almost all the students (96.4 per cent) ever thought about moral norms as the system of universally recognized values and the regulators of professional activity in medicine, including ones who often thought - 30 69,7 % (95 % CI 64,2 - 74,6) and sometimes minded - 26,7 % (95% CI 22,0 - 31,9). A very small proportion amounted to people never reflecting on it (a 2,3 %; 95 % CI 1,1 - 4,7) and those who found it difficult to answer (to 1,3 %; 95 % CI 0,5 - 3,4). After studying the course, the distribution of students by interest in questions of morality remained the same - to 72,7 % (95 % CI 66,4 - 78,3); 22,1 % (95 % CI 17.0 - 28,1); Of 1,4 % (95 % CI 0,50 - 4,1) and 3,8 % (95 % CI of 1,9 - 7.2), accordingly (%2 = 0,582, p = 0,446). The majority of surveyed (71,9 %; 95 % CI 66,6 per - 76,7) sees the nature of the morality origin in human activity, 6,0 % of surveyed (95 % CI 3,8 - 9,3) see it in nature activity and 5,7 % (95 % CI 3,6 - 8,9) - in God activity. The percentage of people who never thought about it was up to 8,7 % (95 % CI 6,0 - 12,4), meanwhile 7,7 % (95 % CI 5,2 - 11,3) found it difficult to answer. After studying the course, the structure of ideas about the nature of the origin of morality remained unchanged for 65,7 % (95 % CI 59,1 - 71,8); 8,5 % (95 % CI 5,4 - 13,0); 6,6 % (95 % CI 4,0 - 10,7); 8,9 % (95 % CI 5,8 - 13,5) and 10,3 % (95 % CI 6,9 - 15,1) accordingly (%2 = 2,233, p = 0,135). The large share of students (68,5 %; 95 % CI 63.0 - 73,5) acknowledges the addiction medicine from morality, only 16,8 % (95 % CI 13,0 - 21,4) denies this fact. A very small number (2,4 percent; 95 % CI 1,1 to 4,8) believes that medicine is morally repugnant. The amount of surveyed who could say nothing about it was 12,3 % (95 % CI of 9,1 and 16,2). After studying the course, the structure of representations about dependence of medicine from morality has not undergone significant changes - 64,8 % (95 % CI 58,2 - 70,9); 17,4 % (95 % CI 12,9 - 23,0); 1,4 % (95 % CI 0,5 - 4,1) and 16,4 % (95 % CI 12,1 - 22,0), accordingly (%2 = 0,755, p = 0,385). The use of religious morality norms in the formation of a bioethical outlook is possible only when there is a certain degree of religious consciousness in students, as evidenced by the prevalence of religious views among them. Religious consciousness is demonstrated in the majority of students (43,7 %; 95 % CI 38,2 percent by 49,5). However, in every third one (32,7 %; 95 % CI of 27,6 - 38,2) it is completely absent, and every fourth (23,6 %; 95% CI 18,3 - 29,6) failed to give a clear definition of it. After studying the course, the realization of their own religiosity remained the same - to 43,2 % (95 % CI 36,749,9); 33,3 % (95 % CI 27,4 - 39,9) and 23,5 % (95% CI 18,3 - to 29,6), accordingly (%2 = 0,027, p = 0,987). The majority of respondents (64,9 %; 95 % CI 59.3 - 70,1) believes that the basis of the worldview is Orthodox Christianity; for 14,7 % (95 % CI of 11,2 - 19,2) - other religious denominations. Only very small part of respondents (12,4 %; 95 % CI 9,1 to 16,6) has an atheistic worldview. The remaining 8% (95 % CI 5,5 - 11,7) could not determine the basis. After completing the course, the existing ratio has remained unchanged - 62,0 % (95 % CI 55.3 - 68,2); 16,9 % (95 % CI 12,5 - 22,5), 10,3 % (95 % CI 6,9 - 15,1) and 8,8 % (95 % CI 5,8 - 13,5), accordingly (%2 = 0,456, p = 0,500). The wide prevalence of religious beliefs among the students comes as a result of the large number of people (70,8 %; 95 % CI 65,4 - 75,7), who are of aware of the need to preserve the traditional religious value in the Russian society. The percentage of students who completely reject them was equal to 10,4 % (95 % CI of 7,4 to 14,4). However, a significant proportion of surveyed (18,8 %; 95 % CI 14,8 - 23,6) has no definite position. After completing the course, there were no significant changes in the structure of the opinions (68,5 % (95 % CI 62,0 - 74,4); 12,2 % (95 % CI of 8,5 to 17,3) and 19,3 % (95 % CI of 14,5 to 25,1), accordingly (%2 = to 1.893, p = 0,595). Recognition of the norms of religious morals reflect the views of the students about the early life and pre - marital chastity of the person. The conception is considered to be the beginning of human life by every second person (54,1 %; 95 % CI 48,4 - 59,6). Another 32,8 % (95 % CI 27,7 - 38,3) include birth in this concept, and only 6,4 % (95 % CI 4,2 - 9,8) - different stages of pregnancy. Are unable to answer this question of 6,7 % (95 % CI 4,4 - 10,2). Premarital chastity as a virtue is adopted by almost every second student (44,4 %; 95 % CI 38,8 - 50,1). Meanwhile, the other 30,5 % of respondents (95 % CI 25,5 36,0) do not agree to the above. Furthermore, every fourth (25,1 %; 95 % CI for 20,5 - 30,3) did not answer this question. After studying the course, the structure of ideas about the beginning of life (%2 = 0,050, p = 0,823) and premarital chastity (%2 = 0,519, p = 0,771) remained unchanged.Implementation of the religious morality norms in medical practice of future doctors entails the awareness of the link between morality, medicine and religion and the recognition of the need for their interaction. Before studying the course the fact of the dependence between morality and religion was obvious for 38,9 % (95 % CI 33,6 - 44,6). This fact was denied by every second (48,0 %; 31 95 % CI 42,4 - 53,6). Consistent with research findings, 13,1 % of students (95 % CI 9,7 - 17,4) had difficulty answering this question. After completing the course, the structure of the representations has changed significantly. Students became 1,3 times less likely to consider that religion and morality are not linked with each other (37,1 % (95 % CI of 30,9 to 43,8) vs. 48,0 %) (x 2 = 6,004, p = 0,014). At the same time there was an increase in the percentage of persons recognizing the dependence of morality and religion (44,6 %; 95 % CI 38,1 - 51,3) and those who found it difficult to answer (18,3 %; 95 % CI of 13,7 to 24,1). The minority of surveyed supported the fact of the influence of religious beliefs on medicine (of 10,3 %; 95 % CI 7,4 - 14,3). On the contrary, the majority of respondents (74,0 %; 95 % CI of 68,8 and 78,6) fully rejected the possibility of such influence. A large proportion of the students (15,7 %; 95 % CI of 11,4 to 19,5) had no opinion on this issue. However, after completing the course, the student opinions have undergone significant changes (%2 = 7,023, p = 0,030). There was a 1,8 increase in the percentage of persons recognizing the influence of religious views supported by medical workers on the provision of related services (18,3 % (95 % CI 13,7 to 24,1) against 10,3 %). The amount of surveyed who denied this fact and found it difficult to answer was 65,7 % (95 % CI 59,1 - 71,8), and 16,0 % (95 % CI of 11,7 to 21,5), accordingly. Before the course of bioethics the necessity of the interference of religion in medicine was realized by a very small number of students (to 4,4 %; 95 % CI of 2,6 to 7,4). The vast majority of surveyed (84,5 %; 95 % CI 79,9 - 88,1) spoke out against religious interference in medical activities. Every tenth (11,1 %; 95 % CI 8,1 to 15,2) was not able to determine his position. After studying the course, a 2,3 increase was registered in the necessity of the interference of religion in medicine (10,3 % (95 % CI 6,9 15,1) versus 4,4 %) (x 2 = 8,419, p = 0,015). The proportion of respondents who denied the need for religious intervention and those who found it difficult to answer was equal to 75,6 % (95 % CI of 69,4 - 80,9) and 14,1 % (95% CI 10,1 - 19,4), accordingly. The students attitude to the teaching of bioethics existential themes by priests (death, life as a value) indicates a significant internal barriers preventing the intervention of religion in medicine. Its suitability is aware of the minority (16,9 %; 95 % CI 13,0 21,7). More than half of respondents (56,3 %; 95 % CI 50,6 per - 61,8) do not support this idea. A significant portion of surveyed (26,8 %; 95 % CI 22,1 - 32,1) found it difficult to answer. After completing the course, significant changes in the structure of ideas did not happen - 23,9 % (95 % CI of 18.7 - 30,1); A 49,3 % (95% CI 42,7 - 56,0) and 26,8 % (95 % CI of 21,3 - 33,1), accordingly (x2 = 4,179, p = 0,124). The awareness of the need for bioethical outlook, commitment to moral norms and the presence of moral values according to chosen profession are considered to be necessary conditions for the formation of bioethical outlook. Almost all students (compared to 90,1 %; 95 % CI of 86,2 - 93,0) attributed the achievement of professionalism in medicine with the acquisition of ethical knowledge and the development of moral character. A small proportion of the students (5,5 %; 95 % CI 3,4 - 8,7) do not recognize necessity of the achievement of the above - mentioned goals and (4,4 %; 95 % CI of 2,6 to 7,4) found it difficult to answer. After studying the course, in the structure of the students views there were no significant changes - at 86,4 % (95 % CI 81,1 - 90,4); of 4,7 % (95% CI 2,6 - 8,4) and 8,9 % (95 % CI 5,8 - 13,5), accordingly (X2 = 6,432 p = 0,092). The vast majority of respondents (82,6 %; 95 % CI 77,8 - 86,4) acknowledged the necessity of forming adherence to moral standards in the medical community, confirmed by the fact of taking the Hippocratic Oath. Only 12,4 % (95 % CI from 9,1 to 16,7) denied its necessity, and 5,0 % (95 % CI 3,1 - 8,1) did not answer this question. After completing the course, there was a small negative change in the structure of representations - 77,0 % (95 % CI 70,9 82,1); 14,5 % (95 % CI 10,5 - 19,9) and 8,5 % (95 % CI 5,413,0), accordingly, but changes occurred negligible (x2 = 5,291, p = 0,152). The presence of moral values in chosen profession contributes to the formation of a bioethical ideology, the most universally of which becomes the ideal. Some believe that the ideal is a real man to whom all aspire to imitate. For others, the role of the ideal is played by a hero of literary or cinematic hero. However, the majority of people creates its own ideal of a set of traits that they would like for life to develop. This explains the very small number of students who have moral values in chosen profession, as they appeared embodied for them in a particular individual. The proportion of respondents who know and can name the person who exemplifies the ideal physician was equal to 25,9 % (95 % CI of 21,2 - 31,4 million). However, for most students (74,1 %; 95 % CI 68.7 - 78,9), this question still remains open. 32 After the completion of a course of study, no significant changes in the structure of representations took place (25,8 % (95% CI of 20,4 - 32,1) and 74,2 % (95 % CI 67,9 of 79.6), accordingly) (%2 = 5,291, p = 0,152). An objective perception of the external conditions (contextual factors), in which the process of professional learning occurs: the state and prospects of development of Russian society and health care, plays an important role in shaping bioethical outlook. Before studying the course slightly less than half of students (45,6 %; 95 % CI 39,9 - 51,3) perceived negative influence of media on morality of society, and 13,7 % (95% CI 10,2 - 18,1), on the contrary, have never noticed that influence. However, most (40,7 %; 95 % CI 35,3 - 46,5) found it difficult to give any assessment of this phenomenon. After studying the course, the 1,4 increase was noted in the number of surveyed who expanded media in Russian society propaganda of consumption and hedonistic values (61,5 % (95 % CI 54,8 per - 67,8) versus 45,6 %) (x 2 =17,137; p 0,001). The proportion of respondents who denied this fact and those who found it difficult to assess was equal to 15,0 % (95 % CI 10,9 - 20,4) and 23,5 % (95% CI 18,3 - to 29.6), accordingly. The analysis of the causes for trouble in domestic medicine showed that the majority (68,0 %; 95 % CI 62,5 - 73,0) see the reason in the lack of funds. However, every fifth person (22,7 %; 95% CI 18,3 - 27,7) refers to these causes the distortion of moral values. Only 9,3 % (95 % CI of 6,5 to 13,2) had difficulty in assessing the causes. After the completion of a course of study, the structure of the representations has not changed (66,7 % (95 % CI 60,1 - 72.7); 24,4 % (95 % CI 19,1 - 30,6) and 8,9 % (95 % CI 5,8 13,5), accordingly) (%2 = 5,291, p = 0,152). In the case of granting the right of choosing the future place of work roughly the same number of students either stay to work in Russia (41,8 %; 95 % CI 36,3 - 47,5) or leave the country (to 39,4 %; 95 % CI 34,0 - 45,1). However, every fifth student (18,8 %; 95 % CI of 14,8 23,7) has not decided yet. After completing the course, the structure of submissions remained the same - to 45,1 % (95 % CI 38,5 - 51,8), 38,5 % (95 % CI 32,2 - 45,2) and 16,4 % (95 % CI 12,1 - 22,0), accordingly (%2 = 0,974, p = 0,615). Summing up the conducted research, we consider it necessary to draw attention to the traditionally high moral principles of domestic medicine that have always differentiated it from other medical practices and systems. This results from the peculiarities of the historical development of our country, its Orthodox faith and cultural traditions, providing the moral regulation of life activities of a centralized Russian state throughout the long history of its existence. The most common national idea of the Russian world has always been the love for the homeland. The fact that every second or third student (from 39,4 % to 38,5 %) connects professional future with his departure from Russia testifies to a certain strain of the national idea. However, the study of primary moral ideas of future physicians suggests the presence of a certain degree of maturity and relative stability in time. As a result of mastering the discipline of "Bioethics" significant changes in moral representations of students occurred in 4 of 17 investigated characteristics. These characteristics present the essential changes in the key representations that reflect the current realities of the interaction of religion, morality, and medicine and evaluation of morality of Russian society. The analysis of the received experimental training data allows us to consider the initial state and the dynamics of the moral views of students as a sufficient basis for successful and targeted development of bioethical outlook among future doctors.

About the authors

T. G Svetlichnaya

Northern state medical University

Email: statiana64@yandex.ru
Doctor of medical Sciences, professor of the Department of Public health, Health Care and Social work Arkhangelsk

E. S Stepanov

Northern state medical University

Email: saintses777@gmail.com
Post - graduate student of the Department of Public health, Health Care and Social work Arkhangelsk

References

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