Journal of Medical Ethics 1999;25:514-521

Teaching medical ethics

An international survey of medical ethics
curricula in Asia
Michio Miyasaka, Akira Akabayashi, Ichiro Kai and Gen Ohi Niigata University, Niigata City, The Universityof Tokyo, Tokyo and The National Institute for Environmental Studies, Tsukuba City, Japan

Abstract
Setting Medical ethics education has becomecommon, and the integrated ethics curriculum has
been recommended in Western countries. It should bequestioned whether there is one, universal method ofteaching ethics applicable worldwide to medical
schools, especially those in non-Western developing
countries.
Objective-To characterise the medical ethics
curricula at Asian medical schools.
Design-Mailed survey of 206 medical schools in
China, Hong Kong, Taiwan, Korea, Mongolia,
Philippines, Thailand, Malaysia, Singapore,
Indonesia, Sri Lanka, Australia and New Zealand.
Participants-A total of 100 medical schools
responded, a response rate of 49%, rangingfrom 23%- 100% by country.
Main outcome measures The degree of
integration of the ethics programme into the formal
medical curriculum was measured by lecture time;
whether compulsory or elective; whether separate
courses or unit of other courses; number of courses;
schedule; total length, and diversity of teachers'

specialties.
Results A total of 89 medical schools (89%)
reported offering some courses in which ethical topics
were taught. Separate medical ethics courses were
mostly offered in all countries, and the structure ofvertical integration was divided into four patterns.
Most deans reported that physicians' obligations andpatients' rights were the most important topics fortheir students. However, the evaluation was diverse

for more concrete topics.
Conclusion-Offering formal medical ethics
education is a widespreadfeature of medical curricula
throughout the study area. However, the kinds ofprogrammes, especially with regard to integration into
clinical teaching, were greatly diverse.
(7ournal of Medical Ethics 1999;25:514-521)
Keywords: Medical ethics education; curriculum survey;
medical school; Asia

Introduction
In the last two decades, formal ethics education
has become one of the common features of medical curricula in many Western countries.' The
formation of a formal programme led to a generalempirical understanding of how medical ethics
should be taught. In the United Kingdom theInstitute of Medical Ethics recommended that
medical ethics teaching should recur at regularintervals throughout medical teaching, and thattime should be set aside within existing teachingfor ethical reflection relevant to each stage of a
student's experience.2 Miles and colleagues in the
USA argued similarly that ethics education should
be conceptually coherent, vertically and horizontally integrated through preclinical and clinicaltraining, multidisciplinary, academically rigorous,and should demonstrate humane and valueconscious medical practice.3 Thus, the integrationof ethics into the formal curriculum has become
the standard recommended programme design of
medical ethics education.
However, examples of well-integrated ethics
programmes, quite often found in the literature,
are mostly limited to Western industrialised countries. Few have questioned whether this standard
programme design is universal, applicable worldwide to all medical schools, especially to those in
non-Western developing countries. The fundamental changes in medical ethics are usually
attributed to social factors common to Westerndeveloped countries, namely the novel moral viewof respect for patient's autonomy; the development of high-tech medical technology, and theshift of major causes of death from acute curable
diseases to chronic incurable ones, which haveforced physicians to think of therapeutic options
concerning patients' quality of life.'0`14 In many
developing countries, acute diseases are still
killing many people, and therapeutic options concerning comfortable quality of life are not realistic
for many people. Furthermore, individualistic

Miyasaka, Akabayashi, Kai, et al 515

patient choice in clinical settings is not usual
in non-Western countries, even today. Some
Japanese scholars have criticised Western bioethics
as placing too much weight on the principle ofrespect for autonomy that poorly fits the EastAsian ethos, which appreciates human interaction
and communitarian empathy.'5 16
If Western individualistic ethics has promoted
formal medical ethics education, and if it is reallyunacceptable for the South and the East, it could
be assumed that formal medical ethics educationis neither common, nor even needed in mostAsian countries. On the other hand, taking into
account that most issues in medical ethics, such asorgan transplantation and termination of life support, are now faced in Asian countries, and thatthe worldwide trade of medical technology has
created a greater disparity in the distribution ofhealth care resources, even within countries, it
could be argued that Asian medical schools
should prepare their students for ethical dilemmas, and indeed, for ethical dilemmas that could
be much more complicated than in the West.
This study was designed to survey the medical
ethics programmes of medical schools in the East,
South-east, South Asia, and Oceania. The purpose of the study is to analyze how much ethics
education is formally given, and how much is
integrated into the medical curriculum.

Methods
SUBJECTS

We included all medical schools of the area whichappeared in the World Health Organisation'sWorld Directory of Medical Schools.'7 Medical
schools which specified they taught only traditional medicine were excluded. A four-pagequestionnaire was developed and sent to the deanor the president of the medical school. The initialmailing was made in November 1994, and fourmonths later, a follow-up mailing was sent tonon-respondents. The last response was received
in October 1995. The mailing included an
introductory letter. The letter and the questionnaire were in English. In a separate study,
Japanese data were collected using a Japanesetranslation of the questionnaire used in thissurvey, and were submitted elsewhere.'8 Part of
the Japanese data was used to make statisticalcomparisons in this report. In Taiwan, where nodata were cited in the directory, Dr Tai-Yuan
Chiou of Taiwan University kindly informed us of
the mailing addresses of all of the ten medical
schools at that time.

QUESTIONNAIRE AND ANALYTIC TECHNIQUESThe questionnaire consisted of two parts. One
addressed the programme of medical ethics orsimilar courses. Deans were asked to fill in thename of the course, school years in which thecourse was offered, the length of the course,
whether it was compulsory or elective, and teachers' specialties. The second part asked thepersonal opinion of the dean on: ethics education;
the degree of satisfaction with ethics education at
his/her school; the importance of ethics educationcompared with other subjects; what kind of
programme he/she would like to see and whatkind of backgrounds he/she would prefer teachers
to have, and what lecture topics he/she regarded as
desirable for students. Respondents were required
to note their nationality, sex, age, religion,
specialty, the number of students in a school year,
the number of full-time teachers, total school
years (duration of medical degree course), andduring which school years bed-side teaching wasscheduled.
A "separate medical ethics course" was defined
as a course whose title contained both (1) words
representing medicine/medical care, ie "medicine", "health", "physician", "patient", "clinic",and (2) words representing ethics/moral philosophy, ie "ethics", "moral", "rule", "value". Other
courses were categorised as "medicine related
courses"; these were courses whose title contained
only medicine-related words, or as "othercourses"; these were courses whose titles included
no medicine-related words.
We separated the medical degree course into
three segments: before, during, and after bed-side
teaching (BST) school years. The "BST school
years" were defined as including school years at
the beginning and end of BST, and all school years
in between. Therefore, if BST was offered in thesecond and the fourth years, the third year was
also regarded as "during BST".
Teachers' specialties were categorised into four
categories; (1) physician/health professional; (2)philosopher/ethicist; (3) theologian/priest/monk,and (4) lawyer/ jurist/social scientist. Interdisciplinary backgrounds were identified by combinationof the four categories. For instance, "medical ethics" was coded as "(1) and (2)". We didn't distinguish between the following two cases: (A) where
one teacher had two or more backgrounds, and(B) where two or more teachers took part, buteach of them had one-but a differentbackground.
With regard to Singapore and Mongolia, bothof which had only one medical school, the country
data are not shown in this report.

516

Teaching medical ethics:An international survey of medical ethics curricula in Asia

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Teaching mledical ethics: An international survey of medical ethics cuirricuila in Asia

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MEDICAL ETHICS PROGRAMMESWe did not analyze countries from which fewer
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Table 1 summarises the characteristics ofwhich had lectures on ethical topics.
Eighty-nine per cent (89/100) of medical schools
had some courses. Seven schools did not have acourse, but said they would have in the near
future. One Thai school answered that they did
not have a course, and did not expect to have any
course in the near future. A diversity of allocatedlecture time was found in most countries.
However, in China, Taiwan and the Philippines,
60% or more medical schools allocated more than
20 hours to ethics courses, while in Hong Kong,
Korea, Indonesia, Malaysia, Thailand and Sri
Lanka, this ratio was below 40'%O. In every country,
most of the courses were compulsory. Seventynine per cent of medical schools required students
to take all courses, and three per cent offered
elective courses in addition to required ones. Fourper cent of medical schools which responded said
they had elective courses only.
The number of medical schools offering
separate medical ethics courses was 8 1 % (8 /1 00)
of all respondents. The majority of the separate
courses were referred to as "medical ethics","bioethics", or "clinical ethics".
The longitudinal schedule, reflected in thenumber and the schedule of the course, was asdiverse as any other aspect of the curriculum. In
China, Taiwan and Malaysia, more than 60% of
medical schools reported one course, while inHong Kong, the Philippines, Thailand, Sri Lanka,
Australia and New Zealand, two or more courses
were more common than one course. In particular, in the Philippines, Australia and New
Zealand, 60% or more replied that they offered
three or more courses. The schedule of ethics
teachings was found to differ widely by country. In
China, Korea, and Indonesia, the number of
medical schools offering ethics courses during
BST school years was less than half. In contrast, in
Taiwan, Hong Kong, Malaysia, the Philippines,
Sri Lanka, and Australia, ethics courses werescheduled during BST school years in 60% ofschools, or more. Medical schools offering ethics
both before and during BST school years were
found in most countries. In the Philippines, Thailand, Sri Lanka, Australia, and New Zealand, 30%ocourses

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Miyasaka, Akabayashi, Kai, et al 519

or more of schools had this kind of multi-steppedschedule.
The analysis of diversity in teacher specialty was
limited to cases in which specialties could be
identified concretely enough to be categorised
into four groups. Fifty-eight per cent of medical
schools reported that persons with medical backgrounds were teaching ethics. The proportion of
medical schools featuring philosopher/ethicist,
theologian priest/monk, and lawyer/jurist/social
scientist, were 27%, 11%, and 10%, respectively.
Theologian/priest/monk, and/or lawyer/jurist werereported to be teaching medical ethics in a limited
number of countries.

Discussion
Our survey has shed some light on both similari-ties and differences in medical ethics education in
Asian countries. It is obvious that medical ethics
education has become a universal component ofundergraduate formal medical training in mostcountries. Except for Japan, where many schools
were not teaching medical ethics in separate
courses, and China, where the data of nonrespondents might significantly alter the results,
medical ethics was commonly taught in required
separate courses. We could not obtain detailed
data which would illustrate how the ethics
programme had been developed in each school
reported herein. Nevertheless, the development
appears to have occurred in the last two
decades,'9 -21 as in many Western medical schools.
ATTITUDE OF RESPONDENTS TO ETHICS EDUCATION
It
should be noted that the spread of formal mediWe mailed the questionnaire to deans andrequested them to express their personal opinions. cal ethics education is not limited to industrialised
However, it should be noted that we could not countries, where high-tech medicine forces physicians to face new ethical dilemmas which arecorrectly identify the person(s) who directly familiarin the literature of bioethics. Also, in
answered the questionnaire. Therefore, we do notdeveloping
countries, where physicians are redescribe the attitude of respondents as that of quired to covera large population, with high-tech"deans".
medicine usually beyond their reach, medical
The number of respondents who were "satis- schools are becoming aware of ethical dilemmas
fied" or "moderately satisfied" reached 80% in unique to their own medical and sociocultural
China, Taiwan, the Philippines, Thailand and context, and that students should be prepared forAustralia, while in Korea and Malaysia, this ratio these dilemmas.
was 50 to 60% or lower (table 1). Eighty-three per
On the other hand, there were many different
cent of all respondents considered ethics educa- sorts of medical ethics teaching programmes. Onetion to be "very important" compared with other of the most conspicuous differences was foundsubjects (not shown in the tables). However, fewer between Japan and other countries. In all
respondents thought more time should be allo- countries except Japan, courses dealing with ethical topics were separate ones, mostly with explicit
cated to ethics courses.
Table 2 shows which topics the respondents titles such as "medical ethics" or "bioethics".
thought ought to be covered in lectures during However, the majority of Japanese medical
medical ethics courses at their schools. "Physi- schools were teaching medical ethics as a unit ofcians' obligations/etiquette" was evaluated as the "introduction to medicine" or similar courses.
most important topic by 64% of all respondents. This was not likely to be due to the matter of"Patient's right/autonomy," "informed consent," wording or translation. The original Japanese forand "patient's privacy/confidentiality", were all "introduction to medicine," igaku gairon, has beenhighly evaluated, but the ratio of respondents who defined and translated in various ways (ie "thechose these as "most important" decreased to philosophy of medicine"22 or "medical
since its establishment in 1942. By
40%, 24%, and 15% respectively. On the other humanities"23)
it aims to cover a broadanydefinition,
hand, the evaluation was diverse and may reflect of humanities and social sciences which spectrum
will form
some difference between countries for specific a foundation for the study of medicine. Thus, theitems. "Artificial abortion" was considered as goal of "introduction to medicine" is similar to"most important" or "very important" by 78% of that of the medical humanities. However, quite aFilipino respondents and 73% of Indonesian few Japanese medical schools seemed to allocate
respondents. However, in China, Thailand, and only a short time to ethical topics in their
Australia the figure did not reach 30%. "Popula- courses,24 and most Japanese deans did not feeltion control" was highly evaluated in China. "The their ethics teaching was well organised.29 In thecare of children, the rights of children" received Japanese survey,'8 the number of Japanese medicalhigh evaluation in Thailand, Malaysia, the Philip- schools offering separate medical ethics courses
was 14 (22% of 64 schools responded), but thispines and Sri Lanka.

520

Teaching medical ethics: An international survey of medical ethics curricula in Asia

figure was a leap from 7 (9% of 80 respondents) in1990.24 Furthermore, Japanese respondents werethe least satisfied with their ethics education.
Putting all accounts together, offering medical
ethics in separate courses is becoming a common
feature of Asian medical schools, including
Japanese ones.
From the standpoint of vertical integration,
medical ethics should be taught step by step
throughout preclinical and clinical education. The
results suggest that the structure of vertical
integration in this area was divided into fourstages. Medical ethics is given as either: (1) a single course before BST school years (dominant in
China and Korea; (2) a single course during BST
school years (dominant in Taiwan and Malaysia);(3) multiple courses during BST school years andother years (dominant in the Philippines and Australia), or (4) a unit of courses not specified for
medical ethics before BST school years (dominant in Japan). Judging from the longitudinal
structure of the programme, the third pattern
appears to be the most explicit mode of the vertically integrated programme, in which medical
ethics literally recurs through preclinical andclinical training, as recommended by Westernobservers.2 3 Medical ethics curricula categorisedin other groups seemed to be suffering from theabsence of either preclinical or clinical ethics education. It can be argued that preclinical and clinical ethics education have different goals from eachother, and that both are indispensable. This
standpoint appears to be becoming accepted inmany Asian countries, because the vertically integrated programme was found in most countries
surveyed herein. At the same time, the wide rangeof differences in the patterns within countries
suggested that the longitudinal cohesiveness of
ethics education is still of less concern to medical
educators in this area. The importance of longitudinal cohesiveness has only been recognised very
recently, and it might be a hard task for medical
schools where the curriculum is overcrowded, tointroduce another set of courses throughout multiple school years.
Our results indicated that, on the one hand,interdisciplinary teaching was popular in many
schools, but on the other hand, that teachers withreligious backgrounds only took a modest part in
the teaching of medical ethics. Modern academic
medical ethics, or bioethics, has been developed asa secular discipline, dominantly influenced by the
Anglo-American social context, even though there
has been a significant contribution by theologians
to its development. Our data suggest that medical
ethics teaching at Asian medical schools has asecular character. However, the dominance ofsecular teachers raised questions about education
on sensitive ethical issues such as abortion andeuthanasia where there can be conflicts between
medical conduct and religious beliefs. Most Asian
countries maintain diverse, and sometimes conflicting, traditional religious beliefs or social
habits. Furthermore, the conflict between modern
medicine and traditional values is very often hardto mediate. The diversity observed in the
respondents' evaluation of ethical topics suggests
the contents of medical ethics education candiffer, perhaps reflecting the sociocultural andhistorical context in which the medical school
stands. Therefore, in the educational setting,teachers need carefully to address this conflict,
especially when no one from the religious camp isparticipating in the programme. In this regard,interdisciplinary teaching was highly appreciatedby deans; respondents expected more diversity
than the current teachers had. The recruiting of
more lecturers can be done without a drastic reformation of the curriculum, without needing tohire full-time teachers, and without having toestablish an independent department or programme. However, the successful institutionalisation of medical ethics education would be hard toachieve without a core responsible organisation.
The form of the core organisation could vary
according to the availability of multidisciplinaryteachers, and the support of the dean and the college. Therefore, the most serious weaknesses ofAsian medical ethics education may be that only a
few countries have centres for training teachers,'6
and that the standardisation or qualification of
medical ethics teachers is still poorly developed.

Exchanging experiences
On the basis of our survey we can say that theteaching of medical ethics is obviously widespreadin the South and the East. Therefore, it may not betrue to describe modern medical ethics as a discipline unique to the industrialised West. Rather,
medical ethics education, like other disciplines,
should be taken to be an essential part of medical
education that is mandated to meet society's needfor a supply of competent practitioners. On theother hand, the diversity in vertical integration of
the programmes suggested a difference of contents
or goals of medical ethics teachings. The recommendation for an integrated programme, as put
forward by Western observers, seems grounded in
the practical character of medical ethics, and thebelief that it should be incorporated as a unit ofclinical education. In countries like Japan, which
has traditionally taken medical ethics education asa unit of medical humanities, and given it acharacter resembling liberal education, it is not yetMiyasaka, Akabayashl, Kai, et al 521

certain how medical ethics will be given a practicalcharacter, and integrated into clinical education.
Although setting goals, designing programmes,
and recruiting appropriate teachers are left foreach country and each medical school to decide,these tasks would be harder to achieve without theaccumulation of empirical study in the field.
Therefore, exchanging experiences may be themost feasible method for Asian medical schools toestablish well-organised programmes of medical
ethics education.

Acknowledgements
The authors wish to thank all participants who
were involved in the studies, and Dr Darryl Macer
ofTsukuba University, for his critical review of thequestionnaire and this manuscript. This study waspartly supported by the TOYOTA foundation,and by grant-in-aid for scientific research No
07672437 by the Ministry of Education, Science,Sport and Culture, Japan.
Michio Miyasaka, PhD, (corresponding author), is
Lecturer in the School of Health Sciences, Faculty of
Medicine, Niigata University, Niigata City, Japan.
Akira Akabayashi, MD, PhD, is Lecturer in The
School of Health Sciences and Nursing, The University of Tokyo, Tokyo, J7apan. Ichiro Kai, MD, PhD,
MPH, is Professor in The School of Health Sciences
and Nursing, The University of Tokyo, Tokyo. Gen
Ohi, MD, PhD, MPH, is Director General of The
National Institute for Environmental Studies, Tsukuba City, Japan.

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