Article
An innovative approach to teaching bioethics in management of healthcare
Nursing Ethics 2016, Vol. 23(2) 167–175 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014558967 nej.sagepub.com
Silviya Aleksandrova-Yankulovska Medical University of Pleven, Bulgaria
Abstract Background: Bioethical courses were introduced in the curricula in medical universities in Bulgaria in 1990s. In the beginning, the courses were mainly theoretical, and systematic case analyses and discussions of movies were introduced later on. The benefits of using films to teach ethics have been previously analyzed in the literature; however, to our knowledge such studies in Bulgaria are yet lacking. Objective: The aim of this study was to survey the opinions of students and analyze the results from the application of movies in bioethics teaching in a medical university in the north of Bulgaria. Methodology: A survey was carried out among 92 students in the management of healthcare. Two movies were used, and separate protocols for film discussion were developed. Ethical considerations: The study was conducted anonymously and with students’ free informed consent. Results and discussion: The students distinguished in total 21 different dilemmas and concepts in the first movie. The ethical dilemmas were classified into five groups: general ethical issues, deontological issues, special ethical issues, principles of bioethics, and theories of ethics. The second movie focused students’ attention on the issues of death and dying. In total, 18 elements of palliative care were described by the students. The range of different categories was a positive indicator of an increased ethical sensitivity. The students evaluated the movies’ discussions as a generally positive educational approach. They perceived the experience as contributing to their better understanding of bioethical issues. Conclusion: The innovative approach was well accepted by the students. The introduction of movies in the courses of bioethics had the potential to provide vivid illustrations of bioethical issues and to contribute to the exploration of specific theses and arguments. The presentation and discussion should be preceded by accumulation of theoretical knowledge. The future of effective bioethics education lays in the interactive involvement of students. Keywords Bioethics, ethical dilemmas, innovative approach, movies’ discussion, teaching bioethics
Introduction The first courses in bioethics were introduced in the medical curricula in medical curricula in Bulgaria in 1990s. In the beginning, the courses were mainly theoretical and focused on the general part of bioethics Corresponding author: Silviya Aleksandrova-Yankulovska, Department of Public Health Sciences, Faculty of Public Health, Medical University of Pleven, 1 Kliment Ohridski Street, 5800 Pleven, Bulgaria. Email: [email protected]
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Table 1. The benefits of using films to teach ethics. Wohlke and Schicktanz5
Giacalone and Juriewicz6
Provide narratives for bioethical reflection; Provide useful case studies; Give fleshed-out interpretations of bioethical claims; Compelling illustrations for philosophical ideas; Intellectually stimulating; Can offer interpretation and advanced understanding of philosophical ideas.
Provide a systemic context for ethical decisions; Have depth and richness not found in cases; Develop critical thinking skills; Make the connection between theoretical and practical ethical decision-making.
(i.e. theories of ethics, basic principles, confidentiality, informed consent, models of relationships, patients’ rights). Special issues such as ethical problems related to human reproduction, end-of-life care, transplantation, human experimentation, and resource allocation were barely discussed. The teachers were mainly public health specialists since medical ethics in Bulgaria was not a separate specialty but a part of public health. Only a few teachers had the chance to receive specific ethical training and to broaden their qualification abroad. The increased access to specialized literature on bioethics played an important role in improving the qualification of the teachers. Initially, the teaching approaches included mainly lectures and discussions of short cases. The cases were predominantly used as an illustration of the theoretical concepts and for determining violation of norms. The methodology of detailed case analysis was first introduced in the bioethics teaching in Bulgaria by Silviya Aleksandrova-Yankulovska1 in her textbook Practical Assignments with Case Studies in 2010. The inclusion of cases in ethical teaching, however, has some limitations. First, the clinical data in written cases are usually scarce and lots of additional information is needed in order to arrive at a sound decision. In addition, medical ethics courses for students in medicine, nursery, and midwifery are taught during the early years of training, when students are unfamiliar with the clinical settings in which ethical issues arise and experience difficulties in comprehending the situation. Second, the written cases are focused on “dry information” and fail to present the patient’s viewpoint. Films, on the other hand, can help in overcoming these drawbacks by presenting more personal and professional details of a certain situation. The advantages of films as a teaching instrument have been discussed by different authors. Volandes2 pointed the ability of films to fill in the imaginative leap of the clinically inexperienced students. Films offer a visualization of concepts that might be abstractly presented in textbooks and lectures, and students respond favorably to the link between the film scenes and the abstract theory and concepts.3 Specific medical terms which often appear in the traditional written cases lose their abstract qualities.2,4 Films also present the sometimes overlooked patient’s perspective and voice and allow for deeper understanding and appreciation of the individual’s experience of having a disease. The students in the management of healthcare, who were involved in this study, were mostly practicing nurses and midwives. They did not lack practical experience per se, but they came from different professional environment. Since caring for different patients exposed care givers to specific experience, the students demonstrated different perceptions when discussing philosophical issues such as the following: what “good death” was, moral acceptability of abortion and assisted reproduction technologies, and limitations of artificial life support. A systematic revision of the benefits of using films to teach ethics is provided in Table 1. The limitations of films as teaching materials were also recognized in the literature. Film clips could be manipulated to favor a particular perspective.2,7 The social and emotional elements of the presented stories could hinder professional judgment and achievement of educational goals if students forgot about the specific
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objectives of the film discussion. Bearing this in mind, ethics teachers could direct movies’ discussions to answer questions such as the following: How is the movie biased with respect to different ethical perspectives? Which arguments and perspectives are stressed and which are underestimated?5 The teacher’s preparation included viewing the film in advance and preparing the discussion questions that linked the theoretical knowledge to the storyline. The discussion after the movie could be guided in oral form or could be done in written form by each student.
Aim The aim of this study was to survey the opinions of students in the management of healthcare and analyze the results from the application of movies in bioethics teaching in a medical university of north Bulgaria.
Methodology For the purpose of the current analysis, two movies were selected and applied in the bioethics courses of different specialties in the studied university: “Whose life is it anyway?” (1981) is a Hollywood drama presenting the story of Ken Harrison, who was a sculptor. He was involved in a car accident and was paralyzed from his neck. All he could do was talk, and he wanted to die. In the hospital, he made friends with some of the staff, and they supported him when he went to trial to be allowed to die.8 “My life” (1993) is a story about the life of Bob Jones, a young man with a successful career and a happy family, whose wife is pregnant. Bob finds out he has cancer and will die within months. He sets out to video-tape his life’s acquired wisdom for his child and ends up on a voyage of selfdiscovery and reconciliation.9 The choice of the movies was made in accordance with two criteria: range of ethical issues presented in the movie and consistency with the preliminary theoretical preparation of the students. The first movie was presented and discussed in the course of medical ethics. Although this movie told the story of a man who pleaded for euthanasia, class discussion was rather directed toward the wide range of ethical issues surrounding patient care. The second movie was presented and discussed in the course of management and ethics of hospice care. The movie had been chosen because of the representation of the specific philosophical concepts in relation to terminal care. The study was conducted in the period September 2013–March 2014. In total, 92 students in the management of healthcare, bachelor’s and master’s degree, were involved. The movie “Whose life is it anyway?” was seen by 39 students (25 bachelor’s and 14 master’s students). The movie “My life” was seen by 53 students (17 bachelor’s and 36 master’s students). Only 11 master’s degree students saw both movies due to organizational reasons. The comparison between students who saw only one of the movies and the group of students who saw both movies was not part of the objectives of this study and therefore was not performed. Two questionnaires (protocols) designed for bioethical film discussion were developed and applied in this study. The questionnaire for the movie “Whose life is it anyway?” included five open-ended questions: 1. Please, summarize the story of the movie. 2. What ethical dilemmas have been presented in the movie “Whose life is it anyway?” 3. What is your general impression of the movie?
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4. Do you consider movies as useful in ethics training? 5. Express your opinion about the movie. The questionnaire for the movie “My life” included six open-ended questions: 1. 2. 3. 4. 5. 6.
Please summarize the story of the movie. Which elements of palliative care have you been able to recognize in the movie “My life”? Which of the Elizabeth Kubbler-Ross’ stages of psychological reaction were illustrated in the movie? What is your general impression of the movie? Do you consider movies as useful in education? How the movie contributed to your better understanding of hospice/palliative care?
Ethical considerations The study was conducted anonymously. Study objectives were explained to the students before the distribution of the protocols. The teacher was not present at the answering of the questionnaire. The protocols were returned in a specially designed closed box. Students, who did not want to participate in the study, had the option to return empty protocols. The participation in the study was in no way related to the assessment of students’ performance in the studied courses.
Results and discussion The first focus of interest was the students’ perception of the presented story. Since full-length movies were complex and reach in storylines,4 students could “grasp” different problems on first place. Almost equal percentage of students (41% and 49%, respectively) made formal summary of the story of both films. An interesting scene of the movie “Whose life is it anyway?” presented the court discussion on the wish of the patient to be allowed to die. This scene was in the focus of 41% of students’ resumes. The collision between the patient and the hospital team was marked in 12.8% of the answers. Bigger variety of interpretations was found in the resumes of the movie “My life.” Equal number of students (17%) made philosophical interpretation of the story and focused on the birth of Bob’s son. The concept of fully lived rest of Bob’s life almost got the same attention (15%). The stages of the main characters’ transformation and family support were present in the answers of 9.4% of the students who had seen the movie “Whose life is it anyway?” and 5.7% of the students who had seen the movie “My life.” Although the majority of the resumes were formal representations of the movies’ storylines, the variety of the students’ interpretations was a positive indicator for the effect of movie discussion as an educational approach. In view of the medical background of the students, the attempt to make philosophical interpretation of the story deserved special attention. There was no other philosophical course in these students’ curricula, and the transformation to an abstract way of thinking could be linked to the ethics studies. The ethical dilemmas distinguished by the students in the movie “Whose life is it anyway?” could be arranged in several groups (Table 2): general ethical issues in medical practice, deontological issues, special ethical issues, principles of bioethics, and theories of ethics. The central problems recognized by the students were respect for autonomy issues (69.2%), medical paternalism (28.2%), and issues surrounding euthanasia (35.9%). The application of the casuistry approach during the court discussions and the final decision-making in the film case was noted by 15.4% of the students. A small number of students were even able to distinguish elements of applied ethics (5.1%), utilitarianism (5.1%), ethics of justice (2.6%), and ethics of care (2.6%). In total, 21 different ethical dilemmas and concepts were defined. The movie “My life” offered a different experience to the students. Since it told the story of a terminally ill man, many theoretical concepts from the area of end-of-life care were illustrated in the film (Table 3). In all,
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Table 2. The ethical dilemmas distinguished by the students in the movie ‘‘Whose life is it anyway?’’ What ethical dilemmas have been presented in the movie ‘‘Whose life is it anyway?’’ General ethical issues in medical practice Paternalism ‘‘Physician–patient’’ relationships Patient’s rights Objectivity of second opinion Professional relationships Personal relationship with medical professionals Confidentiality Deontological issues Professional duty Malpractice Informed consent Competency assessment Special ethical issues Euthanasia Emergency treatment Principles of bioethics Respect for autonomy Beneficence and non-maleficence Justice Theories of ethics Applied ethics Utilitarianism Casuistry Ethics of justice Ethics of care
% 28.2 25.6 20.5 10.3 7.7 2.6 7.7 15.4 7.7 20.5 15.4 35.9 10.3 69.2 33.3 7.7 5.1 5.1 15.4 2.6 2.6
45.3% of the students focused their attention on pain control as a key element of palliative care. The provision of care at the patient’s home was observed by 37.7% of students. Enabling patients to stay at their homes at the terminal stage of their illness is one of the most significant characteristics of the hospice/palliative care which distinguishes it from the traditional hospital care.10 The other elements of the “total pain” concept11 were also determined by a significant number of students: spiritual support (28.3%), psychological support (26.3%), and social support (17%). The concept of “total pain” itself was pointed out by 20.8% of the students. The importance of family support (one of the cornerstones in the film script) was underlined in 13.2% of the responses. It is worth mentioning that one student was able to see an illustration of one of the goals of palliative care—“coming home.” In the movie, it was presented with three of its five possible meanings: one’s own home, one’s own body (feeling comfortable in one’s own body as a result of adequate symptom control), and spiritual environment in respect of patient’s preferences and values.12 A few students (1.9%) determined concepts as Practical palliative nursing service and Sheffield model of palliative care in the movie. In total, 18 elements of palliative care were present in students’ answers. The range of different categories was a positive indicator for the increased ethical sensitivity of the students to the issues of death and dying as a result of the education. Special emphasis in the discussion of the movie “My life” was placed on the recognition of Elizabeth Kubbler-Ross’13 five stages of grief: denial, anger, bargaining, depression, and acceptance (Figure 1). Considering that there is certain disagreement even among ethicists about the interpretation of these stages, the task of the students was more than mere recalling of the theoretical definitions. In the opinion of 30.2% of the
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Table 3. The ethical dilemmas distinguished by the students in the movie ‘‘My life.’’ Which elements of palliative care have you been able to recognize in the movie ‘‘My life’’?
%
Pain control Home care Spiritual support Psychological support ‘‘Total pain’’ The role of the nurse in care provision Provision of equipment at the patient’s home Social support Family support Intensity Comprehensiveness Quality of life Acceptance of medicine’s limitations Practical palliative nursing service ‘‘Coming home’’ Sheffield model of palliative care Respect for autonomy Protection of patient’s dignity
45.3 37.7 28.3 26.4 20.8 18.9 17 17 13.2 13.2 9.4 7.5 3.8 1.9 1.9 1.9 1.9 1.9
92,5%
Acceptance of death 30,2%
Depression Bargain
79,2%
Anger
85% 71,7%
Denial 0
20
40
60
80
100
Figure 1. The students’ perception about the presence of Elizabeth Kubbler-Ross’ stages of psychological reaction in the movie ‘‘My life.’’
students and in my own view, the stage of depression was not experienced by Bob Jones (the character in the movie “My life”). As for the rest of the stages, the students recognized them in a different manner. According to 92.5% of the students, Bob Jones accepted death in its spiritual meaning. One common idea in the literature is that persons/patients who reached the stage of acceptance have a “good death.”14 In this study, however, none of the respondents linked the story in the movie with the concept of “good death.” More discussions on this concept needed to be incorporated in the future ethical courses so that students could see not only the elements but also the “whole picture” of what “good death” might be. Next step would be the discussion of the relevance of this concept to the contemporary end-of-life care. Bearing in mind that the majority of the students in the management of healthcare were experienced nurses and midwives, the significance of such discussion is undoubted.
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Table 4. The students’ answers to the question: ‘‘What is your general impression of the movie?’’ Movie
Students answers
‘‘Whose life is it anyway?’’
Provokes empathy Mixed feelings I’ve seen the movie ‘‘through different eyes’’ after the education Provokes philosophical thoughts about life Affective The question has been misunderstood Not answered Mixed feelings Provokes thoughts about the significance of family Provokes sadness Provokes philosophical thoughts about life Affective The question has been misunderstood Not answered
‘‘My life’’
% 5.1 10.3 10.3 12.8 30.8 12.8 23.1 3.8 7.5 13.2 17 28.3 26.4 9.4
Table 5. The students’ answers to the question: ‘‘Do you consider movies as useful in ethics training?’’ Movie ‘‘Whose life is it anyway?’’ ‘‘My life’’
Positive answer
Negative answer
Partially useful
Not answered
97.4% 94.3%
2.6% 1.9%
– 1.9%
– 1.9%
The majority of the students (30.8% and 28.3%, respectively) defined their general impression of the movies as affective (Table 4). The movie “Whose life is it anyway?” provoked empathy in 5.1% of the students and philosophical thoughts about life in 12.8% of the students. The reactions on the movie “My life” were different. It provoked thoughts about significance of the family (7.5%), sadness (13.2%), and philosophical thoughts about life (17%). Mixed feelings were reported by 10.3% of the students in relation to the movie “Whose life is it anyway?” and by 3.8% of the students in relation to the movie “My life.” Additionally, 10.3% of the students felt the influence of the education on their perception of the movie “Whose life is it anyway?” As a whole, the students gave positive opinion about the usefulness of movies in ethics training (97.4% and 94.3%, respectively) (Table 5). Despite the general positive results of this study, regular application of movies in bioethics teaching requires structural changes in the programs. Currently, bioethics courses for students in the management of healthcare include 20 academic hours’ lectures. The presentation of a full-length movie requires about 90–120 min (2–3 academic hours) and at least 30 min for discussion in an oral or a written form. Thus, this educational approach is rather time-consuming, and the current number of academic hours does not allow its wide application. On the other hand, an effective movie discussion can be initiated only after the introduction of the theoretical concepts. Last but not least, movies’ presentations require special technical equipment. From an educational perspective, we still have to overcome the insufficient training of ethics teachers to make the best use of a movie discussion. It is a common misbelief that movie presentation and discussion do not require special training of teachers. In fact, this is a very exigent approach which requires good preparation in advance. Teachers should be able to direct discussion toward achievement of educational goals and avoid emotional distractions. In this sense, the original protocols for film discussion, developed for this study, present an important methodological contribution to ethics teaching.
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The favorable results of this study could support further updates in the teaching programs to include more time for movies’ presentations and discussions. These could also be offered in the form of extra activities— study circles/groups. However, such activities are optional, and not all students will be exposed to the same educational methods.
Conclusion The inclusion of full-length non-documentary movies in ethics teaching is an innovative approach for our country. In the medical curricula, short documentaries are used rather for illustrative purposes in different courses but not for discussion. The presented innovative approach of teaching bioethics was well accepted by the students. The films provided a better understanding of the social experience of illness and placed the patient’s perspective in the foreground. In comparison with the classical written cases, film cases cut across the pathology and stressed on the effect of the disease on patient’s life. Thus, movies had the potential not only to attract students’ attention and illustrate vividly bioethical issues but also to contribute to the exploration of specific theses and arguments and enable the construction of different perspectives of patient’s situation. The movies were not a substitute for other teaching approaches, but rather they allowed the presentation of ethical dilemmas in situations resembling the real clinical cases. Thus, the movies could create a stimulating learning environment. However, watching films could be a difficult activity since it was an active form of study which required training and experience.15 The application of this innovative approach should be preceded by theoretical instruction. Starting with “simple” educational approaches as mere theoretical presentations illustrated by cases and passing through systematized ethical case analysis, the future of bioethics education seems to be in interaction. Interaction can be “imposed” on students by role models games, discussion groups, drawing problem trees, and many other moral games.16 None of these, however, affects students’ emotions and imagination and creates such natural drive for discussion as movies do. Comparing the results of our study with the preliminary expectations based on the literature review (Table 1), confirmation was found in the following aspects: film cases were richer than classical written ones and were found to be useful by the students; movies illustrated well theoretical philosophical ideas and bioethical claims. Subsequent group discussions were based on the provided narratives and showed an advanced understanding of philosophical ideas and improvement in students’ critical thinking skills. Further research in the same cohort of students after their graduation could provide more reliable information about the connection between theoretical and practical decision-making, which can be an objective for future studies. Conflict of interest The author declares that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References 1. Александрова-Янкуловска С [Aleksandrova-Yankulovska S]. Ръководство за практически упражнения по биоетика [Practical assignments in bioethics with case studies]. Плевен [Pleven]: Издателски център на МУ-Плевен [Publishing center of MU-Pleven], 2010, p. 104.
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2. Volandes A. Medical ethics on film: towards a reconstruction of the teaching of healthcare professionals. J Med Ethics 2007; 33(11): 678–680. 3. Champoux JE. Using film to visualize principles and practices. 1st ed. Cincinnati, OH: South-Western College Publishing, 2001. 4. Kester GW, Cooper GJ, Dean RA, et al. Hollywood movies in the classroom: bringing finance and business ethics alive. In: Wankel C and Stachowicz-Stanusch A (eds) Handbook of research on teaching ethics in business and management education, vol. 1. Hershey, PA: IGI Global, pp. 622–639. 5. Wohlke S and Schicktanz S. Movies as teaching material—ethical issues in organ transplantation. In: Wiesemann C and Wohlke S (eds) Teaching ethics in organ transplantation and tissue donation. Cases and movies. Gottingen: Universitatsverlag Gottingen, 2010, pp. 67–75. 6. Giacalone RA and Juriewicz CL. Lights, camera, action: teaching ethical decision making through the cinematic experience. Teach Bus Ethics 2001; 5(1): 79–87. 7. Kalman JZ. Teaching ethics can be fun. Consider film clips to pump up your presentation. ABA Bus Law Sect 2005; 15(2), www.americanbar.org 8. IMDb. Whose life is it anyway? 1981, http://www.imdb.com/title/tt0083326/ (accessed 18 July 2014). 9. IMDb. My life, 1993, http://www.imdb.com/title/tt0107630/ (accessed 18 July 2014). 10. International Association for Hospice and Palliative Care (IAHPC). Hospice/palliative care: getting started. Houston, TX: IAHPC Press, 2005. 11. Clark D. “Total pain,” disciplinary power and the body in the work of Cicely Saunders, 1958–1967. Soc Sci Med 1999; 49(6): 727–736. 12. Dekkers W. Coming home. On the goals of palliative care. In: Ten Have H and Janssens R (eds) Palliative care in Europe. Amsterdam: IOS Press, 2001, pp. 117–127. 13. Kubbler-Ross E. On death and dying. New York: Touchstone, 1969, p. 286. 14. Walters G. Is there such thing as a good death? Palliat Med 2004; 18: 404–408. 15. Pilant J. Using film to teach business ethics. Pilant’s business ethics blog, 2010, http://southwerk.com/2010/08/17/ using-film-to-teach-business-ethics/ (accessed 18 July 2014). 16. Macer DRJ. Moral games for teaching bioethics. The International Center for Health, Law and Ethics, UNESCO Chair of Bioethics, Haifa, Israel, 2008, p. 128.
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An innovative approach to teaching bioethics in management of healthcare
Nursing Ethics 2016, Vol. 23(2) 167–175 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014558967 nej.sagepub.com
Silviya Aleksandrova-Yankulovska Medical University of Pleven, Bulgaria
Abstract Background: Bioethical courses were introduced in the curricula in medical universities in Bulgaria in 1990s. In the beginning, the courses were mainly theoretical, and systematic case analyses and discussions of movies were introduced later on. The benefits of using films to teach ethics have been previously analyzed in the literature; however, to our knowledge such studies in Bulgaria are yet lacking. Objective: The aim of this study was to survey the opinions of students and analyze the results from the application of movies in bioethics teaching in a medical university in the north of Bulgaria. Methodology: A survey was carried out among 92 students in the management of healthcare. Two movies were used, and separate protocols for film discussion were developed. Ethical considerations: The study was conducted anonymously and with students’ free informed consent. Results and discussion: The students distinguished in total 21 different dilemmas and concepts in the first movie. The ethical dilemmas were classified into five groups: general ethical issues, deontological issues, special ethical issues, principles of bioethics, and theories of ethics. The second movie focused students’ attention on the issues of death and dying. In total, 18 elements of palliative care were described by the students. The range of different categories was a positive indicator of an increased ethical sensitivity. The students evaluated the movies’ discussions as a generally positive educational approach. They perceived the experience as contributing to their better understanding of bioethical issues. Conclusion: The innovative approach was well accepted by the students. The introduction of movies in the courses of bioethics had the potential to provide vivid illustrations of bioethical issues and to contribute to the exploration of specific theses and arguments. The presentation and discussion should be preceded by accumulation of theoretical knowledge. The future of effective bioethics education lays in the interactive involvement of students. Keywords Bioethics, ethical dilemmas, innovative approach, movies’ discussion, teaching bioethics
Introduction The first courses in bioethics were introduced in the medical curricula in medical curricula in Bulgaria in 1990s. In the beginning, the courses were mainly theoretical and focused on the general part of bioethics Corresponding author: Silviya Aleksandrova-Yankulovska, Department of Public Health Sciences, Faculty of Public Health, Medical University of Pleven, 1 Kliment Ohridski Street, 5800 Pleven, Bulgaria. Email: [email protected]
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Table 1. The benefits of using films to teach ethics. Wohlke and Schicktanz5
Giacalone and Juriewicz6
Provide narratives for bioethical reflection; Provide useful case studies; Give fleshed-out interpretations of bioethical claims; Compelling illustrations for philosophical ideas; Intellectually stimulating; Can offer interpretation and advanced understanding of philosophical ideas.
Provide a systemic context for ethical decisions; Have depth and richness not found in cases; Develop critical thinking skills; Make the connection between theoretical and practical ethical decision-making.
(i.e. theories of ethics, basic principles, confidentiality, informed consent, models of relationships, patients’ rights). Special issues such as ethical problems related to human reproduction, end-of-life care, transplantation, human experimentation, and resource allocation were barely discussed. The teachers were mainly public health specialists since medical ethics in Bulgaria was not a separate specialty but a part of public health. Only a few teachers had the chance to receive specific ethical training and to broaden their qualification abroad. The increased access to specialized literature on bioethics played an important role in improving the qualification of the teachers. Initially, the teaching approaches included mainly lectures and discussions of short cases. The cases were predominantly used as an illustration of the theoretical concepts and for determining violation of norms. The methodology of detailed case analysis was first introduced in the bioethics teaching in Bulgaria by Silviya Aleksandrova-Yankulovska1 in her textbook Practical Assignments with Case Studies in 2010. The inclusion of cases in ethical teaching, however, has some limitations. First, the clinical data in written cases are usually scarce and lots of additional information is needed in order to arrive at a sound decision. In addition, medical ethics courses for students in medicine, nursery, and midwifery are taught during the early years of training, when students are unfamiliar with the clinical settings in which ethical issues arise and experience difficulties in comprehending the situation. Second, the written cases are focused on “dry information” and fail to present the patient’s viewpoint. Films, on the other hand, can help in overcoming these drawbacks by presenting more personal and professional details of a certain situation. The advantages of films as a teaching instrument have been discussed by different authors. Volandes2 pointed the ability of films to fill in the imaginative leap of the clinically inexperienced students. Films offer a visualization of concepts that might be abstractly presented in textbooks and lectures, and students respond favorably to the link between the film scenes and the abstract theory and concepts.3 Specific medical terms which often appear in the traditional written cases lose their abstract qualities.2,4 Films also present the sometimes overlooked patient’s perspective and voice and allow for deeper understanding and appreciation of the individual’s experience of having a disease. The students in the management of healthcare, who were involved in this study, were mostly practicing nurses and midwives. They did not lack practical experience per se, but they came from different professional environment. Since caring for different patients exposed care givers to specific experience, the students demonstrated different perceptions when discussing philosophical issues such as the following: what “good death” was, moral acceptability of abortion and assisted reproduction technologies, and limitations of artificial life support. A systematic revision of the benefits of using films to teach ethics is provided in Table 1. The limitations of films as teaching materials were also recognized in the literature. Film clips could be manipulated to favor a particular perspective.2,7 The social and emotional elements of the presented stories could hinder professional judgment and achievement of educational goals if students forgot about the specific
Downloaded from nej.sagepub.com at LOYOLA UNIVERSITY CHICAGO on April 14, 2016
Aleksandrova-Yankulovska
169
objectives of the film discussion. Bearing this in mind, ethics teachers could direct movies’ discussions to answer questions such as the following: How is the movie biased with respect to different ethical perspectives? Which arguments and perspectives are stressed and which are underestimated?5 The teacher’s preparation included viewing the film in advance and preparing the discussion questions that linked the theoretical knowledge to the storyline. The discussion after the movie could be guided in oral form or could be done in written form by each student.
Aim The aim of this study was to survey the opinions of students in the management of healthcare and analyze the results from the application of movies in bioethics teaching in a medical university of north Bulgaria.
Methodology For the purpose of the current analysis, two movies were selected and applied in the bioethics courses of different specialties in the studied university: “Whose life is it anyway?” (1981) is a Hollywood drama presenting the story of Ken Harrison, who was a sculptor. He was involved in a car accident and was paralyzed from his neck. All he could do was talk, and he wanted to die. In the hospital, he made friends with some of the staff, and they supported him when he went to trial to be allowed to die.8 “My life” (1993) is a story about the life of Bob Jones, a young man with a successful career and a happy family, whose wife is pregnant. Bob finds out he has cancer and will die within months. He sets out to video-tape his life’s acquired wisdom for his child and ends up on a voyage of selfdiscovery and reconciliation.9 The choice of the movies was made in accordance with two criteria: range of ethical issues presented in the movie and consistency with the preliminary theoretical preparation of the students. The first movie was presented and discussed in the course of medical ethics. Although this movie told the story of a man who pleaded for euthanasia, class discussion was rather directed toward the wide range of ethical issues surrounding patient care. The second movie was presented and discussed in the course of management and ethics of hospice care. The movie had been chosen because of the representation of the specific philosophical concepts in relation to terminal care. The study was conducted in the period September 2013–March 2014. In total, 92 students in the management of healthcare, bachelor’s and master’s degree, were involved. The movie “Whose life is it anyway?” was seen by 39 students (25 bachelor’s and 14 master’s students). The movie “My life” was seen by 53 students (17 bachelor’s and 36 master’s students). Only 11 master’s degree students saw both movies due to organizational reasons. The comparison between students who saw only one of the movies and the group of students who saw both movies was not part of the objectives of this study and therefore was not performed. Two questionnaires (protocols) designed for bioethical film discussion were developed and applied in this study. The questionnaire for the movie “Whose life is it anyway?” included five open-ended questions: 1. Please, summarize the story of the movie. 2. What ethical dilemmas have been presented in the movie “Whose life is it anyway?” 3. What is your general impression of the movie?
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4. Do you consider movies as useful in ethics training? 5. Express your opinion about the movie. The questionnaire for the movie “My life” included six open-ended questions: 1. 2. 3. 4. 5. 6.
Please summarize the story of the movie. Which elements of palliative care have you been able to recognize in the movie “My life”? Which of the Elizabeth Kubbler-Ross’ stages of psychological reaction were illustrated in the movie? What is your general impression of the movie? Do you consider movies as useful in education? How the movie contributed to your better understanding of hospice/palliative care?
Ethical considerations The study was conducted anonymously. Study objectives were explained to the students before the distribution of the protocols. The teacher was not present at the answering of the questionnaire. The protocols were returned in a specially designed closed box. Students, who did not want to participate in the study, had the option to return empty protocols. The participation in the study was in no way related to the assessment of students’ performance in the studied courses.
Results and discussion The first focus of interest was the students’ perception of the presented story. Since full-length movies were complex and reach in storylines,4 students could “grasp” different problems on first place. Almost equal percentage of students (41% and 49%, respectively) made formal summary of the story of both films. An interesting scene of the movie “Whose life is it anyway?” presented the court discussion on the wish of the patient to be allowed to die. This scene was in the focus of 41% of students’ resumes. The collision between the patient and the hospital team was marked in 12.8% of the answers. Bigger variety of interpretations was found in the resumes of the movie “My life.” Equal number of students (17%) made philosophical interpretation of the story and focused on the birth of Bob’s son. The concept of fully lived rest of Bob’s life almost got the same attention (15%). The stages of the main characters’ transformation and family support were present in the answers of 9.4% of the students who had seen the movie “Whose life is it anyway?” and 5.7% of the students who had seen the movie “My life.” Although the majority of the resumes were formal representations of the movies’ storylines, the variety of the students’ interpretations was a positive indicator for the effect of movie discussion as an educational approach. In view of the medical background of the students, the attempt to make philosophical interpretation of the story deserved special attention. There was no other philosophical course in these students’ curricula, and the transformation to an abstract way of thinking could be linked to the ethics studies. The ethical dilemmas distinguished by the students in the movie “Whose life is it anyway?” could be arranged in several groups (Table 2): general ethical issues in medical practice, deontological issues, special ethical issues, principles of bioethics, and theories of ethics. The central problems recognized by the students were respect for autonomy issues (69.2%), medical paternalism (28.2%), and issues surrounding euthanasia (35.9%). The application of the casuistry approach during the court discussions and the final decision-making in the film case was noted by 15.4% of the students. A small number of students were even able to distinguish elements of applied ethics (5.1%), utilitarianism (5.1%), ethics of justice (2.6%), and ethics of care (2.6%). In total, 21 different ethical dilemmas and concepts were defined. The movie “My life” offered a different experience to the students. Since it told the story of a terminally ill man, many theoretical concepts from the area of end-of-life care were illustrated in the film (Table 3). In all,
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Table 2. The ethical dilemmas distinguished by the students in the movie ‘‘Whose life is it anyway?’’ What ethical dilemmas have been presented in the movie ‘‘Whose life is it anyway?’’ General ethical issues in medical practice Paternalism ‘‘Physician–patient’’ relationships Patient’s rights Objectivity of second opinion Professional relationships Personal relationship with medical professionals Confidentiality Deontological issues Professional duty Malpractice Informed consent Competency assessment Special ethical issues Euthanasia Emergency treatment Principles of bioethics Respect for autonomy Beneficence and non-maleficence Justice Theories of ethics Applied ethics Utilitarianism Casuistry Ethics of justice Ethics of care
% 28.2 25.6 20.5 10.3 7.7 2.6 7.7 15.4 7.7 20.5 15.4 35.9 10.3 69.2 33.3 7.7 5.1 5.1 15.4 2.6 2.6
45.3% of the students focused their attention on pain control as a key element of palliative care. The provision of care at the patient’s home was observed by 37.7% of students. Enabling patients to stay at their homes at the terminal stage of their illness is one of the most significant characteristics of the hospice/palliative care which distinguishes it from the traditional hospital care.10 The other elements of the “total pain” concept11 were also determined by a significant number of students: spiritual support (28.3%), psychological support (26.3%), and social support (17%). The concept of “total pain” itself was pointed out by 20.8% of the students. The importance of family support (one of the cornerstones in the film script) was underlined in 13.2% of the responses. It is worth mentioning that one student was able to see an illustration of one of the goals of palliative care—“coming home.” In the movie, it was presented with three of its five possible meanings: one’s own home, one’s own body (feeling comfortable in one’s own body as a result of adequate symptom control), and spiritual environment in respect of patient’s preferences and values.12 A few students (1.9%) determined concepts as Practical palliative nursing service and Sheffield model of palliative care in the movie. In total, 18 elements of palliative care were present in students’ answers. The range of different categories was a positive indicator for the increased ethical sensitivity of the students to the issues of death and dying as a result of the education. Special emphasis in the discussion of the movie “My life” was placed on the recognition of Elizabeth Kubbler-Ross’13 five stages of grief: denial, anger, bargaining, depression, and acceptance (Figure 1). Considering that there is certain disagreement even among ethicists about the interpretation of these stages, the task of the students was more than mere recalling of the theoretical definitions. In the opinion of 30.2% of the
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Table 3. The ethical dilemmas distinguished by the students in the movie ‘‘My life.’’ Which elements of palliative care have you been able to recognize in the movie ‘‘My life’’?
%
Pain control Home care Spiritual support Psychological support ‘‘Total pain’’ The role of the nurse in care provision Provision of equipment at the patient’s home Social support Family support Intensity Comprehensiveness Quality of life Acceptance of medicine’s limitations Practical palliative nursing service ‘‘Coming home’’ Sheffield model of palliative care Respect for autonomy Protection of patient’s dignity
45.3 37.7 28.3 26.4 20.8 18.9 17 17 13.2 13.2 9.4 7.5 3.8 1.9 1.9 1.9 1.9 1.9
92,5%
Acceptance of death 30,2%
Depression Bargain
79,2%
Anger
85% 71,7%
Denial 0
20
40
60
80
100
Figure 1. The students’ perception about the presence of Elizabeth Kubbler-Ross’ stages of psychological reaction in the movie ‘‘My life.’’
students and in my own view, the stage of depression was not experienced by Bob Jones (the character in the movie “My life”). As for the rest of the stages, the students recognized them in a different manner. According to 92.5% of the students, Bob Jones accepted death in its spiritual meaning. One common idea in the literature is that persons/patients who reached the stage of acceptance have a “good death.”14 In this study, however, none of the respondents linked the story in the movie with the concept of “good death.” More discussions on this concept needed to be incorporated in the future ethical courses so that students could see not only the elements but also the “whole picture” of what “good death” might be. Next step would be the discussion of the relevance of this concept to the contemporary end-of-life care. Bearing in mind that the majority of the students in the management of healthcare were experienced nurses and midwives, the significance of such discussion is undoubted.
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Table 4. The students’ answers to the question: ‘‘What is your general impression of the movie?’’ Movie
Students answers
‘‘Whose life is it anyway?’’
Provokes empathy Mixed feelings I’ve seen the movie ‘‘through different eyes’’ after the education Provokes philosophical thoughts about life Affective The question has been misunderstood Not answered Mixed feelings Provokes thoughts about the significance of family Provokes sadness Provokes philosophical thoughts about life Affective The question has been misunderstood Not answered
‘‘My life’’
% 5.1 10.3 10.3 12.8 30.8 12.8 23.1 3.8 7.5 13.2 17 28.3 26.4 9.4
Table 5. The students’ answers to the question: ‘‘Do you consider movies as useful in ethics training?’’ Movie ‘‘Whose life is it anyway?’’ ‘‘My life’’
Positive answer
Negative answer
Partially useful
Not answered
97.4% 94.3%
2.6% 1.9%
– 1.9%
– 1.9%
The majority of the students (30.8% and 28.3%, respectively) defined their general impression of the movies as affective (Table 4). The movie “Whose life is it anyway?” provoked empathy in 5.1% of the students and philosophical thoughts about life in 12.8% of the students. The reactions on the movie “My life” were different. It provoked thoughts about significance of the family (7.5%), sadness (13.2%), and philosophical thoughts about life (17%). Mixed feelings were reported by 10.3% of the students in relation to the movie “Whose life is it anyway?” and by 3.8% of the students in relation to the movie “My life.” Additionally, 10.3% of the students felt the influence of the education on their perception of the movie “Whose life is it anyway?” As a whole, the students gave positive opinion about the usefulness of movies in ethics training (97.4% and 94.3%, respectively) (Table 5). Despite the general positive results of this study, regular application of movies in bioethics teaching requires structural changes in the programs. Currently, bioethics courses for students in the management of healthcare include 20 academic hours’ lectures. The presentation of a full-length movie requires about 90–120 min (2–3 academic hours) and at least 30 min for discussion in an oral or a written form. Thus, this educational approach is rather time-consuming, and the current number of academic hours does not allow its wide application. On the other hand, an effective movie discussion can be initiated only after the introduction of the theoretical concepts. Last but not least, movies’ presentations require special technical equipment. From an educational perspective, we still have to overcome the insufficient training of ethics teachers to make the best use of a movie discussion. It is a common misbelief that movie presentation and discussion do not require special training of teachers. In fact, this is a very exigent approach which requires good preparation in advance. Teachers should be able to direct discussion toward achievement of educational goals and avoid emotional distractions. In this sense, the original protocols for film discussion, developed for this study, present an important methodological contribution to ethics teaching.
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The favorable results of this study could support further updates in the teaching programs to include more time for movies’ presentations and discussions. These could also be offered in the form of extra activities— study circles/groups. However, such activities are optional, and not all students will be exposed to the same educational methods.
Conclusion The inclusion of full-length non-documentary movies in ethics teaching is an innovative approach for our country. In the medical curricula, short documentaries are used rather for illustrative purposes in different courses but not for discussion. The presented innovative approach of teaching bioethics was well accepted by the students. The films provided a better understanding of the social experience of illness and placed the patient’s perspective in the foreground. In comparison with the classical written cases, film cases cut across the pathology and stressed on the effect of the disease on patient’s life. Thus, movies had the potential not only to attract students’ attention and illustrate vividly bioethical issues but also to contribute to the exploration of specific theses and arguments and enable the construction of different perspectives of patient’s situation. The movies were not a substitute for other teaching approaches, but rather they allowed the presentation of ethical dilemmas in situations resembling the real clinical cases. Thus, the movies could create a stimulating learning environment. However, watching films could be a difficult activity since it was an active form of study which required training and experience.15 The application of this innovative approach should be preceded by theoretical instruction. Starting with “simple” educational approaches as mere theoretical presentations illustrated by cases and passing through systematized ethical case analysis, the future of bioethics education seems to be in interaction. Interaction can be “imposed” on students by role models games, discussion groups, drawing problem trees, and many other moral games.16 None of these, however, affects students’ emotions and imagination and creates such natural drive for discussion as movies do. Comparing the results of our study with the preliminary expectations based on the literature review (Table 1), confirmation was found in the following aspects: film cases were richer than classical written ones and were found to be useful by the students; movies illustrated well theoretical philosophical ideas and bioethical claims. Subsequent group discussions were based on the provided narratives and showed an advanced understanding of philosophical ideas and improvement in students’ critical thinking skills. Further research in the same cohort of students after their graduation could provide more reliable information about the connection between theoretical and practical decision-making, which can be an objective for future studies. Conflict of interest The author declares that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References 1. Александрова-Янкуловска С [Aleksandrova-Yankulovska S]. Ръководство за практически упражнения по биоетика [Practical assignments in bioethics with case studies]. Плевен [Pleven]: Издателски център на МУ-Плевен [Publishing center of MU-Pleven], 2010, p. 104.
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2. Volandes A. Medical ethics on film: towards a reconstruction of the teaching of healthcare professionals. J Med Ethics 2007; 33(11): 678–680. 3. Champoux JE. Using film to visualize principles and practices. 1st ed. Cincinnati, OH: South-Western College Publishing, 2001. 4. Kester GW, Cooper GJ, Dean RA, et al. Hollywood movies in the classroom: bringing finance and business ethics alive. In: Wankel C and Stachowicz-Stanusch A (eds) Handbook of research on teaching ethics in business and management education, vol. 1. Hershey, PA: IGI Global, pp. 622–639. 5. Wohlke S and Schicktanz S. Movies as teaching material—ethical issues in organ transplantation. In: Wiesemann C and Wohlke S (eds) Teaching ethics in organ transplantation and tissue donation. Cases and movies. Gottingen: Universitatsverlag Gottingen, 2010, pp. 67–75. 6. Giacalone RA and Juriewicz CL. Lights, camera, action: teaching ethical decision making through the cinematic experience. Teach Bus Ethics 2001; 5(1): 79–87. 7. Kalman JZ. Teaching ethics can be fun. Consider film clips to pump up your presentation. ABA Bus Law Sect 2005; 15(2), www.americanbar.org 8. IMDb. Whose life is it anyway? 1981, http://www.imdb.com/title/tt0083326/ (accessed 18 July 2014). 9. IMDb. My life, 1993, http://www.imdb.com/title/tt0107630/ (accessed 18 July 2014). 10. International Association for Hospice and Palliative Care (IAHPC). Hospice/palliative care: getting started. Houston, TX: IAHPC Press, 2005. 11. Clark D. “Total pain,” disciplinary power and the body in the work of Cicely Saunders, 1958–1967. Soc Sci Med 1999; 49(6): 727–736. 12. Dekkers W. Coming home. On the goals of palliative care. In: Ten Have H and Janssens R (eds) Palliative care in Europe. Amsterdam: IOS Press, 2001, pp. 117–127. 13. Kubbler-Ross E. On death and dying. New York: Touchstone, 1969, p. 286. 14. Walters G. Is there such thing as a good death? Palliat Med 2004; 18: 404–408. 15. Pilant J. Using film to teach business ethics. Pilant’s business ethics blog, 2010, http://southwerk.com/2010/08/17/ using-film-to-teach-business-ethics/ (accessed 18 July 2014). 16. Macer DRJ. Moral games for teaching bioethics. The International Center for Health, Law and Ethics, UNESCO Chair of Bioethics, Haifa, Israel, 2008, p. 128.
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