Attitudes towards informed consent, confidentiality, and substitute treatment decisions in southern African medical students: a case study from Zimbabwe

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Abstract

This study explored the attitudes of biomedical science students (medical students) in a non-Western setting towards three medical ethics concepts that are based on fundamental Western culture ethical principles. A dichotomous (agree/disagree) response questionnaire was constructed using Western ethnocentric culture (WEC) based perspectives of informed consent, confidentiality, and substitute decision-making. Hypothesized WEC-Biased responses were assigned to the questionnaire’s questions or propositions. A number of useful responses (169) were obtained from a large, cross-sectional, convenience sample of the MBChB students at the University of Zimbabwe Medical School. Statistical analysis described the differences in response patterns between the student’s responses compared to the hypothesized WEC-Biased response. The effect of the nine independent variables on selected dependent variables (responses to certain questionnaire questions) was analyzed by stepwise logistic regression. Students concurred with the hypothesized WEC-Biased responses for two-thirds of the questionnaire items. This agreement included support for the role of legal advocacy in the substitute decision-making process. The students disagreed with the hypothesized WEC-Biased responses in several important medical ethics aspects. Most notably, the students indicated that persons with mental dysfunctions, as a class, were properly considered incompetent to make treatment decisions. None of the studied independent variables was often associated with students’ responses, but training year was more frequently implicated than either ethnicity or gender. In order to develop internationally and culturally relevant medical ethics standards, non-Western perspectives ought to be acknowledged and incorporated. Two main areas for further efforts include: curriculum development in ethics reasoning and related clinical (medico-legal) decision-making processes that would be relevant to medical students from various cultures, and; the testing of models that could increase legal system input in the clinical process in societies with limited jurisprudence resources.

Introduction

Biomedical science can be reasonably viewed as a Western world ethnocentric ‘cultural phenomenon’ (Helman, 1991). It is not surprising to find that the writings and discourse on biomedical ethics has been dominated by Western philosophy, moral thinking and social consciousness perspectives (Pellegrino, 1992).

Today’s biomedical science students (‘medical students’) will shape the future practice of medical ethics. As used here, ‘medical ethics’ or ‘ethics’ refers to the standards of conduct considered proper for members of the biomedical science (‘medical’) profession. The terms are not meant to refer to fundamental principles of ethics reasoning (Beauchamp and Childress, 1989). Medical students around the world are likely to embrace differing perspectives in medical ethics. The students’ native culture and unique life and educational experiences will shape their perspectives (Pellegrino et al., 1992). Diminishing Western culture’s hegemony in clinical ethics by integrating non-Western cultural perspectives will enrich those ethics. This enrichment process would parallel how an appreciation of ‘alternative’ (non-Western) medical systems such as acupuncture, meditation, massage, and diet manipulation (Peterson, 1996, Kaul, 1996, Schimpff, 1997) has enriched Western biomedicine practice and theory.

Exploring the attitudes towards Western inspired clinical ethics concepts of medical students who were born, raised and are training in non-Western settings would help determine in what ways, if any, the Western inspired attitudes are not embraced. The exploration might also give some indication about what alternative perspectives should be more carefully considered in an effort to support the internationalization of medical (and ‘health care’) ethics.

A project was undertaken at the University of Zimbabwe Medical School, Department of Psychiatry to ascertain the extant medical ethics attitudes of health care providers and care-seekers in Zimbabwe. This paper reports on a study undertaken as part of that project. This study explored how medical students from a respected University in a clearly non-Western cultural setting perceived three crucial, clinically relevant concepts in medical ethics. The three crucial concepts are confidentiality, treatment (informed) consent, and substitute treatment decision-making. A plethora of writings from philosophical, medical, legal, social, and religious perspectives attests to each concept’s canonization in Western medical ethics.

Review of several medical, psychological and social literature computer databases did not reveal reports from similar studies that focused on medical students in a southern African country nor in other parts of the world.

Section snippets

Setting

The Godfrey Huggins School of Medicine at the University of Southern Rhodesia, located in the country’s capital city, was established in 1969. It granted MBChB (equivalent to the USA ‘MD’) degrees in conjunction with the University of Birmingham in England until the mid-1980s. Today, it grants degrees independently as the University of Zimbabwe Medical School.

Since national independence in 1980 and the formation of the Republic of Zimbabwe, the faculty and student body membership at the

Results

All distributed questionnaires were returned. Fourteen questionnaires were excluded because they had missing data for 5% or more of the dependent and/or independent variables. A further 44 questionnaires were excluded because gender was not given or because total years of schooling in Zimbabwe was recorded as less than 13 and, therefore, were deemed to have been inaccurately recorded. The remaining sample of 169 students was nearly identical to the original sample in terms of the demographic

Discussion

This work sought to define ‘what would the student do’ or ‘what is the student’s attitude towards …’ in relation to several biomedical ethics concepts as elaborated by Western ethnocentric perspectives. The study was not meant to explore the reasoning process by which the students arrived at their decisions nor was it intended to be an in-depth, qualitative exploration of what are these students’ perceptions concerning medical ethics in general. Such studies are left for other efforts.

It is

Acknowledgments

This study was supported by a grant from the Oak Foundation, Zimbabwe. Appreciation is due Dr. M. Hove for his assistance and encouragement in this project.

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    This work was completed while the author was: Consultant and Lecturer, Department of Psychiatry, University of Zimbabwe Medical School, Harare, Zimbabwe

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