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March 2018, Volume 68, Issue 3

Special Communication

Culture and ethics in medical education: The Asian perspective

Muhammad Shahid Shamim  ( Surgery, and Medical Education Unit, Rabigh Medical College, King Abdulaziz University, Jeddah, Saudi Arabia )
Lubna Baig  ( APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan )
Adrienne Torda  ( Prince of Wales Clinical School, Sydney, Australia University of New South Wales, Sydney, Australia )
Chinthaka Balasooriya  ( Medical Education Development School of Public Health & Community Medicine University of New South Wales, Sydney, Australia )

Abstract

The world is geographically divided into hemispheres, continents and countries, with varying cultures in different regions. Asia, the largest of continents, has a variety of philosophically distinctive cultures and lifestyles, informing the norms of societies that are much different from cultures in other continents. These complexities in the societal norms in Asian cultures have created unique issues in development of ethics education in the region. This paper looks in to the distinctions in what is generally referred to as the "non-western" Asian culture, the importance of cultural context and how it influences the ethics curriculum in the region.

Keywords: Asia, Culture, Religion, Ethics, Education.

Introduction

The United Nations Educational, Scientific and Cultural Organization (UNESCO) 2002, describes culture as "…the set of distinctive spiritual, material, intellectual and emotional features of society or a social group, and that it encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions and beliefs." Within the Asian region, the regional cultures are dominated by varying traditions and beliefs of people. Although the social structure of major cities is progressively pluralizing with secular modernization, the general lifestyles of communities are by-and-large traditional and belief-oriented1 In this context, it is often challenging for educationists to teach medical ethics embedded in moral philosophy and values, to healthcare professionals dealing with patients (and their families) from different traditional norms and varying beliefs.2 Additionally, the medical curricula being based on Western models,3 institutional factors; like limited resources, motivation and interest of faculty members,economic and geo-political contexts of the countries in the region4,5 further complicate the delivery of ethics in medical education. 
It is therefore, necessary for medical ethics curriculum designers to understand these influences and empower their students with the ability to face ethical issues through relevant contextual discourse and reasoning.6
This paper looks in to the distinctions in what is generally referred to as the "non-western" Asian culture, the importance of cultural context and how it influences the ethics curriculum in the region.

Cultural Diversity and Ethics in Medical Education

The world is geographically divided into hemispheres, continents and countries. In the educational arena, developed countries of North America, Western Europe, Australia and New Zealand, where the process of medical education is considered established and standardized, are often referred to as "West" in the literature.3,7-9 "Non-western" countries include most of the Asian, African, South American and central European states where medical education is still developing, and generally follows the western trends and technological progress. In this global scenario, the "non-western" Asia (including Middle-East, Sub-Continent, and Far-East regions) represents a wide variety of diverse social structures based on spoken languages and socio-cultural ways of life. These
cultures have been carved through the influences of political history, local traditions (practices) and religious beliefs (and sects on the basis of beliefs).3,8,10 People living in these countries are considered socially different from the western population in their day-to-day lives, including expectations from the society and interactions with professionals. Chandratilake and colleagues (2012) conducted a multi-regional study on cultural similarities and differences in medical professionalism. They suggest that Asians are generally "collectivist" in nature, and tend to "value membership of a long-term group (like family or community) and therefore social orientation is comparatively high".11 They and other social scientists consider Asians as community oriented and less tolerant towards views against traditions and beliefs, compared to their individualist western counterparts.11,12
The findings from research on cultural differences also reflect on the complexities of medical ethics education in the region. In 2009, Lam and Lam published a review article on medical education reforms in developed and developing countries of Asia. They believe that "the curricula and teaching methods of medical education in Asia are based on traditional Western model". The article concludes that "experiences in developed countries of Asia have shown that what has worked in the West may not necessarily be successful in Asia because of different social and cultural dispositions".3 The reports augment the authors\\\' observations that although science and technology in use by medical professionals are mostly similar around the world, expectations from healthcare providers\\\' attitude towards their patients and community markedly vary in different regions and countries due to their diverging cultures.13

Influence of Cultural Context on Medical Ethics Education

Pratt and co-authors (2014) acknowledge the cultural differences and relate them to ethics education in Asian context. They performed a review of literature from four different Asian countries, including China, Bangladesh India and Pakistan, to evaluate how religion and sociocultural differences effect the interpretations of western ethical standards. Their report found that in these countries, medical
ethics is developed from "centuries-old religious and traditional traditions [customs]". The authors perceive that there are areas in medical profession, inspired by religious and philosophically influenced cultural concepts of Asians, which are not explained by western ethical standards.8
AlKabba and colleagues (2013) studied the teaching methods and tools used for ethics education in public sector medical schools in Saudi Arabia, (country dominated by a single religion) where the societies have developed under high influence of their centuries old traditions, while the legal and moral framework is substantially inspired by their religious theology. The authors conclude that "although there is a growing interest and commitment in teaching ethics, …, there is lack of standardization and evaluation methods". In discussing their findings, they argue that "importation" of a secular western curriculum of ethics is "problematic" in Saudi Arabia, as it is not in line with the Islamic teachings, and hence "may not address legal and moral issues" from a local contextual perspective, much different from the western norms.14
Ho and colleagues (2012) share similar views with regards to medical professionalism, with evidence from a study conducted with Taiwanese students. They report significant cultural differences in concept of professionalism (and medical ethics) in Taiwan, a society with deep rooted influence of Confucian\\\'s relationalism, compared to the Western-framed concept.9
The Romanell Report, a product of the Project to Rebalance and Integrate Medical Education (PRIME), acknowledges the contextual complexities of ethics in medical education. The report suggests that ethics education should include contextually desired outcomes and objectives of professionalism curriculum. In addition, the report recommends that customized methods of delivery of content, assessment and evaluation should also be contextualized according to the needs of students and the society.15

Medical Ethics in Asian Context

Hence, there is ample evidence to show the influence of culture on medical ethics education.The cultural diversity within a broadly collectivistic Asian society is reflected in day-to-day activities of medical professionals, such as doctor-patient interactions, process of decision-making, and matters pertaining to consenting, confidentiality, privacy, breaking bad news, beginning and end of life care.16,17 Shimon Glick (1994), physician and teacher of ethics, after working for two decades each in North America and Middle East, discusses the differences he noticed while teaching ethics in different cultures. He concludes that "one person\\\'s principled belief is for another individual, a rigid dogma", suggesting that the doctrines of ethics taught in the West may not be considered absolute in heterogeneous and enriching cultural settings of Asian countries. Glick believes the current basics of academic medical ethics is "purely" western in concepts that needs to be reviewed and modified according to socio-cultural norms of non-western [Asian] regions for effective ethics education in these regions.18
The influence of culture on medical profession is a consistent reflection. The doctor-patient relationship is seen as a partnership in the West, where doctor is the provider of required information and the patient is expected to take independent decision. While in most Asian societies, the relationship is paternalistic in nature. The doctor is often given an authoritative position where s/he has a major role in clinical decision-making.8 Similarly the concept of confidentiality is different in most Asian societies where patients are considered a part of a collective family or tribal unit with shared gains and sufferings. In this context, it is frequently considered a norm to share an adult patient\\\'s information with the "family elders".13 Values of Asian population are more than often integrated with traditional rulings and beliefs, for example, death is considered a transfer process to a new and even better place, rather than the end of life as the general western concept.19 These and other cultural and social differences in different regions in Asian countries, as discussed above, must be considered by local curriculum planners and medical ethics educators while defining the goals of ethics teachings and implementing them into their medical curriculum.

Conclusion

There are a number of factors that may influence delivery of ethics in medical education and need to be confronted. However, this paper specifically provides insight in to the influences of cultural differences from an Asian perspective. We conclude that the educators in different regions must realize the diversities in their cultural context before developing and implementing ethics curriculum.

Disclaimer: The manuscript is part of the PhD work of Dr. Muhammad Shahid Shamim.
Conflict of Interest: None to declare.
Funding Disclosure: None to declare.

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