The teaching moral practices and techniques used in bioethics as a discipline in the Faculties of Medicine in the state of São Paulo

This research analyzed the teaching of moral practices and techniques used in the teaching-learning process of bioethics as a discipline through the information provided by students and teachers. It aims to understand how these practices can contribute in the students’ moral formation. Five Faculties of Medicine in the State of São Paulo were assessed by of questionnaire. Nine teachers were interviewed as well as 206 students and five focal groups of 56 students responded to closed questionnaires which were analyzed quantitatively. The responses of the focal groups and interviews were evaluated and classified qualitatively in categories using Bardin’s categorical content analysis method. Among students’ answers, it was noted that the moral practices and techniques which most mobilized them were: deliberative activities such as feature film and/or TV series discussions, case discussions, roleplaying – dramatization, discussion debates, and lectures and in a smaller proportion traditional lecture classes i.e., the theoretical-practical component tutored from an expositive dialogical perspective. Therefore, these can enable and enhance the process of forming moral identity, which students undergo; if planned adequately to their experiences and through practice and a structural use and if applied with some knowledge of the methodological rationale behind the techniques thus, allowing both the moral intelligence capabilities and building-up of the students’ moral personality to be stimulated and developed.


Introduction
The teaching methods used by teachers in the classroom, most of the times, resort to traditional expositive lectures as a method employed to approach a given content, in which case the student is a passive agent in the process of All the debate revolving around the types of methodologies which are still incorporated in tutoring, according to Anastasiou (2009), occurred because of the legacy left by the Jesuit and Ratio Studium (dated from 1599), whose premise advocated that there should be three basic steps necessary in a lesson: "the lecturing of the content by the teacher, the feedback and questions and the consolidation exercises for students, who are held responsible for memorization for a test" (Anastasiou, 2009, p.17). This conservatory pedagogical practice, which considered as reference the "listen, read, memorize and repeat" throughout the history of education, is the reflection of the Newtonian-Cartesian paradigm that characterizes science from XVII century up to a great part of the XX century aiming to imbue a fragmented and reductionist view (Behrens, 2012). It is noted that although many years have gone by, this methodology still remains present to this day as a one of the most resorted resource which base the foundation and represent the pedagogical thought of professors today.
The main objective in the teaching of bioethics is what is known as moral education, being synonymous with education in values as form of differentiating from the discipline of Moral and Civic Education (MCE), which was created by the Military Junta in Decree /Law Nº 869 of September 1969 and made compulsory in all levels of education and was only extinct in 1993, aiming to a) defend the democratic principle through the preservation of religious spirit, the dignity of human being and love of liberty with responsibility, under the inspiration of God; b) guarantee the preservation, the strengthening and projection of spiritual and ethical values in nationalism." (Brasil, 1969) Neves Júnior W, Serpa de Araújo L, Rego S MedEdPublish https://doi.org/10.15694/mep.2018.0000205.1 Page | 3 This differs completely from what is proposed today as the teaching of bioethics, the moral education and the moral development of the students in all levels of teaching. From both psych pedagogical and experiential knowledge point of view it is in the interindividual relationships that the norms develop and they are those which enable individuals become conscious of Duty and place it above themselves this normative reality which moral consists (Piaget, 2003). Therefore, according to Piaget, "there is no moral without moral education; "education" in the broad sense of the term, which overshadows the innate constitution of the individual" (Piaget, 2003, p.11). To Piaget (2003), there is a proposal all educators and psychologists agree, which states that no moral reality is innate. To La Taille and Menin (2009), utilize Moral Education as Value Education, despite the fact that many values are not moral values, normally, when regarding Education in Values, implicitly, the same values are associated to it, the choices and moral objectives (La Taille and Menin, 2009).
To all those who work with the ethical and moral formation of students, it is understood that moral education can become a way to achieve the objective of forming students better prepared to face ethical and values conflicts. Regarding moral (from the Latin Morale which refers to costumes), and ethics (éthikos -human conduct and customs) have in common the fact that both of them deal with and/or taking care of human values (Hossne, 2004). According to Dewey (2004), one of the main goals of morality is the control of human nature. Besides, feelings such as reasoning appear within the action. Knowing when one should and should not maintain the deeds in a real moral judgement is in itself an important factor to morality (Dewey, 2014).
One of the main objectives of the teaching of Bioethics should be that of developing, in students, the process of finding solutions which involve several abilities, what Kohlberg labels as the capacity of moral pondering and defines it as being the capacity of deciding and judging in moral situations, namely, based on internal principles and actions according to such pondering (Kohlberg, 1964). To both Piaget (1994) and Kohlberg (1987), morality is not only related to moral ideas or attitudes but has a strong cognitive aspect or competence aspect. And the moral reasoning, as a competence, possesses affective and cognitive properties, which are distinct, but inseparable aspects of moral behavior. Nevertheless, according to these authors, to promote the discussion or moral education can trigger a progressive development of morality, which would change from heteronomous to autonomous through among other factors an intellectual understanding even more sophisticated in moral themes (Piaget, 1978;Kohlberg,1987).
According to Piaget (1994) moral judgment and moral behavior are a question of cognitive development, those of which requires a biological maturity of mental structures, as well as the quality of interaction -of the human beings -with its environment, as biopsychosocial (Piaget, 1994). The major challenge of the teacher in education to promote imbalance in situations, and all of which should be adequate to the level of development of the student in each phase of their education.
To Puig and Martin (1998), in order to understand and discuss what moral education means it can be preceded in two ways: in a broad sense defined as socialization whose main objective is to aid students to integrate with their community; and to do so they should use their abilities and cultural awareness as to be able to acquire and adapt to the moral codes established by society (Puig and Martin, 1998). In a more restricted sense, it is intended that each individual should be the author of their own story, and highlight their creative, critical and transforming aspect (Puig and Martin, 1998). Still according to the authors, moral education aims to collaborate so that students develop their moral intelligence and acquire the necessary culture to face autonomously and dialogical those situations that propose a conflict of values or moral controversy thus they are able to live in a fair, solidary and happy manner (Puig and Martin, 1998).
With regard to the methodology used by the educator, it must be based on the students' reality, linking the comprehension theories with a reality of a specific practice, which can be the teaching of a given pedagogical content in this case (Vasconcelos, 2002). Therefore, the activities adopted by teachers, the teaching techniques chosen, the bibliographical reference indicated, the assessment criterion, the rapport establish with the students, the Neves Júnior W, Serpa de Araújo L, Rego S MedEdPublish https://doi.org/10.15694/mep.2018.0000205.1 Page | 4 type of debate raised, the treatment given to the discipline or field of expertise, should be coordinated directly with the methodologies of moral education utilized in the disciplines of bioethics. Rego, Gomes and Siqueira-Batista (2008) cited the current most used techniques in bioethics are: discussion cases, club debates and competitions, film discussions, roleplaying and the direct teaching of ethical theories and discussion methods. Puig adopts some methodologies of moral education some of which are named moral practices that can be used in various fields of education and were classified and adapted in this research in the teaching of bioethics. For this reason, it is understood that the major challenge in educating a learner is to provoke situations and gauge them to their level of development and in each phase of its development. It is in this line of thought that the moral practices meet, based on authors of development moral theories among them Dewey, Durkheim, Piaget and Kohlberg all of them were idealized by Puig (2004) and they represent the perspective of a social-cultural approach to moral education.
The moral practices open doors to the understanding of reality and goes beyond the psychological models (individualistic) and the socio ones too (objectivists). To Puig (2004), the moral practices allow to see the subject as agents in a net; immersed agents in their social-cultural habitat involved in activities. These practices are units of analyses which make part of the subject and the social-cultural environment in its totality (Puig 2004). Therefore, a moral practice is a means of teaching and learning which involve both real-life like as well as routine-like situations of life; is a well-thought situation and proposed to learn in the social practice (Puig, 1996). In the table below there is a way of classifying, elaborated in this research, with the most used techniques used in the classes of the discipline of Bioethics, based on the moral practices proponent of Puig (1995Puig ( , 1998Puig ( , and 2004.

Reflective Practices
• The use of certain psychological abilities which allow perform various operations about oneself. The most common are observed: a) self-observation; b) self-assessment and c) selfregulation.
• This type of practice in its different levels requires that each individual look at themselves to the expense of a relevant issue. • It will ask the subject the information that he can produce regarding the theme dealt with.
• Activities with body images; • Analyses of attitudinal e physical and changes; • Production of autobiographical texts; • Self-assessment exercises; • Personal interviews; • The establishing of one's one feelings and point of view in a conflict situation; • Self-regulative exercises.

Deliberative Practices
• Identify values such as selfrenunciation to one's own interest and convictions, especially if exaggerated or wrong; • The recognition of the points of view of the other participants involved; • The compromise in search of the truth and righteousness; and • The hope of a fair agreement and a better mutual comprehension.
• Class assembly to conflict resolution and to school mediation; •

Normative Practices
• Learning of Norms through their use; and • Learning of Norms through processes of deliberation and reflection.
• Norms which rule all the other practices of value • Norms which rule school life in all details

Virtues Practices
• The protagonist whether it may be a group formed by a part or a whole class; • Require a cooperative task done among various individualsone task aimed to satisfy some need related to living together, school work animation of the class group; that is to say, with the life of the collectively The current article aims reflect upon some of the questions which are relevant in the process of learning and teaching of the disciplines of Bioethics and can contribute and facilitate the process of learning and moral development of learners. Do the teaching techniques used by the teachers today stimulate and promote moral education? Which of these techniques, according to the learners, make them more engaged to participate, individually as well as the whole group, and discuss in class? Does the use of these techniques contribute to learners put at stake their opinion or to reflect deeply about themes discussed?

Methods
This research was carried out through a descriptive study of a quantitative and qualitative field research. The choice of such approach aimed to pull out data as to obtain a perspective of the reality and of the moral practices used in the discipline of Bioethics. When collecting the data, it was used questionnaires and focal groups with the learners and interviews with the professors of the faculty of medicine of the Estate of São Paulo, observed the academic and social contexts. The choice of questionnaires as a technique had as the objective to describe one variable, its central tendency or dispersion and to describe its frequency (Victoria, Knauth and Agra, 2000). Within the focal groups and interviews the objective was to comprehend the context where some phenomenon occurs, in an attempt to allow an observation of various elements simultaneously in small groups (Victoria, Knauth and Agra, 2000). Yet according to the authors, this approach is able to promote a deep knowledge of an event making possible the explanation of behaviors (Victoria, Knauth and Agra, 2000). To Minayo (2012) qualitative research tries to answer very peculiar questions, in a level of reality which can hardly or could not be quantified (Minayo, 2012). According to the same author, this approach: Works with the universe of meanings, of motives, of aspirations, of creeds, of values and attitudes. This set of human phenomena is understood here as part of the social reality, thus the human being distinguish itself not only by acting, but also by thinking about what they do and as well as the interpretation of their actions within and from the reality lived and shared with their peers (Minayo, 2012).
The objective qualitative research, in general, provokes a situation as to the very researchers become aware of their own problems and the conditions which generate them in order to elaborate means and strategies to resolve them (Chizzotti, 2003). According to Bonet (2004), this research exists because it deals with an environment where academic aspects and the daily practice intertwine and where the social tensions, psychological and economic meet.
The medicine was chosen as an object of study because it is the habitus and praxis of the researchers as university professors, because of its social relevance, because of the demands doctors face, almost daily, to resolve moral conflicts while on the job. Before this, there was this interest in identify and analyze how the moral practices are developed in the discipline of Bioethics, thus it is in this academic space where the moral and ethical aspects of the profession are developed.

Subjects of the research and method
The protocol of the research was submitted to the Committee of Ethics Research (CER) from ENSP/FIOCRUZ and was approved 03 April 2015 (CAAE nº 41664615.3.1001.5240) and has been conducted within the guidelines of the Declaration of Helsinki. After approval, it was carried out a qualitative field research, descriptive, pulling out data made available on the internet through official portals: Medicine which met our criteria, it was made direct contact with the faculty directors and coordinators, as well as with the professors in charge of teaching the discipline of bioethics or any other discipline that possessed contents dealt in bioethics. Those responsible for the disciplines were contacted directly by telephone and e-mail, when present meeting where scheduled in order to present the research by the researcher, specify the objectives, techniques to used and other important data about the research and, lastly, it was required and confirmed the participation of the colleges and, the consent and the delivery of the term of consent to the director and/or coordinators of the courses of medicine.
3 rd phase -Application of the research tools. After the approval of the faculties to take part in the research, it was elaborated within the academic calendar from each faculty one booking together with the professors. The questionnaires were applied after explaining and requiring the participation of the learners in the research during the classes of the professors responsible for the disciplines. But in the focal groups of learners, some groups were previously scheduled by the professors or required to participate after the class. 4 th phase -Listing and analysis categorical of the results: After the collection of the data, the answers from the research tools of the learners were analyzed with the characteristics of the discipline, for the analysis of the data, the answers were transcribed, compiled, selected, pre-analyzed and classified into categories emerging from the selected says, according to the categorical analyze proposed by Lawrence Bardin, with the objective of structuring the results found. From analyzing the contents which emerged from the learner's contributions, the categories were established to discuss the results.

Results/Analysis
It was identified a total of 77 faculties of Medicine in Brazil with grade 5 in ENADE (from 2010-2013), from which 23 are located in the southeast region of Brazil and 9 (nine) in the state of São Paulo. ENADE is a national exam, whose objective is to assess the undergraduates and graduates' performance in the contents of the courses in which they are attending. From then on, the coordinators of these 9 courses were contacted and the professors responsible for the disciplines of bioethics or those disciplines that deal with the same content of bioethics. From the 9 faculties, 7 took part in the research, but 5 the complete collection of data was possible: where there was a total of 56 learners that participated in the focal groups and 206 answered the questionnaire. The table below (Table 2) represents the distribution of the total participation in the research, both in the faculties and among learners. In the closed questionnaire, for the learners, it was asked whether they remembered which techniques were used in the classes and we obtained the following answers which are represented by the frequencies in the table below (Table 3): It was asked to the learners whether the discussions with this technique contributed to change their opinion when needed to think about the theme discussed, the answers were (Table 4).

Discussion
From a total of 206 questionnaires, it was noted that the teaching techniques most used in the disciplines of bioethics or the ones alike were: case discussions, lectures, debates, film discussions and seminars (Table 3). The discussions of clinical cases and the lectures were the most techniques used in class by the professors according to the learners. It is important to highlight that the clinical cases are one option very much used by professors, in such a way that learners apply a learned content to a particular case; this way, they can demonstrate how well they have learned in applying a general knowledge in a particular case (Rego, Gomes and Batista-Siqueira, 2008).
As for the lectures, it was verified that the result is in accordance with the literature, this technique is generally the most used one. The theoretical classes are related almost exclusively to the expositive method. Its main feature is to speak to learners in a unidirectional way, being one of the most common in classrooms for its facility to reach a larger number of learners (Alfaro, 2006). This becomes one evidence of a lecture as the norm and we can verify in the students transcripts A1, "[…] talk and have lectures , they are a bit boring and deals more with the code of ethics therefore becoming more tiring", but to transcript A2: "[…] as a whole, the classes which were less lecture like, not being just that passive lesson, but being more practical in something we could see, generated good discussions, […] and the classes which are like this tend to be more productive for us". To Anastasiou (2009), the lecture needs to be dialogical, with learners' participation so that they may question, interpret and discuss the object being studied, from the recognition and confront with reality.
Among the techniques that were less mentioned. In other words, it is probably underexplored by the professors as a classroom tool, portfolios, role-playing and the simulated jury. According to Rego, Gomes and Batista-Siqueira (2008), other teaching techniques which can also be used in the teaching of bioethics are: Case discussions, club debate and competition, film discussion; roleplaying and the direct teaching of ethical theories and discussion of methods. In the interview with the professors, it was perceived through the learners' say that they possess an interest and availability to use new techniques and resources, but not always know how to do and use these tools more efficiently in the classroom. This becomes evident in the script of a professor P1 in which they say that "Although we are eager to use innovative techniques and such things -better than we do, we are not prepared and able to change much, we basically use" it was also very clear from the majority of the professors' says that they would rather work with the undergraduates in smaller groups; that they do not work individually with their learners due to the unviability of the large number of learners per class and to the reduced number of professors, what makes it difficult for them to work as they would like to.
To be able to understand what happens in practice, focal groups were asked which of these techniques learner felt more stimulated. The answers allowed us to identify that: the techniques that most contributed to good discussions in class, according to the learners, were the deliberative practices, film/tv series discussion, case discussions, roleplaying-dramatization, discussion of debates, invited guests and in a smaller number lectures. It is evident that for learners to participate more and be better stimulated, according to Rego, Palácios and Schramm (2004) affirm it is necessary to use group discussions profusely as well as other pedagogical techniques so that the group work should be desired. For the development of a group activity the professors should deal with some interracial aspects such as: the coordination of the participating learners in carrying out the task, provide information, sequence tasks, process information, integrate and take action; be careful and observe the participation of all learners; make them feel at ease so that communication should be fluid and argument wise and all can express themselves (Lizarraga, 2010).
It was observed ( Table 4) that, from learners' answers 72,5% -161 answered that stopped to think about the theme; 17,5% -39 changed their opinion and 8% -18 did not change their opinion. Even though they were not multiplechoice questions, this data show that the majority of learners after the debates, discussions, dialogues and argumentations informed that they have thought and reflected upon the proposed subject matter and some even changed their opinions. To Puig and Martín Garcia (2010, p.88), participation means get involved, be part of it intervene in one activity or project. This participation cannot be in the void, it is needed concrete opportunities which facilitate and channel the interests and the personal involvement. Thus, it is evident that, depending on the technique and the themes used in class, learners feel motivated or not to take part, in addition to that the technique facilitates the debate, the discussion, the dialogue and listen to other contrary arguments giving their value. To Piaget (2003), the procedures for moral education can be classified from different points of view, and from those methods will be very different if what is wished for is a free personality or an individual within a social conformity which he or she belongs to. The thing is that in some situation, even not agreeing with the others, some stopped to rethink their concepts and tried to understand why others may think differently (empathy). Learning from dialogue depends on the innumerable number of exchanges between professor and learners which bring about practical examples of routine life (Puig, 1995). in the interviews the professors reported, as an example of a professor's speech P2: "I always do the discussions thoroughly to stimulate and to provoke imbalance among the learners. In order to stimulate autonomy and dialogue as moral capacities, it is necessary to rethink the planning and the types of moral practical guidelines which allow facing moral conflicts (Puig, 1996). The professor must guide the discussion stimulating a deeper reflection for the theme not to treat it as a simple informal talk among friends. The discussion must be reflective regarding the moral values involved in the theme.
In this perspective when asked and analyzed the opinions so the focal groups about the why or not change the opinion, it was possible to identify and comprehend some reasons that made learners hold this opinion. According to them, change or not their opinion depended on the following factors: a) the content and the personal experiences that aided in the reflection/or in the decision-taking; b) listen different opinions and arguments that facilitate reflection; c) the difficulty and the reluctance to change one's opinion. To Kohlberg (2008), the techniques such as the discussions of moral dilemmas enables the discussion of values and conflict of values and have an important role to the model of life n group, but not only as a means to promote individual development, if not also, as a form of telling how the group will work as a social unit.
In some parts of the learner's speech it was verified that some did not change their opinion, because they did not want to admit that they were wrong or for being adamant in what they believe to be true. This became crystal clear in the snippets from A5: "when you listen to an opinion which you disagree, you start to understand why the person thinks that way. I believe it is important." And from A6: "[…] while this you perceive that is not a dichotomy, this is very cool in the discussions, why this presentation of various points of view, complete me as a professional, as a student, but also as a person." This heteronomy dependency justifies itself from the conviction that your own values are absolute, in other words, "it is to say that they are impossible to be discussed and timeless, not subjected to alterations, thus forcing them in a way that cannot be put in dialogue and not even can repair or chance the differences" (Puig and Martín Garcia, 2010, p.19).
After analyses and identification, in the learners answers, of how techniques aid and contribute in the discussions to the reflection of the theme and, consequently, to their moral formation, it was asked to the professors: How often do you reassess the teaching techniques used in your discipline while method? In what ways? These questions were made in order to understand how this learning process is measured and/or assessed in the faculties of Medicine and by doing so know whether the techniques can increment moral education of their learners as a teaching methodology.
The great majority of teachers reported that the institutions or the very faculty possess forms of assessment, and that, when analyzed the courses of Medicine, they are characterized in general in modules, where the disciplines are available in the course's political pedagogical project. An example of this are the progress tests adopted in the courses of Medicine; in which, sometimes, the results are informed to professors, but it is questionable what the parameters and criteria are used to assess learners. The progress test is a longitudinal assessment tool, aiming to evaluate the gain of knowledge regularly enrolled in the graduation course of Medicine, in an attempt to diagnose its deficiencies/strengths along the curricular structure.
This fact was noted in the interviews with some professors, as an example the P3: "we have one formal assessment in the faculty; the under-graduation teaching commission carries out one assessment of the disciplines every time it is offered and this evaluation is sent to us afterwards". Some disciplines do their meetings at the end of the term or year to assess their methodologies, as it was noted in the professor's speech P4: "every end of the term we have a meeting with all professors who participate in the discipline where we discuss how the course is going, what worked, what did not work". It is perceived that some professors make an effort to assess their methodologies, but do not ask directly to the learners which ones work better and which ones they like best, as it is clear in this snippet from a professor P5: "we discuss here among ourselves whether a methodology is being more effective or not, when we note that learners begin to show some resistance to a particular methodology".
As a whole, the assessments done are based in general tests from the curricular disciplines, not necessarily in a specific form under the application of methodologies. This theme was a recurrent one in the speeches, they were virtually identical among the professors: "we haven't done a systematic assessment, this we haven't done". P6 said: "we do not have any specific method, no checklist to call assessment, there is none, it is something empirical". P7 and P8 admitted: "but we do not have no systematic assessment of the discipline itself which we use regularly, we do this assessment of ours and there is the one from the teaching commission".
In the same way the professors said they had a feedback assessment in some situations, others do not receive any return, and end up making alterations without knowing whether they are achieving their goals or, even whether the learners agree with the methodologies used. This was noted in P9: "what happens is a dialogue among the professors and the involved people, as we sometimes it is difficult to have feedback we end up altering some things without understanding whether those changes in the year worked or not."

Conclusion
The idea of moral education or education of values as one viability to form ethical graduates and the moral practices can become possible forms of being developed in class. It is highlighted here, once more, that the model used as reference in this research, it is not superior to the others, and the models are complementary to the teaching practice.
It was noted through the answers from the learners the importance of the teaching techniques so that good discussions could be generated in class, aiming stimulate the learners to learn to respect, to listen one another, express their opinions, have dialogues, take decisions, be critical and contribute to their own moral development.
And that the moral practices which mobilize and make possible this moral learning were the deliberative practices such as: film/tv series discussions case discussions, roleplaying -dramatization, discussion of debates and invited guests, and in a smaller proportion the normative practice, in this case, the lecture, however dialogical in which there is participation of the active subjects.
The professors reported that in some institutions they receive a feedback of the assessment and the results are sent to the professors. Other professors said that their own faculty possess a form of assessment and others do not receive any return. It was also informed that they do not possess any tool to assess the discipline and they end up making alterations without knowing whether they are reaching their goals or not and, even whether the learners agree or not with the methodologies used. Thus, it is noted, generally, the learners are not listened regarding the methodologies used in the disciplines, maybe because of little time of the disciplines, what makes the assessment more difficult due to the small number of professors in the disciplines, maybe because of the demand and even the listing of the voluntary participation of the learners.
Therefore, the discipline of bioethics and the moral practices as methodology to the education in moral or values, as it was observed in the answers from the learners and professors, are tools which can aid and facilitate the moral development of the students of medicine. However, it is necessary an adequate planning to the practice and living, through the structured use and necessary knowledge of the rationale of the methods and their techniques. Nevertheless, it is needed more study in this area in order to develop methods of assessment of the moral practices and build valid evidence or not that these techniques can stimulate the development of the capabilities and structure of the moral reasoning and form more competent moral agents.

Take Home Messages
The Moral education or education through values as viability for the ethical and humanistic education of medical students; The importance of teaching techniques in the classroom in order to encourage students to learn to respect, listen to others, expose their ideas, dialogue, make decisions, be critical; The discipline of bioethics and moral practices are tools that can aid and facilitate the moral development of medical students.