Understanding of Professional Ethics Among a Sample of Medical Practitioners in Bangladesh

Background: Ethical practice not only protects the rights of patients but is also a safeguard of medical practitioners. But, practicing medical ethics among the Bangladeshi health care professionals are not at a satisfactory level. Objectives: The study was aimed to assess the level of understanding regarding medical ethics among the health care professionals. Methods: A descriptive cross-sectional survey was conducted among registered 400 doctors of tertiary care hospitals and general practitioners in Dhaka City during June 2016 to January 2017. A non-probability sampling method was used for selecting the medical colleges, hospitals, institutions, medical university and general practitioners from the different areas of Dhaka city. A self-administered questionnaire was used for data collection assuring confidentiality and anonymity. Ethical approval was obtained from the National Research Ethics Committee (NREC) of Bangladesh Medical Research Council (BMRC) and from the Institutional Review Board (IRB) of the American University of Sovereign Nations (AUSN). The collected data were analysed through SPSS software, windows, version 21 (SPSS Inc., Chicago, IL, USA) and R programming language. Results: Of the 400 respondents, 68.0% were male. Mean (±SD) age of them was 30 (±6.5) years. About 93.0% respondents had only a MBBS degree and 65.0% were medical officers. About 38.0% respondents have below 5 years of clinical experience. Highest number of respondents got ethical information from book, second highest from lectures and then general text. About 32.0% respondents got ethical knowledge from one source. About 97.0% respondents agreed that medical ethics should be included in both undergraduate and postgraduate medical studies and 90.0% of them know only about theHippocratic Oath. Very few of them knew the Nuremberg Code (16.0%) and Helsinki Declaration (16.0%).Only 27.0% participants said that they never face any ethical problems in their clinical practice. About 75.0% reported that ethical practice is important in workplace. About 35.0% respondents have a very little knowledge and 46.0% have average knowledge on ethical law. Conclusion: Findings of the study indicate that ethical knowledge of the respondents is not satisfactory although they realise that it is important in clinical practice and should include both undergraduate and graduate medical studies. Also need to develop practice in the workplace by law and legislations according to the guidelines of Bangladesh Medical & Dental Council (BMDC) and Bangladesh Medical Association (BMA).


Introduction
Medical ethics also indicate the basic principles for medical professionals in order to practice of medicine and make a relationship with patients and health professionals. 1 These health professionals practice this ethics in a compact environment.A few ethical issues like confidentiality, rapport with clients, and take consent for treatment have been faced by health professionals. 2 Medical practice worldwide over and above the Hippocratic Oath is governed by normative or moral philosophical theories as enshrined in (contemporary) medical ethics.In developed countries; just as with governance, there are checks and balances which ensure good state governance, and in that sense good professional code of practice.In ancient civil society, medical ethics was applied according to Hippocratic Oath.With the change of time, codes of conduct, laws have been upgraded. 3Nowadays, medical ethics is a basic module of medical curriculum at the institutes of Bangladesh Med Res Counc Bull 2020; 46:168-175 developed countries like USA, Canada, and many European countries. 4ysicians and nurses commonly encounter ethical and legal issues in their workplace.However, many of these professionals are either unaware of their importance or unable to appropriately deal with these issues.Since the findings of the study, identify that learning at workplace has been valuable to gain knowledge about ethics and law, there is a need to identify those who appear to be indifferent to ethical and legal issues and devise means to sensitize them to these issues in the workplace.Practical education in ethics, particularly in a multidisciplinary setting, could assist in bridging the gap in ethical approaches between nurses and physicians. 5e issue of doctor-patient relationship is not that straight forward, as several factors influence the balance of forces at play in that relationship.Doctors are very frequently come across ethical dilemmas in their day to day practice.They are not provided formal training in practical aspects of ethics in their medical curricula.In addition to this; identification of departmental lectures/teaching is also not very favourable among them, so there is an urgent need to include practical education of ethics, particularly in a multidisciplinary setting, to bridge the gap in the knowledge, attitude, and practices towards ethics in clinical practice and research. 6study of ethical relations between physicians and pharmaceutical industries mentioned that existing Bangladesh Medical and Dental Council Actprohibit any unethical relation between physician and pharmaceutical industry; there are evidences that pharmaceutical industries are providing cash, hospitality, pleasure trips, medical equipments, books, sponsorship for conferences, workshop, decoration for chamber, professional and nonprofessional gifts for doctors.7 The Ministry of Health and Family Welfare of Bangladesh enforces and governs the medical practice according to legislation and laws.The government regulatory body also governs the hospitals, clinics, and diagnostic centers.Health professionals follow these principles to perform their professional tasks as well World Health Organization.8 There was given education about medical ethics in all medical institutes at the undergraduate level in Bangladesh. Pessional misconduct and other fundamental issues were taught in that set course and curriculum for medical practice.9 In Bangladesh, the Bangladesh Medical and Dental Council (BMDC) regulate the discipline in relation to misconduct, malpractice, negligence, and conduct in medical practice.Regarding this issue, the investigator shall conduct study about assessment of knowledge among medical professionals towards medical ethics and challenges that hinder daily practice.So far there are very few of this type of research done in many countries.One of the research done in Indiabut in Bangladesh specifically this type of research not yet done.Moreover, from this research hope that if would be found out the factors for giving increased attention on medical ethics.
Ethical challenges are prevalent in modern-day medicine.Patients, their families, those who provide medical care, and the institutions where this care is conducted face difficult choices almost as a matter of routine.In addition to those arising in clinical practice, important and controversial ethical concerns also arise in the arena of clinical research and in educational practices.No domain of modern medicine is untouched.In particular, the problem of conflict of interest has become an issue especially relevant in this time. 10alth is a very important human value and hence healthcare is a paramount social good.In this context doctors have more responsibility on health of every people. 11The doctor-patient interaction and relationship has been considered as the core of medical practice.
In Bangladesh, there are approximately 3.05 physicians for 10,000 people, and in some hospitals, a single doctor must see the about 40-50 patients per day.The medical officers, post-graduate senior physicians, who after their office hour goes straight to respective private chamber or to some private hospital to work as a private practitioner. 12e theory of economy stated, like other individuals, doctors also aim to maximize their income, autonomy, professional ethics whereas theories of work motivation in Psychology give prominence to individual needs, values, personality and so on.In the context of developing countries, autonomy being a major reason to growth of private practice and as private practitioners are much independent, self-employed and can be entrepreneur themselves, scope of handsome income in contrast to the fixed salary of public service is also a motivating factor for the physicians to become more involved in the private practice.Nowadays, the private practice is very common and popular in Bangladesh but some physicians also faced problems in their private practice setting due to poor concern of ethics.In recent, the New Age reported on 6 July 2017 according to the Bangladesh Medical Association (BMA) based on 73 physicians came to be attacked on allegations that they had provided wrong treatment in the past five years.While the attack on medical service providers by patients or their relatives is condemnable, the BMA's decision to abstain from private practice to demand safe work environment is also a breach of their professional's ethics. 13

Materials and Methods
This descriptive cross-sectional study was aimed to assess the level of understanding regarding medical ethics among health professionals.It was conducted among 400 registered medical practitioners working in the tertiary care hospitals as well as private general practitioners in Dhaka city.A nonprobability sampling method was chosen for selecting the study sites viz.Dhaka Medical colleges and hospitals, Sir Salimullah Medical College and Hospital Shahid Sorwadhary Medical College and Hospital, doing General Practice at Dhaka city.
A stratified random sampling technique was adopted to obtained the study population from different departments of the hospitals.
The study was conducted over a period of eight months from June 2016 to January 2017.The sample size was estimated using the formula.Considering the non-response rate and missing data the sample size will be rounded to 400.
After that, the purposive sampling technique was used for selecting health professionals.

Data collection instrument
Data were collected using a pre-tested, elfadministered questionnaires were filled anonymously after explanation to every participant.The data collectors briefed the objectives and benefits of this study to the respondents.All the study participants had been assured about their confidentiality and anonymity.In order to identify the questionnaires, numbers were assigned to each respondent (for future reference).Data collected from positive respondents only.Before starting data collection eight data collector were selected, all of them are young physicians who had just completed their graduation.They were given one week training on how to collect the data as well as how to prepare a concern form, how much time they spent and ethical implication of the study prior to collection of data.
All collected data were checked with full attention and sincere efforts and kept in the sequences in which those have been numbered.The data were entered into personal computers by expert computer operator followed to SPSS programme (version 23.0).The appropriate statistical tests were done depending on the distribution of the data.Both descriptive and inferential statistics were used and presented in the form of tables, graphs and diagrams.
The investigator was fully monitored whole data collection process.After data collection, firstly checking, editing and omission were done by investigator on the scientific basis.Data analysis was done by SPSS 23.0 Version, R programming language and Ms-Excel software.with small number of sample size (only 400 doctors) which make barriers to generalise the study findings.

Results
This descriptive cross sectional study was carried out among 400 doctors.Of them, 68.0% respondents were male and 32.0% female.
Experience, knowledge as well as basic perceptions, all components depend on age.For this aspect, the study included the participants age.Out of 400 respondents 262were in 21-30 years in age group and 120 were 31-40 years in group and very few (only 18) was in above age group (figure 1).
The mean age ± SD =30.37±6.454years of the study participants.The study found major group (238 respondents) was the medical officer.that the second most study participants about 77 were postgraduate students and third general practitioner.Only twenty onewere Consultants (figure 2).The study enrolled 400 medical doctors whereas majority (372 respondents) 93.0% were MBBS and rest of them (28 respondents) only 7.0% were PhD, MD/MS, FCPS, MPH and Diploma holders (figure 3).Among the respondents, the majority (38.0%) had working experience of below 5 years, 25.0% had 6-10 years working experience, 28.0% had 11-15 years and the rest of them, 9%, were more than 15 years working experience (table I).After calculation of data, 32.0% respondents informed they learned from one source, 16.3% learnt from three sources, 16.0% learnt from two sources, more than six sources was 1.8% (table III) There was a significant association between importance of knowledge on ethics in work place and usefulness source of knowledge on medical ethics (table IV).
The study dealt with the views of participants regarding inclusion of medical ethics in curriculum (undergraduate and post-graduate) and found that 97.0% respondents (388 persons) said that medical ethics should be included in the curriculum.The ethics has a standard guideline which is highly accepted worldwide.There are some contents of ethics among the doctors are very popular in Bangladesh (such as Hippocratic Oath, Nuremberg Code, Helsinki Declaration).To consider the contents, the researchers were interviewed to the participants to know about those.The participants respond by cluster barwhich shows that majority (90.0%) have knowledge about the Hippocratic Oath (figure 4).On the other hand, only 15.0% of respondents have very few knowledge on Nuremberg Code and Helsinki Declaration.
It was to be found that 27.0% respondents said that they never faces any difficulties in their working place.But other respondents, 20.5% faced a problem monthly, 19.0% daily, 16.8% weekly and 16.8% yearly or less (table V).

Discussion
Application of medical ethics in clinical practice not only ensures the patients' right but also responsible for securing clinical practice of the health profession.This study tries to explore the knowledge and practice of medical ethics among the doctors in Bangladesh.
In terms of clinical experience, more than half (52.0%) respondents had 6 to 15 years experiences and one third had less than 5 years experiences.
Research studies found that the senior doctors (either by age or qualification) had better knowledge of healthcare ethics either because of experience or increased attendance at conferences and workshops.Similar findings had also been raveled by an Indian study and a study from the West Indies. 14,15udy revealed that book on ethics (61.0%), lectures (45.0%), general texts (44.0%) and seminar/workshop (38.0%) were the more common source of ethical knowledge of the respondents.Additionally about one third respondents (32.0%) learn ethical knowledge from only one source and very minimal proportion learn from more than one sources.
In one sense this is not a good practice for health professionals just to depend on books and class lectures in this modern world.Literature explored that historically the oath has been used to swear in a student at the beginning of medical students.This oath is still used in modern times but has been updated to fit with the different language and culture.One of the most important ideas codified in the Hippocratic oath is that the physician is accountable for his/her actions should problems arise and the oath has an extremely individualistic perspective. 17However, this reflection has found from the study itself that less than half (47.0%) respondents have average knowledge on law pertaining at workplace.The reason for this situation is lack of mandate from government and Bangladesh Medical and Dental Council (BMDC) following ethical practice according in clinical practice.
Not obeying the ethical practice may constitute several problems including practitioner himself.Although, practitioners in Bangladesh don't need to face problems regarding ethical issue in their clinical practice as most of the clients are not well educated but day by day the situation is changing.As this study reflects the same situation like 27.0% never face any ethical related problem in their practice life but rest of them faced problem at least yearly to at most daily.Therefore, more than two third (75.0%) respondents are now agreeing with the importance of medical ethics.But unfortunately, less than half (46.0%) have average knowledge about law in the workplace.A study revealed that in India, legal suits on doctors have increased in recent year; this can be largely attributed to lack of knowledge and practice of medical ethics. 18So, necessary steps should be taken to improve the knowledge on law in the workplace of the practitioners.Bangladesh Medical and Dental Council (BMDC) and Bangladesh Medical Association (BMA) can arrange several seminar and workshop throughout the country on a regular basis.Educational leaflet can be distributed among the practitioners.Mobile text can be one of the better options for regular update information.

Conclusion
Findings of this study shows that the current knowledge level and practice of medical ethics among the health practitioners in Bangladesh.Are not at satisfactory level.Responsible authorities like BMDC and professional body like BMA should think about this matter.Inclusion of medical ethics elaborately in the undergraduate and postgraduate medial courses which enrich the medical professionals to practice the ethics properly, thus recommended.

Figure 1 :
Figure 1: Distribution of the respondents according to their age group

Figure 2 :
Figure 2: Distribution of the respondents according to their designation

Figure 3 :
Figure 3: Distribution of the respondents according to their height level of Education Years 31-40 Years 41-50 Years 51-60 Years

Figure 4 :
Figure 4: Distribution of the respondents according to the main content of ethics

Table I :
Distribution of the respondents according to their work experience

Table II :
Distribution of the respondents according to their gained knowledge on medical ethics from different sources

Table III :
Usefulness of the gained knowledge on medical ethics

Table IV :
Relationship between importance of medical ethics knowledge related with its number of sources.

Table V :
Distribution of the respondents according to their status of facing difficulties in work place regarding ethics and its importance.

Table VI :
Participants knowledge on law pertaining at work place