Knowledge, Perception, and attitude towards medical ethics among undergraduate medical students

: Objectives : This study aimed to assess knowledge, perception, and attitude towards medical ethics among undergraduate medical students at College of Medicine,Jouf University (COM-JU), Kingdom of Saudi Arabia (KSA). Material and Methods: A cross-sectional study was conducted on a convenience sample of 118 undergraduate medical students at Jouf University, KSA using a self-administered questionnaire that included section I (Basic demographic characteristics), section II (Knowledge about medical ethics), and section III (Perception and attitudes towards different aspects of medical ethics). Descriptive analysis was carried out. Results: More than two-thirds of the participating students were knowledgeable about different aspects of medical ethics. Despite that, about half of them did not consider confidentiality as a fundamental issue in medical ethics, and more than half accepted that a physician could ignore a patient’s privacy. About 78.2 % believed that health practitioners must comply with the ethics of their profession. Nearly 75.5 % of respondents believed that a specialized Committee should be present in the college to set ethical rules. Interestingly, 71.7 % declared that there is a necessity of incorporating medical ethics into an undergraduate curriculum. Conclusion : Our results emphasize the need for increasing the incorporation of medical ethics issues into the undergraduate medical curriculum to enhance their knowledge and strengthen their positive attitude towards medical ethics.


Introduction:
Medical ethics is a set of moral rules that govern the application of values and judgments in medical practice. 1Ethical principles assist in determining what is regarded as right or wrong in a specific time and society, based on the perceived moral repercussions of the conduct. 2 During ancient times, the Hippocratic oath emphasized the connection between medicine and ethics. 1 The public is becoming more conscious of medical practitioners' ethical behavior, and complaints against doctors appear to be on the rise.Violations of the four essential medical ethics concepts of autonomy, beneficence, nonmaleficence, and fairness are the most commonly asserted transgressions in medical practice.Healthcare practitioners are expected to understand such ethical principles after finishing their studies. 2,3Healthcare providers will have to rely on ethical values and principles that will shape their professional judgment, attitudes, and actions in order to successfully cope with the ethical dilemmas they face. 4ven the increasing attention paid to patient safety and medical errors, it is critical to emphasize the relevance of medical ethics as a vital component of undergraduate education. 5This can be linked to a variety of factors, including morally and ethically demanding breakthroughs in science and technology, substantial socio-cultural and ideological shifts, and heightened public awareness and demand for ethical healthcare. 6Furthermore, during the undergraduate study, faculty could carry considerable mentormentee roles and meet their mentees' needs. 7It is mandatory for medical students to undergo ethical and/or bioethical education while they are in medical college. 8It is a great way to prepare them for ethical challenges they may face in the future. 9dical students encounter ethical dilemmas from the very beginning of their medical studies. 10Future physicians must be taught scientific information within the framework of the ethical foundation of their interaction with patients, as well as how human values are embedded in clinical decision-making.This would contribute to better treatment results and increased patient satisfaction. 11To be a physician, one must be able and ready to behave in conformity with generally recognized moral standards and values. 12he ethical issues that medical students anticipate they will face while working in these environments, as well as their attitudes and opinions on the subject of medical ethics' aims, learning, and evaluation techniques, remain obscure. 13The 2020 research by Al-Shehri, Siddiqui, and Khalil stated that residents' understanding, attitude, and practice of medical ethics are lacking, highlighting the necessity of improving Saudi Arabia's medical ethics curriculum. 11dergraduate medical students at Jouf University, KSA are exposed to a short course of medical ethics as a part of their undergraduate medical curriculum in their clinical clerkship in the 5 th year (2 nd semester) in collaboration with Islamic medical jurisprudence.Determining the level of basic knowledge and attitudes of undergraduates in the region is the first step in developing an advanced ethics curriculum.As a result, the purpose of this study is to analyze medical ethics knowledge, perception, and attitudes among undergraduate medical students at Jouf University, KSA in order to aid in the construction of well-developed curricula and to guide their professional behavior.

Materials and Methods:
A cross-sectional study was conducted among medical students, Jouf University, KSA.An anonymous self-administered questionnaire was used.The questionnaire was developed guided by previous literature and the help of experts in the Community Medicine department, COM-JU. 3,14,15rticipants were recruited as a convenience sample of 188 undergraduate medical students (with a response rate 70.6%) at Jouf University, KSA during the academic year 2019/2020, from the first to the fifth-medical class.The questionnaire was conveyed online to all participating students through google form which was communicated to the students on their personal electronic devices.Informed consent was obtained from all participants before their participation.The purpose of the study and the nature of the information that has to be collected from students were explained in a detailed information sheet at the beginning of the online questionnaire.Students who refused to participate were excluded from the study.
For questionnaire validation, a pilot testing of the questionnaire was performed before starting the study on 30 undergraduate medical students (15 male and 15 female).These students were excluded from the main study.Modifications were made for a better understanding of the questionnaire.To assess the content validity, we distributed the questionnaire to some experts with knowledge and expertise in medical ethics.Regarding reliability, the overall Cronbach alpha was 0.934, which indicates a high level of internal consistency for our questionnaire with this specific sample.
The questionnaire includes three sections.Section I includes basic demographic characteristics, age, gender, academic year, marital status, and prior studying of medical ethics.Section II includes knowledge about medical ethics regarding medical ethics principles and guidelines, characteristics of the field of medical ethics, physician-patient relationship, confidentiality and privacy, and informed consent.These were assessed using true/ false choices.Section III includes perceptions and attitudes towards different aspects of medical ethics (Health practitioners' ethical medical practice, Medical Ethics Committee, studying medical ethics).These were assessed using a 5-point Likert scale (1-strongly agree, 2-agree, 3-neutral, 4-disagree, and 5-strongly disagree).

Statistical analysis:
The data were coded and analyzed.Data from the questionnaire were analyzed using IBM SPSS version 26.Descriptive statistics were applied in the form of frequencies and percentages.Concerning the "perceptions and attitudes" section, we merged "strongly agree" and "agree" to "agree" and "strongly disagree", and "disagree", to "disagree".

Results:
The researchers surveyed 188 undergraduate medical students who agreed to participate in the study giving a response rate 70.6%.Mean age of studied participants was 21.54±1.56.About 60.6 % were males, approximately 98% were single.Approximately, 39% had prior study of medical ethics (Table -1).

Medical ethics principles and guidelines
There are basic principles and guidelines that govern medical ethics 71.8 28.2 There are medical ethics principles that guide handling emergency situations 69.1 30.9 There is an ethical framework that guides the duties and responsibilities of physicians towards patients

21.3
There is an ethical framework that guides the duties and responsibilities of physicians towards community 74.5 25.5

Characteristics of the field of medical ethics
Technological advances resulted in the emerge of new ethical challenges 72.3 27.7 The Discussion: Teaching ethics is often regarded as a critical component of medical education aimed at improving professionalism. 6Incorporating an advanced and well-developed medical ethics curriculum into the undergraduate curriculum necessitates assessing the current basic knowledge, perception, and attitudes towards medical ethics among undergraduate medical students at Jouf University, KSA.
As regards the knowledge of the participating students about medical ethics, the gap in knowledge regarding certain aspects of medical ethics suggests that the students are judging these issues without applying the basic ethical principles.These results agree with several previous studies as Majeed et  al. 2020 where their results showed a fundamental lack of understanding of certain basic medical ethics aspects. 15According to Iswarya and Bhuvaneshwari 2018 findings, students were knowledgeable as our studied students about different aspects of medical ethics as ensuring that patient's decision is uninfluenced; the requirement of truth-telling about wrong doing in the physician-patient relationship; and the informed consent in case of children.On the other hand, their students showed more knowledge regarding privacy, and confidentiality. 3The results of our study disagree with Mohamed, Ghanem, and Kassem 2012 study.Their studied participants showed higher knowledge level about medical ethics.Despite that, only 18% had learned what they knew throughout their medical school study years. 14heir higher knowledge level could be related to the experience the residents have faced during their clinical practice that enhanced their knowledge about medical ethics.
To practice "good medicine," doctors require more than simply strong knowledge and abilities; they also need the proper attitude, behavior, and the capacity to make tough ethical judgments concerning the treatment of their patients. 16ncerning the perceptions and attitudes of the participating students, most of them believed positively regarding the importance of adherence to ethical principles and its positive consequences as well as a positive attitude towards Medical Ethics Committee establishment.These positive attitudes are promising and need to be strengthened.These results were in accordance with Jatana et al. 2018 study where majority of students showed good attitudes towards the fundamental principles that guide doctors, and the obligations of physicians towards patients. 17rprisingly, more than half of the participants in this study thought that health practitioners might sometimes behave unethically and that doctors could violate patients' autonomy.This result contradicts their knowledge that ethical principles ensure that patient's decision is uninfluenced.The negative attitudes of about half of the participants regarding considering ethical behavior only to avoid legal action, not refusing to do abortion, and doing laboratory investigations as a routine even in clinically confirmed cases raised a lot of concern and reflects the need for inculcating ethical values and principles among medical students.
The results of our study concerning the attitude towards medical ethics agree to some extent with some of the results of Mohamed, Ghanem, and Kassem 2012 study .Around 60.2% of their studied physician residents had a good perception regarding ethical aspects.8 On the other hand, our results disagree with those of Shajil, Channabasappa, and Dekal 2021 survey in which 97.2 percent said that a doctor must preserve patient confidentiality.However, they showed a deficiency in understanding other basic issues of medical ethics. 19cording to Subramanian, Mathai, and Kumar 2013 study's conclusions, doctors need greater training in the healthcare ethics. 20The unsatisfactory knowledge, perception, and attitude towards certain aspects of medical ethics among the studied students could be attributed to the deficiency in prior studying of medical ethics as only 38.8% of the participating undergraduate medical students had a prior study of medical ethics.
To overcome the gap in knowledge, attitude, and behaviors concerning medical ethics, Mohammad and Ahmad (2011) concluded that there is an imperative need to incorporate ethics education, in an engaging manner, in a multidisciplinary environment. 21ost of our participating students believed positively regarding studying medical ethics.These results agree with several previous studies that emphasized the necessity of studying medical ethics at undergraduate level.Vodenitcharova, Leventi, and Popova 2019 survey results showed that students had a good attitude towards medical ethics education.They considered medical ethics as a daily decisionmaking tool. 22Kavas et al. 2020 results declared that a pressing need exists to integrate ethics courses into the 6-year professional training. 6Imran et al.
2014 study demonstrated that majority of the studied participants agreed that understanding of ethics is essential for their profession and should be introduced into the undergraduate curriculum. 23Students who took part in Al-Haqwi and Al-Shehri 2010 study viewed medical ethics as a subject worth learning and comprehending rather than merely relying on common sense. 5Al-Shehri, Siddiqui, and Khalil 2020 denoted the necessity of enhancing medical ethics education in Saudi Arabia. 11AlKabba et al.
2013 have emphasized the need for medical licensing organizations to set standards to assist medical schools in the creation of their curriculum. 24The medical ethics course material should be culturally appropriate and based on social requirements, with the consideration of the worldwide experience. 16oreover, training in the form of workshops could enhance medical students' knowledge, performance, and contentment. 25e positive consequences of teaching an advanced and well-developed medical ethics curriculum at the undergraduate level can be evident in helping students who are future physicians to become more ethically conscious and, in turn, help "rehumanize" medicine by ensuring respect of patients' rights.Accordingly, students will be well-prepared to face real-life ethical challenges when they become physicians.The optimum time to introduce medical ethics to students is during their undergraduate study, when they are receptive and not overburdened with the everyday demands and strains. 16,17,20nclusion: Our study demonstrated that the majority of the participating students were able to understand the importance of medical ethics in their future career.Most of them were knowledgeable about different aspects of medical ethics and showed good perception and a positive attitude towards studying medical ethics.Including an advanced and well-developed medical ethics curriculum into the undergraduate curriculum must be considered, as well as providing ongoing educational initiatives including workshops, and conferences to underline the importance of ethical practice.Our results could help in the development of such an advanced curriculum.

Limitations of the Study
The main limitation of the current study is the fact thatit was a cross-sectional study carried out onlyamong medical students in COM-JU.Consequently, the findings of this study may influence generalizability.
A larger sample size involving other medical schools issubstantial to enhance and improvedata on the knowledge and perception of medicalstudents.
Recall bias and social desirability effects are other limitations.

Table - 1
: Basic demographic characteristics of study participants Table-2 shows the knowledge of the participating students about medical ethics.About 71.8% were knowledgeable about the existence of basic principles and guidelines that govern medical ethics.About 69.1 % knew about the medical ethics principles that guide handling emergency situations.The majority of them (78.7%)stated that there is that a physician can't ignore a patient's privacy, and half of the participants knew that confidentiality is a fundamental issue in medical ethics.About 52.1% considered the statement "Consent is not required for treatment" a false one.About 75% stated that it is true that children should never be treated without the consent of their parents/guardians except in an emergency.Table-2:Knowledge of the participating undergraduate medical students about medical ethics Iswarya S. and Bhuvaneshwari S. 2018 study showed some negative attitudes towards certain ethical issues as in our study but with different percentages.Around 65% of their students believed that doctors must do what is best for patients regardless of their opinion.Nearly 30.3 % thought that ethical conduct is only vital to avoid legal action.