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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 236-243

Knowledge and awareness of ethics among phase 1 medical students: appraising the role of the foundation course

1 Department of Pharmacology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
2 Department of Physiology, Government Institute of Medical Sciences (GIMS), Greater Noida, Uttar Pradesh, India
3 Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
4 Department of Pharmacology, G S Medical College & Hospital, Hapur, Uttar Pradesh, India

Date of Submission12-May-2021
Date of Acceptance05-Jun-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Dr. Bharti Bhandari
Department of Physiology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.mgmj_25_21

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Background: The increasing incidence of disconnect between doctors and patients in India makes it imperative to teach principles and practice of ethics to medical graduates before they move into substantive clinical practices. The competency-based medical education (CBME) curriculum was recently introduced in India. The CBME curriculum encompasses teaching ethics at the beginning of the undergraduate medical curriculum. The study was planned to assess the knowledge and awareness of ethics among first-year undergraduate medical students at the beginning of the foundation course and after 40h of ethics training during the course. Materials and Methods: A standard 35-item questionnaire was administered to the first-year medical students at the beginning of the foundation course and after 40h of ethics training/teaching scattered throughout the foundation course. No personal information was recorded on the questionnaire to ensure the confidentiality and anonymity of participants. Results: There was a significant increase in the knowledge regarding some of the items in the questionnaire, such as “patient’s wishes must always be adhered to,” “if the patient refuses to be treated on religious grounds, they should be instructed to find another doctor.” Similarly, there was an improvement in the students’ knowledge of the practice of ethics. The students generally agreed that an awareness of ethics is important and should be an integral part of the MBBS curriculum. Conclusion: To prevent ethical erosion, ethics education should be introduced early during the undergraduate years, and continuous reinforcement is vital. We should strive to promote discussions about real occurrences directly involving students.

Keywords: CBME, ethics, ethics education, foundation course, practice of ethics

How to cite this article:
Sidhu JK, Chopra D, Bhandari B, Singh S, Rai J. Knowledge and awareness of ethics among phase 1 medical students: appraising the role of the foundation course. MGM J Med Sci 2021;8:236-43

How to cite this URL:
Sidhu JK, Chopra D, Bhandari B, Singh S, Rai J. Knowledge and awareness of ethics among phase 1 medical students: appraising the role of the foundation course. MGM J Med Sci [serial online] 2021 [cited 2022 Jan 25];8:236-43. Available from: http://www.mgmjms.com/text.asp?2021/8/3/236/325535

  Introduction Top

Ethics is the rigorous and systematic consideration of moral values and the application of moral judgments and actions. Medical ethics relates to the application of these fundamental principles. The purpose of education in ethics is to allow students to recognize and deal with challenging circumstances both rationally and ethically. It helps students of medicine to consider and evaluate moral concepts and develop their own beliefs.[1] Students need to build a logical approach to address the ethical dilemmas they will face in day-to-day patient care roles. A doctor’s lack of regard for a patient’s wishes and widespread rise in unethical practices has tainted their reputation in society. Medical practice has become more and more commodified globally. Evidence of unethical activity by medical students, resident doctors, and nurses has been documented in different settings.[2] The four fundamental principles of medical ethics (autonomy, justice, beneficence, and nonmaleficence) form the basis for healthcare professionals to direct and determine the activities and interventions in clinical settings that are ethical.[3] Hippocratic oath, Nuremberg Code, Declaration of Helsinki, and Indian Council of Medical Research guidelines are the key healthcare ethics documents on which these fundamental ethical standards are based.[2] Future doctors and nurses are expected to know and adhere to these ethical standards and documents in their professions as early as possible.

With the implementation of the competency-based medical education (CBME) curriculum, the major focus is on attitude, ethics, and communication. Measures are needed for improving awareness of ethics among healthcare providers for a healthy doctor–patient relationship. In an attempt to prepare the students for the challenges they will face throughout their professional careers, ethics in medical education has been incorporated early during the foundation course. This study aimed at assessing the awareness of ethics and knowledge about the practice of ethics among first-year MBBS students after teaching ethics to them during the foundation course. The importance of the teaching of medical ethics to medical undergraduate students has also been considered.

  Materials and methods Top

It is a cross-sectional study including the first-year medical students who volunteer to participate. The study was approved by the Institutional Ethics Committee. All students were briefed on the study’s purpose and invited to participate. In recognition of students’ vulnerability at the start of their courses, every attempt was made to ensure that students did not feel beleaguered to participate. Students were assured that confidentiality would be maintained. Informed verbal consent was obtained from those who chose to participate. At the commencement of the academic year 2019, at the beginning of the foundation course, the validated modified questionnaire in paper form was distributed to the students and they were asked to fill it.[4],[5] The modified questionnaire consisted of 35 items, and it was classified into four sections. The first section of the questionnaire covered demographic information such as age and sex. The second section consisted of 12 items about their knowledge and awareness of ethics. The third section consisted of items 13–24, which explored their knowledge about the practice of ethics by the doctors in the society (including issues such as consent and confidentiality, privacy). The last section with items 25–34 dealt with the importance of the teaching of medical ethics. For the initial 33 items, the participants were asked to select from a Likert scale five-point rating: “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree.” Question 34 options included “Not at all,” “Some-what important,” “Important,” “Very important,” and “Extremely important.” Question 35 inquired the students about the source of their knowledge.

After the baseline, students were exposed to the sessions on professionalism and ethics. In the newer CBME curriculum, 40h was allotted for this topic, which is to be covered during the foundation course of a one-month duration. This introductory course aimed at introducing the students to the central importance of ethical principles in medical practice during the very first month of the undergraduate medical program. The topics covered in ethics and professionalism during the foundation course as per the CBME curriculum by the National Medical Commission are listed in [Table 1].[6]
Table 1: Topics covered under professionalism and ethics during foundation course of MBBS training

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After the completion of the foundation course, the questionnaire was again administered to the students. Statistical analysis was done for the nominal data using Statistical Package for the Social Sciences, version 21 (IBM Corp., Armonk, NY, USA). Fischer’s exact test was applied for finding the level of significance between categorical data. A P value of less than 0.05 was considered statistically significant.

  Results Top

Eighty-two students participated in the study. Of the total, 30 were girls. The mean age of the students on entry to the course was 18 ± 0.8 years. [Table 2] shows the items in the prevalidated questionnaire. Overall, it was observed that after the sessions on ethics and professionalism during the foundation course, there was an increase in the students’ level of knowledge and awareness regarding ethics. Their knowledge regarding the practice of ethics also improved. Similarly, more students realized the importance of teaching ethics during undergraduate medical training. The responses about the knowledge and awareness of ethics among doctors are shown in [Figure 1].
Table 2: Prevalidated questionnaire on the knowledge, attitude, and practice of ethics

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Figure 1: Knowledge and awareness

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There was a significant increase in some of the items regarding the knowledge and awareness of ethics [Figure 1]. After the course, the students became aware of the fact that the patient’s wishes must always be adhered to and children should not be treated without their consent. There was a significant decrease in the number of students who believed that if the patient refuses to be treated on religious grounds, they should be instructed to find another doctor.

The responses related to the practice of ethics are depicted in [Figure 2]. After the lectures, there was a significant increase in the number of students who believed that copying answers in degree examinations is “bad/sin,” and they became aware that doctors receiving income from referring patients for medical tests is “unethical” and that the doctors are getting influenced by drug companies’ inducements, including unethical gifts. A significant decrease was observed in the percentage of students who believed that “to prevent transmission of tuberculosis (TB), disclosure of TB positive status to neighbors should be done.” [Figure 3] depicts the responses with regards to the importance of teaching medical ethics. Their interest in studying ethics increased significantly after the course, and they found the topics related to ethics in the new curriculum to be relevant.
Figure 2: Practice of ethics. BP = blood pressure, CNS = central nervous system, TB = tuberculosis

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Figure 3: Importance of teaching ethics. ME = medical education

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Almost all the students stated that the topics on ethics covered during the foundation course were helpful. The sources of knowledge of ethics among the students before the sessions were newspapers and television. However, after the sessions, lecture notes were the primary source of ethics knowledge.

  Discussion Top

Medical ethics is an essential component and an indispensable aspect of health care. With the changing times, doctors are now coming across an increased number of litigations against them, most of which are linked to ethical issues. Given the current level of distrust that has started between the doctors and the patients and the worsening of the doctor–patient relationship, it has become important that doctors are professionally sound with all required competencies. It is expected that while the doctors are dealing with patients, their attendants, and relatives, they practice ethical behavior with relevant competencies.[6] The physicians must recognize the importance of being sensitive to ethical issues that they can face during clinical practice and develop in them the aptitude to effectively tackle ethical concerns.[7] The new medical undergraduates should understand and possess high personal and professional values, and they should also comprehend the ethical and legal issues they can face.[8] They need to provide care to their patients, respecting their autonomy and maintaining their self-esteem.[9] Therefore, the integration of medical ethics into the medical curriculum to provide opportunities for understanding, analyzing ethical dilemmas, and guiding students in making thoughtful ethical clinical decisions was considered important.[10],[11]

The General Medical Council, the United Kingdom, affirmed that medical ethics and law should constitute one of the essential components of the medical curriculum.[12] Evidence from literature demonstrates that many of the doctors when interviewed felt inadequately prepared for common ethical problems.[13] A study by Jacobson, et al. showed that residents from internal medicine residency programs indicated an interest in expanded teaching about medical ethics.[14] Similarly, the present study showed that the students are in favor of integrating medical ethics within the medical curriculum. It has been also realized that formal teaching of medical ethics, however, continues to be limited by the lack of clearly defined goals for such teaching.[13] Nevertheless, the teaching of medical ethics is a part of the routine curriculum in many countries and the programs are running successfully for many years, to endow medical students with the required knowledge, and understanding of the ethical challenges.[15],[16]

Considering the great need for the topic of medical ethics, with the implementation of a CBME curriculum in India, a special ethics module has been introduced, with the educational objectives of primarily arousing interest, internalizing the concepts, and understanding the applications of ethics. The first stage of the module aims at introducing ethics in the early phase of medical training, within a month of joining the medical graduate program.[6]

There are a limited number of studies on the effectiveness of teaching medical ethics in undergraduate medical education, and there is no recognized single best model for delivering medical ethics education.[17],[18] Learning ethics in small groups is widely accepted and is practiced in some universities.[19],[20],[21],[22],[23] Considering this fact, we used different teaching /learning methodologies for sensitization of the students to this topic.

Through these sessions, the students were sensitized to the ethical principles and consequences of unethical practices. Students’ knowledge of the basic concept of autonomy improved after the teaching sessions. Ethics education must, in addition to the traditional values, seek to nurture present-day cultural sensibilities in medical students.[24] Walrond, et al.[25] found that students had uncertainties on how to deal with religious differences in treating patients, on the information to be given to relatives, and on how violently patients should be treated.

Results showed that before the course, more than half (63.9%) of the students agreed with the statement “Patients, who refuse to be treated on religious or other grounds should be told to find another doctor or accept the treatment offered”; the percentage decreased (49.4%) after the sessions, which is a positive sign. Similarly, Chatterjee and Sarkar[26] reported that 55.9% of the medical students agreed that they would refer the patient to another doctor for religious conflict situations. The results of the present study showed before the course that only 25.3% of students wanted that “Close relatives should always be told about the patient’s condition”; after the course, the percentage increased to 28.9%. Contrary to this, Chatterjee and Sarkar found that 86% of the students would tell the truth to the “close relatives.”[26] Singh, et al.[4] reported that 68.2% of consultants and the majority (80.8%) of the residents agreed with the statement that “Close relatives should always be told about the patient condition.” Brogen, et al. also showed that the majority (82.9%, 89.4% of junior doctors and faculty, respectively) were in favor of the above statement.[27]

In the present study, pre-course, 9.6% of the students were in favor of the statement that “Doctors and nurses should refuse to treat a violent patient”; the percentage increased to 10.8% after the sessions. Chatterjee and Sarkar found that 21.7% of the students thought of refusing violent patients.[26] Hariharan, et al.[28] found that 7% of the physicians were in favor of refusing violent patients. Brogen, et al.[27] found that 28.7% of junior doctors were more likely to be in favor of not negotiating with, or treating, uncooperative patients. Singh, et al. also reported that 16.4% of the senior residents and 11.4% of the consultants were in favor of the above statement.[4] The evidence from the literature shows a trend toward more junior doctors being in favor of refusing violent patients, as compared with the consultants.

In the present study, in-session, 10.8% of the students agreed with the statement that “Privacy of one patient may be ignored for the benefit of the larger group”; the percentage of students agreeing increased to 18.1% after the sessions. In contrast to this, Chatterjee and Sarkar reported that around half of the students (55.9%) agreed with the above statement.[26] The reason for this could not be explained, as the response to this statement is very subjective, varying with the prevailing condition or situation.

Around 19% of students believed that the ethical aspect is important only to avoid legal action; however, this decreased after the sessions. Chatterjee and Sarkar found that 37.8% of the students agreed with the above statement,[26] whereas Singh, et al. reported that 20.5% of the residents and 11.5% of the consultants agreed with the above statement.[4] Integrity is a necessary attribute of the medical profession. Evidence from literature shows that students showing academic dishonesty during student days are more likely to indulge in unethical practices later on.[29] It is also documented that explaining to students what is acceptable behavior is an important step when trying to reduce dishonesty.[30],[31] After the session, many students believe that engaging in dishonest behavior is bad. It was heartening to observe positive changes in students’ attitudes. Eighty-eight percent of students before the session disagreed with the opinion that physicians must aid patients who wish to die, regardless of the illness, which further increased to 90.4% after the session. Similarly, Chatterjee and Sarkar found that 64% of the students disagreed with the suggestion of euthanasia.[26]

The present study showed that even nominal teaching has not only increased the knowledge of the students but also brought about a change in their attitude. Similarly, Ypinazar and Margolis also demonstrated that first-year students were able to identify medical ethical issues in a clinical setting after minimal instruction.[32] A study by colleagues and self found a significant increase in the level of moral reasoning of the students exposed to the medical ethics course regardless of the format of teaching (lectures, case discussions).[33] Similar to this, other studies from India have also shown an increase in the knowledge of students after the training.[34]

Students recognized the importance of teaching ethics and were passionate to bring about a change in their behavior toward patients. Literature reveals that the teaching of ethical principles and professional codes are welcomed by both teachers and students. Indian studies also showed that students and faculty recognize the importance of medical ethics in their professional life.[26],[34]


The limitation of the present study is the brief nature of the introductory sessions on ethics, and the fact that students are still inexperienced (as they were exposed at the very beginning of their medical training). Hence, for improving the performance and effectiveness of the program, continuing education with reinforcement is recommended.

  Conclusion Top

The need of the hour is to give attention to the teaching of medical ethics early within the undergraduate curriculum and its reinforcement throughout the MBBS course. There should be a continuum between practice and education.


  1. Teaching ethics should be a continuous process.

  2. After implementation in the foundation course, reinforcement in every phase of the MBBS course is recommended.

  3. The ethics module should be designed to promote the development of critical thinking skills for the analysis of ethical and medicolegal issues among students.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Ethical consideration

As the research study proposal is a questionnaire-based study and falls under the category of less than minimal risk, and no identifiable information is being collected or recorded for the present study, therefore Institutional Ethics Committee has provided exemption from review vide letter no. GIMS IEC-ECR/1224/Inst/UP/2019 dated 18 May 2020.

  References Top

Iswarya S, Bhuvaneshwari S. Knowledge and attitude related to medical ethics among medical students. Int J Community Med Public Health 2018;5:2222-5.  Back to cited text no. 1
Adhikari S, Paudel K, Aro AR, Adhikari TB, Adhikari B, Mishra SR. Knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses from a resource poor setting, Nepal. BMC Med Ethics 2016;17:68.  Back to cited text no. 2
Summers J, Morrison E. Principles of Healthcare Ethics. Health Care Ethics. 2nd ed. Sudbury: Jones and Bartlett Publishers; 2009. p. 41-58.  Back to cited text no. 3
Singh S, Sharma PK, Bhandari B, Kaur R. Knowledge, awareness and practice of ethics among doctors in tertiary care hospital. Indian J Pharmacol 2016;48:89-93.  Back to cited text no. 4
[PUBMED]  [Full text]  
Jatana SK, Soe HHK, Phyu KL, Lwin H, Than NN. A survey on knowledge and attitudes towards medical ethics among undergraduate medical students. Education 2018;8:48-53.  Back to cited text no. 5
Medical Council of India. Foundation Course for the Undergraduate Medical Education Program. 2019. p. 1-46. Available from: https://www.nmc.org.in/wp-content/uploads/2020/08/FOUNDATION-COURSE-MBBS-17.07.2019.pdf [Last accessed on 2021 March 15].  Back to cited text no. 6
World Health Organization, Regional Office for South-East Asia. Module for Teaching Medical Ethics to Undergraduates. New Delhi: WHO Regional Office for South-East Asia; 2009. Document no. SEA-HSD-321. Available from: https://apps.who.int/iris/handle/10665/205534  Back to cited text no. 7
General Medical Council. Tomorrow’s Doctors: Outcomes and Standards for Undergraduate Medical Education. London: General Medical Council; 2009. 104p. Available from: http://www.ub.edu/medicina_unitateducaciomedica/documentos/TomorrowsDoctors_2009.pdf  Back to cited text no. 8
Stirrat GM, Johnston C, Gillon R, Boyd K; Medical Education Working Group of Institute of Medical Ethics and Associated Signatories. Medical ethics and law for doctors of tomorrow: The 1998 consensus statement updated. J Med Ethics 2010;36:55-60.  Back to cited text no. 9
Beigy M, Pishgahi G, Moghaddas F, Maghbouli N, Shirbache K, Asghari F, et al. Students’ medical ethics rounds: A combinatorial program for medical ethics education. J Med Ethics Hist Med 2016;9:3.  Back to cited text no. 10
Henderson H, Ballard I, Alsuwaidi L, Thomas R, Ezimokhai M. Simulation: Teaching medical ethics to first year medical students within the United Arab Emirates. Med Ed Publish 2018;7:1-11. Available from: https: //doi.org/10.15694/mep.2018.0000016.1  Back to cited text no. 11
General Medical Council. Outcomes for Graduates (Tomorrow’s Doctors) July 2015: Working With Doctors Working for Patients. London: General Medical Council; 2015. Available from: https://www.gmc-uk.org/-/media/documents/outcomes-for-graduates-jul-15-1216_pdf-61408029.pdf  Back to cited text no. 12
Forrow L, Arnold RM, Frader J. Teaching clinical ethics in the residency years: Preparing competent professionals. J Med Philos 1991;16:93-112.  Back to cited text no. 13
Jacobson JA, Tolle SW, Stocking C, Siegler M. Internal medicine residents’ preferences regarding medical ethics education. Acad Med 1989;64:760-4.  Back to cited text no. 14
Al-Haqwi AI, Al-Shehri AM. Medical students’ evaluation of their exposure to the teaching of ethics. J Family Community Med 2010;17:41-55.  Back to cited text no. 15
Moodley K. Teaching medical ethics to undergraduate students in post-apartheid south africa, 2003 2006. J Med Ethics 2007;33:673-7.  Back to cited text no. 16
De La Garza S, Phuoc V, Throneberry S, Blumenthal-Barby J, McCullough L, Coverdale J. Teaching medical ethics in graduate and undergraduate medical education: A systematic review of effectiveness. Acad Psychiatry 2017;41:520-5.  Back to cited text no. 17
Eckles RE, Meslin EM, Gaffney M, Helft PR. Medical ethics education: Where are we? Where should we be going? A review. Acad Med 2005;80:1143-52.  Back to cited text no. 18
Claudot F, Alla F, Ducrocq X, Coudane H. Teaching ethics in Europe. J Med Ethics 2007;33:491-5.  Back to cited text no. 19
Mattick K, Bligh J. Teaching and assessing medical ethics: Where are we now? J Med Ethics 2006;32:181-5.  Back to cited text no. 20
Roff S, Preece P. Helping medical students to find their moral compasses: Ethics teaching for second and third year undergraduates. J Med Ethics 2004;30:487-9.  Back to cited text no. 21
Wrage S. Teaching ethics at a military academy. Int Stud Perspect 2012;13:21-5.  Back to cited text no. 22
Kolb JA, Lin H, Frisque DA. Teaching ethics in a multicultural classroom. Teaching Ethics 2005;5:13-30.  Back to cited text no. 23
Voo TC, Braddock CHIII, Chin J, Ho A. Ethics and attitudes. In: Dent JA, Harden RM, Hunt D, editors. A Practical Guide for medical teachers. Edinburgh: Elsevier Ltd; 2017. p. 195-202.  Back to cited text no. 24
Walrond ER, Jonnalagadda R, Hariharan S, Moseley HS. Knowledge, attitudes and practice of medical students at the cave hill campus in relation to ethics and law in healthcare. West Indian Med J 2006;55:42-7.  Back to cited text no. 25
Chatterjee B, Sarkar J. Awareness of medical ethics among undergraduates in a West Bengal medical college. Indian J Med Ethics 2012;9:93-100.  Back to cited text no. 26
Brogen SA, Rajkumari B, Laishram J, Joy A. Knowledge and attitudes of doctors on medical ethics in a teaching hospital, Manipur. Indian Journal of Medical Ethics 2009;6:194-7.  Back to cited text no. 27
Hariharan S, Jonnalagadda R, Walrond E, Moseley H. Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados. BMC Medical Ethics 2006;7:7.  Back to cited text no. 28
Gitanjali B. Academic dishonesty in Indian medical colleges. J Postgrad Med 2004;50:281-4.  Back to cited text no. 29
[PUBMED]  [Full text]  
Baldwin DC Jr, Daugherty SR, Rowley BD. Residents’ and medical students’ reports of sexual harassment and discrimination. Acad Med 1996;71:S25-7.  Back to cited text no. 30
Wagner RF Jr. Medical student academic misconduct: Implications of recent case law and possible institutional responses. Acad Med 1993;68:887-9.  Back to cited text no. 31
Ypinazar VA, Margolis SA. Western medical ethics taught to junior medical students can cross cultural and linguistic boundaries. BMC Med Ethics 2004;5:E4.  Back to cited text no. 32
Self DJ, Wolinsky FD, Baldwin DC Jr. The effect of teaching medical ethics on medical students’ moral reasoning. Acad Med 1989;64:755-9.  Back to cited text no. 33
Kaur G, Singh J, Bhutani K, Delmotra NJ, Goyal A. Development of module on medical ethics in patient care to MBBS students. Int J Med Res Prof 2019;5:22-7.  Back to cited text no. 34


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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