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Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 48-53

Teaching bioethics needs more than just a module: A comparison of knowledge and attitude of bioethics principles in 1st- and 3rd-year physiotherapy undergraduates

Physiotherapy School and Centre, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission01-Jun-2022
Date of Decision20-Sep-2022
Date of Acceptance30-Oct-2022
Date of Web Publication31-Jan-2023

Correspondence Address:
Dr. Mariya Prakash Jiandani
Physiotherapy School and Centre, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pjiap.pjiap_12_22

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CONTEXT: Ethics is a building block of health-care practice. Medical ethics is values and behavior applied during patient care. It may be ingrained through culture, education, upbringing, and observation. Learning by observation during a clinical posting is a hidden part of the curriculum. With experiential learning, the students may change their attitude and behavior. Whether physiotherapy students have adequate knowledge of principles of bioethics and if it changes with clinical exposure is not known.
AIMS: The aim of this study was to evaluate the perception of bioethics at entry level and post clinical exposure in physiotherapy students.
SETTINGS AND DESIGN: This was a cross-sectional study carried out in physiotherapy school of tertiary care hospital.
SUBJECTS AND METHODS: Sixty-five first-year (Group A) and 65 third-year (Group B) physiotherapy undergraduates participated after institutional ethical approval. The knowledge and attitude of medical ethics was evaluated using a prevalidated structured questionnaire.
RESULTS: Descriptive analysis and responses of Group A and Group B were compared using Mann–Whitney U-test using SPSS 16 software. There was a felt need of more than 90% of students in both the groups for sound knowledge and training in bioethics. A statistically significant difference was obtained in domains of consent, privacy, confidentiality, honesty, and integrity between 1st- and 3rd- year students. There were mixed responses in principles of autonomy, shared decision-making, and professional boundaries. Many respondents were neutral and many statements showed mixed responses indicating lack of knowledge.
CONCLUSIONS: The study concludes a need for sensitization in bioethics during clinical training to reinforce the principles in physiotherapy undergraduates beyond a formal module.

Keywords: Attitude, bioethics, knowledge, medical ethics, physiotherapy

How to cite this article:
Jiandani MP, Ranka NM, Thakur OM. Teaching bioethics needs more than just a module: A comparison of knowledge and attitude of bioethics principles in 1st- and 3rd-year physiotherapy undergraduates. Physiother - J Indian Assoc Physiother 2022;16:48-53

How to cite this URL:
Jiandani MP, Ranka NM, Thakur OM. Teaching bioethics needs more than just a module: A comparison of knowledge and attitude of bioethics principles in 1st- and 3rd-year physiotherapy undergraduates. Physiother - J Indian Assoc Physiother [serial online] 2022 [cited 2023 Jun 3];16:48-53. Available from: https://www.pjiap.org/text.asp?2022/16/2/48/368872

  Introduction Top

Ethics is a branch of philosophy dealing with moral behavior and values.[1] It is an inherent part of health care and every health-care practitioner holds a moral obligation to "do good always." Bioethics was evolved out of growing concern of professional conduct and has extended to include research ethics, clinical ethics, and biosphere including advancement in technology, medicine, and biology.[2] Attitudes, Ethics, and Communication skills and the new competency-based medical education syllabus for Indian medical graduates has formalized the importance of ethics and attitudes for health-care professional students during medical school training. Every professional course has a particular level of training within the curriculum. Related to health and health outcomes, the physiotherapy curriculum goals and clinical training are different from the medical student.

Within the physiotherapy, curriculum ethics has been taught as a formal program in few universities. Whether experiential learning with patient interactions causes a change in attitude and behavior during the progressive years of training for physiotherapy student is unknown and needs to be explored. This study was designed to explore the knowledge and attitude toward bioethics of undergraduate physiotherapy students at entry level, i.e., 1st year and with experiential learning, i.e., in the 3rd year.

  Subjects and Methods Top

A cross-sectional study was carried out in physiotherapy school of tertiary care hospital. Approval from the Institutional Ethics Committee was obtained and written informed consent was taken. Students were free to opt out of the study without any coercion. Purposive sampling was used, wherein 65 1st- and 65 3rd-year physiotherapy students were enrolled. Students were divided into two Groups "A" 1st year students who did not receive any form of sensitization to bioethics and "B" 3rd year students who had clinical exposure and sensitization to bioethics through an interactive module on principles of bioethics involving videos and case vignettes. Students with incomplete academic term were excluded from the study to maintain experiential exposure the same.

The knowledge and attitude toward bioethics in 1st and 3rd year was assessed using a validated questionnaire which was prepared after literature review[3],[4],[5],[6] and using opinion of experts in the field of bioethics. Existing literature on perception of knowledge, attitude and practice in bioethics was reviewed. A 27-item questionnaire was prepared from the literature available. Three physiotherapy students from bioethics student wing were asked to outline the areas of concern. Following this, three experts related to bioethics field were asked to rate the content and relevance of each item of the questionnaire (Content: Adequate/Inadequate/Needs modification; Relevance: 1 = not relevant/not clear 4 = very relevant/clear). Item reduction, modification, and allocation of items to bioethics domains were done by the experts. The questionnaire was presented to ethics committee of institution for review. Post suggestion of ethics committee two questions was deleted. The 25-item modified questionnaire was revalidated by three experts from ethics committee and bioethics unit of institute. The final questionnaire had a total of 25 questions based on various ethical principles and need. There were seven questions on general need for ethics and its evaluation, four questions under autonomy, one question under human dignity and respect, five questions under consent, privacy and confidentiality, two questions under the domain of equity and equality, three questions under honesty and integrity; and three questions under the domain of beneficence and harm. Responses to questions were graded on a 5 points Likert scale, where 1 was Strongly Disagree, 2 – Disagree, 3 – Neutral, 4 – Agree, and 5 – Strongly Agree.

  Results Top

Results were compiled for descriptive analysis and responses of Group A and Group B were compared using Mann–Whitney U-test using SPSS 16 software (Statistical Package for social sciences version 16, SPSS Inc,Chicago, USA). The total number of students participating in the study was 130. There were 121 females and 9 males only due to dominance of female students in physiotherapy professional course. All were in the age range of 19–22 years. [Graph 1] and [Graph 2] describe the knowledge and attitude toward bioethics.

Regarding the general need of ethics in the curriculum over 85% of the students in both the groups agreed that ethical problems are faced frequently by health-care practitioners. Majority of students were in agreement that it was important for them to gain sound knowledge about medical ethics, i.e., 97% students in Group A and 99% in Group B. The agreement that clinical rotations should evaluate and score the students based on ethical values, principles and behavior was by 86% in Group A and 91% in Group B students. Responsibility and accountability were considered a part of ethical principles by 88% of students in Group A and 91% in Group B. In Group A, 17% of students and in Group B, 25% of students agreed that ethical conduct was important only from a legal perspective to avoid litigations. Whereas 60% in Group A and 50% in Group B disagreed for the same, the rest remaining neutral.

In today's digital era where social networking and use of social platforms are common, mixed responses were obtained for whether social relationships with patients could be maintained on social networking sites. Group A was equally distributed with 34% agreement, 35% neutral and 31% disagreeing with the statement whereas in Group B only 19% agreed, 54% were neutral and 28% disagreed.

There was a strong consensus seen between both groups of study participants about ethical principles such as honesty and integrity. To forge clinical findings just for the sake of documentation and sheet notes completion It was disagreed by 71% of Group A students and 78% of Group B students. While answering whether any wrongdoing by a health-care practitioner of the team should be informed to the patient, 85% in Group A and 94% in Group B agreed to it; in concern to receiving referral fees, 42% in Group A and 65% in Group B disagreed to the statement and considered it ethically wrong to receive referral fees; however, 28% in Group A and 22% in Group B did not consider it unethical.

With reference to equity and equality, there was strong consensus between the study groups for triaging patients as per the urgency to receive healthcare, with more than 80% of participants agreeing with the statement. The concept of justice was agreed by 83% in both groups as distributing health-care resources to the needy. However, in response to receiving financial incentives for organ donation, around half, i.e., 51% in Group A and 48% in Group B were in agreement to provide, whereas 20% in Group A and 23% in Group B disagreed.

In response to autonomy and shared decision-making, 15% of Group A and 31% of Group B students agreed, irrespective of the relative's opinion, that health-care practitioners should continue the line of treatment as decided by him/her in case the patient is unable to decide it himself/herself, whereas 35% Group A and 40% Group B students disagreed; in response to supporting the wish of the family to continue admission against the patient wish of discharge after treatment 39% in Group A and 49% in Group B disagreed to support the family's decision, whereas 25% in Group A and 11% in Group B agreed that family wish has to be respected. Furthermore in regard to physician assistance to dying irrespective of illness 69% in Group A and 74% in Group B disagreed with the use, whereas 8% of students in Group A and 3% of students in Group B agreed. So also a mixed response was seen in assisting decision to undergo abortion within 20 weeks without questioning, wherein 40% in Group A and 48% in Group B agreed to the statement, 48% in Group A and 30% in Group B disagreed to the statement.

Disclosure of information is an important ethical aspect that involves consent, protecting patient's privacy and confidentiality. With reference to disclosing positive HIV status to the wife irrespective of patient consent, 71% of Group A and 60% of Group B students agreed to disclose; however, 19% in Group A and 31% in Group B disagreed. The opinion varied with disclosure of Tuberculosis (TB) to neighbors where the majority of students, 52% of Group A and 71% of Group B, disagreed to disclose the positive TB status to neighbors and contacts irrespective of patients consent. However, 72% of Group A and 57% of Group B students agreed with the statement that medical diagnoses should always be revealed to the family members.

Routine examination such as blood pressure measurement was agreed as needing consent by 60% in Group A and 62% in Group B, whereas 22% in Group A and 23% in Group B disagreed with the need for consent. Only a small proportion of students, i.e., 12% in Group A and 8% in Group B, were in agreement that consent was needed for surgical procedures and not for routine medical evaluations.

Physiotherapy students have shown mixed responses to the statement which stated that a doctor can refuse to treat the patient who acts violently. They were also neutral on the question related to animal research. Cultural sensitivity being an important domain, students strongly disagreed with the statement which stated that patients with different religious beliefs, when it came to accepting appropriate treatment from doctors, should be asked to find doctors with similar religious beliefs. Upholding Human dignity and respect, about 50% of the students (49% of Group A and 51% of Group B students) agreed that a male doctor can refuse to treat a female patient (not in an emergency) in the absence of a chaperone.

There were mixed responses to almost all questions related to bioethics principles, and many respondents were neutral to the questions. A comparison between Group A and Group B on various domains, as shown in [Table 1], shows there was a statistically significant difference in both the groups for the domain of honesty and integrity (P = 0.022); and consent, privacy, and confidentiality (P = 0.001).
Table 1: Comparison of Group A and Group B in various domains

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  Discussion Top

Bioethics is based on a set of values that a health-care professional can lean on in case of conflict or dilemma. In this era of increased technology and patient awareness, where there has been a shift from a patriarchal delivery to shared decision-making, the knowledge of bioethics is a prerequisite for health-care practice. The questionnaire tested knowledge and attitude toward various domains of ethical principles, in the formative years of undergraduate training in physiotherapy at a tertiary care hospital. It also stimulated thinking and discussion, which helped students understand various ethical principles commonly faced in practice. This is probably the first study evaluating physiotherapy undergraduate students and hence did not have any direct supporting or contradicting literature. The responses have been compared with the literature available with medical and nursing students. There was a mixed response seen in many of the questions related to principles of bioethics in both groups, and many respondents were neutral. This indicates a lack of knowledge, awareness, and confidence in that domain or dealing with the dilemma.

There was an agreement by both groups that ethical problems are frequently faced, and there is a need for adequate knowledge of bioethics and its evaluation during clinical posting. This calls for preparing students to resolve ethical dilemmas and providing them with adequate support and continuous training as needed. This is also supported by a study done in south India by Janakiram and Gardens and in Nepal among undergraduate health care professional students.[7],[8] Fifty percentage of students disagreed that ethics is important only from the legal standpoint, similar to the study by Iswarya and Bhuvaneshwari and Subramanian et al.[9],[10] However, a greater proportion of students from Group B felt that ethical conduct was important to prevent litigation, indicating a need to bridge the understanding between law and ethics.

With the increased use of technology by both patients and health-care providers, it is important to clarify when and how social media should be used and what should be the limits and rules governing professional behavior on social media. The greater proportion of students from Group B compared to Group A were in disagreement with the use of social media with patients. Majority of the students giving neutral responses indicate a lack of understanding regarding professional boundaries and social relationships with patients on social networking sites. Honesty and integrity being important in any profession, an honest attitude was reflected in the students from both groups where completion of notes, documentation, and reporting of errors is concerned. This improves trustworthiness of the health-care system. These behaviors are generally seen and picked up in students while they have to complete their own case presentation papers, academic log books, etc., which are carried forward as professional documentation. Accountability and responsibility were recognized as important characters in ethics.

There seemed to exist a dilemma in financial incentives, be it for referral practice or organ donation. Earning and income generation for sustenance and livelihood is an important aspects of any profession. Cut practice or referral remuneration is very common. Newly budding therapists generally fall prey and take support from this to build up their practice. The greater proportion of students from Group B considered it ethically wrong to receive referral fees as incentive. However around 50% of both groups were of the opinion that financial incentives should be provided for organ donation generating a debate. When the question regarding resource distribution was concerned, both groups have shown a good understanding of the principle of equity and equality.

The students in both groups seemed to lack a fundamental understanding of the principle of autonomy and shared decision-making, similar to the study done in the United States.[11],[12] A little more than 1/3rd disagreed with the physician continuing his line of treatment, irrespective of the opinion of family members. This is contradictory to the study done by Iswarya on medical students. Family and caregivers plays an important role in compliance and support of therapeutic intervention. Almost double the proportion in Group B had an attitude that the health-care provider knows the best and should be the decision maker instead of the family if patients do not have the capacity to decide. However, at the same time, larger proportion from Group B disagreed with physician assistance in dying and also upheld the family decision of admitting the patient irrespective of his will. This indicates the application of principles in complex scenarios where consent and decision-making was concerned needs greater deliberations and discussions. Despite the lack of knowledge about abortion rules, there was an agreement to assist the decision within the law without questioning. Hence as problems became complex ethical decision-making in dilemmas needed further exploration.

Group B better understood the concept of consent and confidentiality and disclosure of diseases. Understanding the principle of beneficence to the partner and society, a large majority of the students felt that disclosing positive disease status to their partner, irrespective of patient consent, was fair. This was in contrast with a study in Canada that showed many family physicians fully understood their obligations toward patient confidentiality.[13] There was also a discrepancy in responses between groups regarding refusal to treat violent patients and research on animals, probably because of lack of exposure. Majority of students in both groups showed a positive attitude toward human dignity and respect, indicating strong inbuilt ethical moral values.[14]

Though clinical exposure seemed to improve the perception and understanding toward ethical principles, there was a gap seen in knowledge and attitude in applying principles of bioethics. A considerable proportion of students in Group B in spite of being sensitized to the bioethics module, were at crossroads and responded neutral with almost all the questions. This highlights that a single module of training is insufficient to impart knowledge about complex scenarios. Clinical experience, the influence of social factors, media, and mixed emotional reactions may also be factors for the neutral response. When 3rd year students were asked about the focus of ethical discussions during clinical exposure and case presentations, none had gone through it, as the primary focus was on improving patient care. This indicates that clinical training should also be used to reinforce ethical knowledge and practice. This also brings in the need for training faculty in bioethics. Research has suggested positive attitudes and beneficial outcomes due to educational innovations[15] such innovations should be implemented in the field of bioethics.

The study has limitations of being from a single center, using a self-reported validated questionnaire and not being longitudinal in nature.

  Conclusions Top

There seems to be a knowledge-attitude gap about a variety of ethical issues, which needs to be met by early sensitization and continuous training in bioethics to help students make more ethical decisions. There may be multiple factors that could influence one's decision about ethical practice; hence, training in bioethics and evaluation beyond a formal program needs consideration along with the development of curricular content for physiotherapists. Clinical placements for experiential learning should have deliberate, focused learning in bioethics.


We thank Dr Hemant Deshmukh, Dean and Chairperson of bioethics Unit and Dr. Santosh Salagre for the support extended as Head of Bioethics Unit. Dr. Padmaja Samant and Dr. Y B Chavan Bioethics unit members for contributing to validating the questionnaire, Ms. Gautami Chaudhari for contributing in designing the study. Prof Amita Mehta Ex Head of Physiotherapy for her support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Avci E. A normative analysis to determine the goals of ethics education through utilizing three approaches: Rational moral education, ethical acculturation, and learning throughout life. Int J Ethics Educ 2017;2:125-45.  Back to cited text no. 1
Wikipedia Bioethics. Available from: http://en.wikipedia.org/wiki/Bioethics. [Last accessed on 2022 Sep 20].  Back to cited text no. 2
Jatana SK, Soe HH, 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. 3
Chopra M, Bhardwaj A, Mithra P, Singh A, Siddiqui A, Dr R. Current status of 4.knowledge, attitudes and practices towards health care ethics among doctors and nurses from Northern India-A multicenter study. JKIMSU 2013. 2013 Jul;2:102-7.  Back to cited text no. 4
Hariharan S, Jonnalagadda R, Walrond E, Moseley H. Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados. BMC Med Ethics 2006;7:E7.  Back to cited text no. 5
Mohamed AM, Ghanem MA, Kassem A. Knowledge, perceptions and practices towards medical ethics among physician residents of University of Alexandria Hospitals, Egypt. East Mediterr Health J 2012;18:935-45.  Back to cited text no. 6
Janakiram C, Gardens SJ. Knowledge, attitudes and practices related to healthcare ethics among medical and dental postgraduate students in south India. Indian J Med Ethics 2014;11:99-104.  Back to cited text no. 7
Sharma S, Ratna Shakya D, Adhikari S, Chetri VA, Singh RR. Awareness, knowledge and attitude towards bioethics among first year undergraduate students of a health science institute in Eastern Nepal. Glob Bioeth Enquiry 2020;8:151-6.  Back to cited text no. 8
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. 9
Subramanian T, Mathai AK, Kumar N. Knowledge and practice of clinical ethics among healthcare providers in a government hospital, Chennai. Indian J Med Ethics 2013;10:96-100.  Back to cited text no. 10
Hébert PC, Meslin EM, Dunn EV. Measuring the ethical sensitivity of medical students: A study at the University of Toronto. J Med Ethics 1992;18:142-7.  Back to cited text no. 11
Fulford KW, Yates A, Hope T. Ethics and the GMC core curriculum: A survey of resources in UK medical schools. J Med Ethics 1997;23:82-7.  Back to cited text no. 12
Geiderman JM, Moskop JC, Derse AR. Privacy and confidentiality in emergency medicine: Obligations and challenges. Emerg Med Clin North Am 2006;24:633-56.  Back to cited text no. 13
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Vol. 4. New York: Oxford University Press; 2001. p. 174-5.  Back to cited text no. 14
Perkins HS, Geppert CM, Hazuda HP. Challenges in teaching ethics in medical schools. Am J Med Sci 2000;319:273-8.  Back to cited text no. 15


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