Building Medical Ethics Education to Improve Japanese Medical Students’ Attitudes Toward Respecting Patients’ Rights

Tohoku J. Exp. Med., 2011, 224, 307-315Ethical Development among Medical Students 307

Yukiko Saito,1 Yasushi Kudo,2 Akitaka Shibuya,2, 3 Toshihiko Satoh,4 Masaaki Higashihara5 and Yoshiharu Aizawa6

1Department of Medical Humanities, Research and Development Center for Medical Education, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan 2Department of Health Care Management, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan 3Department of Risk Management and Health Care Administration, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan 4Kitasato Clinical Research Center, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan 5Department of Hematology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan 6Department of Preventive Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan

In medical education, it is important for medical students to develop their ethics to respect patients’ rights. Some physicians might make light of patients’ rights, because the increased awareness of such rights might make it more difficult for them to conduct medical practice. In the present study, predictors significantly associated with “a sense of resistance to patients’ rights” were examined using anonymous self-administered questionnaires. For these predictors, we produced original items with reference to the concept of ethical development and the teachings of Mencius. The subjects were medical students at the Kitasato University School of Medicine, a private university in Japan. A total of 518 students were analyzed (response rate, 78.4%). The average age of enrolled subjects was 22.5 ± 2.7 years (average age ± standard deviation). The average age of 308 male subjects was 22.7 ± 2.8 years, while that of 210 female subjects was 22.1 ± 2.5 years. The item, “Excessive measures to pass the national examination for medical practitioners,” was significantly associated with “a sense of resistance to patients’ rights.” However, other items, including basic attributes such as age and gender, were not significant predictors. If students spent their school time only focusing on the national examination, they would lose the opportunity to receive the ethical education that would allow them to respect patients’ rights. That ethical development cannot easily be evaluated with written exams. Thus, along with the acquisition of medical knowledge, educational programs to promote medical students’ ethics should be developed.

In medical ethics education, improving medical stu- lies at the core of a patient’s decision-making based on their dents’ attitudes toward respecting patients’ rights is an free will. essential task (American Hospital Association 1972; World Eckles et al. (2005) suggested that there are two points Medical Association 1981; Annas and Densberger 1984; of view regarding the purpose of teaching medical ethics: Beauchamp and McCullough 1984; Saito 1997; Ministry of “creating virtuous physicians” and “providing physicians Education, Culture, Sports, Science, and Technology 2001; with a skill set for analyzing and resolving ethical dilem- Post 2004a, 2004b; Eckles et al. 2005; Beauchamp and mas.” In Japan, the Ministry of Education, Culture, Sports, Childress 2008; Ministry of Education, Culture, Sports, Science, and Technology (2001) reported that the purpose Science, and Technology 2008). The “Patient’s Bill of of medical education is to “create physicians who are com- Rights (American Hospital Association 1972)” and mitted to ethics and have problem-solving skills.” “Declaration of Lisbon on the Rights of the Patient (World Subsequently, the Ministry of Education, Culture, Sports, Medical Association 1981)” state that a physician must Science, and Technology (2008) added the following respect the rights of patients. In the field of medical ethics, regarding qualities needed to become physicians in a model “respect for autonomy” (Beauchamp and Childress 2008) core curriculum: “keep physician’s responsibilities and

Received May 9, 2011; revision accepted for publication July 21, 2011. doi: 10.1620/tjem.224.307 Correspondence: Yasushi Kudo, Department of Health Care Management, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan. e-mail: [email protected]

307 308 Y. Saito et al. medical ethics, and always take patient-oriented view honor of their teachers. points” and “have a well-rounded character while being This type of education stresses that medical students deeply conscious of the dignity of life.” become aware of and improve their attitudes toward daily In the field of ethics development, the following four living through such education. These activities may con- concepts are mostly regarded as influential factors in the tribute to the creation of a desirable environment for devel- ethical development of people: “role-models” (Merton et al. oping students’ ethical reasoning. To the best of our knowl- 1957; Wright 1998; Eckles et al. 2005), “respect for people” edge, no Japanese universities actually implement such (Durkheim 1973; Ministry of Education, Culture, Sports, educational activities. These activities may affect the ethi- Science, and Technology 2006), “utilitarianism” (Bentham cal reasoning to respect the rights of patients. This study 1988; Post 2004c; Iseda and Katagi 2006), and “compli- also examines the associations between “shurei-keijin edu- ance” (Kohlberg 1976). cation” and the “students’ ethical reasoning.” Application of the above ethical concepts (Merton et al. 1957; Durkheim 1973; Kohlberg 1976; Bentham 1988; Subjects and Methods Wright et al. 1998; Post 2004c; Eckles et al. 2005; Iseda Participants and Katagi 2006; Ministry of Education, Culture, Sports, The subjects were 661 medical students of the Kitasato Science, and Technology 2006) to Japanese medical stu- University School of Medicine, a private university in Japan. dents can be effective to analyze their ethical development. Students who had withdrawn from school temporarily were excluded. However, the previous studies on ethics education for medi- During the period of January to February 2009, the anonymous self- cal students have only investigated their awareness or actual administered questionnaires (original version in Japanese, see the conditions regarding ethics, such as surveys of students’ Appendix) with return envelopes and the Japanese explanations of the awareness of ethics education (Tanida et al. 2003; Miyata study were distributed to the students. To get the students’ truthful and Yamamoto 2010), surveys of ethical issues in medical opinions, the completed questionnaires were then sealed in envelopes education (Kato and Suzuki 2005; Hirakawa et al. 2005), by the students themselves. The students could either place the ques- and curriculum surveys (Kodama et al. 2009; Matsui et al. tionnaires in the collection boxes or hand them directly to the person- nel in charge. A collection box was placed at the door of the adminis- 2009). trative office to the end of March 2009. To the best of our knowledge, there are no studies that applied the above four ethical concepts in the field of ethics education to medical education. The present study involved Survey items 1. A sense of resistance to patients’ rights the preparation of a questionnaire by referring to those four This item was produced with reference to previous studies concepts. We evaluated the associations between those (American Hospital Association 1972; World Medical Association concepts and the attitude toward patients’ rights among 1981; Annas and Densberger 1984; Beauchamp and McCullough medical students. 1984; Saito 1997; Ministry of Education, Culture, Sports, Science, The term “shurei-keijin” in Japanese was taken from and Technology 2001; Post 2004a, 2004b; Eckles et al. 2005; the teachings of the Chinese philosopher, Mencius. This Beauchamp and Childress 2008; Ministry of Education, Culture, philosophical term conveys the meaning of “treating others Sports, Science, and Technology 2008). Respecting the patients’ with decency and respect” and has been passed down for rights is extremely important for medical students. However, if such generations as the concept best expressing the ideal for awareness increases, some students may imagine that they might get human beings (Kaizuka 1999; Aizawa 2007). Our medical various complicated demands from the patients. If that happens, they school focuses on not only teaching medical knowledge and may consequently consider the patients’ rights negatively. skills but also humanity to our students. To do so, Kitasato “A sense of resistance to patients’ rights” was rated on a 7-point University School of Medicine has focused on the Mencian scale from “definitely agree” to “definitely disagree” by asking “If the philosophical idea of “shurei-keijin” and has conducted awareness of patients’ rights increases, it may become more difficult educational programs to put this unique philosophy into to conduct medical practice.” practice since 2007. So that medical students can examine their attitudes 2. Concepts affecting ethical development toward daily living, educational activities are conducted. The following 5 items were produced: “encounters with role For example, questionnaire surveys on “shurei-keijin” are models,” “shurei-keijin education,” “being treated with respect and dignity by teachers,” “excessive measures to pass the national exami- conducted. Our university has also established a hallway nation for medical practitioners,” and “obedience to societal rules next to the medical library where people always greet each irrespective of penalties.” These factors were rated on a 7-point scale other in passing called, “the path of respect.” Our students’ from “definitely agree” to “definitely disagree.” impressions of and reflections on “shurei-keijin” are attached to the walls along this path. Teachers, as well as Encounters with role models the students, need to examine their own “shurei-keijin” The term “role model” means any person who serves as an attitudes toward daily living. The teacher who practices example, whose behavior is emulated by others (Merton et al. 1957; “shurei-keijin” well is chosen by the students and given an Wright et al. 1998; Eckles et al. 2005). For professionals, role models award at an annual ceremony given by new graduates in have a strong influence on their careers. This concept is also natu- Ethical Development among Medical Students 309 rally true of physicians. For young physicians, physicians serving as feelings. We hypothesized that “obedience to societal rules irrespec- role models in clinical settings will help nurture values, attitudes, and tive of penalties” was significantly associated with “a sense of resis- behavior essential for creating responsibility, humanity, and ethical tance to patients’ rights.” behavior. The images of ideal role models of physicians can be pro- jected by sharing professional experiences with physicians as role 3. Basic Attributes models even without being taught verbally. Polanyi (1966) termed The subjects were asked to provide their age, gender, and grade. this “tacit knowledge.” We proposed a hypothesis whereby “encounters with role models” is associated with ethical reasoning among Analyzed subjects medical students. The analyzed subjects are shown in Table 1. Of the 661 questionnaires distributed, 553 responses were collected for a return ratio Shurei-keijin education of 83.7%. The questionnaires, which have one or more missing val- As explained in the Introduction, the Kitasato University School ues, were excluded for analyses. A total of 518 subjects were ana- of Medicine conducts “shurei-keijin education.” “Shurei-keijin” lyzed (response rate: 78.4%). The average age of the analyzed sub- forms the basis of human education. We also proposed a hypothesis jects was 22.5 ± 2.7 years (average age ± standard deviation). The whereby “shurei-keijin education” is associated with ethical reason- average age of 308 male subjects was 22.7 ± 2.8 years, and that of ing among medical students. 210 female subjects was 22.1 ± 2.5 years.

Being treated with respect and dignity by teachers Statistical analyses Teachers treating their students and co-workers with respect is To investigate the factors associated with “a sense of resistance considered ethically important (Durkheim 1973; Ministry of to patients’ rights,” standard partial regression coefficients were com- Education, Culture, Sports, Science, and Technology 2006). In addi- puted using forced-entry multiple linear regression analysis. “A sense tion, students’ recognition of being respected by their teachers affects of resistance to patients’ rights” was a dependent variable. their personal inner growth, e.g., self-respect and attachment to social “Encounters with role models,” “shurei-keijin education,” “being groups (Durkheim 1973). Ethics development of medical students treated with respect and dignity by teachers,” “excessive measures to could be promoted by the act of receiving respect from their teachers. We examined the associations between this concept and medical stu- Table 1. The distribution of the basic attributes. dents’ ethical development. n % Excessive measures to pass the national examination for medical Age practitioners 18 15 2.9 We also proposed a hypothesis whereby “excessive measures to 19 47 9.1 pass the national examination for medical practitioners” affects stu- 20 67 12.9 dents’ ethical development. This subject was created based on the concepts of utilitarianism (Bentham 1988; Post 2004c; Iseda and 21 73 14.1 Katagi 2006). This utilitarianism is the concept of achieving the 22 68 13.1 greatest happiness for the greatest number of individuals and society. 23 89 17.2 Based on utilitarianism, the item, “excessive measures for the 24 66 12.7 national examination for medical practitioners,” was produced for this 25 44 8.5 study. This particular item is considered a practical part of education 26 19 3.7 for medical students. If the students are merely concerned with pass- 27 10 1.9 ing the national examination for medical practitioners, they may lose 28 10 1.9 important opportunities to consider patients’ rights. If so, they bear a sense of resistance to patients’ rights. On the other hand, the medical 29 3 0.6 students who are focused on passing the national examination for 30 - 7 1.4 medical practitioners are diligent. Such students may ponder patients’ rights. Therefore, they most likely do not harbor a sense of resistance Gender to patients’ rights. Male 308 59.5 We hypothesized that students who are focused on passing the Female 210 40.5 national examination for medical practitioners harbor “a sense of resistance to patients’ rights.” However, this hypothesis could be Academic year erroneous. Most students are highly ethical and do not harbor a sense of resistance to patients’ rights. We examined how this variable 1st 104 20.1 affects the ethical development. 2nd 86 16.6 3rd 93 18.0 Obedience to societal rules irrespective of penalties 4th 64 12.4 People who obey societal rules are considered to be in higher 5th 85 16.4 stages of personal inner growth, even if there is no legal punishment 6th 86 16.6 (Kohlberg 1976). As medical students develop this higher sense of Total 518 100 personal growth, they may be more considerate regarding patients’ 310 Y. Saito et al. pass the national examination for medical practitioners,” and “obedi- Table 2. The distribution of each variable. ence to societal rules irrespective of penalties” were independent n % variables. Moreover, to examine the relationships between the dependent variable and the independent variables, Pearson’s correlation Encounters with role models coefficient was calculated or nonparametric tests were performed. Definitely agree 40 7.7 ® PASW Statistics 18.0 was used for all statistical analyses. The Agree 91 17.6 values of p < 0.05 were considered to indicate statistical significance. Somewhat agree 177 34.2 Neither agree nor disagree 122 23.6 Ethics Somewhat disagree 45 8.7 The Japanese explanations of the study in addition to the anony- Disagree 27 5.2 mous self-administered questionnaires with return envelopes were distributed to the 661 subjects. The Kitasato University Medical Definitely disagree 16 3.1 Ethics Committee (B section) judged that this study does not need an Shurei-keijin education (treating others with decency and respect) ethical review committee. Definitely agree 58 11.2 Agree 79 15.3 Results Somewhat agree 136 26.3 The distributions of each variable are shown in Table 2. Neither agree nor disagree 117 22.6 Regarding “a sense of resistance to patients’ rights,” 87 Somewhat disagree 39 7.5 (16.8%) responded “definitely agree,” 78 (15.1%) “agree,” Disagree 37 7.1 216 (41.7%) “somewhat agree,” 81 (15.6%) “neither agree Definitely disagree 52 10.0 nor disagree,” 28 (5.4%) “somewhat disagree,” 18 (3.5%) Being treated with respect and dignity by teachers “disagree,” and 10 (1.9%) “definitely disagree.” Definitely agree 29 5.6 The relationships between “a sense of resistance to Agree 105 20.3 patients’ rights” and basic attributes of the subjects are Somewhat agree 166 32.0 shown in Table 3. “A sense of resistance to patients’ rights” Neither agree nor disagree 115 22.2 was significantly correlated with age (Pearson’s correlation Somewhat disagree 61 11.8 coefficient [r] = 0.108). The Kruskal-Wallis test also Disagree 27 5.2 showed significant differences among academic grades (p < Definitely disagree 15 2.9 0.05). Excessive measures to pass the national examination for medical Relationships between “a sense of resistance to practitioners patients’ rights” and each variable are shown in Table 4. “A Definitely agree 44 8.5 sense of resistance to patients’ rights” was significantly cor- Agree 51 9.8 related with “encounters with role models” (r = 0.161), Somewhat agree 93 18.0 “being treated with respect and dignity by teachers” (r = Neither agree nor disagree 198 38.2 0.094), and “excessive measures to pass the national exami- Somewhat disagree 67 12.9 nation for medical practitioners” (r = 0.155). Disagree 30 5.8 The results of multiple regression analysis are shown in Table 5. “Excessive measures to pass the national exam- Definitely disagree 35 6.8 ination for medical practitioners” was significantly associ- Obedience to societal rules irrespective of penalties ated with “a sense of resistance to patients’ rights” (stan- Definitely agree 26 5.0 dardized partial regression coefficient = 0.130). The Agree 35 6.8 adjusted R2 = 0.045. The variance inflation factors were < 3 Somewhat agree 99 19.1 in all variables. Neither agree nor disagree 136 26.3 Somewhat disagree 51 9.8 Discussion Disagree 73 14.1 A total of 73.6% (“definitely agree” to “somewhat Definitely disagree 98 18.9 agree” is shown in Table 2) of students who felt that it A sense of resistance to patients’ rights becomes difficult to conduct medical practice as the aware- Definitely agree 87 16.8 ness of patients’ rights is enhanced. In medical education, Agree 78 15.1 it is important for medical students to develop their ethics Somewhat agree 216 41.7 to respect patients’ rights (American Hospital Association Neither agree nor disagree 81 15.6 1972; World Medical Association 1981; Annas and Somewhat disagree 28 5.4 Densberger 1984; Beauchamp and McCullough 1984; Saito Disagree 18 3.5 1997; Ministry of Education, Culture, Sports, Science, and Definitely disagree 10 1.9 Technology 2001; Post 2004a, 2004b; Eckles et al. 2005; Beauchamp and Childress 2008; Ministry of Education, Total 518 100 Ethical Development among Medical Students 311

Table 3. A sense of resistance to patients’ rights and basic attributes. P value of Neither Definitely Somewhat Somewhat Definitely Correlation non- Agree agree nor Disagree Total agree agree disagree disagree coefficient parametric disagree test Age 18-19 12 (19.4%) 6 (9.7%) 27 (43.5%) 8 (12.9%) 3 (4.8%) 4 (6.5%) 2 (3.2%) 62 (100%) r = 0.108 20-21 14 (10.0%) 24 (17.1%) 62 (44.3%) 23 (16.4%) 9 (6.4%) 4 (2.9%) 4 (2.9%) 140 (100%) P = 0.014 22-23 26 (16.6%) 22 (14.0%) 61 (38.9%) 27 (17.2%) 13 (8.3%) 6 (3.8%) 2 (1.3%) 157 (100%) 24-25 23 (20.9%) 19 (17.3%) 45 (40.9%) 17 (15.5%) 2 (1.8%) 2 (1.8%) 2 (1.8%) 110 (100%) 26-27 4 (13.8%) 4 (13.8%) 18 (62.1%) 3 (10.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 29 (100%) 28-29 4 (30.8%) 2 (15.4%) 3 (23.1%) 2 (15.4%) 0 (0.0%) 2 (15.4%) 0 (0.0%) 13 (100%) 30- 4 (57.1%) 1 (14.3%) 0 (0.0%) 1 (14.3%) 1 (14.3%) 0 (0.0%) 0 (0.0%) 7 (100%)

Gender Male 60 (19.5%) 47 (15.3%) 117 (38.0%) 49 (15.9%) 16 (5.2%) 13 (4.2%) 6 (1.9%) 308 (100%) P = 0.360 Female 27 (12.9%) 31 (14.8%) 99 (47.1%) 32 (15.2%) 12 (5.7%) 5 (2.4%) 4 (1.9%) 210 (100%)

Academic year 1st 19 (18.3%) 13 (12.5%) 44 (42.3%) 13 (12.5%) 8 (7.7%) 6 (5.8%) 1 (1.0%) 104 (100%) 2nd 7 (8.1%) 15 (17.4%) 33 (38.4%) 18 (20.9%) 5 (5.8%) 3 (3.5%) 5 (5.8%) 86 (100%) P = 0.026 3rd 13 (14.0%) 11 (11.8%) 39 (41.9%) 19 (20.4%) 5 (5.4%) 4 (4.3%) 2 (2.2%) 93 (100%) 4th 12 (18.8%) 12 (18.8%) 25 (39.1%) 11 (17.2%) 4 (6.3%) 0 (0.0%) 0 (0.0%) 64 (100%) 5th 19 (22.4%) 12 (14.1%) 36 (42.4%) 10 (11.8%) 5 (5.9%) 3 (3.5%) 0 (0.0%) 85 (100%) 6th 17 (19.8%) 15 (17.4%) 39 (45.3%) 10 (11.6%) 1 (1.2%) 2 (2.3%) 2 (2.3%) 86 (100%)

Total 87 (16.8%) 78 (15.1%) 216 (41.7%) 81 (15.6%) 28 (5.4%) 18 (3.5%) 10 (1.9%) 518 (100%)

Pearson’s correlation coefficient (r) was calculated to examine the relationships between “a sense of resistance to patients’ rights” and age. “A sense of resistance to patients’ rights” was rated from “definitely disagree” to “definitely agree” using a 7-point scale (1=definitely disagree, 7=definitely agree). The actual age was used as a continuous variable. Mann-Whitney U test was used for gender. Kruskal-Wallis test was used for academic year.

Culture, Sports, Science, and Technology 2008). However, consider the patients’ rights. Therefore, the medical profes- 73.6% of students have ethically undesirable feelings. It is sionals involved in medical education should provide necessary to reconsider the contents of ethical education for opportunities for students to acquire medical knowledge as medical students. well as explore better approaches in medical education to We also investigated the factor associated with the “a nurture students’ ethical reasoning abilities. However, such sense of resistance to patients’ rights.” As results, “a sense programs are generally not well developed. of resistance to patients’ rights” was significantly associated To become a physician in Japan, a 6-year education at with “excessive measures to pass the national examination a medical university and acceptance by passing the national for medical practitioners.” examination for medical practitioners are required (Medical This item was produced with reference to utilitarian- Practitioners Act 2007). Students’ level of knowledge can ism (Bentham 1988; Post 2004c; Iseda and Katagi 2006). It be assessed by such written tests; however, progress of their is not ethically wrong to be highly utilitarian. However, ethical development cannot be so easily evaluated. The utilitarianism, which is characterized by individual prefer- teachers in a medical faculty need to conduct educational ence, may lead to the pursuit of self-interest (Post 2004c; activities while being aware of students’ ethical develop- Iseda and Katagi 2006). If that happens, one may come to ment. make light of the happiness of others and society. Such a For example, encouraging volunteer activities and/or person may commit ethically undesirable deeds and harbor providing opportunities to help people suffering from natu- ethically undesirable opinions. ral disasters may promote students’ inner growth. Such Physicians compose a professional group of people experiences are beneficial for ethical development, which who protect the life and health of others on a daily basis. cannot easily be evaluated by a written exam. Encouraging Physicians require not merely knowledge but also inner students to study abroad and interact with other cultures growth for feeling happy to see others happy. However, if may nurture students’ potential to learn various values and students spend their school time focusing only on the accept them. Such experiences may also promote students’ national examination, they lose opportunities to learn to inner growth. In medical education, making an attempt to 312 Y. Saito et al.

Table 4. Relationships between a sense of resistance to patients’ rights and each variable. Pearson’s Definitely Somewhat Neither agree Somewhat Definitely Agree Disagree Total correlation agree agree nor disagree disagree disagree coefficient Encounters with role models Definitely agree 20 (50.0%) 2 (5.0%) 9 (22.5%) 6 (15.0%) 0 (0.0%) 2 (5.0%) 1 (2.5%) 40 (100%) Agree 10 (11.0%) 17 (18.7%) 42 (46.2%) 13 (14.3%) 4 (4.4%) 4 (4.4%) 1 (1.1%) 91 (100%) Somewhat agree 24 (13.6%) 29 (16.4%) 87 (49.2%) 26 (14.7%) 6 (3.4%) 4 (2.3%) 1 (0.6%) 177 (100%) Neither agree nor disagree 19 (15.6%) 17 (13.9%) 50 (41.0%) 26 (21.3%) 7 (5.7%) 2 (1.6%) 1 (0.8%) 122 (100%) Somewhat disagree 5 (11.1%) 7 (15.6%) 20 (44.4%) 4 (8.9%) 8 (17.8%) 0 (0.0%) 1 (2.2%) 45 (100%) Disagree 3 (11.1%) 4 (14.8%) 8 (29.6%) 3 (11.1%) 3 (11.1%) 5 (18.5%) 1 (3.7%) 27 (100%) Definitely disagree 6 (37.5%) 2 (12.5%) 0 (0.0%) 3 (18.8%) 0 (0.0%) 1 (6.3%) 4 (25.0%) 16 (100%) 0.161 (P <0.001)

Shurei-keijin education (treating others with decency and respect) Definitely agree 16 (27.6%) 3 (5.2%) 23 (39.7%) 7 (12.1%) 2 (3.4%) 7 (12.1%) 0 (0.0%) 58 (100%) Agree 10 (12.7%) 14 (17.7%) 33 (41.8%) 20 (25.3%) 2 (2.5%) 0 (0.0%) 0 (0.0%) 79 (100%) Somewhat agree 17 (12.5%) 22 (16.2%) 76 (55.9%) 12 (8.8%) 5 (3.7%) 4 (2.9%) 0 (0.0%) 136 (100%) Neither agree nor disagree 19 (16.2%) 13 (11.1%) 48 (41.0%) 26 (22.2%) 10 (8.5%) 1 (0.9%) 0 (0.0%) 117 (100%) Somewhat disagree 2 (5.1%) 8 (20.5%) 13 (33.3%) 7 (17.9%) 7 (17.9%) 0 (0.0%) 2 (5.1%) 39 (100%) Disagree 8 (21.6%) 8 (21.6%) 12 (32.4%) 3 (8.1%) 1 (2.7%) 4 (10.8%) 1 (2.7%) 37 (100%) Definitely disagree 15 (28.8%) 10 (19.2%) 11 (21.2%) 6 (11.5%) 1 (1.9%) 2 (3.8%) 7 (13.5%) 52 (100%) 0.050 (P =0.260)

Being treated with respect and dignity by teachers Definitely agree 15 (51.7%) 2 (6.9%) 6 (20.7%) 2 (6.9%) 1 (3.4%) 2 (6.9%) 1 (3.4%) 29 (100%) Agree 15 (14.3%) 24 (22.9%) 42 (40.0%) 15 (14.3%) 5 (4.8%) 3 (2.9%) 1 (1.0%) 105 (100%) Somewhat agree 16 (9.6%) 22 (13.3%) 88 (53.0%) 24 (14.5%) 10 (6.0%) 4 (2.4%) 2 (1.2%) 166 (100%) Neither agree nor disagree 15 (13.0%) 16 (13.9%) 50 (43.5%) 29 (25.2%) 3 (2.6%) 2 (1.7%) 0 (0.0%) 115 (100%) Somewhat disagree 13 (21.3%) 9 (14.8%) 24 (39.3%) 4 (6.6%) 8 (13.1%) 2 (3.3%) 1 (1.6%) 61 (100%) Disagree 8 (29.6%) 2 (7.4%) 5 (18.5%) 5 (18.5%) 1 (3.7%) 5 (18.5%) 1 (3.7%) 27 (100%) Definitely disagree 5 (33.3%) 3 (20.0%) 1 (6.7%) 2 (13.3%) 0 (0.0%) 0 (0.0%) 4 (26.7%) 15 (100%) 0.094 (P =0.033)

Excessive measures to pass the national examination for medical practitioners Definitely agree 24 (54.5%) 3 (6.8%) 10 (22.7%) 4 (9.1%) 2 (4.5%) 0 (0.0%) 1 (2.3%) 44 (100%) Agree 8 (15.7%) 10 (19.6%) 20 (39.2%) 7 (13.7%) 4 (7.8%) 0 (0.0%) 2 (3.9%) 51 (100%) Somewhat agree 11 (11.8%) 24 (25.8%) 45 (48.4%) 9 (9.7%) 2 (2.2%) 1 (1.1%) 1 (1.1%) 93 (100%) Neither agree nor disagree 21 (10.6%) 16 (8.1%) 96 (48.5%) 43 (21.7%) 10 (5.1%) 11 (5.6%) 1 (0.5%) 198 (100%) Somewhat disagree 8 (11.9%) 16 (23.9%) 23 (34.3%) 12 (17.9%) 6 (9.0%) 2 (3.0%) 0 (0.0%) 67 (100%) Disagree 5 (16.7%) 5 (16.7%) 12 (40.0%) 4 (13.3%) 1 (3.3%) 2 (6.7%) 1 (3.3%) 30 (100%) Definitely disagree 10 (28.6%) 4 (11.4%) 10 (28.6%) 2 (5.7%) 3 (8.6%) 2 (5.7%) 4 (11.4%) 35 (100%) 0.155 (P <0.001)

Obedience to societal rules irrespective of penalties Definitely agree 17 (65.4%) 4 (15.4%) 5 (19.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 26 (100%) Agree 2 (5.7%) 13 (37.1%) 12 (34.3%) 4 (11.4%) 0 (0.0%) 3 (8.6%) 1 (2.9%) 35 (100%) Somewhat agree 11 (11.1%) 14 (14.1%) 55 (55.6%) 13 (13.1%) 3 (3.0%) 3 (3.0%) 0 (0.0%) 99 (100%) Neither agree nor disagree 15 (11.0%) 12 (8.8%) 65 (47.8%) 33 (24.3%) 7 (5.1%) 1 (0.7%) 3 (2.2%) 136 (100%) Somewhat disagree 2 (3.9%) 7 (13.7%) 20 (39.2%) 11 (21.6%) 9 (17.6%) 2 (3.9%) 0 (0.0%) 51 (100%) Disagree 10 (13.7%) 15 (20.5%) 29 (39.7%) 9 (12.3%) 5 (6.8%) 5 (6.8%) 0 (0.0%) 73 (100%) Definitely disagree 30 (30.6%) 13 (13.3%) 30 (30.6%) 11 (11.2%) 4 (4.1%) 4 (4.1%) 6 (6.1%) 98 (100%) 0.082 (P =0.063)

Total 87 (16.8%) 78 (15.1%) 216 (41.7%) 81 (15.6%) 28 (5.4%) 18 (3.5%) 10 (1.9%) 518 (100%)

To calculate Pearson’s correlation coefficient, “a sense of resistance to patients’ rights,” “encounters with role models,” “shurei- keijin education (treating others with decency and respect),” “being treated with respect and dignity by teachers,” “excessive measures to pass the national examination for medical practitioners,” and “obedience to societal rules irrespective of penalties” were rated from “definitely disagree” to “definitely agree” using a 7-point scale (1 = definitely disagree, 7 = definitely agree). Ethical Development among Medical Students 313

Table 5. Predictors associated with a sense of resistance to patients’ rights. Standardized partial Variable P VIF regression coefficient Age 0.038 0.534 1.986 Gender −0.045 0.314 1.059 2nd year −0.074 0.180 1.655 3rd year −0.038 0.514 1.789 4th year 0.061 0.298 1.834 5th year 0.041 0.540 2.410 6th year 0.053 0.446 2.614 Encounters with role models 0.087 0.110 1.603 Shurei-keijin education (treating others with decency and respect) −0.018 0.719 1.401 Being treated with respect and dignity by teachers 0.034 0.519 1.491 Excessive measures to pass the national examination for medical practitioners 0.130 0.005 1.130 Obedience to societal rules irrespective of penalties 0.039 0.400 1.142

Adjusted R2 = 0.045; VIF, Variance Inflation Factor. In conducting multiple regression analysis, “a sense of resistance to patients’ rights,” “encounters with role models,” “shurei-keijin education (treating others with decency and respect),” “being treated with respect and dignity by teachers,” “excessive measures to pass the national examination for medical practitioners,” and “obedience to societal rules irrespective of penalties” were rated from “definitely disagree” to “definitely agree” using a 7-point scale (1 = definitely disagree, 7 = definitely agree). The actual age was used as a continuous variable. Gender was rated as male = 0 or female = 1. Regarding academic year, the 1st year was used as the standard, and then dummy variables representing the 2nd through the 6th years were produced. introduce such education and, then assessing those effects In our university, team medicine education on collabo- is considered important. ration with each department is also carried out. However, In the future, the analyses of each item from various our university does not have any social science depart- viewpoints are needed along with the accumulation of such ments. In the case of national universities, various students data. The distribution of “Excessive measures to pass the majoring in economics and law are admitted, in addition to national examination for medical practitioners” is shown in medical students. The interaction with people in other aca- Table 2. The answer “neither agree nor disagree” was demic fields in the university may contribute to learning extremely dominant. Medical students have conflicts various values. This may encourage students to respect between emphasizing passing the national examination for patients’ rights more than they do currently. In the future, it medical practitioners and spending their time in school will be more necessary to compare medical students among doing other activities. Opinion surveys are needed on how different universities. students regard the national examination itself. The multiple linear regression analysis did not show “A sense of resistance to patients’ rights” showed no any statistical differences in academic year and age. significant associations with “encounters with role models,” However, the crude data analyses shown in Table 3 showed “shurei-keijin education,” “being treated with respect and significant differences. Eckles et al. (2005) pointed out the dignity by teachers,” and “obedience to societal rules irre- importance of developing the ability to cope with ethical spective of penalties.” Regarding “encounters with role dilemmas in medical education. For example, as the aca- models” and “being treated with respect and dignity by demic years progress, students practice on the hospital teachers,” items about factual conditions were made. wards and care for more patients directly. Some medical Regarding “shurei-keijin education” and “obedience to students may recognize the difficulty in respecting the societal rules irrespective of penalties obedience,” items awareness of patients’ rights and have dilemmas in sup- about students’ opinions were made. It is important to have pressing their feelings. As people grow older they develop questions from different perspectives. For example, it is the ability to cope with such kinds of dilemmas. In ethical meaningful to examine whether or not medical students education, it is important to research the kinds of ethical have the habit of greeting others in their daily lives as a dilemmas that occur in each academic year and/or age. result of “shurei-keijin education.” There are two limitations that need to be acknowl- Kitasato University was established in 1962. Kitasato edged regarding the present study. The first limitation was University currently has seven schools of life sciences that because a cross-sectional design was used, it was diffi- (Medicine, Nursing, Pharmacy, Allied Health Sciences, cult to identify causal relations. The second limitation has Veterinary Medicine, Marine Science, and Science) and to do with discrimination questionnaires with missing val- four teaching hospitals. The Kitasato University School of ues and those not submitted were excluded from the analy- Medicine was established in 1970. ses. 314 Y. Saito et al.

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“Excessive measures to pass the national examination for Appendix medical practitioners” Questionnaire items (original version in Japanese) 4. The education at Kitasato University School of “Encounters with role models” Medicine should more than before be focused on preparing 1. I encountered physician role models at Kitasato the students to pass the national examination for medical University School of Medicine. practitioners.

“Shurei-keijin education” “Obedience to societal rules irrespective of penalties” 2. The “shurei-keijin education” (treating others with 5. Penalties are needed to make people obey societal decency and respect) conducted regularly at Kitasato rules. University School of Medicine helps me to develop my own inner growth. “A sense of resistance to patients’ rights” 6. If the awareness of patients’ rights increases, it may “Being treated with respect and dignity by teachers” become more difficult to conduct medical practice. 3. The teachers at Kitasato University School of Medicine treat the students with respect.