Education and Practice of Medical Ethics in Bulgaria after Political and Socio-Economic Changes in the 90's
Dimitrov, Borislav D., Glutnikova, Zlatka, St Dimitrova, Bogdana, Ethics & Medicine
Social and economic changes in Bulgaria are a continuous process of transformation of the way of thinking, attitudes and behavours towards an open society of liberty, free-market economy and democratic values. The political events at the end of the landmark year of 1989 and during the following months have given hope and expectancies to all the people for better life and prospective future. These transitions influenced in an unprecedented manner all sectors of the societal organisation as well as every single aspect of life, education, practice and professional endeavours. Undoubtedly, this socioeconomic process required a new vision for the development of the whole system of health care delivery, organisation and medical education. As a matter of fact, single hours of teaching medical ethics existed within the undergraduate curriculum of Social Medicine before 1989. Within such dynamic and challenging environment of the societal transition, however, a separate curriculum on medical ethics in Bulgarian medical schools was badly needed. At that time, the initial isolated attempts to introduce hours or short courses on medical ethics were lacking not only of infrastructure but also of a systematic, theoretically sound and evidence-based approach corresponding to the mainstream development of medical ethics and its education worldwide. On the other hand, the process of the health care reform, which was envisaged to start in the mid 90's, required a synchronisation of the practice of medical ethics with the tendencies and practices in developed countries.
The process of introducing the education of Medical Ethics in medical schools as an indispensable part of the undergraduate medical curriculum started in the early 90's. It was strengthened by the organisation of national and international meetings and conferences in Bulgaria as well as by the attendance of courses and exchange of experience on medical ethics in France, Germany, The Netherlands, etc. by our university professors and lecturers. One good example of such a new approach is the first introduction in mid 90's of problem cases with the use of videofilms on medical ethics (as provided by the AMA and U.S. Air Force Reserve) during the practical sessions with medical students in Stara Zagora as lead by professors St. Markova, J. Marinova, S. Dimitrova and B. D. Dimitrov. This translational experience was later transferred to other medical schools in Bulgaria as supported by internationally recognised research activity (e.g., patients and the "coping" problem; physicians and the moral of medical profession; opinions and attitude of medical students,1 etc.). Some of the landmark events in the education of medical ethics have been summarised (see Table below), starting with the publication of the first handbook on medical ethics in Bulgarian language (see Figure below).2
The present curriculum for medical students and nurses is uniform among all medical schools and consists of general and specific parts. The general part includes topics such as "Principles and codes of medical ethics", "Models of the relationships between doctors and patients", "Patients' rights", etc. The special part includes ethical aspects of various practical issues such as "Problemsof reproduction", "Problems of chronically-ill patients", "Terminal care", "Palliative care", "Euthanasia and assisted suicide", "Donors and transplantation", "Biotechnologies and genetic screening", etc. New modules are now being developed to complement the special part with such problematic and specific issues as health-related quality of life of patients, production and use of genetically-engineered cells and tissues (e.g., stem-cell research), benefits and drawbacks of the participation of patients in clinical trials, ethics of promotion of healthy products and providing health information or medical advice through Internet, etc.
The attitude of physicians and other allied-health professionals towards the education of medical ethics has improved considerably over the last years, as evidenced by the ever-increasing number of postgraduate courses and seminars on medical ethics all over the country. …