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Bangladesh Journal of Bioethics 2015; 6(3):1-9 
 

 

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Original Article 

 

Knowledge, attitude and practice of medical ethics among medical intern 

students in a Medical College in Kathmandu 
 

Ramesh P Aacharya1, Yagya L Shakya2 

Department of Emergency and General Practice  

Tribhuvan University Teaching Hospital 

Institute of Medicine, Maharajgunj 

Kathmandu, Nepal  

Email: raacharya@yahoo.com  

 

 

Abstract: This baseline study was conducted to find out the knowledge, attitudes and practices of 

medical ethics among the undergraduate medical interns who did not have structured ethics 

curriculum in their course. A descriptive, cross-sectional study was carried out using a self-

administered structured questionnaire among the medical undergraduate interns of Maharajgunj 

Medical Campus, the pioneer medical college of Nepal which enrols 60 students in a year. A total 

of 46 interns participated in the study. The most common source of knowledge on ethics was 

lectures/seminars (35.7%) followed by experience at work (24.5%), training (21.4%) and own 

reading (17.3%). The main contents of Hippocratic Oath were known to 98.8% while 60.9% knew 

the main contents of Nepal Medical Council (NMC) code of ethics. Great majority (91.3%) regard 

ethics as very important in medical profession. “Doctors know the best irrespective of patients’ 

opinion” was disagreed by only 39.1% indicating the paternalistic attitude. However, 78.3% were 

in favour of adhering to the patient’s wish. None of the participant agreed to abandon 

confidentiality. Only about one-fourth (26.1%) claim to encounter ethical dilemma every day 

while the highest number (43.5%) had once in a month. To deal with the situation of ethical 

dilemma, majority approached to immediate supervisor followed by head of the department and 

colleagues. Eighty-seven percent of participating interns were involved in research activities 

involving human subjects. Only one of the participants had encountered the ethical issue on end-

of-life and it was do-not-resuscitate consent in a terminally ill patient. On implementation of the 

curriculum on medical ethics focus should be - principles of biomedical ethics, sensitive ethical 

dilemmas like end-of-life care and practical experiences with participation in deliberations of the 

ethics committee.  

 

Keywords: Biomedical ethics, ethical dilemma, medical education, interns doctors. 

 

 

 

 



Bangladesh Journal of Bioethics 2015; 6(3):1-9 
 

 

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Background: Medical Council regulations on undergraduate medical courses include practice the 

principles of medical ethics as one of the core competencies1 and is an important component of 

medical education. Regional meetings of medical councils coordinated by World Health 

Organization (WHO) South East Asia Regional Office (SEARO) has realised the need to 

incorporate medical ethics in undergraduate medical education2. Students need to develop a 

rational approach to solve ethical dilemmas that they will face in daily responsibilities of caring 

the patients. Tribhuvan University (TU), Institute of Medicine has incorporated the medical ethics 

in the latest version of undergraduate medical curriculum3 and its implementation is in the process. 

However, the medical interns enrolled in this study were from the previous curriculum and did not 

undergo structured curriculum on ethics.  

 

There have been many reports stressing the importance of incorporating ethical and legal issues in 

medical curricula4 .Medical students are taught various subjects to tackle medical problems; they 

also need ethics to solve the moral quandaries that they are likely to face in their practice in the 

future.5 Medical ethics are integral to all clinical encounters and public health interventions, and a 

foundation in medical ethics is essential for students to become virtuous doctors6. Studies in other 

South Asian countries have realised the need of medical ethics to be part of the undergraduate 

medical curriculum7-8. Doctors are expected to have ingrained attitude and practice of ethics. A 

study in neighbouring Indian state of Manipur revealed the need to sensitise the doctors on medical 

ethics9. In the developed world, ethical discussions centre on 'micro ethics' like cloning and 

euthanasia but underdeveloped countries are lagging to deal with the basic questions of ethical 

professional practice10. However, the ethical issues of all nature do exist in our society as well. 

Science and technology has to be used to protect rather than endanger human dignity, health, well-

being and diversity. Incorporating bioethics in medical curriculum contributes to ensure the 

appropriate use of science and technology in this direction11. 

 

Studies have revealed that most of the knowledge of biomedical ethics is acquired during the 

undergraduate training12. Ethics teaching has been shown to have a profound influence on medical 

professionals' attitudes10,13. It should be a part of ongoing medical education including residency12-

14. Effective medical ethics education enhances the goals of medicine in tangible ways15. It is 

important to identify deficiencies of students and/or professionals on ethical issues and arrange 

sensitization and at times, appropriate training16-17. However, implementation of medical ethics 

curriculum remains ambiguous18. 

 

Methods: A cross sectional study was carried out using a self-administered structured 

questionnaire about knowledge, attitude and practice of healthcare ethics among the medical 

undergraduate interns of Maharajgunj Medical Campus (MMC) – the first medical college of 

Nepal enrolling 60 students per year. Recently, the number of enrolment has been increased to 75 

students per year. The knowledge was assessed on training in medical ethics, existing professional 

code of conduct and ethical guidelines. Attitude of medical intern students was compiled in terms 

of informed consent, confidentiality and paternalism. The statements to assess the attitude were 

optioned in 5 point Likert scale – strongly disagree, disagree, not sure, strongly agree and agree. 

Similarly, the practice was evaluated with their involvement in informed consent process and 

encountering ethical dilemmas in medical practice. The questionnaire was pilot tested in 5 interns 

and necessary revisions were made. 



Bangladesh Journal of Bioethics 2015; 6(3):1-9 
 

 

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Before the commencement of the study, ethical approval was taken from the Institutional Review 

Board (IRB) of TU, Institute of Medicine. 

 

Results: Questionnaires were distributed to 55 medical undergraduate interns and out of them 46 

(84.6% response rate) returned the filled questionnaires. Among the total participants of this study, 

almost three-fourth (73.9%) had completed 11 months of their internship. 

I. Knowledge  

a. Regarding the source of knowledge of medical ethics, naturally there were more than 

one sources for three-fourth (73.9%) of the participants. The most common source was 

lectures/seminars (35.7%) followed by experience at work (24.5%), training (21.4%) 

and own reading (17.3%). One participant mentioned YouTube video as a source of 

knowledge of medical ethics. Only one participant had attended formal training on 

ethics. 

b. Codes and guidelines: The ‘yes’ answer to a question – would you say ‘you know the 

main contents of’ was as follows: 

i. Hippocratic Oath 98.8% 

ii. Nepal Medical Council (NMC) code of ethics 60.9% 

iii. Nepal Health Research Council (NHRC) ethical guidelines 4.3% 

None of the participants knew the main contents of Nuremberg code and Helsinki 

declarations. 

 

II. Attitude : 

a. Importance of ethics – Regarding the importance of ethics in their work, great majority 

(91.3%) mentioned as very important. The statement that ‘Ethical conduct is only 

important to avoid legal action’ was disagreed by 87% while 8.7% were ‘not sure’. 

b. Autonomy  

i. A statement on autonomy ‘Consent required only in case of operations and not 

for tests and medications’ was strongly disagreed by 26.1% and disagreed by 

52.2% (Fig-I). Similarly, when asked about the stand on dealing with patients 

who refuse blood transfusion or operation or treatment; 82.6% were in favour 

of respecting patient decision while the remaining 17.4% mentioned to find 

another doctor with their belief. None of the participants were in favour of 

attempting the procedure forcefully.  

ii. Paternalism – Three different statements were used to assess the paternalistic 

attitude (Table-1). 

 

c. Justice – Regarding resource mobilization, the statement ‘Certain medical practitioners 

charge more from financially sound patients in order to raise money for treating poor 

patients’, was agreed by about one-fourth (26.1%). A substantial number of participants 

(30.4%) were in dilemma and answered as ‘not sure’, while 43.4% disagreed with this 

statement. 

 

d. Confidentiality–‘Confidentiality cannot be kept in modern era and should be 

abandoned’ was strongly disagreed by 34.8% and disagreed by 60.9%. The remaining 

4.3% were ‘not sure’. None of the participant agreed with this statement. 

 



Bangladesh Journal of Bioethics 2015; 6(3):1-9 
 

 

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Table 1 – Paternalism (n = 46) 

Statement 
Strongly 

disagree 
Disagree Not sure Agree 

Strongly 

agree 

‘Doctors know the best 

irrespective of patients’ opinion 
2 (4.3%) 16 (34.8%) 10 (21.7%) 16 (34.8%) 2 (4.3%) 

‘Patient should always be 

informed of wrong doing’ 
0 (0.0%) 8 (17.4%) 10 (21.7%) 18 (39.1%) 10 (21.7%) 

‘Patient wishes should be always 

adhered’ 
2 (4.3%) 8 (17.4%) 0 (0.0%) 32 (69.6%) 4 (8.7%) 

 

 

III. Practice : 

a. Frequency of ethical dilemma – Coming across ethical dilemma once in a month was 

the highest (43.5%), followed by 26.1% claimed to encounter every day (Fig-II). 

 
 

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Strongly

disagree

Diaagree Not sure Agree Strongly

agree

P
e

rc
e

n
ta

g
e

Attitude on consent in healthcare services

Figure I- Consent is required only in case of operations 

and not for tests and medications

Daily

26%

Weekly

19.6

Monthly

43.5

Yearly

9%

Never

2%

Figure II - Frequency (in %) of encountering with ethical dilemma



Bangladesh Journal of Bioethics 2015; 6(3):1-9 
 

 

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To deal with the situation, majority claimed to approach immediate supervisor followed 

by head of the department and colleagues (Fig-III). 

b. Research ethics – Big majority (87.0%) of participating interns claimed to be involved 

in research activities involving human subjects. In this process, 82.6% were involved 

in taking informed consent – written 47.8% and verbal 34.8%. A small number (6.5%) 

did not realise the participant’s right to withdraw from the study as a part of informed 

consent. 

c. Ethical issue on end-of-life – Only one of the participants had encountered the ethical 

issue on end-of-life and it was do-not-resuscitate consent in a terminally ill patient. 

 

Discussions: Regarding the source of knowledge of medical ethics, the most common source was 

lectures/seminars (35.7%) followed by experience at work (24.5%), training (21.4%) and own 

reading (17.3%). B Shiraz et al reported similar findings in a study among surgical residents and 

interns in Pakistan7. Another study among medical students in India revealed lecture to be the most 

common (54.7%) source19. 

 

Ethical codes and guidelines are the basis for acquiring knowledge on the subject. In this study, 

almost all (98.8%) claimed to know the main contents of’ Hippocratic Oath. However, only 60.9% 

were acquainted with the code of ethics for medical practitioners published by the Nepal Medical 

Council (NMC). In Karachi, about half of the surgical residents and interns had heard about the 

Code of Ethics formulated by the Pakistan Medical and Dental Council7. 

 

Regarding the importance of ethics in their work, great majority (91.3%) mentioned as very 

important. In a study from Barbados, all physicians and 90% of nursing staff responded that 

knowledge of ethics is important to their work16. The statement that ‘Ethical conduct is only 

important to avoid legal action’ was disagreed by 87% while 8.7% were ‘not sure’. This was 

different than the study done on medical students done in India where 37.8% had rather agreed 

and 18.3% were uncertain19. 

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

Colleague

Supervisor

Head of Department

Hospital administrator

Ethics committee

Professional association

Internet

Find solution by yourself

Percentage

A
p

p
ro

a
ch

 f
o

r 
e

th
ic

a
l 

p
ro

b
le

m

Figure III - Whom do you approach for ethical problem?



Bangladesh Journal of Bioethics 2015; 6(3):1-9 
 

 

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A statement on autonomy ‘Consent required only in case of operations and not for tests and 

medications’ was disagreed by 78.3% (strongly disagreed by 26.1% and disagreed by 52.2%). 

Thus, about one-fifth (21.7%) of the interns either do not feel the need of consent for tests and 

medications or not sure about the issue. In studies from Barbados, 91% of medical students and 

72% of physicians disagreed16-17. 

 

Sensitivity to cultural diversity need to be reinforced continually starting from the medical student 

life and continue throughout the professional careers.20 In this study, when asked about the stand 

on dealing with patients who refuse blood transfusion or operation or treatment; 82.6% were in 

favour of respecting patient decision while the remaining 17.4% mentioned to find another doctor 

with their belief. None of the participants were in favour of attempting the procedure forcefully. 

The ethical and medicolegal reasoning regarding consent to and/or refusal of treatment is based on 

the principle of autonomy.21 Autonomy can be ensured only when the individual comprehends the 

procedure and the consequences and thus, it is informed consent or informed refusal. 

 

The Hippocratic physician respected a principle of professional responsibility and by tradition, the 

duty of the patient was to accept the physician's decisions and intervention22. Beauchamp and 

Childress define paternalism as “the intentional overriding of one person’s known preferences or 

actions by another, where the person who overrides justifies the action by the goal of benefiting or 

avoiding harm to the person whose preferences or actions are overridden” 23. Paternalistic attitude 

prevailed in the participants as majority (60.8%) of them either disagreed (39.1%) or were not sure 

(21.7%) about the statement - “Doctors know the best irrespective of patients’ opinion”. This may 

be due to the focus on learning abundant clinical information rather than the ethics. On the other 

hand, the statement that ‘Patient wishes should be always adhered’ was agreed by 78.3% revealing 

the important understanding of autonomy. Such contradiction was observed in Indian study as 

well19. Anyone not adhering to the patient's wishes indicate the lack of knowledge of the basic 

principles of medical ethics16. 

 

‘Patient should always be informed of wrong doing’ was agreed by 60.8% in this study. Studies 

have shown up to 74.5% of medical students and 79% nurses agree with this statement16-17. In 

relation to mistakes and/or negligence, the explanation for the excessive deference towards health 

care professionals was the presumption of beneficence to their patients but the medical fraternity 

should be more open to scrutiny with regards to their decision making24. 

Regarding resource mobilization, the statement ‘Certain medical practitioners charge more from 

financially sound patients in order to raise money for treating poor patients’, was agreed by about 

one-fourth (26.1%). A substantial number of participants (30.4%) were in dilemma and answered 

as ‘not sure’, while 43.4% disagreed with this statement. Of course, the issue of justice is not 

straight forward and probably, because of this, the opinion is fairly distributed throughout the scale. 

It is important to elucidate the moral dimension of distribution choices through balanced 

argumentation to come to a decision of healthcare package25. 

 

None of the participant agreed with this statement - ‘Confidentiality cannot be kept in modern era 

and should be abandoned’. It was disagreed by 95.7% - strongly disagreed by 34.8% and disagreed 

by 60.9%. The remaining 4.3% were ‘not sure’ about the issue. Similar studies have revealed the 

disagreement ranging from 82% to 89%16-17. Though electronic medical records pose new 



Bangladesh Journal of Bioethics 2015; 6(3):1-9 
 

 

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obstacles to maintain confidentiality, physicians have a professional ethical obligation to protect 

patients’ health information and it cannot be abdicated26. At times the perception of physician may 

be inconsistent with the patient’s perceptions of how his/her medical information should be 

treated27. 

 

Coming across ethical dilemma once in a month was the highest (43.5%), followed by 26.1% 

claimed to encounter every day. To deal with the situation, majority claimed to approach 

immediate supervisor followed by head of the department and colleagues. Similar findings have 

been reported in other studies majority of physicians and medical students reporting to the 

immediate supervisor16-17 .Regarding ethical issue on end-of-life, only one of the participants had 

encountered the ethical issue on end-of-life and it was do-not-resuscitate consent in a terminally 

ill patient. 

 

Big majority (87.0%) of participating interns claimed to be involved in research activities 

involving human subjects but only 4.3% knew the main contents of Nepal Health Research Council 

(NHRC) ethical guidelines. In the research activities, 82.6% were involved in taking informed 

consent – written 47.8% and verbal 34.8%. A small number (6.5%) did not realise the participant’s 

right to withdraw from the study as a part of informed consent. A signed consent document does 

not necessarily mean an informed consent and rather it is a process of giving the participant 

understandable information about the study, providing ample opportunity for the participant to 

consider all options and alternatives to taking part in the study, ensuring that the participant 

comprehends the information he or she is given, obtaining the participant’s voluntary agreement 

to take part, and continuing to provide additional pertinent information during and after study 

completion28. None of the participants of this study knew the main contents of Nuremberg code 

and Helsinki declarations. This is one of the important areas in biomedical ethics which needs 

priority in medical education. 

 

Limitations: The sample size of this study was limited due to the number of students in the college. 

It may not represent the national scenario. All the principles of biomedical ethics have not been 

explored to the same extent. As the sample size was small, no comparisons were planned between 

the groups and statistical tests were not used. 

 

Conclusions: This baseline study among the medical graduates of the institute serves a basis to 

identify the areas requiring focus on implementation of the curriculum on medical ethics. 

Paternalism was evident in the attitude that doctors know the best irrespective of patients’ opinion. 

However, it was better regarding the informing wrong doing and adhering to patient wishes. The 

principles of biomedical ethics and sensitive ethical dilemmas like end-of-life care deserve 

attention including deliberation activities of the ethics committees. The results of the study are 

expected to assist the faculties for upgrading the quality of teaching medical ethics and guiding 

them for professional conduct. 

 

Conflict of interests: None. 

 

Authors' contributions: RPA conceptualized, designed the study and drafted the manuscript. 

YLS coordinated data collection and revised the manuscript. Both authors reviewed and 

approved the final manuscript. 



Bangladesh Journal of Bioethics 2015; 6(3):1-9 
 

 

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Acknowledgements: The authors are grateful to Dr. Shankar Raj Lamichhane of Nepal Medical 

Students’ Society for his assistance in data collection. 

 

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