Barriers to Effective Formulation of Code of Ethics in a Medical University.

BACKGROUND: Every year many organizations formulate a Code of Ethics (COE) but when it comes to implementing, it does not achieve the desired purposes. Ineffectiveness of COEs can stem from different factors and surely, one of them is bad formulation. This research was conducted to identify the barriers to effective formulation of COEs in one of the main state universities of medical sciences in Iran.
METHODS: A qualitative approach using thematic analysis in three stages of descriptive coding, interpretative coding and overarching themes was adopted to analyze data collected through 27 semi-structured interviews. This study was conducted in 2014-15 at Shahid Beheshti University of Medical Sciences, Tehran, Iran.
RESULTS: Totally 135 descriptive themes, 12 interpretive themes and 3 overarching themes emerged through analyzing interviews.
CONCLUSION: In order to have an implementable COE, 12 barriers in three categories including "goal-setting", "approach" and "content" of the COE, must be removed. In "goal-setting", real cultural conditions of the medical university must be considered. Moreover, the COE must be in response to perceived internal needs and its philosophy must be clear for all members of the university. Besides, the formulation "approach" of the COEs must be specialist, participatory and expertised. Finally, in "content", different stakeholders with diverse values, levels of knowledge and needs should be carefully addressed. In addition, it is proposed to emphasize religious and humane values to encourage participation of people. As a final point, the university should avoid imitation in the content of the COE, and conceptualize the values in motivating, inspirational and guiding words.

Introduction

Reviewing the history of medicine in Iran shows that ethical rules had always been part of the medical education (1). The first Iranian ethical code in medicine compiled by Borzuya (6th -7th century AD) about 1500 years ago (2). In Islamic age, as Islam puts a great emphasis on ethics and the Messenger of Islam (peace be upon him), introduces his prophet-hood reason, “to complete ethical virtues”, the emphasis on ethical issues increased in different areas, especially medicine. Motivated by Islamic teachings, Muslim physicians have put much emphasis on ethical principles as a religious issue in their practice and education of medicine. For example, Razi (865 - 925 AD), Ali ibn Abbas Ahwazi (930 - 994 AD) and Avicenna (980–1037 AD) have some pamphlets including valuable guidelines on medical ethics.

Also, in recent centuries, by the establishment of medical colleges and universities in Iran, training medical ethics has been some part of their education (1) and in the last decades, many Iranian medical universities have formulated COEs in order to institutionalize ethical values in the attitude and behavior of their members.

Stevens defines COEs as “policy documents which define the responsibilities of organizations to stakeholders” (3). COEs articulate the behavior expected of people (3) and show the ethical standards and values that all of the organizational members in ever-hierarchical position are required to obey them (4).

Every year many organizations formulate COEs but when it comes to implementing, it turns into “nothing else than the notorious paper in the drawer”, without achieving its aims, as Nijhof et al mention (5). herefore, COEs have many pros and cons and many scholars have discussed about the extent to which they achieve their objectives (6).

Same as many organizations that confront problems in implementing their COE, the COE of the studied medical university, formulated in 2004, has not been acceptably effective in making the university more ethical and its desired outcomes are not achieved yet, as the managers and staff of the university, especially its cultural affairs manager mention. Ineffectiveness of the COE of the studied medical university can stem from different factors and surely one of them is its bad formulation, as Messikomer and Cirka argue (7).

Already numerous studies have been conducted in the field of professional ethics in different fields particularly medical and nursing fields; But, based on the searches done, few studies has addressed the problems of formulating COEs in educational environments, especially “medical universities”. Furthermore, most of the existing researches about academic ethics have studied American codes, although in recent decades, studies in other countries have been performed (7). Hence, because of the observed lack of research on the COEs in Iranian medical universities, the authors-comprising an interdisciplinary team in ethics, professional ethics and cultural policymaking-conducted this research to identify the barriers to effective formulation of the COE in one of the main state universities of medical sciences in Iran, resulting in its imperfect implementation.

Materials and Methods

According to “research onion” proposed by Saunders et al (9) this research was performed as shown in Fig. 1.

Fig.1:

Research onion (based on 8)

Research Context

This study was conducted in 2014–15 at Shahid Beheshti University of Medical Sciences (SBUMS), Tehran, Iran. This university, funded by government, is one of the largest medical universities in Iran, established in 1961. It has 1300 full time academic staff in 12 schools, training some 12500 students in different fields and levels. It has also 4 research institutes, and 62 research centers. The vision of SBUMS is to “be referral, innovative, and outstanding in education and research”, “be responsive in treatment and health”, “succeed in rendering student and cultural services and satisfy the learners” … (10).

The educational and administrative COE of the university was formulated in 2004, by the Office of Inspections, who is now responsible for implementing it.

Data Collection Method

Mainly, the deep semi-structured interview method was employed for data collection and the observation method was added to it, to enhance data validity:

Deep Semi-structured Interview: The interviews began with a general and broad question and after receiving all the information the interviewees had in this field, three semi-structured questions was asked. The structure of the interviews is shown in Table 1.

Table 1:

Interview questions

General and broad question

What are the barriers to success of the COE of the medical university

Semi-structured questions

1. What are the barriers to success of the COE of the medical university, originated in its goal-setting?

2. What are the barriers to success of the COE of the medical university, originated in its formulation?

3. What are the barriers to successful implementation of the COE of the medical university?

To eliminate the errors caused by the presence of the researcher, the employees were interviewed by a fellow university employee, the faculty members were interviewed by one of the professors, and the students were interviewed by a post-graduate student (after training and a primary interview). The recorded interviews were transcribed and before analysis, a number of them were returned to the interviewees for modification or correction of potential errors. Each interview was transcribed and typed immediately on the same day. All scripts and interviews were reviewed many times before analysis to gain a closer and more realistic understanding about the data and the interviews and then it was analyzed and coded immediately.

The observation and field note-taking method were employed in addition to interviews so as to gain familiarity with the medical university context and enhance data validity. Totally, about 40 h of observation was performed during almost a working wk.

Data Sampling Method and Sample Size

Sampling method of this research was purposive method. Among purposive sampling techniques, the main technique of this research was snowball sampling (also known as chain sampling) (11). This way, in this research each interviewee was asked to introduce more people for the subsequent interviews according to the understanding he/she had obtained about the research. In addition to snowball sampling, convenience sampling was used to select students and stakeholders from other universities.

Data gathering was started by interviewing the people responsible for implementation of the COE and its formulation team. Then they introduced some other informed people who also recommended more people and this chain sampling continued to the 27th interview. The demographics of the interviewees are summarized in Table 2.

Table 2:

The demographics of the interviewees

Academic Level
Ph.D.: 10	Ph.D. Candidates: 1	M.Sc. & GP: 3	M.Sc. Students: 5	B.Sc.: 6	Diploma and Less: 2
Job Title
Faculty member: 8	Student: 7	Employee: 6		Manager: 4	stakeholders from other universities: 2
Interviewees’ Relationship with the COE
The COE formulation & Implementation team: 4		Target group: 17		people affected by the COE implementation: 6

In qualitative research the sampling is continued until theoretical saturation is achieved (12). Theoretical saturation occurs when no new ideas about the phenomena is created by gathering and analyzing new data (13). In this research, data collection and analysis was continued to the 27th interview and was stopped due to theoretical saturation in the last interviews. Table 3 shows how theoretical saturation was achieved. In this table we can trace the number of new descriptive codes emerged in each interview for every interpretive code. Data saturation is achieved for every interpretive code when no new descriptive code is emerged in it, in the last interviews.

Table 3:

Theoretical saturation

	Interviews	Number of descriptive codes, emerged in each interview																											Total
	Interpretive Codes	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20	21	22	23	24	25	26	27
Goal-setting	Idealism	4	3	1	1	0	0	0	0	1	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	0	0	0	11
	Unclear Philosophy	2	2	1	0	0	0	0	0	0	0	1	0	0	0	1	1	0	0	0	0	0	0	0	0	0	0	0	8
	Needlessness	3	2	2	2	1	0	1	0	0	0	1	0	0	1	0	1	1	0	0	1	0	0	0	0	0	0	0	16
Approach	Generalistic Approach	1	0	1	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0	0	0	0	3
	Top-Down Approach	3	3	1	1	1	2	0	0	1	0	0	0	1	0	0	0	0	1	0	0	0	0	0	0	0	0	0	14
	Non-expertised Approach	2	1	0	1	0	0	0	0	0	1	0	0	0	0	0	1	1	0	0	0	0	1	0	0	0	0	0	8
Content	Disregarding the Values of Some Stakeholders	3	3	1	0	0	0	0	1	0	0	0	1	0	0	1	0	0	0	0	1	0	0	0	0	0	0	0	11
	Lack of Operational Definitions	7	5	5	3	2	3	1	0	0	2	2	2	1	1	1	0	1	0	0	0	0	0	0	0	1	0	0	37
	Disregarding Different levels of Knowledge and Needs	5	3	3	2	0	1	0	1	1	0	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	0	0	16
	Emphasizing Administrative Values	3	2	0	1	2	1	0	0	1	1	0	0	1	1	0	0	0	1	1	0	0	0	0	0	0	0	0	15
	Being Imitative	1	3	0	0	0	1	0	0	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	6
	Inappropriate Conceptualization	5	3	3	2	2	1	0	1	0	1	0	1	0	0	1	0	0	0	0	1	0	0	0	0	0	0	0	21

Analysis of Data

Thematic analysis was carried out for analyzing interview data. Mills et al. define thematic analysis “a systematic approach to the analysis of qualitative data that involves identifying themes or patterns of cultural meaning; coding and classifying data, usually textual, according to themes; and interpreting the resulting thematic structures by seeking commonalties, relationships, overarching patterns, theoretical constructs, or explanatory principles” (14).

Various processes have been presented for thematic analysis. In this research a 3-stage process introduced by King and Horrocks were adopted. The first stage of this process is descriptive coding. In this stage, after reading the transcript of every interview, the relevant parts of it were selected and descriptive codes were defined. In the second stage, which is interpretive coding, descriptive codes were clustered and the meanings of clusters were interpreted in relation to research question and disciplinary position. Finally, in the third stage, i.e. overarching themes, key themes were derived for whole data set as a whole, by considering interpretive themes from theoretical and/or practical stance of the research project and a diagram was constructed to represent relationships between levels of coding in the analysis (15).

Trustworthiness of the research

Qualitative research scholars have introduced criteria such as trustworthiness, verisimilitude, relevance and plausibility for qualitative researches (16). These standards have their special methods, different from quantitative researches, to be proved (17). In this research, investigator triangulation (18), recording data mechanically (19), using low inference descriptors (20), member validation (21) and comparison with previous studies (22) were adopted to enhance the trustworthiness of the research.

Research Ethics

The following principles were abided in this research:

Having authorization from the public relations department and security administration unit of the University for performing the research.

Maintaining the confidentiality of the medical university, interviewees and expressed opinions and information.

Resorting to note-taking in cases that the interviewees disagree with recording the interviews.

All interviewers participated in the research with their full consent without any external compulsions.

Results

A total of 27 interviews were performed to identify the barriers to an effective formulation of the COE at the studied medical university. Data analysis resulted in 135 descriptive codes, 12 interpretive codes and 3 overarching themes including barriers in the goal-setting, approach and content of the COE emerged. The obtained overarching and interpretive themes are described below and evidences from the interviews are mentioned in each theme.

Overarching theme 1: Goal-setting

The first overarching theme addresses the problems with the objectives of the COE. It contains 3 interpretive codes:

The real conditions at the university are not well considered in the COE, and the objectives are not defined in an achievable manner:

“The goals of the COE are not achievable”.

There is a deep gap between the realities of the university and the principles of the COE”.

The main objective and the philosophy of the COE are unclear, and are not clarified for the members of the medical university:

“At the present, the COE is in an inert and insignificant condition”.

“The employees of the university are not aware of the philosophy of the COE”.

Each organizational plan can be improving when it is the result of an internal need; but, the present COE is not formulated based on the needs of the medical university for ethical excellence:

“The COE is not formulated to solve any problem in the university”.

“The COE was not created based on a real need”.

Overarching theme 2: Approach

The second overarching theme concentrates on the shortcomings of the approach that is utilized in formulating the COE and includes 3 interpretive codes:

Particular characteristics of a medical university are not considered enough in this COE and its content is formulated in a very generalistic manner:

“The unique and educational missions of the medical university is not addressed in the COE”

“The COE must be more specialistic, and fit with the type of the organization”

Lack of participation of all deputies and organizational units in COE formulation, and having a top-down approach to it, in addition to the lack of necessary interaction among the managers and employees in its formulation are among the defects of the present COE:

“The participation of all organizational units, having different missions, is ignored in the formulation of the COE”.

“There is no effective interaction between the managers and the staff”.

The present COE is not formulated by the help of experts in professional ethics in medical education and depending on a scientific methodology:

“The ideas and expertise of the experts of the university was not employed in the formulation of the COE”.

“No specific methodology is utilized in the formulation and implementation of the COE”.

Overarching theme 3: Content

The third overarching theme explains the defects existing in the body of the COE and includes 6 interpretive codes:

The implementation of a COE requires the cooperation of all stake-holders; but, since the present COE have not considered all such values, the required companionship is not shaped and consequently the implementation of the COE has encountered some problems:

“The content of the COE has neglected the values and rights of the students and some organizational members”.

“Addressing the values of different organizational groups in the COE builds self-control in them”.

The principles and values, stressed in the COE content, are presented in a general manner and their operational definitions, which can create a common understanding of these values and principles for the organizational members, is missing, and their objective behavioral instances are not elaborated on:

“The managers behave tastefully in many cases and don’t have scientific behavioral indexes”.

“At present, correct and exact indexes are not defined for qualitative behaviors”.

There is a great deal of difference between the specialty and organizational level of the individuals in the studied medical university. We can see highly educated professors beside employees and service staff. This has caused conspicuous differences in their salary and benefits resulting in a difference in their needs; but these differences are not considered enough in the COE:

“There is a deep gap between the salary and job security of the staff and faculty members”.

“The gap in the education level between the staff and faculty members is very deep”.

Religious ideology principles are not applied correctly and in an up-to-date manner in the present COE, and the administrative values emphasized instead of generally accepted religious and humane ones:

“It is necessary to stress on human values instead of administrative values in the COE”.

“It should be an emphasis on deep religious and humane values in defining the values of the COE”.

Despite the long history of ethical thoughts in Iran, the present COEs of many Iranian organizations are imitative, and the COE at the studied medical university is no exception. In fact it is not completely domesticized for an Iranian medical university; as such, it fails in establishing the necessary communication with the organizational members:

“The present COE is imitated from other organizations”.

“The methodology and tools of the COE are imitated from foreign organizations”.

Poor choice of words and inability in conceptualizing and integrating words and expressions in a purposeful distinguished framework, and the use of peremptory imperative sentences instead of guiding ones are among other defects of the present COE:

“There is a weakness in the words map and composition of sentences”.

“The content of the COE is boring and slogan-like”.

“The COE content shouldn’t be directorial and authoritative”.

Thematic network of the COE Formulation Barriers is shown Fig.2.

Fig. 2:

Thematic network of the COE Formulation Barriers

Discussion

In the following, the obtained results from this research are discussed and compared with previous studies.

Based on the first interpretive theme of this overarching theme, the realities of the studied medical university are not well considered, and the COE is formulated at an ideal level. As Alvani et al. argue, the codes are sometimes ideal and unreal, having a negative effect on their addressees and as their addressees are ordinary people in their ethical virtues, the COEs do not usually find their addressees and sometimes need a pious person to act accordingly (23). In addition, Khaki mentions one of the defects of COEs in Iranian organizations, their slogan-like nature (24). According to this theme, the COEs must be formulated regarding the present organizational condition and the real ethical level of its employees. The second interpretive theme expresses that the philosophy of the COE is not well defined beside other improvement tools. Indeed, the university must know which vacancy it wants to cover using the COE. It should be mentioned previous studies have not addressed this theme directly before. The third theme states that the studied COE is not formulated according to an internal need. As Alvani et al. state, when only “having a COE” becomes important and the organization thinks only about making a good social image and brand, it does not pay the necessary attention and endeavor in formulating COEs; thus, some incompatible and unrealistic values are formulated (23). Therefore, the COE may cause vibrancy in the university, as long as it is formulated based on the well-understood needs for moralization by the academic members.

The first interpretive theme is the lack of consideration for particularities of a medical education environment. Indeed, the features and professional tasks of an organization have a determining role in setting up the COE content (25). The second barrier is the use of a top-down approach and the absence of some stakeholders in COE formulation. Gilley et al. emphasize the need for including community leaders and key employees in the COE formulation process (26). Participation of the stakeholders in the formulation not only leads to a more accurate and effective address of values, but also insures their strength, endurance, and true implementation (25). Zakaria et al. discuss that the implementation of the ethical and behavioral codes without making a common shared understanding about them is impossible, and believe that the bottom-up approach is more effective than the top-down approach (27). At last the third problem with the approach of the COE formulation is the absence of an interdisciplinary expert team. Benefiting from experts and specialized trustees, with certain and clear ethical attributes, in the COE formulation team may lead to a better institutionalization and implementation of codes (25). According to Aref, having a mastery of the dynamics of interpersonal communications is a requirement for implementing the COEs. Since the university managers are usually selected from the professors, they may lack the necessary skills and knowledge in formulating a COE (28). Here, we must avoid the fallacy that, if someone has a special ability in one specific domain, it is highly probable that his/her entire ideas are correct (29) and complement the formulation team with experts in professional ethics and cultural programming.

The first interpretive theme in this area addresses the issue of not considering all the values of the stakeholders so that some of them do not find the COE relevant to themselves. As Gilley et al. mention, some codes address only the employees and do not address the managers. This problem creates a negative mentality for the personnel about the purpose of formulating and implementing the COE in the organization (25). Therefore the COE must cover the values of all stakeholders and not individual interests of some of them (25) so that all members feel to be its addressees.

The second barrier is that the organizational members cannot behave according to the COE because of the absence of operational definitions and behavioral instances for its principles and values and the ambiguous concept of “being ethical”; whereas the COEs must be transparent, i.e. clear in their expected behavior (30). In fact, the values and principles presented in the COE need to become objective as much as possible so as to become applicable in organizational routine activities; otherwise, different individuals will behave according to their interpretations and the COE would be easily overlooked.

Effective beliefs of the employees and their knowledge and expertise can strongly affect the success of a COE (31). The third shortcoming of the studied COE content is that it is formulated disregarding different levels among the involved people whereas not all university members are the same in their knowledge, beliefs, needs, etc. and their different levels must be taken into consideration in formulating the COE. So the COE principles must be compiled and stated accordingly in order to be executable, otherwise, the COE would not be implemented successfully (32).

According to the fourth interpretive theme, the foundation of the university moralization must be laid on the religious and humane values, which are familiar for people and have turned into social norms. In fact, people behave ethically when they feel they are treated ethically and are not considered as instruments. According to the analyzed interviews, when administrative values are emphasized instead of religious and humane ones, people feel to be looked at as instruments and will certainly oppose it. It must be noted that no previous research had covered this theme.

Adopting imitative values is the fifth defect of the content of the studied COE. The COEs in every society are affected by the ontological and anthropological foundations of that society and the effect of these foundations is even more in the implementation stage. Both those who want to implement the COE and the stakeholders who want to abide by moral principles are affected by their ontological and anthropological beliefs and act according to them (32). Yet the cultural aspects are not sometimes considered in the COE formulation and a COE from another organization is adopted, exactly or with some formal changes, instead of trying to formulate a suitable COE with the organization. It shows that probably the content of the COE is not so important and only having a COE is sufficient for dissembling others, following the trends, not falling behind other organizations, etc. (25).

The last interpretive theme of the overarching theme 3 refers to the absence of correct, aptly concepts, and right grammatical tone in the COE. The COEs must be clear and unambiguous in meaning, as well as being an effective guide to accepted behaviors (30). The codes sometimes contain ambiguous words leading to various interpretations from their articles. This paves the ways for evading or abusing them, and a precise implementation becomes dramatically difficult for the addressees (33). Furthermore, according to Zakaria et al., soft methods are more effective than the hard ones in ethical training (27).

Conclusion

One of the prerequisites of a successful implementation of the COEs in medical universities is to formulate them in an effective and fitting manner. Based on the results of this research, 12 barriers in three overarching themes must be removed to have an appropriate and ready to implement COE. According to the first overarching theme, i.e. “goal-setting”, the COE must be formulated, considering real cultural conditions of the medical university and in response to perceived internal need for ethical excellence. Furthermore, the philosophy of the COE should be clear for all members of the university. The second overarching theme discussed the “approach” of the COE formulation, prescribed a specialist and expertised approach, and proposes adding bottom-up approach to the present top-down approach. Finally, the third overarching theme focused on the defects of the COEs “content” and proposed a more motivating, inclusive, operational and humanistic content for the COE.

Ethical considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.