Background

Ethics covers both what ought to be done and what must be done in a kind, considerate and respectful way.1 Generally, the study of morality and ethical principles that are accepted in daily life, known as ethics, aims to establish what is ethically good and wrong in human behaviour. Medical ethics analyses ideas, assumptions, beliefs, attitudes, emotions, reasoning and arguments behind medico-moral decisions.2 The professionalism of the medical staff is a crucial component of the ethical framework that governs healthcare.3 Healthcare ethics mirror local legislation, whereas economic and societal factors can influence ethical behaviour. Medical professionals are mandated to act in patients’ best interests, which strengthens the impact of assessing their mental and physical health conditions during healthcare provision in both the public and private sectors.4 This is what stated in the Geneva Declaration of the World Medical Association and the International Code of Medical Ethics.5

The ethical behaviour of healthcare workers (HCW) has been a subject of significant public concern.6 This is often reflected in complaints about unethical behaviour and a rise in legal action against healthcare professionals. Informed consent, non-disclosure and deceptions, patient confidentiality, death determination, doctor–patient interaction, sexual contact between professionals and clients, drug company gifts and research/publishing misconduct are common ethical dilemmas, especially for physicians.7 Bioethics, the burgeoning area of medical ethics, addresses such ethical concerns.8 9 In addition to endangering doctor–patient relationships, failing to follow healthcare ethics and handling situations inadequately might result in subpar service provision as well as perhaps sparking violent and abusive incidents.10 Complex ethical problems have emerged because of medical advancements and an atmosphere in the healthcare sector that is increasingly demanding. These together have increased the burden on healthcare professionals.11 The rise in public awareness of unethical behaviour among HCWs may contribute to the growing number of complaints against them.12

Evidence of unethical behaviour seen by medical students, residents, physicians and nurses in a variety of contexts has been reported.13–15 Healthcare practitioners, nurses and those who work in other paramedical fields are required to understand ethical concepts and use them in their clinical practice after finishing their education.16 17 Unfortunately, undergraduate and postgraduate medical programmes have been neglected to educate ethics for many years.18 As a consequence, many HCWs are not putting ethical principles into practice regularly, which has led to a major gap in the quality of patient care.19 Moreover, a lack of understanding and application of biomedical ethics has resulted in legal actions being taken against medical personnel.20 In this regard, Pakistan is not an exception, where accusations of ethical misconduct and an increase in lawsuits against healthcare practitioners have been seen in recent years.21 Although the Pakistan Medical and Dental Council has a unique code of medical ethics that addresses the issues faced by Pakistani medical professionals in their particular social and cultural context, there are virtually no bioethics teaching curricula for undergraduate and graduate training programmes, respectively.22–24

In resource-constrained countries such as Pakistan, there has not been much research evaluating all healthcare professionals (physician or non-physician) deep understanding and awareness regarding healthcare ethics across healthcare facilities (basic health units (BHU), rural health centres (RHC), tehsil headquarters hospitals (THQ) and district headquarters hospitals (DHQ)) and private hospitals. To address this gap, the proposed research would aim to explicate the level of bioethics insights and awareness among healthcare professionals (doctors, nurses, female health visitors (FHVs), medical tech/dispensers and other medical personnel) working in both public and private hospitals in Haripur district, Pakistan, as well as its relationship with sociodemographic factors, training and teaching of medical ethics, ethics in healthcare practice and specific issues in medical ethics. This research would be crucial for keeping an eye on ethical practices and moral behaviour and improving patient outcomes. The findings of this research will also enable us to emphasise how crucial it is for all medical professionals to be taught bioethics.

MethodologyStudy design and setting

The study design was cross-sectional and conducted between March and May 2023, following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist criteria for observational studies (see online supplemental file for STROBE statement). The settings for the study were the public healthcare facilities (BHU, RHC, THQ and DHQ) and private hospitals located in the Haripur district, Pakistan.

Study populationInclusion criteria

Healthcare professionals or service providers with at least 6 months of experience in the study setting were eligible for enrolment in the study because, in the Pakistani context, they typically serve under close supervision of senior professionals and may not encounter ethical dilemmas on their own.

Exclusion criteria

However, health service providers who would not regularly come into contact with patients were excluded from the study.25

Sampling procedure

This research employed a census sampling (complete enumeration approach) to target all healthcare professionals (doctors, nurses, FHVs, medical technicians/dispensers and other medical personnel) working in each department of the BHU, RHC, (THQ, DHQ and private hospitals/clinics in Haripur district, Pakistan. The study aimed to gather diverse perspectives on bioethics from healthcare professionals in a single district, Haripur, due to its strategic location, accessibility to healthcare facilities and diverse geographical features, addressing logistical constraints and improving research feasibility and data collection. A total of 745 healthcare personnel were provided with questionnaires, out of which 98 questionnaires were returned. Ultimately, the study population consisted of 647 healthcare professionals, resulting in a response rate of 86.8%.

Study instrument

The level of ethical insights and awareness in healthcare practice, as well as the particular dilemmas in medical ethics shown by healthcare professionals, were evaluated using a previously pretested and validated structured questionnaire called Omani Physicians’ Bioethics and Medical Law Awareness,26 with minor modifications.27 28 The final questionnaire comprised a total of 35 items and was self-administered, following a structured format with closed-ended questions. The first 12 general questions covered participants’ sociodemographic and professional characteristics, training or teaching of medical ethics and organisational ethical guidelines. The subsequent items (13–25) were designed to explore participants’ perspectives on various aspects of healthcare ethics and ethical dilemmas within healthcare practice. Each response was assigned a score from 0 to 2, with the highest score given to the accurate response. The remaining items focused on specific issues in medical ethics (online supplemental appendix 1). The questionnaire’s content was validated and pretested with 30 physicians, nurses, FHVs and chemists to ensure comprehensibility and to resolve any ambiguities, yielding a Cronbach’s α coefficient of 0.659 (online supplemental appendix 2).

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Data analysis

Descriptive analyses were conducted using frequencies and percentages to demonstrate the sociodemographic characteristics. The χ2 test was employed to compare ethical insights and awareness among healthcare professionals regarding the teaching and understanding of bioethics. Additionally, Cramer’s V value and phi coefficient were calculated to assess the strength of association with awareness about ethical issues in healthcare practice and specific issues in medical ethics. The effect size was calculated via Cramer’s values of 0.1, 0.1–0.5 and >0.5, which were used for small, medium and large, respectively.27 29 All quantitative data (scores) were reported as mean and standard deviation (mean±SD) and analysed using the Mann-Whitney and Kruskal-Wallis tests. A p value of <0.05 was considered statistically significant.

ResultsDemographic characteristics of study population

Out of the total 647 healthcare professionals, 159 participants were from BHU, 103 from RHC, 104 from THQ, 162 from DHQ and 119 from Private hospitals. The majority of them were consultants and medical officers, comprising 30.1% (195 individuals) (figure 1). The gender distribution among healthcare professionals showed a majority of males (56.9%), with females accounting for 43.1%. The majority (74%) belonged to the Hazaras ethnic group, known for their unique language, culture and contributions, primarily residing in the Hazara division of Pakistan, including Haripur district. Most participants had fewer than 10 years of work experience, and the overwhelming majority (97%) pursued medical studies in Pakistan (online supplemental table S1).

Figure 1

Distribution of the healthcare professionals. Professionals were categorised according to their place of posting and job titles. Y-axis represents percentages and X-axis represent categories of jobs and place of posting in two separate groups. BHU, basic health units; DHQ, district headquarters hospitals; FHV, female health visitor; RHC, rural health centres; THQ, tehsil headquarters hospitals.

Teaching/training of bioethics

The awareness of bioethics with the number of credit hours studied varies significantly across different healthcare professionals (χ²=47.76, p<0.001). Respondents with different job categories reported different levels of exposure to ethics education during their professional studies. A notable proportion of consultants (73.9 %) nurses (72.1 %) and medical technicians/dispensers (73.4 %) reported receiving 1–5 hours of ethics training, whereas, medical officers (41.7 %) reported exposure to 6–10 hours of ethics education compared with other groups. FHVs had the highest proportion (40.8 %) of professionals who did not study ethics formally. The perception of the relevance of teaching medical ethics to one’s practice was not significantly different across different healthcare professionals (χ²=8.51, p=0.13). The majority of respondents across all job categories expressed a strong opinion of the relevance of medical ethics education to their practice, with percentages ranging from 73.7 % to 88.2 %. Knowledge of the four principles of medical ethics showed a significant variation among healthcare professionals (χ²=36.65, p<0.001). Consultants, medical officers, nurses and medical technicians/dispensers showed a higher awareness (over 85 %) of these principles. The existence of a written code of ethics outlining ethical considerations in organisations showed a significant association with job categories (χ²=23.58, p<0.001). A majority of consultants (94.6 %), nurses (87.5 %) and medical technicians/dispensers (91.3 %) indicated the presence of a written code of ethics in their organisations. However, a significant proportion of medical officers (26.2 %) reported the absence of such a code (table 1).

Table 1

Awareness of bioethics/bioethics education of healthcare professionals

Ethical issues in various aspects of healthcare practice

The frequency of encountering ethical situations in practice, finding answers to ethical questions and observing unethical decisions in practice was found to vary statistically significantly among healthcare professionals (p<0.001). Responses varied across job categories, with the majority of respondents from different designations reporting that they encountered ethical situations ‘rarely’ (57.6 % to 68.2 %). Some healthcare professionals, particularly nurses and medical technicians/dispensers, indicated encountering ethical situations ‘occasionally’ (22.2%–41.7%). In particular, a significant proportion of consultants (67.4 %), nurses (40.4 %) and other medical personnel (59.6 %) expressed finding answers ‘often’ (50%–75% of the time), whereas medical officers (31.1 %), medical technician/dispenser (34.7 %) and FHV are (39.5%) more likely to find answers ‘occasionally’ (25%–50% of the time). A significant number of healthcare professionals across different job categories reported observing unethical decisions ‘rarely’ (22.2%–51.1%) and ‘sometimes’ (26.6%–48.7%). However, nurses (49.0 %) and consultants (26.1 %) were more likely to encounter unethical decisions ‘often’ (49%–50%) compared with other job categories. The areas where healthcare personnel encountered ethical problems were ‘religion’, ‘law’, ‘traditional and value’, ‘conflict of interest’, ‘financial’ and ‘other’ areas. In particular, religious and legal aspects were prominently reported as areas of ethical concern. Moreover, preferred resources for finding answers to ethical questions varied, ‘books’, ‘internet’ and ‘senior colleague’ were the primary sources chosen by healthcare professionals. Senior colleagues were particularly preferred by a significant number of consultants, medical officers and medical technicians and dispensers. In addition, healthcare professionals also identified factors that prevented unethical practice such as ‘religion’, ‘law’, ‘traditional values’ and ‘ethics teaching’ as the most important influences that prevent unethical practices. It is noteworthy that ‘ethics teaching’ was highlighted as a factor by a significant proportion of consultants and medical officers (table 2).

Table 2

Exploring various aspects of healthcare ethics among healthcare professionals

Ethical dilemmas in healthcare practice

There was a significant relationship between the designation of healthcare professionals and the perception of treating children without parental consent (χ²=101.16, p<0.001). In particular, respondents from different job categories, from 50.0% to 91.9%, ‘agree’ that children should not be treated without parental consent. The association between the designation of healthcare professionals and the intention to inform close relatives of a patient’s condition was also found to be significant (χ²=98.68, p<0.001), with a Cramer’s V (0.39) indicating a moderate association. Across job categories, a significant proportion of respondents (41.3%–92.1%) ‘agree’ that close relatives should be informed about the patient’s condition. The relationship between job categories and the opinion of refusing to examine a female patient when a female practitioner is unavailable was also statistically significant (χ²=60.56, p<0.001). Responses ranged from 21.2% to 80.8% ‘agree’ across job categories (online supplemental table S2).

Specific issues in medical ethics

A significant association exists between job categories/designations of healthcare professionals and various ethical issues such as acceptance of gifts from patients, pharmaceutical companies, acceptance of remuneration for referrals, advising patients to purchase specific company products, discussion of patient problems in public places, failure to disclose medical errors, not fully informing patients about treatment, collection of donations from patients, performing tasks for personal financial benefit. P value<0.05 was considered to be statistically significant. With different job categories and designations of healthcare professionals, the majority were found to be unethical; however, there were differences in their views on the order in which patients should get treatment recommendations (table 3).

Table 3

Healthcare professionals’ perspectives on specific issues in medical ethics

General characteristics and bioethics awareness scores

Overall, the mean awareness score for ‘ethics in healthcare practice’ was 8.0±2.38, whereas the mean score for ‘Specific Issues in Medical Ethics’ was 32.0±5.21. The result revealed a significant influence of gender on awareness scores in ‘ethics in healthcare practice’ (p=0.004). Specifically, male participants showed slightly higher awareness scores (8.21±2.32) compared with their female counterparts (7.73±2.45). However, gender did not affect the awareness scores in ‘Specific problems in medical ethics’ (p=0.482). Age showed a significant relationship with awareness scores in both ‘ethics in healthcare practice’ and ‘specific issues in medical ethics’. Particularly participants aged 41 years or older showed the highest awareness scores in both categories. We found that ethnicity/cultural background significantly influenced awareness scores in both ‘ethics in healthcare practice’ and ‘specific issues in medical ethics’. Different ethnic backgrounds were associated with varying levels of ethical awareness among participants. Although job categories/designation of healthcare professionals did not significantly affect the awareness scores in ‘ethics in healthcare practice’ (p=0.487), they showed a notable impact on the awareness scores in ‘specific issues in medical ethics’ (p<0.001). This finding emphasises the different perspectives that different health roles bring. Occupational settings where healthcare professionals were employed or carried out their professional duties showed a strong association with awareness scores in both categories (p<0.001). Participants working in BHU and private hospitals showed the highest awareness scores. The country of professional education did not significantly affect awareness scores in either category whereas professional experience showed a significant influence on awareness scores in both ‘ethics in healthcare practice’ and ‘specific issues in medical ethics’ (p<0.001). Participants with more than 10 years of experience showed the highest awareness scores, reflecting the potential effect of accumulated experience. Furthermore, awareness scores were significantly influenced by the presence of a written code of ethics in the organisation (table 4).

Table 4

Relationship of ethical dilemmas in healthcare practice and specific issues in medical ethics’ awareness scores (mean, SD) by selected sociodemographic and profession-related information

Discussion

The current research indicates that both physicians and non-physicians need to enhance their knowledge of healthcare ethics. Several factors, such as the inability to decide or commit to a certain response and lack of understanding or experience in the field, may contribute to many respondents disagreeing with certain answers. Consultants, doctors, nurses, FHVs, medical technicians/dispensers, and other medical personnel all have different roles in patient care, leading to varying perspectives on ethical challenges. The study highlighted that nurses had relatively lower awareness scores and were less prepared to face ethical dilemmas compared with doctors. This difference could potentially be attributed to variations in education and training received by different categories of healthcare personnel.16 However, findings from previous research30 suggest that even doctors may not be fully aware of new laws or regulations concerning ethical aspects like consent. Solutions such as continuous training and professional development programmes are proposed to address knowledge gaps and ensure all healthcare professionals are well equipped to navigate ethical challenges effectively. This highlights the importance of ongoing education and training for both physicians and non-physicians. Additionally, there seems to be a potential gap in teaching and exposure to ethical principles during professional education, as considerable variation was observed in credits awarded to ethics during professional studies. When comparing the findings of this study with the current literature, it is noteworthy that the level of participation in postgraduate training in medical ethics seems to be much lower in comparison to the academic pursuit experienced during undergraduate studies.18 28

The findings of ethical practice revealed intriguing insights into the frequency with which ethical challenges are encountered, sources of guidance sought during ethical dilemmas, and the impact of situational factors on unethical decisions. Healthcare professionals reported frequently encountering ethical situations, a frequency substantially lower than that reported in a previous study.31 According to the previous finding,26 medical professionals routinely face unethical practices and ethical dilemmas in the course of their daily job and report feeling unprepared to cope with them. Healthcare professionals sought the assistance of their more experienced colleagues, searched the internet or read books to find solutions to these conundrums in the present study, as the same scenario has also been reported in other investigations.32 In particular, the study reflected the findings from previous research26 33 that healthcare personnel often face ethical challenges related to religion, law, traditional values, conflicts of interest and financial considerations which emphasises the universality of these ethical dilemmas across different health contexts.

Culture plays a crucial role in an individual’s ethical ideology, influencing their inclination to behave ethically. Organisations also have an obligation to comply with the culture of ethical practices, which is essential for ethical decision-making (EDM).34 Religious affiliation also influences daily life and health-related decisions, affecting both moral decision-making and behaviour. Healthcare providers must consider the religious aspects of patients’ lives to understand how their beliefs, practices and experiences may affect their health and adherence to medical advice.35 Ethical sensitivity is interwoven with cultural competence, and healthcare professionals need to be trained in both aspects integratively, both preprofessionally and during continuing education. Cultural competence and EDM should be viewed as interrelated within higher education and research to ensure healthcare professionals can function efficiently in clinical practice in both situational and global contexts. Balancing professional ethics with cultural competence is essential for providing responsive services to individual clients and ensuring the best intervention outcomes.

Current research highlights a varying degree of awareness among healthcare personnel about various ethical issues in practice. While some issues appear to have a higher level of awareness, others are less recognised. This variation can be attributed to the complexity and diversity of ethical challenges that arise in the healthcare system. It is noteworthy that opinions vary significantly across different roles in the healthcare system. For example, the data highlight different attitudes towards providing ethical help for a patient who wants to die, with doctors showing some consensus compared with other healthcare professionals.36 Monsudi et al37 and Imran et al14 have posited that variations in the level of professional training contribute to divergent perspectives among healthcare professionals.

Moreover, this study also identified new aspects that align with the existing literature.24 38–40 For instance, ethical challenges such as accepting gifts from pharmaceutical companies and patients, discussing patient information publicly, accepting fees for referral to specific doctors and failing to inform patients about treatment advantages and risks emerged as significant concerns among healthcare professionals. This may reflect evolving practices and increased awareness of potential conflicts of interest. Additionally, the findings indicate that a significant proportion of participants believed that healthcare professionals should prioritise patients with influential references, which challenges the principle of fair care provision, especially for emergency patients.41

The demographic distribution revealed interesting patterns in ethical awareness scores, with gender having a modest influence. Age and professional experience, on the other hand, play a more significant role. Participants aged 41 years and older and healthcare professionals with more than 10 years of experience showed significantly higher awareness scores, emphasising the value of accumulated experience in shaping ethical understanding and practice in healthcare. This finding is consistent with previous research, indicating potential cumulative learning effects over time.42 43 Variations also emerged concerning ethnic background and culture, suggesting that cultural nuances and values can influence ethical perspectives within the healthcare system.44 45 Furthermore, in terms of designation, consultants and medical technologists/dispensers showed the highest awareness scores, possibly due to their extensive involvement in ethical practice and patient care.

The workplace has a significant impact, with professionals in private hospitals scoring significantly higher in ethical awareness. This may reflect a greater emphasis on ethical considerations in private healthcare settings. Moreover, the presence of a written code of ethics in hospitals corresponds to higher ethical awareness scores. This highlights the positive influence of clear ethical guidelines on professionals’ understanding and recognition of ethical issues. Administrators’ involvement in ethical practice by developing a written code of ethics can strengthen ethical insights among healthcare professionals.46

The findings of this study have practical implications for both health institutions and decision-makers. First and foremost, the study emphasises the importance of standardised and comprehensive bioethics education and targeted training for all healthcare providers, with particular attention to non-physician training programmes. Incorporating regular ethics workshops and case-based discussions and encouraging collaboration between healthcare providers, ethicists and legal experts to foster a comprehensive approach to ethical issues in healthcare can empower healthcare professionals to navigate complex ethical dilemmas more effectively, ultimately leading to improved patient care. Efforts should be made to bridge the awareness gap between different job categories. Furthermore, the data suggest a need for a written code of ethics in job settings and clearer guidelines for certain ethical issues.

The study highlights the need to incorporate bioethics as a core component of medical and healthcare curricula, especially in non-physician training programmes. It also emphasises the importance of easily accessible resources for EDM. Developing platforms or databases in healthcare facilities that provide ethical guidelines, case studies, and expert opinions can empower healthcare professionals to navigate complex ethical dilemmas more effectively. Furthermore, the data suggest a need for clearer guidelines on certain ethical issues, such as accepting gifts/fees from patients/companies or prioritising patients based on recommendations. These ethical challenges influence the daily provision of care and treatment for patients. Healthcare institutions and regulatory bodies should collaborate to develop and enforce policies that reduce potential conflicts of interest.

Addressing these issues requires ethical competencies encompassing awareness, knowledge, consideration, decision-making, action, and behaviour. Students, as the future workforce, need training to successfully cope with morally problematic circumstances, while experienced professionals must develop strategies for dealing with ethical issues. Therefore, ethics education is crucial for promoting the learning and development of ethical competencies among healthcare professionals and students pursuing careers in healthcare.

The study also recommends increasing HCWs’ ethical sensitivity by strengthening organisational ethics culture through clear guidelines, incorporating ethical considerations into clinical practice guidelines, conducting regular assessments of ethical sensitivity and conducting longitudinal studies to assess the long-term impact of educational interventions. These ideas contribute to the broader discussion of healthcare ethics and offer valuable assistance to those striving to encourage ethical practice among healthcare personnel. The findings will help create an environment that encourages ethical practice in healthcare settings.

The limitations of the current study include that bias can occur during the potential response of HCWs as they have time constraints due to work overload. Further longitudinal studies can also examine whether increased bioethics teaching translates into improved ethical practice over time in clinical settings.

Conclusion

In conclusion, the findings underscored varying degrees of awareness and compliance with ethical principles among different healthcare roles. While a significant proportion of participants demonstrated strong awareness of bioethical principles, there were areas of concern, particularly regarding ethical issues. The influence of factors such as age, professional experience and organisational support became evident in shaping individuals’ ethical awareness and decisions. This study highlights the need for targeted continuous training and the development of robust ethical guidelines within healthcare institutions to enhance ethical awareness. Further research may explore the effectiveness of training programmes and their impact on improving ethical practice across various healthcare settings in Pakistan.