Medical schools and accompanying teaching hospitals have proliferated in the Arabian Gulf countries including Oman in the past decade. Healthcare infrastructure in Oman has been internationally lauded for its efficiency. Medical ‘culture’ and required awareness of medical ethics are increasingly recognized as an unalienable part of medical practice, intimately linked to medical professionalism, and considered as best practice in medical settings. Physician awareness of principles of bioethics and medical law in such healthcare systems in the Arabiann Gulf countries remains largely unanswered. A cross-sectional study was conducted to explore the practice and awareness of bioethics among physicians working in a teaching hospital in Oman.
For exploring physician awareness and practice of bioethics and medical law, an instrument the Oman physician’s bioethics and medical law awareness (OBMLA) questionnaire was designed for physicians practicing in Oman. Exploratory factor analysis (EFA) generated three factors: (i) the practice of bioethics subscale items and (ii) incentive related bioethics subscale items and (iii) medico-legal awareness subscale items. The internal consistency and reliability of the OBMLA questionnaire were found to be adequate (Cronbach’s α: 0.73–0.8).
Oman has one governmental (public) university for teaching medicine and one private medical school. A teaching hospital is the vanguard for inoculating tomorrow’s doctors with the essence of medical professionalism. The study targeted physicians of all specialties, designations, and nationalities. The study sample thus represented the cadres of physicians in Oman.
There is a perceived laxity in awareness of bioethics and medical law among physicians in Oman. The current study combined many variables to answer the question as to what factors influence ethical medical practice. Through regression analysis, more specifically, multivariate linear regression modelling, the association between awareness of bioethics and Omani medical law scores with selected socio-demographic and professional characteristics of participants was examined.
Waddell  noted that it is not clinical issues but individual characteristics that shape medical professionalism. Previous studies have identified many attributes among physicians that vary between genders including emotional intelligence, physician-patient relationship, and indices of professionalism. The influence of gender on practice of bioethics was analyzed. Male physicians appeared to be more likely to be faced with ethical dilemmas. The gender gap was statistically significant in ethical dilemmas pertaining to law and finance. Although it did not reach statistical significance, genders also differed in their response to conflicts of interest.
The majority of participants endorsed that they had minimal exposure to education of bioethics. Teaching of bioethics in medical school was perceived to be inadequate in terms of content and number of hours assigned for the course by most participants. In this study, senior doctors were more likely to have obtained their medical degree from outside Oman, and junior doctors were more likely to have qualified from Oman. Participants who had obtained their medical degree from outside Oman were found to have more hours of exposure to bioethics teaching and had better knowledge of bioethics.
In general, the teaching of bioethics in medical schools in Western Europe and North American is highly developed, in contrast to non-western societies.[,] Alkabba et al  evaluated teaching of bioethics in 14 medical schools in Saudi Arabia, and reported that while medical schools did offer courses in bioethics, none of the schools had a dedicated unit for teaching ethics and the focus on the teaching of bioethics was sporadic and substandard. Lehmann et al  surveyed medical ethics education in US and Canadian medical schools and suggested that insufficient time allocated in the curriculum for teaching bioethics and dearth of competent teachers were the main obstacles to implementation of ethics education. Capacity development is essential, if not paramount, for development of professionalism linked to bioethics in Arabian Gulf countries. The content of the medical ethics curriculum, the number of hours dedicated to them, and approach towards teaching needs to be standardized.[,] In Saudi Arabia, Alkabba et al] have called for standardization of the teaching of bioethics in medical schools and introduction of uinteractive and student-engaging methods as opposed to passive lecturing. In Oman, the recently introduced Oman Medical Specialty Board which has embraced accreditation by Accreditation Council for Graduate Medical Education–International (ACGME-I) and supervises resident training in the country, has a strong focus on bioethics in its curriculum. It remains to be seen how the new curriculum would salvage the present suboptimal literacy and awareness in of bioethics and medical law.
The study revealed that physicians frequently encounter ethical dilemmas and unethical practice during routine work and felt ill-equipped to deal with them. In an attempt to resolve them they sought help from senior colleagues, or searched the internet or available literature. Such a scenario has been documented in other studies. The endorsed unethical practices in this study are likely to have negative repercussions. Al-Mandhari et al  conducted a community survey to assess the understanding of the term “medical error” among Omani general public. The study indicated that 49% were aware of what constitutes a medical error and 49% felt the primary cause of a medical error was suboptimal professionalism among healthcare workers. This negative perception has been speculated to contribute towards many Omanis seeking healthcare services outside Oman  despite the fact that Oman has been lauded to have one of the most efficient healthcare systems in the world.
In this study physicians reported that majority of issues that posed ethical dilemmas were those that clashed with prevalent social and cultural practices or scriptural teaching. The study indicated that the most reported drive to abstain from conducting unethical practice was religion and traditional values. Alkabba et al] listed ten major ethical issues perceived by physicians in Saudi Arabia including patients’ rights, equity of resource distribution, patient confidentiality, patient safety, conflicts of interest, ethics of privatization, informed consent, dealing with the opposite gender, beginning and end of life issues, and healthcare team ethics, and argued that very little attention has been given to these challenges in Saudi Arabia. They called for initiation of more in-depth discussions on the ethical issues, in order to bring about changes in policies, particularly on resource allocation. Some of the issues raised by Alkabba et al were applicable to physicians in Oman; this is understandable as Oman sharer the Arabic-Islamic moral values with Saudi Arabia.
Ethical dilemmas often fall into two broad categories. One with affinity to moral discernment which, in turn, define medical policy, practice and professionalism. The second category comprises situations that have arisen due to the emergent and new practices in biomedical sciences. Regardless of the type, little research has explored suitability in implementing practices in a society where ethos of life is different from the tenet of modern ethical principles. Existing principles of bioethics rests strongly on the western philosophical principles of respect for persons and a strong emphasis on autonomy.  In collective societies in the Arabian Peninsula, commonly considered as societies in transition, such ethos appears to be alien and therefore deemed to be a source of attrition than suitable practice. Medical practitioners practice medicine without adhering to international bioethical standards stipulated by UNESCO.  There are some strong critiques of those who enforce western principles of bioethics without considering the organic sociological bond of the society. At the same time, for accreditation by international bodies, medical schools should have an internationally accepted curriculum of bioethics. Recognizing the diversity of cultures and what might be considered as norm in certain societies, principles of bioethics may need to take into consideration Islamic law, which focuses on duties and obligations as delineated in the Qur’an or the teachings of Prophet Muhammed. The current study plays an important role in examining the suitability of existing bioethics principles in a non-western population.
This study also explored awareness of the Omani medical law and code of professional conduct for doctors. Majority of participants were uncertain of some of the stipulations in the Omani Medical law. Improved awareness is anticipated to improve the relation with patients and their families and would maintain a high and healthy trust in the healthcare system by the general public in Oman, as found by the survey conducted in 2012 among members of the general public in Oman in order to explore the preferences for and perceptions of medical error disclosure (MED) by the public. The study revealed a disclosure gap between respondents’ preferences for MED and perceived current MED practices in Oman, and called for addressing this issue in order to increase public confidence in the national healthcare system. With respect to patient confidentiality, the majority again were uncertain about the Omani medical law; similar misunderstanding persisted with respect to the law regarding substance misuse and self-prescription of psychotropic medications. On the contrary, majority of participants were aware of what to do with a patient with pulmonary tuberculosis. According to the code of conduct, physicians have obligation to alert the communicable disease surveillance and control section under the auspices of the Ministry of Health. Confidentiality is waived if the patient has a condition that could affect public health. There is a need to heighten awareness of Omani Medical Laws amongst doctors in Oman.
This study is not without limitations. First, non-probability sampling method (convenience sampling) was used to collect the data from physicians at one hospital and hence results cannot be generalized to the whole country. In order to scrutinize the findings from this study, the study would have to be extended to other healthcare settings in Oman. Second, the relatively small sample size affected the power of the study to detect differences. Not all observations in this study were statistically significant across categories. Thirdly, the study is cross-sectional, so the observed trend does not postulate the cause and effect due to a lack of temporality and potentially reversed causality in cross-sectional studies. Finally, the study would have more generalizability if it employed a previously validated instrument to study awareness and practice of medical ethics. However, extensive literature search did not reveal the existence of such an instrument.