The purpose of this study was to assess the impact of WBEL, a novel educational strategy, on students’ ethics-relatedknowledge and course engagement, in the context of the region of the Middle East and South Asia. The countries in the Middle East and South Asian regions share commonalities that set them apart from developed western cultures in relation to this component of medical programs. The differences are in terms of societal norms, politics, legislation, beliefs, traditions and lifestyles . It is important to note that these regions also have a substantial global impact on medical education as they contain 60% of the medical institutes producing medical graduates . These graduates provide healthcare services to a large local population within the region and form a significant portion of international medical graduates (IMGs) serving in the developed western World . For example, an estimated 45 per cent of the IMGs in the USA originate from the Middle East and South Asian regions .
As noted previously, several countries in the Middle East and South Asian regions face resource constraints and gaps that impact undergraduate medical ethics education. Among these constraints, the lack of culturally relevant texts is significant, as contemporary medical ethics has not developed indigenously and instead is considered an imported western concept [12, 13]. In support of this view, educators in Saudi Arabia  and Pakistan  argue that the importation of a secular western curriculum of ethics is not in accord with the religious teachings in the region. They emphasise that ethics education requires an inclusive, more reflective, and socially relevant approach to which the students can relate. Several other medical ethics educators in the region also opine that the Anglo-European ethical traditions that shape contemporary medical ethics education are not sufficient to encompass the indigenous values and beliefs of students in these regions [4, 14, 49–51]. Other constraints that have been identified as hampering the integration of medical ethics into the curriculum include a lack of competent, dedicated medical ethics teachers and often indifferent institutional policies [2, 6–9].
This study shows that the WBEL strategy is an enabler for the delivery of ethics education, and helps overcome the above resource constraints by creating appropriate content and methods through a robust consultative process . The inclusion of focussed reading material and social interaction with peers and faculty in the WBEL model explicitly compensates for the lack of learning resources relevant to the regions [52, 53]. The strategy is further strengthened by the inclusion of reflective writing and feedback towards the end of the learning process. The reflection and feedback process also supports the students in assessing their learning by articulating how they have approached the given task using their previous knowledge and understanding of the new information . The iterative refinement of this strategy with input from external experts, local faculty, and students (Shamim et al., 2021) is likely to enhance the strategy’s effectiveness.
One of the aims of this study was to evaluate students’ engagement in terms of satisfaction and enjoyability with this novel teaching strategy. Students’ satisfaction and enjoyability have shown to be related to the diversity of the methods used in their learning process . In addition to offering diversity to the learning process, the use of various teaching methods effectively covers different aspects of ethics education, like concepts, analysis, decision-making, that require distinct teaching methods for effective learning . The feedback from students enrolled in this study showed an overwhelmingly positive response towards the diverse educational methods, like small group discussions, role-plays and video demonstrations, used in the ethics course.
Karagiorgi and Symeou (2005) suggest that students take ownership of problems or tasks and provide authentic, sound solutions when these are closer to their reality. For example, students find narration of problems that originate from their facilitators’ or their own experiences as most stimulating and authentic [57, 58]. Therefore, in accordance with the CREEM framework, each session in the medical ethics course in this study started the learning process with a socio-culturally relevant experience based within an environment familiar to the students. The participants of this study acknowledged the value of this ownership and relevance. In other words, the ethics course provided the students with an authentic experience to construct their further learning.
In this study, the pre-and post-test, using KFQ and SCT items, systematically assessed the impact of the intervention. KFQ is focused on challenging aspects of clinical problems where learners are more likely to make errors . Similarly, based on script theory in cognitive psychology (Charlin et al., 2000), SCT has shown to assess students’ organisation of ethical knowledge while making decisions . The combination of the KFQ with SCT as pre-post-test measures provided a robust method to evaluate the impact of WBEL on developing ethical reasoning skills (abilities to identify ethical dilemmas and make decisions in a situation of uncertainty).
Although the course faculty belonged to diverse disciplines, without a primary qualification in ethics, the knowledge and guidance they received through the Workbook empowered them to deliver the course content effectively. The resource material in the Workbook informed the faculty about the scope and depth of content needed while sharing their experiences during the discourse. A shortage of medical teachers who are specifically trained to teach medical ethics is not a new  or isolated  phenomenon and has previously been identified as a resource constraint in medical ethics education in various contexts [8, 62, 63]. Students’ feedback regarding the facilitators’ performance during the course suggests that the provision of the Workbook and guidance for facilitators helped them overcome this constraint to some extent. Students’ positive feedback about the overall ethics course and appreciation of different methods used was also seen as a source of encouragement to the faculty involved in delivering the ethics course in this study.
The findings of this study, thus, make some significant contributions to the literature. Firstly, the findings illustrate the practical relevance of the CREEM framework and WBEL strategy for the delivery of medical ethics education in the studied context. Secondly, the findings are likely to apply to othercontexts with similarities to the study’s regions. Last but not least, the paper contributes to the existing literature by providing initial evidence on the use of an innovative educational strategy for contextually relevant ethics education, thereby creating avenues for further contextually relevant research in medical ethics education.