Journal of Bioethical Inquiry

, Volume 13, Issue 2, pp 261–270 | Cite as

Medical Students’ Opinions About the Commercialization of Healthcare: A Cross-Sectional Survey

  • M. Murat Civaner
  • Harun Balcioglu
  • Kevser Vatansever
Original Research

Abstract

There are serious concerns about the commercialization of healthcare and adoption of the business approach in medicine. As market dynamics endanger established professional values, healthcare workers face more complicated ethical dilemmas in their daily practice. The aim of this study was to investigate the willingness of medical students to accept the assertions of commercialized healthcare and the factors affecting their level of agreement, factors which could influence their moral stance when market demands conflict with professional values. A cross-sectional study was conducted in three medical schools in Turkey. The study population consisted of first-, third-, and sixth-year students, and 1,781 students participated in total. Students were asked to state if they agreed with the assertions of commercialized healthcare. Of all students, 87.2 per cent agreed with at least one of the assertions, and one-fifth (20.8 per cent) of them agreed with more than half of the assertions. First-year students significantly agreed more with some assertions than third- and sixth-year students. Being female, having mid-level family income, choosing medicine due to idealistic reasons, and being in the third or sixth years of medical study increased the probability of disagreement. Also, studying in a medical school that included integrated lectures on health policies, rights related to health, and health inequities, along with early field visits, increased the probability of disagreement. This study suggests that agreement with the assertions of commercialized healthcare might be prevalent among students at a considerable level. We argue that this level of agreement is not compatible with best practice in professional ethics and indicates the need for an educational intervention in order to have physicians who give priority to patients’ best interests in the face of market demands.

Keywords

Commercialization Privatization Medicine Professionalism Medical education Professional ethics 

Introduction

On the subject of commercialized healthcare in the United States, Arnold S. Relman has written, “In no other healthcare system in the world do investors and business considerations play such an important role” (Relman 2007a, S66). Considering the last decade, there are good reasons to claim that this phenomenon is no longer unique to the United States. Reforms based on budget cuts, cost-effectiveness, deregulation, and privatization are being rapidly implemented worldwide, including in high-income countries. This reform pandemic is based on certain assertions claiming that public healthcare services suffer from highly centralized decision-making that causes misallocation of resources, inequity of accessing care, inefficiency, and exploding costs (World Bank 1993). Healthcare services in Turkey are also being privatized via a World Bank project called “Transformation in Health” (World Bank 2014). The project aims to transform the organization, financing, and provision of healthcare from a public to a private model. Centres for primary healthcare have been transformed into family physicians’ private clinics, and public hospitals have become autonomous institutions that are expected to compete in the market with each other. Thus medical practice is becoming “a specialized form of business enterprise that [is] best left to market forces” (Relman 2005, ¶9). In this process of commercialization, medical care is being transformed into an economic commodity: patients are viewed as customers; physicians, as providers.

However, there is a considerable amount of literature showing that the key assertions of commercialized healthcare are highly controversial. It has been criticized for failing to improve the quality of care and efficiency (Homedes and Ugalde 2005; Maynard 2012; Tuan et al. 2005; Ravindran 2010), limiting access to care (Alvarez, Salmon, and Swartzman 2011; Wilkes, Coulter, and Hurwitz 1998; Villa and Kane 2013; Naylor 1988; Waitzkin, Jasso-Aguilar, and Iriart 2007; Aksan, Ergin, and Ocek 2010), serving to aggravate inequities (Fins 2007; Price et al. 1999; Schoen and Doty 2004; Price 1988; Schoen et al. 2000), and increasing costs unnecessarily (Ugalde and Homedes 2005; McCoy 2012; Waitzkin, Jasso-Aguilar, and Iriart 2007; Woolhandler and Himmelstein 1997). It has been found that privatization both decreases wages and intensifies the workloads and job insecurity of healthcare workers (Oh et al. 2011; Zuberi and Ptashnick 2011). The experiences of various countries have shown that commercialization also has a detrimental effect on the healthcare system. Studies have emphasized that it promotes curative services rather than community-centred, preventive, and primary care (Naylor 1988), creates disorganization within the healthcare system (McCoy 2012), and fragments the public health infrastructure by impairing communication and diminishing control over performance (Keane et al. 2002). It is also noted that it reduces the self-esteem of physicians so that professional identity cannot be sustained (Churchill 2007).

There are serious concerns as well about the effects of the business approach on the patient-physician relationship. A number of international physician organizations have published the Charter on Medical Professionalism. It states that the very nature and values of medical professionalism are threatened by market forces, globalization, and problems in healthcare delivery and that “physicians find it increasingly difficult to meet their responsibilities to patients and society” (ABIM Foundation, ACP–ASIM Foundation, EFIM 2002, 244). This shows the consequences of medicine losing its roots in self-sacrifice and the dissolution of the contract between medicine and society. Various authors have argued that commodified care is incompatible with professional values (Relman 2007b), and that clinical decision-making is adversely affected when cost factors are added up (Keshavjee 2004); furthermore, trust—an essential component of the healing process—is seriously damaged (Andereck 2007).

Obviously these are all important problems that should be dealt with seriously. As many national and international codes emphasize, physicians should give priority to the patient’s best interest, not allow their judgment to be influenced by personal interest or unfair discrimination, and protect the health of patients and the public (Association 2006; General Medical Council 2013; ABIM Foundation, ACP–ASIM Foundation, EFIM 2002). However, little is known about their opinions on the assertions of healthcare reforms based on commercialization. What do they think about privatization policies? Do they agree that a business approach should dominate healthcare? Which factors influence their considerations? Thoughts and judgments about these kinds of questions are important, as they could influence physicians’ moral stance when market demands conflict with professional values. Accordingly, their thoughts and moral positions could be potential sources for conflict of interests. Therefore, we aimed to take a step towards gaining an understanding on this issue, and carried out a study on medical students, because professional identity usually starts to be shaped during medical education. To that end, we have investigated how willing they are to accept the basic assertions of commercialization and have explored the factors affecting their level of agreement. We also aimed to determine whether their opinions differed over the course of medical education.

Methods

Research Design

A cross-sectional study was conducted in three medical schools in Istanbul, Ankara, and Izmir—the three largest cities in Turkey. This is the first phase of a sequential explanatory study (Hanson et al. 2005) with plans for completion using semi-structured in-depth interviews based on preliminary results.

Settings

Ankara University School of Medicine (AUSM), Istanbul University Cerrahpasa School of Medicine (CSM), and Ege University School of Medicine (EUSM) are among the top five medical schools in Turkey and are well-established institutions, founded eighty, one hundred fifty, and fifty-five years ago, respectively. In Turkey, students with sufficient National University Selection Exam scores are assigned to the faculties on their wish lists. The three medical schools included in this study enrol students with similar National University Selection Exam scores. However, there are some differences between the schools regarding curricula and teaching strategies. In EUSM there are specific vertical corridors on “Community Health and Field Studies” and “Ethics and Law” running from the first to the third year. The Community Health corridor has mostly been taught using small group activities and field visits, and its content includes health economics and politics, rights related to health, and global and national health inequities, while emphasizing the importance of equitable and accessible primary healthcare for all population groups. The Ethics corridor is interdisciplinary in orientation, and the ethical aspects of healthcare services are discussed, especially in weekly case presentations during the third year. AUSM has an integrated curriculum that includes problem-based learning sessions in preclinical years, while CUSM has a traditional discipline-based curriculum based solely on lectures.

Study Population

The study population consisted of first-, third-, and sixth-year students of the three medical schools. First-year students were selected because they were newcomers who had just begun to encounter medical issues and had no clinical experience. Third-year students had gained some clinical experience during propaedeutic courses, taken basic medical science lectures and introductory lectures on clinical sciences, and had limited experience in a clinical environment. Sixth-year students had sound experience from two years of clerkships in various clinics and one year of internship. The total number of first-, third-, and sixth-year students was 2,721, and the aim was to access all of them. The overall response rate was 65.5 per cent (63.5 per cent in CSM, 65.6 per cent in AUSM and 67.2 per cent in EUSM). Of all 1,781 participants, 47.9 per cent were female, and 52.1 per cent were male; this distribution is concordant with the general medical student population.

Data Collection

After gaining approval from the three universities’ research ethics committees, data were collected using a questionnaire developed by the researchers. A short explanation about the study was given in writing and orally, anonymity was assured, and the voluntary participation of students was requested.

The first section of the questionnaire gathered data concerning independent variables such as gender, parents’ occupations, family income, type of high school attended, and reasons for choosing medicine as a profession. The second section aimed to determine level of agreement on basic assertions of commercialization in healthcare. In order to gather the main arguments defending commercialized healthcare, various sources were examined, including reports published by the World Bank and articles addressing organizational transformation and financial models of healthcare services. Also, materials issued by the Turkish Ministry of Health regarding “Transformation in Health” were explored. Thus, the statements reflecting commercialization policies in healthcare chosen to be used in the questionnaire were as follows:
  • Healthcare services should be provided according to market rules (World Bank 2003; Ruthjersen 2007; World Bank 1993; Navarro 2008; Griffin 2007; Breen 2001; Dougherty 1990; Mackintosh 2003; Unger et al. 2008; Homedes and Ugalde 2009; Ministry of Health 2001, 2007, 2009).

  • Healthcare services should be privatized (World Bank 2003; Ruthjersen 2007; World Bank 1993; Navarro 2008; Griffin 2007; Breen 2001; Dougherty 1990; Mackintosh 2003; Unger et al. 2008; Homedes and Ugalde 2009; Ministry of Health 2001, 2007, 2009).

  • Decreasing expenditures for patients should be the priority when deciding the quantity and type of healthcare services to be provided (Mackintosh 2003; World Bank 2003; Navarro 2008; Homedes and Ugalde 2009; Ruthjersen 2007; Ministry of Health 2001, 2007, 2009).

  • Hospitals that do not make a profit should be privatized, services that are not profitable should be ceased, and unproductive healthcare staff should be replaced (Dougherty 1990; Mackintosh 2003; Unger et al. 2008; World Bank 1993; Ruthjersen 2007; World Bank 2002; Ministry of Health 2001, 2007, 2009).

  • Everybody should pay for health services either through direct payment or through insurance premiums (Dougherty 1990; Mackintosh 2003; Navarro 2008; Unger et al. 2008; World Bank 1993; Ruthjersen 2007; Ministry of Health 2001, 2007, 2009).

  • Only certain healthcare services (vaccination, outpatient care, etc.) should be provided free of charge. Others should be paid for by the patients, otherwise the healthcare system cannot be sustained financially (World Bank 1993; Ruthjersen 2007; Ministry of Health 2001, 2007, 2009).

  • Scientific developments in medicine necessitate huge investments, and the money needed can only be afforded by private companies, not the state. If companies did not support R&D studies, many current drugs and high-tech devices such as MRI would not have been developed (Angell 2005).

  • It should be regarded as normal that pharmaceutical, medical technology, and hospital companies give priority to increasing their profits, as in other commercial sectors (Angell 2005; World Bank 1993, 2003).

  • The world is becoming a fairer, freer, and economically stronger place with globalization (Ruthjersen 2007; Griffin 2007).

  • One of the most important patient rights is the right to choose the physician and healthcare institution (Dougherty 1990; Day 2008; Dixon et al. 2010; Ruthjersen 2007; Ministry of Health 2007, 2009).

Opinions were rated on a four-point Likert scale. The mid-point category of “neither agree nor disagree” was not put on the scale in order to direct students to take sides with the statements. The reliability of the questionnaire form was determined using Cronbach’s Alpha coefficient. Cronbach’s Alpha was high, with a level of 0.802 for the ten items aiming to determine the level of agreement. The construct validity of the questionnaire was explored by explanatory factor analysis using principal component analysis, with varimax rotation, considering the probable dependency of components. Ten statements were included in the analysis and selection of the number of factors was based on the eigenvalues greater than 1, and the scree plot (Field 2009). The first factor had an eigenvalue of 3.777 (accounting for 37.771 per cent of the variance), and the second factor had an eigenvalue of 1.202, explaining 12.015 per cent of the variance. The two factors together accounted for a total of 49.8 per cent of the variance; items one to seven were allocated under factor one, and items eight to ten were allocated under factor two. Table 1 shows the factor loadings after rotation. The two-factor structure was identified representing justification for commercialization of health care (factor one), and basic assertions of commercialization (factor two).
Table 1

Construct validity of the “basic assertions of commercialization in health care” questionnaire: Results of the principal component analysis

 

Factors

 

Factor 1 (Justification for commercialization of healthcare)

Factor 2 (Assertions of commercialization)

1. One of the most important patient rights is the right to choose the physician and healthcare institution.

0.505

0.314

2. Scientific developments in medicine necessitate huge investments, and the money needed can only be afforded by private companies, not the state. If companies did not support R&D studies, many current drugs and high-tech devices such as MRI would not have been developed.

0.688

0.127

3. Only certain healthcare services (vaccination, outpatient care, etc.) should be provided free of charge. Others should be paid for by the patients, otherwise the healthcare system cannot be sustained financially.

0.737

0.244

4. Decreasing expenditures for patients should be the priority when deciding the quantity and type of healthcare services to be provided.

0.432

0.268

5. Everybody should pay for health services either through direct payment or through insurance premiums.

0.606

0.325

6. Hospitals that do not make a profit should be privatized, services that are not bringing in money should cease, and unproductive healthcare staff should be replaced.

0.689

0.374

7. It should be regarded as normal that, as in other sectors, pharmaceutical, medical technology and hospital companies give priority to increasing their profits.

0.641

0.250

8. Healthcare services should be privatized.

0.321

0.712

9. The world is becoming a fairer, freer, and economically stronger place with globalization.

0.097

0.696

10. Healthcare services should be provided according to market rules.

0.230

0.778

Percentage of explained variance

37.4 %

11.4 %

All analyses were completed using PASW Statistics 18 statistical software.

Data Analysis

To summarize the data, total scores of the statements were computed by summing up the students’ ratings. As the rating scale included four points, agreement categories (certainly agree, agree) were assigned one and two points, whereas disagreement categories (disagree, certainly disagree) were assigned three and four points. The value-weight of each statement was accepted as equal because there was no previous knowledge showing their predictive power for reflecting one’s agreement level with the discourse. The students with total scores of twenty-nine or lower and who gave a rating of one or two on any statement were categorized as “agree to a certain degree” and were further analysed.

Logistic regression analysis was used to predict the probability that a participant would agree with commercialized healthcare. Beta weights and odds ratios with confidence intervals were calculated, and backward stepwise (likelihood ratio) models were used to determine the influences of the predictor variables and to estimate the magnitude of those influences for predicting the students’ agreement and disagreement with basic assertions of commercialized healthcare. The predictor variables in the model included a participant’s gender, type of high school attended, reasons for choosing medicine, school of medicine, and year of medical study (Table 3). ANOVA was conducted in order to test the significance of the differences in the total score according to medical school, family income and father’s occupation categories. A chi-square test was used to examine the relation between year of study and reasons for choosing medicine as a profession.

Results

Agreement on Statements

Of all students, 12.8 per cent of them disagreed with all statements, while 87.2 per cent agreed with at least one (Table 2). The percentage of students who agreed with more than half of the statements was 20.8 per cent.
Table 2

The levels of agreement with each statement

Statements

% of agreement

% of agreement by year of study

p

first year

third year

sixth year

1. One of the most important patient rights is the right to choose the physician and healthcare institution.

79.2

77.5

80.5

76.4

0.083

2. Scientific developments in medicine necessitate huge investments, and the money needed can only be afforded by private companies, not the state. If companies did not support R&D studies, many current drugs and high-tech devices such as MRI would not have been developed.

42.1

45.8

41.1

36.4

0.013

3. Only certain healthcare services (vaccination, outpatient care, etc.) should be provided free of charge. Others should be paid for by the patients, otherwise the healthcare system cannot be sustained financially.

35.8

39.8

33.9

31.2

0.003

4. Decreasing expenditures for patients should be the priority when deciding the quantity and type of healthcare services to be provided.

30.0

28.8

28.2

33.1

0.142

5. Everybody should pay for health services either through direct payment or through insurance premiums.

29.1

26.5

23.0

26.4

0.01

6. Hospitals that do not make a profit should be privatized, services that are not profitable should be ceased, and unproductive healthcare staff should be replaced.

25.4

34.5

25.0

25.5

0.006

7. It should be regarded as normal that, as in other commercial sectors, pharmaceutical, medical technology and hospital companies give priority to increasing their profits.

22.8

24.5

22.9

19.8

0.226

8. Healthcare services should be privatized.

18.7

22.4

15.9

15.8

0.001

9. The world is becoming a fairer, freer, and economically stronger place with globalization.

12.9

10.9

12.8

14.3

0.158

10. Healthcare services should be provided according to market rules.

10.2

11.1

8.7

10.5

0.008

Participants agreed the most on the statement “One of the most important patient rights is the right to choose the physician and healthcare institution” (79.2 per cent). One-third of the participants were in favour of the statements about the specific policies of commercialization in healthcare, such as “Decreasing expenditures should be the priority when deciding the quantity and type of healthcare” (35.8 per cent) and “Everybody should pay for health services either through direct payment or through insurance premiums” (29.1 per cent) (Statements three, four, five, and six in Table 2). Agreement level decreased when participants were asked whether they agreed with the statements “Healthcare services should be privatized” (18.7 per cent), “The world is becoming a fairer, freer, and economically stronger place with globalization” (12.9 per cent) and “Healthcare services should be provided according to market rules” (10.2 per cent).

First-year students significantly agreed more with some statements (Statements two, three, six, and eight in Table 2) than third- and sixth-year students. In addition, third-year students significantly agreed less with the fifth and tenth statements, compared to first and sixth-year students.

Independent Variables Affecting Agreement

Logistic regression analysis was used to predict the probability that a participant would agree with the assertions of commercialized healthcare (Table 3). The odds ratios indicated that, when holding all other variables constant, being female, choosing medicine due to idealistic reasons and being in the third or sixth years of medical study increased the probability of disagreement with basic assertions of commercialized healthcare 1.4, 1.3, and 1.4 times, respectively.
Table 3

Relationships between students’ disagreement with basic assertions of commercialized healthcare and the independent variables

Dependent variables

Independent variables

β

Odds Ratio (95 % C.I.)

P

Disagreement with assertions of commercialized healthcare

Gender (1: Female, 2: Male)

0.363

1.438 (1.174-1.761)

0.000

High school attended (1: Public school, 2: Private school)

0.426

1.412 (0.975-2.050)

0.067

Reason for choosing medicine as profession (1: Scientific or social idealism, 2: Other - income, social status, family pressure, etc.)

0.229

1.257 (1.021-1.547)

0.031

Year of study (1: First year, 2: Third or sixth year)

0.361

1.434 (1.163-1.769)

0.001

Female students were almost two times more likely to disagree with the statements than male students. Among first-year medical students, disagreement was almost one third less than third- or sixth-year students (p = .002).

A one-way ANOVA was conducted to test for differences in the mean ratings for the basic assertions of commercialized healthcare among four categories of family income. The mean total score for the statements significantly differed among family income groups (F [3, 1551]: 5.938, p = .001). Bonferroni post-hoc comparisons of the four groups indicate that the family income = 1001–2000 TL (~370–740 €) group (M = 28.77, 95 % CI [28.40–29.15]) gave significantly lower ratings to assertions than the family income < 1001 TL (~370 €) group (M = 29.90, 95 % CI [29.33–30.46]), p = .007; the family income = 2001–3000 TL (~640-1110 €) (M = 29.82, 95 % CI [29.32–30.31]), p = .007; and the family income > 3001 TL (<1110 €) (M = 29.73, 95 % CI [29.18–30.29]), p = .027. Differences in the agreement with the assertions among seven categories of father’s occupation were not statistically significant (F [6, 1517]: 1.440 p = .196).

In order to test the differences among the medical schools in the mean ratings for the basic assertions of commercialized healthcare among three categories, a one-way ANOVA was conducted. The mean total score for the statements significantly differed among the medical schools (F [2, 1593]: 25.082, p < .001). Bonferroni post-hoc comparisons of the three schools indicate that students from Cerrahpasa Medical School (M = 28.12, 95 % CI [27.70–28.55]) significantly agreed more with the statements than the students from Ege University Medical School (M = 30.19, 95 % CI [29.79–30.58]), and from Ankara University Medical School (M = 29.56, 95 % CI [29.64–29.95]), p < .001.

Discussion

On the Agreement Levels

Although the agreement levels for statements are not high enough to reflect a widespread, internally consistent discourse among students that we could describe as pro-commercial, we have observed that agreement with the basic assertions of commercialized healthcare is prevalent at a considerable level. One-third supported the assertion that “Decreasing expenditures should be the priority” and that “Services that are not profitable should be ceased.” Students’ agreement with policies that conflict with the right to health are worrying, as they might be an indicator that they have already internalized, as a part of the hidden curriculum, the dominant ideas and values of the climate surrounding them. Considering the fact that these opinions might make future physicians more vulnerable to the persuasiveness of the business approach, we think that this vulnerability should be dealt with through medical education, in order to train physicians who are able and willing to act according to their patient’s best interests.

Agreement levels were low with the statements that explicitly remarked that healthcare services should be provided according to market rules and globalization makes the world fairer. It is possible that students easily grasped the plainly discernible meaning of those assertions. On the other hand, there was notably more agreement with more sophisticated statements such as those about patients’ right to choose their physician and health institution. The right to choose sounds non-problematic, even tempting, since it evokes freedom. It is one of the fundamental justifications of the market approach, asserting that the choices of informed customers would moderate prices and improve quality in medical markets (Relman 2005). In fact, patients might not determine what kind of healthcare service they need before consulting a physician, even after being given some information on the qualities of physicians or institutions; therefore, making an informed choice is unlikely. Undoubtedly, patients might need a physician or an institution with a certain qualification, such as being able to communicate in the patient’s language, or being geographically closer to a patient with a disability. However, as Churchill stated, the problem is “commercialization of choice, the idea that choosing in medical care should be conceived on a commercial paradigm and as a market exercise, rather than as a way of individualizing care in a patient-centered manner” (Churchill 2007, 411). Based on our findings, it seems essential to train medical students about the assertions with rhetorical wrappings that conceal the market approach. Focusing on health policies, along with the right to health and patient rights, could be an effective initiative in order to create awareness about these kinds of assertions.

On the Effects of Independent Variables

The results indicate that gender, family income, the school of medicine, and the year of study significantly affect the level of agreement, while father’s occupation and high school attended do not. Being female might negatively influence opinions on basic assertions of commercialized healthcare, as women are found to score significantly higher on moral reasoning tests and tend to be more care-oriented (Baldwin and Self 2006). As for family income, we think sociological explanations based on further studies might be needed in order to understand how it affects opinions. However, it seems more possible and useful to comment in detail on the effect of medical education, because it might provide practical possibilities for effective intervention.

The Curriculum

Students at CUSM were found to be more likely to agree with the statements. A possible explanation for the difference might be the features of the education programs of the three medical schools. A study conducted at EUSM showed that, after the introduction of a new programme of specific vertical corridors in community health and ethics and law, there was a significant difference between student cohorts (Ocek et al. 2008). Students attending the new programme achieved learning objectives related to holistic care and evaluation of healthcare needs and prevention at higher levels than the previous program cohort. It seems that opening up space for field visits in the preclinical years and introducing students to medical training with lectures on health economics, health policies, health rights, and global and national health inequities might be effective initiatives to make students see and understand the effects of health policies. Additionally, moral deliberations on case presentations might be useful to make students think about the relationship between the health policies and the ethical problems practitioners face in their daily routine. Therefore, students might evaluate the assertions of commercialization by confronting the social and economic realities caused through the implementation of policies, such as the effects of cost-effectiveness measures. This study indicates that there is a need for further correlational or experimental research to reveal the influence of relevant educational strategies on students' opinions on commercialization in healthcare.

The Year of Study

Students’ opinions differed according to the year of study. First-year students agreed more with the overall discourse, especially on some statements, than third- and sixth-year students. Because the study was not designed to follow up cohorts, it is not possible to know the reasons behind this difference. A possible explanation could be the inherent features of different generations. Hafferty has emphasized that students might have different value stances than their predecessors (Hafferty 2003). Younger generations might be more convinced about the assertions of commercialization and might have internalized its values more because they are more exposed to them in today’s globalized world. The transformative effects of neoliberal policies on society in general might also be having an effect on students, because students’ values “may be more a reflection of society than their profession,” as Wilkes et al. have stated (Wilkes, Coulter, and Hurwitz 1998). This explanation especially makes sense for Turkey, where the current government came into power in 2002 and has been applying the World Bank’s privatization programs strictly ever since; consequently, the present first-year students may already have different values from the first-year students of six years ago.

Another possible explanation for the difference between first-year students and the other students might be the effect of medical education. It is reasonable to assume that senior students might be more informed and experienced and, therefore, more conscious of the effects of health policies after encountering patients in the real environment that is being shaped by the macro policies. In that sense, it is possible to think that medical education itself makes students more aware of the determinants of ethical problems. However, the question here is whether the content and methods of the curriculum matter. Our study makes it possible to give an affirmative answer to this question: students from EUSM are the ones who are least likely to agree with it. This finding supports the comment that the curriculum of EUSM, which includes lectures on health policies and field visits in preclinical years, might give an insight to students on the effects of the commodification of healthcare. Further studies, preferably qualitative ones, are needed to understand this phenomenon in depth.

This study’s main strength is methodological. Its widespread coverage, with 1,781 medical students from the biggest cities of Turkey, and its inclusion of three medical schools with different medical curricula allow us to evaluate the findings with more confidence. In addition, the participation of first-, third-, and sixth-year students gave us the opportunity to see the difference between preclinical and clinical years. However, this type of study is best carried out as a longitudinal study that examines the same cohort at the first-, third-, and sixth years of medical study. This study provides the foundation for a future sequential explanatory study, one that will also include qualitative methods.

A further limitation relates to the profile of the three schools as renowned medical schools located in more popular and richer cities in Turkey, potentially leading to bias in students’ opinions. Additionally, data collection from first- and third-year students was relatively easier, as they could be accessed during lectures or exams. The number of questionnaires collected from sixth-year students was relatively low compared to the other years, due to the lack of any opportunity to access all interns at the same time.

In the international conversation over professionalism, it is frequently emphasized that market-based policies in healthcare erode values and that what should be put into practice are principles of the primacy of patient welfare, patient autonomy, and social justice, together with a set of professional responsibilities, such as commitment to improving quality of care, a just distribution of finite resources, and maintaining trust by managing conflicts of interest (ABIM Foundation, ACP–ASIM Foundation, EFIM 2002). However, acquiring those virtues and finding ways to implement them in specific circumstances is getting harder in the face of market demands. An affirmative approach to the policies of commercialized healthcare would certainly make the task more challenging. Physicians and students should be equipped with appropriate knowledge and skills in order to be able to critically appraise the assertions of commercialization. They should be able to determine the right action, the one that respects those principles and responsibilities. Otherwise, it would not be easy to claim that professionalism is more than a complaint, which hardly helps practitioners’ vulnerability to the enterprise culture.

Notes

Acknowledgements

Authors do not have competing interest to declare. An earlier version of this paper was orally presented at an international conference and a national symposium:

•M. Civaner, Y.I. Ulman, H. Balcıoglu, and K. Vatansever. 2009. Medical students’ opinions about commodification of healthcare services and the alteration during medical education. EACME Conference, September 10–11, Venice, Italy.

•M. Civaner, Y.I. Ulman, H. Balcıoglu, and K. Vatansever. 2011. Tip ogrencilerinin saglik hizmetlerinin metalastirilmasi hakkindaki dusunceleri: Tip egitimi boyunca degisim [in Turkish].Topluma Dayalı Tıp Eğitimi—Eğitim Araştırmaları Sempozyumu, Tıp Eğitimini Geliştirme Derneği, May 5–7, Antalya, Turkey.

Yesim Isil Ulman, the second author of the presentation, has withdrawn from the study of her own will and has documented her decision (the signed document is available at request). The authors are grateful to Yesim Isil Ulman for her contributions and also to Raymond De Vries, Marcello Ienca, and Ademola Kazeem Fayemi for their critical review.

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Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2016

Authors and Affiliations

  1. 1.Department of Medical EthicsUludag University School of MedicineBursaTurkey
  2. 2.Department of Medical EducationAnkara University School of MedicineAnkaraTurkey
  3. 3.Department of Medical EducationEge University School of MedicineIzmirTurkey

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