690566

research-article2017
HEJ0010.1177/0017896917690566Health Education JournalAraújo et al.

Short report

Health Education Journal

Teaching bioethics in high schools

2017, Vol. 76(4) 507­–513
© The Author(s) 2017
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DOI: 10.1177/0017896917690566
https://doi.org/10.1177/0017896917690566
journals.sagepub.com/home/hej

Joana Araújo, Carlos Costa Gomes,

António Jácomo and Sandra Martins Pereira
Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal
UNESCO Chair in Bioethics, Institute of Bioethics, Universidade Católica Portuguesa, Portugal.

Abstract
Objective: The Bioethics Teaching in Secondary Education (Project BEST) aims to promote the teaching of
bioethics in secondary schools. This paper describes the development and implementation of the programme
in Portugal.
Design: Programme development involved two main tasks: (1) using the learning tools previously developed
by the US Northwest Association of Biomedical Research and the Council of Europe and (2) applying
the project in classrooms, conducting lectures on bioethics for students and teachers, and then using the
previously developed learning tools.
Setting: 32 schools representing the most densely populated regions of Portugal.
Methods: Two surveys, based on previously validated measures, were used to evaluate the project.
Results: The surveys were answered by the 179 students and 16 teachers attending a conference held by
the project, which concluded the project’s implementation phase. The findings point to the positive impact
of this project.
Conclusion: Based on evidence collected to date, it is clear that (1) students can develop reflective skills
using this kind of an approach, (2) the project is well suited to secondary school syllabuses and to the age
range of students from secondary schools, and (3) the teaching of values should start earlier at school,
thereby helping young people develop a critical perspective on problems linked to scientific development
and its implications on human health.

Keywords
Bioethics, decision-making, high schools, Portugal, teaching, values

Corresponding author:
Sandra Martins Pereira, Instituto de Bioética, Universidade Católica Portuguesa, Rua Diogo Botelho 1327, 4169-005
Porto, Portugal.
Email: smpereira@porto.ucp.pt
508 Health Education Journal 76(4)

Introduction
Bioethical reflection requires a solid foundation so that arguments from different scientific fields
can be integrated into reasoning (Osswald, 2007). From an educational point of view, the teaching
of bioethics presents an opportunity to foster the development of critical thinking and abilities,
including concepts of responsibility, democracy and respect for others. This is particularly relevant
in the development of competences for decision-making, health promotion, education, and
empowerment.
Bioethics is a transdisciplinary subject involving reflection on ethical issues in health care, sci-
ence, business, law and policy. Fields of bioethical enquiry include medical ethics, animal ethics
and environmental ethics, some of which overlap. According to Post (2003), bioethics offers a
reflection on the moral significance of nature and human nature, and on the development and appli-
cation of biomedical technologies. As outlined by Potter (1971), the concept of bioethics covers
not only medical ethics but also all that inferes with the phenomenon of life (Archer, 1996). The
ethics of all interventions on the human being (Lamarre, 2000) – including health education and
promotion – is amenable to being framed within this type of approach.
It is increasingly accepted that bioethics should be taught to young people in secondary school.
In fact, standards of science literacy emphasise not only the importance of scientific content and
processes but also the need for students to learn about science that is contextualised in real-world
situations involving personal and community decision-making (Chowning et al., 2012; Sadler and
Zeidler, 2009). According to Harter (2012), many teenagers already have a clear sense of self-
awareness, which may foster their openness towards ethical issues. This is also recognized by the
Committee on Bioethics of the Council of Europe, which has developed an educational fact sheet,
aiming to train young students using a participatory approach, fundamental to education for citi-
zenship, by organizing and informed, multidisciplinary debate about bioethical issues (Council of
Europe, 2009).
According to Sørensen et al. (2012), an individual’s ability to understand and use health knowl-
edge lies at the heart of health literacy. An individuals’ health learning capacity also affects how
young people understand and use the health information provided to them and their capacity to
maintain their own health (Freeman et al., 2016). A similar framework can be applied to learning
about ethical issues that have an impact on health.
While debate and critical thinking on issues concerning life and its intrinsic dignity lie at the
cornerstone of scientific processes, students in secondary schools have few opportunities to engage
in it (Chowning et al., 2012). Moreover, teachers often find this task difficult and are not comfort-
able with it, mostly due to lack of time, uneasiness concerning the discussion of moral topics, fear
of polemics and lack of self-confidence (Bryce and Gray, 2004; Shepherd et al., 2016). In contrast,
students whose interest about bioethical issues is awakened by the media or by discussion with
their peers would like to see bioethics taught in their schools.
There are many difficulties to the institutionalisation of this type of educational intervention,
since bioethics is not a subject like, for instance, biology or mathematics. Indeed, while the sci-
ences seem to be value-free, bioethics is value-loaded (Azariah, 2009). A promising approach lies
in allotting time in subjects such as biology, philosophy, sexual education and religion to discuss
the bioethical problems pertaining to each respective area of knowledge (Osswald, 2006). In this
way, bioethics could form a ‘bridge’ between the arts and sciences, between the sciences (Azariah,
2009), and also ‘to the future’, as advocated by Potter (1971).
In order to achieve this aim, it is essential to motivate teachers in different subject areas to
debate the bioethical issues that arise within their fields. A baseline consensus on the value of this
needs to be reached. Project BEST, Formação Bioética no Ensino Secundário: Estratégias e
Araújo et al. 509

Instrumentos nas Ciências da Vida e do Meio (Bioethics Teaching in Secondary Education:

Strategies and Instruments in Life and Environmental Sciences), is an outreach programme devel-
oped by the Instituto de Bioética at the Universidade Católica Portuguesa (IB, UCP). The project
was initiated with the goal of promoting the teaching of bioethics in secondary schools after teach-
ing staff at the IB, UCP noticed that university students seemed ill-prepared to engage in discus-
sions of ethical implications in each of their scientific fields. According to international literature
(Bishop and Szobota, 2015; Chowning et al., 2012; Harada et al., 2008; Keskin-Samanci et al.,
2014), this may be due to the lack of preparatory work at the secondary level. Therefore, we chose
to get in touch with a sample of secondary schools in order to offer their teachers and pupils the
opportunity to discuss, in an academic way, ethical problems related to matters taught in different
disciplines (e.g. biology, philosophy, sexual education and religion). This paper reports on the
activities and the evaluation of the project.

Project BEST
Project BEST was initiated in 2011 from the assumption that in a pluralistic society like Portugal, it
is not easy to reach consensus concerning the moral evaluation of interventions of a technical and
biological nature. However, developing a shared language and framework for thinking about these
matters was acceptable to most of the people involved (Kelly, 2003; Salako, 2008; Trotter, 2002;
Turner, 2003). Bioethics is a rich area of research and practice, highlighting regulatory strategies,
changing relations between different professionals and raising questions of an ethical nature and
expertise (Wilson, 2011). Therefore, we sought to develop a values-based education programme as
described by Gracia (2001, 2003, 2011) and Oggletree (2003) to encourage careful deliberation by
interested people (teachers, pupils). Although certain values may not be shared by everyone, others
are more consensual in character (e.g. peace or solidarity).
We adopted the schematic process described by Gracia (2003) as the mainstay of bioethical
reasoning: critical analysis of the facts from a scientific perspective, discussion of the values
involved and of the duties arising from them, and final decision. The latter must satisfy the tests
of legality (i.e. whether or not the decision is legal), public exposure (i.e. the willingness to
defend a position publicly if necessary) and consistency over time (i.e. if by having more time to
make a decision, the decision would be the same). Failing one of these tests or steps would mean
that the decision is not the most prudent one, hence calling for the decision-making process to be
restarted again.
Since the IB, UCP included among its masters and doctoral students, teachers of biology, phi-
losophy and health (e.g. Physicians, Nurses), we asked them to take part in the implementation of
the project, and many agreed to do so. Thereafter, the Ethics Primer developed by the Northwest
Association for Biomedical Research in Seattle (Chowning and Fraser, 2007) and the Bioethical
Issues–Education Fact Sheets of the Council of Europe (2009) were adopted as guideline tools to
be used by the educators (members of the project and teachers) in the classroom.
Six themes of bioethical relevance, akin to the curricular programmes of biology and philoso-
phy (i.e. cloning, stem cells, scientific research, the beginning of human life, the end of life and
climate and sustainability), were chosen for the teaching sessions. In order to facilitate the learn-
ing process, the following stepwise strategies were used: (1) focusing on the principles and
values of bioethics; (2) watching a relevant film, such as The Lifeboat; (3) creating awareness
and ethical questioning; (4) critical reasoning and analysis; (5) documentary film analysis; and
(6) narrative ethics. Using such an approach, selected cases were provided for discussion, and
movies focusing on ethical issues were shown and analysed critically. Popular books dealing
with the above-mentioned subjects were recommended for further reading (Table 1).
510 Health Education Journal 76(4)

Table 1.  List of films and books used in Project BEST.

Themes Movies Books

Cloning Never let me go (2010)
The 6th Day (2001)
Godsend (2004)
The clone (1997)
The clone (2004)
The Island (2005)
Stem cells (genetic Gattaca (1997)
engineering) Resident Evil (2002)
The Island of Doctor Moreau (1996)
Scientific research The Constant Gardener (2005)
Miss Evers’ Boys (1997)
Das Experiment (2001)
The Serpent’s Egg (1977)
Begin of human life My Sister’s Keeper (2009)
Juno (2007)
Vera Drake (2004)
The wish to have a child (2012)
End of life The Sea Inside (2004)
Million Dollar Baby (2004)
The Barbarian Invasions (2003)
The Diving Bell and the Butterfly
(2007)
Climate and An Inconvenient Truth (2007)
sustainability The Day After Tomorrow (2004)
A Civil Action (1998)
Erin Brockovich (2000)
Never Let Me Go (Kazuo Ishiguro)
Brave New World (Aldous Huxley)
Next (Michael Crichton)
Brave New World (Aldous Huxley)
The Constant Gardener (John Le Carré)
Intuition (Allegra Goodman)
The Memory Artists (Jeffrey Moore)
Next (Michael Crichton)
The Speed of Dark (Elizabeth Moon)
The Immortal Life of Henrietta Lacks (Rebecca
Skloot)
My Sister’s Keeper (Jodi Picoult)
Un enfant pour l’éternité (Isabelle de Mezerac)
Óscar et la dame rose (Eric-Emmanuel Schmitt)
Silvie’s Life (Marianne Rogoff)
Tuesdays with Morrie (Mitch Albom)
Óscar et la dame rose (Eric-Emmanuel Schmitt)
The Death of Ivan Ilyich (Leon Tolstoy)
Le Scaphandre et le Papillon (Jean-Dominique
Bauby)
Paula (Isabel Allende)
Patrimony (Philip Roth)
Para sempre (Vergílio Ferreira)
Sétimo Selo (José Rodrigues dos Santos)
Blue Gold (Clive Cussler)
Get a Life (Nadine Gordimer)

BEST: Bioethics Teaching in Secondary Education.

A total number of 32 schools representing the most populated regions of Portugal were selected,
and they agreed to participate in Project BEST. The Board of Directors of each of the institutions
was contacted, and the project was described in an introduction session, and where there was an
interest, the following plan of activities was agreed upon and implemented

1. Meetings with 11th and 12th school year teachers of biology and philosophy to introduce
them to the project.
2. Coaching sessions for the teachers (3 hours).
3. Discussion sessions with groups of pupils (usually 20–25 pupils per group, 90 minutes).
4. Discussion sessions with teachers in order to develop the specific programme to be fol-
lowed in their classes over the whole school year.
Araújo et al. 511

Table 2.  Total number of participants (2012/2013 and 2013/2014).

Groups of participants Total number

Teachers 215
Pupils (10th–12th classes) 2,215
Schools recruiteda 32
Schools participatingb 15
Sessions with teachers 25
Sessions with pupilsc (given by the authors) 53
Duration of each session 90 minutes
aNumber of schools contacted and which agreed to receive viva voce information during a 90-minute session.
bNumber of schools that decided to participate in the programme and pupils in classes 10–12 with information and
discussion on the bioethical issues referred to in the accompanying text.
cIn line with the wishes of each school, some of the bioethical issues were presented by one of the authors.

5. Classes taught by the respective teachers, with the possible inclusion of a member of the
Project BEST group, if wished. During this time, pupils together with their teachers decided
which theme(s) they were willing to prepare presentations on for inclusion in an oral or
poster session at a Project BEST conference.
6. Project BEST conferences were conducted involving all the classes that participated in the
project. In these conferences, groups of pupils discussed their presentations and posters that
focused on the ethical themes of their choice. Conferences were held in Oporto (EDP
Foundation) and Coimbra (St. Teotónio College). The conferences were quite appreciated
by the students and teachers and presented communications (orally or in poster sessions)
were of good to excellent quality triggering lively discussion.

Table 2 provides an overview of those involved in the project.

At the end of the second year of the project (2013–2014), we evaluated participants’ opinions of
it using a questionnaire. The latter was responded by the 179 pupils and 16 teachers (100% response
rate) who participated in the final project conference held in Oporto in 2014. Questions included
the following items: meeting expectations, fostering of bioethical knowledge, deeper involvement
in bioethics and increase in knowledge of bioethics. All items were assessed using a 3-point Likert
scale ranging from 1 (disagree) to 3 (totally agree); option 2 signified ‘I agree’.
The descriptive analysis shows that the majority of responses voiced a positive opinion con-
cerning these aspects: meeting expectations (52% agreement among the participants), fostering of
bioethical knowledge (51% agreement), deeper involvement in bioethics (61% agreement) and
increase in knowledge of bioethics (57% of agreement). Option 1 (I disagree) was chosen by only
a small minority of participants (11%–15%) in each case. In 32%–39% of the cases, participants
said the project did not have a significant effect on their opinions and attitudes.

Concluding remarks
Project BEST was a challenging venture that required multiple visits and meetings with teachers
and pupils who occasionally refused to collaborate or did so in a sceptical way. Nevertheless, many
of them were enthusiastic in their involvement and devoted many hours towards project implemen-
tation and success. It is perhaps not surprising that, despite being predominantly positive and
showing an attitude of support, the evaluation suggested that about one-third of the respondents
considered that the project had no marked influence on their views about bioethical issues.
512 Health Education Journal 76(4)

Although the answer to the question ‘Should we promote Bioethics Teaching in Biology and
Philosophy classes at secondary schools?’ was clearly affirmative (not only because the majority
of the respondents voiced a positive opinion but also due to the high quality of many of the posters
and oral communication presented by pupils), we tend to believe, as Harter (2012) and Freeman
et al. (2016) do, that this sort of teaching should begin earlier. Harter (2012) argues that from an
early stage teenagers in high school possess self-awareness and have a clear sense of themselves,
in terms of attitudes, feelings and cognition.
It is also appropriate to observe that our results do not differ very much from those reported by
the relatively few researchers who have developed similar projects in other countries and cultural
settings. Bishop and Szobota (2015) in the USA and Nord (2001) and Nordic Committee on
Bioethics (NCBio) (2008) in Norway suggest that there is definite value in teaching bioethics in
secondary schools, although it is important to lay the foundations for this at an early age with an
atmosphere which is supportive of the development of critical thinking and ethical appraisal.
Based on our findings, it is our belief that the teaching of values, essential reasoning and
bioethical issues should begin earlier, for instance, in primary and preparatory school. This would
help societies prepare young people to develop their own thoughts, attitudes and decisions about
the problems scientific progress create, especially concerning implications for human health.
Further research is required on the relevant issues and the school contexts in which they can be
introduced.

Acknowledgements
The authors would like to acknowledge the contribution of everyone involved in the project, especially the
school teachers and pupils, and Susana Magalhães, Professor of English Language and Literature, who revised
and edited the final version of the manuscript. S.M.P. would also like to thank the Grünenthal Foundation and
the Merck, Sharpe and Dohme Foundation for their support to Project InPalIn, during which this manuscript
was written. Author contributions were as follows: J.A. contributed to the study concept and design, imple-
mentation of Project Bioethics Teaching in Secondary Education (BEST), data collection, analysis and inter-
pretation of the data, and writing of the manuscript; C.C.G. and A.J participated in the implementation of
Project BEST, data collection, analysis and interpretation of the data and writing of the manuscript; and
S.M.P. contributed to the analysis and interpretation of the data, and critically edited, revised and commented
on the manuscript. All authors (J.A., C.C.G., A.J. and S.M.P.) approved the final version of the manuscript
before submission.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publi-
cation of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: Project Bioethics Teaching in Secondary Education (BEST) was funded by the
Calouste Gulbenkian Foundation, José de Mello Saúde and Fundação EDP.

Supplementary material
Project data and materials are available from the authors upon request.

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