Medical education is not limited to acquiring knowledge of disease, diagnosis, and treatment. It also involves the development of professional values, communication, respect for patients and ethical decision making (1). Clinics are an integral component of medical education at the undergraduate level due to their ability to provide the student with exposure to real patient care, bedside learning, and a gradual acquisition of clinical skills. This can, however, lead students to encounters in training where ethical concepts may be challenging to apply (2, 3).

Medical students must enter the clinical environment as students, but also as professionals and with respect of patient rights (4). Students might encounter ethical concerns in relation to informed consent, patient privacy, confidentiality, gender sensitivity, and dignity in examination situations during ward rounds, outpatient visits, emergency care, case discussions, and during clinical procedures. Such difficulties might get more complicated if a student is not clear on his or her role, lacks self-confidence, or is under pressure from older doctors, teachers, or the routine of the hospital (5, 6).

Patient consent is one of the most critical issues of ethics during clinical rotations. Students should be notified to patients when the students are taking history, examining or performing procedures. However, at times, consent can be inferred instead of explicitly obtained in busy clinical settings. This may cause patient/student discomfort (7, 8). Likewise, privacy while on duty at the bedside may be compromised in busy wards, in shared rooms, in emergency rooms and in outpatient clinics. Students can also see patient information openly discussed in other areas, impacting professional boundaries.

The other major hurdle is the pressure of doing more than one can do. Medical students are expected to help in procedures, examine patients or do clinical work before they are sufficiently trained or supervised. While clinical exposure is essential to learning, it must be directed by patient safety, appropriate supervision and respecting patient autonomy. Students may feel anxious if they are not being well supervised, uncertain about whether to refuse or keep going with the project, or frightened that they will make a mistake (9).

There are also ethical issues related to the hierarchy in clinical training. Students might observe that other staff members treat the patient in an inappropriate way, don't communicate well with the patient, don't keep patient information confidential or do something inappropriate; however, they may not report these things for fear of being evaluated negatively, embarrassment, or lack of clear reporting process. This silence can further intensify emotional distress and can become a normal occurrence if students are not properly guided in an unethical manner. Thus, clinical ethics education should not be confined to classroom instruction of principles, but should also be provided to students to prepare them to handle ethical dilemmas in clinical settings.

Ethics training in the past might make students more confident in solving ethical issues. But knowledge of ethics is limited to theory and it may not be all students are ready for in a clinical context. In order to reinforce ethical practice during rotations, case based discussion, role modeling, reflective learning, mentorship and safe reporting systems are required. It is essential to comprehend the nature and prevalence of ethical dilemmas that students encounter in medical education and safeguard patient rights.

Therefore, the present study was conducted to determine the ethical challenges faced by medical students during clinical rotations. The study aimed to identify common ethical problems, assess students’ responses to these dilemmas, and evaluate the association of ethical challenge level with year of study and previous ethics training.

This study was conducted to assess the ethical challenges faced by medical students during their clinical rotations. A descriptive cross-sectional study design was used because the objective was to determine the frequency and pattern of ethical issues experienced by students at a specific point during their clinical training. This design was considered suitable for evaluating students’ exposure to ethical dilemmas related to patient privacy, informed consent, confidentiality, supervision, professional conduct, and reporting of unethical incidents.

The study was carried out at HBS Medical and Dental College over a period of 6 months January 20205 to June 2025. Medical students who were currently attending clinical rotations in different departments were included in the study. These departments were medicine, surgery, gynecology and obstetrics, pediatrics and emergency, depending upon the clinical posting schedules of the institution. The subjects were MBBS students from clinical years, who had direct or indirect contact with the patients during ward rounds, OPDs, emergency department, bedside teaching, and supervised clinical procedures.

In total, 77 medical students participated in the study. The sample size was determined based on the number of eligible students during the time of the study. Non-probability sampling technique – consecutive sampling technique was used. All medical students who met the inclusion criteria and agreed to participate were included until the desired sample size was achieved. This sampling method was employed as students were approached during their regularly scheduled clinical postings and all eligible students available during the data collection period were invited to participate.

The subjects of the study were the students of the third year, fourth year and final year MBBS who had undergone clinical rotation and were willing to give informed consent. Students were excluded from the study if they had not performed a clinical rotation, did not attend the pre-clinical years, did not attend during the period of data collection or did not consent to participation. To ensure accurate results, students who returned questionnaires that were incomplete were also not included in the final analysis.

Ethical issues arising from clinical rotations were characterized as situations in which students had difficulty in upholding accepted ethical standards in the provision of care, or while observing others doing so, while on a clinical rotation. These were issues of informed consent, confidentiality of patients, privacy during examination, gender related discomfort, pressure to perform clinical tasks which one is not competent, lack of supervision during procedures, disrespectful behavior towards patients, conflict between learning needs and the rights of patients and fear of reporting unethical practices. Presence and intensity of ethical challenges faced by medical students during clinical rotations was the main outcome measure.

The data was collected through a structured questionnaire which was formulated after the literature search and ethical issues normally faced in clinical training. The questionnaire included the following sections: demographic information, clinical rotation information, previous ethics training, types of ethical problems the students encountered, frequency of ethical problems, how students responded to ethical problems, emotional reactions, and students' perceptions of a need for additional ethics training. Most questions were closed ended with answers provided as either ‘yes' or ‘no' or on a categorical scale from ‘never' to ‘often'. The questionnaire included simple language to enable the students to understand and answer the questions correctly.

The study was presented to all participants and the purpose explained prior to data collection. Written informed consent received from each student. It was voluntary participation and students were informed that their refusal to participate would have no impact on their academic record, clinical assessment, and relationship with teachers. They also were told they could drop out of the study at any time, for no reason. Complete confidentiality and anonymity were ensured throughout the study. Students' names, roll numbers, or personal information have not been written on the questionnaire. All the collected data was for research only. Upon clinical rotation, students were asked to answer honestly, according to their personal experience. Questionnaires were completed privately and responses were not solicited from clinical supervisors, to minimize response bias.

The collected data was age, gender, year of MBBS, type of clinical rotation, duration of clinical exposure, previous ethics trainings, awareness of medical ethics, and various ethical problems faced by students. Ethical challenge factors were violation of confidentiality, absence of informed consent, problems keeping patients' information confidential, being pushed to perform beyond one's abilities, lack of adequate supervision, discomfort with physical examination due to gender, and mistreatment of patients, by seniors, by others, and because of fear of reprisal for reporting unethical actions. Student variables measured were: staying quiet, talking to peers, talking to supervisors, formal reporting, emotional distress, and perceived need for formal ethics training.

All questionnaires were then assessed for completeness after they had been collected. The data were entered in SPSS version 26 and were analyzed. Categorical variables (gender, year of study, previous ethics training, type of ethical challenge, student response to ethical dilemma) were summarized in terms of frequencies and percentages. For quantitative variables (e.g. age), mean and standard deviation were computed. The ethical challenge of the overall situation was rated as low, moderate, or high based on the number and frequency of ethical issues reported by each student. Chi-square test was used for inferential analysis to check the association between different variables (gender, year of MBBS, previous ethics training, type of clinical rotation) with ethical challenge level. Fisher's exact test was employed when the cell size was small. The P value < 0.05 was regarded as statistically significant. Data were presented in tables, frequencies, percentages and a bar chart displaying the highest frequency ethical challenges encountered in clinical rotations by medical students.

A total of 77 medical students were included in the study. Demographic profile indicated that the students were mostly in MBBS clinical years with representation from medicine, surgery, gynecology and obstetrics, pediatrics and emergency rotations. The average age of the subjects was 22.4 ± 1.3 years. More than half of the female students were more than the male students. The majority of the students indicated some basic teaching about medical ethics, but many of them were not yet confident enough to address the ethical issues in actual clinical scenarios.

Table 1: Demographic Characteristics of Medical Students

The majority of students reported having at least one ethical issue during their clinical rotations. The most common problems were issues with patient privacy, patient informed consent, patient confidentiality, and pressure for patients to perform actions that they are not capable of doing. The results suggest that there were ethical problems identified and this did not appear to be a problem of just one department or rotation.

Table 2: Frequency of Ethical Challenges Faced During Clinical Rotations

An overall score for the level of ethical problems students were exposed to was calculated, indicating that nearly half of the students had experienced moderate and approximately one-third a high level of ethical difficulty. Only a small proportion reported low exposure. This indicates that for many students, ethical issues were a frequent occurrence during clinical rotations.

Table 3: Overall Level of Ethical Challenges Experienced by Students

Students were also asked how often they faced ethical problems in their clinical postings. Most reported sometimes or often encountering such problems. This indicates that ethical issues were not uncommon occurrences but were encountered a number of times, in relation to patient interactions, bedside teaching and learning through procedures.

Table 4: Frequency of Encountering Ethical Problems

As far as what students do when they encounter ethical issues, many students had expressed a preference for not saying anything when they see an ethical issue. Common reasons cited included fear of negative evaluation, lack of confidence, and not knowing where to report. Less than half of the students discussed the problem with a supervisor. This underscores the importance of a secure and supportive environment where students feel safe reporting any ethical concerns.

Table 5: Student Responses to Ethical Dilemmas

Correlations between selected student characteristics and a high ethical challenge level was tested. The final year students had a higher percentage of ethical challenges than the students in the other clinical years and this was statistically significant. There were also a significantly higher number of ethical challenges for students who had no previous ethics training. The level of ethical challenges presented was not significantly related to gender.

Table 6: Association of Ethical Challenge Level with Selected Variables

Students' self-confidence on their ethical problem solving skills was also evaluated. One third of students indicated good ethical dilemma handling confidence. A substantial proportion (over 90%) said that they required to be better trained formally in ethical issues during clinical years. Based on these results, it can be concluded that theoretical knowledge is important for them, but they still need more hands-on guidance, role modeling, and supervised discussions of ethical issues while performing clinical rotations.

Table 7: Ethical Preparedness and Need for Training

Overall, the results showed that ethical challenges were commonly experienced by medical students during clinical rotations. There was a strong emphasis on issues of privacy, consent, confidentiality, supervision and fear of reporting. High level of ethical challenges was reported by the final year students and those who had no ethics training. The majority of students agreed that the need of clinical training in a better ethics learning environment is the need of structured ethics teaching, better supervision, and clear reporting mechanism.

The graph shows that the most frequent ethical challenge was difficulty maintaining patient privacy (68.8%), followed by lack of informed consent (63.6%) and fear/uncertainty about reporting unethical incidents (61.0%).

The present study assessed ethical challenges faced by medical students during clinical rotations and found that such challenges were common among the participants. The most frequently reported issue was difficulty maintaining patient privacy, followed by lack of informed consent, breach of confidentiality, fear of reporting unethical incidents, and pressure to perform beyond competence. These findings suggest that clinical rotations expose students not only to clinical learning but also to complex ethical situations in which patient rights, student learning needs, institutional culture, and hierarchical relationships may overlap. Similar observations were reported by Marsden et al., who found that medical students encountered a wide range of ethical issues during surgical clerkship, including decision-making, communication, justice, consent, and patient-related concerns (10). Stites et al. also reported that medical students experience several forms of ethics conflicts during clinical training, supporting the need to align ethics education with real clinical exposure (11).

A primary ethical issue in the present study was the confidentiality and privacy of patients. This is a significant discovery as students frequently see and discuss patient information with the specialist team during ward rounds, bedside teaching, clinical examinations and presentations of cases to their supervisor. Many final year medical students knew about the importance of confidentiality, but poor practices with regard to clinical histories and patient data were still noted, such as accessing patient records without appropriate safeguards, reported Beltran-Aroca et al. (12). Likewise, Terán et al. found that students' attitudes about patient privacy may shift during their medical education, suggesting that ethical attitudes can be shaped by clinical experience and/or institutional context (13). The results of this study were similar to those of the present study, with privacy and confidentiality not only as theoretical issues, but also as a practical challenge when it came to clinical rotations.

Lack of informed consent and conflict between patient rights and student learning were also important issues in the present study. Students in medicine need to have clinical experience to be competent, but they must not deprive patients of their autonomy, dignity or comfort in the process. Kaur et al. noted this issue with PEAs under anaesthetic where consent for student participation may not always be explicit (14). Li et al. also studied ethical decision making of medical students in a scenario where the patient was not interested in their participation, providing evidence of possible difficulties in performing tasks that are against patient's wishes (15). The present finding that students require guidance on consent, supervision, and limits of participation in patient care are supported by these studies.

A key finding was that many students did not respond to the sight of unethical behaviour or did not formally report on it. This might be because they fear adverse ratings, lack authority, are unsure about the reporting systems or rely on seniors for clinical ratings. Ferine et al. found that during clerkship rotations, students tended to be silent or talk informally about unethical behavior rather than address it directly (16). Similarly, Wesevich et al. discovered that students can encounter breakdowns while facing ethical challenges in their clerkships, especially when they feel unsure, unsure of their role or unsupported by their institution (17). Abraham et al also noted a challenge with ethical dilemmas on emergency medicine clerkship, due to the nature of their clinical environment which demanded more rapid clinical environments for students, allowing less time to reflect and report on ethical issues (18). The results indicate that reporting behaviors that are safe and encouraging peer mentorship from the faculty are crucial for the ethical development of students in their clinical training.

The present study also revealed that the final year students and students with no ethics training demonstrated significantly more ethical challenges. This could be because they are more likely to come across ethical issues and have more patient contact as they are senior students. Meanwhile, if ethics training is not structured, students might not be confident in recognizing and resolving ethical issues. Langerman et al. called for the integration of ethics education into the clinical clerkships and went on to discuss its benefits over teaching in the classroom setting (19). Hlaing et al. reported that case-based ethical discussions enabled students from health professions to apply principles of autonomy, beneficence, non-maleficence and justice to practice-oriented dilemmas (20). Other studies discussed by Ong et al. also pointed to moral distress in medical students due to unresolved moral conflicts (13). Thus, ethics education should be practical, practical case-based, integrated clinically and should also be complemented with the role model provided by teachers and supervisors.

The study concluded that ethical challenges are commonly faced by medical students during clinical rotations. The most frequent issues were related to patient privacy, informed consent, confidentiality, fear of reporting unethical incidents, inadequate supervision, and pressure to perform beyond competence. Final-year students and those without previous ethics training were more likely to report higher levels of ethical challenges. These findings highlight the need for structured clinical ethics teaching, clear consent practices, confidential reporting pathways, and supportive supervision during clinical rotations. Medical colleges should integrate practical ethics training into clinical clerkships through case discussions, reflective learning, role modeling, and mentorship so that students can develop ethical confidence along with clinical competence.

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