The response rate of the present study was 62% (313/502), whereas a relatively similar study conducted in a district of western Sri Lanka 5 years after the study discussed here reported a response rate of 79% . Another study carried out in a teaching hospital in Manipur, India  had a response rate of 78.1% (315/403). The relatively low response rate of the present study may be due to the sensitive nature of the questions asked, especially regarding the medical practice; it may also be due to the lack of time to complete the questionnaire which took 20 min on average. In any case, doctors have been well-recognized in surveys as a professional group with low response rates .
The level of knowledge on medical ethics
This study found that 81.2% of doctors had poor knowledge of medical ethics. A study conducted 5 years after the study under discussion (in 2014), to assess the knowledge and perception of selected aspects of medical ethics and medico-legal duties among medical officers in a district of Sri Lanka (Kaluthara District) reported that 52.2% had a poor level of knowledge, 43.9% had a fair level whereas only 3.9% had a good level of knowledge . In both these studies, the majority of doctors had a poor level of knowledge on medical ethics even though they were all provided with a copy of the ethical guidelines upon registration at the SLMC. This indicates that the mere provision of guidelines does not serve the purpose. Many doctors have probably neither read it nor understood its contents. Poor knowledge of medical ethics could have contributed to the increase of complaints against doctors for alleged unethical medical practices. It is our considered opinion that an adequate mechanism for 3600 appraisals prior to the revalidation of the license to practice should be introduced in Sri Lanka to induce doctors to self-update their knowledge on ethics (as much as their clinical knowledge). However, having a higher level of knowledge on ethical guidelines per se is not a guarantee of ethical conduct.
Studies conducted in India and Pakistan reported a similar situation. For example, a study conducted in Manipur found a poor level of knowledge on ethics in 70% of the participants, whereas a study undertaken by Shirazi et al. in Pakistan reported that the knowledge of medical ethics and its application in surgical wards was extremely poor [12, 13]. All these studies used self-administered questionnaires and the questions were based on the codes of ethics developed by the medical councils of the respective countries. These findings indicate that improving medical education on medical ethics is a timely necessity not only for Sri Lanka but for some other south Asian countries as well.
The teaching of medical ethics in Sri Lanka was considered “thoroughly inadequate”  in the 1990’s. Nearly two decades later, in this study, 91% of participants agreed that the undergraduate curriculum on medical ethics is inadequate. Over 70% of the participants had graduated five or more years before this study was conducted. Their perceptions may be different from that of newly graduated doctors who may have benefited from the global movement to include more teaching on medical ethics in the medical curriculum in the recent past . The results of this study can be used as a baseline to assess whether subsequent changes in undergraduate and postgraduate curricula have made a difference. Based on our recent review of literature, and to the best of our knowledge, there has been no similar study conducted in Sri Lanka for the last 10 years.
Attitude towards medical ethics
Most doctors (69.3%) believed that the extent of ethical medical practice at present is not satisfactory, necessitating further exploration of the reasons driving this perception of the professional conduct of doctors. A study conducted in the UK among newly qualified doctors revealed that they were aware of “ethical erosion in themselves and their colleagues” . This indicates the possibility of many doctors being aware of unethical practice. Moreover, 95.3% doctors in the present study identified in-service training on medical ethics as a necessity, indicating a positive response to interventions that can enhance knowledge and attitudes for more ethical practice. Incorporating training workshops on medical ethics into in-service training programmes conducted by academic colleges, regional level training programmes organized through regional clinical societies most of which have monthly educational sessions and annual conferences could be used as the entry points to provide further training in ethics.
Most respondents (79.2%) agreed that junior doctors tend to follow their consultants’ attitude towards patient care. This reflection denotes the potential for role models such as consultants and other senior doctors to influence their junior doctors to inculcate ethical medical practice. Whilst role models may not necessarily be the most appropriate way to learn medical ethics, medical students and junior doctors do continue to learn many professional attributes from senior doctors and consultants , suggesting the need for better awareness of the impact of the hidden curriculum.
Effective doctor-patient communication is a key requirement for ethical medical practice. However, 22.4% of doctors disagreed with the guideline-based statement ‘under no circumstances does a doctor have the right to shout at a patient,’ seemingly indicating an acceptance that there may be instances where a doctor could raise his/her voice when speaking to patients. If some doctors believe so, is it in the best interests of the patients? Do doctors behave authoritatively and expect patients to be submissive? These questions should be explored in a culturally sensitive manner. There have been incidents where patients have specifically stated that hospital staff including doctors are rude and that they do not respect patients resulting even in assaults on hospital staff by patients .
Sri Lankan doctors sometimes face an ethical dilemma when managing patients presenting with a history of abortion. In Sri Lanka, abortion is illegal unless the mother’s life is in danger . In this study, 47.3% doctors agreed that the abortions should be legalized, 33.2% disagreed and 19.5% had no opinion. These results indicate that the more inconclusive nature of personal opinions may affect how patients experiencing abortions are managed. On the other hand, Sri Lanka being a multi-ethnic and multicultural society, opinions on legalizing abortions are likely to be influenced by religious opinions.
Practice of medical ethics
In general, doctors reported that they deliver services ethically ‘always’ and ‘often’. The self-reported practices are more likely to be positively biased due to over reporting ethical practice and under reporting unethical practice. However, study results revealed certain unethical medical practices among doctors.
Examining patients, especially physical examination without the presence of a chaperone has led to a number of allegations against doctors for professional misconduct. In this study only 24.6% doctors reported get a chaperone “sometimes” whereas 3.5% of doctors never obtained the presence of a chaperone. Though the scarcity of staff is a common justification, in most instances, it could be mere negligence especially when doing intimate examinations such as breast, genitalia and rectal examinations. The presence of a chaperone could prevent potential allegations of professional misconduct by doctors and potential harm to patients. The Ayling report on key points of having chaperones stated that across the NHS, there was lack of understanding on the purpose and the use of chaperones. The report recommended that “Trained chaperones should be available to all patients having intimate examinations. Untrained administrative staff or family or friends of the patient should not be expected to act as chaperones” .
When prescribing drugs, 40.6% doctors wrote the generic name of the drug alongside the brand name ‘sometimes’; 6.7% never wrote the generic name and only the brand name of the drug. Brand-name prescription contributes to greater out of pocket expenditure; this is already relatively high (50.12% in 2016) in Sri Lanka . High out of pocket expenditure may push households into poverty where the poor (below and near the poverty line) are the most vulnerable [26, 27]. It has been noted that a significant proportion of Sri Lankan doctors including specialists contribute to increasing the costs of medicines  leading to further widening of health inequalities. High rates of generic drug use through policy development have resulted in savings of money in developed countries such as United Kingdom, Germany, Netherlands, Canada, United States etc. . However, it was evident from a recent systematic review that sufficient evidence on effective interventions to promote generic prescriptions in low- and middle-income countries were lacking .
In this study, 54% doctors responded that they never accept gifts from pharmaceutical companies in recognition of their prescribing pattern while 37.7% said they accepted gifts ‘sometimes’. Accepting gifts given in recognition of prescribing pattern is always an unethical practice based on SLMC medical ethics guidelines. Gifts offered by pharmaceutical companies range from a simple pen to free lunches to international travel expenditure including lodging. The globally recognised significant positive association between drug company sponsored Continuous Medical Education (CME) activities and increased prescribing of sponsors’ medicines [30, 31] may well apply in the Sri Lankan context. Understanding this conflict of interest is very important for eliminating the biased prescription patterns. Evidence suggests that policies against gifts should not be based on the size and the value of the gifts, instead gifts should be prohibited . Even though this might look idealistic, it would be a straightforward policy decision.
Punctuality is a fundamental discipline in any profession, reflecting the characteristics of taking responsibility and truthfulness. Nearly one-fourth of the study population (24.6%) knew two habitual late comers out of five fellow practitioners. Lack of punctuality among doctors has been identified by patients in other south Asian countries as well . The lack of punctuality may be related to problems in work-life balance, burnout and in priority setting, indicating a need for including time management training in CME activities.
Factors associated with the level of knowledge
There was a significant difference in the mean knowledge score (GHK-51.5, THP-49.1, SBSCH-45.3) between the three institutions studied (p = 0.008, ANOVA test). This difference may be due to the lack of CME activities in the newly established teaching hospital included in the study whereas regular CME activities are a feature of the other two hospitals. All three are tertiary care level teaching hospitals where there are many opportunities for doctors to acquire new knowledge. The proportion of postgraduate trainees who had a good knowledge of ethics (60.7%) was higher than the doctors who had no postgraduate training (p = 0.02). This is a positive sign that indicates the possibility of improving the knowledge on medical ethics through providing more learning opportunities. There were no significant associations between overall level of knowledge and the factors such as age, sex, religion, duration of the service, marital status and the private practice.
The study instrument was assessed only to establish judgmental validity whereas reliability of the study instrument was not assessed statistically. The results of the study cannot be generalized to all doctors since study participants were selected from only three hospitals based on a convenience sampling method. The potential for selection and information bias regarding under reporting of unethical practice cannot be excluded. Data analysis was carried out using univariate methods, therefore confounding cannot be eliminated.