Analyzing the Evolution of Medical Ethics Education: A Bibliometric Analysis of the Top 100 Cited Articles

Ethics education plays a pivotal role in healthcare by providing professionals and students with the essential competencies to navigate intricate ethical challenges. This study conducts a comprehensive bibliometric analysis of the most-cited articles on ethics education, investigating parameters such as citation count, document types, geographical origin, journal analysis, publication year, author analysis, and keyword usage. The findings reveal a substantial impact characterized by high citation counts and the influence of a prominent publication focusing on the hidden curriculum and structure of medical education. Moreover, the analysis demonstrates a discernible increase in research output since 2000, signaling a growing recognition of the significance of ethics education in the healthcare domain. Notably, specific journals, particularly those dedicated to medical education and ethics, emerge as major contributors in this field, publishing many articles. Renowned authors have made noteworthy contributions, and emerging themes encompass the ethical implications of virtual reality and artificial intelligence in healthcare education. Additionally, undergraduate medical education garners significant attention, emphasizing the importance of establishing ethical values and professionalism early. Overall, this study highlights the imperative of interdisciplinary collaboration and the necessity for effective ethics education programs to equip healthcare professionals with the requisite skills to navigate complex ethical challenges. The findings inform educators, curriculum developers, and policymakers about enhancing ethics education and ensuring the ethical competence of future healthcare practitioners.


Introduction And Background
Ethics education holds profound significance in healthcare, as it equips healthcare professionals and students with the essential competencies to navigate the intricate web of ethical challenges and dilemmas that pervade clinical practice [1]. These ethical predicaments, encompassing conflicts and dilemmas, exert a palpable influence on the daily provision of patient care and treatment. By delving into the dimensions of sensitivity, knowledge, reflection, decision-making, action, and behavior, ethics education cultivates a holistic foundation of ethical competencies that are indispensable for effectively grappling with ethically problematic situations [1,2]. As the torchbearers of the future healthcare workforce, students undergoing training require meticulous instruction to adeptly confront the ethical complexities that await them. Simultaneously, experienced professionals must continually refine their ability to manage and resolve ethical predicaments, ensuring their ongoing growth and development [3]. Ethics education thus assumes a pivotal role in fostering the acquisition and enhancement of ethical competencies among healthcare professionals and trainees, empowering them to address and surmount the multifaceted challenges inherent in their practice.
However, it is crucial to recognize that the study of ethics extends far beyond providing explicit answers or rigid rules of conduct for individual ethical dilemmas. Rather, ethics education offers a framework for cultivating practical wisdom, enabling healthcare professionals to navigate the intricacies of moral quandaries with sagacity and discernment [4]. It serves as a compass, guiding them in defining problems, establishing fundamental principles, and solving ethical conundrums. Moreover, the study of ethics provides a valuable lens through which healthcare professionals can identify appropriate goals and attain clarity of purpose, thereby forging a meaningful trajectory toward their realization. The responsibility of facilitating ethics education falls upon healthcare supervisors, who must provide educational opportunities that nurture professionals capable of taking ethical stands grounded in sound and rational thinking [5]. By fulfilling this duty, individuals within healthcare facilities make invaluable contributions to their profession and society. They cultivate a new generation of healthcare professionals with an unwavering ethical stance fortified by the knowledge, critical thinking skills, and moral integrity nurtured through robust ethics education. In doing so, they forge a path toward a high standard of healthcare practice, one driven by an unwavering commitment to ethical principles and compassionate patient care.
In addition to emphasizing the importance of ethics education in healthcare, it is important to mention that a comprehensive understanding of the field will be furthered by looking at existing research on the topic [6]. Therefore, to shed light on the landscape of ethics education in the research arena, a bibliometric analysis was conducted to explore the scholarly contributions in this domain. Through this analysis, an extensive examination of relevant literature was undertaken, encompassing scholarly articles, research papers, and academic publications. By employing analytical techniques, such as citation analysis, key trends, seminal works, and influential authors in the field of ethics education were identified.

Review Methodology
The study examined the 100 most-cited articles related to ethics education, utilizing the SCOPUS engine as the primary data source. The search was performed using predefined search terms, namely, "ethics education," "medical education," and "medical ethics education," to ensure comprehensive coverage of the relevant literature. All types of scientific papers, including original research articles, reviews, and conference papers, were included in the analysis if they pertained to ethics education in healthcare. The articles were systematically assessed, considering various vital parameters for a comprehensive evaluation. These parameters included the journal title, year of publication, total number of citations, citation density, geographic origin, and article type.
The total number of citations received by each article was considered an objective measure of its impact and visibility within the academic community. Additionally, the geographic origin of these papers was examined to ascertain the global distribution of research contributions in ethics education. This analysis provided valuable insights into international collaboration and perspectives in the field. Furthermore, the article type was categorized to identify the diverse scholarly outputs contributing to the ethics education literature. Data extraction and analysis were performed meticulously to ensure accuracy and reliability. Statistical tools were employed to derive meaningful conclusions and identify significant trends within the dataset.

Results
The initial search conducted in the SCOPUS database using the predefined methodology yielded 286 documents. To ensure the inclusion of relevant articles, further refinement was undertaken by combining the research items and narrowing down the search field to focus solely on the "article title." This step was crucial in aligning the search results with the specific objectives of our study. Considering the diverse linguistic landscape of the retrieved manuscripts, it was observed that translations accompanied all non-English-language articles. We decided not to restrict the search to English-language publications to ensure a comprehensive analysis. This approach allowed us to capture a broader spectrum of literature and gain a more inclusive perspective on ethics education.
Subsequently, a meticulous screening process was conducted to identify the top 100 most-cited articles in accordance with the predetermined criteria. In total, 186 documents were omitted from the analysis, ensuring a focused selection of the most influential and impactful articles in accordance with the top 100 list. The titles of these articles have been presented in Table 1, providing a reference for further examination and analysis.

Citation count, document types, and geographical origin
Collectively, these aforementioned articles amassed a total of 4,284 citations, demonstrating the widespread recognition and enduring influence of the selected publications. On average, each article received 42 citations (mean ± SD = 42.84 ± 11.18). Figure 1 provides a visual representation of the citation counts for the top 100 articles in the ethics education field. Notably, the publication by Hafferty and Frank, titled "The hidden curriculum, ethics teaching, and the structure of medical education," published in Academic Medicine (1994), emerges as a standout with the highest number of citations [7].
The analysis of document types within these top 100 articles revealed distinct patterns in scholarly contributions ( Figure 2). The majority of articles, comprising 65% of the dataset, were classified as original articles. These original research articles signified primary investigative endeavors and empirical studies conducted in the field of ethics education, highlighting the commitment to advancing knowledge and understanding. Additionally, 19% of the articles were identified as review articles. These comprehensive literature reviews synthesized existing research, critically analyzing and consolidating knowledge on specific aspects of ethics education. Within the remaining document types, notes and letters were identified as separate categories in the SCOPUS database. However, it is important to note that most journals typically classify them as either "letters" or "comments." Together, these shorter forms of communication constituted 9% of the overall dataset.

Journal analysis and publication year
The analysis of the top 100 articles in ethics education revealed a notable concentration of publications in a select number of journals ( Table 2). Among the identified journals, Academic Medicine emerged as the leading publication, with 16 papers included in the top 100. It is noteworthy to mention that the Journal of Medical Education, although now known as Academic Medicine, was considered separately in this analysis due to the fact that the original articles were published under that name. This distinction is maintained to acknowledge the historical context and ensure accuracy in referencing the original articles. Additionally, the Journal of Medical Ethics and Medical Education both had nine papers, each within the top 100 articles, reflecting their substantial contributions to the ethical dimensions of healthcare education. Medical Teacher also featured prominently, with four papers included in the top 100. This journal specializes in medical education, offering a platform for sharing innovative teaching methods and pedagogical approaches.    Table 3). During this period, 33 articles were published, indicating a surge in scholarly activity and a growing emphasis on ethics education in healthcare. This increase in publications reflects a heightened recognition of the importance of ethical considerations in healthcare practice and the need to equip healthcare professionals with the necessary ethical competencies. Therefore, it signifies a collective effort to address the ethical challenges and dilemmas that arise in providing healthcare services.

Author analysis and keyword usage
The analysis of authors within the top 100 articles in ethics education provides insights into the individuals who have made significant contributions to the field ( Table 4). David J. Doukas, a bioethicist based at Tulane University [107], is recognized as one of the most influential authors in the field of ethics education, with five articles in the top 10 list attributed to his name that have amassed a total of 296 citations. Similarly, Laurence B. McCullough, another prominent figure in the field, is also credited with five articles within the top 100 and a total citation count of 286. Interestingly, McCullough shares four of his top 10 cited papers with Doukas, indicating mutual exploration of similar research themes [16,19,26,27].

Gail Geller 3
Raanan Gillon 3  The author keywords of all 100 articles were subjected to a comprehensive analysis using VOSviewer network analysis, as illustrated in Figure 4. This analysis aimed to identify the main keywords used by the authors and gain insights into the prevailing themes in ethics education. Notably, keywords such as "medical education," "medical ethics," "education," "curriculum," "ethics," and "professionalism" were identified as central themes within the field of ethics education.

Discussion
Ethics education in healthcare is a critical component of medical training, aiming to equip healthcare professionals with the necessary ethical competencies to navigate complex ethical dilemmas. In this study, we examined the 100 most-cited articles related to ethics education in healthcare, analyzing various parameters such as citation count, document types, geographical origin, journal analysis, publication year, author analysis, and keyword usage.
The analysis of the citation count revealed that the selected articles had a significant impact on the academic community, with a total of 4,284 citations. The most cited article, "The hidden curriculum, ethics teaching, and the structure of medical education" by Hafferty and Frank, published in Academic Medicine in 1994, stands out as the most influential publication in the dataset [7]. This seminal work continues to shape the discourse on ethics education, highlighting the importance of addressing the hidden curriculum and the In addition to the parameters analyzed in the previous discussion, it is important to note that a significant proportion of the top 100 articles in ethics education focused on undergraduate medical students. These articles recognized the importance of starting ethics education early in medical training to shape the ethical development of young minds. Ethics education for undergraduate medical students is crucial as it lays the foundation for the ethical principles and values that guide their professional practice throughout their careers. By introducing ethics education early, students can develop a strong ethical framework, enhance their moral reasoning skills, and cultivate a sense of professionalism.
Interestingly, analysis of the newer articles (2015 onward) reveals a shift in focus toward themes such as virtual reality and artificial intelligence [60,74]. These emerging topics highlight the evolving landscape of healthcare education and the ethical considerations that arise with integrating new technologies.
Regrettably, simulation-based education, despite its increasing popularity and relevance in healthcare education, seems to be comparatively underrepresented within the dataset. Nonetheless, it offers an exceptional platform for ethics education as it creates a safe and controlled environment for students to delve into and navigate intricate ethical dilemmas. Learners can significantly enhance their ethical competence by actively engaging in decision-making, ethical reasoning, and communication skills. Simulated scenarios also provide a unique opportunity for students to develop and refine their ethical frameworks, clinical judgment, and interprofessional collaboration, ultimately equipping them to tackle the ethical challenges they will inevitably face in their future clinical practice [108].

Conclusions
Overall, this study sheds light on the current landscape of ethics education by analyzing the most-cited articles in the field. It identifies emerging themes, highlights the importance of simulation-based education, and emphasizes the need for interdisciplinary collaboration in ethics education. The findings of this study can inform educators, curriculum developers, and policymakers in designing and implementing effective ethics education programs that prepare future healthcare professionals to navigate complex ethical challenges. Further research and exploration in these areas are warranted to continue advancing ethics education and ensuring the ethical competence of healthcare professionals.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.