In Russia, medical education is going through transformation today. The values of a future doctor are changed. Their professional knowledge and skills should be complemented with the skills of effective communication with the patient to obtain the best healthcare result. One of the most essential competences of a medical school graduate includes the ability and readiness to implement the principle of respect for autonomy. This principle is legally enshrined in Federal Law as of November 21, 2011 On Fundamental Healthcare Principles in the Russian Federation. It means that the interests of a patient should be prioritized while rendering medical aid [1]. In real-world contexts, it means that a patient can independently solve health-related issues, while a doctor is obliged to submit the entire volume of medical information as well as data required to take an informed decision by a patient.

In theory, medical students understand the meaning and importance of this principle. However, it is difficult to implement it during cross-cultural communication. On the one hand, a language barrier exists, on the other hand, understanding the principle is totally different from its implementation in practice. Foreign language classes in medical school make a successful dialogue with patients possible. During the dialogue, linguistic and ethical components are integrated into real practice, producing a positive effect on the quality of teaching a foreign language in medical school.

The purpose of the article is to explain the necessity and ways of implementing the principle of respect for autonomy during English lessons in medical school. The purpose is implemented through the following objectives:

• An essential analysis of the principle of respect for autonomy and its role in modern medical practice;
• Displaying the potential of Foreign Language and Foreign Language for Professional Communication lessons to prepare future physicians to implement the principle during cross-communication;
• Developing the method of integrating an ethical component into the process of teaching a foreign language using role-playing games and

FOUNDATIONS OF THE PRINCIPLE OF RESPECT FOR AUTONOMY

Modern bioethics is based on four fundamental principles such as beneficence, non-maleficence, justice and respect for autonomy. According to the principle of respect for autonomy, a patient has a right to take health-related decision. Practically, it is believed that any patient has a moral and legal right to make voluntary, informed decisions about their medical care, including accepting or refusing treatment instead of blindly following a physician’s will [2].

The principle of respect for autonomy has significant legal warranties based on the Universal Declaration on Bioethics and Human Rights of UNESCO and Federal Law of the Russian Federation No. 323-FZ On Fundamentals of Citizens’ Health Protection in the Russian Federation [1-3]. It displays the value of every human being who is the master of their life and can take decisions regarding the body and health. The principle changed the outdated model when a doctor decided on what would be better for a patient based on own experience and moral values. The respect for autonomy principle altered the paternalistic model empowering the patient with subjectivity and, as a consequence, a right to act in accordance with own life values and be responsible for the choice made.

Voluntary participation, understanding and competence are the essential conditions that allow to implement the principle of respect for autonomy. The patient takes a decision freely, without any physical or moral pressure. He uses all the significant information about health, treatment options, risks, advantages, etc. To make the decision, a patient has to understand the information completely, analyze it, take a sound decision based on the analysis and act in accordance with that decision.

The principle of respect for autonomy is however not absolute. This is an entire system of conditions. Thus, a patient should be competent, understand the consequences of the decisions that will not do any harm to the patient and other people, and will not be in conflict with legal standards. A physician should submit all the information and respect a patient’s choice.

The principle of respect for autonomy is implemented when a patient provides an informed consent to a medical intervention. A physician’s communicative skills should help explain the essence of the medical procedure, its risks and consequences, and inform of the alternatives. As medicine becomes more globalized, English proficiency is essential to uphold the principle of respect for autonomy [4].

ENGLISH LESSONS IN MEDICAL SCHOOL AS A MEANS TO PREPARE FOR IMPLEMENTATION OF THE RESPECT FOR AUTONOMY PRINCIPLE

Professional requirements of medical school students change the methodology of teaching foreign languages. The core principles of teaching English for medical professional communication include professionalization, problem-based learning, and an innovative focus [5].

Professional medical standards urge teachers of foreign languages to solve global tasks. Thus, they teach students to use communication skills to perform employment duties and solve professional issues. English classes allow to simulate patient-physician interactions while trying to comprehend professionally the principle of respect for autonomy. It can be possible while working with authentic English materials devoted to ethical dilemmas in medicine or summing up the experience of foreign colleagues. In this regard, understanding ethical issues requires mastery of vocabulary and grammar in English.

Role-playing games are the most suitable for simulation of the doctor-patient communication as they prepare students how to obtain informed consent through explaining diagnosis and treatment options. The games that involve a patient whose autonomy is respected allow better provision of patient-oriented aid. Discussion of treatment options in English taking into account adverse effects and alternatives develops the skills of argumentation, critical thinking and cross-cultural communication among students.

To integrate the principle of respect for autonomy into an English lesson, several stages are required. At the first stage, it is necessary to make an introduction to the problem. Students are shown English texts that display the essence of the respect for autonomy principle. Follow-up activities should include lexical and grammar exercises designed to consolidate the material [6].

At the second stage, students are asked to analyze clinical cases with the principle of respect for autonomy being clearly expressed. Discussion in English will showcase the problem and how to cope with it. The third stage includes the role-playing game. Its final step should be accompanied with reflection in English to develop professional competencies of medical communication in English. During the final lesson devoted to the respect for autonomy principle, medical students can write an essay in English. Refusal from vital treatment for religious reasons can be one of the topics.

IMPLEMENTING THE RESPECT FOR AUTONOMY PRINCIPLE THROUGH DISCUSSING TREATMENT ROLE-PLAYING GAME

The principle of respect for autonomy can be most clearly manifested when discussing a treatment plan. According to this principle, the doctor is not the only person making all health-related decisions. According to medical ethics, the patient is an equal participant whose perspectives and feelings must be integrated into doctor-patient communication. The role-playing game is the most convenient method to train vocabulary, grammar skills and ethical directives. Below is an example of such a game: Mrs Black, a patient, aged 39, has been complaining of very heavy periods. An ultrasound scan shows she has a small fibroid in her uterus. She is asking about treatment. These options are possible: 1. Do nothing. 2. Remove the fibroid. Hysterectomy.

The instructional conversation should sound as follows:
Offering treatment options. A student who acts as a doctor offers several options and explains advantages and disadvantages, negative consequences and positive outcomes. To start the conversation, the following phrases can be used: There are a couple of options we can use… The first option is…The other option is…If you are still concerned, we can…

1. Advising a course of action. A doctor acts as a guide who shows the way and gives clear instructions. The instructions, however, must not sound imperatively. To support the strategy, the students should use modal constructions, modal verbs and subjunctive The level of mastery of the grammar structures should be high enough, therefore, before starting the role-playing game, it is necessary to revise Modal Verbs and Subjunctive Mood, as well as to practice phrases such as: It might help you if…; It would be helpful if…; Other things might help like…; We could start with…; You could try…; If you still have pain, you can…
2. Advising patients to avoid The doctor’s advice, although given in the imperative mood, should not sound rude. The patient needs to see that they are taken care of and worried about and that it is not about imposition of rules. The students should be taught to use softening words and constructions such as Perhaps cut out fatty food. Giving up smoking would help. You should try to avoid…
3. Warni It is necessary to warn a patient about the negative consequences of ignoring the doctor’s instructions. On the one hand, such a warning should be firm, but at the same time rudeness is unacceptable. It is neither advice nor order. Thus, a common sense of the patient should be appealed to. The Imperative Mood combined with a negation is used in this case: Do not stop taking the tablets or…; Do not forget about your diet…; You really must come back and see me again if…

The instructional dialogue regarding the treatment plan is useful from the linguistic point of view. It updates lexical and grammar skills of a medical student in English, increases their professional awareness, teaches to respect a patient, the patient’s psychological condition and shows how to become an active participant of the process instead of being a passive observer. This should be implemented in practice in accordance with the respect for autonomy principle.

ADVANTAGES AND CHALLENGES OF PRACTICAL IMPLEMENTATION OF THE RESPECT FOR AUTONOMY PRINCIPLE DURING ENGLISH CLASSES

The suggested role-playing game, instructional dialogue devoted to Discussing the Treatment and integration of the ethical principle of respect for autonomy into the lexical and grammar context of the foreign language course in medical school has a set of absolute advantages. The most important is the possibility to integrate ethical and linguistic content in accordance with modern requirements for future doctor preparation. Medical English as a professional language allows to include the ethical content into the base and develop an integral and ethically correct idea about the activity of a doctor, as well as the doctor’s professional and personal qualities [7].

Another advantage of the role-playing game is its methodological validity. As an active educational method, the game enables students not only to acquire linguistic knowledge, but also to develop practical communication skills with the patient in special stressful conditions, which in turn requires the development of self-control and self-organization skills. It is an essential condition for achieving the goal of education.

Role-playing game is English, which is an international language now, is used to simulate the situations a doctor can come across during the professional activity [8]. Globalization of medical practice increases a number of patients who can speak English and refer to medical aid in Russia. A patient’s right to obtain all the information about own health in the language, which seems clear to them, is part of the principle of respect for autonomy and professional competence of a modern doctor.

Nevertheless, use of this approach while teaching English to medical students has some difficulties. Their overcoming is a challenge for a teacher of a foreign language in medical school. A teacher should have not only linguistic, but also an ethical competence. It will allow to discuss ethical dilemmas in a sound way. Interdisciplinary approach and interaction with teachers of major subjects are required. To obtain the best outcomes in professionally oriented teaching a foreign language, it is important to appeal to the learning experience of students, urge them to update the obtained knowledge during other lessons, including major subjects and general subjects such as history, philosophy, history of medicine, and psychology.

CONCLUSION

The principle of respect for autonomy in English classes in medical school can be successfully implemented when ethical and linguistic components are integrated. This will allow a student to develop not only lexical and grammar skills as well as the skills of speaking a foreign (English) language, but also look closely at the fundamental principles of medical ethics and develop the readiness to conduct a professional activity based on these principles. 
The approach that uses the role-playing game to simulate doctor-patient communication in English allows to meaningfully apply the principle of respect for autonomy, forms communicative and ethical competencies for building relationships with patients based on mutual respect and respect for rights on both sides [9].
Methodological research in this area should be aimed at developing specific educational materials that illustrate the principle of respect for autonomy and enable future doctors to consolidate their willingness to apply it in their professional activities.