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PubMed2005

Viewpoint: teaching professionalism: is medical morality a competency?

The Accreditation Council for Graduate Medical Education (ACGME) has declared medical professionalism to be a competence analogous to competence at medical practice. Medical educators accordingly seek to develop ways in which to teach and assess medical professionalism as they now teach and assess clinical medicine. The author contends that professionalism is medical morality and that while being moral in the world of medical practice can involve skill, morality differs from domain-based skills such as medicine in important respects. The norms of morality are both more exigent and more difficult to live up to than the norms of medical expertise. And any morality we learn in the course of medical education does not simply establish itself in our repertoire as a new skill, but must contend with our preexisting moral outlook. These differences have implications for the inculcation and assessment of professionalism. Professionalism can be taught, but the current model employed by medical education, cognitive engagement followed by supervised practice, will not suffice for its inculcation. Nor will objective cognitive or behavioral testing suffice for its assessment. Medical educators can seek and achieve compliance with professional norms during the formative periods of training (internship and residency). Committed observance of professional norms cannot be coerced but may emerge among trainees through their responsiveness to the lived moral life of virtuous faculty, encouraged by the tacit and explicit invitation of such faculty to imitation over time. To be valid, assessment of professionalism must be subjective, narrative, personal, undertaken during periods of stress, and obtained during routine activity (rather than on special occasions).

Competency-Based Education↗
PubMedDate not supplied

Moral discord, cognitive coping strategies, and medical intensive care unit nurses: insights from a focus group study.

Moral discord occurs when contextual factors prevent nurses from implementing felt moral mandates. Medical intensive care unit (MICU) nurses frequently confront moral issues and hold themselves personally responsible for their moral actions. They use a variety of cognitive coping strategies to deal with moral discord. This article describes common moral dilemmas encountered by MICU nurses, explores patterns of both conscious and unconscious cognitive coping behaviors, and reviews steps that nurses can take to reduce the degree of moral discord they experience.

Adaptation, Psychological↗
PubMed1999

Nursing, morality, and emotions: phase I and phase II clinical trials and patients with cancer.

This article reflects three nurses' views of the moral dimensions of their work in caring for patients receiving phases I and II of cancer clinical trials in a dedicated cancer clinical trials unit (CCTU). The nurses took part in a semistructured, tape-recorded, group interview in which they talked about any aspect of their work that they felt demonstrated its ethical or moral dimensions. The nurses were not employed as research nurses, but had chosen to specialize in cancer and palliative care in a CCTU environment. Three key themes emerged from the interview: being valued and moral distress; caring in a climate of scientific research; and care, cure, and consequences for moral reasoning. Working in an environment suffused with moral conflicts can be painful and damaging for the professionals involved. It would appear that if nurses are to function effectively, they need to be proactive in promoting an exploration of the role that emotions play in moral decision making and in examining the contribution of emotions to what they care about and why. A commitment to a shared understanding and valuing of divergent ethical reasoning in and across professional cultures of care and research paradigms also appears to be necessary. The terms "ethics" and "morals" are used interchangeably throughout this article.

Attitude of Health Personnel↗
PubMed2004

Law and the sources of morality.

This paper argues that morality is a product of basic human psychological characteristics shaped over prehistorical and historical time by diachronic dialectical transactions between what individuals do and what they are supposed to do in the culture in which they live. Some principles are pancultural: individuals are motivated to look after their own interests, to be cooperative and kind to other group members and to look after their children. The moral precepts of every society are based on these principles, but may differ according to the vicissitudes that the society has experienced. Thus the basic principles can be seen as absolute; the precepts based on them may be specific to particular societies. Moral precepts, and the laws derived from them, are mostly such as to maintain the cohesion of the society, but some have been formulated to further the interests of those in power. The evidence suggests that laws have been developed, by common consent or by rulers, from generally accepted moral intuitions. In general, legal systems have been formulated to deal with the more extreme infringements of moral codes. Morality prescribes how people should behave; the law is concerned with how they should not. New laws, if not imposed by force, must generally be in tune with public conceptions of morality.

Behavior↗
PubMed1997

Doing the right thing: relief agencies, moral dilemmas and responsibility in political emergencies and war.

In recent years a new generation of relief workers and relief agencies has become embroiled in the heat of civil wars and political emergencies, and the humanitarian community has had to revisit its fundamental principles and address the ethics of what it does. This paper sets out to continue this important debate by emphasising that ethical analysis should always be an essential part of humanitarian practice. The paper seeks to recognise the difficult moral choices relief agencies are facing today and gives some practical guidelines to relief agency staff when confronting the ethics of a given situation. In particular, it hopes to introduce some ethical principles into the debate about humanitarianism and contribute to the moral vocabulary which is being developed to improve relief agencies' ethical analysis. The paper starts by looking at the essential characteristics of a moral dilemma, and the way in which other types of tough choice can masquerade as moral dilemmas. It then introduces some basic moral principles surrounding the key ethical notions of action consequences and moral responsibility in an effort to show how relief agencies might begin to develop a process of ethical analysis in their work. Finally, it explores how relief agencies might develop a more intuitive form of ethical analysis based on an organisational conscience and moral role models.

Decision Making↗
PubMed2006

Students' moral reasoning, Machiavellianism and socially desirable responding: implications for teaching ethics and research integrity.

OBJECTIVE: To investigate the relationship between psychological constructs related to professional and research integrity and moral reasoning among medical students. METHODS: Medical students, 2nd-year (n = 208, 85.6% of 243 enrolled students), answered the moral reasoning test-defining issues test 2 (DIT2) and the Machiavellianism and Paulhus socially desirable responding (SDR) scales. RESULTS: Students had the highest score on the post-conventional schema of moral reasoning (mean +/- standard deviation, 35.2 +/- 11.6 of a possible 95) compared with personal interest (27.2 +/- 12.3) and maintaining norms schemae (29.2 +/- 11.5; P < 0.001, repeated-measures anova). Female students scored higher than their male collegues on post-conventional moral reasoning (37.6 +/- 11.0 versus 31.2 +/- 22.4, P < 0.001, independent-sample t-test). Of all 4 Machiavellianism subscales students scored highest on deceiving, where female students scored higher than their male colleagues (24.5 +/- 4.2 versus 22.9 +/- 5.1 of a possible 30; P = 0.037, independent-sample t-test). Female students also scored higher on the impression management subscale, whereas their male colleagues scored higher on the self-deception subscale of the Paulhus SDR scale. Moral reasoning scores were associated with cynicism, deceiving and flattering Machiavellianism scores, but not with Paulhus SDR scores. Multiple regression analysis showed the Machiavellianism amorality score as a significant negative predictor (beta = -0.183, P = 0.017) and female sex as a positive predictor (beta = 0.291, P < 0.001) for the post-conventional schema score on the DIT2. The Machiavellianism flattering score was a significant negative predictor for the personal interest schema score (beta = -0.215, P = 0.006). CONCLUSIONS: Although moral reasoning is generally seen as independent of variables related to personality, our study indicated that Machiavellianism, especially its amorality and flattering subscales, were associated with moral reasoning. These results have important implications for teaching ethics and the responsible conduct of research in different cultural and socio-economic settings.

Education, Medical, Undergraduate↗
PubMed2006

The role of conscious reasoning and intuition in moral judgment: testing three principles of harm.

Is moral judgment accomplished by intuition or conscious reasoning? An answer demands a detailed account of the moral principles in question. We investigated three principles that guide moral judgments: (a) Harm caused by action is worse than harm caused by omission, (b) harm intended as the means to a goal is worse than harm foreseen as the side effect of a goal, and (c) harm involving physical contact with the victim is worse than harm involving no physical contact. Asking whether these principles are invoked to explain moral judgments, we found that subjects generally appealed to the first and third principles in their justifications, but not to the second. This finding has significance for methods and theories of moral psychology: The moral principles used in judgment must be directly compared with those articulated in justification, and doing so shows that some moral principles are available to conscious reasoning whereas others are not.

Adult↗
PubMed2005

Being hurt and hurting others: children's narrative accounts and moral judgments of their own interpersonal conflicts.

Children's narrative accounts and moral evaluations of their own interpersonal conflicts with peers were examined. Girls and boys (N = 112) in preschool (M= 4.8 years), first grade (M = 6.9 years), fifth grade (M = 10.9 years), and tenth grade (M = 16.2 years) provided one narrative of a time when they had been hurt by a peer ("victim"), and one of a time when they had hurt a peer ("perpetrator"). Victim and perpetrator narratives were equally long and detailed and depicted similar types of harmful behaviors, but differed significantly in terms of various measures of content and coherence. Narratives given from the victim's perspective featured a self-referential focus and a fairly coherent structure. When the same children gave accounts of situations in which they had been the perpetrators, their construals were less coherent and included multiple shifts between references to their own experience and the experience of the other. Children's moral judgments also varied by perspective, with the majority of victims making negative judgments and nearly half the perpetrators making positive or mixed judgments. These differences in moral judgments were related to the distinct ways in which victims and perpetrators construed conflict situations. Age differences were also found in both narrative construals and moral evaluations, but regardless of their age children construed conflict situations differently from the victim's and the perpetrator's perspectives. By integrating, within the study of moral development, children's interpretations of the social interactions that are at the basis of moral thinking, this approach brings us a step closer to conceptualizing the study of children's moral behavior.

Child↗
PubMed2000

The evolution of moral dispositions in the human species.

Kohlberg's model of moral development is viewed from the perspective of evolutionary biology. Moral judgments defining Kohlberg's stages of moral development are seen as manifestations of structures evolved to uphold systems of cooperation. Game theory research on adaptive strategies of cooperation supports the conclusion that humans inherit dispositions to uphold the systems of cooperation implicit in the first three stages in Kohlberg's sequence, but not the systems of cooperation implicit in the highest stages. The empirical evidence on real-life morality is more consistent with a biological model of ontogenesis than is the model espoused by Kohlbergians. Although people occasionally make moral judgments in their everyday lives to reveal their solutions to moral dilemmas, as Kohlberg's model assumes, they more often make moral decisions that advance their adaptive interests.

Adaptation, Psychological↗
PubMed2004

A longitudinal study on the development of moral judgement in Korean nursing students.

This longitudinal study examined the development of moral judgement in 37 nursin students attending a university in Suwon, Korea. The participants completed the Korean version of the Defining Issues Test to allow analysis of their level of moral judgement. The development of moral judgement was quantified using 'the moral development score' at each stage (i.e. the six stages detailed by Kohlberg) and the 'P(%) score' (a measure of the overall moral judgement level). The results were as follows: (1) the moral development score for stage 5A was consistently the highest across the four years of the students' course, showing significant differences in some sociodemographic factors including home, birth order and monthly income; and (2) the P(%) score was higher in fourth-year (47.47 +/- 11.21) than in first-year (46.13 +/- 9.73) students. There was no significant difference in the P(%) score according to sociodemographic factors. Further studies will examine in detail the correlation between curriculum and moral judgement development. We suggest that courses in ethics education should be made more relevant.

Data Collection↗
PubMed2005

Moral competence in nursing practice.

This article presents the derivation of moral competence in nursing practice by identifying its attributes founded on Thai culture. In this process moral competence is formed and based on the Thai nursing value system, including personal, social and professional values. It is then defined and its three dimensions (moral perception, judgment and behavior) are also identified. Additionally, eight attributes as indicators of moral competence are identified and selected from three basic values. The eight attributes are loving kindness, compassion, sympathetic joy, equanimity, responsibility, discipline, honesty, and respect for human values, dignity and rights. All attributes are discussed by addressing the three moral dimensions in order to present how to deal with ethical issues in nursing practice. As a summary, a model of moral competence is presented to demonstrate moral competence in nursing practice in Thailand.

Empathy↗
PubMed2006

Measuring moral distress in pharmacy and clinical practice.

This article presents the development, validation and application of an instrument to measure everyday moral distress in different health care settings. The concept of moral distress has been discussed and developed over 20 years. A few instruments have been developed to measure it, predominantly in nursing. The instrument presented here consists of two factors: level of moral distress, and tolerance/openness towards moral dilemmas. It was tested in four medical departments and three pharmacies, where 259 staff members completed a questionnaire. The two factors were found to be reliable. Differences in levels of moral distress were found between pharmacies and clinical departments, and between the youngest and oldest age groups; departmental staff and the youngest group experienced higher levels of moral distress. Departments reported less tolerance/openness towards moral dilemmas than pharmacies. The instrument needs to be tested further, but its strengths are the focus on everyday ethical dilemmas and its usefulness in different health care settings.

Adaptation, Psychological↗
PubMed2001

Frontopolar and anterior temporal cortex activation in a moral judgment task: preliminary functional MRI results in normal subjects.

OBJECTIVE: To study the brain areas which are activated when normal subjects make moral judgments. METHOD: Ten normal adults underwent BOLD functional magnetic resonance imaging (fMRI) during the auditory presentation of sentences that they were instructed to silently judge as either "right" or "wrong". Half of the sentences had an explicit moral content ("We break the law when necessary"), the other half comprised factual statements devoid of moral connotation ("Stones are made of water"). After scanning, each subject rated the moral content, emotional valence, and judgment difficulty of each sentence on Likert-like scales. To exclude the effect of emotion on the activation results, individual responses were hemodynamically modeled for event-related fMRI analysis. The general linear model was used to evaluate the brain areas activated by moral judgment. RESULTS: Regions activated during moral judgment included the frontopolar cortex (FPC), medial frontal gyrus, right anterior temporal cortex, lenticular nucleus, and cerebellum. Activation of FPC and medial frontal gyrus (BA 10/46 and 9) were largely independent of emotional experience and represented the largest areas of activation. CONCLUSIONS: These results concur with clinical observations assigning a critical role for the frontal poles and right anterior temporal cortex in the mediation of complex judgment processes according to moral constraints. The FPC may work in concert with the orbitofrontal and dorsolateral cortex in the regulation of human social conduct.

Adult↗
PubMed1999

Altruistic moral judgment among older adults.

This study investigated altruistic moral judgment among the elderly, and examined its relationships to demographic and personality variables, self-reported helping, and subjective social integration (the perception that one is integrated into one's social milieu). The moral judgment interview included three stories, each of which contained a moral dilemma. Participants solved each dilemma and gave reasons for their solutions. The moral dilemmas and scoring system emphasized the positive, prosocial aspects of morality, rather than a prohibition-oriented approach. The categories used most often were, in descending order of frequency 1) pragmatic needs-of-others oriented reasons, 2) empathy-based reasons, 3) reasons based on internalized and/or abstract moral principles, and 4) hedonistic reasons. Of the higher levels of moral judgment, only reasoning based on abstract internalized principles had significant positive relationships with self-reported helping, the personality correlates of helping, and with subjective social integration into one's social milieu.

Aged↗
PubMed1989

Moral reasoning in college students: implications for nursing education.

The purpose of this study was to investigate the moral reasoning levels of undergraduate students, freshman through senior (N = 266), in a liberal arts college. Three groups of students, two liberal arts, and one nursing participated in the study. All three groups had enrolled in one of two general education curricular tracks. Two of the groups, one liberal arts and one nursing, were enrolled in a traditional general education curriculum; the third group enrolled in an integrated general education curriculum which used decision-making as an organizational structure. Moral reasoning levels were determined for the three groups via Rest's Defining Issues Test. Results revealed the liberal arts students in the integrated curriculum had significantly higher moral reasoning levels than those in the traditional curriculum. The nursing students were intermediate in moral reasoning levels to the two liberal arts groups. These results suggest that baccalaureate nursing educators should consider an approach similar to the integrated curriculum with a decision-making organizational structure to facilitate students' moral reasoning development. Regardless of their area of clinical practice, today's professional nurses are increasingly confronted with ethical dilemmas and often required to make moral/ethical decisions. Nurses who reason at a high moral or ethical level are assumed to practice by a code of moral principles and thus more likely to make decisions which value others and respect their rights and dignity (Felton & Parsons, 1987). In response to this relatively complex dimension in nursing practice, nursing educators have begun to discuss how best to prepare the nursing student to make these high-level ethical decisions.(ABSTRACT TRUNCATED AT 250 WORDS)

Cognition↗
PubMed2004

[Perceived social support and morale of the elderly staying at home].

PURPOSE: This study was done to identify the relationship between social support and morale in the elderly. METHOD: A structured questionnaire was carried out from April, 2003 to June, 2003 on 203 elderly. The data was analyzed with a SPSS program for descriptive statistics, Pearson's correlation coefficients, t-test, ANOVA, and stepwise multiple regression was done RESULT: The level of social support was moderate, and family support was the highest score. In types of support, appraisal support was the highest score. The level of morale was slightly lower than moderate, and the score of social support showed significantly positive correlation with morale. In general characteristics, several variables were significantly related to social support and morale. The most powerful predictor of morale was material support by family and the variance was 19.6%. A combination of material support by family, emotional support by relatives, level of satisfaction with pocket money, perceived health, level of intimacy with one's children, and material support by friends account for 43.3% of the variance in morale of the elderly. CONCLUSION: To increase the morale of the elderly, it is necessary to consolidate material support by family and relatives.

Aged↗
PubMed1998

Stress and morale in general practice: a comparison of two health care systems.

BACKGROUND: Poor morale and high levels of stress among general practitioners (GPs) are causing concern. Little research has previously been carried out to study possible differences in morale and stress between GPs working in two different but geographically similar health care systems. AIM: To compare perceived levels of stress and morale between GPs working in two different health care systems--one having a state monopoly (Northern Ireland) and the other having mixed private and state funding (Republic of Ireland)--and to look for factors that might help explain any differences in stress levels and morale between the two systems. METHOD: Anonymous and confidential questionnaires were sent to all 986 National Health Service (NHS) GPs in Northern Ireland (NI) and a random sample of 900 GPs in the Republic of Ireland (ROI). A common set of core questions on demographic details, partners and work patterns, perceived levels of stress and morale, safety, violence, and complaints were asked. RESULTS: Response rates were high in both areas: 91% in NI and 78% in the ROI. GPs in NI had significantly higher stress levels and significantly lower levels of morale than GPs in the ROI. The NI sample expect matters to get worse over the following year. Doctors in the ROI were more likely to be single handed and to work from two sites. Also, more GPs in ROI had fears for their safety and had been the subject of physical violence, but fewer had received complaints and medico-legal actions than in NI. CONCLUSIONS: A significant proportion of both groups of doctors report feeling highly stressed but GPs in NI appear more unhappy and have a poorer outlook for the future. It is suggested that the structure, management, and expectations of the NHS have taken a severe toll on its GPs, whereas a system in which doctors have less practice support but more control is good for morale.

Family Practice↗
PubMed1991

Tom, Huck, and Oliver Stone as advocates in Kohlberg's just community: theory-based strategies for moral education.

Kohlberg's studies of moral reasoning provide a good theoretical framework for describing the developmental process that may serve as the basis for programs of moral education for adolescents. Kohlberg viewed moral education, particularly during adolescence, as the stimulation of the natural developmental process which leads to mature moral reasoning. Building on Kohlberg's work, specifically his concept of the just community approach where the teacher and more advanced peers serve as advocates of mature moral reasoning, this article presents the educator with a theoretical rationale for implementing procedures that can foster moral development. A case is made for using contemporary films and literature as mechanisms for stimulating moral development among adolescents.

Adolescent↗