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PubMed2002

A history of psychiatric ethics.

In the not-far-distant past, ethics for all doctors was, at best, an ill-attended lecture or two on how to keep out of trouble; it was assumed the rest was absorbed by a form of social and professional osmosis. Although ethics has entered the undergraduate curriculum, continuing medical education programs, journals, and books, it still is in a state of flux. Although immense progress has been made in the last 30 to 40 years, much remains to be done. Trainees are often naïve, and the older generation is on a steep learning curve. An encouraging feature is the current lively debate on matters ethical and how they can best be incorporated into everyday clinical practice. The long-held notion of ethics resting complacently in the paternal arms of Hippocrates has, with almost brutal haste, been projected into a rapidly evolving modern world of technologic, moral, and societal change. Yet, at its core, ethics has to retain its humanism and guard against influences from every quarter that tries to make it a set of rules, thereby negating the diversity and uniqueness of our patients. Even as you read, there will be new influences and pressures on clinical practice that have an ethical dimension. For instance, we are adjusting to new privacy laws in Australia that allow patients, whether public or private, access to their psychiatric records. Globalization is not restricted to world trade; it also operates in the framework of societal change and the wider dissemination and implementation of libertarian views. If such "freedoms" are not currently available to patients, they soon will be. This brief historical foray in identifying some of these forces can assist in their early recognition so that as a profession, we are forewarned and forearmed and, in that respect, be ahead of both Henry Ford ("History is more or less bunk...") [42] and the Bourbons ("They learn nothing and they forget nothing") [43].

Ethics, Medical↗
PubMed2000

Protecting the vulnerable: testing times for clinical research ethics.

This paper describes a number of historical breaches of research ethics. Typically the victims of such breaches belong to vulnerable populations, such as prisoners, mentally disabled people, women and people in developing countries. This article provides a brief introduction to the main ethical approaches in bioethics. Subsequently it looks at a number of currently discussed ethical issues in clinical research ethics, notably the ethics standards of clinical trials in developing countries, the use of prisoners and incompetent people in clinical research, and the modus operandi of research ethics committees.

Clinical Trials as Topic↗
PubMed2004

Living with conflicts-ethical dilemmas and moral distress in the health care system.

During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as "moral distress". The present article derives from Andrew Jameton's development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies. The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas. Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff.

Conflict, Psychological↗
PubMedDate not supplied

Developing an ethical basis for student-teacher interaction.

This article first reviews the literature on the development of ethical content within nursing curricula and its impact on nursing education. This is followed by a discussion of faculty responsibility for the preparation of ethically competent graduates. Faculty behaviors that appear to be related to ethically sound education practices are discussed along with examples of positive and negative behaviors. The article concludes with five principles to use in developing an ethical basis for student-teacher relationships. These principles include mutual respect, open communication, demonstration of linkages between ethical principles and behavior, facilitating students' understanding of their behaviors, and recognition of legitimate individual differences in ethical positions.

Curriculum↗
PubMed1999

Fostering ethical willingness: integrating emotional and contextual awareness with rational analysis.

Ethical dilemmas are inherently challenging. By definition, clinicians decide between conflicting principles of welfare and naturally confront competing pulls and inclinations. This investigation of students' responses to an ethical scenario highlights how emotions and concerns can interfere with willingness to implement ethical knowledge. Clear-cut rules are the exception in psychotherapy, and clinicians must judge ethical issues on the basis of the unique context of each case. As such, subjectivity and emotional involvement are essential tools for determining ethical action, but they must be integrated with rational analysis. Strategies for attending to influential emotions and contextual factors in order to mobilize ethical commitment are described.

Attitude of Health Personnel↗
PubMed1995

Uncertainties in the teaching of ethics to students of nursing.

Whilst ethics is now commonplace on nursing curricula in the United Kingdom there remains doubt as to how and what to teach. This doubt has its origins in interlinked uncertainties within nursing, ethics and education. In nursing there are uncertainties about whether we are teaching ethics to professionalize or because we are a profession, and about whether there is something which is uniquely 'nursing ethics'. In ethics there are competing paradigms of ethical theory and competing theories of moral development. In education there are competing epistemologies, theories of learning and models of curriculum planning. These uncertainties are interlinked and an understanding of them will help clarify the debate as to what to teach and how to teach it.

Curriculum↗
PubMed2000

A process evaluation of medical ethics education in the first year of a new medical curriculum.

BACKGROUND: Despite the recent increase in activity in the field of medical ethics education, few evaluative studies have been carried out. Most studies have taken place in North America, in curricula where teaching is discipline-based, and have concentrated on outcome rather than on the curricular processes adopted. AIM: To evaluate the process of medical ethics education in the first year of a new learner-centred, problem-based, integrated medical curriculum. METHOD: A qualitative, multi-method approach was adopted using open questionnaires, focus groups and tutor evaluation rating scales. The study involved all 238 students in the first year of the new medical curriculum, and the 30 clinical tutors who facilitated ethics learning. A stratified sampling technique was used to choose focus group participants. RESULTS: Small group teaching proved highly acceptable to both students and tutors. Tutors' teaching skills were central to its effectiveness. Tutors played an important role in promoting students' appreciation of the relevance of medical ethics to clinical practice, and in establishing a climate where constructive criticism of colleagues' actions is acceptable. Course integration, including the provision for students of clinical experiences on which to reflect, was an important aid to learning. Students and tutors were noted to be driving the ethics curriculum towards having a contextual rather than theoretical base. CONCLUSION: This evaluation identified those aspects of the medical ethics course which contributed to its effectiveness and those which detracted from it. This information will be used to inform future development.

Curriculum↗
PubMed2002

Ethics of practicing medical procedures on newly dead and nearly dead patients.

OBJECTIVE: To examine the ethical issues raised by physicians performing, for skill development, medically nonindicated invasive medical procedures on newly dead and dying patients. DESIGN: Literature review; issue analysis employing current normative ethical obligations, and evaluation against moral rules and utilitarian assessments manifest in other common perimortem practices. RESULTS: Practicing medical procedures for training purposes is not uncommon among physicians in training. However, empiric information is limited or absent evaluating the effects of this practice on physician competence and ethics, assessing public attitudes toward practicing medical procedures and requirements for consent, and discerning the effects of a consent requirement on physicians' clinical competence. Despite these informational gaps, there is an obligation to secure consent for training activities on newly and nearly dead patients based on contemporary norms for informed consent and family respect. Paradigms of consent-dependent societal benefits elsewhere in health care support our determination that the benefits from physicians practicing procedures does not justify setting aside the informed consent requirement. CONCLUSION: Current ethical norms do not support the practice of using newly and nearly dead patients for training in invasive medical procedures absent prior consent by the patient or contemporaneous surrogate consent. Performing an appropriately consented training procedure is ethically acceptable when done under competent supervision and with appropriate professional decorum. The ethics of training on the newly and nearly dead remains an insufficiently examined area of medical training.

Attitude to Death↗
PubMed2002

Philosophical challenges in teaching bioethics: the importance of professional medical ethics and its history for bioethics.

The papers in this number of the Journal originated in a session sponsored by the American Philosophical Association's Committee on Philosophy and Medicine in 1999. The four papers and two commentaries identify and address philosophical challenges of how we should understand and teach bioethics in the liberal arts and health professions settings. In the course of introducing the six papers, this article explores themes these papers raise, especially the relationship among professional medical ethics, the "long history" of medical ethics, and bioethics. The tendency of bioethics to deprofessionalize medical ethics is rejected, in favor of an historically informed professional medical ethics. It is suggested that bioethics should be critically reconsidered from the perspective of medical ethics as professional ethics.

Bioethics↗
PubMed2005

Core topics of health care ethics. The identification of core topics for interprofessional education.

OBJECTIVES: The aim of this project was to identify core topics of health care ethics that could be taught through an inter-professional approach to undergraduate education. DESIGN: Five nominal group technique workshops. SETTING AND PARTICIPANTS: Teaching staff from different professional disciplines in our university (nursing branches, occupational therapy and physiotherapy). RESULTS: Seven core topics of health care ethics that are common across all disciplines were identified. However participants in all workshops identified the need for case studies used in teaching and learning to be specific to the clinical setting encountered by the student. CONCLUSION: Despite the identification of core topics that apply to all disciplines, caution should be taken when seeking to integrate these into an inter-professional undergraduate programme. There is evidence from other studies that students have difficulty in transferring knowledge from one context to another. In view of this, an inter-professional approach to health care ethics teaching to a group, members of which do not encounter shared clinical ethical problems may be inappropriate. It is suggested that inter-professional learning in undergraduate health care ethics should focus on facilitating learning in the clinical area with students who share similar ethical encounters, in which case the learning will be truly inter-professional.

Bioethics↗
PubMed2004

Teaching medical ethics: implementation and evaluation of a new course during residency training in bahrain.

AIM: This paper describes the development, implementation and evaluation of a new biomedical ethics course. The major educational goal was to enable the participants to critically analyse and resolve ethical dilemmas based on sound ethical and moral reasoning. BACKGROUND: The course was developed and implemented in the Family Practice Residency Program (FPRP) in the Kingdom of Bahrain. METHODOLOGY: Thirty-six family physician trainees participated in this course in May 2002 and January 2003. The curriculum was divided into five sessions, and each session had specific objectives, contents and teaching methods. The course was evaluated using pre- and post-tests, direct observation of participants and overall course assessment. RESULTS: Evaluations demonstrated that the participants scored higher in the post-test than in the pre-test. There was a significant statistical difference between the mean scores of both tests. After completing the course, participants produced more justifiable decisions than those generated at the beginning and felt more confident discussing and reasoning their decisions based on sound ethical and moral concepts. CONCLUSION: Our experience had demonstrated that the trainees benefited from a structured curriculum in biomedical ethics. We believe that the development and implementation of our course may serve as a case study for training and teaching postgraduates in the area of medical ethics.

Adult↗
PubMedDate not supplied

Ethics and professionalism: what does a resident need to learn?

Training in ethics and professionalism is a fundamental component of residency education, yet there is little empirical information to guide curricula. The objective of this study is to describe empirically derived ethics objectives for ethics and professionalism training for multiple specialties. Study design is a thematic analysis of documents, semi-structured interviews, and focus groups conducted in a setting of an academic medical center, Veterans Administration, and community hospital training more than 1000 residents. Participants were 84 informants in 13 specialties including residents, program directors, faculty, practicing physicians, and ethics committees. Thematic analysis identified commonalities across informants and specialties. Resident and nonresident informants identified consent, interprofessional relationships, family interactions, communication skills, and end-of-life care as essential components of training. Nonresidents also emphasized formal ethics instruction, resource allocation, and self-monitoring, whereas residents emphasized the learning environment and resident-attending interactions. Conclusions are that empirically derived learning needs for ethics and professionalism included many topics, such as informed consent and resource allocation, relevant for most specialties, providing opportunities for shared curricula and resources.

Adult↗
PubMed1998

Developing a social work research agenda on ethics in health care.

This article advocates greater empirical research on ethics in health care by social work researchers. Although an extensive theoretical literature exists, scant empirical research has been conducted on ethical issues by social work researchers since 1980, compared with physicians and other health care researchers. A theoretical framework is presented as a heuristic device to stimulate research on a range of topics, including the content and nature of ethical deliberations, contextual factors, and ethical outcomes. By demonstrating empirically that their interventions improve ethical outcomes, social work researchers can provide ammunition to support social work's role in ethical deliberations in health care settings.

Delivery of Health Care↗
PubMed1990

Ethics and the universality of morality.

Ethics is one of the forces shaping the life of human societies and the ethical system contributes to the group's survival and to keep peace and order to satisfy social needs. The definitions of ethics, of what is good and what makes an action right or wrong, varies widely at different times and at different places. However, some basic moral elements are acceptable to most advanced societies. Furthermore, many modern scholastic writers defend the absolute universality of at least some ethical laws. The limitations of universality survives in war, in race discrimination, etc. In modern times, it might be appropriate to search for principles for the universality of morality in ecological considerations. Progress in ethics is lagging far behind and we must understand now, when the complete annihilation of human species is a real possibility, that ethics and philosophy are at least as important as science.

Ethics↗
PubMed1982

Using simulated case studies to evaluate a clinical ethics course for junior students.

An experimental teaching program in clinical ethics was developed and evaluated. All junior medical students who rotated through a general internal medicine service (75 percent of the class) were required to attend 12 to 14 hours of a clinical ethics seminar which met on a general medicine unit. The teaching sessions were structured around actual cases presented by the junior medical students. One of the evaluation techniques developed is discussed here: the use of simulated clinical-ethical cases. The questions themselves, the method of scoring them, and the findings will be examined. On the basis of this evaluation procedure, some tentative conclusions can be drawn: (a) it is possible to develop evaluation techniques to assess objectively students' ethical reasoning after participating in such a course, and (b) junior medical students who participate in a clinical ethics course show increased reflectiveness regarding ethical decisions.

Curriculum↗
PubMed1994

How medical students think about ethical issues.

BACKGROUND: Although bioethics has become an established part of medical school curricula, relatively little is known about how students apply didactic material to clinical problem-solving situations. METHOD: Each of 92 second-year students (54 men and 38 women) at the University of California, Irvine, College of Medicine in 1991-92 wrote a paper identifying and attempting to resolve a clinical ethical dilemma of his or her choice. The papers were then coded for content, use of ethical theories and principles, degree of resolution, and level of personal orientation (i.e., evidence of personal involvement in the dilemmas). Data were analyzed by student sex and age, using chi-square tests of significance and correlational analysis. RESULTS: The students had no difficulty in identifying a range of ethical dilemma. Most students appeared to have understood and become familiar with the major ethical theories and principles currently in use, and to have employed them correctly. A majority of the students were able to successfully resolve their ethical dilemmas. Differences between the men and the women students were found regarding choice of topic, ethical principles used (p = .03), and level of personal orientation (p < .01). CONCLUSION: The women tended to be interested in issues involving broad social perspectives; to favor arguments emphasizing the rights of patients and families; and to incorporate personal responses, as well as abstract theories, in their assays. The men tended to be interested in issues involving personal control, authority, and responsibility; to advocate utilitarian, cost-containment thinking, and to rely exclusively on abstract, logical arguments. Further research should determine whether these differences can be identified in actual clinical decision making, and whether the differences have implications for the nature or quality of clinical decisions.

Attitude↗
PubMed1995

The adequacy of medical ethics education in a pediatrics training program.

PURPOSE: To identify ethical dilemmas commonly encountered during pediatrics training as a step toward improving medical ethics curricula for residents. METHOD: The authors identified seven recurring topics by reviewing the required case reports on ethical dilemmas experienced by students in the third-year pediatrics clerkship from June 1992 to June 1994 at the State University of New York at Buffalo School of Medicine and Biomedical Sciences. Based on the topics identified, the authors then surveyed pediatrics housestaff in 1993-94 regarding the frequency of encountering the topics, levels of comfort in addressing the topics, role models and resources, and perceived need for improved training. RESULTS: A total of 214 student essays were reviewed. Thirty-six of 50 residents responded to the survey. In the following list of the seven topics, percentages are given for students who reported the topic, for residents who encountered the topic "very frequently" or "sometimes," and for residents who felt "very comfortable" or "somewhat comfortable" addressing the topic: child abuse or neglect (students reported, 28%, residents encountered, 94%, residents felt comfortable, 86%); use of heroic measures to maintain a terminal patient (20%, 89%, 69%); patient confidentiality (19%, 81%, 92%); resource allocation (12%, 67%, 54%); surrogate decision making (7%, 69%, 75%); patient autonomy (4%, 86%, 69%); and disclosure of information (2%, 69%, 60%). Eighty percent of the residents felt they could not intervene when they disagreed with decisions; 69% felt their training had not prepared them to address ethical dilemmas; 69% thought attending physicians were interested in discussing ethical issues; and 74% desired more training. CONCLUSION: Based on their self-reported experiences with topics identified as occurring frequently in pediatrics training, the residents perceived their training to be inadequate and desired more ethics education, but felt that the faculty were willing to assist in that training.

Adolescent↗
PubMed2000

Medical students' cases as an empirical basis for teaching clinical ethics.

PURPOSE: To identify ethical issues that interns encounter in their clinical education and thus build a more empirical basis for the required contents of the clinical ethics curriculum. METHOD: The authors analyzed a total of 522 required case reports on ethical dilemmas experienced by interns from September 1995 to May 1999 at the medical school of Vrije Universiteit in Amsterdam. They identified four regularly described and numerous less frequently described topics. RESULTS: The interns addressed a wide range of ethical themes. In 45% of the cases, they mentioned disclosure or non-disclosure of information and informed consent; in 37%, medical decisions at the end of life; in 16%, medical failures; and in 9%, problems transferring patients from one caregiver to another. The interns also identified 27 themes linked to their unique position as interns and 19 themes related to specific types of patients. CONCLUSION: Based on self-reported experiences, the authors conclude that clinical ethics teachers should reflect on a multitude of dilemmas. Special expertise is required with respect to end-of-life decisions, truth telling, medical failures, and transferring patients from one caregiver to another. The clinical ethics curriculum should encourage students to voice their opinions and deal with values, responsibilities, and the uncertainty and failings of medical interventions.

Decision Making↗