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PubMed2005

Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students.

PURPOSE: To systematically examine ethical conflicts reported by all State University of New York Upstate Medical University third-year students, compare them with conflicts reported in the literature, and identify content areas that compel new or renewed emphasis in national educational objectives, standard curricula, and texts. METHOD: From 1999 to 2002, all third-year students submitted papers for a required bioethics course. These papers depicted ethical issues arising during clinical clerkships. The authors devised a checklist of ethical issues; after analyzing the students' papers, the authors applied the checklist to the papers to create a taxonomy. RESULTS: Three hundred twenty-seven students submitted 688 cases involving 40 ethical issues. The most common issues were deliberate lies or deceptions (n = 68), patients' right to refuse recommended treatment (n = 48), and insistence on futile treatment (n = 46). Students perceived overt and subtle discrimination toward patients, reflected in substandard or excessive treatment. In 81 cases (12%), students expressed reluctance to speak up about moral conflict for fear of reprisal. This fear was expressed in 18 (45%) of the 40 issues-particularly student-specific (36 [52% of 69]) and quality of care (7 [24% of 29])-and most frequently in cases involving surgery (p < .025) and obstetrics-gynecology patients (p < .01). CONCLUSIONS: Students discerned ethical dilemmas in both "usual and customary" and seemingly incidental situations. Students who described fear of speaking up perceived a tradeoff between academic survival and patients' interests. The cases demonstrated that students still lacked the tools to navigate ethical dilemmas effectively. The authors propose that moral courage is within the realm of professional expectations for medical students; its cultivation is an appropriate formal objective for medical education.

Attitude of Health Personnel↗
PubMed1992

Care of the dying: an ethical and historical perspective.

OBJECTIVE: To provide a historical perspective, from ancient Greece to the middle of the 20th century, on ethical issues and principles commonly associated with medical care for the dying in Western civilization. SOURCES: Writings of noted philosophers, historians, ethicists, and physicians, as well as published legal and ethical guidelines. INFORMATION EXTRACTION: The sources used highlight the origins of various ethical principles associated with care of the dying. They also identify the opinions of prominent individuals throughout the history of medical ethics. SUMMARY: Devotion to medical beneficence, concern for the quality of life, and respect for the sanctity of life are all expressed in the earliest medical and philosophical writings of ancient Greece. With regard to care of the dying, these considerations led to a wide acceptance of avoiding or terminating treatment in hopeless cases. They also led to active debate regarding medicine's role in hastening the dying process. The rise of Christianity during the Middle Ages markedly suppressed such debate by strongly reinforcing the principle of sanctity of life. Later, the optimism of the enlightenment added the hope of prolonging life. Finally, modern advances in medical science have made that hope a reality of complex ethical dimensions. CONCLUSIONS: Ethical debates regarding appropriate care for the dying are as old as medicine itself. Although beneficent concerns have characterized the medical community in almost every period of history, tensions have repeatedly arisen as diverse religious and philosophical ideologies have produced varying standards to define such beneficence. In the Christian world, the sanctity of life was often extolled as the paramount standard. For the ancient Greeks and Romans, and again in many post-Renaissance philosophies, quality of life considerations assumed equal or greater importance. Modern life-prolonging technologies heighten the debate by allowing these two standards to dramatically conflict, particularly in the critical care setting.

Beneficence↗
PubMedDate not supplied

Ethics orientation as a mediator of organizational integrity in health services organizations.

Increasing scrutiny of ethical misconduct by federal and state agencies has prompted health services organizations to adopt codes of ethics and institute legal compliance programs. However, there is little understanding of the impact of ethics programs or the manner in which program elements act to enhance organizational integrity. This study examined the effect of five ethics program elements on organizational integrity and the mediating role played by ethics orientation in this relationship. It found that program elements influence organizational integrity by engendering among employees a values orientation, a compliance orientation, or both. Furthermore, program elements that induced both orientations have a larger impact on integrity. These findings have important implications for health services managers involved in designing and implementing an ethics program.

Attitude of Health Personnel↗
PubMedDate not supplied

Influence of practice environment and nurse characteristics on perinatal nurses' responses to ethical dilemmas.

BACKGROUND: Previous research on nurses' responses to ethical dilemmas has focused either on nurse characteristics or on practice environment characteristics, but has not examined both influences concurrently. OBJECTIVE: To explore the relative contributions of practice environment characteristics and nurse personal and professional characteristics to perinatal nurses' willingness to be involved in activities to resolve clinical ethical dilemmas. METHODS: A descriptive correlational design and hierarchical multiple regression were used to examine responses of 127 perinatal nurses to three instruments: the Nursing Ethical Involvement Scales (NEIS), Perinatal Values Questionnaire (PVQ), and Demographic Data Sheet (DDS). RESULTS: The organizational variable, nursing influence, accounted for the greatest amount of variance in nurses' reported resolution actions, with nurses' concern about ethics and consequentialist values also contributing significantly. The three predictors together accounted for 31% (24% adjusted) of the variance in actions to resolve clinical ethical dilemmas. Level of nursing education was not a statistically significant influence. CONCLUSIONS: These results suggest that nurses are more likely to be involved in dilemma resolution activities when they perceive themselves to have higher levels of influence in their practice environments and higher levels of concern about the ethical aspects of clinical situations. Nurses who emphasize consideration of morally relevant aspects of individual patient situations (consequentialist value orientation) and deemphasize adherence to abstract standards, rules, and policies also are more likely to be involved in dilemma resolution.

Adult↗
PubMed2001

Philosophy for managers? An exploration of what the great philosophers can do to assist ethical decision making.

Ethics is attracting increasing attention in management of both public- and private-sector organisations. For managers within health-care systems, ethical issues can be most acute, especially given the human nights issues involved in new legislation. This paper explores some of the ways in which philosophy may potentially offer guidelines to managers faced with the need to make decisions ethically. It draws on a small number of philosophical perspectives to demonstrate how they can assist in informing ethical decision making, and illustrates its arguments through one topic, suicide prevention, an area of relevance to health managers but one that is beset by some of the most profound ethical dilemmas. The ways in which philosophy may assist in decision making in this one example are, it is argued, generalisable to many other health issues where complicated decisions have to be made. The paper develops a philosophical framework consisting of the ethical considerations of "self-love", "humanity", "the value of human life" and "duty to others" and demonstrates, through the use of two hypothetical case studies, how these can be applied to a decision-making process so as to reduce inconsistencies in attitudes and practice.

Decision Making↗
PubMed2003

Public health ethics: asylum seekers and the case for political action.

This paper is a case study in public health ethics. It considers whether there is a basis in ethics for political action by health professionals and their associations in response to inhumane treatment. The issue arises from Australia's treatment of asylum seekers and the charge that this treatment has been both immoral and inhumane. This judgement raises several questions of broader significance in bioethics and of significance to the emerging field of public health ethics. These questions relate to the role of health professionals in response to inhumane treatment of people in their charge; to the discipline of public health in light of a growing recognition of its ethical basis; and the role of public health and bioethical associations in response to ethical issues arising in a political context. It is argued that, in serious cases of humanitarian and human rights abuses affecting health and well-being, there is a case for political action by health professionals, academic and professional institutions, and associations of public health and ethics.

Australia↗
PubMed2004

Psychiatric ethics; a critical introduction for mental health nurses.

Drawing upon the author's experience as a mental health nurse lecturer, this paper suggests that many mental health nurses seem to have difficulty engaging with the ethical issues in psychiatry, and appreciating the relevance of those issues to their everyday practice. In an attempt to address this difficulty, this paper will present a framework that can serve as an accessible introduction to the ethical issues in psychiatry. Reflecting upon general, clinical examples from psychiatric practice, it will be suggested that many ethical issues in psychiatry are concerned with acts of paternalism and with the common justification for those acts. Having presented this framework, the paper will then subject it to a preliminary critique by drawing upon contemporary, critical approaches to health care ethics. It is hoped that this will serve to stimulate both a deeper appreciation of the relevance of ethics to the practice of mental health nursing and an ongoing critical consideration of the ethical issues in psychiatry.

Ethics, Nursing↗
PubMed1988

Teaching psychiatric ethics.

In the last decade, we have witnessed a burgeoning of interest in ethical issues amongst psychiatrists. Teaching of the subject, however, remains at a rudimentary stage. Various approaches to such instruction are available, particularly modelling (students observe their experienced counterpart), the case method (examining specific clinical situations which involve a need for ethical decision-making), and the seminar approach (trainees are exposed to a core body of knowledge, mainly theoretical in nature). Faced with these different teaching models, the University of Oxford Department of Psychiatry has opted for a blend of all three approaches, which incorporates two goals: an increase in the trainees' sensitivity to the many intricate moral dilemmas facing the psychiatric profession; and their familiarity with salient concepts in moral philosophy which constitute a basis for ethical reasoning and which have a bearing on clinical practice. The teaching programme comprises the following: a pair of trainees prepares a presentation on an aspect of psychiatric ethics under the supervision of a senior psychiatrist. A moral philosopher assumes the role of discussant of the ethical problems raised by the trainees; this is followed by a general discussion. Topics have included involuntary hospitalization, dual loyalty, suicide, psychiatric diagnosis, and ethical issues in various spheres of psychiatric practice such as sex therapy, psychotherapy and child psychiatry. The approach has worked effectively and proved rewarding to all participants involved.

England↗
PubMed2004

The impact of a modern medical curriculum on students' proposed behaviour on meeting ethical dilemmas.

OBJECTIVE: To evaluate the impact of a modern medical curriculum on students' proposed behaviour on encountering ethical dilemmas. DESIGN: Cohort design. SETTING: University of Glasgow Medical School. SUBJECTS: The first intake of students into Glasgow's new curriculum (n = 238). Main outcome measure Student answers consistent with consensus professional judgement on the ethical dilemmas posed by the vignettes of the Ethics and Health Care Survey Instrument. RESULTS: The probability of giving a consensus answer was lowest pre-Year 1 and highest post-Year 1. It reduced slightly post-Years 3 and 5, but remained significantly higher than at pre-Year 1. The performance of students undertaking a 1-year intercalated BSc, however, appeared to regress on testing post-Year 4. CONCLUSIONS: While the first year of the curriculum had a positive impact on students, the remainder of the curriculum did not impact to the same extent. These findings support the recommendation that small group teaching, the predominant teaching method in Year 1, should be preferred to lecture and large group teaching, the predominant method of the remaining curricular years. Full integration of ethics and law teaching within the rest of the curriculum is recommended, particularly during the clinical years. This has training implications for all medical teachers involved in the curriculum. The assessment of ethics should be incorporated into all formal examinations. It is recommended that ethics be addressed as part of a wider approach to professionalism in order to promote integration.

Cohort Studies↗
PubMed1997

An ethic of caring: conceptual and practical issues.

The purpose of this paper is to explore the concept of an ethic of care. Caring as a concept has long been associated with nursing, but in more recent times there has been a strong move to promote an ethic of care as a fundamental concept of nursing. Literature and a personal perspective are used to explore the concept of an ethic of care. It is a premise of this paper that care should be taken that an ethic of care, as currently described, does not contribute to nurses' powerlessness in ethical decision-making in the clinical area. Issues that need to be addressed include the inadequate articulation of the concept to inform and guide practice, and also the emotively laden language utilized by some writers. It is concluded that an ethic of care shows promise to advance nursing knowledge and practice and requires increased research and dialogue to clarify the concept.

Altruism↗
PubMed2006

Facilitating the development of moral insight in practice: teaching ethics and teaching virtue.

Abstract The teaching of ethics is discussed within the context of insights gleaned from ancient Greek ethics, particularly Aristotle and Plato and their conceptions of virtue (arete, meaning excellence). The virtues of excellence of character (moral virtue) and excellence of intelligence (intellectual virtue), particularly practical wisdom and theoretical wisdom, are considered. In Aristotelian ethics, a distinction is drawn between these intellectual virtues: experience and maturity is needed for practical wisdom, but not for theoretical wisdom. In addition to this, excellence of character is acquired through habitual practice, not instruction. This suggests that there is a need to teach more than theoretical ethics and that the ethics teacher must also facilitate the acquisition of practical wisdom and excellence of character. This distinction highlights a need for various educational approaches in cultivating these excellences which are required for a moral life. It also raises the question: is it possible to teach practical wisdom and excellence of character? It is suggested that virtue, conceived of as a type of knowledge, or skill, can be taught, and people can, with appropriate experience, habitual practice, and good role models, develop excellence of character and become moral experts. These students are the next generation of exemplars and they will educate others by example and sustain the practice of nursing. They need an education which includes theoretical ethics and the nurturing of practical wisdom and excellence of character. For this purpose, a humanities approach is suggested.

Attitude of Health Personnel↗
PubMed2006

Partnership as an ethical model for medical research in developing countries: the example of the "implementation trial".

The existing model for ethical review of medical research consists primarily of regulations designed to prevent exploitation of participants. This model may fail when reviewing other ethical obligations, particularly the responsibility to provide valuable knowledge to society. Such failure is most apparent in developing countries, in which many stakeholders lack incentives or power to uphold society's interests. An alternative ethical model is that of partnership, which actively involves all partners during ethical review and aims to secure partners' best interests through compromise. Unlike the existing "regulatory" model, the partnership model effectively addresses ethical obligations to provide positive benefits to society. For the partnership model to be effective, power must be shared among partners; thus, the partnership model can be harmonised with the "regulatory" model through explicit consideration of power structures. One opportunity for crafting power balance in developing countries is apparent in "implementation trials"-randomised trials motivated by and integrated into the implementation of long term public health interventions. Given the failings of the existing ethical review model, alternative models-for example, partnership-and means to balance power-for example, implementation trials-must be explored to ensure that medical research provides knowledge of value to societies in the developing world.

Cooperative Behavior↗
PubMed2006

Ethical international research on human subjects research in the absence of local institutional review boards.

International health-related research on human subjects entails unique ethical responsibilities and difficulties. Often, these difficulties are augmented by the lack of a local ethical review infrastructure. In a recent cross-national study conducted by us, three critical components of ethical regulation were identified--external oversight, local oversight and subject involvement--and integrated into the study design. These three concepts are outlined and established as an important aspect of ensuring ethical coherence in the local context, particularly when reviews by the local institutional review boards cannot practically be obtained. The three levels of ethical oversight identified are suggested to be the framework within which future field studies on human subjects are developed and a standard for maintaining ethical rigorousness in research on humans.

Developing Countries↗
PubMed2006

Reporting ethics committee approval and patient consent by study design in five general medical journals.

BACKGROUND: Authors are required to describe in their manuscripts ethical approval from an appropriate committee and how consent was obtained from participants when research involves human participants. OBJECTIVE: To assess the reporting of these protections for several study designs in general medical journals. DESIGN: A consecutive series of research papers published in the Annals of Internal Medicine, BMJ, JAMA, Lancet and The New England Journal of Medicine between February and May 2003 were reviewed for the reporting of ethical approval and patient consent. Ethical approval, name of approving committee, type of consent, data source and whether the study used data collected as part of a study reported elsewhere were recorded. Differences in failure to report approval and consent by study design, journal and vulnerable study population were evaluated using multivariable logistic regression. RESULTS: Ethical approval and consent were not mentioned in 31% and 47% of manuscripts, respectively. 88 (27%) papers failed to report both approval and consent. Failure to mention ethical approval or consent was significantly more likely in all study designs (except case-control and qualitative studies) than in randomised controlled trials (RCTs). Failure to mention approval was most common in the BMJ and was significantly more likely than in The New England Journal of Medicine. Failure to mention consent was most common in the BMJ and was significantly more likely than in all other journals. No significant differences in approval or consent were found when comparing studies of vulnerable and non-vulnerable participants. CONCLUSION: The reporting of ethical approval and consent in RCTs has improved, but journals are less good at reporting this information for other study designs. Journals should publish this information for all research on human participants.

Editorial Policies↗
PubMed2006

A public health perspective on research ethics.

Ethical guidelines for conducting clinical trials have historically been based on a perceived therapeutic obligation to treat and benefit the patient-participants. The origins of this ethical framework can be traced to the Hippocratic oath originally written to guide doctors in caring for their patients, where the overriding moral obligation of doctors is strictly to do what is best for the individual patient, irrespective of other social considerations. In contrast, although medicine focuses on the health of the person, public health is concerned with the health of the entire population, and thus, public health ethics is founded on the societal responsibility to protect and promote the health of the population as a whole. From a public health perspective, research ethics should be guided by giving due consideration to the risks and benefits to society in addition to the individual research participants. On the basis of a duty to protect the population as a whole, a fiduciary obligation to realise the social value of the research and the moral responsibility to distribute the benefits and burdens of research fairly across society, how a public health perspective on research ethics results in fundamental re-assessments of the proper course of action for two salient topical issues in research ethics is shown: stopping trials early for reasons of efficacy and the conduct of research on less expensive yet less effective interventions.

Bioethical Issues↗
PubMed1980

A philosophy of a clinically based medical ethics.

Pellegrino and Siegler have argued that medical ethics must be taught 'at the bedside', or clinically. This paper is an attempt to establish the need for clinical teaching of medical ethics both to medical students and to medical ethicists who are not physicians. Through a critique of six positions regarding the aims of medical ethics, four principles are established which are the basis of a philosophy of education for medical ethics. The need for a clinically-based educational programme in medical ethics is thereby established, not on practical grounds, but on solid philosophical ones. The paper concludes with practical examples of a clinically-based medical ethics programme following from the four principles.

Curriculum↗
PubMed1982

Five ethical doctrines for medical education.

In recent years a relative barrage of journal articles has surfaced concerning the formal instruction of medical ethics in our medical schools. Philosophical debates usually ensue over either the conspicuous absence (or, in some cases, the questionable need (I) (2) of a formal ethics course, or the manner and method by which ethics is to be taught (3). There is, however, a paucity of literature as to what constitutes ethical medical 'pedagogy'. Germane is the principle that the physician-teacher should strive to be ethical both in what he or she teaches as well as the manner in which it is taught. This is also to review medical ethics from a broader perspective including the institution of instruction itself. The following discourse focuses upon five doctrines which would augment the medical curriculum by adding to the mere instruction of facts and skills a respect for the human values and rights innate to the practice of medicine.

Cost-Benefit Analysis↗
PubMed1996

Ethical dimensions of psychotherapy: a personal perspective.

A substantial increase in the interest devoted to ethical issues has been a defining feature of my 50 years in psychotherapeutic practice. Reasons include a shift from a paternalistic to a contractual model of the doctor-patient relationship, increased litigiousness, and greater emphasis on the business rather than professional aspects of practice. Many ethical violations stem from misuse of therapist power in the psychotherapeutic relationship. One of the most egregious of these is overt sexual acting out between therapist and patient, a dereliction now viewed much more sternly, largely because of the rise of the women's movement. Therapist power can also be misused for purposes of psychopathological gratification, such as to dominate patients or impose values, and by emphasizing financial rewards over patient needs. A sea change I have observed has been the gradual replacement of a two-party by a three-party system of payment for psychotherapy. Among its most serious consequences in the ethical domain has been the weakening of the therapist's guarantee of absolute confidentiality to the patient. Managed care has further compounded the ethical dilemma by imposing a need to choose between the interests of patients and the organizations from which therapists receive remuneration. In their efforts to ensure parity coverage for psychotherapy, therapists need to respond to certain questions about their claims that their work promotes both individual welfare and the common good. Questions include the professional qualifications for skillful practice of psychotherapy, the evidence for its efficacy, the delimitation of the conditions properly treated by psychotherapy, and the extent to which these conditions fall within the medical model and thus satisfy the criterion of medical necessity. I conclude that, in spite of the efforts needed to maintain ethical standards, the "ethical revolution" that I have witnessed has enhanced the integrity and value of psychotherapy, both for its practitioners and for the public that they serve.

Child↗