Ethics and genetics: an international survey

Wertz and Fletcher briefly summarize the findings of their 1985-86 survey of responses to ethical dilemmas by medical geneticists in 19 countries. Geneticists identified six categories of ethical problems encountered in practice: (1) the duty to warn third parties of genetic harm vs. the duty to preserve patient confidentiality; and (2) full disclosure of sensitive information; (3) full disclosure of test results; (4) directive vs. nondirective counseling; (5) patient requests for prenatal diagnosis without medical indication; and (6) mandatory vs. voluntary screening programs and access by third parties to test results. Survey participants ranked issues that they believed would be of greatest ethical concern to their field within the next 10 to 15 years. The authors caution that issues seen as less problematic by medical geneticists may be those of most concern to the public.     

The Oregon priority-setting exercise: quality of life and public policy

In 1989 the Oregon State legislature passed the Oregon Basic Health Services Act, which created a Health Services Commission charged with "developing a priority list of health services, ranging from the most important to the least important for the entire population to be served." The goal of this legislation was to permit the expansion of Medicaid to 100 percent of all Oregonians living in poverty by covering only services deemed to be of sufficient importance or priority...Instead, the OHSC developed a set of seventeen health service "categories," which described either a specific type of service...or, more generically, the expected outcomes of care... Commissioners formally ranked these seventeen categories in order of importance according to three subjective criteria: value to the individual, value to society, and whether the category seemed "necessary." Each treatment was then assigned to the single most appropriate category, based on Commissioners' judgment. Services were ranked within categories according to the degree of benefit expected from treatment... Estimates of how treatments affect quality of life were by far the single most important factor in determining the priority order on that list....     

Health Care Surrogacy Laws Do Not Adequately Address the Needs of Minors

A couple and their five-year-old daughter are in a car accident. The parents are not expected to survive. The child is transported to a children's hospital, and urgent treatment decisions must be made. Whom should the attending physician approach to make decisions for the child? When such cases arise in, for example, the hospitals where we work, the social worker or chaplain is instructed to use the Illinois Health Care Surrogacy Act as a guidepost to identify a decision-maker. But in our state and the country overall, the limitations of such statutes leave hospital workers to make a judgment call among friends, family, and clergy who may come forward. While surrogate decision-making statutes comprehensively address surrogate decision-makers for adults, a patchwork of laws—permanency statutes, kinship provider statutes, standby guardianship statutes, and, in some cases, surrogate decision-making statutes—provide variable decision-making pathways for children.     

From undergraduate medical education to pre-registration house officer year: how prepared are students?

Studies in the United Kingdom show that the first year of being a new doctor is a difficult transition from being an undergraduate medical. These doctors feel ill-prepared by their undergraduate medical student education and ill-equipped for their new role. This is a questionnaire study looking at 193 pre-registration house officers (PRHOs) and 212 consultant educational supervisors within the West Midlands Deanery in England, UK. The study asked how well prepared these new doctors were in seventeen basic subject areas (using a General Medical Council based template), and also, using the same template, how well prepared their consultant educational supervisors felt they were. Statistical testing included ranking of subject areas for each group, reliability testing and comparisons of views of house officers and consultants. Both groups ranked communication skills areas highest (best prepared) and ranked basic doctoring skills (such as prescribing, treatment, decision making and emergencies) lowest. House officers rated themselves significantly higher than did their consultant supervisors in thirteen out of the seventeen areas tested. In discussion, we ask if we have gone too far in teaching effective communication at the expense of basic doctoring skills. We also consider whether indeed young doctors have an inflated opinion of their own competencies, or are the older generation seeing the world through rose tinted spectacles?     

To what extent do students generate learning issues that correspond to pre-set faculty objectives?

The aim of this study was to investigate whether the content of the problems in a problem-based learning programme directs the students to the faculty's educational objectives. Sixteen students in two study groups in a three-year programme for training in psychotherapy generated 228 learning issues. The tutors reported the issues and the discussion themes. The learning issues and themes were compared with the faculty objectives. The correspondence between faculty objectives and learning issues/themes was 79% in the study groups, which showed that the problems presented direct the students to the faculty goals. The result also shows that it is important to study not only the learning issues but also what students talk about while preparing the reports in their group.     

Quality of student-generated learning issues in a problem-based curriculum

In a problem-based curriculum students generate learning issues that are the guidelines for their individual study. In an earlier study it was found that a useful learning issue contains a keyword that demarcates the content of a certain topic to be studied and is formulated concisely and unambiguously for all members of the tutorial group. This study investigates two questions. First, how many learning issues can be classified as being of good or bad quality as evaluated against three criteria? Second, what are examples of well and badly formulated learning issues? Learning issues were collected for two problems in the first year during two tutorial meetings of the Maastricht Medical School in the academic year 1998-99. In the next academic year, 12 first year-students were asked to judge the learning issues for each problem against three criteria. The results showed that 21% of the learning issues for one problem and 32% for the other problem were classified as scoring high on all three characteristics. A very small percentage of learning issues (5% and 2%) were classified as scoring low on all three characteristics. Most learning issues scored differently on each of the characteristics. Although most learning issues contain a keyword, many of them were formulated ambiguously and not concisely. It is concluded that first-year students are not yet able to formulate clear learning issues.     

A comparison between UK and US medical student attitudes towards cultural diversity

The views that students hold about cultural diversity and its teaching have been investigated to a limited extent in the UK and North America. The objective of this study was to establish whether there is a difference in attitudes between UK and US medical students with regard to this issue. A questionnaire survey was carried out on 191 year one medical students at the University of Illinois (Chicago and Urbana campuses) and University of Leicester. Differences of attitudes between students from the two countries and also between the same ethnic groups across the two countries were compared. There were statistically significant differences between UK and US students in each of the key areas of the balance between different cultures, attitudes of doctors and their practice relating to cultural diversity, culture and its associations with race/skin colour, perspectives on specific cultures and attitudes towards diversity teaching. There were some similarities in how students define culture but differences in how they understand multiculturalism. These findings suggest that programmes need to be tailored to particular circumstances, and that complex models of diversity need to be utilized in order for students to engage with them in a substantive way.     

The breadth of bioethics: core areas of bioethics education for hospital ethics committees

The multidisciplinary nature of bioethics can result in narrow "sub-specialists" within the field, whose work reflects the issues and concerns most relevant to their "home discipline." This can result in work which is insensitive to the important ways in which particular areas of bioethics are interrelated, and which (while viable in the context of the sub-specialty) is not viable in a broader context. The narrow focus of many healthcare ethics committees on issues directly related to clinical patient care can exacerbate this problem. Increasingly, issues in the clinical care of patients cannot be separated from issues in research, organizational ethics, and public policy. I argue that these problems call for a need to identify "core" areas for bioethics education. This is especially true for education of hospital ethics committees, which increasingly face complex cases involving concerns that fall outside traditional patient care issues. I then consider nine areas examined in detail in A Companion to Bioethics edited by Helga Kuhse and Peter Singer, as potential candidates for "core" areas of bioethics education. At the same time, I evaluate the range of issues examined in each area of the book, in the context of the book's ability to provide an introduction to each area.     

Developing practical criteria for evaluating online patient simulations: a preliminary study

Online patient simulations are increasingly used in medical education. However, uniform criteria for evaluating simulations don't exist. This study explored expert opinion regarding the essential components of online simulations. Preliminary criteria were examined through a survey of 22 medical educators and follow-up interviews with nine educators. Features involving routine tasks and the teaching of problem solving skills-histories, physicals, labs, and differential diagnoses were highly rated. Features conveying realism such as time constraints and the use of multimedia were ranked lower. Interviewees noted three impediments to wider use of simulations: time required to develop content, limits of current technology and the absence of usable authoring tools.     

Promoting self-directed learning for continuing medical education

Self-directed delivery modes for continuing medical education (CME) are the most effective approaches for improving physician performance. However, instructor-directed programs are still the most popular methods used for CME. The purpose of the study was to assess the utilization, preferences and barriers to use of nine different CME delivery methods by physicians. A self-administered survey of all licensed physicians in Nevada was conducted over a three-month period. Results were analyzed using SPSS for windows (version 10). In-person conferences (92%) and journal review (64%) were the most frequently utilized modes of instruction. Rural physicians were more likely to use interactive video. The top three ranked preferences were in-person conference, print-based self-study and CD-ROM. It is concluded that computer training, dedicated time in the workplace for self-directed methods, and the development of more interactive CD-ROM and Internet programs will encourage the use of self-directed CME.     

Experience with a program of faculty development

The authors describe the faculty development program at the University of Nebraska Medical Center. Faculty needs were identified in instructional skill development, academic socialization and mentoring. Committees with campus-wide representation designed the instructional activities. Among the total 749 faculty, 59% attended at least one faculty development offering consisting of one and two-day institutes or two-hour luncheon workshops in the past five years. Evaluations ranked each event highly for quality, relevance, impact on teaching and usefulness. Experiences in creating a successful faculty development program at an academic medical center are reported. Success was measured by attendee numbers and increased participation of faculty in teaching and mentoring. Factors contributing to this success include generous financial support by leadership, broad-based planning and administrative support.     

Animals, science, and ethics -- Preface; introduction: the troubled middle in medias res; future directions

This is a report from The Hastings Center project, "The Ethics of Animal Experimentation and Research." As project members, we wanted to take a fresh look at the complex ethical issues that arise in the scientific use of animals in a non-adversarial and non-ideological forum. We were convinced that these issues required a genuinely interdisciplinary approach. This meant including laboratory and field scientific researchers; veterinarians; philosophers, lawyers, and scientists particularly interested in animal welfare issues; and physicians and philosophers with long-standing bioethical interests but who previously had not confronted the ethics of the human use of animals. This Special Supplement to the Hastings Center Report is the outcome of two years of deliberation.     

Gender,identity, and bioethics

Transgender people and issues have come to the forefront of public consciousness over the last year. Caitlyn Jenner' very public transition, heightened media coverage of the murders of transgender women of color, and the panicked passage of North Carolina's “bathroom bill” (House Bill 2), mean that conversations about transgender health and well‐being are no longer happening only within small communities. The idea that transgender issues are bioethical issues is not new, but I think that increased public awareness of transgender people and the ways that their health is affected by systems that bioethics already engages with offers an opportunity for scholarship that works to improve transgender health in meaningful ways.     

Upstream ethics in nanomedicine: a call for research

Insufficient attention has been given to ethical and social issues integral to nanomedicine. Part of this deficiency arises from some mistaken assumptions about ethics. I consider five of these: that ethics is only important when a technology is mature (reactionary ethics); that there are no new ethical issues in nanomedicine; that ethics involves a kind of risk assessment that is already being conducted; that ethics is a hindrance to science; and that ethics is a luxury for an ideal world. After critically assessing these assumptions, I consider two types of nanomedicine and the kinds of ethical issues they raise. Type 1 nanomedicine is of an incremental kind, and proper ethical assessment of the issues must involve a fine grained study of the specific application. Type 2 nanomedicine is of a more foundational, programmatic kind. Ethical issues raised by these more programmatic developments include challenges integral to formation of interdisciplinary teams; issues related to intellectual property, authorship and publication; development of informed consent and confidentiality protections associated with new data sets; future challenges to the clinician-patient relation and personalized medicine. Ethical analysis should also consider some of the reductionistic implications of engineering models and metaphors integral to nanomedicine, as well as uses of nanomedicine for non-medical purposes, such as human enhancement. Many of these challenges concern rate-limiting steps in nanomedical research, and they should be prominently featured in developing nanomedicine initiatives.     

Ethical issues in the managed care setting: a new curriculum for primary care physicians

Several challenging ethical issues have been associated with the shift to managed healthcare in the United States. Our objective was to develop, implement, and evaluate a curriculum designed to help physicians identify and examine ethical issues encountered in the managed care setting. The curriculum was developed during a year-long workshop at Johns Hopkins Bayview Medical Center. The content of the curriculum was established through literature review, focus group discussions with physicians, and a needs assessment of targeted learners (primary care physicians practicing in managed care settings). Some of the key issues addressed in the curriculum include: changing professional responsibilities of physicians; fair use of resources; and threats to the doctor-patient relationship as a consequence of the new healthcare delivery system. The 7.5-h curriculum was taught over five sessions using varied teaching methods. Evaluations demonstrated that the curriculum was successful in increasing learner awareness of ethical issues confronted in the managed care environment and improved learner knowledge in these areas. The physician-learners reported that this educational experience would change their teaching of medical students and residents. After completing the curriculum, learners felt that they were at least somewhat better able to cope with ethical challenges encountered in the managed care setting. Future research might examine whether such a curriculum could positively affect physician behavior or enhance physician satisfaction with the managed care setting.     

Assessments in evidence-based medicine workshops: loose connection between perception of knowledge and its objective assessment

The outcome of continuing education programs is often based on self-assessment. We evaluated the relationship of self-assessment of knowledge based on rating scales with scores obtained on objective validated tests in evidence-based medicine workshops. In the West Midlands region (1998), 55 participants attended three workshops in critical appraisal of the medical literature.They completed two self-assessment questionnaires: one used a rating scale to subjectively examine the level of knowledge of six different literature appraisal issues; the other objectively assessed participants' literature appraisal knowledge in those issues using validated multiple true-false questions. Comparison of subjective scores reflecting understanding of specific literature appraisal issues with corresponding objective test scores revealed a poor correlation (r(s) ranged from -0.29 to 0.60 for the different knowledge issues assessed). Perception of ones level of knowledge did not always correlate with correctly possessed knowledge. In some instances, those who thought they were knowledgeable actually possessed incorrect knowledge. Therefore, continuing medical education programs should focus on objective, not subjective tests to assess outcome.     

Italy: old problems, new books

Agazzi's bibliographic essay of recent titles in Italian on biomedical issues also discusses the Catholic versus the secular approaches to bioethics in Italy. Among the publications mentioned are several of a philosophical or theological nature: M. Mori's volume on artificial insemination, and second editions of well-established textbooks on biomedical ethics by S. Leone, E. Sgreccia, S. Spinsanti, and D. Tettamanzi. Legal issues in reproductive technologies are addressed in the Santosuosso Commission's report on regulating artificial procreation, and in a book discussing the report. Secular writings on ethical issues have appeared in issues cited here of the journals Prospettive Settanta and Biblioteca della Libertà. Also mentioned in Agazzi's essay are a critique of the Vatican Congregation for the Doctrine of the Faith's Instruction on Respect for Human Life, and a booklet of articles related to the 20th anniversary of the encyclical Humanae Vitae.     

Preparing students for the ethical challenges on international health electives: A systematic review of the literature on educational interventions

International health electives pose specific ethical challenges for students travelling from to low and middle income countries. We undertook a systematic review of the literature on interventions to prepare students to identify ethical issues addressed, educational approaches and to collate evidence on the effectiveness of different strategies. We searched nine electronic databases of peer-reviewed literature and identified grey literature through key word searches; supplemented through citation mapping and expert consultation. Articles that described ethical training conducted by universities or professional bodies were included for review. We reviewed forty-four full text articles. Ten sources of published literature and seven sources of grey literature met our inclusion criteria. We identified thirteen ethical situations that students should be prepared to manage and eight generic skills to support this process. Most interventions were delivered before the elective, used case studies or guidelines. Some suggested ethical principles or a framework for analysis of ethical issues. Only two papers evaluated the intervention described. Our paper collates a small but growing body of work on education to prepare students to manage ethical issues. Ethical training should have elements that are delivered before, during and after the elective. Interventions should include case studies covering thirteen ethical issues identified here, linked to ethical principles and a process for responding to ethical issues. We suggest that evaluations of interventions are an important area for future research.     

Bad apples spoil the barrel: Addressing unprofessional behaviour

Given the changes in society we are experiencing, the increasing focus on patient-centred care and acknowledgement that medical education including professionalism issues needs to continue not only in the residency programmes but also throughout the doctors career, is not surprising. Although most of the literature on professionalism pertains to learning and teaching professionalism issues, addressing unprofessional behaviour and related patient safety issues forms an alternative or perhaps complementary approach. This article describes the possibility of selecting applicants for a medical school based on personality characteristics, the attention to professional lapses in contemporary undergraduate training, as well as the magnitude, aetiology, surveillance and methods of dealing with reports of unprofessional behaviour in postgraduate education and CME.