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.     

Two concepts of medical ethics and their implications for medical ethics education

People who discuss medical ethics or bioethics come to very different conclusions about the levels of agreement in the field and the implications of consensus among health care professionals. In this paper I argue that these disagreements turn on a confusion of two distinct senses of medical ethics. I differentiate (1) medical ethics as a subject in applied ethics from (2) medical ethics as the professional moral commitments of health care professions. I then use the distinction to explain its significant implications for medical ethics education. Drawing on the recent work of John Rawls, I also show the centrality of philosophy in medical ethics by illustrating how contemporary philosophy can be used to construct an ethical framework for the medical professions.     

Medical ethics and tomorrow's physicians: an aspect of coverage in the formal curriculum

Medical ethics has created contentious issues and requires reforms in medical education such as renewed emphasis on formal instruction. The aim here was to review the current status of bioethics teaching in medical schools, determine Saudi students' perception of its coverage in the formal curriculum and make recommendations. Using a self-administered questionnaire in a cross-sectional study, undergraduate students' opinion about medical ethics coverage was obtained. Fourteen clinical departments and 201 students were studied. Only 46% of respondents were satisfied with the current coverage of ethical issues in the formal curriculum; 23% were unaware of the value of the subject. Students' approval rate was highest in Neurology and Psychiatry (70%). The study confirmed inadequate formal instruction on medical ethics in a developing country. Five recommendations are made. At admission, students' integrity and character should be assessed. Bioethics should be taught in clinical settings. In the Islamic world, medical curricula should include the Islamic code of medical ethics. Peers, nurses and patients should evaluate graduates' performance in ethics at the bedside. Evidence-based assessment and continuous quality improvement are required to maintain the requisite standard.     

Ethics tests for medical boards: the state of the question

Callahan introduces five articles drawn from presentations made at a December 1982 meeting at The Hastings Center. William Ruddick, in "What should we teach and test?," discusses the skills and knowledge that ethics tests on medical boards might evaluate. Ruth Macklin and Johanna Jones describe "The experience of the National Board of Medical Examiners" in assessing competency in medical ethics; Lynn O. Langdon and Albert R. Jonsen describe "The experience of the American Board of Internal Medicine"; Vanessa Merton discusses "Ethics tests in the legal profession"; and Carol Levine, in "Do ethics tests get a passing grade?," summarizes various views on the use of oral examinations and on the effects of ethics testing on ethics teaching.     

How can we know that ethics education produces ethical doctors?

This article examines the challenges that medical ethics education faces, given its aim of producing ethical doctors. Starting with an account of the ethical doctor, it then inquires into the key areas of medical students' ethical development, viz. knowledge, habituation and action, and describes more specific outcomes in these areas. Methods of teaching aimed at achieving specific outcomes are also discussed. The authors then turn to some difficulties that stand in the way of achieving the desired outcomes of medical ethics education, and survey what has been achieved so far, by considering a number of studies that have evaluated the efficacy of a range of medical ethics courses. The article concludes by suggesting that medical ethics education should give attention to the problems of evaluation of ethics curricula as the discipline comes of age.     

Does Medical Ethics Have Its Own Theory?

Sumner, a philosophy professor at the University of Toronto, reviews Robert Veatch's 1981 book, A Theory of Medical Ethics, and assesses the current theoretical status of the field of medical ethics. Although he considers Veatch's book valuable in its treatment of specific medical issues and its critique of codes of professional ethics, he finds fault with Veatch's attempt at constructing a general theory of medical ethics. Sumner concludes that medical ethics is still dependent on appropriating for its use the ethical theories developed by moral philosophers.     

Sweden: growing interest in ethics

Lindahl's bibliographic essay highlights five books, two doctoral theses, and several journal articles that are Sweden's major contributions to the bioethics literature. The books are H. Fagerberg's edited work on medical ethics (1984), widely used as a textbook in Sweden's medical and nursing schools; G. Wretmark, A. Wretmark, and J. Ludvigsson's co-authored text on ethics in medical care (1983); physician A. Andrén-Sandberg's case book (1986); theologian B. Hanson's collection of essays (1988); and Fagerberg's edited work on the ethics of prenatal diagnosis (1980). The theses are C. Blomquist's (1971), the first in Sweden on medical ethics, and C. Kjellstrand's 1988 work on high technology medicine. The articles include two on medical ethics in Sweden written by Lindahl and published in issues of Theoretical Medicine, the only cited works in English.     

The United Kingdom and Australia: new titles

In 1987, a number of significant publications reflected the upsurge of interest in medical ethics in Britain and Australia. Topics considered in these reports and journals include the teaching of medical ethics in medical schools, infertility treatment, surrogacy contracts, euthanasia, human embryo research, and moral issues related to AIDS.     

Twelve tips to teaching (legal and ethical aspects of) research ethics/responsible conduct of research

Teaching research ethics is a requirement within modern health science, nursing and medical curricula. We have drawn on our experience of designing, developing and integrating the teaching of research ethics in a new, fully integrated medical school curriculum, delivered using Problem Based Learning and the recent literature relating to the teaching of research ethics to produce the following 12 Top Tips designed to encourage readers to seek opportunities to embed this teaching within a variety of curricula.     

Health Care Reform and the Future of Physician Ethics

Health care reform proposals threaten to exacerbate tensions physicians already face in trying to balance traditional duties to individual patients against increasing pressure to serve broader societal and institutional goals. To cope with reform, medical ethics must clarify physicians' moral obligations, change existing ethical codes, and develop an ethics of institutions.     

Medical Ethics in the Soviet Union

An American medical ethicist finds the spirit of glasnost and perestroika permeating Soviet medical ethics. These themes, along with a heightened historical consciousness, and a commitment to the Hippocratic tradition, have reinforced a conviction about the infinite value of life     

The nature and limits of the physician's professional responsibilities: surgical ethics, matters of conscience, and managed care

The nature and limits of the physician's professional responsibilities constitute core topics in clinical ethics. These responsibilities originate in the physician's professional role, which was first examined in the modern English-language literature of medical ethics by two eighteenth-century British physician-ethicists, John Gregory and Thomas Percival. The papers in this annual clinical ethics number of the Journal explore the physician's professional responsibilities in the areas of surgical ethics, matters of conscience, and managed care.     

Japan: a new field emerges

In Japan, bioethics is emerging as a discipline in which traditional Japanese values are being compared with ethical insights from scholars around the world. Kajikawa's bibliographic essay discusses recent publications on biomedical ethics by Japanese scholars that reflect topics of current interest and the public context in which they are debated. Works cited include books, conference proceedings, collaborative, multidisciplinary titles, seminar papers, an overview for the general public, and an annual bibliography of medical ethics references prepared by Tokai University. Topics include brain death and organ transplantation, nursing ethics, medical research, and bioethics and medical ethics in general. All titles are cited in English, with their Japanese publishers and dates of publication.     

Making the Rounds: The Ethical Development of Medical Students in the Context of Clinical Rotations

Medical students newly arrived on the wards encounter frustrating ethical predicaments that are complicated by students' place in the hospital hierarchy. A careful scrutiny of medical social structure and culture may enable medical schools to offer their students a more effective ethics education.     

Making sense of ethics and law in the medical curriculum

The moment a patient comes into the treatment room, the medical professional is placed in both an ethical and a legal context. The task for medical teachers is to equip students for this clinical reality in a way that makes sense both to the learners and to the variety of medical educators in the school, all of whom will have their own interpretations of the nature of this subject area. Ethics and law in the medical curriculum (Dowie and Martin 2011), aims to provide an understanding of how ethics and law can be incorporated into the curriculum in a structured, coherent, and logical manner. It is essential that we begin with a vision of the primary purpose of our course, and clarify the overall domain of learning to which it relates. Rather than presenting students with a miscellany of ethico-legal topics, their learning can be reinforced by constructing a frame around the key emphases in law and ethics. A professional ethics frame is proposed, highlighting the everyday, theory-based, habits, intentions, consequences and society elements of this approach. The course also has to be mediated within the wider curriculum, and this benefits from a coherent and communicated course scheme that is directly meaningful within the educational setting of the medical school. Finally, within the Guide, examples of humanistic schemes are presented that centre on aspects of boundary in patient care, themed around body, person and community of practice.     

Reviving A Distinctive Medical Ethic

Our culture is well on its way to reducing medical ethics to legal requirements, general citizen ethics, or personal values. A distinctive ethic for medicine provides critical distance and moral meaning for the profession and an enriched societal ethic.     

An ethicist takes the stand

Paris, an associate professor of social ethics at Holy Cross College, has testified in legal cases involving termination of treatment of brain-dead or irreversibly comatose patients. Here he briefly summarizes his testimony on behalf of the family of Melanie Bacchiochi, who sought to have their brain-dead daughter removed from a respirator in Connecticut, and on behalf of two California physicians charged with murder after they had removed the feeding tube from an irreversibly comatose patient. In such cases, Paris perceives his role to be that of explaining and clarifying for the court the norms and traditions of medical ethics.     

Levinas and the patient as other: the ethical foundation of medicine

The thesis of this paper is that because the significance of Western medicine lies in its ability to enhance the health of persons within a society, the practice of medicine is foremost an ethic and only thereafter a science. In support of the priority of an ethical perspective in medical practice, the paper explores the socio-cultural nature of knowledge, upon which science itself is constructed. Next, it draws from Levinas' philosophy, which illumines the problem of ontological and epistemological priority. Specifically, it examines Levinas' rendering of the human face and of language, as they found the case for the priority of justice, or ethics. Finally, the paper offers the practice of narrative discourse as one solution that elevates the status of ethics within the institution of medicine and that has the potential to counteract the tendency in medical practice to employ a universalizing methodology based in science's power to control the human Other.     

The Ashley Treatment: furthering the anthropology of/on disability

Questions regarding access to and the use of medical and surgical treatment for people with disabilities revisit themes central to medical anthropology. The "Ashley Treatment" is named after a nine-year-old girl, Ashley, who has extreme physical and cognitive disabilities. The Treatment refers to extensive medical and surgical procedures that are claimed to improve quality of life and prevent future medical problems. The Treatment has stimulated lively public debate on disability, medicalization, and caregiving. We illustrate how the Ashley Treatment emphasizes the importance of medical anthropological research on the construction of personhood and childhood disability, agency and autonomy, and the rights of representation and control, as well as the ethics of invasive procedures, hormone therapy, and body modification surgery.