Further thoughts on double effect: some preliminary responses

Since the papers in this issue by Alan Donagan, Don Marquis, William Nelson and Warren Quinn raise complex and challenging questions about almost every aspect of my "Who is Entitled to Double Effect", I cannot, in the present context, provide more than preliminary responses to some of the more important issues they raise in the hope that this might contribute to further clarification of the doctrine of double effect (DDE).     

Too Much Information?

“Too Much Information?”: letters from Michael J. Barry, Jessie Gruman, Wendy Nelson, and Neil C. Manson about “Questioning the Quantitative Imperative: Decision Aids, Prevention, and the Ethics of Disclosure” (March‐April 2011), with a reply from Peter Schwartz; and “Doctors and Torture”: a letter from Fritz Allhoff about “The Tortured Patient: A Medical Dilemma” (May‐June 2011).     

Theology and bioethics: a marriage not made in heaven

Boone reviews the 20th volume in the Philosophy and medicine series, Theology and Bioethics: Exploring the Foundations and Frontiers, edited by Earl E. Shelp (D. Reidel; 1985). The volume's theme, if and how "theology can make a unique contribution to bioethics in our time," is addressed by L. Walters, B. Mitchell, R. McCormick, M. Farley, P. Lehmann, C. Hartshorne, H.T. Engelhardt, S. Hauerwas, J. Childress, and W. Frankena, with a prologue by J. Nelson and an epilogue by J. Cobb. Boone briefly summarizes and critiques each essay. While he responds favorably to the volume, he also believes the work would have been stronger if more attention had been focused directly on the metaethical issues arising from the "gap between theological belief and moral action."     

Nursing ethics: current state of the art

... The essays in this issue of the Journal highlight the types of insights that nursing ethics brings to health care ethics, in general, and attempt to address questions about the adequacy of the conceptual and theoretical foundations of bioethics for a practice discipline like nursing. The essays are written by nurses and non-nurses and bring a surprising balance to the discussion of important issues in nursing ethics from several perspectives. The essays do not represent the full scope of philosophical thought and normative judgements in nursing ethics at the present time, but they do provide a view of nursing ethics through the lens of nursing ethics research, past and present. [Introductions follow to essays by Joy H. Penticuff, Joan Liaschenko and Anne J. Davis, Nancy S. Jecker and Donnie J. Self, Betty J. Winslow and Gerald R. Winslow, Robert J. Connelly, Patricia A. Roth and Janet K. Harrison, and Kevin Wildes].     

Developing scholarly projects in education: a primer for medical teachers

Boyer and Glassick's broad definition of and standards for assessing scholarship apply to all aspects of education. Research on the quality of published medical education studies also reveals fundamentally important elements to address. In this article a three-step approach to developing medical education projects is proposed: refine the scholarly question, identify appropriate designs and methods, and select outcomes. Refining the scholarly question requires careful attention to literature review, conceptual framework, and statements of problem and study intent. The authors emphasize statement of study intent, which is a study's focal point, and conceptual framework, which situates a project within a theoretical context and provides a means for interpreting the results. They then review study designs and methods commonly used in education projects. They conclude with outcomes, which should be distinguished from assessment methods and instruments, and are separated into Kirkpatrick's hierarchy of reaction, learning, behavior and results.     

AMEE Medical Education Guide No. 23 (Part 2): Curriculum,environment, climate,quality and change in medical education - a unifying perspective

This paper looks at five focal terms in education - curriculum, environment, climate, quality and change - and the interrelationships and dynamics bemeen and among them. It emphasizes the power and utility of the concept of climate as an operationalization or manifetation of the curriculum and the other three concepts. Ideas pertaining w the theory of climate and its measurement can provide a greater understanding of the medical cumadurn. The environment is an impoltant detemzinant of behaviour. Environment is perceived by students and it is perceptions of environment that are related w behaviour. The environment, as perceived, may be designated as climate. It is argued that the climate is the soul and spirit of the medical school environment and curriculum. Students' experiences of the climate of their medical education environment are related w their achievements, sangaction and success. Measures of educational climate are reviewed and the possibilities of new climate measures for medical education are discussed. These should take account of current trends in medical education and curricula. Measures of the climate may subdivide it inw dzfferent components giving, for example, separate assessment of so-called Faculty Press, Student Press, Administration Press and Physical or Material Environmental Press. Climate measures can be used in different modes with the same stakeholders. For example, students may be asked to report, first, their perceptions of the actual environment they have experienced and, second, w report on their ideal or preferred environment. The same climate index can be used with different stakeholders giving, for example, staff and student comparisons. The climate is important for staff as well as for students. The organizational climate that teaching staff experience in the work environment that they inhabit is important for their well-being, and that of their students. The medical school is a learning organization evolving and changing in the illuminative evaluation it makes of its environment and its curriculum through the action research studies of its climate. Consderations of climate in the medical school along the lines of continuous quality improvement and innovation are likely to further the medical school as a learning organization with the attendant benefits. Unless medical schools become such learning organizations their quality of health and their longevity may be threatened.     

Redoing the Demos

Forces including extreme economic inequality, cultural polarization, and the monetizing and privatizing of persons as commodities are undermining the forms of moral recognition and mutuality upon which democratic practices and institutions depend. These underlying factors, together with more direct modes of political corruption, manipulation, and authoritarian nationalism, are undoing Western democracies. This essay identifies and explores some vital underpinnings of democratic citizenship and civic learning that remain open to revitalization and repair. Building care structures and practices from the ground up and developing inclusive and egalitarian modes of solidarity in a pluralistic society are the focus of discussion. The essay argues that solidarity and care are essential relationships and practices of moral recognition upon which democratic political agency and freedom rest. The social‐relational lifeworld and the democratic lifeworld are interdependent. Democratic citizenship is itself a relational practice that supports other practices. Democratic governance properly carried out fosters an underlying social solidarity and care and in turn draws moral and political legitimacy upward from them.     

Why patients refuse treatment: a study of seven hospital wards

In a study commissioned by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Paul S. Appelbaum and Loren H. Roth investigated the reasons behind patient refusal of recommended treatment in four hospitals. Using data from 105 cases, Appelbaum and Roth identified several reasons for refusing treatment and the different reactions of physicians and other hospital personnel to this problem, and looked at the clinical and psychological outcomes of such refusals. This brief account summarizes the study's findings and its authors' conclusion that improved communication between physician and patient would decrease the rate of treatment refusal.     

BioForce Nanosciences, Inc

BioForce Nanosciences, Inc. (BFNH.OB) develops and commercializes nanotechnology tools and applications for the life sciences. The company is based in Ames, Iowa, and has two divisions--instruments and applications. The instrument division includes the Nano eNabler system and associated consumables (SPT print cartridges and Sindex substrates) and a surface decontamination device known as the ProCleaner. The applications division develops Nano eNabler-based applications for a variety of purposes. The current application pipeline includes the patented ViriChip pathogen detection and identification system, the Chip-On-A-Tip ultraminiaturized cancer biomarker detection system and a proprietary method for high-throughput molecular interaction screening known as FAST. The unique capabilities of the Nano eNabler system allow the creation of novel applications that take advantage of vastly reduced spatial scales and sample volumes. Popular applications of the Nano eNabler system include: functionalizing biosensors, including micro-electromechanical systems/nano-electromechanical systems devices; patterning surfaces with molecules to study cell growth, behavior and differentiation; performing ultrasensitive bioassays; and printing arrays in confined spaces in microfluidic devices.     

A model for communication skills assessment across the undergraduate curriculum

Physicians' interpersonal and communication skills have a significant impact on patient care and correlate with improved healthcare outcomes. Some studies suggest, however, that communication skills decline during the four years of medical school. Regulatory and other medical organizations, recognizing the importance of interpersonal and communication skills in the practice of medicine, now require competence in communication skills. Two challenges exist: to select a framework of interpersonal and communication skills to teach across undergraduate medical education, and to develop and implement a uniform model for the assessment of these skills. The authors describe a process and model for developing and institutionalizing the assessment of communication skills across the undergraduate curriculum. Consensus was built regarding communication skill competencies by working with course leaders and examination directors, a uniform framework of competencies was selected to both teach and assess communication skills, and the framework was implemented across the Harvard Medical School undergraduate curriculum. The authors adapted an assessment framework based on the Bayer-Fetzer Kalamazoo Consensus Statement adapted a patient and added and satisfaction tool to bring patients' perspectives into the assessment of the learners. The core communication competencies and evaluation instruments were implemented in school-wide courses and assessment exercises including the first-year Patient-Doctor I Clinical Assessment, second-year Objective Structured Clinical Exam (OSCE), third-year Patient-Doctor III Clinical Assessment, fourth-year Comprehensive Clinical Practice Examination and the Core Medicine Clerkships. Faculty were offered workshops and interactive web-based teaching to become familiar with the framework, and students used the framework with repeated opportunities for faculty feedback on these skills. A model is offered for educational leaders and others who are involved in designing assessment in communication skills. By presenting an approach for implementation, the authors hope to provide guidance for the successful integration of communication skills assessment in undergraduate medical education.     

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.     

Lived food and judgments of taste at a time of disease

Medical nutritional therapy (MNT) is a key feature of treatment for and management of type 2 diabetes. There are two elements to this therapeutic approach: collecting a diet history and prescribing therapeutic diets. For the clinical encounters observed in this paper, MNT often became a source of conflict between practitioners and patients. As clinicians endeavor to collect accurate information regarding food choices and eating so as to offer appropriate medical advice, and patients struggle to come to terms with a sickness in which food and eating have become toxic and risky, "judgments of taste" regarding food and patterns of eating become especially profound for both practitioners and those who seek treatment. Bourdieu's (1984) insights into the social situatedness of "taste" provides a useful framework for examining clinical practice and individual foodways. MNT is based upon and promotes a "taste for necessity," - "a form of adaptation to and consequently acceptance of the necessary" (ibid. 372), which judges food choices and eating patterns in terms of the bio-function of food and eating. In addition to this particular judgment of taste, study participants managing type 2 diabetes rely on other "judgments" that have been cultivated over the course of their own socially situated lives. At a time of disease these judgments of taste are conjoined as ongoing, multiply inflected lived histories of food and eating. Collecting life histories of food is one useful method for researching these patterned and idiosyncratic food and eating experiences.     

Civic Learning for a Democracy in Crisis

This essay introduces a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the John S. and James L. Knight Foundation. This multiauthored report offers wide‐ranging assessments of increasing polarization and partisanship in American government and politics, and it proposes constructive responses to this in the provision of objective information, institutional reforms in government and the electoral system, and a reexamination of cultural and political values needed if democracy is to function well in a pluralistic and diverse society. The essays in the special report explore the norms of civic learning and institutions, social movements, and communal innovations that can revitalize civic learning in practice. This introductory essay defines and explains the notion of civic learning, which is a lynchpin connecting many of the essays in the report. Civic learning pertains to the ways in which citizens learn about collective social problems and make decisions about them that reflect the duties and responsibilities of citizenship. Such learning can occur in many social settings in everyday life, and it can also be facilitated through participation in the processes of democratic governance on many levels. Civic learning is not doctrinaire and is compatible with a range of public goals and policies. It is an activity that increases what might be called the democratic capability of a people.     

Learning outcomes and instructional objectives: is there a difference?

Learning outcomes are broad statements of what is achieved and assessed at the end of a course of study. The concept of learning outcomes and outcome-based education is high on today's education agenda. The idea has features in common with the move to instructional objectives which became fashionable in the 1960s, but which never had the impact on education practice that it merited. Five important differences between learning outcomes and instructional objectives can be recognized: (1) Learning outcomes, if set out appropriately, are intuitive and user friendly. They can be used easily in curriculum planning, in teaching and learning and in assessment. (2) Learning outcomes are broad statements and are usually designed round a framework of 8-12 higher order outcomes. (3) The outcomes recognize the authentic interaction and integration in clinical practice of knowledge, skills and attitudes and the artificiality of separating these. (4) Learning outcomes represent what is achieved and assessed at the end of a course of study and not only the aspirations or what is intended to be achieved. (5) A design-down approach encourages ownership of the outcomes by teachers and students.     

Electrospun matrices made of poly(alpha-hydroxy acids) for medical use

Biomaterials are widely used in diverse applications as substances, materials or important elements of biomedical devices. Biodegradable polymers, both natural and synthetic, have been utilized in applications in which they act as temporary substitutes. Poly(alpha-hydroxy acids), especially lactic acids and glycolic acid and their copolymers with epsilon-caprolactone, are the most widely known and used among all biodegradable polymers. They degrade in vivo into safe end products mainly by hydrolysis in a few weeks to several months, depending on several factors, including molecular structure/morphology, average molecular weight, size and shape. They are processed into tailor-made materials for diverse applications, although mainly for soft and hard tissue repair. Electrospinning is a method of producing nanofibers and nonwoven matrices from their solutions and melts. Several factors affect fiber diameter and resulting nonwoven structures/morphologies. Recently, electrospun matrices made of lactic acids, glycolic acid and epsilon-caprolactone homo- and co-polymers have been attracting increasing attention for fabrication of novel materials for medical use. This review briefly describes poly(alpha-hydroxy acids) and the elecrospinning process, and gives some selected recent applications of electrospun matrices made from these polymers.     

Stigma and rejection: living with AIDS in villages in southern Thailand

The problems that face HIV/AIDS patients are now fairly well documented. These include experiences of guilt, anger, grief, fear of abandonment, and potential economic hardship and marginalization due to others' fear of infection and associated stigma. However, limited attention has been paid to the effects of AIDS-related stigma on access to, and the provision of, health services. Understanding how the stigma of AIDS affects the processes and experiences of diagnosis, treatment, prevention, and care is critical to effective public health policy and the delivery of health care programs and medical services. In this article, we examine stigma as experienced by people with HIV and AIDS, and by their families, in village Thailand. We also identify areas for improvement pertaining to people with HIV/AIDS and other stigmatizing diseases.     

Death and injury from automobile collisions: an overlooked epidemic

Automobile collisions are a major source of injury, death, and disability worldwide. Roadway injuries are affected by societal and cultural influences as much as any other health-related event, but have historically received relatively little attention from the medical anthropology community. The development of safety intervention strategies is affected by notions of responsibility for preventive care, including a balance between regulation, technology, and personal choice. This balance may be affected by perceptions of the risks associated with roadway use, potentially related to notions of individual control and the portrayal of collisions in the popular media and lexicon. Prevention efforts are also affected by the definition of injury as a disease-a biological phenomenon requiring research and intervention efforts from the medical and public health communities. Injury prevention priorities and strategies also differ across cultures and locales, dependent in part on economic constraints, native mobility practices, and the quality and expediency of post-trauma care. Progressing injury prevention worldwide requires multidisciplinary action, including an examination of these various cultural and societal influences. We believe that future efforts will benefit from the expertise and analysis of the medical anthropology community.     

The transition from face-to-face to online CME facilitation

This study examines the experiences of nine medical teachers who transitioned from face-to-face teaching to facilitating a course in an online environment. The authors examined the reasons why the teachers agreed to facilitate an online course, the challenges they encountered and their practical solutions, and the advantages and disadvantages they perceived to this teaching environment. Thirty-minute phone interviews were conducted. An iterative process was used to develop the themes and sub-themes for coding. Teachers reported being attracted to the novelty of the new instructional format and saw online learning as an opportunity to reach different learners. They described two facets to the transition associated with the technical and facilitation aspects of online facilitation. They had to adapt their usual teaching materials and determine how they could make the 'classroom' user friendly. They had to determine ways to encourage interaction and facilitate learning. Lack of participation was frustrating for most. This study has implications for those intending to develop online courses. Teacher selection is important as teachers must invest time in course development and teaching and encourage participation. Teacher support is critical for course design, site navigation and mentoring to ensure teachers facilitate online discussion.     

AMEE Medical Education Guide No. 23 (Part 1): Curriculum,environment, climate,quality and change in medical education-a unifying perspective

This paper looks at five focal terms in education - curriculum, environment, climate, quality and change - and the interrelationships and dynamics between and among them. It emphasizes the power and utility of the concept of climate as an operationalization or manifestation of the curriculum and the other three concepts. Ideas pertaining to the theory of climate and its measurement can provide a greater understanding of the medical curriculum. The learning environment is an important determinant of behaviour. Environment is perceived by students and it is perceptions of environment that are related to behaviour. The environment, as perceived, may be designated as climate. It is argued that the climate is the soul and spirit of the medical school environment and curriculum. Students' experiences of the climate of their medical education environment are related to their achievements, satisfaction and success. Measures of educational climate are reviewed and climate measures for medical education are discussed. These should take account of current trends in medical education and curricula. Measures of the climate may subdivide it into different components giving, for example, a separate assessment of so-called Faculty Press, Student Press, Administration Press and Physical or Material Environmental Press. Climate measures can be used in different modes with the same stakeholders. For example, students may be asked to report, first, their perceptions of the actual environment they have experienced and, second, to report on their ideal or preferred environment. The same climate index can be used with different stakeholders giving, for example, staff and student comparisons. In addition to the educational climate of the environment that students inhabit, it is important to consider the organizational climate of the work environment that staff inhabit. This organizational climate is very significant, not only for staff, but for their students, too. The medical school is a learning organization evolving and changing in the illuminative evaluation it makes of its environment and its curriculum through the action research studies of its climate. Considerations of climate in the medical school, along the lines of continuous quality improvement and innovation, are likely to further the medical school as a learning organization with the attendant benefits. Unless medical schools become such learning organizations, their quality of health and their longevity may be threatened.