Interculturalisation of medical education in the Netherlands

The number of immigrants within the Netherlands is rapidly increasing. Towards the year 2010 two million first- or second-generation allochthonous persons will be living in the Netherlands. Their origin is extremely diverse. One district of Rotterdam contains more than 100 different nationalities. Medical education should prepare for these changes in the patient population. Education on import diseases as well as on communication via interpreters is necessary. The characteristics of the Dutch healthcare system (partnership between physician and patient, limited use of drug therapy, emphasis on lifestyle advice, and a central role of primary care) should remain the hallmark of medical education. The rapid influx of second-generation, non-western medical students to the medical faculties should be used to realise internal changes to the medical education system, so that it is adapted to the different medical needs of all persons in the Netherlands.     

临床医学院开展医学伦理学教育的探讨

本文在对医学伦理学概念及其内涵界定的基础上，立足于国内外医学伦理学教育的现状，分析了临床医学院开展医学伦理学教学的必要性，并进一步探讨了如何在临床医学院开展医学伦理学教育，认为临床医学院医学伦理学教育应结合医德教育有重点、分层次推进的模式进行。     

Institutional ethics policies on medical end-of-life decisions: a literature review

OBJECTIVES: The responsibility of healthcare administrators for handling ethically sensitive medical practices, such as medical end-of-life decisions (MELDs), within an institutional setting has been receiving more attention. The overall aim of this paper is to thoroughly examine the prevalence, content, communication, and implementation of written institutional ethics policies on MELDs by means of a literature review. METHODS: Major databases (Pubmed, Cinahl, PsycINFO, Cochrane Library, FRANCIS, and Philosopher's Index) and reference lists were systematically searched for all relevant papers. Inclusion criteria for relevance were that the study was empirically based and that it focused on the prevalence, content, communication, or implementation of written institutional ethics policies concerning MELDs. RESULTS: Our search yielded 19 studies of American, Canadian, Dutch and Belgian origin. The majority of studies dealt with do-not-resuscitate (DNR) policies (prevalence: 10-89%). Only Dutch and Belgian studies dealt with policies on pain and symptom control (prevalence: 15-19%) and policies on euthanasia (prevalence: 30-79%). Procedural and technical aspects were a prime focus, while the defining of the specific roles of involved parties was unclear. Little attention was given to exploring ethical principles that question the ethical function of policies. In ethics policies on euthanasia, significant consideration was given to procedures that dealt with conscientious objections of physicians and nurses. Empirical studies about the implementation of ethics policies are scarce. CONCLUSIONS: With regard to providing support for physicians and nurses, DNR and euthanasia policies expressed support by primarily providing technical and procedural guidelines. Further research is needed whether and in which way written institutional ethics policies on MELDs could contribute to better end-of-life care.     

Teaching of medical ethics

Teaching medical ethics in Manchester within the introductory course of obstetrics and gynaecology is a joint activity with the Centre for Social Ethics and Policy. This interdisciplinary teaching has evolved through lecture sessions with small-group discussions dealing with topics of interest in human reproduction. The small-group discussion have been replaced by an open debate conducted by the students. Their own involvement and participation and an exposure to the disciplines of the humanities has broadened their approach to different ways of problem-solving of these real issues.     

A checklist system for critical review of medical literature

In order to teach critical review of medical literature, an approach was devised in a family practice residency setting for teaching students and doctors to review medical literature quickly while remaining critical of what is read. This is done through the use of a simple checklist which guides the user in reading an article. Such a checklist is readily modified to suit individual needs, is self-explanatory, and lends itself to use in journal club settings as well as in private reading.     

Reimbursement for alternative medical treatment in the Netherlands, incomprehensible

It is remarkable that, at a time when not only doctors but also the Health Care Inspectorate (IGZ) and the health insurance companies are paying increasing attention to the quality of conventional medicine, many alternative methods of treatments without a scientific basis are accepted in the Netherlands. Even though it has been conclusively demonstrated that most alternative therapies do not work and despite the absence of scientific proof of the safety and efficacy of alternative treatments, health insurance companies do often reimburse the incurred costs. Because the safety of alternative therapies is not guaranteed, these are neither in the interest of the patient nor of society. Moreover, they are associated with considerable costs for the individual patient. By reimbursing the costs of insufficiently proven treatments, the health insurance companies are applying double standards. Reimbursement for these therapies is made at the expense of other effective and proven treatments. This can be changed through the concerted efforts of policy-makers, doctors, the IGZ, and health insurance companies.     

Negotiating fees for medical specialists in The Netherlands

This article presents an analysis of the negotiations on fees for medical specialists in the Netherlands since the introduction of the Law on Health Care Charges (WTG) in 1982. The peculiar position of the medical specialists and the institutional setting of the negotiations have produced a complex decision making process. Negotiations between the government and the health insurers on the one hand and the association of medical specialists on the other hand have been dominated by deep conflicts which were sometimes settled by temporary "peace contracts'. Attention is paid to the policy network, to the participants in the network and their principal goals, to the strategic use of the WTG by each participant and to the political effectiveness of the WTG. The article ends with a short overview of some recent developments and a sketch of three alternative scenarios on the future of the payment for specialist care.     

现代医德:医学伦理本性的回归

医德是医学的伦理本性的集中体现。现代社会的发展客观上要求医学不断彰显其伦理本性,而现实中医德正面临着一个失去规范的时代,这使医学越来越偏离其伦理本性。重整现代医德是要使医学回归其伦理本性的根本途径。     

Teaching medical ethics: A review of the literature from North American medical schools with emphasis on education

Efforts to reform medical education have emphasized the need to formalize instruction in medical ethics. However, the discipline of medical ethics education is still searching for an acceptable identity among North American medical schools; in these schools, no real consensus exists on its definition. Medical educators are grappling with not only what to teach (content) in this regard, but also with how to teach (process) ethics to the physicians of tomorrow. A literature review focused on medical ethics education among North American medical schools reveals that instruction in ethics is considered to be vitally important for medical students. Agreement by medical educators on a possible “core curriculum” in ethics should be explored. To develop such a curriculum, “deliberative curriculum inquiry” by means of a targeted Delphi technique may be a useful methodology. However, the literature reveals that medical curricular change is notoriously slow. General implications for medical ethics education as a discipline are discussed. This revised version was published online in July 2006 with corrections to the Cover Date.     

Feminist directions in medical ethics

I explore some new directions - suggested by feminism - for medical ethics and for philosophical ethics generally. Moral philosophers need to confront two issues. The first is deciding which moral issues merit attention. Questions which incorporate the perspectives of women need to be posed - e.g., about the unequal treatment of women in health care, about the roles of physician and nurse, and about relationship issues other than power struggles. "Crisis issues" currently dominate medical ethics, to the neglect of what I call "housekeeping issues." The second issue is how philosophical moral debates are conducted, especially how ulterior motives influence our beliefs and arguments. Both what we select - and neglect - to study as well as the "games" we play may be sending a message as loud as the words we do speak on ethics.     

Health care ethics teaching for medical students

This paper describes an innovatory teaching programme in health care ethics for medical undergraduates. The general aims and objectives are outlined and the 1990 course is discussed specifically. The course has several unusual features, including the use of performers and the presentation of ethically based decisionmaking implements, which are highlighted. The course is evaluated. The 1990 results are encouraging.