Talking about cases in bioethics: the effect of an intensive course on health care professionals

Bioethical knowledge in students and health professionals: a systematic review

Introduction

Bioethics training is essential for healthcare professionals as it enables them to address ethical dilemmas in their clinical practice. However, there is still a lack of rigorous teaching programs, and assessing bioethical knowledge poses challenges.

Methodology

Systematic review using the PRISMA method.

Results

Analysis of 27 studies reveals a lack of ethical knowledge and skills among healthcare professionals and students. Specific training in bioethics is effective in developing bioethical competencies. Different approaches have been employed, including integrated training in academic curricula and intensive or ongoing programs. The results demonstrate improvements in knowledge, attitudes, and ethical values, although regularly updating these courses is recommended.

Conclusion

Specific training, institutional support, and considering regional and disciplinary differences are necessary to enhance ethics in the practice of healthcare professionals.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023437146, identifier CRD42023437146.

An exploration of how gender, political affiliation, or religious identity is associated with comfort and perceptions of controversial topics in bioethics

Bioethics is an important aspect of understanding the relationship between science and society, but studies have not yet examined undergraduate student experiences and comfort in bioethics courses. In this study, we investigated undergraduate bioethics students' support of and comfort when learning three controversial bioethics topics: gene editing, abortion, and physician-assisted suicide (PAS). Furthermore, student identity has been shown to influence how students perceive and learn about controversial topics at the intersection of science and society. So, we explored how students' religious affiliation, gender, or political affiliation was associated with their support of and comfort when learning about gene editing, abortion, and PAS. We found that most students entered bioethics with moderated viewpoints on controversial topics but that there were differences in students' tendency to support each topic based on their gender, religion, and political affiliation. We also saw differences in student comfort levels based on identity: women reported lower comfort than men when learning about gene editing, religious students were less comfortable than nonreligious students when learning about abortion and PAS, and nonliberal students were less comfortable than liberal students when learning about abortion. Students cited that the controversy surrounding these topics and a personal hesitancy to discuss them caused discomfort. These findings indicate that identity impacts comfort and support in a way similar to that previously shown in the public. Thus, it may be important for instructors to consider student identity when teaching bioethics topics to maximize student comfort, ultimately encouraging thoughtful consideration and engagement with these topics.

Ethics Education in COVID-19: Preclinical Medical Students' Approach to Ventilator Allocation

Introduction COVID-19 has confronted clinicians with a potential need to ration ventilators. There is little guidance for training medical students to make such decisions in future practice. How students would make ventilator triage decisions remains unknown. Methods One hundred fifty-three medical students in 18 problem-based learning groups participated in a ventilator-rationing exercise in April 2020 as part of an ethics curriculum adapted in response to the COVID-19 pandemic. Students were provided with a prompt requiring fictional patients to be prioritized for ventilators in the face of scarce resources. The authors reviewed group responses, tallied triage criteria, and identified approaches to triage decisions. Results The most common triage criteria were patient comorbidities, clinical status, age/life stage, prognosis, life expectancy, and an individual's role in pandemic response. Additional criteria included quality of life, ventilator availability, public perception, and patient need. Students approached triage decisions by developing systems for triage, appealing to empirical evidence and academic literature, making value judgments, and identifying adjuncts and alternatives to triage. Discussion With minimal input from educators, students learned key ethical principles in triage medicine, recapitulated approaches to triage described in the clinical and bioethics literature, and suggested methods for tolerating distress of complex ethical decisions. Medical education should equip students to critically consider bioethical concerns in triage and prepare for possible moral distress during public health crises.

Postgraduate ethics training programs: a systematic scoping review

BACKGROUND

Molding competent clinicians capable of applying ethics principles in their practice is a challenging task, compounded by wide variations in the teaching and assessment of ethics in the postgraduate setting. Despite these differences, ethics training programs should recognise that the transition from medical students to healthcare professionals entails a longitudinal process where ethics knowledge, skills and identity continue to build and deepen over time with clinical exposure. A systematic scoping review is proposed to analyse current postgraduate medical ethics training and assessment programs in peer-reviewed literature to guide the development of a local physician training curriculum.

METHODS

With a constructivist perspective and relativist lens, this systematic scoping review on postgraduate medical ethics training and assessment will adopt the Systematic Evidence Based Approach (SEBA) to create a transparent and reproducible review.

RESULTS

The first search involving the teaching of ethics yielded 7669 abstracts with 573 full text articles evaluated and 66 articles included. The second search involving the assessment of ethics identified 9919 abstracts with 333 full text articles reviewed and 29 articles included. The themes identified from the two searches were the goals and objectives, content, pedagogy, enabling and limiting factors of teaching ethics and assessment modalities used. Despite inherent disparities in ethics training programs, they provide a platform for learners to apply knowledge, translating it to skill and eventually becoming part of the identity of the learner. Illustrating the longitudinal nature of ethics training, the spiral curriculum seamlessly integrates and fortifies prevailing ethical knowledge acquired in medical school with the layering of new specialty, clinical and research specific content in professional practice. Various assessment methods are employed with special mention of portfolios as a longitudinal assessment modality that showcase the impact of ethics training on the development of professional identity formation (PIF).

CONCLUSIONS

Our systematic scoping review has elicited key learning points in the teaching and assessment of ethics in the postgraduate setting. However, more research needs to be done on establishing Entrustable Professional Activities (EPA)s in ethics, with further exploration of the use of portfolios and key factors influencing its design, implementation and assessment of PIF and micro-credentialling in ethics practice.

Ethics and empathy: The relationship between moral reasoning, ethical sensitivity and empathy in medical students

High-quality clinical practice includes not only improving clinicians' expertise in scientific and technical aspects but also managing values, ethical sensitivity and skills for assessing and dealing with ethical conflicts. The reviewed literature suggests the presence of an "ethical erosion", according to which ethical competence and empathy decrease or do not progress during medical training. The aim of this study was to determine the relationship between ethics (moral reasoning and ethical sensitivity) and empathy in a group of medical students and to determine the relationship with other variables such as academic year and sex.

MATERIAL AND METHOD

A cross-sectional observational study was conducted with 193 medical students from different academic years, who were administered a sociodemographic questionnaire, the Rest sociomoral dilemma test, clinical vignettes to measure ethical sensitivity (Problem Identification Test [PIT]) and a cognitive and emotional empathy test (test de empatía cognitiva y afectiva, TECA).

RESULTS

We found a direct and significant relationship between moral development, ethical sensitivity and greater empathy. We detected an increase in moral reasoning and ethical sensitivity among first and third-year students, with no increase between the third year and later academic years. There were no significant differences between these variables and sex.

CONCLUSIONS

This study found a correlation between moral reasoning, ethical sensitivity and empathy and a lack of progression of the first 2 variables in the last years of the medical degree.

[Assessing bioethics education: Teaching to be virtuous doctors or just doctors with practical ethical skills]

Objetivo

La bioética se ha incorporado en la formación de las Facultades de Medicina las últimas décadas. Diversos estudios analizan el desarrollo ético-moral de los estudiantes y el efecto de la educación ética, midiendo la evolución del razonamiento moral de Kohlberg (médicos virtuosos), y la sensibilidad ética para resolver casos clínicos (médicos con habilidades éticas). El objetivo del estudio es valorar el impacto de la formación en ética en estas dos variables en nuestro ámbito.

Diseño

Estudio observacional transversal.

Emplazamiento

Facultad de Medicina, Universidad de Lleida.

Participantes

Un total de 175 estudiantes de tercer curso de medicina (78 antes de realizar bioética y 97 después de realizar bioética, en diferentes cursos).

Intervención

Formación reglada en bioética.

Mediciones principales

Se administra un cuestionario sociodemográfico, el Defining Issue Test de Rest como medida del razonamiento moral, y el Problem Identification Test de Hébert como medida de la sensibilidad ética.

Resultados

Se halla una relación consistente y significativa entre razonamiento moral y sensibilidad ética. Las mujeres presentan mayor razonamiento posconvencional, es decir, mayor desarrollo moral. No se aprecian cambios en el estadio de razonamiento moral global de Kohlberg con la formación ética. Sí se incrementa de forma significativa y global la sensibilidad ética, medida en forma de Problem Identification Test.

Conclusión

No se hallan diferencias en el desarrollo moral de estudiantes de medicina antes y después de la formación reglada en bioética, pero sí con respecto a las habilidades en resolución de casos. Se plantea si esta mejora es suficiente para formar médicos preparados para los nuevos retos.

A Meta-analytic Comparison of Face-to-Face and Online Delivery in Ethics Instruction: The Case for a Hybrid Approach

Despite the growing body of literature on training in the responsible conduct of research, few studies have examined the effectiveness of delivery formats used in ethics courses (i.e., face-to-face, online, hybrid). The present effort sought to address this gap in the literature through a meta-analytic review of 66 empirical studies, representing 106 ethics courses and 10,069 participants. The frequency and effectiveness of 67 instructional and process-based content areas were also assessed for each delivery format. Process-based contents were best delivered face-to-face, whereas contents delivered online were most effective when restricted to compliance-based instructional contents. Overall, hybrid courses were found to be most effective, suggesting that ethics courses are best delivered using a blend of formats and content areas. Implications and recommendations for future development of ethics education courses in the sciences are discussed.

Process factors facilitating and inhibiting medical ethics teaching in small groups

PURPOSE

To examine process factors that either facilitate or inhibit learning medical ethics during case-based learning.

METHODS

A qualitative research approach using microanalysis of transcribed videotaped discussions of three consecutive small-group learning (SGL) sessions on medical ethics teaching (MET) for three groups, each with 10 students.

RESULTS

This research effort revealed 12 themes of learning strategies, divided into 6 coping and 6 evasive strategies. Cognitive-based strategies were found to relate to Kamin's model of critical thinking in medical education, thereby supporting our distinction between the themes of coping and evasive strategies. The findings also showed that cognitive efforts as well as emotional strategies are involved in discussions of ethical dilemmas. Based on Kamin's model and the constructivist learning theory, an examination of the different themes within the two learning strategies-coping and evasive-revealed that these strategies may be understood as corresponding to process factors either facilitating or inhibiting MET in SGL, respectively.

CONCLUSIONS

Our classification offers a more nuanced observation, specifically geared to pinpointing the desired and less desired process factors in the learning involved in MET in the SGL environment. Two key advantages of this observation are: (1) it brings to the forefront process factors that may inhibit and not merely facilitate MET in SGL and (2) it acknowledges the existence of emotional and not just cognitive process factors. Further enhancement of MET in SGL may thus be achieved based on these observations.

Review of Instructional Approaches in Ethics Education

Increased investment in ethics education has prompted a variety of instructional objectives and frameworks. Yet, no systematic procedure to classify these varying instructional approaches has been attempted. In the present study, a quantitative clustering procedure was conducted to derive a typology of instruction in ethics education. In total, 330 ethics training programs were included in the cluster analysis. The training programs were appraised with respect to four instructional categories including instructional content, processes, delivery methods, and activities. Eight instructional approaches were identified through this clustering procedure, and these instructional approaches showed different levels of effectiveness. Instructional effectiveness was assessed based on one of nine commonly used ethics criteria. With respect to specific training types, Professional Decision Processes Training (d = 0.50) and Field-Specific Compliance Training (d = 0.46) appear to be viable approaches to ethics training based on Cohen's d effect size estimates. By contrast, two commonly used approaches, General Discussion Training (d = 0.31) and Norm Adherence Training (d = 0.37), were found to be considerably less effective. The implications for instruction in ethics training are discussed.

Assessment of perceived needs and preferences with regard to the education of residents in Medical Ethics in King Abdulaziz University Hospital

INTRODUCTION:

Medical ethics is the branch of ethics that deals with moral issues in medical practice. Many postgraduate training programs have developed educational interventions in ethics to meet accreditation standards and prepare learners for certification examinations and clinical practice. The aim of this study was to assess the attitude of residents in King Abdulaziz University Hospital (KAUH) toward the need for ethics education and identify the most effective methods of teaching ethical issues.

MATERIALS AND METHODS:

A cross-sectional study of residents in different specialties at KAUH was conducted using a self-administered questionnaire. The questionnaire consisted of four parts: demographic data, assessment of the educational need for ethics education, assessment of the impact of various learning methods, and assessment of the need for ethically important practices and behavior. SPSS version 16.0 was used for data entry and analysis. Descriptive analysis included frequency distribution, percentages, mean, and standard deviation (SD); Chi-square test and t-test were employed to determine statistical significance.

RESULTS:

Eighty-eight of the 102 residents invited to participate in the study returned completed questionnaires, providing a response rate of 86.3%. Their ages ranged between 24 and 38 years with a mean of 27.7 (standard deviation 2.8) years. Approximately two-thirds of the residents (65.9%) agreed that medical ethics can be taught and learned while only 19.3% of them disagreed. The most effective methods of ethical education according to the residents were discussion groups of peers led by a knowledgeable clinician (78.4%), clinical rounds (72.7%), and an incorporation of ethical issues into lectures and teaching rounds (69.3%).

CONCLUSION:

This study documents the importance residents placed on ethics education directed at practical, real-world dilemmas and ethically important professional developmental issues.

Qualitative Evaluation Methods in Ethics Education: A Systematic Review and Analysis of Best Practices

Although qualitative research offers some unique advantages over quantitative research, qualitative methods are rarely employed in the evaluation of ethics education programs and are often criticized for a lack of rigor. This systematic review investigated the use of qualitative methods in studies of ethics education. Following a review of the literature in which 24 studies were identified, each study was coded based on 16 best practices characteristics in qualitative research. General thematic analysis and grounded theory were found to be the dominant approaches used. Researchers are effectively executing a number of best practices, such as using direct data sources, structured data collection instruments, non-leading questioning, and expert raters. However, other best practices were rarely present in the courses reviewed, such as collecting data using multiple sources, methods, raters, and timepoints, evaluating reliability, and employing triangulation analyses to assess convergence. Recommendations are presented for improving future qualitative research studies in ethics education.

Exploring Institutional Research Ethics Systems: A Case Study From Uganda

BACKGROUND

The increasing globalization of research drives a need for greater research ethics capacity in low resource countries. Several programs have attempted to expand research ethics capacity by training individuals, but few have focused on broader research ethics systems and institutions. This study describes and applies an institutional research ethics model to assess the institutional research ethics capacity of Makerere University College of Heath Sciences (MakCHS) in 2011.

METHODS

Internal and external stakeholders conducted the assessment of MakCHS using the multidimensional Octagon framework. Five methods were used to collect data on current ethical processes and institutional relationships.

RESULTS

MakCHS scored in the mid range on all Octagon domains, with some variation between external and internal assessments. The external Octagon scores suggest that MakCHS's areas of strengths are in identity, structure, relevance, target groups, and working environment; needs are greater in the areas of production, competence, and systems of finance and administration. Discrepancies in external and internal assessment can serve as a useful platform to shape ongoing discussions and strategic efforts.

CONCLUSIONS

The assessment identified strengths, opportunities, and challenges for institutional research ethics capacity at MakCHS. We believe this systematic approach was helpful in evaluating research ethics needs and provides a benchmark for institutions to measure progress over time.

What is it to do good medical ethics? Minding the gap(s)

This paper discusses the character of medical ethics and suggests that there are significant gaps that warrant greater attention. It describes ways in which the content and form of medical ethics may exclude or marginalise perspectives and contributions, thereby reducing its influence and its potential impact on, and value to, patients, students, carers and society. To consider what it is 'to do good medical ethics' suggests an active approach that seeks out, and learns from, contributions beyond the traditional boundaries of scholarship.

Research ethics capacity development in Africa: exploring a model for individual success

The Johns Hopkins-Fogarty African Bioethics Training Program (FABTP) has offered a fully-funded, one-year, non-degree training opportunity in research ethics to health professionals, ethics committee members, scholars, journalists and scientists from countries across sub-Saharan Africa. In the first 9 years of operation, 28 trainees from 13 African countries have trained with FABTP. Any capacity building investment requires periodic critical evaluation of the impact that training dollars produce. In this paper we describe and evaluate FABTP and the efforts of its trainees. Our data show that since 2001, the 28 former FABTP trainees have authored or co-authored 105 new bioethics-related publications; were awarded 33 bioethics-related grants; played key roles on 78 bioethics-related research studies; and participated in 198 bioethics workshops or conferences. Over the past nine years, trainees have collectively taught 48 separate courses related to bioethics and have given 170 presentations on various topics in the field. Many former trainees have pursued and completed doctoral degrees in bioethics; some have become editorial board members for bioethics journals. Female trainees were, on average, less experienced at matriculation and produced fewer post-training outputs than their male counterparts. More comprehensive studies are needed to determine the relationships between age, sex, previous experience and training program outputs.

A multicenter study of the awareness and attitudes of Egyptian faculty towards research ethics: a pilot study

The awareness and attitudes of faculty towards research ethics committees (RECs) and research ethics practices are largely unknown. Accordingly, we conducted a cross-sectional survey study involving various faculties (Medicine, Nursing, Pharmacy, and Dentistry) from four universities in Egypt. A large majority (> 85%) held positive attitudes towards RECs, but almost a third thought that RECs would delay research. More than half had not received prior training in research or medical ethics, but more than 90% thought that this subject matter should be taught to postgraduates. A large majority recognized the need for informed consent and confidentiality protections in research, but some held attitudes regarding certain research ethics practices that were questionable. We conclude that a curriculum in research ethics should be developed for university faculty and that further qualitative studies should explore the basis of several of the attitudes regarding practices in research ethics.

Towards an understanding of resilience and its relevance to medical training

OBJECTIVES

This article explores the concept of resilience and its potential relevance to medicine. It also looks at the dimensions of resilience and its ethical importance for effective professional practice, and considers whether a focus on resilience might be useful in medical training.

METHODS

An applied literature search was conducted across the domains of education, ethics, psychology and sociology to answer the research question: 'What is resilience and what might it mean for professional development in medical education?' This article predominantly considers the findings in relation to training in undergraduate and postgraduate settings, although the literature is wide-ranging and findings may be applicable elsewhere.

RESULTS

  Resilience is a dynamic capability which can allow people to thrive on challenges given appropriate social and personal contexts. The dimensions of resilience (which include self-efficacy, self-control, ability to engage support and help, learning from difficulties, and persistence despite blocks to progress) are all recognised as qualities that are important in clinical leaders. Much of what is deemed good practice in modern pedagogical approaches to medical training may support the development of resilience in adulthood, but this concept has rarely been used as a goal of professional development. More research is needed on the ways in which resilience can be recognised, developed and supported during and after clinical training.

CONCLUSIONS

  Resilience is a useful and interesting construct which should be further explored in medical education practice and research.

Knowledge, Awareness, and Attitudes about Research Ethics among Dental Faculty in the Middle East: A Pilot Study

Objective. To assess the knowledge, awareness, and attitudes of dental faculty regarding research ethics and research ethics committees (RECs). Design. Through convenience sampling, we distributed a survey to academics at dental faculties at two universities in the Middle East. We used descriptive, chi-square, and logistic regression statistics to analyze the data. Results. Our response rate was 62.5%. A large majority (>90%) held positive attitudes towards RECs; however, almost half (44.0%) thought that RECs would delay research. Less than half (36.8%) had received prior training in research ethics, and the average score they achieved on the questions on research ethics was only 40.2%. Most (>90%), however, were favorable towards research ethics education. Finally, some faculty held attitudes regarding certain research ethics practices that were not optimal. Conclusions. We conclude that among the dental faculties participating in our study, there is broad-based acceptance of RECs and training in research ethics, while there are knowledge gaps in research ethics. We recommend further studies to determine the generalizability of our findings to other institutions.

Medical student attitudes about bioethics

Professionalism is demonstrated through attitudes and behaviors. Medical education is concerned with teaching and evaluating it among students. It is often bioethicists who teach professionalism to medical students. Most bioethics curricula use lectures and group discussions to introduce principles and theories, but there is variation in number of credit and contact hours, placement in the curriculum (which year(s) and alongside which courses bioethics is placed), the extent of individual mentoring, and the emphasis placed on any particular philosophical approach. Bioethics curricula also vary in whether and how explicitly and extensively they address topics, including professionalism, cultural competence, medical humanities, spirituality, death and dying, and community service, and in the number and topics of vignettes, controversies, assignments, and course activities.

Ethics and adolescent care: an international perspective

PURPOSE OF REVIEW

This update reviews the concepts underlying ethical issues in various contexts and countries, highlighting the evolution in the use of the core values underpinning the field and practice of bioethics as applied to healthcare.

RECENT FINDINGS

It stresses the specific position of the adolescent as being a unique individual searching for autonomy and, most of the time, being competent to make decisions regarding the adolescent's own health. It briefly outlines the principles of a 'deliberative' approach in which the practitioner, while keeping in mind the legal context of the country where the practitioner is working, assesses to what extent the adolescent can be considered as competent, and then discusses with the adolescent the medical and psychosocial aspects of the various actions to be taken in a situation, as well as the basic ethical values linked with each of the various options available. The deliberation can involve relevant stakeholders, provided the issues concerning confidentiality have been fully discussed with the adolescent.

SUMMARY

This process forces the practitioner, the adolescent patient and those who care for the adolescent patient to look outside their usual frameworks and make a decision that is in the best interest of the young person, and is informed by various ethical values.

Dysthanasia, euthanasia, orthotanasia: the perceptions of nurses working in intensive care units and care implications

This study aimed to analyze the perceptions of nurses working in the Intensive Care Unit (ICU) of a University Hospital in Brazil concerning dysthanasia, orthotanasia and euthanasia and characterize potential implications of their perceptions for care. This quantitative study was carried out with the application of a questionnaire to 27 nurses after approval from the institution's Ethics Committee and authorization from participants were obtained. None of the nurses were able to explain euthanasia, half of them explained dysthanasia, and only a third explained orthotanasia, 65.39% recognized some of these processes in their daily practice, 25.9% believed nurses cannot provide any contribution even being familiar with these concepts and their applicability, 82.36% believed that knowledge of bioethical principles is relevant but only 14.81% were able to mention these principles. The bases of nurses' professional practice were not homogeneous and knowledge about the subject was limited. Orthotanasia, bioethical principles and the delivery of humanized care should be the foundation of nursing care.

Application of a sensemaking approach to ethics training in the physical sciences and engineering

Integrity is a critical determinant of the effectiveness of research organizations in terms of producing high quality research and educating the new generation of scientists. A number of responsible conduct of research (RCR) training programs have been developed to address this growing organizational concern. However, in spite of a significant body of research in ethics training, it is still unknown which approach has the highest potential to enhance researchers' integrity. One of the approaches showing some promise in improving researchers' integrity has focused on the development of ethical decision-making skills. The current effort proposes a novel curriculum that focuses on broad metacognitive reasoning strategies researchers use when making sense of day-to-day social and professional practices that have ethical implications for the physical sciences and engineering. This sensemaking training has been implemented in a professional sample of scientists conducting research in electrical engineering, atmospheric and computer sciences at a large multi-cultural, multi-disciplinary, and multi-university research center. A pre-post design was used to assess training effectiveness using scenario-based ethical decision-making measures. The training resulted in enhanced ethical decision-making of researchers in relation to four ethical conduct areas, namely data management, study conduct, professional practices, and business practices. In addition, sensemaking training led to researchers' preference for decisions involving the application of the broad metacognitive reasoning strategies. Individual trainee and training characteristics were used to explain the study findings. Broad implications of the findings for ethics training development, implementation, and evaluation in the sciences are discussed.

A qualitative approach to Responsible Conduct of Research (RCR) training development: identification of metacognitive strategies

Although Responsible Conduct of Research (RCR) training is common in the sciences, the effectiveness of RCR training is open to question. Three key factors appear to be particularly important in ensuring the effectiveness of ethics education programs: (1) educational efforts should be tied to day-to-day practices in the field, (2) educational efforts should provide strategies for working through the ethical problems people are likely to encounter in day-to-day practice, and (3) educational efforts should be embedded in a broader program of on-going career development efforts. This article discusses a complex qualitative approach to RCR training development, based on a sensemaking model, which strives to address the afore-mentioned training concerns. Ethnographic observations and prior RCR training served the purpose of collecting information specific to a multi-disciplinary and multi-university research center with the goal of identifying metacognitive reasoning strategies that would facilitate ethical decision-making. The extensive qualitative analyses resulted in the identification of nine metacognitive reasoning strategies on which future RCR training will be developed. The implications of the findings for RCR training in the sciences are discussed.

A dynamic model of ethical reasoning in speech pathology

Ten new graduate speech pathologists recounted their experiences in managing workplace ethical dilemmas in semi-structured interviews. Their stories were analysed for elements that described the nature and management of the ethical dilemmas. Ethical reasoning themes were generated to reflect the participants' approaches to managing these dilemmas. Finally, a conceptual model, the Dynamic Model of Ethical Reasoning, was developed. This model incorporates the elements of awareness, independent problem solving, supported problem solving, and decision and outcome evaluation. Features of the model demonstrate the complexity of ethical reasoning and the challenges that new graduates encounter when managing ethical dilemmas. The results have implications for preparing new graduates to manage ethical dilemmas in the workplace.

Critique of the "tragic case" method in ethics education

It is time for the noon conference. Your job is to impart a career-changing experience in ethics to a group of students and interns gathered from four different schools with varying curriculums in ethics. They have just finished 1 1/2 h of didactic sessions and lunch. One third of them were on call last night. Your first job is to keep them awake. The authors argue that this "tragic case" approach to ethics education is of limited value because it limits understanding of moral problems to dilemmas; negates the moral agency of the student; encourages solutions that are merely intellectual; and suggests that ethical encounters are a matter for experts. The authors propose an alternative that focuses on three issues: the provider-patient relationship, the relationships between providers in the everyday world of health work and, the social position of healthcare providers in society. In this approach, teachers are not experts but more like guides on a journey who help students to learn that much of ethical practice comprises living through difficult situations of caring for vulnerable others and who help students to navigate some of these difficulties.

Ethical decision making on truth telling in terminal cancer: medical students' choices between patient autonomy and family paternalism

INTRODUCTION

The effect of medical education is often hard to evaluate. We tried to assess whether a 2-hour, small-group discussion could alter student perspectives on truth telling. Currently, in Taiwan it is common practice to consult with the family of a terminally ill patient before telling the truth to the patient, which may be in conflict with patient autonomy.

METHODS

The study was based on content analysis of self-reflective written texts after a 2-hour group discussion on a clinical case describing a truth-telling situation. The changes in decision patterns regarding the emphasis placed on patient autonomy versus family paternalism and the connection to related moral reasoning were subjected to focus analysis.

RESULTS

The students' initial attitudes regarding the subject of truth telling were categorised into 4 patterns, namely, patient-centred (n = 46), family-centred (n = 20), simultaneous informing (n = 1), and situational informing (n = 5) modes. The discussion stimulated perspective changes in many of the students and their attitudes were then regrouped as patient-comprehensive (n = 35), family-centred (n = 1), and family-comprehensive (n = 36) modes. It was found that variations on 'common sense' and moral reasoning existed prior to the class and the students initially tended to overlook the complexity of truth telling in terminal cancer. Through the discussion and reflective learning, they were enabled to acknowledge the vulnerability of both the patient and his or her family, and to make decisions based on more comprehensive considerations.

CONCLUSION

Group discussion seemed to be able to enhance ethical consideration. Further research is required to determine whether the benefits of this approach can be translated into behavioural changes in practice.

Barriers to translating emerging genetic research on smoking into clinical practice. Perspectives of primary care physicians

OBJECTIVE

Smoking remains the leading cause of preventable death nationally. Emerging research may lead to improved smoking cessation treatment options, including tailoring treatment by genotype. Our objective was to assess primary care physicians' attitudes toward new genetic-based approaches to smoking treatment.

DESIGN AND SETTING

A 2002 national survey of primary care physicians. Respondents were randomly assigned a survey including 1 of 2 scenarios: a scenario in which a new test to tailor smoking treatment was described as a "genetic" test or one in which the new test was described as a "serum protein" test.

PARTICIPANTS

The study sample was randomly drawn from all U.S. primary care physicians in the American Medical Association Masterfile (e.g., those with a primary specialty of internal medicine, family practice, or general practice). Of 2,000 sampled physicians, 1,120 responded, yielding a response rate of 62.3%.

MEASUREMENTS AND MAIN RESULTS

Controlling for physician and practice characteristics, describing a new test as "genetic" resulted in a regression-adjusted mean adoption score of 73.5, compared to a score of 82.5 for a nongenetic test, reflecting an 11% reduction in physicians' likelihood of offering such a test to their patients.

CONCLUSIONS

Merely describing a new test to tailor smoking treatment as "genetic" poses a significant barrier to physician adoption. Considering national estimates of those who smoke on a daily basis, this 11% reduction in adoption scores would translate into 3.9 million smokers who would not be offered a new genetic-based treatment for smoking. While emerging genetic research may lead to improved smoking treatment, the potential of novel interventions will likely go unrealized unless barriers to clinical integration are addressed.

Ethics and communication between physicians and their patients with cancer, HIV/AIDS, and rheumatoid arthritis in Mexico

BACKGROUND

Despite evidence that open communication concerning diagnosis of a disease substantially improves the doctor-patient relationship, in developing countries physicians often provide partial information.

METHODS

We carried out a cross-sectional study with 379 physicians practicing at 11 hospitals in Mexico City and in the central Mexican state of Morelos to quantify their communication patterns with patients with cancer, HIV/AIDS, and rheumatoid arthritis. Communication patterns were defined as physician self-reported communication with patients with regard to their diagnosis, prognosis, and treatment. Logistic, ordinal, multivariate models were constructed for analysis.

RESULTS

Assigning a high level of value to communication (odds ratio [OR] 5.5, 95% confidence interval [95% CI] 2.1-14.8), and bioethics training (OR 1.5, 95% CI 1.0-2.3) were principal predictors of explicit communication with cancer patients. We found a very strong association between explicit communication with HIV/AIDS patients and an accepting attitude of the physician toward death (OR 34.6, 95% CI 8.5-141.0). As for communication with rheumatoid arthritis patients, we observed an association between a very paternalistic attitude on the part of the physician (OR 6.8, 95% CI 1.9-24.1) and complete communication.

CONCLUSIONS

In Mexico, physicians exercise power and authority over patients in an effort that they perceive as beneficial or preventing harm. In most cases, physicians do not seem to recognize or respect their patients' autonomy; therefore, communication is generally partial and vague. Our study established the need among physicians for bioethics and communication training. A discussion of this topic is necessary to transform the doctor-patient relationship and to establish a consensus for policies and norms for communication that benefits patients.

Education in ethics

Ethics is the system of thought that analyzes moral judgments. Among the key features of ethics are: (1) it must be translatable into moral action; (2) it is a public system rather than a private activity, and no one can act morally without reference to other individuals; and (3) the fundamental ethical principles underpinning medical ethics are those of society in general. Among the purposes of education in ethics are the development of consistent, critical, and reflective attitudes to ethical decision-making; increasing awareness of ethical dilemmas in one's own practice and that of others; and reinforcement of best practices in clinical and research governance. Ethics is the system of thought that analyzes moral judgments. Among the key features of ethics are: (1) it must be translatable into moral action; (2) it is a public system rather than a private activity, and no one can act morally without reference to other individuals; and (3) the fundamental ethical principles underpinning medical ethics are those of society in general. Among the purposes of education in ethics are the development of consistent, critical, and reflective attitudes to ethical decision-making; increasing awareness of ethical dilemmas in one's own practice and that of others; and reinforcement of best practices in clinical and research governance.