A traditional approach to teaching medical ethics aims to provide knowledge about ethics. This is in line with an epistemological view on ethics in which moral expertise is assumed to be located in theoretical knowledge and not in the moral experience of healthcare professionals. The aim of this paper is to present an alternative, contextual approach to teaching ethics, which is grounded in a pragmatic-hermeneutical and dialogical ethics. This approach is called moral case deliberation. Within moral case deliberation, healthcare professionals (...) bring in their actual moral questions during a structured dialogue. The ethicist facilitates the learning process by using various conversation methods in order to find answers to the case and to develop moral competencies. The case deliberations are not unique events, but are a structural part of the professional training on the work floor within healthcare institutions. This article presents the underlying theory on ethics and illustrates this approach with an example of a moral case deliberation project in a Dutch psychiatric hospital. The project was evaluated using the method of responsive evaluation. This method provided us with rich information about the implementation process and effects the research process itself also lent support to the process of implementation. (shrink)

Knowledge of the ethical and legal basis of medicine is as essential to clinical practice as an understanding of basic medical sciences. In the UK, the General Medical Council requires that medical graduates behave according to ethical and legal principles and must know about and comply with the GMC’s ethical guidance and standards. We suggest that these standards can only be achieved when the teaching and learning of medical ethics, law and professionalism are fundamental to, and thoroughly integrated both vertically (...) and horizontally throughout, the curricula of all medical schools as a shared obligation of all teachers. The GMC also requires that each medical school provides adequate teaching time and resources to achieve the above. We reiterate that the adequate provision and coordination of teaching and learning of ethics and law requires at least one full-time senior academic in ethics and law with relevant professional and academic expertise. In this paper we set out an updated indicative core content of learning for medical ethics and law in UK medical schools and describe its origins and the consultative process by which it was achieved. (shrink)

Background Studies have shown that medical students and residents believe that their ethics preparation has been inadequate for handling ethical conflicts. The objective of this study was to determine the self-perceived comfort level of medical students and residents in confronting clinical ethics issues. Methods Clinical medical students and residents at the University of Maryland School of Medicine completed a web-based survey between September 2009 and February 2010. The survey consisted of a demographic section, questions regarding the respondents’ sense of comfort (...) in handling a variety of clinical ethics issues, and a set of knowledge-type questions in ethics. Results Survey respondents included 129 medical students (response rate of 40.7%) and 207 residents (response rate of 52.7%). There were only a few clinical ethics issues with which more than 70% of the respondents felt comfortable in addressing. Only a slight majority (60.8%) felt prepared, in general, to handle clinical situations involving ethics issues, and only 44.1% and 53.2% agreed that medical school and residency training, respectively, helped prepare them to handle such issues. Prior ethics training was not associated with these responses, but there was an association between the level of training (medical students vs residents) and the comfort level with many of the clinical ethics issues. Conclusions Medical educators should include ethics educational methods within the context of real-time exposure to medical ethics dilemmas experienced by physicians-in-training. (shrink)

Objective—To report the ethical development of medical students across four years of education at one medical school.Design and setting—A questionnaire was distributed to all four classes at the Wake Forest University School of Medicine during the Spring of 1996. Participants—Three hundred and three students provided demographic information as well as information concerning their ethical development both as current medical students and future interns. Main measurements—Results were analyzed using cross-tabulations, correlations, and analysis of variance.Results—Results suggested that the observation of and participation (...) in unethical conduct1 may have disparaging effects on medical students' codes of ethics with 35% of the total sample (24% of first years rising to 55% of fourth years) stating that derogatory comments made by residents/attendings, either in the patient's presence or absence, were “sometimes” or “often” appropriate. However, approximately 70% of the sample contended that their personal code of ethics had not changed since beginning medical school and would not change as a resident. Conclusions—Results may represent an internal struggle that detracts from the medical school experience, both as a person and as a doctor. Our goal as educators is to alter the educational environment so that acceptance of such behaviour is not considered part of becoming a physician. (shrink)

Objectives - To explore the wvay ethical principles develop during a medical education course for three groups of medical students - in their first year, at the beginning of their penultimate (fifth) year and towards the end of their final (sixth) year. Design - Survey questionnaire administered to medical students in their first, fifth and final (sixth) year. Setting - A large medical school in Queensland, Australia. Survey sample - Approximately half the students in each of three years (first, fifth (...) and sixth) provided data on a voluntary basis, a total of 385 students. Results - At the point of entry, minor differences were found between medical students and first year law and psychology students. More striking were differences between male and female medical students, suggesting early socialization had a substantial impact here. Conclusions - Results indicate that substantial changes in attitude have developed by the beginning of fifth year with little change thereafter. Gender difference persisted. Some difference in ethical attitudes were found when groups of different ethnic backgrounds were compared. The impact of a move to a graduate medical course, which gives high priority to ethics within a professional development domain, can now be evaluated. (shrink)

Moral distress in health care has been identified as a growing concern and a focus of research in nursing and health care for almost three decades. Researchers and theorists have argued that moral distress has both short and long-term consequences. Moral distress has implications for satisfaction, recruitment and retention of health care providers and implications for the delivery of safe and competent quality patient care. In over a decade of research on ethical practice, registered nurses and other health care practitioners (...) have repeatedly identified moral distress as a concern and called for action. However, research and action on moral distress has been constrained by lack of conceptual clarity and theoretical confusion as to the meaning and underpinnings of moral distress. To further examine these issues and foster action on moral distress, three members of the University of Victoria/University of British Columbia (UVIC/UVIC) nursing ethics research team initiated the development and delivery of a multi-faceted and interdisciplinary symposium on Moral Distress with international experts, researchers, and practitioners. The goal of the symposium was to develop an agenda for action on moral distress in health care. We sought to develop a plan of action that would encompass recommendations for education, practice, research and policy. The papers in this special issue of HEC Forum arose from that symposium. In this first paper, we provide an introduction to moral distress; make explicit some of the challenges associated with theoretical and conceptual constructions of moral distress; and discuss the barriers to the development of research, education, and policy that could, if addressed, foster action on moral distress in health care practice. The following three papers were written by key international experts on moral distress, who explore in-depth the issues in three arenas: education, practice, research. In the fifth and last paper in the series, we highlight key insights from the symposium and the papers in the series, propose to redefine moral distress, and outline directions for an agenda for action on moral distress in health care. (shrink)

This paper attempts a partial, critical look at the construction and use of case studies in ethics education. It argues that the authors and users of case studies are often insufficiently aware of the literary nature of these artefacts: this may lead to some confusion between fiction and reality. Issues of the nature of the genre, the fictional, story-constructing aspect of case studies, the nature of authorship, and the purposes and uses of case studies as "texts" are outlined and discussed. (...) The paper concludes with some critical questions that can be applied to the construction and use of case studies in the light of the foregoing analysis. (shrink)

Clinical ethics committees (CECs) in the United Kingdom (UK) have developed significantly over the past 15 years. The issue of access to and participation in clinical ethics consultation by patients and family members has, however, gone largely unrecognized. There are various dimensions to this kind of contact, including patient notification, consent and participation. This study reports the first specific investigation of patient contact with UK CECs. A questionnaire study was carried out with representatives from UK CECs. Results suggest that patient (...) participation in clinical ethics consultation is low and unlikely to change significantly in the near future. Attitudes towards patients having a role in clinical ethics consultation are mixed, with a variety of reasons put forward both for and against patient participation. These results are discussed in the light of common themes in the literature and the practical and political context of clinical ethics support in the UK. (shrink)

Ethics consultation is a novel paradigm in European health-care institutions. In this paper, patient involvement in all clinical ethics activities is scrutinized. It is argued that patients should have access to case consultation services via clearly defined access paths. However, the right of both health-care professionals and patients indicates that patients should not always be notified of a consultation. Ethics education, another well-established function of an ethics committee, should equally be available for patients, lay people and hospital staff. Beyond access (...) and utilization, lay membership on a clinical ethics service is a matter of transparency, equal participation, empowerment and democratization. Lay and patient perspectives will contribute to the quality of ethics services on all levels from case consultations to ethics education and policy development. (shrink)

Undergraduate medical ethics education currently focuses on ethical concepts and reasoning. This paper uses an intern’s story of an ethically challenging situation to argue that this emphasis is problematic in terms of ensuring students’ ethical practice as junior doctors. The story suggests that it is aligning their actions with the values that they reflectively embrace that can present difficulties for junior doctors working in the pressures of the hospital environment, rather than reasoning to an ethically appropriate action. I argue that (...) junior doctors need skills for implementing their ethical decisions and that these ought to form a central component of undergraduate medical ethics education. (shrink)

In January 2010, fifth year medical students in the medical programme at the University of Auckland were asked to write a 1200-word report as part of their ethics assessment. The purpose of the report was to get students to reflect critically on the ethical dimension of a clinical case or situation they had been involved in during the past 2 years. Students were required to identify and discuss the salient ethical issues that arose as they saw them, and consider what (...) they had personally learnt from the situation. The purpose of the following discussion is twofold: first, to outline some of the ethical issues raised by year five medical students in their ethics reports; and second, to reflect on what we, as educators and health professionals can learn from their experiences and insights. (shrink)

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 1½ 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. (shrink)

Educational efforts in bioethics are prevalent, but little is known about their efficacy. Although previous work indicates that courses in bioethics have a demonstrable effect on medical students, it has not examined their effect on health care professionals. In this report, we describe a study designed to investigate the effect of bioethics education on health care professionals. At the Intensive Bioethics Course, a six-day course held annually at Georgetown University, we administered a questionnaire requiring open-ended responses to vignettes both before (...) and after the course. Following the course, respondents defended their responses more carefully and articulated their thoughts more clearly. In addition, after the course respondents seemed to have a more subtle understanding of the relevant issues in the cases and applied theory to these cases more frequently. These findings help to formulate an understanding of the effect of bioethics education on health care professionals. (shrink)

Bioethics case reports generally treat aspects of moral fathomability, characterised and addressed in different ways. This paper reads the case as a textual model of scenarios and draws attention to its structure, narrative shape, linguistic register, and the effects of tone and temporality on reader expectation and responsiveness. Such textual elements of case composition reflect authorial purpose and influence the interpretation, including moral and ethical interpretation, of bioethics cases.

Recent UK reports have revealed extensive evidence of unethical care practices. Older and vulnerable patients in some British health services have experienced appalling and avoidable suffering. Explanations for, and solutions to, these care failures have been proposed with wide-ranging recommendations. Many of these have direct implications for clinical ethics with additional frameworks for ethical values proposed, a heightened awareness of the moral culture of organisations acknowledged and a renewed interest in the ethics component of professional education debated. In this paper, (...) I suggest that we integrate insights from the slow movement into clinical ethics practice. Distinctions are made between fast and slow healthcare practice and between fast and slow ethics. I argue that, whilst there is a place for both, slow ethics enables us to assume a more positive stance in relation to ‘crisis’, and requires that we learn from past accounts and scholarship and consider the role of clinical ethics in sustaining caring cultures. (shrink)

Fricker shows that virtue epistemology provides a general epistemological idiom in which these issues can be forcefully discussed.

Clinical ethics has developed significantly in Europe over the past 15 years and remains an evolving process. While sharing our experiences in different European settings, we were surprised to discover marked differences in our practice, especially regarding the position and role of patients. In this paper, we describe these differences, such as patient access to and participation or representation in ethics consults. We propose reasons to explain these differences, hypothesizing that they relate to the historic and sociocultural context of implementation (...) of clinical ethics consultation services (Cecs), as well as the initial aims for which each structure was established. Then, we analyse those differences with common ethical arguments arising in patient involvement. We conclude that there is no unique model of best practice for patient involvement in clinical ethics, as far as Cecs reflect on how to deal with the challenging ethical issues raised by patient role and position. (shrink)

What is illness? Is it a physiological dysfunction, a social label, or a way of experiencing the world? How do the physical, social and emotional worlds of a person change when they become ill? And can there be well-being within illness? In this remarkable and thought-provoking book, Havi Carel explores these questions by weaving together the personal story of her own serious illness with insights and reflections drawn from her work as a philosopher. Carel shows how the concepts and language (...) used to describe illness today are inappropriate and misleading. Too often illness is viewed as a localised biological dysfunction while ignoring the actual experience of the ill person, their fears, their hopes, the way they interact with others and, ultimately, experience life. By focusing on the impact of illness on the ill person's life and reflecting on the experience of illness as lived from within, Carel shows how illness is a life-changing process rather than a limited physiological problem. Carel's fresh approach to illness raises some uncomfortable questions about how we all - whether healthcare professionals or not - view the ill and challenges us to become more thoughtful. "Illness" unravels the tension between the universality of illness and its intensely private, often lonely, nature. It offers a new way of looking at a matter that affects every one of us. For those who are ill, it offers insights on our ability to remain happy within the constraints of illness. (shrink)