Ethics education for medical house officers: long-term improvements in knowledge and confidence

Analyzing the Evolution of Medical Ethics Education: A Bibliometric Analysis of the Top 100 Cited Articles

Ethics education plays a pivotal role in healthcare by providing professionals and students with the essential competencies to navigate intricate ethical challenges. This study conducts a comprehensive bibliometric analysis of the most-cited articles on ethics education, investigating parameters such as citation count, document types, geographical origin, journal analysis, publication year, author analysis, and keyword usage. The findings reveal a substantial impact characterized by high citation counts and the influence of a prominent publication focusing on the hidden curriculum and structure of medical education. Moreover, the analysis demonstrates a discernible increase in research output since 2000, signaling a growing recognition of the significance of ethics education in the healthcare domain. Notably, specific journals, particularly those dedicated to medical education and ethics, emerge as major contributors in this field, publishing many articles. Renowned authors have made noteworthy contributions, and emerging themes encompass the ethical implications of virtual reality and artificial intelligence in healthcare education. Additionally, undergraduate medical education garners significant attention, emphasizing the importance of establishing ethical values and professionalism early. Overall, this study highlights the imperative of interdisciplinary collaboration and the necessity for effective ethics education programs to equip healthcare professionals with the requisite skills to navigate complex ethical challenges. The findings inform educators, curriculum developers, and policymakers about enhancing ethics education and ensuring the ethical competence of future healthcare practitioners.

Teaching Professionalism in Postgraduate Medical Education: A Systematic Review

PURPOSE

This systematic review sought to summarize published professionalism curricula in postgraduate medical education (PGME) and identify best practices for teaching professionalism.

METHOD

Three databases (MEDLINE, Embase, ERIC) were searched for articles published from 1980 through September 7, 2017. English-language articles were included if they (1) described an educational intervention addressing professionalism, (2) included postgraduate medical trainees, and (3) evaluated professionalism outcomes.

RESULTS

Of 3,383 articles identified, 50 were included in the review. The majority evaluated pre- and posttests for a single group (24, 48%). Three (6%) were randomized controlled trials. The most common teaching modality was small-group discussions (28, 56%); other methods included didactics, reflection, and simulations. Half (25, 50%) used multiple modalities. The professionalism topics most commonly addressed were professional values/behavior (42, 84%) and physician well-being (23, 46%). Most studies measured self-reported outcomes (attitude and behavior change) (27, 54%). Eight (16%) evaluated observed behavior and 3 (6%) evaluated patient outcomes. Of 35 studies that evaluated statistical significance, 20 (57%) reported statistically significant positive effects. Interventions targeting improvements in knowledge were most often effective (8/12, 67%). Curriculum duration was not associated with effectiveness. The 45 quantitative studies were of moderate quality (Medical Education Research Study Quality Instrument mean score = 10.3).

CONCLUSIONS

Many published curricula addressing professionalism in PGME are effective. Significant heterogeneity in curricular design and outcomes assessed made it difficult to synthesize results to identify best practices. Future work should build upon these curricula to improve the quality and validity of professionalism teaching tools.

Health informatics competencies in postgraduate medical education and training in the UK: a mixed methods study

OBJECTIVE

To assess health informatics (HI) training in UK postgraduate medical education, across all specialties, against international standards in the context of UK digital health initiatives (eg, Health Data Research UK, National Health Service Digital Academy and Global Digital Exemplars).

DESIGN

A mixed methods study of UK postgraduate clinician training curricula (71 specialties) against international HI standards: scoping review, curricular content analysis and expert consultation.

SETTING AND PARTICIPANTS

A scoping literature review (PubMed until March 2017) informed development of a contemporary framework of HI competency domains for doctors. National training curricula for 71 postgraduate medical specialties were obtained from the UK General Medical Council and were analysed. Seven UK HI experts were consulted regarding findings.

OUTCOMES

The International Medical Informatics Association (IMIA) Recommendations for Biomedical and Health Informatics Education were used to develop a framework of competency domains. The number (maximum 50) of HI competency domains included in each of the 71 UK postgraduate medical specialties was investigated. After expert review, a universal HI competency framework was proposed.

RESULTS

A framework of 50 HI competency domains was developed using 21 curricula from a scoping review, curricular content analysis and expert consultation. All 71 UK postgraduate medical curricula documents were mapped across 29 of 50 framework domains; that is, 21 domains were unrepresented. Curricula mapped between 0 (child and adolescent psychiatry and core surgical training) and 16 (chemical pathology and paediatric and perinatal pathology) of the 50 domains (median=7). Expert consultation found that HI competencies should be universal and integrated with existing competencies for UK clinicians and were under-represented in current curricula. Additional universal HI competencies were identified, including information governance and security and secondary use of data.

CONCLUSIONS

Postgraduate medical education in the UK neglects HI competencies set out by international standards. Key HI competencies need to be urgently integrated into training curricula to prepare doctors for work in increasingly digitised healthcare environments.

Must we remain blind to undergraduate medical ethics education in Africa? A cross-sectional study of Nigerian medical students

BACKGROUND

As the practice of medicine inevitably raises both ethical and legal issues, it had been recommended since 1999 that medical ethics and human rights be taught at every medical school. Most Nigerian medical schools still lack a formal undergraduate medical ethics curriculum. Medical education remains largely focused on traditional medical science components, leaving the medical students to develop medical ethical decision-making skills and moral attitudes passively within institutions noted for relatively strong paternalistic traditions. In conducting a needs assessment for developing a curriculum germane to the Nigerian society, and by extension most of Sub-Saharan Africa, this study determined the views of Nigerian medical students on medical ethics education, ethical issues related to the doctor-patient relationship and the ethical/professional dilemmas they are confronted with.

METHODS

Using self-administered 63-item structured questionnaires, a cross-sectional survey of the final year medical students of the University of Nigeria was conducted in July 2015.Using the Statistical Package for the Social Sciences software (SPSS Version 17), frequency counts and percentages were generated.

RESULTS

The sample included 100 males (71.4%) and 40 females (28.6%), with the respective mean (SD) age being 24.6(5.61) and 21.8 (6.38) years. Only 35.7% were satisfied with their medical ethics knowledge, and 97.9% indicated that medical ethics should be taught formally. Only 8.6% had never witnessed a medical teacher act unethically. The dilemmas of poor communication between physicians and patients, and the provision of sub-standard care were reported highest for being encountered 'often'. A majority (60.7%) indicated that "a doctor should do his best always, irrespective of the patient's wishes". No significant difference in responses across gender was noted.

CONCLUSION

There is a strong desire by the contemporary Nigerian medical student for medical ethics education. Their lack of exposure in medical ethics in an ethically challenging environment suggest a dire need for the development of an appropriate medical ethics curriculum for them and the provision of an ethically conducive learning environment.

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.

Knowledge and Perceptions of Health Workers' Training on Ethics, Confidentiality and Medico-Legal Issues

Introduction

Health care delivery in recent times has become more complicated, as patients expect health personnel to not only provide professional services but be accountable as well. It is thus imperative that health personnel are aware of their responsibility to the patient and also sensitive to medico legal issues if quality health care is to be assured.

Objective

The aim of the study was to assess the knowledge and perception of health care workers on their training in ethics, confidentiality and medico-legal issues. It was expected that the results would inform policy on the training of the health workers.

Method

A cross-sectional survey was conducted among some categories of health workers (Doctors, Nurses and Health care assistants) at the Accident and Emergency directorate of Komfo Anokye Teaching Hospital, Ghana. A self-administered questionnaire was used to elicit information on ethics, confidentiality and medico- legal issues. Data collected was analyzed using SPSS version 16.

Results

A total of 103 health care workers were enrolled on the study representing 96% response rate. The study revealed that 74% had knowledge on ethics, confidentiality and medico- legal concepts; and 35.4% of the respondents indicated that health workers attitudes to ethics, confidentiality and medico- legal concepts was inadequate. About 28.3% indicated that their attitudes were good while 26.3% indicated attitudes were adequate with only 2% indicating that attitudes were very good. Nearly, 49% of the respondents also indicated that training on medico-legal issues should be taught during formal training and also on-the-job.

Conclusion

Knowledge of health workers on ethics confidentiality and medico-legal issues is high and their perceptions are positive. However, regular training to update their knowledge will be necessary in order to ensure continuous improvement of the quality of health care delivery.

A trial of a reproductive ethics and law curriculum for obstetrics and gynaecology residents

OBJECTIVE

Prior ethics educational interventions for residents have shown improvement in confidence and knowledge scores strictly in an internal medical resident population. Baseline knowledge and attitudes regarding reproductive ethics and law of obstetrics and gynaecology (ob/gyn) residents were assessed via a survey. Then, after completion of a 20-h curriculum for the residents, the residents were resurveyed in order to assess impact of the curriculum.

METHODS

An online survey with both multiple-choice and open-ended questions was administered to residents both prior to and after curriculum completion.

RESULTS

A total of 39 residents (85% of the total ob/gyn residents) completed the survey. 67% of respondents thought ethics was very important in clinical practice, but only 3% considered themselves very familiar with medical ethics. Respondents were asked five case-based questions to assess baseline knowledge and only 10% answered all questions correctly prior to the curriculum. After the residents completed the curriculum, 31 subjects (79% of the original 39 resident respondents) responded to the same survey. 52% of respondents answered all five questions correctly and 31% considered themselves very familiar with medical ethics.

CONCLUSIONS

Despite the importance placed on reproductive ethics and law by survey respondents including its impact on their clinical practices, there continues to be a deficiency in formal ethics education in ob/gyn. Our curriculum demonstrated both improvement in confidence as well as knowledge of residents towards issues of reproductive ethics and law.

Assessing levels of support for residents following adverse outcomes: a national survey of anesthesia residency programs in the United States

AIM

The impact of physician burnout is becoming apparent in the medical community, especially among anesthesiologists and young physicians. Anesthesia residents will experience emotionally charged adverse events during their training. The objective was to determine the prevalence, efficacy and utilization of support structures in place for residents following adverse events in order to develop a best-practices model of resident support.

METHODS

We sent an anonymous internet-based survey to program directors (PDs) at all American College of Graduate Medical Education (ACGME)-approved Anesthesia Residency programs, with an optional secondary survey of residents.

RESULTS

There was a 53% response rate among PDs with most reporting resource availability. The strongest support programs were the anesthesia support programs, morbidity and mortality (M&M) conference, and "individual meetings with department leadership." These results were mirrored in the responses of residents at the 32 programs who opted to participate in the secondary survey. Both also cited M&M conference as being highly utilized, but not efficacious. The strongest support programs had a low prevalence.

CONCLUSIONS

These data suggest that a best-practices model of resident support entails establishing a department-based support program, facilitating comfortable meetings with departmental leadership and optimizing M&M conference.

Morning report: can an established medical education tradition be validated?

BACKGROUND

Morning report is accepted as an essential component of residency education throughout different parts of the world.

OBJECTIVE

To review the evidence of the educational value, purpose, methods, and outcomes of morning report.

METHODS

A literature search of PubMed, Ovid, and the Cochrane Library for English-language studies published between January 1, 1966, and October 31, 2011, was performed. We searched for keywords and Medical Subject Heading terms related to medical education, methods, attitudes, and outcomes in regard to "morning report." Title and abstract review, followed by a full-text review by 3 authors, was performed to identify all pertinent articles.

RESULTS

We identified 71 citations; 40 articles were original studies and 31 were commentaries, editorials, or review articles; 56 studies (79%) originated from internal medicine residency programs; 6 studies (8%) focused on ambulatory morning report; and 63 (89%) originated from the United States. Identified studies varied in objectives, methods, and outcome measures, and were not suitable for meta-analysis. Main outcome measures were resident satisfaction, faculty satisfaction, preparation for professional examinations, use of evidence-based medicine, clinical effects on patient care, adverse event detection, and utilization of a curriculum in case selection.

CONCLUSIONS

Morning report has heterogeneous purposes, methods, and settings. As an educational tool, morning report is challenging to define, its outcome is difficult to measure, and this precludes firm conclusions about its contribution to resident education or patient care. Residency programs should tailor morning report to meet their own unique educational objectives and needs.

Development of a Test of Residents' Ethics Knowledge for Pediatrics (TREK-P)

BACKGROUND

Professionalism is one of the Accreditation Council for Graduate Medical Education's core competencies. Residency programs must teach residents about ethical principles, which is an essential component of professionalism.

OBJECTIVES

We aimed to formally develop a valid and reliable test of ethics knowledge that effectively discriminated among learners in pediatric residency training and to improve methods for measuring outcomes of resident education in medical ethics.

METHODS

We created an instrument with 36 true/false questions that tested knowledge in several domains of pediatric ethics: professionalism, adolescent medicine, genetic testing and diagnosis, neonatology, end-of-life decisions, and decision making for minors. All questions and their correct answers were derived from published statements from the American Academy of Pediatrics Committee on Bioethics. We invited a range of participants from novices to experts to complete the test. We evaluated the instrument's reliability and explored item discrimination, omitting 13 items with the least discriminatory power. Score differences between the 3 categories of examinees were evaluated.

RESULTS

The 23-item test, completed by 54 participants, demonstrated good internal reliability (Kuder-Richardson 20 statistic  =  0.73). The test was moderately difficult and had a mean overall score of 17.3 (±3.3 standard deviation). Performance appropriately improved with degree of expertise: median scores for medical students, postgraduate year-3 residents, and ethicists were 15 (65%, range, 11-19), 19 (83%, range, 14-23), and 22 (96%, range, 20-23), respectively. Ethicists' scores were significantly higher than those of medical students (P < .001) and residents (P  =  .007). Moreover, residents performed significantly better than medical students (P  =  .001).

CONCLUSIONS

We developed a standardized instrument, entitled Test of Residents' Ethics Knowledge for Pediatrics (TREK-P), to evaluate residents' knowledge of pediatric ethics. The TREK-P is easy to administer, reliably discriminates among learners, and highlights content areas in which knowledge may be deficient.

Confidence and knowledge regarding ethics among advanced practice nurses

As the scope of advanced practice nursing expands and the educational requirements increase, so do the ethical responsibilities. How prepared are advanced practice nurses (APNs) to manage the ethical challenges in advanced practice? The purpose of this study was to determine APNs' ethics knowledge and perceived level of confidence in their ability to manage ethical problems in advanced practice. Assuming ethics knowledge and abilities of APNs are similar to those of medical residents, a survey instrument for medical residents was modified for use with APNs. Responses to the modified survey indicated a fairly high level of confidence but a fairly low level of knowledge. Studies show that ethics education can be effective in improving knowledge, confidence, and ethical behavior. Given the expanding role of APNs as doctors of nursing practice, research is needed to determine the ethics knowledge needs and teaching strategies to better prepare nurses for the challenges of advanced practice.

Evaluating the Effects of an Integrated Medical Ethics Curriculum on First-year Students

Introduction: An integrated biomedical ethics track was implemented as part of the new medical undergraduate curriculum at the National University of Singapore Yong Loo Lin School of Medicine in academic year (AY) 2008/2009. This study analyses the effects of the new curriculum on first-year students’ knowledge, confidence and opinions in relation to the subject. Materials and Methods: In a cohort-based quasi-experimental study, we administered a pre-course and post-course questionnaire to a group of first-year students in AY2008/2009 who underwent the new biomedical ethics curriculum. The same questionnaire was carried out with the first-year cohort of AY2007/2008, who had received only ad hoc teaching in biomedical ethics. The questionnaire focused on the students’ opinions on selected taught topics in biomedical ethics and law, and formal ethics education; their confidence in relation to specific clinical ethical competencies; and their knowledge of selected taught topics in the first-year syllabus. Results: The experimental cohort acquired more knowledge and confidence. They rated more positively formal ethics teaching and assessment as a requirement of medical education. Attitudes were found to have been ‘professionalised’ within the experimental group, with significantly greater receptiveness towards ethical codes of the profession and the regulatory role of the Singapore Medical Council. They were found to be more conservative with respect to legislative changes in healthcare. Conclusion: The pioneer biomedical ethics curriculum had significant effects on the ethical development of first-year medical students. Longitudinal research through further phases of the integrated curriculum is needed to identify learning issues that affect the consolidation of knowledge, confidence and attitudes in medical ethics, law and professionalism. Keywords: Ethics/attitudes, Professionalism, Learning outcomes

Professing professionalism: are we our own worst enemy? Faculty members' experiences of teaching and evaluating professionalism in medical education at one school

PURPOSE

To explore clinical faculty members' knowledge and attitudes regarding their teaching and evaluation of professionalism.

METHOD

Clinical faculty involved in medical education at University of Toronto Faculty of Medicine were recruited to participate in focus groups between 2006 and 2007 to discuss their knowledge, beliefs, and attitudes about teaching and evaluating professionalism and to determine their views regarding faculty development in this area. Focus groups were transcribed, analyzed, and coded for themes using a grounded theory approach.

RESULTS

Five focus groups consisting of 14 faculty members from surgical specialties, psychiatry, anesthesia, and pediatrics were conducted. Grounded theory analysis of the 188 pages of text identified three major themes: Professionalism is not a static concept, a gap exists between faculty members' real and ideal experience of teaching professionalism, and "unprofessionalism" is a persistent problem. Important subthemes included the multiple bases that exist for defining professionalism, how professionalism is learned and taught versus how it should be taught, institutional and faculty tolerance and silence regarding unprofessionalism, stress as a contributor to unprofessionalism, and unprofessionalism arising from personality traits.

CONCLUSIONS

All faculty expressed that teaching and evaluating professionalism posed a challenge for them. They identified their own lapses in professionalism and their sense of powerlessness and failure to address these with one another as the single greatest barrier to teaching professionalism, given a perceived dominance of role modeling as a teaching tool. Participants had several recommendations for faculty development and acknowledged a need for culture change in teaching hospitals and university departments.

[Medical ethics teaching]

In most European countries, medical ethics has become a more or less established subject in medical school curricula. Accordingly, the need to evaluate its success has arisen. In our paper, we describe the controversial debate about the proper goals of teaching medical ethics. Secondly, we present an overview of current efforts to measure and evaluate the outcome and effect of different medical ethics teaching programmes on medical students and young physicians. We conclude that medical ethics teaching is amenable to a great variety of teaching and evaluation methods. Finally, we argue that medical ethics teaching should include: (1) the teaching of moral reasoning skills, (2) the instruction about relevant ethical knowledge, as well as (3) the development of certain character traits. Methods to evaluate ethical knowledge and moral reasoning skills are readily available, while the evaluation of the development of character traits poses important conceptual difficulties.

When providers and patients come from different backgrounds: perceived value of additional training on ethical care practices

Fostering the therapeutic alliance, safeguarding confidentiality, gaining informed consent, and enhancing treatment adherence are critical aspects of patient care. We examined whether multidisciplinary health care providers perceive additional training on these areas as helpful in their work with patients from different ethnic backgrounds than the provider. Data are drawn from a National Institute on Drug Abuse-funded survey of 1555 providers in 8 disciplines in New Mexico and Alaska. Clinicians viewed additional training as moderately helpful for ensuring treatment adherence, establishing the therapeutic alliance, safeguarding confidentiality, and engaging in informed consent processes, in that order. Women were more receptive than men to additional training. Modest differences were detected between behavioral and physical health providers and between minority and majority providers. Implications of providers' only modest interest in such training are discussed.

Ethics and professionalism: what does a resident need to learn?

Training in ethics and professionalism is a fundamental component of residency education, yet there is little empirical information to guide curricula. The objective of this study is to describe empirically derived ethics objectives for ethics and professionalism training for multiple specialties. Study design is a thematic analysis of documents, semi-structured interviews, and focus groups conducted in a setting of an academic medical center, Veterans Administration, and community hospital training more than 1000 residents. Participants were 84 informants in 13 specialties including residents, program directors, faculty, practicing physicians, and ethics committees. Thematic analysis identified commonalities across informants and specialties. Resident and nonresident informants identified consent, interprofessional relationships, family interactions, communication skills, and end-of-life care as essential components of training. Nonresidents also emphasized formal ethics instruction, resource allocation, and self-monitoring, whereas residents emphasized the learning environment and resident-attending interactions. Conclusions are that empirically derived learning needs for ethics and professionalism included many topics, such as informed consent and resource allocation, relevant for most specialties, providing opportunities for shared curricula and resources.

Developing an ethics curriculum for an internal medicine residency program: use of a needs assessment

BACKGROUND

Residency programs are required to teach and evaluate trainees in the area of professionalism and medical ethics. Prior to developing a curriculum in this area, residents and fellows were surveyed to assess learning needs.

DESCRIPTION

A case-based survey was developed based on published curricula. Residents and fellows were asked to describe their comfort level in 11 clinical scenarios on a Likert-type scale ranging from 1 (not at all comfortable) to 10 (extremely comfortable).

EVALUATION

151 surveys were returned for an overall response rate of 73%. Comfort levels ranged from a low of 3.1 to a high of 8.5 on the 10-point scale. Despite additional years of clinical training, fellows only reported an increased comfort level in 1 case.

CONCLUSION

Learning needs exist in residents and fellows in the area of medical ethics. Use of a needs assessment was instrumental in planning and designing an ethics curriculum.

Educating researchers: ethics and the protection of human research participants

To improve the protection of human participants in research, the federal government has mandated education and training in bioethics and issues relevant to human research. Despite the large time and financial commitments involved with such education, little is known about whether these efforts will actually improve the protection of human subjects. In this article, I review the history of ethics education in research leading up to the 2000 mandate. I then explore ethics education and its evaluation in the biological sciences and medicine and describe the previous successes and failures of these efforts. Many objectives can be the focus of educational interventions and evaluation. Some interventions in these fields had small, though statistically significant, effects on moral reasoning skills, knowledge, and confidence. Interventions are more likely to have lasting impact on moral reasoning if they were of moderate duration and involved small group discussion of dilemmas. Whether these measurable differences lead to changes in behavior or real-time application of moral reasoning skills remains to be determined. By having a clear understanding of the specific objectives, strengths, and limitations of an educational intervention, educators can design programs that may have an increased likelihood of improving protection of human research participants.

Ethical dilemmas confronting dentists in Queensland, Australia

BACKGROUND

This paper details contemporary ethical dilemmas encountered by Queensland dentists.

METHODS

An age-stratified sample of 499 dentists resident in Queensland was surveyed. The questionnaire contained scenarios of five common ethical dilemmas. In addition, open-ended questions sought the respondent's most frequent, difficult and recent ethical dilemmas, and where they would seek guidance in dealing with ethical problems.

RESULTS

Respondents acknowledged the patient's rights in treatment decisions and the dentist's right to refuse demands for inappropriate treatment. However, responses varied in the extent to which dentists may influence treatment decisions. Few respondents would ignore evidence of poor dental treatment but they are evenly divided in choosing to inform the patient, the dentist or both. Poor quality treatment is the most frequent and difficult dilemma, and half have experienced this problem recently. Requests by patients for fraudulent receipts occur in a third of responses. Dentists develop ethical values from multiple sources but for help with dental ethical problems, 90 per cent of respondents would consult another dentist.

CONCLUSIONS

Of the ethical dilemmas discussed in this survey, those relating to poor quality treatment confronted most respondents. Also the actions of dentists in dealing with these dilemmas were most varied.

Medical ethics education: to what ends?

The goals of medical ethics education comprise several dimensions: legal duties to secure informed consent, tell the truth and protect confidentiality; objective competencies that include an understanding of DNR regulations and surrogate decision-making procedures; discursive moral skills such as moral sensitivity, reciprocity and moral development that combine into the capacity for moral dialogue and debate; and finally, behavioural goals that challenge moral education to nurture a more humane, sensitive and communicative physician. Part one of this paper describes each of these goals, together with some of the inherent difficulties affecting implementation. Part two presents survey data from medical ethics instructors (n = 126) who were asked about the importance of each goal and their ability to successfully achieve each aim. While each goal is highly rated, only those goals associated with legal duties and objective competencies are thought to be achieved with any degree of relative success. Goals associated with character transformation, unique to medical ethics education, are among the most difficult to achieve. Additional empirical data corroborate these impressions. Moreover, it is not clear that medical ethics education has much to do with good care. Empirical data are scarce and the conceptual relationship between ethics and care remains highly problematic. Part three offers a number of divergent interpretations of care and concludes that they have little to do with medical ethics. There is no reason to expect that medical competence should be affected by moral competence. Medical ethics therefore might then be viewed as an educational enhancement: unnecessary for healthy doctoring but desirable among a small percentage of the profession who maintain an interest in ethical problems.

Clinical ethics revisited

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.

Dealing with prejudice

Few of us are free of all prejudices, however subtle and subconscious, and they may affect both patient care and teaching. Here I use reflection about a patient with HIV infection, from the points of view of two doctors caring for him and the patient himself, to explore prejudice against lifestyles that are considered "dangerous". The paper then goes on to discuss research about physicians' attitudes to such cases, the teaching of ethics in a clinical environment and the need to support junior medical staff.

C.A.R.E.: an approach for teaching ethics in medicine

Various societal factors have contributed to an increase in the ethical dilemmas faced by physicians, yet limited formal training in ethical decision-making is provided for those practitioners during their medical education. The pluralistic nature of contemporary medicine seems amenable to the development of common clinical and educational approaches to ethical dilemmas. The authors propose one such framework--a four question approach called C.A.R.E.--that encourages physicians at all levels of training to acknowledge individual and collective factors that enter into ethical decision-making. These questions are clearly described, and examples for use of the model in teaching settings are also provided. The authors believe that this approach can have significant utility in medical education and clinical settings, and advocate for its use and evaluation.

Evaluating ethics competence in medical education

We critically evaluate the ways in which competence in medical ethics has been evaluated. We report the initial stage in the development of a relevant, reliable and valid instrument to evaluate core critical thinking skills in medical ethics. This instrument can be used to evaluate the impact of medical ethics education programmes and to assess whether medical students have achieved a satisfactory level of performance of core skills and knowledge in medical ethics, within and across institutions.

What is an oath and why should a physician swear one?

While there has been much discussion about the role of oaths in medical ethics, this discussion has previously centered on the content of various oaths. Little conceptual work has been done to clarify what an oath is, or to show how an oath differs from a promise or a code of ethics, or to explore what general role oath-taking by physicians might play in medical ethics. Oaths, like promises, are performative utterances. But oaths are generally characterized by their greater moral weight compared with promises, their public character, their validation by transcendent appeal, the involvement of the personhood of the swearer, the prescription of consequences for failure to uphold their contents, the generality of the scope of their contents, the prolonged time frame of the commitment, the fact that their moral force remains binding in spite of failures on the part of those to whom the swearer makes the commitment, and the fact that interpersonal fidelity is the moral hallmark of the commitment of the swearer. Oaths are also distinct from codes. Codes are collections of specific moral rules. Codes are not performative utterances. They do not commit future intentions and do not involve the personhood of the one enjoined by the code. Recent attacks on oath-taking by physicians are discussed. Two arguments in favor of oath-taking are presented: one on the basis of the nature of medicine as a profession and the other on the basis of rule-utilitarian considerations. No attempt is made to define which oath a physician should swear.

Teaching medical ethics to orthopaedic surgery residents

Orthopaedic surgery residents will be faced with a variety of ethical issues when they enter clinical practice. A previous survey suggested that they lack knowledge about how to approach several types of medical ethics dilemmas. We developed a medical ethics curriculum for orthopaedic surgery residents and presented it over a one-year period to the residents in one training program. The effect of the educational intervention on the residents' knowledge of medical ethics and their ability to handle hypothetical situations was measured by comparing their responses to a questionnaire, administered before and after the intervention, with those of residents in a training program in which the intervention was not provided. The twenty-five residents at the site of the educational intervention had a mean improvement of 0.10 in the overall score, from a mean score of 0.71 on the baseline survey to a mean score of 0.81 on the follow-up survey. This improvement was significantly greater than the mean improvement of 0.02 for the thirty residents at the control site, who had a mean score of 0.72 on the baseline survey and a mean score of 0.74 on the follow-up survey (p = 0.002). Six residents who participated in the medical ethics curriculum rated it as very useful; seventeen, as somewhat useful; one, as slightly useful; and one, as not at all useful. A medical ethics curriculum can increase orthopaedic residents' knowledge of medical ethics. Whether this curriculum also will lead to behavioral changes requires additional evaluation.