Great Expectations: Teaching Ethics to Medical Students in South Africa

Many academic philosophers and ethicists are appointed to teach ethics to medical students. We explore exactly what this task entails. In South Africa the Health Professions Council's curriculum for training medical practitioners requires not only that students be taught to apply ethical theory to issues and be made aware of the legal and regulatory requirements of their profession, it also expects moral formation and the inculcation of professional virtue in students. We explore whether such expectations are reasonable. We defend the claim that physicians ought to be persons of virtuous character, on the grounds of the social contract between society and the profession. We further argue that since the expectations of virtue of health care professionals are reasonable, it is also sound reasoning to expect ethics teachers to try to inculcate such virtues in their students, so far as this is possible. Furthermore, this requires of such teachers that they be suitable role models of ethical practice and virtue, themselves. We claim that this applies to ethics teachers who are themselves not members of the medical profession, too, even though they are not bound by the same social contract as doctors. We conclude that those who accept employment as teachers of ethics to medical students, where as part of their contractual obligation they are expected to inculcate moral values in their students, ought to be prepared to accept their responsibility to be professionally ethical, themselves.     

Research ethics and the use of placebo: status of the debate in Canada

The question of the use of the placebo is one of the most controversial in the field of the ethics of research today. The use of the placebo remains the standard practice of biomedical research in spite of the fact that various revisions of the Helsinki Declaration have sought to limit its use. In Canada, the Tri-council policy statement: Ethical conduct for research involving humans adopted a very restrictive position with respect to the use of placebos, precisely defining the situations in which its use would meet the demands of ethical research. The positions taken by the various ethical decision-making bodies are, however, hardly shared by regulatory bodies such as the Food and drug administration (FDA), the Council for international organization of medical sciences (CIOMS) or the European agency for the evaluation of medicinal products (EMEA). This divergence of opinions reveals two quite different conceptions of what constitutes the ethical. In the case of decision-making bodies in the ethical field, it is clearly medicine's Hippocratic Oath which explains their reluctance to use placebos. The first responsibility of the doctor is to "do no harm" to his or her patient. This duty is inherent to the medical profession and as such is not grounded in the view of medicine as a contract for care. In the case of regulatory bodies, it is the vision of "medicine as contract" which is in view; and it is this notion that justifies the use of placebos once free and informed consent has been obtained. It is also worth noting that these regulatory bodies make frequent use of arguments based on utilitarian ends. In an unprecedented move, the World medical association published in October 2001 a clarification note about the use of placebos. An analysis of this text raises the question about its real meaning: clarification or concession?     

What Is the Good of It—Ethical Controls of Human Subject Health Research?

The term “ethics” covers a multitude of virtues and possibly some sins where ethical perspectives differ. Given the diversity of ethical philosophies there is a question about what common ground can, or should, inform health research ethics. At a minimum it must be consistent with the law. Beyond that, ethics embraces a variety of possible approaches. This raises the question—what criteria are applied in determining the appropriate approach and what standards by way of quality control are applied to its decisional application by ethics committees or other authorities exercising responsibility in this difficult area. The particular issue of ethical perspectives on the use of “big data” in medical research also raises complex issues for consideration.     

Expectations and obligations: professionalism and medicine's social contract with society

As health care has become of great importance to both individual citizens and to society, it has become more important to understand medicine's relationship to the society it serves in order to have a basis for meaningful dialogue. During the past decade, individuals in the medical, legal, social sciences, and health policy fields have suggested that professionalism serves as the basis of medicine's relationship with society, and many have termed this relationship a social contract. However, the concept of medicine's social contract remains vague, and the implications of its existence have not been fully explored. This paper endorses the use of the term social contract, examines the origin of the concept and its relationship to professionalism, traces its evolution and application to medicine, describes the expectations of the various parties to the contract, and explores some of the implications of its use.     

Instructors' practices in and attitudes toward teaching ethics in the genetics classroom

There is strong consensus among educators that training in the ethical and social consequences of science is necessary for the development of students into the science professionals and well-rounded citizens needed in the future. However, this part of the curriculum is not a major focus of most science departments and it is not clear if, or how, students receive this training. To determine the current status of bioethics education of undergraduate biology students in the United States, we surveyed instructors of introductory genetics. We found that there was support for more ethics education both in the general curriculum and in the genetics classroom than is currently being given. Most instructors devote <5% of class time to ethical and social issues in their genetics courses. The majority feels that this is inadequate treatment of these topics and most cited lack of time as a major reason they were unable to give more attention to bioethics. We believe biology departments should take the responsibility to ensure that their students are receiving a balanced education. Undergraduate students should be adequately trained in ethics either within their science courses or in a specialized course elsewhere in the curriculum.     

涉及人的医学科研项目伦理审查实践体会

本文就国内涉及人的医学科研项目伦理审查现状进行了简要介绍,并结合武汉大学中南医院医学伦理委员会近年来伦理审查的工作实际,对涉及人的医学科研项目伦理审查中存在的共性问题进行了初步探讨,提出管理部门和伦理委员会应加强对研究人员伦理知识的宣传教育,加强科研项目伦理行为的过程监督,保护受试者权益,保证医学科研的健康发展。     

伦理管理在人类辅助生殖技术中的应用与价值

辅助生殖技术（assisted reproduction technique,ART）的飞速发展给社会带来了复杂伦理难题。因此,在ART全过程中加强伦理管理并对其后果进行评价,具有深刻的内涵价值和深远的社会意义。只有发挥生殖医学伦理委员会作为一个工作机构的职能,在医患人群中加强ART技术基本原理及相关伦理原则的宣传教育,强化医学伦理的监督机制,落实充分的知情同意等措施,才能促使医患人群都能够自觉遵守优良的医学伦理道德规范,保证人类辅助生殖技术的健康发展,使ART发挥积极的、革命性的意义。     

医学研究伦理学的发展现状与前景

创新技术的开展和转化医学的注重给医学的发展注入了新的活力,但同时,也带来了一系列社会伦理问题和法律问题。生命医学伦理学的兴起和发展催生了医学研究伦理学分支学科形成,目的在于推进解决涉及人体的医学研究的伦理问题。当前,面临的最突出的伦理问题在于,对医学研究合法性、先进性及伦理性的把握,对医学研究伦理审查必要性的认知,对医学研究方案设计与伦理道德的匹配,对医学研究知情同意的告知,对医学研究风险与受益的平衡。逐步与国际接轨,加强伦理委员会制度建设;提高伦理审查能力建设,形成高水平的伦理审查队伍;学术组织和团体共同努力,推进医学研究伦理学的发展,这将助推医学研究伦理学的发展。     

Randomized Controlled Trials of Maternal‐Fetal Surgery: A Challenge to Clinical Equipoise

This article focuses on maternal‐fetal surgery (MFS) and on the concept of clinical equipoise that is a widely accepted requirement for conducting randomized controlled trials (RCT). There are at least three reasons why equipoise is unsuitable for MFS. First, the concept is based on a misconception about the nature of clinical research and the status of research subjects. Second, given that it is not clear who the research subject/s in MFS is/are, if clinical equipoise is to be used as a criterion to test the ethical appropriateness of RCT, its meaning should be unambiguous. Third, because of the multidisciplinary character of MFS, it is not clear who should be in equipoise. As a result, we lack an adequate criterion for the ethical review of MFS protocols. In our account, which is based on Chervenak and McCullough's seminal work in the field of obstetric ethics, equipoise is abandoned. and RCT involving MFS can be ethically initiated when a multidisciplinary ethics review board (ERB), having an evidence‐based assessment of the risks involved, is convinced that the value of answering the research hypothesis, for the sake of the health interests of future pregnant women carrying fetuses with certain congenital birth defects, justifies the actual risks research participants might suffer within a set limit of low/manageable.     

The short history and tenuous future of medical professionalism: the erosion of medicine's social contract

The profession of medicine is based on a shared set of tacit and explicit agreements about what patients, doctors, and society at large should be able to expect from each other, a social contract that defines the profession. Historically, the development of this set of agreements depended upon the creation of social organizations that could speak for the entire profession. Over the last several decades, however, the perceived need for these organizations, and especially the umbrella organization for the profession, the American Medical Association, has waned. The reasons for this are complex, but the consequences are significant: an eroding social contract, fragmentation, lack of cohesion and integrity, and loss of the public's confidence. The present social contract is one-dimensional, overly simplistic, and failing to sustain the public's trust. To address these problems, a renewed social contract is necessary. Although this renewed contract should be based on foundations similar to the original, it must directly confront such contemporary challenges as resource allocation and conflicts of interest. Equally as important, to reinvigorate our social contract more physicians will need to come to grips with a basic truth: to sustain professionalism we need a strong, unified professional association.     

Taking the "I" out of IRB--and putting "community" in

If one looks back on the history of American research ethics, a bold pattern emerges. Since World War II, about every twenty years or so a breach of the social contract between investigators and human research subjects galvanizes public and professional interest in the ethical foundations and oversight mechanisms governing research with humans.     

China's struggle for practical regulations in medical ethics

The introduction of ethical regulations in medicine in China might seem at odds with the country's social and moral reality. Chinese bioethicists find themselves torn between the necessity to re-create a fully-fledged modern health-care system and aspirations to become global players in the biomedical sciences. The result is a top-down approach in medical ethics, created on behalf of the people. Despite its introduction, there are concerns about whether China is prepared to embrace the standards it claims to have adopted.     

什么是生命伦理学？——从历史发展的视角

生命伦理学是20世纪60年代兴起于美国的一门新兴学科,旨在应对生命科学和生物技术的发展或医疗保健的演变使人类面临的种种伦理难题。生命伦理学的兴起有着特殊的社会历史背景。它在发展过程中出现的一些里程碑式的案例,对生命伦理学的发展产生了深远的影响。从其发展特征上看,生命伦理学和医学伦理学紧密联系,有着更为广泛的研究内容和独特的专业特性。生命伦理学要有效回应现代医学和生命科学的发展给人类带来的伦理难题,既要准确地界定伦理问题,又要以适当的方式将伦理学基础理论应用到具体问题当中。对生命伦理学的基本理论进行概述。     

论＂医德＂的基本范畴

医德是医疗卫生领域精神文明建设的重要部分,也是调整医务人员与病人、医务人员之间以及与社会之间关系的行为准则。医德范畴是指人们对现代医务人员职业道德和医患关系的总结,它不仅概括了医生所应履行的职责义务,而且反映着一段时间内医患关系的本质。本文通过对医德范畴内,医生的权利和义务、责任和良心、功力和荣誉、审慎和保密四类问题的阐述,探讨当下医生在工作中应该保持何种心态,如何与患者进行沟通,以期更好地提供医疗服务。     

Was bioethics founded on historical and conceptual mistakes about medical paternalism?

Bioethics has a founding story in which medical paternalism, the interference with the autonomy of patients for their own clinical benefit, was an accepted ethical norm in the history of Western medical ethics and was widespread in clinical practice until bioethics changed the ethical norms and practice of medicine. In this paper I show that the founding story of bioethics misreads major texts in the history of Western medical ethics. I also show that a major source for empirical claims about the widespread practice of medical paternalism has been misread. I then show that that bioethics based on its founding story deprofessionalizes medical ethics. The result leaves the sick exposed to the predatory power of medical practitioners and healthcare organizations with only their autonomy-based rights to non-interference, expressed in contracts, to protect them. The sick are stripped of the protection afforded by a professional, fiduciary relationship of physicians to their patients. Bioethics based on its founding story reverts to the older model of a contractual relationship between the sick and medical practitioners not worthy of intellectual or moral trust (because such trust cannot be generated by what I call 'deprofessionalizing bioethics'). On closer examination, bioethics based on its founding story, ironically, eliminates paternalism as a moral category in bioethics, thus causing bioethics to collapse on itself because it denies one of the necessary conditions for medical paternalism. Bioethics based on its founding story should be abandoned.     

Medical education and society.

As health care changes under the pressures of restraint and constraint our vision of the future of medical education should be based on the medical school''s responsibility to the community. The medical school is "an academy in the community": as an academy, it fosters the highest standards in education and research; as an institution in the community, it seeks to improve public health and alleviate suffering. The author argues that to better achieve these goals medical schools need to become more responsible and responsive to the population they serve. Medical schools have been slow to accept fully the social contract by which, in return for their service to society, they enjoy special rights and benefits. This contract requires that medical educators listen to the public, talk honestly and constructively with government representatives and assess the needs and expectations of the community.     

Stemming the Tide of Normalisation: An Expanded Feminist Analysis of the Ethics and Social Impact of Embryonic Stem Cell Research

Feminists have indicated the inadequacies of bioethical debates about human embryonic stem cell research, which have for the most part revolved around concerns about the moral status of the human embryo. Feminists have argued, for instance, that inquiry concerning the ethics and politics of human embryonic stem cell research should consider the relations of social power in which the research is embedded. My argument is that this feminist work on stem cells is itself inadequate, however, insofar as it has not incorporated an analysis of disability into its considerations of the ethical and political issues that surround the phenomena. Thus, I consider claims that disability theorists and anti-disability activists have made about the research. I conclude by indicating that stem cell research must be situated within a cultural matrix that operates in the service of normalisation.     

Publication: an ethical imperative.

Publication of medical research is both a monitor of the researcher''s ethics and an audit of the local or regional ethics committee that approved it. Selectivity of publication or of the intention to publish lessens this audit. Opinions differ about what is ethically allowable in clinical and benchtop medical research. Ethical permission and ethical monitoring of medical research are subject to a hierarchy of pyramidal controls, starting in hospital and ending with the local, institutional, or regional ethics committee. Currently, such committees function with widely varying degrees of efficiency and quality of output, and with differing viewpoints on many ethical issues. Without an a priori insistence by institutional ethics committees that there be an intention to publish all medical research involving human subjects, ethics committees cannot routinely be subject to the scrutiny or audit which they themselves demand of researchers.     

Sick autonomy

Complex social and economic forces have placed patient autonomy at the center of medical ethics, and thereby displaced an older ethic of physician beneficence. This development arose, and is sustained, by waning trust in the traditional doctor-patient relationship. As patients have increasingly become clients and consumers, a contract basis for medical care has put the ancient covenant of care in jeopardy. Here, a philosophical approach to harmonize the apparent conflicting claims of patient autonomy and physician beneficence is offered by demonstrating that autonomy need not be understood as protecting a threatened identity. If persons are regarded as atomistic, certain defensive notions of individualistic rights-based autonomy prevail; if a relational construction of personal identity is employed instead, then respect for autonomy becomes part of a wider morality of relationship and care. By reconfiguring trust within this latter understanding of personhood, bioethics better balances its concerns over choices and actions with those of relationship and responsibility. Neither atomistic autonomy nor the ethics of responsibility can claim hegemony, for they are mutually interdependent, and a complete account of medicine's moral axis requires that they be integrated. This reorientation is crucial for reasserting the ethos of clinical medicine, whose fundamental mandate remains the care of others.     

Biological weapons, genetics and social analysis: emerging responses, emerging issues--I

Recent terrorist attacks in the USA have generated significant attention in many countries to the threats posed by biological weapons. In response to these events and the spectre of future attacks, bioscientists and professional organizations have begun or intensified asking questions about the possible malign applications of their research. As Part I of a two-part article, this paper surveys how genetics might contribute to the development of novel forms of weaponry. It is further argued that the dilemmas and difficulties facing bioscientists pose pressing and thorny questions for the hitherto agendas and orientations of those concerned with the social, ethical and political implications of genetics. Part II will examine the emerging responses initiated by biomedical organizations and spokespersons in the US and the UK. This will be done with a view to asking how scientific and medical research communities are defining and policing notions of professionalism, responsibility and accountability. On the basis of this, suggested lines for future social analysis will be offered.