Developing Ethical Awareness in Global Health: Four Cases for Medical Educators

In recent years, the growth of interest in global health among medical students and residents has led to an abundance of short‐term training opportunities in low‐resource environments. Given the disparities in resources, needs and expectations between visitors and their hosts, these experiences can raise complex ethical concerns. Recent calls for best practices and ethical guidelines indicate a need for the development of ethical awareness among medical trainees, their sponsoring and host institutions, and supervising faculty. As a teaching tool to promote this awareness, we developed a scenario that captures many common ethical issues from four different perspectives. Each perspective is presented in case format followed by questions. Taken together, the four cases may be used to identify many of the elements of a well‐designed global health training experience.     

北京试行医药分开改革对医患双方的影响观察

医药分开改革的目的是从制度上消除“以药养医”,从利益机制上规范医疗行为,加强合理用药,减轻患者负担,体现医务人员的劳动价值。对北京试行“医药分开”改革对医患双方产生的影响进行分析,探求公立医院优化管理模式的途径。同时,通过验证改革实施所取得的效果挖掘政策存在的不足,为政策的进一步改进和完善提供有益建议和决策依据。     

构建医患和谐：大型医院图书馆的医学信息服务的“三个面向”

针对临床医疗引发的医患矛盾,从医学信息服务角度提出了以面向医院管理层、临床医务人员和患者的医学信息服务来化解矛盾,阐述了大型医院图书馆以医学信息服务为纽带,构建医患和谐的工作要点。     

Community Members' Engagement with and Involvement in Genomic Research: Lessons to Learn from the Field

In this paper, we describe the potential role laypersons on ethics committees can play in ensuring community concerns are addressed in the design and implementation of genomic research. We draw inferences from the outcome of an empirical study of the impact of training of laypersons to address community engagement issues in ethics review of research protocol. While this paper does not advocate a particular solution, it describes the importance of community engagement in genomic research, the current limitations there are in engaging communities in the design of these research projects and how communities can be indirectly engaged in the design and implementation of genomic research through the engagement of laypersons on ethics committees. However, to ensure that these laypersons can play this role, their capacity needs to be built to play this role appropriately. There is evidence to show that where resources are invested in building the capacity of laypersons to play their role as community ‘watchdogs’ in research, they play this role aptly. Community engagement is important in genomic research as genomic researchers will increasingly require community perspectives in critical ethics decision making.     

医德视域下医学生医学精神的建构

近些年来,我国十分重视医学生职业道德教育,然而,在医德教学实践中仍存在着观念落后、内容失衡和方法单一等多方面问题。同时,随着我国多元结构社会的形成,医学生的思想状况和价值观趋于复杂化,从业时职业道德水平出现滑坡。针对目前医学生医德教育存在的种种问题,试图从加强和改进医学生医德教育的角度,探索医学生医德教育改革,增强医学生医德教育的实效性。     

Organ Donation After Acute Brain Death: Addressing Limitations of Time and Resources in the Emergency Department

It is not unusual for emergency physicians to quickly identify whether a patientwould have wanted to be resuscitated or intubated in a cardiac arrest situation,but patients’ other preferences for end-of-life care or organ donation are lesscommonly ascertained in the emergency department. Typically, the decisionprocess regarding such goals at end of life may be “deferred” to the intensivecare unit. We present a case illustrative of the complexity of discussing organdonation in the emergency department and suggest that patients who die in theemergency department should be afforded the respect and consideration providedin other parts of the hospital, including facilitation of organ transplantation.As circulatory determination of death becomes a more common antecedent to organtransplantation, specific questions may arise in the emergency departmentsetting. When in the emergency department, how should organ donation beaddressed and by whom? Should temporary organ preservation be initiated in thesetting of uncertainty regarding a patient’s wishes? To better facilitatediscussions about organ donation when they arise in emergency settings, wepropose increased coordination between organ procurement organizations andemergency physicians to improve awareness of organ transplantation.     

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.     

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。     

医务社工与志愿者在医院服务管理中作用的评价

目的 通过实证调查采集患者、医务工作者和志愿者对医务社工及志愿者工作的评价,解析医务社工及志愿者在医院服务管理中的作用。方法 采用问卷调查、文献查阅、深度访谈法,调研上海市三家三级甲等公立医院获取第一手资料。结果 调查结果显示,患者、医务人员及医务管理人员高度认可医务社工与志愿者在医院服务管理的作用。结论 医务社工和志愿者在医院服务管理中能发挥独特的作用,可以增进医患沟通,缓解或预防医患矛盾,给患者更多人文关怀和增值服务,一定程度上解决医患之间的诊治经费问题,提升服务品质、降低人力成本,应当得到全社会更多的重视。     

河北省医院卫生技术人员继续医学教育费用负担研究

目的 分析河北省二甲、三甲医院卫生技术人员参加继续医学教育项目学习的状况和经费负担特点。方法 采用分层抽样方法对45所二甲、三甲医院6 013名卫生技术人员问卷调查和描述性研究方法分析。结果 三甲医院人员各类项目参加率均高于二甲医院。两级医院人员参加率高的项目有收益率低,参加率与有收益率背离。教育费用负担有单位全部负担、单位和个人共同负担和个人全部负担3种形式。二甲医院3种负担的课程次数构成比分别为22.23%、16.03%、61.74%,单位全部负担和个人全部负担是主要的负担形式;三甲医院为19.50%、29.56%、50.94%,单位和个人共同负担是主要的负担形式。结论 投入不足和制度落实不到位是二甲医院滞后的主要原因,单位和个人共同负担是较为合理的负担形式。     

医学模拟教学结合以问题为导向的教学模式在重症医学教学中的应用研究

目的:探讨医学模拟教学结合以问题为导向(PBL)的教学模式在重症医学教学中的应用价值。方法:选取2015年1月~2017年1月在我院重症医学科轮转实习的五年制医学生64人作为研究对象。按随机数字表法将64名医学生分为PBL组(n=32)和结合教学组(n=32)。PBL组采用PBL教学,结合教学组采用医学模拟结合PBL教学。分别在入科时和轮转实习结束时对两组学员进行理论考试和技能操作考核,记录成绩并比较。理论考试和技能操作考核后采取发放问卷进行调查的形式获得学员对教学效果的主观评价。结果:轮转实习结束时,两组理论考试分数差异无统计学意义(P0.05);而结合教学组技能操作考核成分数显著高于PBL组,差异具有统计学意义(P0.05)。两组学员在教学方法接受度高、学习兴趣提升、自学能力提升和临床诊疗水平提高所占比例差异无统计学意义(P0.05);结合教学组学员在团队协作能力提高、沟通能力与人文关怀提高和技能操作水平提高所占比例高于PBL组,差异有统计学意义(P0.05)。结论:与单独PBL教学相比较,医学模拟教学结合PBL的教学模式应用于重症医学教学对学员技能操作的掌握有更好的效果,同时能提高学员团队协作能力、沟通能力以及对患者的人文关怀,且受到学员的认同与喜爱,应在重症医学的教学实践中逐步完善并进一步推广应用。     

Benefit Sharing in a Global Context: Working Towards Solutions for Implementation

Due to the state of globalized clinical research, questions have been raised as to what, if any, benefits those who contribute to research should receive. One model for compensating research participants is “benefit sharing,” and the basic premise is that, as a matter of justice, those who contribute to scientific research should share in its benefits. While incorporated into several international documents for over two decades, benefit sharing has only been sparsely implemented. This analysis begins by addressing the concept of benefit sharing, its historical development, and how it has been applied in the context of virus sharing for influenza research. The second portion of this analysis presents recommendations for ensuring benefit sharing. These recommendations are threefold: 1) an emphasis on social pressure, 2) the revision of international documents as means to ensure benefit sharing, and 3) greater collaboration between sponsor IRB and host country IRB. Because clinical research is a globalized industry, a global model will be proposed in the second that focuses on collaboration between the sponsor and host country. This collaboration is vital in order to ensure that proper forms of benefit sharing are accomplished as a matter of justice.     

Molecular Illustration in Research and Education: Past,Present, and Future

Two-dimensional illustration is used extensively to study and disseminate the results of structural molecular biology. Molecular graphics methods have been and continue to be developed to address the growing needs of the structural biology community, and there are currently many effective, turn-key methods for displaying and exploring molecular structure. Building on decades of experience in design, best-practice resources are available to guide creation of illustrations that are effective for research and education communities.     

The Vulnerability of Study Participants in the Context of Transnational Biomedical Research: From Conceptual Considerations to Practical Implications

Outsourcing clinical trials sponsored by pharmaceutical companies from industrialized countries to low‐ (middle)‐income countries – summarized as transnational biomedical research (TBR) – has lead to many concerns about ethical standards. Whether study participants are particularly vulnerable is one of those concerns. However, the concept of vulnerability is still vague and varies in its definition. Despite the fact that important international ethical guidelines such as the Declaration of Helsinki by the World Medical Association or the Ethical Guidelines for Biomedical Research Involving Human Subjects by the Council of International Organizations of Medical Sciences refer to vulnerability as ethical principle, each of their approaches are different. To overcome these shortcomings, we analyze and unite different approaches of vulnerability and develop practical criteria in order to operationalize the concept especially for the context of TBR. These criteria refer to the context of a study as well as the characteristics and the current living situation of study participants. Based on a case study of an HIV‐vaccine‐trial conducted in India we demonstrate how those criteria can be applied in a retrospective way to identify potential ethical conflicts. The criteria can also indicate a prospective function for ethical pre‐assessment. For this, we provide an outlook for three major topics: 1. Vulnerability as a normative concept: Different ways of protection; 2. The relevance of transparency and 3. Vulnerability as an instrument to increase decision participation of human subjects.     

患方不同人群对医患关系认知差异比较研究

目的 了解患方不同人群对医患关系认知的差异,从而对构建和谐医患关系提出具有针对性的对策、建议。方法 对北京市、武汉市、成都市的6家医疗机构的702名患者进行问卷调查。结果 不同性别、年龄、学历、地区、就医类型和医保类型的患者之间对医患关系认知存在差异。结论 微观个人因素影响患者对医患关系的认知,需加快医疗体制改革,缩小地区间差距,逐步提高医疗保险覆盖范围及报销费率,减少宏观经济保障因素对患者认知的影响;提高卫生系统反应性,针对不同类型的患者人群开展提高非技术性服务质量、缩小人群认知差距。     

Presuming patient autonomy in the face of therapeutic misconception

Therapeutic misconception involves the failure of subjects either to understand or to incorporate into their own expectations the distinctions in nature and purpose of personally responsive therapeutic care, and the generic relationship between subject and investigator which is constrained by research protocols. Researchers cannot disregard this phenomenon if they are to ensure that subjects engage in research on the basis of genuine informed consent. However, our presumption of patient autonomy must be sustained unless we have compelling evidence of serious misunderstanding. This article argues that the mere expression of aspects of therapeutic misconception should not necessarily displace the presumption of subject autonomy or undermine ethical inclusion in research for at least three reasons. First, some interpretations of the empirical data do not suggest misunderstanding. Second, assessment of misestimation and optimism are delicate and value‐laden, and turn quickly from questions of autonomy to questions of judgment. Third, incomplete understanding may yet be sufficient to allow a subject to engage in a substantially autonomous decision‐making process. Our point is not to dismiss the possibility of genuine therapeutic misconception, but to question its frequency and fatality to the consent process.     

教学医院医患关系与医德医风评价研析

目的 调查医护人员医德自我评价和患者对医护人员医德评价。方法 对某教学医院306名患者、266名医护人员进行问卷调查,调查信息通过Epidata录入,使用SPSS13.0软件进行统计描述和分析。结果 在医护人员的服务态度、医护人员对患者需求的反应、尊重患者的知情同意权、医药费用问题、患者的信任、医患沟通等方面存在差异。结论 主要从以下几方面进行改善：完善医德医风管理制度,提高医护人员整体素质,注重对医学生医德信念的培养,转变医德医风的教育方式,提高医务人员的待遇。