Contributions of empirical research to medical ethics

Empirical research pertaining to cardiopulmonary resuscitation (CPR), clinician behaviors related to do-not-resuscitate (DNR) orders and substituted judgment suggests potential contributions to medical ethics. Research quantifying the likelihood of surviving CPR points to the need for further philosophical analysis of the limitations of the patient autonomy in decision making, the nature and definition of medical futility, and the relationship between futility and professional standards. Research on DNR orders has identified barriers to the goal of patient involvement in these life and death discussions. The initial data on surrogate decision making also points to the need for a reexamination of the moral basis for substituted judgment, the moral authority of proxy decision making and the second-order status of the best interests standard. These examples of empirical research suggest that an interplay between empirical research, ethical analysis and policy development may represent a new form of interdisciplinary scholarship to improve clinical medicine.     

Where lies social responsibility?

L. Krasner's article, "Behavior Control and Social Responsibility" (see record 1963-00116-001) bypassed several points of view which might clarify some of the issues discussed, and at the same time tone down what seems to be an exaggerated claim for urgency in dealing with problems of social responsibility. In the matter of considering moral and ethical issues, it is important to proceed with calmness and careful consideration rather than to become overly excited about finding the "right" solution. Even the "psychologist-researcher" is human and when he turns his hand to such things as communicating to the lay public he may fall into the pattern of the "sensationalists and popularizers," though obviously not so crudely. First among three basic questions and answers presented by Krasner is that concerning whether or not human behavior is controllable. His answer is to the effect that there is overwhelming experimental evidence that human behavior is controllable. Such a statement seems exaggerated in the face of other evidence from both experimental and clinical impressions. Krasner states that there is a "subtle but important" difference between the "psychology of behavior control" and the science of psychology. There are several objections to some of Krasner's implications that the behavioral scientist is not or at least is less bound by an ethical and moral system. There seem to be no logical grounds for distinguishing in principle between an ethics for behavioral scientists and an ethics for behavior controllers. The atomic scientists produced a bomb as scientists employed by their government while at war. They did their job effectively. As informed private citizens they held some moral reservations as to the consequences of their scientific endeavors. The behavioral scientist and the behavior controller can also perform their professional tasks dispassionately and efficiently, but as people they might well look to the ethical and moral issues involved. They can choose to take appropriate ethical and moral action as private citizens who have the advantages of specialized knowledge. The behavioral scientist and the behavior controller are not to be compartmentalized into a patchwork of separate roles, rather they are to see themselves as integrated individuals functioning in various ways which on occasion may bring about a conflict in ethical and moral values. Then they should be enabled to resolve the conflicts for themselves on a rational basis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Providing feedback in research with human subjects.

Feedback provided to Ss and 3rd parties from intra- and extramural investigators following the completion of research involving an agency's clients or staff is described. Ss were from the division of a public health department that provides mental health and substance abuse services in a city with 740,000 people. The division's research requirements include submission of annual progress reports and final reports. Of 135 studies conducted over 12 yrs, annual reports were received from 37% of investigators, and final reports from 30%. There were no significant differences based on investigator discipline or affiliation. Professional and ethical implications are discussed, including adequacy of professional training, the need for mechanisms to ensure compliance with ethical standards, the obligations of clinic directors, and the impact on public academic liaison programs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Non-fatal acute renal failure due to wasp stings in children

Annals' 25th anniversary is a cause for celebration, but the future imposes a new set of ethical questions and moral dilemmas for emergency physicians. Each physician will need to make personal choices consistent with the courage, judgment, integrity, and dedication of past leaders when dealing with the moral dilemmas of the future.     

Participant partners: College students weigh the costs and benefits of deceptive research.

The contributions of prospective participant perspectives to ethical decisions regarding the design and institutional review board approval of deceptive research are considered in terms of American Psychological Association ethical guidelines and current theoretical, empirical, and metaethical frameworks. The value of participant–investigator partnerships is illustrated through a study assessing how college students rate the scientific merits, methodological alternatives, psychological discomfort, efficacy of dehoaxing, and cost–benefit balance of 3 recently published deception studies. Enhancing the protection of human Ss participating in deceptive research is discussed in terms of the compatibility of deceptive practices with the moral ideologies of participants and the challenges to ethical decision making raised by the interpretation and application of data based on participant perspectives. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Doctor of Psychology degree: From hibernation to reality.

Since the beginning of the American Psychological Association (APA), there have been 3 explicit models of psychologists: scientist, scientist–professional, and professional. In the late 1940's, there was a need for a model of clinical training that the Boulder scientist-professional model fulfilled. However, the emphasis on training in the science of psychology seemed to increase at the expense of training in the applied aspects of psychology. The need was increasingly voiced for a service-oriented training program with a clear professional identity. These pressures culminated in the most recent training conference convened by APA at Vail, Colorado in 1973. The Vail conferees asserted that the development of psychological science had sufficiently matured to justify creation of explicit professional programs. The Doctor of Psychology (PsyD) model and rationale are explained, and essential ingredients of currently operating PsyD programs are discussed. Future developments in professional programs, credentialing and designation, and the critical interface with societal needs are also examined. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preserving moral integrity: a follow-up study with new graduate nurses

The purpose of this follow-up study was to describe, explain and interpret how new graduate nurses perceived their adaptation to the 'real world' of hospital nursing and what they perceived as major influences on their moral values and ethical roles in the 2 years following graduation. The method was qualitative, specifically grounded theory. The earlier study took place when informants were senior nursing students. The follow-up study began after the informants had been practising for 1 year. Research questions guiding the study were: How do new graduate nurses describe their adaptation to the 'real world' of hospital nursing? What do they describe as factors influencing their moral values and ethical roles in hospital nursing? Preserving moral integrity was the basic psycho-social process that explained how these new graduate nurses adapted to the real world of hospital nursing. Six stages of this process were identified: vulnerability; getting through the day; coping with moral distress; alienation from self; coping with lost ideals; and integration of new professional self-concept. Moral distress was a consequence of the effort to preserve moral integrity. It is the result of believing that one is not living up to one's moral convictions. Data supported that the most pervasive attributes of moral distress were self-criticism and self-blame, as informants judged their actions against their moral convictions and their standards of what a good nurse would do. Moral distress was an acute form of psychological disorientation in which informants questioned their professional knowledge, what kind of nurses they were and what kind of nurses they were becoming. Theoretical explanations of these findings are grounded in social interaction and moral psychology theories.     

Nursing students' responses to ethical dilemmas in nursing practice

In literature as well as in nursing practice a growing concern about nurses' ethical competence can be observed. Based on the cognitive theory of moral development by Kohlberg, this research examined nursing students' ethical behaviour in five nursing dilemmas. Ethical behaviour refers not only to the ethical reasoning of nursing students but also to the relationship between reasoning and behaviour. Kohlberg's definition of morality was refined by adding a care perspective. The results show that the majority of students can be located in the fourth moral stage according to Kohlberg's theory, that is, the conventional level of moral development. This finding implies that students are still guided by professional rules, norms and duties, and have not (yet) succeeded in making personal ethical decisions on the basis of their own principles and acting according to such decisions.     

The patient-physician covenant: an affirmation of Asklepios

Medicine is, at its center, a moral enterprise grounded in a covenant of trust. This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times. Today, this covenant of trust is significantly threatened. From within, there is growing legitimation of the physician's materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician's responsibility degrade the physician-patient relationship that is the central element and structure of clinical care. To capitulate to these alterations of the trust relationship is to significantly alter the physician's role as healer, carer helper, and advocate for the sick and for the health of all. By its traditions and very nature, medicine is a special kind of human activity--one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion, and effacement of excessive self-interest. These traits mark physicians as members of a moral community dedicated to something other than its own self-interest. Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it. Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gateclosers, or agents of fiscal policy that runs counter to our trust. Any defection from primacy of the patient's well-being places the patient at risk by treatment that may compromise quality of or access to medical care. We believe the medical profession must reaffirm the primacy of its obligation to the patient through national, state, and local professional societies; our academic, research, and hospital organizations; and especially through personal behavior. As advocates for the promotion of health and support of the sick, we are called upon to discuss, defend, and promulgate medical care by every ethical means available. Only by caring and advocating for the patient can the integrity of our profession be affirmed. Thus we honor our covenant of trust with patients.     

An Opinion on Expressing Opinions to Influence Social Policy.

First, I would like to commend C. Hosticka, M. Hibbard, and N. Sundberg ("Improving psychologists' contributions to the policymaking process," in Professional Psychology: Research & Practice. Vol 14(3), June, 1983, pp. 374-385) on their presentation of the role of the psychologist as scientist to the policy-making process. They treated the subject in a thorough and professional manner. I do, however, have a minor clarification that I believe is important to consider when psychologists attempt to contribute to the formation of public policy. This clarification has to do with the tertiary nature of the professional psychologist--that is, the psychologist as scientist, as practitioner, and as human being. Hosticka et al. do an admirable job of delineating the many problems that confront the psychologist who attempts to influence public policy as a scientist/researcher. However, they neglect to mention the role of the psychologist as a practitioner/clinician or as a human being/citizen. Granted, these roles are probably less complex and perhaps require less attention. Nonetheless, they do warrant at least a cursory review. As scientists, psychologists conduct research in order to accumulate scientific evidence that can be given to policymakers in an effort to influence policy decisions. As practitioners, psychologists have taken a clinical pledge to help others through their potential emotional reactions to public policy. Finally, as human beings, psychologists are free to express opinions and spew out personal beliefs with respect to public policy. However, one note of caution is recommended, that is, we ought not confuse the three roles. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medical investigators' views about ethics and fraud in medical research

The objective of this study was to ascertain the views and attitudes of medical investigators on medical ethics, and ethics and fraud in medical research. We sent postal questionnaires to all principal investigators whose study protocols had been assessed by their regional medical ethics committee for biomedical research (mid-Norway) in the years 1986-92 (n = 159). The response rate was 70% (n = 119). Some 80% agreed that ethical considerations had influenced their research and 12% that they would have had ethical scruples today about some of their previous projects. One in ten agreed that they might have achieved better results if they could have paid less attention to ethics. About 70% of the respondents found that the committee's comments were useful and relevant, but most agreed only in part. Around 85% agreed fully or in part that scientific quality is an important ethical element of any project and that researchers put more effort into their study protocol when they knew it would be evaluated by an ethics committee. One in six (18%) respondents agreed fully or in part that they had been exposed to scientific misconduct. Also, 27% knew about one or more cases of fraud or misconduct while 42% stated that this knowledge was not public. We concluded that ethics in medicine and medical research have an important and increasing role among investigators with little or no theoretical background and training in ethics. Scientific fraud and misconduct in medicine is a growing concern among researchers, who welcome a professional body that can manage allegations and cases of fraud.     

Biomedical ethics and the biomedical engineer: a review

Biomedical engineering is responsible for many of the dramatic advances in modern medicine. This has resulted in improved medical care and better quality of life for patients. However, biomedical technology has also contributed to new ethical dilemmas and has challenged some of our moral values. Bioengineers often lack adequate training in facing these moral and ethical problems. These include conflicts of interest, allocation of scarce resources, research misconduct, animal experimentation, and clinical trials for new medical devices. This paper is a compilation of our previous published papers on these topics, and it summarizes many complex ethical issues that a bioengineer may face during his or her research career or professional practice. The need for ethics training in the education of a bioengineering student is emphasized. We also advocate the adoption of a code of ethics for bioengineers.     

I Itch Too: A Comment.

Provides a comment on articles by L. N. Solomon (see record 2005-07722-001) and T. C. Kahn (see record 2005-07722-002). Man, the ingenious creature, has invented many ways of torturing himself. Perhaps the most clever technique is to raise an itchy rash of doubts all over himself. We psychologists are particularly susceptible to this allergy of modern man. Among our group the clinician in us is continually doubting the humane value of the scientist in us. And the scientist in us is forever nagging about the moral validity of our sympathetic efforts in behalf of patients. This makes the whole profession downright miserable in spots--a self-doubting collection of individuals. So one writer urges that we avoid intrapsychic conflict by letting clinicians be clinicians and experimentalists be experimentalists. And the other writer makes it clear enough that this would by no means relieve the irritation. What would happen, ideally, if the clinician ego could effectively ignore the scientist superego, and the scientist superego could remain oblivious to pressing clinical realities? The author speculates on this ideal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Applying Hamlet's question to the ethical conduct of research: A conceptual addendum.

Contends that decision models used to ensure cost–utility guidelines in research are insufficient because they fail to consider the cost–utility of not conducting a particular study. It is suggested that those who argue that a given study is unethical and should be prohibited should be prepared to answer in ethical and moral terms for the consequences of their decision. It is concluded that ethical responsibilities include protection of the integrity of work to insure that it measures up to the standards of good scientific practice and respect for the dignity of persons and values studied in the pursuit of scientific knowledge. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bioethics and Canadian dentistry

Formal ethical reflection and analysis have become expected components of clinical decision making for all health professionals. The implicit acceptance of professional ethics as the sole determinant of "the right and the good" has been replaced by an expectation for more broadly-based understanding of ethical issues. Dentists, like physicians, must be clear about professional ethics and competent in interdisciplinary and interprofessional discussions of the right and good. Modern bioethics is providing approaches to these issues to help practitioners make ethical clinical decisions. These approaches may not be appropriate for dentistry, especially as practised in Canada. Clearly, there are fundamental questions concerning dentistry as a profession, patient-dentist interactions and dental health that must be addressed to form a basis for an ethic relevant to professional practice. The answers to these questions have profound implications for the initial and continuing education of Canadian dentists and for dentistry itself. Some possible starting points for a truly Canadian ethic for dentistry are suggested from a non-dentist, physician ethicist.     

A theory of ethics for forensic psychiatry

This article offers a justification for a set of principles that constitute the ethical underpinnings of forensic psychiatry. Like professional ethics in general, the principles are based on the particular societal functions performed by forensic psychiatrists and result in the intensification of obligations to promote certain important moral values. For forensic psychiatrists, the primary value of their work is to advance the interests of justice. The two principles on which that effort rests are truth-telling and respect for persons. In the same manner as other physicians who perform functions outside of the usual clinical context (e.g., clinical researchers), forensic psychiatrists cannot simply rely on general medical ethics, embedded as they are in the doctor-patient relationship--which is absent in the forensic setting. Indeed, efforts to retain some residuum of that relationship and its associated ethical principles are likely to create confusion in the minds of both forensic psychiatrists and their evaluees and to heighten the problems of double agency. A virtue of this approach is the clear distinction it offers between clinical and forensic roles.     

Contemporary issues in clinical training.

66 directors of clinical training and 118 randomly selected clinicians responded to a questionnaire concerning issues in clinical training. Directors of training were more favorably inclined toward the scientist–professional model than were random clinicians. Random clinicians were more favorably inclined toward alternative, professional models of training than were directors of training. A factor analysis revealed that endorsement of either a scientist–professional model or a professional model and a rejection of the alternative model accounted for 45% of the variance of responses to the questionnaire. (24 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethical and legal aspects of survey research.

Sample surveys have been received as legal evidence since 1940. Judges have given weight to sample survey research in reaching decisions. Among the problems involved is the legal pressure to disclose names of respondents—a violation of the principle of confidentiality and anonymity under which much survey research is conducted. "It is the purpose of the present paper to call to the attention of relevant professional associations the need for guidance on this ethical and legal issue." Under what conditions should names of respondents be disclosed? Major sections are: The scientist in court, The dilemma, Estimating reliability, A case study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

关于加强企业职业道德建设的思考

加强企业职工思想道德、职业道德建设是我国社会主义精神文明建设的目标,是全民族牢固树立建设有中国特色社会主义的共同理想,信念和职业道德规范。本文拟从思想道德、职业道德及其意义,特别是对强化职业建设的重点进行了阐述。以此加强企业职业道德建设。     

Of rigor and relevance.

A review of the literature on child behavior therapy reveals an inverse relationship between scientific rigor and clinical relevance. It appears that the differences in the constraints operating on the role of the clinician and the role of the scientist force a choice between rigor and relevance and create a dilemma. Occasional studies combine scientifically sound methodology with clinically meaningful conclusions, particularly where the single-S design is employed, but these inevitably suffer from a lack of generalizability. It is felt that one way of resolving the dilemma is to combine detailed studies of individual cases with sound group-comparison studies in the context of comprehensive research programs. Another is the "tracer" method in which extensive information on each participant is available so that it can be retrieved after the data from group-comparison studies have been analyzed. As a less costly alternative to this, the deviant case analysis is proposed wherein detailed case studies are conducted on only those individuals whose data ran counter to the trend displayed by the group. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)