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Ethics education

Not Just About Consent: The Ethical Dimensions of Research Methodology Knowledge in IRBs

15 Jun, 17 | by bearp

Guest Post: Sarah Wieten

The recent article, “Some Social Scientists Are Tired of Asking for Permission” in the New York Times inspired a great deal of debate about the role of institutional research ethics board (IRB) oversight in social science, which some argue is in most cases unlikely to involve significant harm to participants.

While the role IRBs play in sociological research is being re-examined, the importance of IRB oversight for medical research was not similarly called into question. But what exactly does IRB oversight in medical research involve? Should these groups be content with assuring that patients and participants in medical research have provided informed consent? Or do they have wider duties? What is the relationship between methodologically rigorous science and ethical science?

The approval of research projects by IRBs is an integral part of the conduct of research in universities. IRBs ensure that all research follows key ethical guidelines and is pursued for good reason, and in doing so, they aim to keep patients and participants out of harm’s way. IRBs are important gatekeepers of institutional research, and serve as a check on the work of scientists, physicians, and others who are pursuing new knowledge.

We would assume then, that people serving on IRBs have a clear understanding of relevant research design. That way, they can check the research for ethical issues stemming from the methodology. They can also make sure that methodologically poor studies do not proceed, as this would be an unethical waste of resources (and would put participants at risk without a reasonable prospect of gaining reliable knowledge in exchange).


Bridging the Education-action Gap: A Near-peer Case-based Undergraduate Ethics Teaching Programme

6 Feb, 17 | by miriamwood

Guest Post: Dr Selena Knight and Dr Wing May Kong

Paper: Bridging the education-action gap – a near-peer case-based undergraduate ethics teaching programme

Medical ethics and law is a compulsory part of the UK undergraduate medical school curriculum. By the time they qualify, new junior doctors will have been exposed to ethics teaching in lectures and seminars, through assessments, and during clinical placements. However, does this really prepare them for the ethical minefield they will encounter as doctors?

Following my own graduation from medical school I started as a foundation year doctor in a busy London teaching hospital. Despite having had more exposure to ethics and law teaching than most by having completed an intercalated BSc in the subject, I found as a new doctor that I was often encountering ethical dilemmas on the wards but felt surprisingly ill-equipped to deal with them. I was generally able to identify that I was facing an ethical dilemma, but frequently found myself stuck when coming up with a practical solution.

If I felt like this having had an additional year of studying ethics and law, how on earth were other new doctors coping? In fact, when questioning my peers about their experiences they described that they also encountered dilemmas, but either didn’t specifically identify them as ethical in nature (e.g. they described feeling uncomfortable or uneasy with a decision made or a particular situation but couldn’t pinpoint why) and frequently described being unable to do anything to improve the situation either because they didn’t know what to do or they didn’t feel confident to speak up/rock the boat e.g. if they experienced a consultant acting unprofessionally

It became clear that even if ethics teaching at medical school was providing sufficient knowledge to enable junior doctors to identify ethical dilemmas, it was failing to prepare them to actually deal with such issues in practice. My own experiences, together with those I heard from my peers, formed the inspiration for the teaching programme that was subsequently designed.


A Matter of Life and Death

10 Jan, 17 | by bearp

Guest Post by Professor Lynn Turner-Stokes

Re: A matter of life and death – controversy at the interface between clinical and legal decision-making in prolonged disorders of consciousness

In an article published in the JME, I highlight the confusion that exists amongst many clinicians, lawyers and members of the public about decisions with withdraw life-sustaining treatments from patients in permanent vegetative and minimally conscious states.

Recent improvements in acute care for patient who have suffered catastrophic brain injury undoubtedly save lives. However, some patients who would otherwise have died now survive but remain profoundly disabled. Many patients experience a brief period of unconsciousness (or ‘coma’) lasting a few days or weeks. However, an unfortunate few with very severe brain injury remain in a vegetative and minimally conscious state (VS/MCS) for many months – or in some cases permanently.

Unfortunately the lay press, and even much of the medical literature, tends to conflate VS/MCS with coma, but they are in fact very different. Coma is a state of ‘unrousable unresponsiveness’ from which the patient cannot be awakened. It rarely persists for more than a few days or weeks, as the large majority of patients will either die or start to regain consciousness. Patients in VS or MCS are awake, but have either very limited awareness of themselves and their environment (MCS), or none at all (VS). With supportive treatment, many will live in these states for a decade or more.


Free Labour and Quiet Doubts

1 Aug, 16 | by Iain Brassington

Those of us on the academic side of things will almost certainly recognise the situation: you’re sitting in your school’s Teaching & Learning committee, or a staff/student committee meeting, or something like that, and you hear the complaint from students that they should get more contact time.  Academics should spend more time teaching rather than simply doing their own research.  After all, they’re paying however-many thousand pounds for their education.

And you’ll’ve heard the standard rebuttals – and maybe even trotted them out yourself: that course fees cover not just teaching costs, but libraries, labs, buildings and so on; that university learning isn’t about hours in a classroom; that teaching and research are intertwined; that students benefit from being taught by the people who’re writing the papers they’re reading.  But I wonder if these standard responses miss something important.

Back in April, I was getting companionably smashed with some of my final-year students, and we were talking about what they were going to do when they’d graduated, and about possible careers.  One or two were interested in academia, and so a part of the conversation concerned what life’s like from my side of the fence.  Predictably, pay was one thing that interested them.  I mentioned that I’d made about £80 in total from the books I’ve written, spread over 10 years.
“And what do you get paid for a paper?”
I held back my bitter laughter, and explained how much you get paid for papers, and how much you get for peer-reviewing, and all the rest of it.  The students had had no idea that this stuff was expected of us, but not remunerated.  Why would they?  Indeed, isn’t it insane that we’re not paid?

I think that one gets an insight here into students’ complaints about academics’ priorities being wrong.  If they think that we get paid for publishing papers, then of course they’re going to think that we have an incentive to resist extra contact hours – and everything we tell them about extra contact hours being at best academically unnecessary, and likely as not counterproductive, will sound like so much bad faith.  After all, of course we’d tell them that a course only needs 30 hours of lectures rather than 60 if we could be earning extra money with those spare 30 hours.

What prompts all this is an article in the Chronicle of Higher Education.  It’s from 2012, but it’s started popping up in my social media timelines this morning, and Carl posted it on Fear and Loathing in Bioethics last night.  It makes a proposal: more…

CFA/ Registration: Postgraduate Bioethics, 2016

30 Jun, 16 | by Iain Brassington

“Oi, Iain,” says David.  “Could you put a shout out for the Postgraduate Ethics Conference?”

Indeed I could.  The theme is “Bioethics in Theory: Bioethics in Practice”.  Details – including the call for abstracts (the deadline for which is the 8th July) and the registration form – are here.

Writers Whose Expertise is Deplorably Low

4 Jun, 16 | by Iain Brassington

Something popped up on my twitter feed the other day: this document from Oxford’s philosophy department.  (I’m not sure quite what it is.  Brochure?  In-house magazine?  Dunno.  It doesn’t really matter, though.)  In it, there’s a striking passage from Jeff McMahan’s piece on practical ethics:

Even though what is variously referred to as ‘practical ethics’ or ‘applied ethics’ is now universally recognized as a legitimate area of philosophy, it is still regarded by some philosophers as a ghetto within the broader 
area of moral philosophy.  This view is in one way warranted, as there is much work in such sub-domains of practical ethics as bioethics and business ethics that is done by writers whose expertise is in medicine, health policy, business, or some area other than moral philosophy, and whose standards of rigour in moral argument
are deplorably low.  These writers also tend
 to have only a superficial understanding of normative ethics.  Yet reasoning in practical ethics cannot be competently done without sustained engagement with theoretical issues
in normative ethics.  Indeed, Derek Parfit believes that normative and practical ethics are so closely interconnected that it is potentially misleading even to distinguish between them.  In his view, the only significant distinction is between ethics and metaethics, and even that distinction is not sharp.  [emphasis mine]

It’s a common complaint among medical ethicists who come from a philosophical background that non-philosophers are (a) not as good at philosophy, (b) doing medical ethics wrong, (c) taking over.  All right: there’s an element of hyperbole in my description of that complaint, but the general picture is probably recognisable.  And I don’t doubt that there’ll be philosophers grumbling along those lines at the IAB in Edinburgh in a couple of weeks.  There’s a good chance that I’ll be among them.

There’s a lot going on in McMahan’s piece, and his basic claim is, I suppose, open to a claim that, being a philosopher, he would say that, wouldn’t he?  But even if that claim is warranted, it doesn’t follow that it’s false.  And it probably isn’t false.  There is some very low-quality argument throughout bioethics (and, from what I remember from my time teaching it, business ethics) – more particularly, in the medical ethics branch of bioethics, and more particularly still, in the clinical ethics sub-branch.  Obviously, I’m not going to pick out any examples here, but many of us could point to papers that have been simply not very good, because the standard of philosophy was low, without too much difficulty.  Often, these are papers we’ve peer-reviewed, and that haven’t seen the light of day.  But sometimes they do get published, and sometimes they get given at conferences.  I’ve known people who make a point of trying to find the worst papers on offer at a given conference, just for the devilry.

It doesn’t take too much work to come up with the common problems: a tendency to leap to normative conclusions based on the findings of surveys, or empirical or sociological work; value-laden language allowing conclusions to be smuggled into the premises of arguments; appeals to vague and – at best – contentious terms like dignity or professionalism; appeals to nostrums about informed consent; cultural difference used as an ill-fitting mask for special pleading; moral theories being chosen according to whether they generate the desired conclusion; and so on.  Within our field, my guess is that appeals to professional or legal guidelines as the solutions to moral problems is a common fallacy.  Not so long ago, Julian noted that

[t]he moralists appear to be winning.  They slavishly appeal to codes, such as the Declaration of Helsinki.  Such documents are useful and represent the distillation of the views of reasonable people.  Still, they do not represent the final word and in many cases are philosophically naïve.

Bluntly: yes, the WMA or the BMA or the law or whatever might say that you ought to do x; and that gives a reason to to x inasmuch as that one has a reason to obey the law and so on.  But it’s unlikely that it’s a sufficient reason; it remains open to us always to ask what those institutions should say.  Suppose they changed their minds and insisted tomorrow that we should do the opposite of x: would we just shrug and get on with the business of undoing what we did today?

And yet…  The complaint about poor argument is not straightforward, for a couple of reasons. more…

Nurses Cannot be Good Catholics

31 Mar, 16 | by BMJ

Guest Post by John Olusegun Adenitire

It seems that if you are a nurse you cannot be a good Catholic.  Or, better: if you want to work as a nurse then you might have to give up some of your religious beliefs.  A relatively recent decision of the UK Supreme Court, the highest court in the country, seems to suggest so.  In a legal decision that made it into the general press (see here), the Supreme Court decided that two Catholic midwives could not refuse to undertake administrative and supervisory tasks connected to the provision of abortions.

To be sure, no one asked the nurses to directly assist in the provision of abortions.  The Abortion Act 1967 says that “No person shall be under any duty … to participate in any treatment authorised by this Act to which he has a conscientious objection.”  The Nurses argued that this provision of the Act should be understood widely.  Not only should they be allowed to refuse to directly assist in abortion services: they should also be entitled to refuse to undertake managerial and supervisory tasks if those were linked to abortion services.  The nurses’ employer was not impressed; neither was the Supreme Court which ruled that the possibility to conscientiously object only related to a ‘hands-on’ capacity in the provision of abortion services.

In a recent paper in the JME (available here) I have argued, albeit only indirectly, that this decision is only half-correct.  Nurses and other medical professionals have a human right to object to the provision of a wide range of services which they deem incompatible with their conscience.  I say that the decision of the Supreme Court is only half-correct because the Court explicitly avoided investigating the possibility of the nurses’ human right to conscientious objection.  Under the Human Rights Act, individuals have a right to freedom of conscience and religion.  That right may, in appropriate circumstances, entail the right for nurses to object to being involved in administrative and supervisory duties connected with abortion services.  If you ask me how the Supreme Court avoided having to consider the nurses’ human right to freedom of conscience and religion I couldn’t tell you.  I bet neither could any of the Law Dons at Oxford.

I realise that by appealing to human rights I am not necessarily making the nurses’ case any more deserving of sympathy that it already is(n’t). more…

How do Medical Students Learn Ethics?

3 Aug, 15 | by Iain Brassington

Guest Post by Carolyn Johnston

How interested are medical students in learning ethics and law? I have met students who have a genuine interest in the issues, who are engaged in teaching sessions and may go on to intercalate in ethics and law. On the other hand some consider that ethics is “just common sense”. They want to know only the legal parameters within which they will go on to practice and do not want to be troubled with a discussion of ethical issues for which there may not be a “correct” answer.

Ethics and law is a core part of the undergraduate medical curriculum and so in order to engage students successfully I need to know whether my teaching materials are relevant, useful and interesting. In 2010 I ran a student selected component in which MBBS Year 2 students created materials for medical ethics and law topics for pre-clinical students which they considered were engaging and relevant, so that students might go further than learning merely to pass exams. One student, Marcus Sorensen, who had managed a design consultancy focusing on web design and development before starting his medical studies, came up with the idea of a website as a platform for ethics materials for King’s students and he created the website

It was through our ongoing discussions that we identified a lack of information about students’ experiences of learning medical ethics and law, especially outside the classroom environment. more…

Making the Jump to a Medico-Legal Career

15 Jul, 15 | by BMJ

Guest Post by Daniel Sokol

On a number of occasions, I have been asked by early career ethicists about the move from ethics to law, or the wisdom of seeking a legal qualification to supplement their ethical knowledge. In the UK, this can be achieved remarkably quickly. This blog post is an answer to those questions, based only on my own experiences.

In 2008, I was a lecturer in medical ethics and law at St George’s, University of London. I had no legal training, and felt uncomfortable teaching law to medical students. Some of the graduate students were former lawyers and it must have been obvious to them that the limits of my legal knowledge extended no further than the PowerPoint slide.

That year, an old school friend, a solicitor, encouraged me to become a lawyer. “I can imagine calling you ‘My learned friend‘ in court”, he said. And so the seed was planted, and with each soul-sapping marking session, and each article published and quite unread, the seed grew until, in 2009, I resigned from my lectureship to study on the law conversion course, now called the Graduate Diploma in Law (GDL). more…

Bad Surgeons and Good Faith

10 Jul, 15 | by Iain Brassington

This is a bit of a strange post, not least because it involves citing sources – a blog post, and a whole blog -that have since been taken down from the net, for reasons that will become clear.  It’s also going to involve a pair of fairly hefty quotations, largely because it’s the absence of a source that motivates this post – which means I can’t simply tell you to follow the links.  It has to do with an apparent case of a surgeon deliberately causing a serious injury to a patient in the name of teaching, and with deceptions, and with apologies for those deceptions.

It’s also a very long post, even by my prolix standards.

OK: so, as quoted by Orac on his Respectful Insolence blog, here’s the case that gets the story going.  It was originally recounted by someone calling themselves “Hope Amantine”, and was cross-posted, which bills itself as “social media’s leading physician voice”, is written by someone called Kevin Pho, and is a part a site called MedPage Today.  This means that Orac’s version is at least third-hand; but I can’t do better than that, for reasons that will become clear.  That’s a pain, but I’m going to have to take things on good faith – which, given what comes later, is perhaps asking for trouble.  Either way, here’s the story:

So here I was, handling the plane (the layer, or space) around the IVC [inferior vena cava] with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, “Why are you being so dainty with your dissection there?” I answered that I wanted to avoid ripping the cava because they’re so much harder to fix.

Big mistake.

I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.

I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, “Well, are you just going to stand there or are you going to fix that?”

And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow.  I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me.  This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole.  No problem.

All he said was, “Good job.” And we proceeded to complete the case uneventfully.


Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn’t control the bleeding, he would have taken over. And I would have failed.


So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.

I guess I made the cut.

The excisions are mine – they’re where Orac makes a comment.  However, there’s one more part that’s important – and this is now in Orac’s voice:

The reaction to Dr. Amantine’s post was furious and uniformly negative, both in the comments and in the Twittersphere, and yesterday there was an addendum:

Author’s note 7/8/2015: This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.

Orac calls BS on this, and I’m tempted to do likewise; but I’ll put that to one side for now.  I’ll also note that I can’t check the flow of the original post, because it no longer exists.  Indeed, Hope Amantine’s whole blog would seem to have been taken down.  In the meantime, other blogs and pages also picked up the story from KevinMD: PZ Myers noted it on Pharyngula, Janet Stemwedel commented in a piece on Forbes‘ site, and I’m sure there were more.  This is noteworthy, because, as I said, the OP has now gone.  If you want to read it, you’ll have to go to where it was cross-posted or quoted (which makes this whole thing rather like a game of Chinese Whispers).

Indeed, not only has the OP gone: the KevinMD post has also gone.  Where it was, there’s this message: more…

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