The promises and limitations of codes of medical ethics as instruments of policy change.

Codes of medical ethics (codes) are part of a longstanding tradition in which physicians publicly state their core values and commitments to patients, peers, and the public. However, codes are not static. Using the historical evolution of the Canadian Medical Association's Code of Ethics as an illustrative case, we argue that codes are living, socio-historically situated documents that comprise a mix of prescriptive and aspirational content. Reflecting their socio-historical situation, we can expect the upheaval of the COVID-19 pandemic to prompt calls to revise codes. Indeed, Alex John London has argued in favour of specific modifications to the World Medical Association's International Code of Medical Ethics (which has since been revised) in light of moral and scientific failures that occurred during the COVID-19 pandemic. Responding to London, we address the more general question: should codes be modified to reflect lessons drawn from the COVID-19 pandemic or future such upheavals? We caution that codes face limitations as instruments of policy change because they are inherently interpretive and 'multivocal', that is, they usually underdetermine or provide more than one answer to the question, 'What should I do now?' Nonetheless, as both prescriptive and aspirational documents, codes also serve as tools for reflection and deliberation-collective practices that are necessary to engaging with and addressing the moral and scientific uncertainties inherent to medicine.

[Towards the revision of the Italian code of medical ethics: thoughts of an extremist.] / Verso la revisione del Codice di deontologia medica: riflessioni di un estremista.

In November 2022 the Italian medical council (Federazione nazionale degli ordini dei medici chirurghi e odontoiatri) started the revision of the Italian Code of medical ethics (Cme) with the first race dating back ten years. Since then, the Italian doctors are dealing with the scientific, ethical and economic challenges together with the more recent ones posed by the Sars-CoV-2 pandemic to the National health system underlying the ongoing crisis of the medical profession. Additionally, this critical context requires the doctors to develop new technological skills, a complete and effective adherence to the Ebm principles, a new view regarding the relationship with the other health care professionals and the related changes of clinical practices fostering a responsible use of resources. In brief, what is required nowadays from doctors is to rethink about the meaning of science, ethics, economics and public health and to make new and more appropriate connections between the instances conveyed by these different disciplines. The Cme main aim consists in providing appropriate rules in step with the current transformations of medicine and society to doctors for ethically acting in clinical practice, assuring the citizens, the institutions and law of the scientific competence, the protection of the fundamental rights of the sick person in compliance with the constitutional principles. Under this assumption and in line with the above mentioned professional crisis, at least the overall guidelines aimed to solve it should have been settled before starting the Cme review also in order to ensure the necessary coherence between the new contents drawing the doctors new social function and its codal systemisation. Unfortunately this stepwise approach was not considered.Lastly, to develop the new Cme looking towards the progress of medical profession, systematic and methodologically appropriate consultations would have been necessary to know, value and balance all the different positions of doctors, allowing them to be responsible for the change of their profession. However, such a decision was not made.

The effectiveness of online team-based learning in introduction to medical ethics education for medical students at a medical college of Nepal: a pilot study.

BACKGROUND: The effectiveness of online classes is always a concern, and it can be overcome by opting for active learning strategies like team-based learning (TBL). This study was conducted to find out the effectiveness of online TBL as an active learning strategy. We also aimed to explore the satisfaction and perception of students toward TBL. METHODS: This is a mixed-method study conducted among 29 third-year Bachelor of Medicine and Bachelor of Surgery (MBBS) students of Gandaki Medical College using purposive sampling method in the duration of January to September 2021. Three two hours online TBL sessions were used for teaching introduction to medical ethics. The individual readiness assurance test (IRAT) scores were compared to the group readiness assurance test (GRAT) scores to evaluate the effect of TBL through cooperative learning. Learner reactions and satisfaction of students towards TBL were assessed using a validated questionnaire comprising of a five-point Likert scale. An open-ended question asking the participants to describe their overall experience of the TBL sessions was also included to explore their perceptions towards TBL. The data were collected using Google form and exported to Microsoft Excel and the quantitative data were then analyzed using Statistical Package for Social Sciences (SPSS) version 16.0. To check the normal distribution of the data, Kolmogorov Smirnov and Shapiro-Wilk test were used. Non-parametric tests were used for the non-normally distributed data. P value of < 0.05 was regarded as significant. Thematic analysis was conducted for the qualitative data. RESULTS: The median GRAT scores were significantly higher (p = 0.006 in TBL 1 and 0.001 in TBL 2) than IRAT scores. Learner reactions toward TBL sessions were positive as shown by the mean scores which were in the range of 3.59 to 4.66. Five themes were generated from the codes: "effective learning method", "positive experience", "gained knowledge", "expression of gratitude" and "the way of conduction of the sessions". CONCLUSION: Online TBL in medical ethics was effective as a teaching learning tool in our setting. The students were satisfied with the learning process and rated the learning strategy positively.

Autonomy and Social Responsibility: The Post-Pandemic Challenge.

Over the last 80 years, a series of critical events has led to reconsideration of the basic premises of medical ethics. One of these events was the recognition of horrific medical experiments performed by German medical scientists in World War II concentration camps, resulting in intensified emphasis on a consent requirement, later understood as grounded in the bioethical principle of respect for autonomy, as well as on the moral accountability of the experimenter. Another important event that is forcing a reconsideration of respect for autonomy in medicine and health care is the COVID-19 pandemic. But this time the matter pulls in a different direction, from respect for autonomy to social responsibility, represented in problems as disparate as the wearing of masks, vaccination requirements, and equity in vaccine access and distribution. How can modern bioethics, in part a creature of the response to Nazi crimes, accommodate the intensified sensitivity about public health needs that has accompanied the shock of the pandemic? The responses of European medical ethics to the Nazi era provide tools for bioethics as it faces the challenge now at hand. This article uses historical context from postwar Europe to argue that, in light of the pandemic experience, respect for autonomy must systematically incorporate a commitment to social responsibility.

Existing Ethical Tensions in Xenotransplantation.

The genetic modification of pigs as a source of transplantable organs is one of several possible solutions to the chronic organ shortage. This paper describes existing ethical tensions in xenotransplantation (XTx) that argue against pursuing it. Recommendations for lifelong infectious disease surveillance and notification of close contacts of recipients are in tension with the rights of human research subjects. Parental/guardian consent for pediatric xenograft recipients is in tension with a child's right to an open future. Individual consent to transplant is in tension with public health threats that include zoonotic diseases. XTx amplifies concerns about justice in organ transplantation and could exacerbate existing inequities. The prevention of infectious disease in source animals is in tension with the best practices of animal care and animal welfare, requiring isolation, ethologically inappropriate housing, and invasive reproductive procedures that would severely impact the well-being of intelligent social creatures like pigs.

Blended teaching of medical ethics during COVID-19: practice and reflection.

BACKGROUND: With the advancement of information technology, teachers have become able to overcome the limitations of time and room capacity by carrying out teaching activities online. This practice, however, also presents new challenges. The present study explores how to fully capitalize on the advantages of online and offline teaching and improve the quality and impact of the teaching delivered. This article presents an analysis of the planning, implementation, evaluation, and reflection process of reforming the Fujian Medical University (FJMU) medical ethics course. METHODS: After early attempts using the Small Private Online Course (SPOC) and flipped classroom formats, this paper focuses on the comprehensive active implementation of blended teaching practice. In terms of teaching practice, this research makes targeted improvements to overcome the known shortcomings of SPOCs and flipped classrooms, including the significant preparatory workload and lacking enthusiasm for classroom participation, by redesigning the course and evaluation method and changing the role of the teacher in blended teaching. Subsequently, the study used a stratified sampling method to select 20 students enrolled in the clinical medicine course at Fujian Medical University (FJMU). Their course experience was investigated using a semi-structured interview. Interview content related to evaluating teaching effect was extracted and encoded for subsequent qualitative analysis. RESULTS: A qualitative analysis of the student evaluation of blended teaching as implemented on the medical ethics course showed that the main factors influencing student engagement are the method of assigning tasks and that of testing learning outcomes. Student participation in class is influenced by the richness of the curriculum resources available and the role played by the teacher. CONCLUSION: This research presents a discussion of blended teaching and suggests improvements that can be made to address low student engagement and poor classroom participation. This round of blended teaching was shown to improve learning autonomy and classroom participation and to support students in the development of their clinical abilities and higher-order thinking skills. These findings provide a reference for the implementation of online teaching during the COVID-19 pandemic.

The Ethics of Unilateral Do-Not-Resuscitate Orders for COVID-19 Patients.

This paper examines several decision-making models that have been proposed to limit the use of CPR for COVID-19 patients. My main concern will be to assess proposals for the implementation of unilateral DNRs - i.e., orders to withhold CPR without the agreement of patients or their surrogates.

Conducting multiple mini-interviews in the midst of COVID-19 pandemic.

Multiple mini-interview (MMI) is a 'multiple sample-based' approach comprising multiple focused encounters intended to access and assess a range of attributes in order to gain more objectively multiple impressions of an applicant's interpersonal skills, thoughtfulness and general demeanour. It is designed to focus on four domains that are not considered to be comprehensive, but are considered to be vital for a successful career in the health sciences: critical thinking, ethical decision making, communication and knowledge of the healthcare system. Traditionally, the MMI is conducted face-to-face, but with COVID-19 pandemic and the implementation of social distancing measures, no onsite or campus teaching, banning of mass gatherings and cancellation of face-to-face interviews, Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences at Universiti Brunei Darussalam explored the feasibility of conducting MMI through virtual means. This report provides an account of our experience in conducting internet-MMI for the selection of new applicants into the August 2020 cohort of the Medicine programme. We also aimed to determine whether the scores derived from internet-MMI were reliable and equivalent to the scores derived from traditional MMI.

Canadian College of Medical Geneticists (CCMG) points to consider: resuming genetic services in a pandemic-a summary.

The COVID-19 pandemic has disrupted the provision of genetic care in Canada. With the public health effort to flatten the curve, many clinics have moved to virtual care for select populations of patients while triaging and postponing others. As genetic services are asked to gradually resume, a roadmap is needed to ensure clinical care decisions for at-risk patients are transparent and equitable, that postponed care is resumed and that patients with or waiting for a genetic diagnosis are not disproportionately affected or abandoned.The purpose of this document is to highlight the guiding ethical principles and stakeholder considerations in resuming genetic services to help guide the competing needs going forward of both limiting exposures while maintaining high-quality care. Considerations highlighted are (1) environment of practice, (2) nature of consult, (3) patient factors, (4) provider factors, and (5) laboratory factors. The intended users are those providing genetic care in a Canadian context with the recognition that there are clinic-specific and regional variations that will influence decision-making. While specific to the Canadian context, the ethical principles used to guide these decisions would be relevant for consideration in other jurisdictions.