Implementing a formal curriculum on surgical ethics and palliative care for otolaryngology residents.

OBJECTIVE: Residents are faced with ethical issues every day but most residency curriculums do not routinely include formal ethics skills training. In order to address this, a comprehensive curriculum on ethics and surgical palliative care was implemented for otolaryngology residents. METHODS: An 8-h ethics didactics curriculum was designed in collaboration with our institution's Institute of Ethics. Varied strategies were used to cover basic principles and practical skills. Anonymous assessments were completed by learners at 3 points during the curriculum on a 5-point scale. RESULTS: Nine residents were surveyed. Prior to the curriculum, a large majority of residents (85 %) expressed little to no familiarity with basic ethical principles. There was statistically significant improvement in understanding of and familiarity with bioethics topics, including the four principles of bioethics (Δ = 2.4, p = 0.004). There was also statistically significant improvement in comfort with the implementation of ethical decision making and palliative care skills, including with difficult conversations with patients (Δ = 1.3, p = 0.03). Participation in sessions was excellent with positive qualitative feedback. CONCLUSION: An interactive curriculum in ethics and palliative care can be engaging and practical for busy surgical residents, with measurable improvement in comfort with challenging cases and ethical, patient-centered care.

What Do We Do When We "Do" Clinical Ethics? A Primer.

AbstractThis article presents a model for doing clinical ethics consultations. It describes four phases of a consultation: investigation, assessment, action, and review. The consultant must identify the problem and determine whether it is a nonmoral problem (e.g., lack of information) or a moral problem involving uncertainty or conflict. The consultant must be able to identify the types of moral arguments that are used by participants to the situation. A simplified taxonomy of moral arguments is presented. The consultant must then assess the arguments for their cogency and identify where they align and where they conflict. The action phase of the consultation involves finding ways for the arguments to be presented and hopefully reconciled. The normative limitations to the role of the consultant are described.

Professionalism, Organizationalism and Sur-moralism: Three ethical systems for physicians.

Over the last 50 years, the term professionalism has undergone a widespread expansion in its use and a semantic shift in its meaning. As a result, it is at risk of losing its descriptive and analytical value and becoming instead simply an empty evaluative label, a fate described by C. S. Lewis as 'verbicide' (Lewis 1967). This article attempts to rescue professionalism from this fate by down-sizing its extension and reassigning some of its work to two other ethical domains, introduced as the neologisms organizationalism and sur-moralism. Professionalism is defined as a morality based in system of obligations that are assumed by physicians over the course of their professional training and which primarily refer to two groups: patients and colleagues, including trainees. Organizationalism is also a morality, but the obligations are owed to the employing organization and on different grounds. A third ethical domain, here called sur-moralism, comprises actions that are not based in obligations. They are discretionary and potentially meritorious; they cannot be required by the profession or organization. This article presents a conceptual model of the three ethical domains and the shifting borders between them. One practical benefit of this typology is that physicians can more accurately understand the nature and sources of obligations that they are asked to accept, and when necessary prioritize them. Another is that physicians will be able to describe the potential tension between the three domains and understand how and why the borders between them can move. Both should help physicians to be more ethically oriented to their work settings.

Varieties of clinical reasoning.

RATIONALE, AIMS AND OBJECTIVES: Clinical reasoning comprises a variety of different modes of inference. The modes that are practiced will be influenced by the sociological characteristics of the clinical settings and the tasks to be performed by the clinician. METHODS: This article presents C.S. Peirce's typology of modes of inference: deduction, induction and abduction. It describes their differences and their roles as stages in scientific argument. The article applies the typology to reasoning in clinical settings. RESULTS: The article describes their differences, and their roles as stages in scientific argument. It then applies the typology to reasoning in typical clinical settings. CONCLUSIONS: Abduction is less commonly taught or discussed than induction and deduction. However, it is a common mode of inference in clinical settings, especially when the clinician must try to make sense of a surprising phenomenon. Whether abduction is followed up with deductive and inductive verification is strongly influenced by situational constraints and the cognitive and psychological stamina of the clinician. Recognizing the inevitability of abduction in clinical practice and its value to discovery is important to an accurate understanding of clinical reasoning.

Between the quack and the fanatic: movements in our self-belief.

Separate from the question of whether our patients believe us as doctors is the question of whether we ourselves believe in our healing 'performances'. Borrowing from Bernard Williams' model of truth based on the two irreducible virtues of sincerity and accuracy, this article describes a spectrum of states of self-belief, from the quack who does not believe in his acts to the fanatic who does not 'dis-believe', with ranges of pious fraud and bad faith in between and on either side of a variable range of justified self-belief. I describe how as practitioners we move and are moved up and down this range throughout our careers and as a result of the behaviors of others. The model provides the basis for a critique of the marketing efforts of industries related to medical practice.