Challenges in teaching ethics in medical schools.

Modern medical ethics has effected dramatic changes in medicine. Yet teaching medical ethics still presents many challenges. The main teaching methods used--inpatient ethics consultations, courses, and case conferences--have notable weaknesses. In addition, the attitudes and knowledge gaps of some learners may hamper these methods further. To encourage open discussion of the challenges, we outline our current approach to teaching medical ethics. We teach with the conviction that ethics instruction gives physicians vital knowledge not available from science. Our teaching addresses ethical issues directly relevant to residents and students, emphasizes a few important concepts, and nurtures learners' critical reasoning skills. Our teaching also tries to use scarce faculty time efficiently. However, we believe successful medical ethics teaching requires medical schools to commit significant material and moral support. We hope the discussion here encourages medical ethics teachers everywhere to describe the challenges they face and to collaborate on finding solutions.

Cultural differences among health professionals: a case illustration.

This study illustrates that cultural differences arise among similarly trained health professionals. Health professionals must learn to communicate sensitively with colleagues from other cultures, to respect their values, and to recognize and resolve cultural differences that affect patient care. In this shrinking, multicultural world, health professionals cannot afford the comfortable illusion that all similarly trained practitioners share the same values about the care of patients and professional conduct.

Cultural differences and ethical issues in the problem of autopsy requests.

Cross-cultural ethical issues pervade medical care in Texas. This preliminary study concerns the particular issues that arise when an Anglo-American physician requests an autopsy from a Mexican-American family. The study quantified differences in autopsy rates between Mexican-American and Anglo-American patients at one San Antonio hospital. Mexican-Americans had higher rates for patients dying between the ages of 21 and 40, and after 80. Anglo-Americans had higher rates for all other age groups. Differences in autopsy rates between Mexican-American and Anglo-Americans ranged from 5 to 18 autopsies per 100 deaths and varied by age group. The study also involved 33 interviews concerning Mexican-American and Anglo-American culture. Interviewees identified four sources of relevant differences: (1) medicine's professional values, (2) beliefs about the power of medical science to control disease, (3) beliefs about keeping cadavers whole and unmutilated, and (4) beliefs about the sentence of the soul after bodily death. An appreciation of these value differences is the basis for requesting autopsies in culturally sensitive ways.

Medical ethics in Texas: concepts, issues, and resources.

Ethical issues pervade medicine, and no practicing physician can avoid them. The physician must be able to recognize ethical issues in his practice, analyze them critically, and resolve them properly. Because these issues will arise even more frequently and become even more complex in the 1990s than before, Texas Medicine is devoting the Journal sections in its January and February editions to ethical issues in medical practice. This opening article outlines the factors exacerbating medical ethics issues in recent decades, describes the medical ethics teaching and research programs in Texas, and introduces the other articles in the series.

Impact of legal liability, family wishes, and other "external factors" on physicians' life-support decisions.

PURPOSE: The purpose of this study was to determine the impact of external factors on physicians' life-support decisions. "External factors" are those factors that promote the interests of people other than the patient. Examples of external factors include physician legal liability and family wishes about patient care. SUBJECTS AND METHODS: A nationwide sample consisted of 300 randomly selected physician-members from the American Society of Law and Medicine (ASLM) and 300 from the Society for Critical Care Medicine (SCCM); 179 ASLM physicians (60%) and 165 SCCM physicians (55%) responded. A mailed questionnaire presented three cases, each requiring the physician to make a life-support decision. For each case, the physician chose one of several life-support options and rated the importance to his or her decision of specific "decision factors," including some external factors. We assumed the physician would choose the management option supported by the decision factors that the physician considered most important. For this reason, we used discriminant analysis to identify the factors whose importance ratings best predicted management choices. RESULTS: In the first case, 46% of ASLM respondents and 55% of SCCM respondents chose to stop the ventilator of a chronically comatose patient with unknown preferences about life support. Thirty-one percent of ASLM and 27% of SCCM respondents chose to continue the ventilator, and 21% of ASLM and 14% of SCCM respondents chose to apply for a judicial decision. Importance ratings for the external factor, physician legal liability, best predicted management choices. In the second case, 95% of ASLM and 94% of SCCM respondents chose to resuscitate a cancer patient at the patient's request; 3% of ASLM and 4% of SCCM respondents chose no resuscitation. Importance ratings for patient preferences best predicted management choices. In the third case, 38% of ASLM and 35% of SCCM respondents honored a stroke patient's previous refusal of tube feedings, but 59% of ASLM and 62% of SCCM respondents authorized tube feedings in order to secure nursing home placement. Importance ratings for patient preferences best predicted management choices in this case. External factors impacted management choices considerably in the first case and more modestly in the second and third cases. CONCLUSION: External factors impact the life-support decisions of physicians. Physician legal liability may have an especially great impact on these decisions when patients' preferences are not known.