Jacqueline Chin

How can we know that ethics education produces ethical doctors

This article examines the challenges that medical ethics education faces, given its aim of producing ethical doctors. Starting with an account of the ethical doctor, it then inquires into the key areas of medical students’ ethical development, viz. knowledge, habituation and action, and describes more specific outcomes in these areas. Methods of teaching aimed at achieving specific outcomes are also discussed. The authors then turn to some difficulties that stand in the way of achieving the desired outcomes of medical ethics education, and survey what has been achieved so far, by considering a number of studies that have evaluated the efficacy of a range of medical ethics courses. The article concludes by suggesting that medical ethics education should give attention to the problems of evaluation of ethics curricula as the discipline comes of age. Practice points The aim of medical education is to develop doctors who are reflective, empathetic, trustworthy, committed to patient welfare and able to deal with complexity and uncertainty. Medical ethics should be multidisciplinary and multi-professional, academically rigorous, grounded in research, and fully integrated into the medical curriculum. Attention to evaluating ethics education is increasing, but there is a paucity of evidence regarding the effectiveness of medical ethics courses, and there are numerous problems in assessment design. The challenge of training ethical doctors lies in a rigorous evaluation of medical ethics teaching based on clearly defined outcomes and valid assessment methods.

What is the meaning of palliative care in the Asia-Pacific region?

This paper describes the preliminary work required to understand cultural differences in palliative care in the United Kingdom and three countries in the Asia‐Pacific region, in preparation for a cross‐country study. The study is intended to address cultural understandings of palliative care, the role of the family in end of life care, what constitutes good care and the ethical issues in each country. Suggestions are then made to shape the scope of the study and to be considered as outcomes to improve care of the dying in these countries. It is anticipated that the method used to achieve consensus on cross‐country palliative care issues will be both qualitative and quantitative. Identifying key priorities in the delivery and quality measures of palliative care will involve participants in focus groups, a Delphi survey and in the development of clinical indicators towards creating standards of palliative care common to the Asian Pacific region.

Where families and healthcare meet

Recent developments in professional healthcare pose moral problems that standard bioethics cannot even identify as problems, but that are fully visible when redefined as problems in the ethics of families. Here, we add to the growing body of work that began in the 1990s by demonstrating the need for a distinctive ethics of families. First, we discuss what ‘family’ means and why families can matter so deeply to the lives of those within them. Then, we briefly sketch how, according to an ethics of families, responsibilities must be negotiated against the backdrop of family relationships, treatment decisions must be made in the light of these negotiated responsibilities and justice must be served, both between families and society more generally and within families themselves.

Evolving legal responses to dependence on families in New Zealand and Singapore healthcare

Healthcare decision-making has traditionally focused on individual autonomy, but there is now a change occurring in which the involvement of families is gaining prominence. This appears to stem from an increasing emphasis on relational aspects of autonomy which recognises the individuals connectedness to their family, and also state reliance upon families to share the burdens and costs of caring for elderly and disabled dependents. Such a reorientation calls for similar legal emphasis on patient autonomy as understood in relational terms, and one that offers more adequate conceptions of independence, confidentiality and decision-making authority in the light of this change. This paper outlines how two common law jurisdictions, New Zealand and Singapore, have accommodated, or are responding to, these changes.

Clarifying the best interests standard: the elaborative and enumerative strategies in public policy-making

One recurring criticism of the best interests standard concerns its vagueness, and thus the inadequate guidance it offers to care providers. The lack of an agreed definition of ‘best interests’, together with the fact that several suggested considerations adopted in legislation or professional guidelines for doctors do not obviously apply across different groups of persons, result in decisions being made in murky waters. In response, bioethicists have attempted to specify the best interests standard, to reduce the indeterminacy surrounding medical decisions. In this paper, we discuss the bioethicists’ response in relation to the states possible role in clarifying the best interests standard. We identify and characterise two clarificatory strategies employed by bioethicists —elaborative and enumerative—and argue that the state should adopt the latter. Beyond the practical difficulties of the former strategy, a state adoption of it would inevitably be prejudicial in a pluralistic society. Given the gravity of best interests decisions, and the delicate task of respecting citizens with different understandings of best interests, only the enumerative strategy is viable. We argue that this does not commit the state to silence in providing guidance to and supporting healthcare providers, nor does it facilitate the abuse of the vulnerable. Finally, we address two methodological worries about adopting this approach at the state level. The adoption of the enumerative strategy is not defeatist in attitude, nor does it eventually collapse into (a form of) the elaborative strategy.

Management of patients who receive an organ transplant abroad and return home for follow-up care: recommendations from the Declaration of Istanbul Custodian Group

Abstract Eradicating transplant tourism depends on complex solutions that include efforts to progress towards self-sufficiency in transplantation. Meanwhile, professionals and authorities are faced with medical, legal, and ethical problems raised by patients who return home after receiving an organ transplant abroad, particularly when the organ has been obtained through illegitimate means. In 2016, the Declaration of Istanbul Custodian Group convened an international, multidisciplinary workshop in Madrid, Spain, to address these challenges and provide recommendations for the management of these patients, which are presented in this paper. The core recommendations are grounded in the belief that principles of transparency, traceability, and continuity of care applied to patients who receive an organ domestically should also apply to patients who receive an organ abroad. Governments and professionals are urged to ensure that, upon return, patients are promptly referred to a transplant center for evaluation and care, not cover the costs of transplants resulting from organ or human trafficking, register standardized information at official registries on patients who travel for transplantation, promote international exchange of data for traceability, and develop a framework for the notification of identified or suspected cases of transnational transplant-related crimes by health professionals to law enforcement agencies.