Morten Magelssen

Medical students’ attitudes towards conscientious objection: a survey

Objective To examine medical students’ views on conscientious objection and controversial medical procedures. Methods Questionnaire study among Norwegian 5th and 6th year medical students. Results Five hundred and thirty-one of 893 students (59%) responded. Respondents object to a range of procedures not limited to abortion (up to 19%)—notably euthanasia (62%), ritual circumcision for boys (52%), assisted reproduction for same-sex couples (9.7%) and ultrasound in the setting of prenatal diagnosis (5.0%). A small minority (4.9%) would object to referrals for abortion. In the case of abortion, up to 55% would tolerate conscientious refusals, whereas 42% would not. Higher proportions would tolerate refusals for euthanasia (89%) or ritual circumcision for boys (72%). Discussion A majority of Norwegian medical students would object to participation in euthanasia or ritual circumcision for boys. However, in most settings, many medical students think doctors should not be able to refuse participation on grounds of conscience. A minority would accept conscientious refusals for procedures they themselves do not object to personally. Most students would not accept conscientious refusals for referrals. Conclusions Conscientious objection remains a live issue in the context of several medical procedures not limited to abortion. Although most would want a right to object to participation in euthanasia, tolerance towards conscientious objectors in general was moderate or low.

Attitudes towards assisted dying are influenced by question wording and order: a survey experiment

BackgroundSurveys on attitudes towards assisted dying play an important role in informing public debate, policy and legislation. Unfortunately, surveys are often designed with insufficient attention to framing effects; that is, effects on the respondents’ stated attitudes caused by question wording and context. The purpose of this study was to demonstrate and measure such framing effects.MethodsSurvey experiment in which an eight-question survey on attitudes towards assisted dying was distributed to Norwegian citizens through a web-based panel. Two variations of question wording as well as two variations of question order were employed. Respondents were randomized to receive one of four questionnaire versions.ResultsThree thousand and fifty responses were received. There were moderate to large question wording and question order effects. A majority of Norwegian citizens favour the legalization of assisted dying for patients with terminal or chronic disease.ConclusionsStakeholders in the assisted dying debate need to acknowledge potential framing effects, and accordingly should interpret survey results with caution. The same holds for researchers who conduct attitude surveys in the field of bioethics.

Four Roles of Ethical Theory in Clinical Ethics Consultation

When clinical ethics committee members discuss a complex ethical dilemma, what use do they have for normative ethical theories? Members without training in ethical theory may still contribute to a pointed and nuanced analysis. Nonetheless, the knowledge and use of ethical theories can play four important roles: aiding in the initial awareness and identification of the moral challenges, assisting in the analysis and argumentation, contributing to a sound process and dialogue, and inspiring an attitude of reflexivity. These four roles of ethical theory in clinical ethics consultation are described and their significance highlighted, while an example case is used as an illustration throughout.

Conscientious objection to referrals for abortion: pragmatic solution or threat to women’s rights?

BackgroundConscientious objection has spurred impassioned debate in many Western countries. Some Norwegian general practitioners (GPs) refuse to refer for abortion. Little is know about how the GPs carry out their refusals in practice, how they perceive their refusal to fit with their role as professionals, and how refusals impact patients. Empirical data can inform subsequent normative analysis.MethodsQualitative research interviews were conducted with seven GPs, all Christians. Transcripts were analysed using systematic text condensation.ResultsInformants displayed a marked ambivalence towards their own refusal practices. Five main topics emerged in the interviews: 1) carrying out conscientious objection in practice, 2) justification for conscientious objection, 3) challenges when relating to colleagues, 4) ambivalence and consistency, 5) effects on the doctor-patient relationship.ConclusionsNorwegian GP conscientious objectors were given to consider both pros and cons when evaluating their refusal practices. They had settled on a practical compromise, the precise form of which would vary, and which was deemed an acceptable middle way between competing interests.

Sources of bias in clinical ethics case deliberation

A central task for clinical ethics consultants and committees (CEC) is providing analysis of, and advice on, prospective or retrospective clinical cases. However, several kinds of biases may threaten the integrity, relevance or quality of the CECs deliberation. Bias should be identified and, if possible, reduced or counteracted. This paper provides a systematic classification of kinds of bias that may be present in a CECs case deliberation. Six kinds of bias are discussed, with examples, as to their significance and risk factors. Possible remedies are suggested. The potential for bias is greater when the case deliberation is performed by an individual ethics consultant than when an entire clinical ethics committee is involved.

Brain pathology in fatal serotonin syndrome: presentation of two cases.

Serotonin syndrome is a potentially life‐threatening reaction that occurs in patients using drugs that elevate the serotonin level in the body. Excess serotonergic activity in the CNS and peripheral serotonin receptors results in neuromuscular hyperactivity, mental changes and autonomic symptoms. Hyperthermia is a characteristic feature of the syndrome. We describe neuropathological findings from two cases of lethal serotonin syndrome, both patients presenting with hyperthermia and neuromuscular symptoms. One of the patients had been taking amitriptylin and mirtazapin and the other had used amitriptylin and citalopram. They died, respectively, 10 days and 21/2 months after the onset of serotonin syndrome symptoms. Post‐mortem examination of the brains showed subtotal loss of cerebellar Purkinje cells in both cases. In the case with shorter survival time, areas with partial loss of cerebellar granule cells were observed, whereas in the case with longer survival time general and extensive loss of granule cells was found. Cells in other areas of the brain known to be sensitive to hypoxic injury were not affected. Selective loss of Purkinje cells has previously been described in neuroleptic malignant syndrome and heatstroke, conditions that are characterized by hyperthermia. This suggests that hyperthermia may be a causative factor of brain damage in serotonin syndrome. This is the first report describing neuropathological findings in serotonin syndrome.

[Medical students' attitudes towards legalisation of euthanasia and physician-assisted suicide].

BACKGROUND We wished to investigate prevailing attitudes among future doctors regarding legalisation of euthanasia and physician-assisted suicide. This issue is important, since any legalisation of these practices would confer a completely new role on doctors. MATERIAL AND METHOD Attitudes were identified with the aid of a questionnaire-based survey among medical students in their 5th and 6th year of study in the four Norwegian medical schools. RESULTS Altogether 531 students responded (59.5% of all students in these cohorts). Of these, 102 (19%) were of the opinion that euthanasia should be legalised in the case of terminal illness, 164 (31%) responded that physician-assisted suicide should be permitted for this indication, while 145 (28%) did not know. A minority of the respondents would permit euthanasia and physician-assisted suicide in other situations. Women and those who reported that religion was important to them were less positive than men to permitting euthanasia or physician-assisted suicide. INTERPRETATION In most of the situations described, the majority of the students in this survey rejected legalisation. Opinions are more divided in the case of terminal illness, since a larger proportion is in favour of legalisation and more respondents are undecided.

A spiritual dimension is important for many patients.

The existential or spiritual dimension incorporates the basic values of patients, their thoughts on what gives life meaning and religious or non-religious worldview. It also includes beliefs about what happens after death. The aim of this article is to discuss whether these aspects of human life are also relevant for doctors in their encounters with patients, and to provide advice on how to handle the spiritual and existential dimension. Numerous studies have been carried out internationally of the interaction between religious beliefs and health, and the needs of patients for the health service to follow up existential needs (1, 2). However, in Norway little research has been conducted into this field. The results of studies conducted in other countries among patients with particular beliefs cannot be generalized and transferred to other cultures and religions indiscriminately. Nevertheless, in our discussion of this topic it is natural to include studies from other Western countries whose culture and religion are similar to our own.

Rationing at the bedside: Immoral or unavoidable?

Although most theorists of healthcare rationing argue that rationing, including rationing that takes place in the physician–patient relationship (“bedside rationing”) is unavoidable, some health professionals strongly disagree. In a recent essay, Vegard Bruun Wyller argues that bedside rationing is immoral and thoroughly at odds with a sound view of the physician–patient relationship. We take Wyller to be an articulate exponent of the reluctance to participate in rationing found among some clinicians. Our essay attempts to refute the five crucial premises of his argument yet build on his genuine insights. In our analysis, Wyller’s critique of bedside rationing is instructive both for harbouring some very common misconceptions that must be exposed and refuted, but also for offering important words of caution. In particular, bedside rationing must be performed in ways that do not harm the physician–patient relationship. Read irenically, Wyller’s critique is a reminder of what must not be lost in our painful endeavour to update the ethics of medicine to encompass the unavoidability of rationing.

Attitudes of medical students towards abortion

BACKGROUND It is not known whether the attitudes of Norwegian medical students towards abortion change in the course of their studies, or whether the attitudes differ among the four Norwegian medical schools. We have investigated attitudes towards abortion and the right to conscientious objection among medical students early and late in their studies at the four medical schools. Student satisfaction with the teaching on abortion was also surveyed. MATERIAL AND METHODS A questionnaire survey was carried out among medical students at the four Norwegian medical schools, first year and fourth/fifth year students respectively. RESULTS 514 students (58.3 % of the students in the chosen classes) responded. 87.5 % approved of abortion on demand. The students at NTNU were the most liberal (93.5 %). Fourth/fifth year students were more liberal than first year students (91.3 % vs. 84.7 %, p = 0.027). 27.3 % would want to exercise their right to conscientious objection. 41.5 % had been present at a surgical abortion. Of those who had not been present at a surgical abortion, 84.1 % would want to see an abortion being carried out if given the opportunity. 29 % agreed that the teaching did not adequately cover the ethical aspects of abortion. INTERPRETATION Abortion on demand has wide approval among Norwegian medical students. However, many students would consider exercising their right to conscientious objection. More fourth/fifth year students than first year students approved of abortion.