Nuala Kenny

The patient as text: a challenge for problem-based learning.

Objectives  To explore the values and assumptions underlying problem‐based learning (PBL) cases through narrative analysis, in order to consider the ways by which paper cases may affect student attitudes and values.

Shared Moral Work of Nurses and Physicians

Physicians and nurses need to sustain their unique strengths and work in true collaboration, recognizing their interdependence and the complementarity of their knowledge, skills and perspectives, as well as their common moral commitments. In this article, challenges often faced by both nurses and physicians in working collaboratively are explored with a focus on the ways in which each professions preparation for practice has differed over time, including shifts in knowledge development and codes of ethics guiding their practice. A call for envisioning their practice as shared moral work as well as practical strategies to begin that work are offered as a basis for reflection towards enhanced nurse-physician relationships.

Wanted: A New Ethics Field for Health Policy Analysis

Ethics guidance and ethical frameworks are becoming more explicit and prevalent in health policy proposals. However, little attention has been given to evaluating their roles and impacts in the policy arena. Before this can be investigated, fundamental questions must be asked about the nature of ethics in relation to policy, and about the nexus of the fields of applied ethical analysis and health policy analysis. This paper examines the interdisciplinary stretch between bioethics and health policy analysis. In particular, it highlights areas of scholarship where a health policy ethicsspecialization—as distinctive from bioethics—might develop to address health policy concerns. If policy and ethics both ask the same question, that question is: “What is the good, and how do we achieve (create, protect, cultivate) it?” To answer this question, the new field of “health policy ethics” requires development. First, we should develop a full set of ethical principles and complementary ethical theories germane to public policy per se. Second, we must understand better how explicit attention to ethical concerns affects policy dynamics. Third, we require new policy and ethical analytic approaches that contribute to constructive (not obstructive) policy making. Finally, we need indicators of robust, high quality ethical analysis for the purpose public policy making.

An Ethical Analysis of International Health Priority-Setting

Health care systems throughout the developed world face ‘crises’ of quality, financing and sustainability. These pressures have led governments to look for more efficient and equitable ways to allocate public resources. Prioritisation of health care services for public funding has been one of the strategies used by decision makers to reconcile growing health care demands with limited resources. Priority setting at the macro level has yet to demonstrate real successes. This paper describes international approaches to explicit prioritisation at the macro-governmental level in the six experiences most published in the English literature; analyzes the ways in which values, principles and other normative concepts were presented in these international priority setting experiences; and identifies key elements of a more robust framework for ethical analysis which could promote meaningful and effective health priority setting.

Children and decisionmaking in health research.

In March 1998 the Office of Bioethics Education and Research at Dalhousie University hosted a multidisciplinary workshop, “Assent and Dissent in Research Involving Children.” The overall objectives for the meeting were: first, to promote and protect the health and well-being of children by ensuring that potentially beneficial biomedical and health research involving children was not inappropriately precluded; and second, that when such research did proceed, it was appropriately respectful of children. For the purposes of the discussion, appropriate respect included both protection from harm and promotion of the capacity for independent decision-making. Particular attention was focused on the roles and responsibilities of children and their parent(s) or legal guardian(s) in decisionmaking about research participation.

Ethics frameworks in Canadian health policies: Foundation, scaffolding, or window dressing?

Health policy documents increasingly feature ethics frameworks that outline key guiding principles. It is unclear whether such frameworks function as scaffolding for creating policy, foundations for responding to policy, or mere aesthetic frames to make policies appear ethical. This study investigates the nature and quality of ethics frameworks in Canadian health documents. We reviewed the ethics frameworks of 24 strategic health policy documents published from 1998 to 2005 by Canadian government agencies. We found that frameworks typically appear as a list of principles or values. These elements vary widely across the terminal, procedural, and substantive values of conventional ethics, and many are better characterized as goals than as ethics. No two ethics frameworks matched, despite common topic areas and presumably broadly shared values within the Canadian health system. Elements shared by at least half of the documents include: access, accountability, autonomy, client-centredness, collaboration, efficiency, equity, and evidence. However, common elements are interpreted quite differently. The genesis of the framework and its elements is seldom described. Only one third of the documents relate specific ethical elements to specific policies. In conclusion, we draw on the clinical guidelines literature to propose some features of a robust, coherent and meaningful ethics framework.

Professionalism and the basic sciences : an untapped resource

Context  Medical, technological and societal developments influence doctors’ professional responsibilities and present challenges to educating medical students about professionalism. Medical education about professionalism generally focuses on behaviours and competencies which are taught primarily by clinicians in clinical courses and settings.

The Therapeutic Misconception: A Threat to Valid Parental Consent for Pediatric Neuroimaging Research

Neuroimaging research has brought major advances to child health and well-being. However, because of the vulnerabilities associated with neurological and developmental conditions, the parental need for hope, and the expectation of parents that new medical advances can benefit their child, pediatric neuroimaging research presents significant challenges to the general problem of consent in the context of research involving children. A particular challenge in this domain is created by the presence of therapeutic misconception on the part of parents and other key research stakeholders. This article reviews the concept of therapeutic misconception and its role in pediatric neuroimaging research. It argues that this misconception can compromise consent given by parents for the involvement of their children in research as healthy controls or as persons with neurological and developmental conditions. The article further contends that therapeutic misconception can undermine the research ethics review process for proposed and ongoing neuroimaging studies. Against this backdrop, the article concludes with recommendations for mitigating the effects of therapeutic misconception in pediatric neuroimaging research.

Walking the moral tightrope: respecting and protecting children in health-related research.

Special moral, regulatory, and scientific questions surround the inclusion of children in health-related research. These questions arise from a fundamental moral tension between the obligation to expose children to research participation to ensure that they share in the benefits that arise from it and the obligation to protect them from the harms associated with their inappropriate involvement in research. This tension is felt in the development of moral and regulatory frameworks for the protection of child research subjects and in the implementation and interpretation of these frameworks by institutional review boards (IRBs).

Lifelong Learning in Ethical Practice: A Challenge for Continuing Medical Education.

Background: Formal education in the identification, analysis, and resolution of ethical issues in clinical practice is now an essential component of undergraduate and postgraduate medical education. Physicians educated before the 1980s have had little or no formal education in ethics. This article describes a project for assessing the content and format appropriate for the continuing education needs of practicing physicians. Methods: A questionnaire and follow‐up facilitated small‐group discussions with a physician ethicist around case‐based problems were used to identify the ethical issues in practice where participants felt the need for continuing education. Results: The project confirmed that practitioners had very little formal ethics in medical school and less since starting practice despite encountering ethical issues. The most frequently used method of learning about ethics was informal discussion among those who have the same lack of formal education. Physicians did not feel that they needed a “very high” level of confidence and competence in handling ethical issues, even those commonly encountered. Participants indicated strongly that they lacked a systematic approach to the identification and analysis of ethical issues and suggest incorporation of the ethical component into regular CME. Findings: In spite of the small study population and the volunteer nature of the participants, the project demonstrated the identification of ethics content for CME similar to that used in medical education. Further work is needed to assess objective needs for ethics education in addition to the perceived needs of clinicians.