This article analyses teaching reflection skills as a means to inculcate students’ capacity to contribute to justice. Arising out of understandings of professionalism, the rule of law, as well as m...

This article argues that lawyers have personal moral obligations to help ensure that no one who needs legal services goes without and hence that the practice of law should be seen as involving a calling to promote access to justice. One important aim of the law schools should thus be to inculcate in their students a sense of this calling and ideally to ensure that this notion of 'altru-ethical' professionalism becomes part of each lawyer's moral character. Drawing on educational (...) theory, studies on the impact of law clinics on students' ethical values and a survey of the attitudes towards a legal career, this article argues that the most effective way of inculcating such a sense of calling is through lengthy student involvement in live-client law clinics combined with ethics teaching and opportunities for reflection. It then describes a unique new degree, the University of Strathclyde Clinical LLB, which adopts a cradle to grave approach to the integration of ethics teaching and clinical experience into the standard law degree with the aim of increasing the chances of a sense of altruistic calling becoming part of a student's professional moral character. (shrink)

Clinical legal education is playing an increasingly important role in educating lawyers worldwide. In The Global Clinical Movement: Educating Lawyers for Social Justice, editor Frank S. Bloch and contributors describe the central concepts, goals, and methods of clinical legal education from a global perspective, with a particular emphasis on its social justice mission. With chapters written by leading clinical legal educators from every region of the world, The Global Clinical Movement (...) demonstrates how the emerging global clinical movement can advance social justice through legal education. Professor Bloch and the contributors also examine the influence of clinical legal education on the legal academy and the legal profession and chart the global clinical movement's future role in educating lawyers for social justice. The Global Clinical Movement consists of three parts. Part I describes clinical legal education programs from every region of the world and discusses those qualities that are unique to a particular country or region. Part II discusses the various ways that clinical programs and the clinical methodology advance the cause of social justice around the world. Part III analyzes the current state of the global clinical movement and sets out an agenda for the movement to advance social justice through socially relevant legal education. (shrink)

Lawyers pretend as if the process of application of laws, as well as its outcome, could be an analytic-deductive derivation; especially law students learn that legal decision-making is primarily a logic process. But we know that application of laws depends on analytic-logical as well as on voluntaristic (wilful) elements. Exact relations between these components are unknown and will be unknown. At most German law schools students as the most important imperative tool learn the so called “Auslegung” through the use (...) of theoretical instruments, which do not reflect the interpretation of law practice. These mentioned causes result in irrationality of legal decision-making. In order to achieve more rationality in the process and result of legal decision-making, the contribution makes four suggestions regarding legal methodology and legal education. These proposals consist of few long-term pragmatic approaches to more rationality of legal decision-making. (shrink)

Clinical Legal Education programmes now take place in most law schools in England and Wales. However, legal education continues to be predominantly focused on the analysis and application of rules, doctrines, and theories to hypothetical scenarios or essay questions. This form of pedagogy either minimises or ignores the role of the client in terms of supplying lawyers with knowledge pertinent to their case. In other words, it overlooks the fact that the lawyer’s acquisition of knowledge (...) is not confined to technical rationality. This article seeks to achieve three broad aims. First, to contribute to the debate concerning the epistemology of reflective practice. Second, to develop a theoretical reflective cycle, informed by Kant’s transcendental idealism, which seeks to maximise knowledge acquisition in legal education, namely knowledge supplied by the client. Third, to address implicit bias using the proposed reflective cycle. An optimal pedagogy for using this cycle is Clinical Legal Education, namely live client clinics. (shrink)

Current debates in Clinical Legal Education (CLE) exclude essay writing as a legitimate form of ‘clinical’ pedagogy. This article argues that essay writing should be classified as a form of CLE due to its potential to mirror legal practice and enhance students' reflective capacities. By incorporating Hegelian dialectical reasoning, the paper proposes a structured approach to legal essay writing that includes thesis, antithesis, and synthesis. This method encourages students to engage deeply with legal (...) arguments, reflecting on their merits and counterarguments. The dialectical approach aligns with constructivist teaching methodologies, promoting critical thinking and practical skills relevant to legal practice and beyond. The article outlines the theoretical basis of this model and provides a practical framework for its implementation in legal education. It further connects this pedagogical strategy to the development of transferable skills that prepare students for professional legal environments. Through this dialectical method, the paper advocates for a more holistic and nuanced understanding of legal concepts, bridging the gap between academic theory and practical application, and, thus, making the case for the incorporation of Hegel-inspired essay writing into the definition of CLE. (shrink)

This book discusses feature films that enrich our understanding of doctor-patient dilemmas. The book comprises general clinical ethics themes and principles and is written in accessible language. Each theme is discussed and illuminated in chapters devoted to a particular film. Chapters start with a discussion of the film itself, which shares details behind the making of the film; critical reception; casting and other facts about production. The chapter situates the film in a history of medicine and medical sociology context, (...) analyzes ethical issues raised in the film from a clinical ethics lens, and explains to readers how to use each film as a teaching aid for clinical ethics. Readers will understand how each film in this collection served to bring particular clinical ethics issues to the public’s attention, or reflected medico-legal issues that were part of the public discourse. The book is a perfect instructor's guide for anyone teaching bioethics, healthcare ethics, medical sociology, medical history, healthcare systems narrative medicine, or nursing ethics. (shrink)

In clinical research scientific, legal as well as ethical aspects are important. It is well known that clinical investigators at university hospitals have to undertake their PhD-studies alongside their daily work and reconciling work and study can be challenging. The aim of this project was to create a web based course in clinical research bioethics (5 credits) and to examine whether the method is suitable for teaching bioethics. The course comprised of six modules: an initial examination (...) (to assess knowledge in bioethics), information on research legislation, obtaining permissions from authorities, writing an essay on research ethics, preparing one’s own study protocol, and a final exam. All assignments were designed with an idea of supporting students to reflect on their learning with their own research. (shrink)

Resumen: Si bien en Italia el debate sobre las clínicas jurídicas está en una fase inicial, cada vez hay un mayor número de universidades que están poniendo en marcha iniciativas vinculadas a tal fenómeno emergente. Ello permite plantearse nuevas cuestiones, en especial aquellas relacionadas con las clínicas, pero también es posible reconfigurar algunos de los temas “clásicos” y fundamentales de la filosofía del derecho. Este trabajo tiene como objetivo apuntar algunos de tales aspectos. Así tras una reconstrucción del marco general (...) del debate, me detendré sobre los temas principales de la experiencia clínica, esto es la formación del jurista y la tensión por alcanzar la justicia social. Abstract: Although the Italian debate concerning legal clinics is at the beginning, a growing number of Law Schools is starting to explore this approach to legal education. As a consequence, new topics specifically concerning legal clinics arise, while others – more “traditional” for legal-philosophical experts – need to be reconfigured and re-articulated. This essay aims at addressing some of the latter aspects: once the terms of the debate have been reconstructed, I will consider two of the main topics of the clinical experience, namely the jurist’s formation and the tension towards social justice outcomes. (shrink)

Over several decades, ethics and law have been applied to medical education and practice in a way that reflects the continuation during the twentieth century of the strong distinction between facts and values. We explain the development of applied ethics and applied medical law and report selected results that reflect this applied model from an empirical project examining doctors’ decisions on withdrawing/withholding treatment from patients who lack decision-making capacity. The model is critiqued, and an alternative “constitutive” model is supported (...) on the basis that medicine, medical law, and medical ethics exemplify the inevitable entanglement of facts and values. The model requires that ethics and law be taught across the medical education curriculum and integrated with the basic and clinical sciences and that they be perceived as an integral component of medical evidence and practice. Law, in particular, would rank as equal in normative authority to the relevant clinical scientific “facts” of the case, with graduating doctors having as strong a basic command of each category as the other. The normalization of legal knowledge as part of the clinician’s evidence base to be utilized in practice may provide adequate consolation for clinicians who may initially resent further perceived incursions on their traditional independence and discretion. (shrink)

Professional, Ethical, Legal, and Educational Lessons in Medicine: A Problem Based Approach provides a comprehensive review of the complex and challenging field of professional medical practice. Its problem-based format incorporates a vast pool of practical, board-exam-style multiple-choice questions for self-assessment, and is an ideal resource for exam preparation as well as ongoing clinical education among trainees and clinicians The practice of medicine is not only about clinical care of patients. Physicians must navigate ethical conundrums, legal (...) pitfalls, and quality improvement issues while maintaining scrupulous professionalism and being exemplary educators. This volume addresses common issues in the realm of professional medical practice not typically covered in other texts. Each of the 73 chapters presents a problem-based case that branches out into an oral board examination type stem questions. A discussion section with brief review articles summarizes the most recent literature. Multiple-choice questions with answers allows for comprehensive self-assessment or interactive group quizzes. This book will appeal to medical and allied health professionals in all specialties of medicine. It is an excellent and hands-on reference for the related but diverse domains associated with professional healthcare practice by students, physicians, and other healthcare providers compacted into one volume. (shrink)

In June 2013, faculty from the University of Maryland Carey School of Law, along with students from the law school and several health professional schools at the University of Maryland, Baltimore, visited Malawi, in southeast Africa. While there, they met with faculty and students at the University of Malawi Chancellor College to discuss the possibility of establishing an ongoing collaboration between the two universities’ law schools. The starting point for our discussion was the potential establishment of a multi-professional, comparative health (...) law clinic that would focus on serving individuals living with HIV and AIDS. This goal would serve two objectives of the Law & Health Care Program at Maryland: to increase interprofessional education opportunities and to expose law students to more global health law issues. Establishing this clinic would also be consistent with two strategic objectives of the University of Malawi Faculty of Law: to establish links with other law schools providing clinical legal education, and to contribute to Malawi’s efforts to solve HIV/AIDS-related problems. (shrink)

The importance of consulting with other professionals to maintain acceptable standards of care is well documented in many health care professions. However, evidence indicates that many psychologists fail to utilize consultation when needed, and that consultation use varies along dimensions such as the education and training of the consultee, the type of setting, number of years in practice, and proximity to available consultants. In this article, we review the research on the use of consultation by psychologists as well as (...) other health care professionals. We discuss the clinical, ethical, and legal implications of seeking consultation as a professional psychologist. Finally, a detailed and practical model for the regular use of consultation is given to improve the routine use of consultation in clinical practice. (shrink)

This is the first description of the questions that clinicians ask a department of clinical law, relating to the legal rules applicable to the care of their patients.ObjectivesTo describe in detail the demography of clinical legal enquiries made by clinicians of all professions concerning the care of their patients. To collate and categorise the varieties of enquiry, to identify phenotypic patterns. To provide colleges, regulators, commissioners, educators and the NHS with an insight into hitherto undescribed subject (...) matter, better to understand and respond to this aspect of clinical practice.DesignProspective collection of all clinical legal referrals recorded in writing over 12 years by a department of clinical law.SettingAn English Tertiary Hospital NHS Trust.ParticipantsClinical staff of the regulated professions, all seeking to have their clinical legal enquiries answered.Main outcome measuresThe description of the demography of clinical law.Results1251 written records were identified and reviewed. These were divided into nine broad clinical legal subject areas (domains): mental disorders, parents and children, incapacity, consent for treatment, disclosure of private information, other statutory, regulated practice, professional practice, clinical practice. Within these, 149 clinical legal phenotypes were identified to which each case could be assigned.ConclusionsAmong a broad range of enquiries, recognisable clinical legal phenotypes exist and have for the first time been described and categorised. These are clinical situations which clinicians need to be able to recognise and equipped to deal with. Doing so will likely facilitate timely and better treatment. (shrink)

BackgroundAmidst expanding roles in education and policy making, questions have been raised about the ability of Clinical Ethics Committees (CEC) s to carry out effective ethics consultations (CECons). However recent reviews of CECs suggest that there is no uniformity to CECons and no effective means of assessing the quality of CECons. To address this gap a systematic scoping review of prevailing tools used to assess CECons was performed to foreground and guide the design of a tool to evaluate (...) the quality of CECons.MethodsGuided by Levac et al’s (2010) methodological framework for conducting scoping reviews, the research team performed independent literature reviews of accounts of assessments of CECons published in six databases. The included articles were independently analyzed using content and thematic analysis to enhance the validity of the findings.ResultsNine thousand sixty-six abstracts were identified, 617 full-text articles were reviewed, 104 articles were analyzed and four themes were identified – the purpose of the CECons evaluation, the various domains assessed, the methods of assessment used and the long-term impact of these evaluations.ConclusionThis review found prevailing assessments of CECons to be piecemeal due to variable goals, contextual factors and practical limitations. The diversity in domains assessed and tools used foregrounds the lack of minimum standards upheld to ensure baseline efficacy.To advance a contextually appropriate, culturally sensitive, program specific assessment tool to assess CECons, clear structural and competency guidelines must be established in the curation of CECons programs, to evaluate their true efficacy and maintain clinical, legal and ethical standards. (shrink)

We note an increasing consciousness of weakness of legal methodology taught to law students today: The students get neither real idea nor feeling of legal decision-making as mixture of legal matters, issue of facts, personal inputs, diverging interests, and the interplay with other actors. For minimize these defects it is necessary that law students learn in legal studies the following points: (1) Legal decision-making is a special kind of decision-making and is embedded in all problems (...) of this process. (2) Jurisprudence is a hybrid science: It deals with facts of issue as well with legal matter. (3) Jurisprudence will be understood as transnational science and requires greater cooperation between law schools all over the world. (4) Legal education should focus on general principles and legal tools rather than on detailed rules. (5) Legal theory should demonstrate students our lack of understanding legal decision-making. (6) A realistic legal methodology has to take into account the impossibility of absolute certainty of the correctness of legal decision. (7) It is important to point out that analysis of facts of the case as crucial part of legal methodology requires teaching systems to introduce students in the respective techniques in practice like case studies, projects as well as legal clinics or SASLA-system. (shrink)

Since 1989, clinical ethics consultation in form of hospital ethics committees was established in most of the transition countries of Central and Eastern Europe. Up to now, the similarities and differences between HECs in Central and Eastern Europe and their counterparts in the U.S. and Western Europe have not been determined. Through search in literature databases, we have identified studies that document the implementation of clinical ethics consultation in Central and Eastern Europe. These studies have been analyzed under (...) the following aspects: mode of establishment of HECs, character of consultation they provide, and their composition. The results show that HECs in the transition countries of Central and Eastern Europe differ from their western-European or U.S. counterparts with regard to these three aspects. HECs were established because of centrally imposed legal regulations. Little initiatives in this area were taken by medical professionals interested in resolving emerging ethical issues. HECs in the transition countries concentrate mostly on review of research protocols or resolution of administrative conflicts in healthcare institutions. Moreover, integration of non-professional third parties in the workings of HECs is often neglected. We argue that these differences can be attributed to the historical background and the role of medicine in these countries under the communist regime. Political and organizational structures of healthcare as well as education of healthcare staff during this period influenced current functioning of clinical ethics consultation in the transition countries. (shrink)

Background: International developments suggest that providing clinical ethics services to help clinicians negotiate ethical issues that arise in clinical practice is beneficial and reflects best practice in promoting high ethical standards and patient-centered care. The aim of this study was to explore the needs and experiences of clinical staff members to inform the development of future clinical ethics support. Methods: Health professionals at a large regional health service completed an online survey containing questions about the frequency (...) of ethical and legal issues encountered in clinical practice, the type of situations that gave rise to the ethical and/or legal uncertainty or concern, how clinicians currently address these issues, and what support would be welcome. Results: The survey was completed by 369 staff members, including 61% with more than 10 years in the profession and 51% in nursing/midwifery. Two-thirds (66%) indicated they often considered ethical implications of their clinical decisions, and half (49%) often considered the legal implications. More than half (58%) were often/occasionally concerned about the ethically right thing to do. Patient requests for borderline treatment (47%), staff disagreements about patient care (48%), and patients declining recommended treatment (54%) were the most frequent reasons given for ethical or legal uncertainty. Sixty-nine percent of respondents indicated that the way their department addressed ethical issues could be improved and 85% agreed that there is a need for more discussion on ethical issues. The majority (82%) of respondents had encountered ethically challenging clinical situations where additional support would have helped. Common approaches to issues were discussion with colleagues/supervisor (91.1%), discussion at handover/group forums (50.8%), and consultation with guidelines/protocols (60.9%). Conclusions: A majority of clinical staff members surveyed have encountered ethically/legally challenging cases daily for which they have often sought additional advice. This study indicates that many clinical staff members would welcome some form of additional clinical ethics support including advice and education. (shrink)

The integration of artificial intelligence into bioethics education represents a new pedagogical approach that addresses complex moral issues in healthcare. The use of AI-driven platforms like ChatGPT in bioethics education can enhance critical thinking and decision-making skills among students by providing a diverse range of perspectives and solutions. To assess the ability of ChatGPT-4 to understand and resolve ethical dilemmas using validated clinical case vignettes, thereby determining its suitability as a teaching aid in bioethics. Ten clinical (...) scenarios, each with inherent ethical issues, were presented to ChatGPT-4. These scenarios were expert-validated to ensure relevance and complexity. ChatGPT's responses were evaluated by two blinded external raters to eliminate bias. The assessment criteria included identification of bioethical principles, recognition of stakeholders and their outcomes, and comprehension of ethical and legal frameworks. Additionally, the quality of responses was scored on a scale of 1–10. ChatGPT showed proficiency in identifying the pertinent bioethical principles and stakeholders involved in the ethical dilemmas presented. It achieved an overall score of 84.5%, with high marks for its analytical capabilities in complex scenarios. However, the study identified areas for improvement, particularly in proposing comprehensive solutions and alternative actions. ChatGPT demonstrates potential as an effective tool for bioethics education, capable of guiding learners through the resolution of ethical issues in clinical practice. However, to fully integrate ChatGPT into bioethics education, it requires enhancements in delivering detailed, actionable guidance in ethical decision-making. Future development should focus on refining ChatGPT’s ability to offer nuanced solutions aligned with patient values and clinician needs. (shrink)

Background The number of medical lawsuits in Japan was between 14 and 21 each year before 1998, but increased to 24 to 35 per year after 1999. There were 210 lawsuits during this 10-year period. There is a need for skills and knowledge related to ethics, which is as fundamental to the practice of medicine as basic sciences or clinical skills. in Japan education in ethics is relatively rare and its importance is not yet recognized. Establishing ethics (...) class='Hi'>education using legal precedents, which has already been achieved in Western countries, will be a very important issue in Japan. In the present study, a questionnaire survey was conducted among graduate intern doctors, in order to investigate whether ethics education using precedents might have a positive effect in Japan. Methods In 2002, a questionnaire survey entitled Physicians' Clinical Ethics was carried out in a compulsory orientation lecture given to trainees before they started clinical practice in our hospital. The attendees at this lecture were trainees who came from colleges in various districts of Japan. During the lecture, 102 questionnaires were distributed, completed by attendees and collected. The recovery rate was 100%. The questionnaire consisted of 22 questions (in three categories), of which 20 were answered by multiple choices, and the other two were answered by description. The time required to complete the questionnaire was about 10 minutes. Results The recovered questionnaires were analyzed using statistical analysis software (SPSS for Windows, Release 10.07J-1/June/2000), in addition to simple statistical analysis. answers using multiple choices for the 20 questions in the questionnaire were input into SPSS. The principal component analysis was performed for each question. As a result, the item that came to the fore was "legal precedent". Since many intern doctors were interested in understanding laws and precedents, learning about ethical considerations through education using precedents might better meet with their needs and interests. Conclusion We applied a new method in which the results of principal component analysis and frequencies of answers to other questions were combined. From this we deduced that the precedent education used in Western countries was useful to help doctors acquire ethical sensitivity and was not against their will. A relationship was found between reading precedents and the influence of lawsuits, and it was thought that student participation-type precedent education would be useful for doctors in order to acquire ethical sensitivity. (shrink)

The escalating integration of Artificial Intelligence (AI) in clinical settings carries profound implications for the doctrine of informed consent, presenting challenges that necessitate immediate attention. China, in its advancement in the deployment of medical AI, is proactively engaging in the formulation of legal and ethical regulations. This paper takes China as an example to undertake a theoretical examination rooted in the principles of medical ethics and legal norms, analyzing informed consent and medical AI through relevant literature data. (...) The study reveals that medical AI poses fundamental challenges to the accuracy, adequacy, and objectivity of information disclosed by doctors, alongside impacting patient competency and willingness to give consent. To enhance adherence to informed consent rules in the context of medical AI, this paper advocates for a shift towards a patient‐centric information disclosure standard, the restructuring of medical liability rules, the augmentation of professional training, and the advancement of public understanding through educational initiatives. (shrink)

Mediation in a legal sense is a means of alternative dispute resolution (ADR). Having evolved in the USA in the last half of 20th century the procedure is growing in popularity and proliferation all over the world. Many countries enacted particular legislation, and others included relevant articles into Civil and/or Criminal Procedure Codes. Howbeit, lawyers are to be aware of mediation and roles they may play within the process. Law school curriculum drafters face the challenge of including a new (...) up-to-date course in mediation into busy and very full academic programmes. Analysis of existing instructing practice showed that in Anglo-American law schools mediation teaching is a part of clinical legal education. As for European countries, there is a broad range of scenarios and no established experience. Recognition of communicative skills as key skills for mediators prompts the use of a CLIL approach in structuring such a course. Listening, reframing, summarising, questioning are skills to be mastered by law-students both in a foreign language and their mother tongue. Language teachers are in charge of this part of the course while law teachers can work out text contents built on the branches of law mediators deal with more often (family law, employment law, contracts, etc.). Moreover, some texts may cover mediation law in a home country and abroad. Another important factor to take into account is a career path chosen by a law-student – if s/he is going to become a mediator or a lawyer securing clients in mediation. Role plays and scenarios are an integral part of the course. Moreover, the course developed can serve as an introduction to internship in a law clinic. (shrink)

ABSTRACTLegal ethics teaching can be enriched and deepened when students experience legal practice through, for example, client interviews. Further, many legal educators are committed to encouraging their students’ commitment to contribute to the community through making the law and legal system fairer. One means of achieving this goal is by introducing a clinical component into a legal ethics course. Empirical research conducted with current students in Australia, analyses students’ changing understandings of ethical values and practice (...) when conducting legal interviews. The article discusses the relationship between an ‘ethic of care’ and concepts of ‘justice’, examined through students’ experiences of client interviewing. It also examines students’ commitment to the justice system, including the finding that their commitment to making law fairer is reinforced through working with disadvantaged clients. (shrink)

Clinical ethics support, including ethics consultation, has become established in the field of medical practice throughout the world. This practice has been regarded as useful, most notably in the UK and the USA, in solving ethical problems encountered by both medical practitioners and those who receive medical treatment. In Japan, however, few services are available to respond to everyday clinical ethical issues, although a variety of difficult ethical problems arise daily in the medical field: termination of life support, (...) euthanasia and questions about patient autonomy. In light of these conditions, a group of 17 volunteer educators and researchers from the area of biomedical ethics, including the authors, have formed the Clinical Ethics Support and Education Project, and began providing Japan’s first small team clinical ethics consultation service in October, 2006. Members include scholars of biomedical ethics, scholars of philosophy and ethics, legal professionals and legal scholars, nurses and doctors, consisting of five women and 12 men. Consultation teams, made up of a small number of members, were organised each time a request for consultation was received. Over approximately 15 months (October 2006–December 2007), the programme received 22 consultation requests from medical practitioners and medical institutions, and three from the families of patients. In this paper, we will discuss the status of our consultation service and examples of consultation cases we have handled. In addition, we will examine the process of evaluating small team clinical ethics consultation services, as well as the strengths and weakness of such programmes. (shrink)

Students in an undergraduate legal and ethical issues course continually told the authors that they did not have time to study for the course because they were busy studying for their clinical courses. Faculty became concerned that students were failing to realize the value of legal and ethical concepts as applicable to clinical practice. This led the authors to implement a transformational learning experience in which students applied legal and ethical course content in a high-fidelity (...) human simulation (HFHS) scenario. A preliminary evaluation compared the new HFHS experience with in-person and online student groups using the same case. Based on both student and faculty perceptions, the HFHS was identified as the best of the three approaches for providing a transformational learning experience regarding legal and ethical content. (shrink)

This article looks at the relevance of the concept of self-determination to psychiatric patients by studying the existence, importance and manifestations of self-determination. The data were collected by interviewing long-term patients (n = 72) in one mental health care organization, which included a psychiatric hospital and an outpatient department. Self-determination was defined in terms of the right to decision-making, the right to information, the right of consent, the right to refuse treatment, and the right to be heard and taken into (...) account. It was found that, with the exception of the right to refuse and consent, these rights are indeed present in the practice of psychiatric nursing and that they are relevant and important to psychiatric patients. The patients typically gave ethical, practical and legal reasons for a psychiatric patient's right to self-determination. The main reasons why psychiatric patients said they lacked the right to self-determination were illness and staff authority. Recommendations for educational, clinical and methodological implications for the future in nursing are discussed. (shrink)

Law Schools are now required to provide education to law students on bias, cross-cultural competency, and racism under ABA Standard 303(c). Law clinics, with their social justice orientation, have long taught about structural causes of bias and oppression and ways to intervene at system levels to prevent problems. Medical legal partnership (MLP) clinics have done so by employing concepts from social work and health science programs on structural competency. This article examines MLP and related curriculum to meet the (...) ABA mandate. (shrink)

This paper examines the ethical issues faced by health workers managing a fictional case of a female sex worker who is hepatitis B positive with a high level of virus but is asymptomatic. According to guidelines she does not require treatment herself, but is potentially highly infectious to others. Recent legal cases in the UK show it can be criminal to pass on HIV or hepatitis B infection sexually if the risk is known and the partner has not been (...) informed. However, there is no statute or case law showing that health workers are required to intervene to prevent such a potential ‘crime’, particularly when the partners are unknown, as in this case. The health workers could respond in various ways. They could do nothing, thus making further infection probable. They could advise the sex worker to use condoms and to inform her clients. They could treat the sex worker to reduce her level of infectivity, although there is no benefit to her. They could disclose the sex worker's status, although breaking confidentiality is a serious matter ethically and may be of no benefit to the unknown client group. Regulating prostitution might help; but sex workers with infection may work off licence. This paper discusses the clinical, moral and ethical issues associated with such a scenario and concludes that the most beneficial course is to target clients, through health education, to recognise the potential risks of infection from a sex worker and to take suitable precautions including immunisation against hepatitis B. (shrink)

The exponential growth of genetic knowledge and precision medicine research raises hopes for improved prevention, diagnosis, and treatment options for children with behavioral and psychiatric conditions. Although well-intended, this prospect also raise the possibility — and concern — that behavioral, including psychiatric genetic data would be increasingly used — or misused — outside the clinical context, such as educational settings. Indeed, there are ongoing calls to endorse a “personalized education” model that would tailor educational interventions to children's behavioral (...) and psychiatric genetic makeup. This article explores the justifications for, and prospects and pitfalls of such endeavors. It considers the scientific challenges and highlights the ethical, legal, and social issues that will likely arise should behavioral genetic data become available and are routinely incorporated in student education records. These include: when to disclose students' behavioral and psychiatric genetic profile; whose genomic privacy is protected and by whom; and how students' genetic data may affect education-related decisions. I argue that the introduction of behavioral genetics in schools may overshadow the need to address underlying structural and environmental factors that increase the risk for psychiatric conditions of all students, and that the unregulated use of student behavioral genetic profiles may lead to unintended consequences that are detrimental for individuals, families and communities. Relevant stakeholders — from parents and students to health professionals, educators, and policy-makers — ought to consider these issues before we forge ahead with a genomically informed education system. (shrink)

If ethics consultation services influence medical decisions it is important to evaluate how ethical dilemmas are dealt with by clinical ethics committees (CECs). Such evaluation is rare. This study presents a feasible and practical method of evaluating case discussions in CECs and the results emerging from the use of this method. A written presentation of an end-of-life dilemma was sent to all Norwegian ethics committees. The committees were asked to deal with the case as they would do if it (...) was a real case, and to prepare a written report of the discussion. A majority of the committees approached the case systematically. All emphasized the importance of good communication with the next of kin. However, their conclusions varied, medical facts were interpreted differently, possible patient suffering was dealt with differently, and some committees revealed insufficient legal knowledge. Such findings are useful in the future education of committee members. (shrink)

A new Clinical Ethics Advisory Group was created to contribute to NHS Trust policies and guidelines in response to ethical issues arising from the COVID-19 pandemic. An ethical analysis framework used in medical education, the CoRE-Values Compass and Grid, was adapted to form a step-wise ‘ABC’ decision-making process. CEAG members found the framework simple to understand and use and the model facilitated time-efficient decisions that were explicitly justifiable on moral, ethical, professional and legal grounds. The adapted CoRE-Values (...) framework might help facilitate decision-making processes for similar new clinical ethics advisory or support committees. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:464 Feminist Studies 44, no. 2. © 2018 by Feminist Studies, Inc. Claire Raymond and Sarah Corse A Distorting Mirror: Educational Trajectory After College Sexual Assault This article focuses on the broad and specific impacts of college sexual assault on student-survivors’ academic performance, academic trajectory, and their sense of self in relation to the university community. We frame this study with, and relate our findings to, the historic and (...) theoretical literatures that provide the context for this essay, including the large and burgeoning literature on the sexual assault of women college students and recent studies analyzing the role of fraternities in sexual assault, students’ fears and perceptions about college assault, bystander intervention training, and survivors’ grade-point averages after assault.1 Our study also builds on the history of feminist resistance to rape, feminist writings about rape, and campus activism against rape, with the 1. Cortney Franklin, Leana Allen Bouffard, and Travis C. Pratt, “Sexual Assault on the College Campus: Fraternity Affiliation, Male Peer Support, and Low Self-Control,” Criminal Justice and Behavior 39, no. 11 (2012): 1457– 80; Christine A. Gidycz, John R. McNamara, and Katie M. Edwards, “Women ’s Risk Perception and Sexual Victimization: A Review of the Literature,” Aggression and Violent Behavior 11, no. 5 (2006): 441–56; Jennifer Katz and Jessica Moore, “Bystander Education Training for Campus Sexual Assault Prevention: An Initial Meta-Analysis,” Violence and Victims 28, no. 6 (2013): 1054–67; Douglas W. Pryor and Marion R. Hughes, “Fear of Rape among College Women: A Social Psychological Analysis,” Violence and Victims 28, no. 3 (2013): 443–65; Carol E. Jordan, Jessica L. Combs, and Gregory T. Smith, “An Exploration of Sexual Victimization and Academic Performance among College Women,” Trauma, Violence, & Abuse 15, no. 3 (2014): 191–200. Claire Raymond and Sarah Corse 465 goal of shedding light on one aspect of the problem. Groundbreaking (and in some cases controversial) works analyzing the cultures of rape, such as Susan Brownmiller’s Against Our Will and Peggy Sanday’s “The Socio-Cultural Context of Rape” (in which Sanday creates the concept of the rape-producing culture—a concept that is central to our argument in this essay), found immediate reception with feminist activists of the 1970s and early 1980s.2 Mary Koss’s work regarding the scope of rape in college settings is also foundational to our study of campus rape.3 Susan Estrich, Catharine MacKinnon, and other feminist theorists in the mid-1980s developed critical apparatuses to shift the understanding of rape, providing a feminist framework wherein rape is interpreted as violence committed against a woman—in opposition to the patriarchal argument that rape is caused by a woman’s actions or is the product of her distortion of events after the fact.4 Angela Davis and bell hooks were deeply influential in framing understandings of the racial and racist aspects of feminist discussions of rape, while legal scholar Sarah Deer has more recently broadened understandings of the racialized discourse of rape, and Lisa Wade has written on twenty-first century hookup culture and the ways that this social landscape promulgates rates of maleon -female rape that are significantly higher on college campuses than in the general population.5 2. Peggy Reeves Sanday, “The Socio-Cultural Context of Rape: A Cross-Cultural Study,” Journal of Social Issues 37, no. 4 (1981): 5–27; Susan Brownmiller, Against Our Will: Men, Women and Rape (New York: Penguin Books, 1976). 3. Mary P. Koss, Christine A. Gidycz, and Nadine Wisniewski, “The Scope of Rape: Incidence and Prevalence of Sexual Aggression and Victimization in a National Sample of Higher Education Students,” Journal of Consulting and Clinical Psychology 55, no. 2 (1987): 162–70. 4. Susan Estrich, Real Rape: How the Legal System Victimizes Women Who Say No (Cambridge, MA: Harvard University Press, 1988); Duncan Chappell, Robley Geis, and Gilbert Geis, eds., Forcible Rape: The Crime, the Victim and the Offender (New York: Columbia University Press, 1977). 5. Angela Davis, “Rape, Racism, and the Myth of the Black Rapist,” in her Women, Race, and Class (New York: Vintage Books, 1983), 172–201; bell hooks, Feminist Theory: From Margin to Center (Boston: South End Press, 1984); Sarah Deer, The Beginning and End... (shrink)

Objectives—This study examined the issue of confidentiality in relation to i) undergraduate curriculum content in physiotherapy, and ii) the awareness, experiences and attitudes of clinical physiotherapists.Design—Postal survey of universities and focus group interviews with physiotherapists.Setting—Twenty-five universities in the UK and Ireland and 44 therapists in five hospitals in southern England.Results—The survey of universities indicated that legal and ethical aspects of confidentiality featured in virtually all preregistration courses that responded. However, whereas its inclusion was rated as extremely important, the (...) degree of coverage of confidentiality varied considerably between courses. Within the focus groups, 35 informants recollected coverage of confidentiality in their preregistration education, and 12 in postregistration in-service training; in neither case was this coverage in great detail. Informants identified environmental factors and working practices as barriers to preserving confidentiality. Disclosure to others also gave rise to difficulties. Informants were only aware in general terms of the relevant sections of the Chartered Society of Physiotherapy's Rules of Professional Conduct.Conclusions—Aspects of hospital-based physiotherapy practice were seen to create specific problems in relation to confidentiality. More detailed sources of education and guidance on this issue appear to be required. (shrink)

In contrast to theoretical discussions about potential professional liability of clinical ethicists, this report gives the results of empirical data gathered in a national survey of clinical medical ethicists. The report assesses the types of activities of clinical ethicists, the extent and types of their professional liability coverage, and the influence that concerns about legal liability has on how they function as clinical ethicists. In addition demographic data on age, sex, educational background, etc. are reported. (...) The results show that while nearly one third (28.9%) of the ethicists regularly make recommendations about patient care, only 10.8% of them regularly make entries in the medical record; only approximately half (53.0%) of them are covered by professional liability (malpractice) insurance; and the vast majority (84.3%) of them say that concerns about legal liability do not influence the way they function as clinical ethicists. (shrink)

Clinical research with children generates special ethical concern, raising the need for additional protections beyond those for research with competent adults. Most guidelines permit research with children when it offers a prospect of direct benefit, or poses minimal risk. Unlike many other guidelines, the U.S. federal regulations also allow institutional review boards to approve pediatric research that does not offer a prospect of direct benefit when the risks are no greater than a minor increase over minimal risk. To approve (...) research in this category, IRBs must find that two additional conditions obtain:1). The intervention or procedure presents experiences to subjects that are reasonably commensurate with those inherent in their actual or expected medical, dental, psychological, social, or educational situations; and 2). The intervention or procedure is likely to yield generalizable knowledge about the subjects disorder or condition which is of vital importance for the understanding or amelioration of the subjects disorder or condition. (shrink)

In the UK an increasing number of Clinical Ethics Committees (CECs) have been developed mainly in response to local need and interest. Their functions include education of health professionals, of policy and guideline development, and case review (both retrospective analysis of topics and advice on acute cases). The UK Clinical Ethics Network, a charitable foundation provides CEC s with help, support and advice and enables them to share their experience The legal status of UK CECs is (...) unclear but some legal commentators have suggested that CECs lack competencies and procedural rules necessary for acute case review. The UKCEN has proposed core competencies for CECs that lists the ethical, operational and procedural skills, knowledge and personal attributes required and how they may be acquired, assessed and maintained. Their implementation might lead to the development of ethical and legal governance which should benefit to future patient care. (shrink)

Background Euthanasia is a controversial practice in many countries. Since Spain’s Euthanasia Law came into effect on March 24, 2021, healthcare providers have faced a new challenge since they must inform patients, provide care, accompany them, and implement the law. It also represents a new stumbling block at universities, which must adapt to regulatory changes and educate future professionals accordingly. Little is known about the attitude of nursing students in Spain toward euthanasia since this law was implemented. Objective This study (...) aims to answer the following research questions: What is the attitude of nursing students toward euthanasia? What factors influence this attitude? Research design A cross-sectional study was conducted using an online questionnaire. Participants and research context The study population comprised all nursing students at a public university in Barcelona ( n = 444), Spain, during the 2022–2023 academic year. The validated Spanish version of the Euthanasia Attitude Scale was employed. A bivariate analysis was performed. Ethical considerations The university Ethics Committee (CEEAH 6247) approved this study. All participating students signed an informed consent form. Participation was voluntary, and data anonymity and confidentiality were guaranteed. Results Two hundred and forty-four nursing students responded to the questionnaire. The mean total score was 79.64. Participants with religious beliefs presented lower scores, indicating a more negative attitude toward euthanasia. Participants in their second, third, or fourth year of the nursing degree scored higher, demonstrating a more positive attitude. Conclusions The attitude of nursing students toward euthanasia was remarkably positive. Working on ethical content during the degree course and clinical practice are factors that help to develop a more positive attitude. In addition, nursing education should encourage professional aspects to prevail over religious beliefs in euthanasia situations. (shrink)

The COVID-19 pandemic in 2020 has had a lasting impact on all areas of personal life. However, the political, economic, legal and healthcare system, as well as the education system have also experienced the effects. Universities had to face new challenges and requirements in teaching and examinations as quickly as possible in order to be able to guarantee high-quality education for their students.This study aims to examine how the German-speaking medical faculties of the Umbrella Consortium of Assessment (...) Network have dealt with the challenges but also the opportunities that the outbreak of the COVID-19 pandemic created in medical education and whether digitalisation has been driven forward as a result. In an initial online-survey we focused our questions on the current teaching situation with regard to digitised teaching content, the support or establishment of adequate framework conditions by the medical faculties and IT facilities and also the execution of examinations during the summer semester 2020.Between August and September 2020, a total of 88 examiners, educators, dean of study and/or technical admins from 32 partner faculties took part in the survey. Students were not included in our survey. Most respondents stated that a switch to a digital semester had worked, the use of e-learning increased compared to previous semesters and that most courses could be converted, with the exception of practical courses, which were largely cancelled. The respondents also indicated that most examinations could still be taken, with the exception of practical examination formats, like Objective Structured Clinical Examinations. However, in the case of face-to-face examinations, strict distance and hygiene conditions had to be obeyed or there had to be a switch to distance-online examinations, which raised many open issues such as equal opportunities of students and attempts at deception.In conclusion, we identified several issues regarding the rapid transition to a digital semester due to COVID-19 which were categorised into the following topics: Face-to-face teaching could not take place, know-how of educators, integrity aspects, technical aspects, additional personnel required, additional time and effort required for implementation of digital teaching. Our study shows that a switch to digital teaching and distance online examinations is feasible, but many problems were encountered concerning academic integrity and basic ethical principles still need to be solved. In order to investigate whether above mentioned issued could be solved one year after the transition to a digital semester, we conducted a second survey in which the 32 initially surveyed institutions were questioned again. (shrink)

Discussion of real cases encountered by medical students has been advocated as a component of medical ethics education. Suggested benefits include: a focus on the actual problems that medical students confront; active learner involvement; and facilitation of an exploration of the meaning of their own values in relation to professional behaviour. However, the approach may also carry risks: students may focus too narrowly on particular clinical topics or show a preference for discussing legal problems that may appear (...) to have clearer solutions. Teaching may therefore omit areas generally considered to be important components of the curriculum. In this paper, the authors present an analysis of the moral problems raised by medical students in response to a request to describe ethically problematic cases they had encountered during two clinical attachments, for the purpose of educational discussion at case-based seminars. We discuss the problems raised and compare the content of the cases to the UK Consensus Statement on core content of learning. The authors also describe the approaches that the students used to undertake an initial analysis of the problems raised, and consider possible implications for the development of medical ethics education. (shrink)

Behavioural variant frontotemporal dementia (bvFTD) is a subtype of frontotemporal dementia characterized by changes in personality, social behaviour, and cognition. Although neural abnormalities cause bvFTD patients to struggle with inhibiting problematic behaviour, they are generally considered fully autonomous individuals. Subsequently, bvFTD patients demonstrate understanding of right and wrong but are unable to act in accordance with moral norms. To investigate the ethical, legal, and social issues associated with bvFTD, we conducted a scoping review of academic literature with inclusion & (...) exclusion criteria and codes derived from our prior work. Among our final sample of fifty-six articles, four mentioned bvFTD patient-offenders as unfit to stand trial by insanity, and sixteen mentioned the use of dementia evidence in a court of law to better understand the autonomy of bvFTD patients. Additional emergent issues that were discovered include: training police officers to handle situations involving bvFTD patients and educating healthcare providers on how to help caregivers navigate bvFTD. The current literature highlights the inadequacy of traditional applications of medico-legal categories such as autonomy, capacity and competence, in informing cognitive capacity assessments in clinical and legal settings and deserves consideration by neuroethicists. (shrink)

Background Doctors and the Sri Lanka Medical Association recognise the importance of do not attempt cardiopulmonary resuscitation decisions and disclosure; however, few previous studies exist examining these practices in Sri Lanka. Resuscitation decisions have seen significant changes in the UK in recent years, with a legal imperative for clear communication and a move to understand patients’ preferred outcomes before recommending clinical guidance. Methods Participants from two Sri Lankan hospitals were selected purposively to represent a range of specialties and (...) seniorities for semi-structured interview. Results Fifteen participants of varying seniorities were recruited. Practice of do not resuscitate and informing patients is highly variable; there is no definitive guidance published on best practice of these issues in Sri Lanka. Participants felt that inpatients were generally not aware of their medical conditions or treatments. With the poor social and palliative care service provision in Sri Lanka comes a pressure to involve families in the patient care, particularly at the end of life. This feeds into a culture where patient autonomy plays a subordinate role to family involvement. Participants understand the ethical need for do not resuscitate, however, it is viewed to be a consideration for when the patient is close to death. Conclusion Do not resuscitate does not appear to be a prominent feature of end-of-life care in Sri Lanka and thus consideration of the appropriateness of resuscitation is commonly left late in a patient’s deterioration. Education, inclination and respect for doctors are suggested barriers to effective inclusion of patients in their healthcare and end-of-life decisions. (shrink)

Ethics, communication skills, and the law ('practice skills') are important in all aspects of modern health care. Doctors and nurses must be sensitive to the ethical aspects of their work and understand the legal framework within which clinical decisions are made. Well developed skills of communication, with patients, their relatives and other members of the clinical team, are a key feature of good clinical practice Until recently, the important of practice skills has been relatively neglected in (...) health care education. This situation is changing. The UK General Medical Council, for example, has recently identified three aspects as part of the core of the medical course, and the move to degree courses in nursing has led to an increasing focus of practice skills in nurse education. The Oxford Practice Skills Project (OPSP) team have developed a course, within the University of Oxford Clinical School, which covers the teaching of practice skills in an integrated manner. This course is widely recognized as one of the most systematic developments of education in these areas. This manual describes the OPSP course in detail and provides teaching materials. Although developed initially for medical students, it should be helpful to all those involved in teaching ethics, communication skills, and law in health care. Each Seminar is described in detail Tutors' guides are provided Student handouts are included Contains guidelines for introducing 'practice skills' into a busy clinical curriculum Includes over forty case histories for teaching and examination Gives details of many useful sources and resources Details a variety of teaching methods together with their advantages and disadvantages Provides an ethics teaching toolkit for clinical teachers new to this area Readers are welcome to photocopy any part of this manual for their own teaching. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education (...) might be causing them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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The purpose of this essay is to advocate for including jurilinguistics in legal education. It presents jurilinguistics as a tool for understanding law and therefore supports continuing efforts to teach it. Knowing it is not unique, this essay proposes a jurilinguistic approach that focuses on the in-between of legal translation and comparative law. The proposal outlines the importance of educating in the capabilities of teaching a particular subject in a language other than their official one. The idea (...) is to let the Other help to understand the Self. Particularly pertinent in transnational law programs, it is a multicultural approach that not only recognizes the other, but also embraces it. (shrink)

This article argues that to disrupt legal education in a radical sense, students need to become acquainted with the art of worldmaking and the view that law is a “way of worldmaking”. First, I show that law is a cultural semiotic practice that requires decoding and, for that reason, demands a creative intervention by those that want to know, understand, and do things with law. Altogether this amounts to recognizing the different modes in which law creates, and is (...) part of, worlds. Second, I propose that due to different features of their aesthetic form, comics are a particularly effective medium to place students before the myriad ways in which law and lawyers make and reproduce worlds. Third, I illustrate the argument by exploring how the Saga comic series, through its formal multimodality and narrative and cultural complexity, can make good on that challenge. (shrink)