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Teaching Ethics: When Respect for Autonomy, and Cultural Sensitivity Collide.
Abstract
Respect for autonomy is a key ethical principle. However, in some cultures other moral domains such as community (emphasizing the importance of family roles) and sanctity (emphasizing the sacred, and the spiritual side of human nature) hold equal value. Thus an American physician may sometimes perceive a conflict between their desire to practice ethically and their wish to be sensitive to the mores of other cultures. For example, a woman may appear to be making what the physician thinks is a bad clinical choice because her spouse is speaking on her behalf. That physician may find it difficult to reconcile their sense that the patient had not freely exercised her autonomy with their desire to be culturally sensitive. In this article the means by which a physician can reconcile their respect for other cultures with their respect for autonomy is explored. The question of whether physicians must always defer to patients' requests solely because they are couched in the language of cultural sensitivity is also addressed.
... Bioethicists suggest asking patients about their cultural values, about what these values mean for them, and about how these values impact specific situations a patient might encounter in the clinic (Kleinman & Benson 2006;Rollins & Hauck 2015). It is important to note that these conversations should take place with a patient alone, so that family does not have undue influence on a patient's answers (Blackler 2016;Minkoff 2014). ...
... Taking this lesson seriously means taking seriously a challenge to a conception of autonomy under which all patients are expected to value the same model of decision-making, one marked by normative independence from community in decision-making. As bioethicists have highlighted, this model is not the only model of autonomy that patients value, and this lesson underscores the importance of putting that recognition into practice (Engelhardt 1996;Ho 2008;Minkoff 2014). ...
... However, the obligation to respect Mrs. Smith's autonomy required the care team to carefully determine her values. Allowing a patient the chance to tell the care team whether their values involve them voluntarily giving up some autonomy is a compromise position between assuming all patients want full autonomy (and potentially informing a patient about a medical diagnosis she does not want to be informed of) and automatically granting patients from cultures that do not value individual autonomy less autonomy (by not asking patients whether they individually hold these values, potentially stereotyping a patient's values based on their perceived cultural membership [Minkoff 2014]). Mrs. Smith's husband was responding to the fact that this interview prioritized the possibility Mrs. Smith may value individual autonomy over his cultural values. ...
This paper is a clinical ethics case study which sheds light on several important dilemmas which arise in providing care to patients from cultures with non-individ-ualistic conceptions of autonomy. Medical professionals face a difficult challenge in determining how to respond when families of patients ask that patients not be informed of bad medical news. These requests are often made for cultural reasons, by families seeking to protect patients. In these cases, the right that patients have to their own medical information in order to make autonomous decisions is in tension with the possibility that patients could hold values that require limiting their autonomy with regard to medical information disclosure, often based on the idea that family should take on difficult decision-making as an act of care. We describe one such case, of an 83-year old Russian woman whose husband requested she not be informed of a new cancer diagnosis. The appropriate response to this request was to ask the patient about her values separately, without disclosing any medical information until her values were clear. This patient indicated she wanted the care team to uphold her husband's request. This response makes the importance of determining a patient's values before moving forward with disclosure clear: she would not have wanted to be informed of her cancer. We describe our conversation strategy, which allowed value exploration without disclosure and highlighted that the obligation to respect a patient's autonomy sometimes includes an obligation to allow a patient to choose to limit their own autonomy. This case also highlights that this kind of conversation prioritizes the patient's values rather than the family's or care team's, centering patients in the way that is ethically appropriate.
... E. Donate-Bartfield and L, Lausten, Cf. the Ref. [6], recommend that teaching culturally sensitive care should integrate an understanding of ethical issues and that culturally sensitive care be viewed as consistent with core ethical principles. The integrated approach, Cf. the Ref. [17], is validated by H. Minkoff, Cf. the Ref. [3], who cautions that if cultural competence and ethics are presented separately from other content areas, they risk becoming de-emphasized as fringe elements or of marginal importance. When teaching cultural competence, integrating an understanding of ethical issues is crucial. ...
... According to M. Paasche-Orlow, Cf. the Ref. [7] and H. Minkoff, Cf. the Ref. [3] conflicts between autonomy and cultural sensitivity may arise in clinical practice and students need to be prepared for ethical decision making. For instance clients'/ patients' beliefs may involve practices that interfere with established best practice of health care professionals. ...
... For instance clients'/ patients' beliefs may involve practices that interfere with established best practice of health care professionals. Cultural competence involves understanding of the importance of cultural differences, respect for those differences and minimization of the consequences of such differences, Cf. the Ref. [3]. Health care professionals may perceive a conflict between ethical practice and cultural sensitivity to the mores of other cultures. ...
Cultural competence and ethical decision making are two separate, yet intrinsically related concepts which are central to services rendered by all health care professionals. Cultural competence is based on ethical principles and informs ethical decision making. In spite of this important connection, the interrelationship of these two concepts does not receive the attention it deserves in the literature. This issue is addressed by appraising the training and assessment of cultural competence and ethical decision making in the health care professions. The integrated relationship of these two concepts is illustrated within the broader contexts of higher education, research and clinical practice. Health care professionals who incorporate cultural competence and ethical decision making will be empowered to provide the best services to their clients/ patients in multicultural contexts to ensure optimum outcomes.
... We read with interest the article "Risk factors for unscheduled delivery in patients with placenta accreta" by Bowman et al, 1 where the authors address in the discussion the current controversy of timing of delivery of pregnancies with prenatal suspicion of placenta accreta (PA). Based on the results of a large cohort, they argue that it seems reasonable to consider Letters to the Editors ajog.org ...
... Alternative way of removing pessaries that cause genital incarceration TO THE EDITORS: We read with interest the case report of incarcerated genital tissue within a ring pessary and the accompanying impressive imagery. 1 Thubert and Deffieux 1 present an 84-year-old patient who had genital incarceration and urinary retention 5 days after insertion of a ring pessary for genital prolapse. The authors treated her with cold-knife resection of the device and subsequent replacement of a different type of pessary: the doughnut. ...
... Advocating for stronger regulatory systems and participating in policy development can help improve the ethical landscape. [32,33,34] ...
Establishing a functional orthopaedic department in a Nigerian teaching hospital faces challenges like staff attitude, equipment shortages, and regulatory hurdles. Solutions include infrastructure development, equipment procurement, and staff recruitment. Strategies for equipment shortages include capital investment and improved inventory management. Cultural competence training and community involvement address cultural factors impacting patient care. Quality control and innovation are crucial, necessitating audits and research collaborations. Ethical considerations, like patient consent, are paramount. Intramural Private Practice (IPP) integrates private and institutional healthcare, enhancing service delivery. Structured guidelines ensure operational integrity. Overall, a holistic approach focusing on staff management, quality, and patient-centred care is essential for a successful establishment.
... Ethical decision-making principles in health care are aimed at preserving and protecting human life and health in the perinatal and postnatal periods, preventing disease, restoring health and reducing suffering from incurable illness and death [Goloff & Moore, 2019]. There is a direct correlation between the level of competence of medical professionals and their ability to provide culturally sensitive medical services [Mınkoff, 2014]. Nursing staff must have the skills to resolve ethical dilemmas. ...
Background
Ethical values are a guideline for behavior in certain situations. They take on particular importance in patient care. Ethical values depend on many factors including culture.
Objective
The aim of the study is to compare the attitudes of nursing students from different countries towards ethical values.
Design
A cross-sectional study design was used.
Methods
The aim of this study is to compare the attitudes of nursing students towards ethical values. 463 students participated in the survey, including 191 from Poland and 272 from Turkiye. The study was conducted from April to June 2022. For the purposes of this study was used Ethical Values Scale (IEVS). The criteria for excluding participants from the study were nursing student status and consent to participate in the study.
Results
The IEVE total score for all respondents was 68.20 and the median was 68. In the individual subscales: Love-Respect 34.76 (median 35), Justice-Honesty 21.29 (median 21) and Cooperation 12.14 (median 12). Polish students' total IEVS score average was 70.48 ± 6.81 and Turkish students' IEVS total score average was 66.61 ± 9.65. There is a statistically significant difference between the total score average on the IEVS of students from the two countries (p < 0.001).
Conclusion
The formation of ethical attitudes among students should be strengthened, paying attention to their cultural conditions. Research should be continued, expanding to include other socio-cultural factors.
... When facing cultural dilemmas in obstetrics, searching for common ground has proved an effective strategy. 39 Typical shared goals would include optimising the patient's mental and physical health and maintaining positive family relationships. ...
Requesting that serious diagnoses be concealed from patients, a widespread phenomenon in many cultures, presents a professional dilemma. Practical and sensitive communication strategies are needed.
Methodology
In this paper, we use analysis of the existing literature to develop a communication tool for practitioners facing requests for diagnostic non-disclosure. Our approach builds on existing strategies, in providing a mnemonic communication tool, permitting more than one outcome, and focusing on the need for mutual understanding and cooperation.
Results
Existing work on this dilemma highlights the need to appreciate the family's standpoint, affirm their benevolent intentions and correct misperceptions. To this end, we have developed a mnemonic tool, 'ARCHES', to be used in situations where the family has requested diagnostic non-disclosure. The model has six stages: acknowledge the request for non-disclosure, build the relationship, find common ground, honour the patient's preferences and outline the harm of non-disclosure, provide emotional support and devise a supportive solution.
Conclusion
Facing requests for diagnostic non-disclosure is a challenge of communication. The dilemma is particularly marked when practising across cultures. Our model gives a structure for building rapport with the family and realigning their misperceptions while upholding the patient's right to knowledge.
... Various cultural context of patients as well as cultural gap among patients and healthcare team can be the reason of patients' diverse perspectives regarding the ethical subjects. Cultural context of each patient and his/ her family should be considered in providing respect to patient autonomy [11] as well as in providing patients and their families with bitter truth-telling regarding their health issues and treatment plan. [12,13] Even in societies with awareness of medical ethics principles, different understandings and interpretations of these principles can exist. ...
BACKGROUND: Adherence to medical ethics principles by medical professionals is required to improve health-care system's quality. Recognizing medical ethics' challenges and attempting to resolve them are important in the implementation of medical ethics in practice. This study aimed to explore such challenges at Iran's medical sciences universities in 2018.
MATERIALS AND METHODS: This descriptive, qualitative study utilized a conventional content analysis approach for data analysis. This study was conducted using purposeful sampling from participants with experience in teaching or practicing of medical ethics field, and by considering maximum variety of disciplines (e.g., gynecology, internal medicine, surgery, and medical ethics). The data were gathered using semi-structured interviews. The interview guide was designed based on previous research findings by two members of the research team and contained the main interview questions and participants had the opportunity to express their perspectives in detail. Participants were chosen from clinical and ethical faculty members as well as managers. The data collection process continued until the data saturation stage, beyond which no new information or concept achieved by continuing interviews.
RESULTS: After interviewing 14 faculty members and managers, findings were classified into 4 themes, 9 categories, and 42 sub-categories; four main categories of medical ethics challenges are affected by cognitive, educational, practical, and structural factors, respectively.
CONCLUSION: This study suggested that medical ethics' cognitive and educational challenges can alleviate using educational programs intended for improving qualitative and quantitative aspects of medical ethics teaching for medical professionals ranging from students to faculty members. Medical ethics' structural and practical challenges are within policymaking and scheduling activities dealt with through future researches by health-care system's managers and planners.
... It also gives them the right to take actions based on personal values and beliefs (Stiggelbout et al, 2004;Beauchamp and Childress, 2013), even when their decision challenges clinicians' advice (Sedig, 2016). Minkoff (2014) emphasised that autonomy is a key ethical principle in healthcare which takes precedence over other principles. Sedig (2016) agreed, as patient independence is one of the highest priorities in medicine. ...
Background
Autonomy is a key ethical principle in healthcare, giving patients the right to be involved in their own care. Allowing patients to make decisions based on their own values and beliefs is a fundamental aspect of evidence-based practice. Professional autonomy allows paramedics to make critical decisions around patient care in an emergency, enabling them to provide life-saving treatment. A patient's autonomy can conflict with that of a paramedic, leading to complex ethical situations which can affect the way a paramedic performs their duty of care. Decision-making is a fundamental skill for paramedics and often in the prehospital setting, paramedics have to manage situations with a certain degree of risk if they are to manage patients effectively and safely, while respecting patients' legal and ethical rights.
Case presentation
An ambulance crew were called to attend a 62-year-old woman with a history of chronic obstructive pulmonary disease, respiratory arrest and stage 2 respiratory failure, who had breathing difficulties. She was deemed to have capacity by the ambulance crew under the Mental Capacity Act. The patient refused to be taken to hospital for treatment against paramedic recommendation, as she wished to receive no further treatment or hospital admission and wanted to die at home. The ambulance crew referred her to her GP.
Conclusions
Paramedics experience great difficulties in making decisions, as information and alternative treatment options are often limited in the prehospital setting. One major limitation to autonomy is where an autonomous patient is refusing life-saving treatment. This can create ethical dilemmas for paramedics, leaving them to feel a sense of vulnerability and anxiety around performing their duty of care. The law is clear: an autonomous patient's decision to refuse treatment, even if it may seem unwise, must be respected in accordance with the Human Rights Act 1998.
... Private deliberation between patient and doctor -with adequate independent language translation if needed -remains necessary to establish a patient's free decision. 5,16 Proper antenatal education on pain relief and anaesthetic strategies in obstetric emergencies facilitates maternal decision-making during delivery. ...
... A large body of literature has shown that healthcare professionals and patients often encounter challenges in their interactions due to differences in language, culture or (religious) value systems [41][42][43][44]. From a medical ethics perspective, difficulties of migrant populations have particularly been discussed in the light of cultural difference and its implications for a principle-based approach [45], for example when the principle of autonomy collides with the wish to act culturally sensitive due to differences in (understanding of ) moral values as shown by Minkhoff [46]. However, the problem of mutual misunderstandings is interesting insofar as it seems to indicate a fundamental incongruence at a level below cognitive differences or differences in values. ...
Background:
In todays' super-diverse societies, communication and interaction in clinical encounters are increasingly shaped by linguistic, cultural, social and ethnic complexities. It is crucial to better understand the difficulties patients with migration background and healthcare professionals experience in their shared clinical encounters and to explore ethical aspects involved.
Methods:
We accompanied 32 migrant patients (16 of Albanian and Turkish origin each) during their medical encounters at two outpatient clinics using an ethnographic approach (participant observation and semi-structured interviews with patients and healthcare professionals). Overall, data of 34 interviews with patients and physicians on how they perceived their encounter and which difficulties they experienced are presented. We contrasted the perspectives on the difficult aspects and explore ethical questions surrounding the involved issues.
Results:
Patients and physicians describe similar problem areas, but they have diverging perspectives on them. Two main themes were identified by both patients and physicians: >patients' behaviour in relation to doctors' advice< and > relationship issues<.
Conclusions:
A deeper understanding of the difficulties and challenges that can arise in cross-cultural settings could be provided by bringing together healthcare professionals' and patients' perspectives on how a cross- cultural clinical encounter is perceived. Ethical aspects surrounding some of the difficulties could be highlighted and should get more attention in clinical practice and research.
... Litina et al. proves that understanding culture is important for the formation of one's wisdom [12]. Psychological education [13], nursing education [14], even medical education must also have a sensitivity to this cultural value [15]. For students the sensitivity and emotional intelligence to the noble values of this culture is very important for their daily life, such as for communication with teachers, to deal with collectivism conflict between friends [16], and to smooth students' involvement in academic activities. ...
This article describes the findings of a study aimed at producing a set of cultural literacy-oriented critical reading teaching material. This material is developed as a countermeasure to the increasingly thin sensitivity of society, especially the students toward noble values of religion, custom, and culture. With this material student get a significant critical understanding of the discourse with the content of noble value of Indonesian culture. The understanding is attained by students through active reader strategy. There are four important principles developed in understanding the text through this strategy, namely 1) building basic understanding of the text, 2) conducting reading activities in chronological order of the text, 3) identifying the style and language of the text, and 4) critically deepening the understanding of the text. The emphasis on cultural critical understanding became the focus of this research. Thus, critical reading question technique 501 is required. With this technique student can predict causation, establish logical and emotive understanding, and predict the implications of ideas. The implementation of development of this teaching material is based on the stages of Design Based Research. Data is obtained through expert scales and trials to junior high school students in Bandung. The result of this research is a critical reading textbook based on cultural literacy with active reader strategy that is effective to be used for junior high school students. The implication of this research is the acquisition of students' sensitivity toward noble values of religion, custom, and culture that can be internalized in their lives.
... 179-180). For example, notions of autonomy vary across cultures, as well as intraculturally, making it important for clinicians to develop a set of skills and attitudes that allows them to engage effectively with patients whose views differ from their own (Brannigan, 2008;Hyun, 2008;Leever, 2011;Minkoff, 2014). Cultural competence, which is grounded in the belief that all people are due equal moral consideration, allows health care workers to provide "patient-specific care across a culturally diverse population" (Hyun, 2008, p. 169). ...
Over the past 40 years, scholars and practitioners of public relations have often cast public relations workers in the role of the public relations-person-as-corporate-conscience (PRPaCC). This work, however, maintains that this construct is so problematic that invoking it is of negligible use in addressing ethical issues that emerge during a crisis. In fact, a complex crisis, such as the Jahi McMath “brain death” case at Children’s Hospital Oakland (CHO, now UCSF Benioff Children’s Hospital Oakland), demonstrates the need to abandon the PRPaCC construct to better engage affected stakeholders, including “outsiders” to the organization, who often determine whether an organization is facing a crisis. Through an examination of both the concept of the PRPaCC and the McMath crisis, this work makes the case for moving beyond the PRPaCC construct in favor of a more modest role for the public relations person: facilitating widespread ethical deliberation and discussion throughout an organization, potentially helping the organization alleviate concerns that contribute to crises.
... We read with interest the article "Risk factors for unscheduled delivery in patients with placenta accreta" by Bowman et al, 1 where the authors address in the discussion the current controversy of timing of delivery of pregnancies with prenatal suspicion of placenta accreta (PA). Based on the results of a large cohort, they argue that it seems reasonable to consider Letters to the Editors ajog.org ...
... a. Non-judgmental communication: ensuring that personal bias does not enter into a conversation with a patient to influence clinical decisionmaking [10]; b. Culture competency awareness: appreciating how the nuances of a patient's belief system influences their health care decisions and a physician's counseling of that patient [11]; and c. Reflective listening: listening to what the patient is saying and then repeating what he or she has said so as to confirm that one has understood [12]. ...
Background
To ensure optimal patient care, physicians must establish effective patient-physician relationships and thoughtfully incorporate their patients’ perspectives into their counseling. Historically, these skills are acquired with increasing clinical experience. However, given increasing work-hour restrictions, OB/GYN residents have fewer opportunities to develop these skills. Therefore, the objective of this study was to determine if an interactive learning method is an effective tool by which to teach OB/GYN residents how to communicate with complicated patients.
Methods
An experiential simulation model was developed to teach OB/GYN residents effective communication skills for dealing with patients experiencing a pregnancy-related complication. A simulated patient interaction was designed for first-year residents. Specific scenarios were constructed based on challenging clinical scenarios identified by second-year residents. Non-judgmental communication, culture competency awareness and reflective listening were key skills that were taught as part of the clinical scenarios. Both acceptability and utility of the exercise with the first-years was assessed by a follow-up survey.
Results
Seven first-year residents participated in the education session consisting of four physician-patient interactions with specific learning objectives for each. These first-year residents all indicated that they would employ the skills practiced during the intervention into their future practice of medicine, and that their comfort level in caring for complex obstetric patients had increased. Moreover, all first-year residents endorsed that this educational strategy was potentially applicable to other aspects of their training.
Conclusions
Simulated patient exercises can be utilized in multiple arenas to teach OB/GYN residents communication skills, while simultaneously addressing their clinical knowledge deficits. Early implementation of such a curriculum in an OB/GYN residency will lay the foundation for the development of empathetic and culturally competent physicians.
Introduction
Efforts to develop reversible male contraceptives analogous to female oral contraceptives are underway and may be introduced in the next decade. The advent of novel male contraceptives provides an opportunity for an ethical reformulation of the contraceptive paradigm given the relational, rather than individual, nature of sexual relationships, and family planning. For individuals in any sexual relationship that could result in pregnancy, issues of reproductive autonomy, freedom, equality in reproductive decision‐making and risks—both of side effects and of unintended pregnancies—are significant. Historically, however, women have been attributed the greatest responsibilities simultaneously with the most restrictions on their freedom of choice and access to reproductive care.
Objectives
In this paper, we extend our prior “shared risk” model of male contraception to one of “shared risk and responsibility” to ethically inform this discourse.
Conclusions
This updated framework more fully captures the complexity of this novel technology and may be of use to regulatory and legal agencies grappling with an intervention that poses medical risks to the member of the relationship who does not face risks of becoming pregnant.
Autonomy is a key principle in biomedical ethics, giving patients the right to be involved in their own care. Professional autonomy allows paramedics to make critical decisions around patient care in an emergency, enabling them to provide life-saving treatment. A patient's autonomy can conflict with that of a paramedic, leading to complex ethical challenges, which can affect the way a paramedic performs their duty of care. An autonomous patient has the right to refuse treatment, creating ethical challenges for paramedics. An autonomous patient's decision to refuse treatment, even if it may seem unwise, must be respected in accordance with the Human Rights Act 1998.
This essay explores three issues in respect for autonomy that pose unfinished business for the concept. By this, I mean that the dialogue over them is ongoing and essentially unresolved. These are: (1) whether we ought to respect persons or their autonomous choices; (2) the role of relational autonomy; and (3) whether nonhuman animals can be autonomous. In attending to this particular set of unfinished business, I highlight some critical moral work left aside by the concept of respect for autonomy as understood in Beauchamp and Childress' Principles of Biomedical Ethics. Specifically, while significant pragmatic traction is gained by the authors' focus on autonomous choice, carving such a focus out from the broader questions of moral respect and the autonomy of the person leaves aside a number of questions that we might have thought a view about respect for autonomy in biomedicine ought to answer. These include: How should physicians respond when autonomous patients make decisions that appear nonautonomous? What is the impact of the view that autonomy is "relational" for cross-cultural differences in how autonomy is respected? If chimpanzees (and by extension young children) can be autonomous, what does that mean for how they should be treated?
Subject autonomy is widely considered the distinctive achievement of contemporary research ethics. Popular history claims that there were no attempts to protect subject autonomy or informed consent until the Nuremberg Doctors’ Trial brought the Nazi research abuses into infamy. This is however a false history. There were at least two research codes in Europe before the Nazis: the Prussian Decree of 1900 and the German Reichsrundschreiben of 1931. Ironically, these codes had stricter demands for subject autonomy and informed consent than contemporary research codes like the Belmont Report and the Nuremberg Code. Yet, the strict demands were overridden by the Nazi state once it faced the emergencies of war. This historical lesson reveals a fundamental flaw in political liberalism, which caused the pre-Nazi codes to fail. But during the Nuremberg Trial, Allied prosecutors were manipulated by the Nazi defence into forgetting about these pre-Nazi codes. Consequently, a frightening lesson from history was lost to modern ethicists. Modern research codes remain vulnerable to the same problem that caused pre-Nazi codes to fail. Thus, recovering this lost history is as important as ever.
Culturally sensitive health care represents a real ethical and practical need in a Western healthcare system increasingly serving a multiethnic society. This review focuses on cross-cultural barriers to health care and incongruent aspects from a cultural perspective in the provision of health care. To overcome difficulties in culturally dissimilar interactions and eventually remove cross-cultural barriers to health care, a culturally sensitive physician considers his or her own identity, values, and beliefs; recognizes the similarities and differences among cultures; understands what those similarities and differences mean; and is able to bridge the differences to accomplish clear and effective communication.
It is hypothesised and argued that "the four principles of medical ethics" can explain and justify, alone or in combination, all the substantive and universalisable claims of medical ethics and probably of ethics more generally. A request is renewed for falsification of this hypothesis showing reason to reject any one of the principles or to require any additional principle(s) that can't be explained by one or some combination of the four principles. This approach is argued to be compatible with a wide variety of moral theories that are often themselves mutually incompatible. It affords a way forward in the context of intercultural ethics, that treads the delicate path between moral relativism and moral imperialism. Reasons are given for regarding the principle of respect for autonomy as "first among equals", not least because it is a necessary component of aspects of the other three. A plea is made for bioethicists to celebrate the approach as a basis for global moral ecumenism rather than mistakenly perceiving and denigrating it as an attempt at global moral imperialism.
This collection of original essays explores the social and relational dimensions of individual autonomy. Rejecting the feminist charge that autonomy is inherently masculinist, the contributors draw on feminist critiques of autonomy to challenge and enrich contemporary philosophical debates about agency, identity, and moral responsibility. The essays analyse the complex ways in which oppression can impair an agent’s capacity for autonomy, and investigate connections, neglected by standard accounts, between autonomy and other aspects of the agent, including self-conception, self-worth, memory, and the imagination.
I examined the influence of cultural meaning systems on the perception of self among Japanese and American (United States) college students. Given the importance of social context to the Japanese self as compared with the U.S. self, I used two types of free-response format: the noncontextualized Twenty Statements Test (TST), and a contextualized questionnaire asking subjects to describe themselves in various situations. Consistent with prior research, on the TST Japanese subjects listed fewer abstract, psychological attributes than did American subjects, referring more to social role and behavioral context. On the contextualized format, however, this trend was reversed. Japanese scored higher on abstract, psychological attributes than did Americans, who tended to qualify their self-descriptions. In addition, on the TST Japanese surpassed Americans in the number of highly abstract, global self-references. Results point to the impact of divergent cultural conceptions of the person rather than differences in cognitive ability on the perception of self in these two cultures.
DURING the last two decades or so, there has been a struggle over the patient's role in medical decision making that is often characterized as a conflict between autonomy and health, between the values of the patient and the values of the physician. Seeking to curtail physician dominance, many have advocated an ideal of greater patient control.1,2 Others question this ideal because it fails to acknowledge the potentially imbalanced nature of this interaction when one party is sick and searching for security, and when judgments entail the interpretation of technical information.3,4 Still others are trying to delineate a more mutual relationship.5,6 This struggle shapes the expectations of physicians and patients as well as the ethical and legal standards for the physician's duties, informed consent, and medical malpractice. This struggle forces us to ask, What should be the ideal physician-patient relationship?
We shall outline four models of the
The Outcome Project requires high-quality assessment approaches to provide reliable and valid judgments of the attainment of competencies deemed important for physician practice.
The Accreditation Council for Graduate Medical Education (ACGME) convened the Advisory Committee on Educational Outcome Assessment in 2007-2008 to identify high-quality assessment methods. The assessments selected by this body would form a core set that could be used by all programs in a specialty to assess resident performance and enable initial steps toward establishing national specialty databases of program performance. The committee identified a small set of methods for provisional use and further evaluation. It also developed frameworks and processes to support the ongoing evaluation of methods and the longer-term enhancement of assessment in graduate medical education.
The committee constructed a set of standards, a methodology for applying the standards, and grading rules for their review of assessment method quality. It developed a simple report card for displaying grades on each standard and an overall grade for each method reviewed. It also described an assessment system of factors that influence assessment quality. The committee proposed a coordinated, national-level infrastructure to support enhancements to assessment, including method development and assessor training. It recommended the establishment of a new assessment review group to continue its work of evaluating assessment methods. The committee delivered a report summarizing its activities and 5 related recommendations for implementation to the ACGME Board in September 2008.
Patients making difficult choices among therapeutic options often ask their physicians what they would do if they were in the same situation. When faced with that question, physicians might be concerned that a direct answer could infringe on a patient's autonomy by substituting the physician's unique worldview or experience for their patients'. However, refusing to answer the question might lead a patient to feel unsupported at a difficult time. In this article we describe an approach that allows a physician to contribute to the patient's decision without inadvertently being coercive. That approach requires physicians to meaningfully shape therapeutic options, and assist patients in making difficult decisions. It is dependent on the physician being aware of the role of both their patients' values, and health values (eg, autonomy, futility) in decision making. It also requires an awareness of the force of language, both stated and implied, in shaping a patient's choice. To make a good decision, women need more than accurate information. They also need to be supported and sense empathy and understanding from their physicians and feel cared for. Although the facts (benefits and harms related to any given choice) are a necessary component of counseling, without discussion of values, they do not lead to a truly informed decision.
We defend the view that the obstetrician's response to the abortion controversy cannot be based on accounts of the independent moral status of the fetus, because all such accounts are irresolvably disputable. That response, however, can be based on an account of the dependent moral status of the fetus. For such an account the central question is, "When is the fetus a patient?" Viable fetuses are patients. Nonviable third-trimester fetuses are not patients. Previable fetuses are patients solely as a function of the woman's autonomous decision to confer such status. The abortion of a viable fetus is, with few exceptions, never ethically justified, because it is a patient. The abortion of nonviable third-trimester fetuses (i.e., premature termination of pregnancy) is justified when the pregnant women consents to it. Abortion of the previable fetus is justifiable when the pregnant women consents to it. We distinguish between professional and private conscience. We identify the limits of the former and the legitimate role of the latter, especially in the area of religious beliefs. Finally, we address the implications of our view for residency training programs. The most important of these implications is that requiring all residents to perform abortions is ethically unjustifiable.
MEDICAL AND social attitudes toward cancer have evolved rapidly during the last 20 years, particularly in North America.1,2 Most physicians, most of the time, in most hospitals, accept the ethical proposition that patients are entitled to know their diagnosis. However, there remains in my experience a significant minority of cases in which patients are never informed that they have cancer or, although informed of the diagnosis, are not informed when disease progresses toward a terminal phase. Although concealment of diagnosis can certainly occur in cases of other terminal or even nonterminal serious illnesses, it seems to occur more frequently and in more exacerbated form with cancer because of the traditional and cultural resonances of dread associated with cancer.These cases challenge our understanding of and commitment to an ethical physician-patient relationship. In addition, they are observably a significant source of tension between healthcare providers. When the responsible physician persists
Cultural competence curricula have proliferated throughout medical education. Awareness of the moral underpinnings of this movement can clarify the purpose of such curricula for educators and trainees and serve as a way to evaluate the relationship between the ethics of cultural competence and normative Western medical ethics. Though rarely stated explicitly, the essential principles of cultural competence are (1) acknowledgement of the importance of culture in people's lives, (2) respect for cultural differences, and (3) minimization of any negative consequences of cultural differences. Culturally competent clinicians promote these principles by learning about culture, embracing pluralism, and proactive accommodation. Generally, culturally competent care will advance patient autonomy and justice. In this sense, cultural competence and Western medical ethics are mutually supportive movements. However, Western bioethics and the personal ethical commitments of many medical trainees will place limits on the extent to which they will endorse pluralism and accommodation. Specifically, if the values of cultural competence are thought to embrace ethical relativity, inexorable conflicts will be created. The author presents his view of the ethics of cultural competence and places the concepts of cultural competence in the context of Western moral theory. Clarity about the ethics of cultural competence can help educators promote and evaluate trainees' integration of their own moral intuitions, Western medical ethics, and the ethics of cultural competence.
Moral psychology Available at: http://www.psychwiki.com/wiki/Moral_ Psychology
- Psychwiki
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The righteous mind: why good peo-ple are divided by politics and religion
- J Haidt
Haidt J. The righteous mind: why good peo-ple are divided by politics and religion. New York: Random House; 2012.