Comparing First-Year Engineering Student Conceptions of Ethical Decision-Making to Performance on Standardized Assessments of Ethical Reasoning.

The Defining Issues Test 2 (DIT-2) and Engineering Ethical Reasoning Instrument (EERI) are designed to measure ethical reasoning of general (DIT-2) and engineering-student (EERI) populations. These tools-and the DIT-2 especially-have gained wide usage for assessing the ethical reasoning of undergraduate students. This paper reports on a research study in which the ethical reasoning of first-year undergraduate engineering students at multiple universities was assessed with both of these tools. In addition to these two instruments, students were also asked to create personal concept maps of the phrase "ethical decision-making." It was hypothesized that students whose instrument scores reflected more postconventional levels of moral development and more sophisticated ethical reasoning skills would likewise have richer, more detailed concept maps of ethical decision-making, reflecting their deeper levels of understanding of this topic and the complex of related concepts. In fact, there was no significant correlation between the instrument scores and concept map scoring, suggesting that the way first-year students conceptualize ethical decision making does not predict the way they behave when performing scenario-based ethical reasoning (perhaps more situated). This disparity indicates a need to more precisely quantify engineering ethical reasoning and decision making, if we wish to inform assessment outcomes using the results of such quantitative analyses.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice.

BACKGROUND: Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching. RESEARCH QUESTION: How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety? STUDY DESIGN AND METHODS: This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. RESULTS: We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. INTERPRETATION: Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment.

PROBLEM: The Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania. APPROACH: The authors developed RCA simulations based upon authentic adverse events experienced at their institution. To provide relevance to all GME programs, RCA simulation cases varied widely and included examples of errors involving high-risk medications, communication, invasive procedures, and specimen labeling. Each simulation included residents and other health care professionals such as nurses or pharmacists whose disciplines were involved in the actual event. Participants adopted the role of RCA investigation team, and in small groups systematically progressed through the RCA process. OUTCOMES: A total of 289 individuals from 18 residency programs participated in an RCA simulation in 2019-2020. This included 84 interns (29%), 123 residents (43%), 20 attending physicians (7%), and 62 (21%) other health care professionals. There was an increase in ability of GME trainees to correctly identify factors required for an RCA investigation (62% pre vs 80% post, P = .02) and an increase in intent to "always report" for each adverse event category (3% pre vs 37% post, P < .001) following the simulation. NEXT STEPS: The authors plan to expand the RCA simulation program to other GME clinical sites while striving to involve all GME learners in this educational experience at least once during training. Additionally, by collaborating with health system patient safety leaders, they will annually review all new RCAs to identify cases suitable for simulation adaptation.

Veil-of-ignorance reasoning favors the greater good.

The "veil of ignorance" is a moral reasoning device designed to promote impartial decision making by denying decision makers access to potentially biasing information about who will benefit most or least from the available options. Veil-of-ignorance reasoning was originally applied by philosophers and economists to foundational questions concerning the overall organization of society. Here, we apply veil-of-ignorance reasoning in a more focused way to specific moral dilemmas, all of which involve a tension between the greater good and competing moral concerns. Across 7 experiments (n = 6,261), 4 preregistered, we find that veil-of-ignorance reasoning favors the greater good. Participants first engaged in veil-of-ignorance reasoning about a specific dilemma, asking themselves what they would want if they did not know who among those affected they would be. Participants then responded to a more conventional version of the same dilemma with a moral judgment, a policy preference, or an economic choice. Participants who first engaged in veil-of-ignorance reasoning subsequently made more utilitarian choices in response to a classic philosophical dilemma, a medical dilemma, a real donation decision between a more vs. less effective charity, and a policy decision concerning the social dilemma of autonomous vehicles. These effects depend on the impartial thinking induced by veil-of-ignorance reasoning and cannot be explained by anchoring, probabilistic reasoning, or generic perspective taking. These studies indicate that veil-of-ignorance reasoning may be a useful tool for decision makers who wish to make more impartial and/or socially beneficial choices.

Ethical dilemmas during cardiac arrest incidents in the patient's home.

BACKGROUND:: The majority (70%) of cardiac arrests in Sweden are experienced in the patient's home. In these situations, the ambulance nurses may encounter several ethical dilemmas. AIM:: The aim was to investigate Swedish specialist ambulance nurses' experiences of ethical dilemmas associated with cardiac arrest situations in adult patients' homes. METHODS:: Nine interviews were conducted with specialist ambulance nurses at four different ambulance stations in the southeast region of Sweden. Data were analysed using content analysis. ETHICAL CONSIDERATIONS:: Ethical principles mandated by the Swedish Research Council were carefully followed during the whole process. FINDINGS:: Two main themes with six sub-themes were identified: The scene - creating a sheltered space for caring and Ethical decision-making. The results showed that ethical dilemmas might occur when trying to create a sheltered space to preserve the patients' integrity and dignity. A dilemma could be whether or not to invite significant others to be present during the medical treatment. Ethical decision-making was dependent on good communication and ethical reasoning among all parties. In certain situations, decisions were made not to commence or to terminate care despite guidelines. The decision was guided by combining the medical/nursing perspectives and ethical competence with respect to the human being's dignity and a will to do good for the patient. The nurses followed the voice of their heart and had the courage to be truly human. CONCLUSION:: The ambulance nurses were guided by their ethos, including the basic motive to care for the patient, to alleviate suffering, to confirm the patient's dignity and to serve life and health.

[Assessing bioethics education: Teaching to be virtuous doctors or just doctors with practical ethical skills]. / Evaluando la enseñanza de la bioética: formando «médicos virtuosos¼ o solamente médicos con habilidades éticas prácticas.

OBJECTIVE: In the last decades, bioethics has been incorporated into the academic training of the Medical Schools. Some studies analyze the ethical-moral development of medical students and the effect of ethical education in other countries. This evaluation is done by measuring Kohlberg's moral reasoning (virtuous doctors), or ethical sensitivity to resolve clinical cases (physicians with ethical skills). The following study is proposed to assess the impact of bioethics training on these two variables, in Spanish medical students. DESIGN: Observational cross-sectional study. SITE: Faculty of Medicine, University of Lleida. PARTICIPANTS: 175 students from third year of medicine (78 before bioethics and 97 after bioethics, in different courses) were conducted. INTERVENTION: Bioethics course. MAIN MEASUREMENTS: A socio-demographic questionnaire, the Rest Defining Issue test scale, and Problem Identification Test with clinical vignettes were administered. RESULTS: A consistent and significant correlation has been found between moral reasoning and ethical sensitivity. Women presented greater post-conventional reasoning. There were no changes in Kohlberg's stage of global moral reasoning with ethical training. There were changes in ethical sensitivity with bioethical training, with a significantly and globally improvement. CONCLUSION: In our study, training in bioethics does not improve moral development but rather the ethical problem solving skills. It is asked if this improvement is enough to train doctors prepared for the new challenges.

Intelligent machines, care work and the nature of practical reasoning.

BACKGROUND: The debate over the ethical implications of care robots has raised a range of concerns, including the possibility that such technologies could disrupt caregiving as a core human moral activity. At the same time, academics in information ethics have argued that we should extend our ideas of moral agency and rights to include intelligent machines. RESEARCH OBJECTIVES: This article explores issues of the moral status and limitations of machines in the context of care. DESIGN: A conceptual argument is developed, through a four-part scheme derived from the work of Alasdair MacIntyre. No empirical data are used. ETHICAL CONSIDERATION: No primary data were gathered for this study. Secondary sources and authorship have been acknowledged throughout. FINDINGS / DISCUSSION: Certain kinds of social experience, including the narrative unity of a life, and the giving and receiving of care, are essential for moral development. Machines, no matter how advanced, cannot participate in such experiences in key respects, and thus cannot develop as practical reasoners. CONCLUSION: It follows that they cannot be moral agents and that they cannot care. There are, it seems, no such things as care robots. In view of the institutional power of tech companies and commissioning bodies, care practitioners need to take more of a lead in developing new assistive technologies which are appropriate to their practice.

Not explicit but implicit memory is influenced by individual perception style.

Not only explicit but also implicit memory has considerable influence on our daily life. However, it is still unclear whether explicit and implicit memories are sensitive to individual differences. Here, we investigated how individual perception style (global or local) correlates with implicit and explicit memory. As a result, we found that not explicit but implicit memory was affected by the perception style: local perception style people more greatly used implicit memory than global perception style people. These results help us to make the new effective application adapting to individual perception style and understand some clinical symptoms such as autistic spectrum disorder. Furthermore, this finding might give us new insight of memory involving consciousness and unconsciousness as well as relationship between implicit/explicit memory and individual perception style.

Evaluation of moral case deliberation at the Dutch Health Care Inspectorate: a pilot study.

BACKGROUND: Moral case deliberation (MCD) as a form of clinical ethics support is usually implemented in health care institutions and educational programs. While there is no previous research on the use of clinical ethics support on the level of health care regulation, employees of regulatory bodies are regularly confronted with moral challenges. This pilot study describes and evaluates the use of MCD at the Dutch Health Care Inspectorate (IGZ). The objective of this pilot study is to investigate: 1) the current way of dealing with moral issues at the IGZ; 2) experience with and evaluation of MCD as clinical ethics support, and 3) future preferences and (perceived) needs regarding clinical ethics support for dealing with moral questions at the IGZ. METHODS: We performed an explorative pilot study. The research questions were assessed by means of: 1) interviews with MCD participants during four focus groups; and 2) interviews with six key stakeholders at the IGZ. De qualitative data is illustrated by data from questionnaires on MCD outcomes, perspective taking and MCD evaluation. RESULTS: Professionals do not always recognize moral issues. Employees report a need for regular and structured moral support in health care regulation. The MCD meetings are evaluated positively. The most important outcomes of MCD are feeling secure and learning from others. Additional support is needed to successfully implement MCD at the Inspectorate. CONCLUSION: We conclude that the respondents perceive moral case deliberation as a useful form of clinical ethics support for dealing with moral questions and issues in health care regulation.

Students' responses to scenarios depicting ethical dilemmas: a study of pharmacy and medical students in New Zealand.

One of the key learning objectives in any health professional course is to develop ethical and judicious practice. Therefore, it is important to address how medical and pharmacy students respond to, and deal with, ethical dilemmas in their clinical environments. In this paper, we examined how students communicated their resolution of ethical dilemmas and the alignment between these communications and the four principles developed by Beauchamp and Childress. Three hundred and fifty-seven pharmacy and medical students (overall response rate=63%) completed a questionnaire containing four clinical case scenarios with an ethical dilemma. Data were analysed using multiple methods. The findings revealed that 73% of the qualitative responses could be exclusively coded to one of the 'four principles' determined by the Beauchamp and Childress' framework. Additionally, 14% of responses overlapped between the four principles (multiple codes) and 13% of responses could not be coded using the framework. The subsequent subgroup analysis revealed different response patterns depending on the case being reviewed. The findings showed that when students are faced with challenging ethical dilemmas their responses can be aligned with the Beauchamp and Childress framework, although more contentious dilemmas involving issues of law are less easily categorised. The differences between year and discipline groups show students are developing ethical frames of reference that may be linked with their teaching environments and their levels of understanding. Analysis of these response patterns provides insight into the way students will likely respond in 'real' settings and this information may help educators prepare students for these clinical ethical dilemmas.

Professional Decision-Making in Research (PDR): The Validity of a New Measure.

In this paper, we report on the development and validity of the Professional Decision-Making in Research (PDR) measure, a vignette-based test that examines decision-making strategies used by investigators when confronted with challenging situations in the context of empirical research. The PDR was administered online with a battery of validity measures to a group of NIH-funded researchers and research trainees who were diverse in terms of age, years of experience, types of research, and race. The PDR demonstrated adequate reliability (alpha = .84) and parallel form correlation (r = .70). As hypothesized, the PDR was significantly negatively correlated with narcissism, cynicism, moral disengagement, and compliance disengagement; it was not correlated with socially desirable responding. In regression analysis, the strongest predictors of higher PDR scores were low compliance disengagement, speaking English as a native language, conducting clinical research with human subjects, and low levels of narcissism. Given that the PDR was written at an eighth grade reading level to be suitable for use with English as a second language participants and that only one-fourth of items focused on clinical research, further research into the possible roles of culture and research ethics training across specialties is warranted. This initial validity study demonstrates the potential usefulness of the PDR as an educational outcome assessment measure and a research instrument for studies on professionalism and integrity in research.

Case Complexity and Quality Attestation for Clinical Ethics Consultants.

A proposal by the American Society for Bioethics and Humanities (ASBH) to identify individuals who are qualified to perform ethics consultations neglects case complexity in candidates' portfolios. To protect patients and healthcare organizations, and to be fair to candidates, a minimum case complexity level must be clearly and publicly articulated. This proof-of-concept study supports the feasibility of assessing case complexity. Using text analytics, we developed a complexity scoring system, and retrospectively analyzed more than 500 ethics summaries of consults performed at an academic medical center during 2013. We demonstrate its use with seven case summaries that range in complexity from uncomplicated to very complicated. We encourage the ASBH to require a minimum level of case complexity, and recommend that attestation portfolios include several cases of moderate complexity and at least one very complex case.

Moral Reasoning among HEC Members: An Empirical Evaluation of the Relationship of Theory and Practice in Clinical Ethics Consultation.

In light of the ongoing development and implementation of core competencies in bioethics, it is important to proceed with a clear sense of how bioethics knowledge is utilized in the functioning of hospital ethics committees (HECs). Without such an understanding, we risk building a costly edifice on a foundation that is ambiguous at best. This article examines the empirical relationship between traditional paradigms of bioethics theory and actual decision making by HEC members using survey data from HEC members. The assumption underlying the standardization of qualifications and corresponding call for increased education of HEC members is that they will base imminent case decisions on inculcated knowledge. Our data suggest, however, that HEC members first decide intuitively and then look for justification, thereby highlighting the need to re-examine the pedagogical processes of ethics education in the process of standardizing and improving competencies.

Reasoning Backwards by Design: Commentary on "Moral Reasoning among HEC Members".

Empirical assessment of the practice of clinical ethics is made difficult by the limited standardization of settings, structures, processes, roles, and training for ethics consultation, as well as by whether individual ethics consultants or hospital ethics committees (HECs) provide consultation. Efforts to study the relationship between theory and practice in the work of HECs likewise require the spelling out of assumptions and definition of key variables, based in knowledge of the core concepts of clinical ethics and logistics of clinical consultation. The survey of HEC members reported by Wasserman and colleagues illustrates the difficulty of such research and calls attention to need for studies of real-time, complex decision making to inform conclusions about how theory affects practice.

Committing to place: the potential of open collaborations for trusted environmental governance.

Conventional modes of environmental governance, which typically exclude those stakeholders that are most directly linked to the specific place, frequently fail to have the desired impact. Using the example of lake water management in Loweswater, a small hamlet within the English Lake District, we consider the ways in which new "collectives" for local, bottom-up governance of water bodies can reframe problems in ways which both bind lay and professional people to place, and also recast the meaning of "solutions" in thought-provoking ways.

Cognitive diversity and moral enhancement.

One debate in contemporary bioethics centers on whether the development of cognitive enhancement technologies (CETs) will hasten the need for moral enhancement. In this article we provide a new argument in favor of pursuing these enhancement technologies together. The widespread availability of CETs will likely increase population-level cognitive diversity. Different people will choose to enhance different aspects of their cognition, and some won't enhance themselves at all. Although this has the potential to be beneficial for society, it could also result in harms as people become more different from one another. Aspects of our moral psychology make it difficult for people to cooperate and coordinate actions with those who are very different from themselves. These moral failings could be targeted by moral enhancement technologies, which may improve cooperation among individuals. Moral enhancement technologies will therefore help society maximize the benefits, and reduce the costs, associated with widespread access to cognitive enhancements.