The Emotions in Bioethical Decision-making.

In an era of evidence-based medicine and an increasing use of technology the question is raised again as to what extent emotions should play in medical and ethical decision-making. While clearly the correct facts in each case are a sine qua non for ethical decision-making, and one should evaluate each situation rationally in accord with accepted ethical principles, the appropriate role of the emotions in decision-making is gaining increased attention in part as a result of newer research in neuroethics. In end-of-life care there often exists a disconnect between the "rational" analysis by many philosophers and ethicists and the emotional reactions of many physicians and nurses with respect to the comparison between withholding and withdrawal of life-sustaining therapy. It is suggested that these attitudes of many health care workers should not be ignored because they represent a critical, almost universal, and laudable value of reluctance to take human life, a value so strongly ingrained in the ethos of the medical profession.

Response to: 'Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies' by Schuklenk and Smalling.

The recent essay by Schuklenk and Smalling opposing respect for physicians' conscientious objections to providing patients with medical services that are legally permitted in liberal democracies is based on several erroneous assumptions. Acting in this manner would have serious harmful effects on the ethos of medicine and of bioethics. A much more nuanced and balanced position is critical in order to respect physicians' conscience with minimal damage to patients' rights.

Jewish Medical Ethics.

BACKGROUND: Jewish medical ethics is a term coined by the late Lord Rabbi Immanuel Jacobovits in the mid-20th century. Its principles and emphases differ in some significant ways from the currently accepted axioms in Western secular ethics. The emphasis is lesser on autonomy and more on the value of human life and on communitarianism. The Israel Patient's Rights Law reflects these differences from the Western norms.

Policy issues related to educating the future Israeli medical workforce: an international perspective.

A 2014 external review of medical schools in Israel identified several issues of importance to the nation's health. This paper focuses on three inter-related policy-relevant topics: planning the physician and healthcare workforce to meet the needs of Israel's population in the 21(st) century; enhancing the coordination and efficiency of medical education across the continuum of education and training; and the financing of medical education. All three involve both education and health care delivery. The physician workforce is aging and will need to be replenished. Several physician specialties have been in short supply, and some are being addressed through incentive programs. Israel's needs for primary care clinicians are increasing due to growth and aging of the population and to the increasing prevalence of chronic conditions at all ages. Attention to the structure and content of both undergraduate and graduate medical education and to aligning incentives will be required to address current and projected workforce shortage areas. Effective workforce planning depends upon data that can inform the development of appropriate policies and on recognition of the time lag between developing such policies and seeing the results of their implementation. The preclinical and clinical phases of Israeli undergraduate medical education (medical school), the mandatory rotating internship (stáge), and graduate medical education (residency) are conducted as separate "silos" and not well coordinated. The content of basic science education should be relevant to clinical medicine and research. It should stimulate inquiry, scholarship, and lifelong learning. Clinical exposures should begin early and be as hands-on as possible. Medical students and residents should acquire specific competencies. With an increasing shift of medical care from hospitals to ambulatory settings, development of ambulatory teachers and learning environments is increasingly important. Objectives such as these will require development of new policies. Undergraduate medical education (UME) in Israel is financed primarily through universities, and they receive funds through VATAT, an education-related entity. The integration of basic science and clinical education, development of earlier, more hands-on clinical experiences, and increased ambulatory and community-based medical education will demand new funding and operating partnerships between the universities and the health care delivery system. Additional financing policies will be needed to ensure the appropriate infrastructure and support for both educators and learners. If Israel develops collaborations between various government agencies such as the Ministries of Education, Health, and Finance, the universities, hospitals, and the sick funds (HMOs), it should be able to address successfully the challenges of the 21st century for the health professions and meet its population's needs.

Maimonides Reincarnated.

The writings of Maimonides, the 12th-century physician, Talmudic and philosophic scholar, are remarkably relevant for modern medicine. Whereas the specific medical recommendations are obviously outdated, Maimonides' perceptive insights into professional responsibilities and medical ethics remain as useful guides even in our postmodern era.

[Circumcision in male newborns--update].

Recently, there have been efforts in a number of countries to forbid the circumcision of infants and children. This position, which is based on alleged violation of autonomy and on serious harm to the infant or child, is not supported by the medical literature. Controlled studies have accumulated showing the major health benefits of circumcision of infants; there is a decrease in urinary tract infections, a virtual elimination of cancer of the penis, a reduction in HIV and HPV infections, as well as other sexually transmitted diseases, and perhaps, reductions in prostatic cancer and in uterine cervical cancer. The complications of the procedure are minimal, especially when performed in infancy. Recent studies have not confirmed the alleged reduction in sexual pleasure as a result of circumcision. Therefore, there is no justification, whatsoever, for attempts to forbid circumcision of infants. On the contrary, there seem to be good reasons to encourage such practices.

Willingness to treat infectious diseases: what do students think?

INTRODUCTION: Outbreaks of serious communicable infectious diseases remain a major global medical problem and force healthcare workers to make hard choices with limited information, resources and time. While information regarding physicians' opinions about such dilemmas is available, research discussing students' opinions is more limited. METHODS: Medical students were surveyed about their willingness to perform medical procedures on patients with communicable diseases as students and as physicians. Students were asked about their opinions regarding the duty to treat in such cases. RESULTS: 74% of respondents felt that by deciding to enter medical school they were morally obliged to treat any patient despite the risks. Students' willingness to treat as physicians is significantly higher than their willingness to treat as students. HIV was significantly the most tolerated disease with respect to performing mouth to mouth resuscitation. Among preclinical students, we found that willingness to treat during the later years is significantly greater than during the earlier years. Among clinical students, the opposite was observed. DISCUSSION: Students' greater willingness to treat as physicians is mostly attributed to perceptions of higher obligations as a qualified doctor. There is greater but not total willingness to perform resuscitation on patients with HIV relative to other diseases. The increased willingness of preclinical students and the decreased willingness of clinical students both emphasise the importance of patient-physician communication and ethics studies during medical school.

Quo vadis, bioethics.

The recent paper by Giubilini and Minerva suggesting the ethical permissibility of infanticide of normal newborns, calling it "postbirth abortion," represents a dangerous deterioration of generally accepted ethical norms. Their proposal represents a clear example of the so-called slippery slope and we caution against abandoning the age-old traditions of the medical profession assigning intrinsic value to human life from birth. This article discusses the proposed concept, makes comparisons with earlier similar trends of thought, and highlights the dangers of the proposal.

Some Jewish thoughts on genetic enhancement.

The issues of the ethics of germ line modification in general and of enhancement by germ line modification in particular have been the subject of hundreds of articles in the bioethical literature. Both because the techniques are far from perfected and because the potential long term side effects are unkown, there is a widespread consensus that germ line modification for enhancement is absolutely unethical and beyond the pale at the present time. The author considers a thought expperiment projecting into the future in which perhaps the safety and reversibility of germ line modification have been clearly demonstrated. Under such circumstances it is contended that the dividing line between treatment and enhancement is difficult and indeed perhaps impossible to maintain. The Jewish tradition is examined and from the various sources cited it would seem that the benefits of certain kinds of genetic enhancements might well outweigh the objections to such manipulations.

A practical assessment of physician biopsychosocial performance.

BACKGROUND: A biopsychosocial approach to care seems to improve patient satisfaction and health outcomes. Nevertheless, this approach is not widely practiced, possibly because its precepts have not been translated into observable skills. AIM: To identify the skill components of a biopsychosocial consultation and develop an tool for their evaluation. METHODS: We approached three e-mail discussion groups of family physicians and pooled their responses to the question "what types of observed physician behavior would characterize a biopsychosocial consultation?" We received 35 responses describing 37 types of behavior, all of which seemed to cluster around one of three aspects: patient-centered interview; system-centered and family-centered approach to care; or problem-solving orientation. Using these categories, we developed a nine-item evaluation tool. We used the evaluation tool to score videotaped encounters of patients with two types of doctors: family physicians who were identified by peer ratings to have a highly biopsychosocial orientation (n = 9) or a highly biomedical approach (n = 4); and 44 general practitioners, before and after they had participated in a program that taught a biopsychosocial approach to care. RESULTS: The evaluation tool was found to demonstrate high reliability (alpha = 0.90) and acceptable interobserver variability. The average scores of the physicians with a highly biopsychosocial orientation were significantly higher than those of physicians with a highly biomedical approach. There were significant differences between the scores of the teaching-program participants before and after the program. CONCLUSIONS: A biopsychosocial approach to patient care can be characterized using a valid and easy-to-apply evaluation tool.

Promoting a biopsychosocial orientation in family practice: effect of two teaching programs on the knowledge and attitudes of practising primary care physicians.

The bio-psychosocial (BPS) approach to patient care has gained acceptance in medical education. However, reported teaching programs rarely describe the efficacy of alternative approaches to continuing medical education aimed at promoting a BPS approach. The objective was to describe and evaluate the effect of two teaching programs on learners' BPS knowledge, management intentions, patient-centered attitudes, professional self-esteem, burnout, work related strain and mental workload. The learners were Israeli general practitioners. The first ("didactic") program consisted of problem-based reading assignments, lectures and discussions. The second ("interactive") program consisted of reading assignments, lectures and discussions, in addition to role-playing exercises, Balint groups and one-to-one counseling by a facilitator. One month before and six months after the teaching interventions, we used structured questionnaires to test for knowledge, management intentions (responses to questions, such as "what would you tell a patient with ...") and attitudes. Both programs led to measurable improvement in knowledge, intentions, patient-centered attitudes and self-esteem. The interactive teaching approach improved significantly more the learners' professional self-esteem and intentions than the didactic approach. Self-reported burnout significantly increased after the program. It is concluded that teaching intervention enhanced a BPS orientation and led to changes in knowledge, intentions, self-esteem and attitudes. An interactive method of instruction was more effective in achieving some of these objectives than a didactic one. The observed increase in burnout was unexpected and requires further study and confirmation.