Professional virtue of civility and the responsibilities of medical educators and academic leaders.

Incivility among physicians, between physicians and learners, and between physicians and nurses or other healthcare professionals has become commonplace. If allowed to continue unchecked by academic leaders and medical educators, incivility can cause personal psychological injury and seriously damage organisational culture. As such, incivility is a potent threat to professionalism. This paper uniquely draws on the history of professional ethics in medicine to provide a historically based, philosophical account of the professional virtue of civility. We use a two-step method of ethical reasoning, namely ethical analysis informed by pertinent prior work, followed by identifying the implications of clearly articulated ethical concepts, to meet these goals. The professional virtue of civility and the related concept of professional etiquette was first described by the English physician-ethicist Thomas Percival (1740-1804). Based on a historically informed philosophical account, we propose that the professional virtue of civility has cognitive, affective, behavioural and social components based on a commitment to excellence in scientific and clinical reasoning. Its practice prevents a dysfunctional organisational culture of incivility and sustains a civility-based organisational culture of professionalism. Medical educators and academic leaders are in a pivotal and powerful position to role model, promote and inculcate the professional virtue of civility as essential to an organisational culture of professionalism. Academic leaders should hold medical educators accountable for discharge of this indispensable professional responsibility.

Undue burdens created by the Texas Abortion Law for vulnerable pregnant women.

The new Texas abortion law requires the physician to determine whether a fetal heartbeat is present and prohibits abortion after a heartbeat has been documented. An exception is allowed when a "medical emergency necessitated the abortion." These and other provisions of the statute are to be enforced through "civil actions" brought by private citizens. This article identifies 3 populations of vulnerable women who will experience undue burdens created by the Texas abortion law. We begin with an account of the concept of undue burden in the jurisprudence of abortion, as expressed in the 1992 US Supreme Court case, Planned Parenthood v. Casey of Southeastern Pennsylvania. We then provide an evidence-based account of the predictable, undue burdens for 3 populations of vulnerable women: pregnant women with decreased freedom of movement; pregnant minors; and pregnant women with major mental disorders and cognitive disabilities. The Texas law creates an undue burden on these 3 populations of vulnerable women by reducing or even eliminating access to abortion services outside of Texas. The Texas law also creates an undue burden by preventably increasing the risks of morbidity, including loss of fertility, and mortality for these 3 populations of vulnerable women. For these women, it is indisputable that the Texas law will create undue burdens and is therefore not compatible with the jurisprudence of abortion as set forth in Planned Parenthood v. Casey because a "significant number of women will likely be prevented from obtaining an abortion." Federal courts should therefore strike down this law.

John Gregory's medical ethics elucidates the concepts of compassion and empathy.

PURPOSE: This paper draws on eighteenth-century British medical ethics to elucidate compassion and empathy and explains how compassion and empathy can be taught, to rectify their frequent conflation. COMPASSION IN THE HISTORY OF MEDICAL ETHICS: The professional virtue of compassion was first described in eighteenth-century British medical ethics by the Scottish physician-ethicist, John Gregory (1724-1773) who built on the moral psychology of David Hume (1711-1776) and its principle of sympathy. COMPASSION AND EMPATHY DEFINED: Compassion is the habitual exercise of the affective capacity to engage, with self-discipline, in the experience of the patient and therefore become driven to provide effective care for the patient. Empathy is the habitual exercise of the cognitive capacity to imagine the experience of patient and to have reasons to care for the patient. There are rare clinical circumstances in which empathy should replace compassion, for example, in responding to abusive patients. Because the abstract concepts of medical ethics are translated into clinical practice by medical educators, we identify the pedagogical implications of these results by setting out a process for teaching compassion and empathy. THE TASK AHEAD: Eighteenth-century British medical ethics provides a clinically applicable, philosophical response to conflation of the moral virtue of compassion and the intellectual virtue of empathy and applying them clinically.

Potential Impact of Climate Change on Human Trafficking: A Narrative Review.

ABSTRACT: Climate change is a threat to the public health with wide-reaching impacts that are becoming more studied and recognized. An aspect of climate change that has not yet gained adequate scholarly attention is its potential impact on human trafficking. We review the potential impact of climate change on risk factors to human trafficking including poverty, gender inequality, political instability, migration or forced displacement, and weather disasters. We conclude that climate change is a crucially important consideration in understanding the complex and multifactorial risks for human trafficking. These findings add to the priority for health professionals to embrace efforts to prevent and to mitigate the effects of climate change and to take account of these risk factors in screening and identifying trafficked persons.

Professional integrity in maternal - fetal innovation and research: an essential component of perinatal medicine.

OBJECTIVES: Clinical innovation and research on maternal-fetal interventions have become an essential for the development of perinatal medicine. In this paper, we present an ethical argument that the professional virtue of integrity should guide perinatal investigators. METHODS: We present an historical account of the professional virtue of integrity and the key distinction that this account requires between intellectual integrity and moral integrity. RESULTS: We identify implications of both intellectual and moral integrity for innovation, research, prospective oversight, the role of equipoise in randomized clinical trials, and organizational leadership to ensure that perinatal innovation and research are conducted with professional integrity. CONCLUSIONS: Perinatal investigators and those charged with prospective oversight should be guided by the professional virtue of integrity. Leaders in perinatal medicine should create and sustain an organizational culture of professional integrity in fetal centers, where perinatal innovation and research should be conducted.

Climate Change and Risk of Completed Suicide.

Climate change is increasingly recognized as having multiple adverse mental health effects, many of which are just beginning to be understood. The elevated rates of suicides observed in some communities affected by climate change and rising rates of suicide in the United States as climate change intensifies have suggested the two may be associated. We searched PubMed and PsycInfo using the terms climate change and suicide, and provide here a review of the current literature on climate change and suicide that explores possible associations and methodological issues and challenges in this research.

Food Refusal Secondary to Psychosis: A Case Series and Literature Review.

The aim of this article is to emphasize that starvation is an important potential consequence of psychosis and to provide recommendations for management of this condition. A review of the literature on food refusal and starvation in patients with psychotic illnesses was performed. Our search strategy returned 54 articles with one article meeting inclusion criteria. Additional independent research returned an additional four cases of patients with psychosis engaging in self-starvation. The cases of several patients from our institution who engaged in self-starvation behaviors as a result of psychosis are also presented. The management and outcomes of each of these 10 patients are discussed. Starvation secondary to psychosis is an important but underappreciated consequence of psychosis that can lead to serious adverse outcomes in these patients. Few cases have been reported in the literature. More study is warranted to develop evidence-based management guidelines.

A Descriptive Study of United States-Based Human Trafficking Specialty Clinics.

Human trafficking is a crime associated with serious adverse health and mental health outcomes. It has been estimated that more than 40 million people worldwide have been victimized, which has resulted in high rates of traumatic injuries, unwanted and high-risk pregnancies, mental illness, substance use disorders; and suicidality among trafficked persons. Little is known as to what models of health care delivery are best in engaging and sustaining the involvement of trafficked individuals with health care and trafficked individuals have reported discouragement and/or re-traumatization as a result of inadequate or fragmented care. To address the gap in knowledge regarding best practices for engaging and sustaining trafficked patients with health care, the authors of this study set out to identify and describe medical and mental health specialty clinics that work exclusively with trafficked adults, with the goal of assisting organizations and health care providers in program development and to improve clinical outcomes. A patient-centered, comprehensive, interdisciplinary, and trauma informed approach to clinical care is recommended for the treatment of trafficked patients. The authors strongly suggest that human trafficking specialty clinics prioritize psychiatric care and mental health services given the high rate of trauma and mental health issues among trafficked persons.

Current Trends in Psychiatric Education Among Obstetrics and Gynecology Residency Programs.

OBJECTIVE: This study sought to evaluate the status of psychiatric education in Ob/Gyn residencies. METHODS: A 17-item anonymous questionnaire was sent to program directors of 239 Ob/Gyn US residencies. Data analysis was performed using STATA 14.2. RESULTS: Ninety-five programs participated (40%), including partial responses. The majority of Ob/Gyn programs offered didactics in psychiatric topics (84%), with most of the sessions provided by Ob/Gyn faculty. Programs that reported didactics led by psychiatric faculty (57.9%) were more likely to have a higher number of mental health didactics in total. Fewer than half of programs covered intimate partner violence (47%), non-obstetric depression (44%), anxiety (43%), medication management (30%), eating disorders (26%), human trafficking (20%), or PTSD (11%). Elective rotations involving mental health were offered by 20% of programs. Barriers to psychiatric training were lack of integration between Ob/Gyn and psychiatry (46%), ACGME surgical requirements (42%), and lack of knowledgeable instructors (38%). Most program directors (81%) disagreed that residents are fully equipped to identify psychiatric needs in patients. CONCLUSION: Lack of integration between Ob/Gyn and psychiatry was the most cited barrier to effective psychiatric education of Ob/Gyn residents, highlighting the importance of increased partnership between the two fields. Didactic instruction decreased compared to 2001, and considerable gaps still remain. Most program directors perceive that residents are not equipped to identify patients' psychiatric needs.

Tattoo Recognition in Screening for Victims of Human Trafficking.

There is little information on the secondary prevention of human trafficking and how medical professionals can screen for victims. There is a paucity of validated screening tools for use in clinical settings to identify adult trafficked patients, although one for use in pediatric populations exists. Many victims withhold information about their trafficked status. Because traffickers may mark victims, identification of tattoos provides a useful method for screening patients, which complements history taking, especially when victims are unable to disclose that information. We searched existing medical literature, PsycINFO, PubMed, Google, and JSTOR using keywords "human," "trafficking," and "tattoos." Because there is scant literature on this topic, we also searched the gray literature that enabled preliminary identification of several themes used in trafficking tattoos. We also discussed tattoo placement and quality. Tattoo recognition is a critical factor in identifying victims and setting them on a pathway to freedom and recovery.

Identifying Human Trafficking Victims on a Psychiatry Inpatient Service: a Case Series.

Human trafficking is a serious and prevalent human rights violation that closely intersects with mental health. Limited empirical attention has been paid to the presentations and identification of trafficking victims in psychiatric settings. The primary goal of this paper is to describe the varied presentations of trafficking victims on an urban inpatient psychiatric unit. A literature review was conducted to identify relevant empirical articles to inform our examination of cases. Adult inpatient cases meeting criteria for known or possible human trafficking were systematically identified and illustrative cases were described. Six cases were identified including one male and five females. Two had been labor trafficked and four were suspected or confirmed to have been sex trafficked. The cases demonstrated a tremendous diversity of demographic and psychiatric identifying factors. These cases indicate the importance of routinely screening for trafficking victims in inpatient psychiatry settings. Identification of cases is a requisite step in providing informed and evidence-based treatments and enabling the secondary prevention of re-exploitation. Additional research is warranted given the limited current empirical research on this topic area.