The morality of coercion.

The author congratulates Dr Brian Hurwitz, who recently reported the successful "intimidation" of an elderly competent widow into accepting badly needed therapy for a huge ulcerated carcinoma. He reports approvingly of the Israeli Patients' Rights Law, enacted in 1996, which demands detailed informed consent from competent patients before permitting treatment. But the law also provides an escape clause which permits coercing a competent patient into accepting life-saving therapy if an ethics committee feels that if treatment is imposed the patient will give his/her consent retroactively. He suggests this approach as an appropriate middle road between overbearing paternalism and untrammelled autonomy.

Selection for entry to medicine and specialist training.

The task of predicting professional performance during several decades of practice on the basis of any process which takes place a decade earlier is a virtual impossibility. Basically most Western medical schools seek some degree of academic excellence as predicted by school grades and pre-admission examinations. The data suggest that one need not be in the top 1-2% academically for success in medicine. One would therefore do better to place greater emphasis on the key personal qualities desirable in physicians in spite of even greater difficulty in assessing these factors. It seems that trained interviewers using a semi-structured interview can improve the selection process at a considerable expenditure of manpower. Selection for specialty training has heretofore not attempted to seek to identify those qualities specific for each specialty. Application of techniques for this purpose may be the desired trend in the coming years.

Equity in health and health care reforms.

In planning healthcare reforms increasing attention has been focused on the issue of equity. Inequities in the provision of healthcare exist even in relatively egalitarian societies. Poverty is still one of the major contributors to ill health and there are many powerful influences in society that continue to thwart the goal of a maximally equitable system for the provision of healthcare. The principles of equity in a healthcare system have been well articulated in recent years. It is incumbent on healthcare professionals who understand the issues to join the efforts towards a more humane and equitable healthcare system in their societies.

Medical students' attitudes to the physician's oath.

Students at the Ben-Gurion University medical school take the physician's oath at the beginning of their studies. Student attitudes towards the content, timing and relevance of the oath were examined before the ceremony, 3 months later and in the fourth and sixth years. Eight-seven percent of the students were positive about taking the oath, most commonly because the oath represented being part of a medical team that is bound by behavioural norms. Forty-three percent supported giving the oath legal force. There was a progressive decline between the first and final years in positive attitudes towards the oath. The timing most favoured for the oath was the beginning of clinical studies. Three months after the oath ceremony only 18% of the students were able to cite three obligations from the oath. Three percent of the students felt that the oath would affect their behaviour. In students, eyes the oath seems to be an emotionally important ritual, whose value probably transcends its actual content.

Compassionate-empathic physicians: personality traits and social-organizational factors that enhance or inhibit this behavior pattern.

Compassionate-empathic physicians (CEPs) are desired by patients, but rarely found in medical settings. The purpose of this study was to promote our understanding of this gap by determining personal characteristics that distinguish CEPs from other physicians, and organizational factors that might enhance or inhibit physicians' compassionate-empathic behavior (CEB). In the first stage of the study, three groups of physicians who differed in their compassionate-empathic pattern of behavior toward patients were identified by a sociometric questionnaire distributed to 324 physicians in a general hospital. In the second stage, almost all of these physicians (N = 308) were asked to fill out a self administered structured questionnaire, and 214 (69.5%) responded. Comparisons among the three groups show that the physicians identified as CEPs, more than other physicians, are younger, have fewer years in medical practice, and score higher on pro-social, non-stereotypic attitudes toward patients and on empathy measures. Their self-esteem is, however, similar to that of the non-CEPs. The CEPs express similar levels of satisfaction with work on most dimensions, but they report more emotional exhaustion (burnout) than other physicians. A consensus among all physicians was found with regard to two rank orders: (a) the important qualities for being "a good physician"; and (b) the important qualities for being promoted in the hospital. However, while empathic behavior was considered the most important quality for being "a good physician", it was ranked as the least important for being promoted in the hospital. The conclusions can serve as a scientific base for improving methods of selection of medical students, and for re-evaluating the existent criteria for promoting medical staff in general hospitals.

Animals for teaching purposes: medical students' attitude.

Animal rights movements have increased the scope and intensity of their activities over the past decade. While it is generally assumed that doctors and other members of the health care professions favour the use of animals for science, few data are available. Student protests in various medical schools against use of animals in teaching laboratories indicated further need for objective data. A questionnaire about attitudes to the use of animals for teaching purposes was distributed to all the medical students at the Ben-Gurion University of the Negev, present during classes on a given day. All students present (200) returned the questionnaire (70% of the student body). Also queried were attitudes towards related subjects. A high percentage of medical students surveyed had significant reservations about animal experimentation for teaching purposes and about the preferential priority for human life over that of animals. These attitudes, if confirmed, have serious implications for educators both in the health fields and otherwise.

The teaching of medical ethics to medical students.

Teaching medical ethics to medical students in a pluralistic society is a challenging task. Teachers of ethics have obligations not just to teach the subject matter but to help create an academic environment in which well motivated students have reinforcement of their inherent good qualities. Emphasis should be placed on the ethical aspects of daily medical practice and not just on the dramatic dilemmas raised by modern technology. Interdisciplinary teaching should be encouraged and teaching should span the entire duration of medical studies. Attention should be paid particularly to ethical problems faced by the students themselves, preferably at the time when the problems are most on the students' minds. A high level of academic demands, including critical examination of students' progress is recommended. Finally, personal humility on the part of teachers can help set a good example for students to follow.

Selection of medical students: the Beer-Sheva perspective.

In many Western medical schools with a low attrition rate the selection of medical students represents the key hurdle for admission to the practice of medicine. The process therefore deserves careful attention. Described herein are impressions and conclusions from almost two decades' experience in selecting medical students at the Ben-Gurion University in Beer-Sheva, Israel. Emphasis is placed on personal qualities as determined by an interview process of those students who pass a relatively lenient academic threshold. Interviewing is carried out by teams of two, one of whom is a doctor, and each candidate who is accepted is interviewed by four members of the admission committee. Emphasis is placed on clear goals for the interview process, carefully selected and trained interviewers and continual review of the process. In spite of the inherent limitations of a subjective interview process we feel that it offers considerable advantage over other approaches in student selection.

Changes in the nature of inpatient medical services--impact on medical education and patient care.

One hundred sequential admissions to an internal medicine department in a 765-bed teaching hospital in 1973 were compared to 100 admitted in 1987. Mean age in 1973 was 50.3 years as compared to 57.4 in 1987. Length of stay shortened from 8.8 days in 1973 to 4.7 days in 1987. The overwhelming majority of the admissions during both periods had circulatory and/or respiratory disease. The number of diagnoses on admission increased from 2.3 in 1973 to 3.8 in 1987. In 1973, 22% of the patients received no drugs as compared to 6.3% in 1987. X-ray studies per hospital day doubled and invasive procedures more than quintupled. Intravenous fluids were given on 2.5% of days in 1973 and on 22.3% in 1987. Thus medical patients are now older and sicker, yet stay for much shorter periods of time. This radical change in the intensivity and tempo of work raises serious questions about the appropriateness of these sites as major loci for undergraduate teaching.

Compassionate physicians: personality traits and prosocial attitudes.

Three groups of physicians were identified based on their compassionate behavior. Associations with personal characteristics indicate that physicians with high self-esteem are more likely than those with low self-esteem to behave in congruence with their attitudes towards people.

Research in a hierarchy of values.

Research fraud has unfortunately become increasingly troubling and public, undermining public confidence and support of research and threatening the foundation of research. The response of the scientific establishment has varied, but the public perception of the response is that it has been too little and too late. Science, like other institutions supported by public funds, must be accountable to the public and must accept public scrutiny without an overly defensive posture. Cooperation with such public review ultimately benefits science. The root problems underlying fraud in research are not unique to science, but reflect individual and societal moral weaknesses. Science and research, although essential and critical societal activities, do not represent the highest priorities of society, and must be subordinate to higher moral and ethical standards whose sources are external to science itself.