Should We Think of Early Career Cheaters as Capable of Stewardship?

Resistance to acknowledging and curbing cheating should be seen as expressing academic organizations' dereliction of their tacit early career health professional self-regulatory duties. Cheating among students and trainees deserves ethical attention, scrutiny, and self-regulatory responses because cheating behaviors express characterological vices that undermine trust and trustworthiness, which, among other virtues, are key to good stewardship and other duties of health professionals.

Uptown Squirrel Does Not Eat That.

This essay plays out a few ethics reasons we have to reconsider what's really being marketed to us in some free offers that distract us from questions of ethical, cultural, and clinical importance, for example. Possible points of focus for bioethics as a field are related to antimicrobial resistance and stewardship.

You Are What You Eat . . . and What You Take Orally, Intravenously, or Topically.

This brief suggests a few ethical reasons to interrogate our bioproduct supply chains as we have begun interrogating our food chains.

Virtual Eye Contact.

This article draws on architectural analogies and popular culture to consider ethically and clinically important characterizations of causation and nonarbitrariness. This investigation also suggests similarities between intention and design.

Lessons for Ethics From the Kingdom of Fungi.

This article considers lessons about American (individual-centered) anthropocentric (human-centered) thinking that can be applied to how we confer dignity and moral status to beings other than humans. Interestingly, global bioethics might glean such lessons from fungi.

How to Gird Up "Watch One, Do One, Teach One" for the Moral Psychological Demands of Just Action.

This article interrogates the "watch one, do one, teach one" model that is common in health professions education and suggests how to augment it with critical rigor to better prepare all levels of health professional learners for affective demands of just practice.

Art, clinical moral perception, and the moral psychology of healthcare professionalism.

This essay describes an example of how we-one professor of the elective course Art, Medicine, and Clinical Moral Perception at Creighton University School of Medicine, one Director of Adult Programs at the Joslyn Museum of Art in Omaha, Nebraska, and fourth year medical students-practice perception skills using art objects. This essay presents one example of the journal assignments to which students respond in written narratives about their own perception habits. We also share questions any health professions educator can use to guide students' study of their habits of perception using art objects.

Coercion and polio eradication efforts in Moradabad.

We introduce the problem of vaccine coercion as reported in Moradabad, India. We offer commentary and critical analysis on ethical complexities at the intersection of global public health and regional political strife and relate them to broader vaccine goals. We draw upon a historical example from malaria vaccine efforts, focusing specifically on ethical and health justice issues expressed through the use of coercion in vaccine administration. We suggest how coercion is indicative of failed leadership in public health and consider community-based collaborations as models for cultivating local investment and trust in vaccination campaigns and for success in global public health initiatives.

Professionalism, fidelity and relationship-preservation: navigating disagreement and frustration in clinical encounters.

In February 2012, The Wall Street Journal summarized cases and research documenting growth in the numbers of physicians who ask families to leave their practices due to parental refusal of vaccines for pediatric patients. (1) Some physicians ask families to leave because they feel that they have a professional obligation to maintain a standard of care that is unattainable when parents refuse vaccines for their children. Others struggle with how to maintain a therapeutic relationship with a child whose parents' health beliefs conflict with vaccine schedule recommendations. Additionally, one social and cultural trend that seems to influence physician-family relationships in these cases is "anti-intellectualism." I consider some important challenges these issues pose for professionalism in the physician-family relationship, and consider a few values helpful in configuring responses to those challenges.

Challenges for policy makers and organizational leaders: addressing trends in mental health inequalities.

We typically think of acutely and chronically mentally ill patients as those who belong in psychiatric hospitals and the latter category of patients belonging in "regular" hospitals, but the intersection of physical and mental illness draws attention to important challenges for policy makers and organizational leaders. This article illuminates some broad trends in the health status of people with mental illnesses, canvasses important features of inequalities suffered by people with mental illnesses, and suggests strategies for systemic reform. Most reform recommendations I offer are in the area of healthcare organization leadership and management. Other key reforms will likely be legislative, regulatory, and insurance-related. Social and cultural reforms in organizational practices and structures will also be critical.

Good epidemiology, good ethics: empirical and ethical dimensions of global public health.

This paper examines the following ethically and epidemiologically relevant challenges, as yet neglected in public health ethics: how to distribute resources and health risks and benefits, how to define evidentiary criteria that justify public health interventions, and how to define terms in which programme goals, successes, and failures will be assessed and monitored. We illuminate critical intersections of empirical and ethical dimensions of public health work, drawing upon three global public health interventions-inclusion of the Hepatitis B vaccine in the Universal Immunisation Programme, Universal Salt Iodisation, and the Global Polio Eradication Initiative-and suggest strategies for addressing and responding to them.

Legalism, countertransference, and clinical moral perception.

This target article focuses on dynamics that arise in three typical ethically complex cases in which psychiatric consultations are requested by physicians: a dying patient refuses life-prolonging treatment, an uncooperative patient demands to be allowed to go outside and smoke, and an angry patient demands to be admitted to the hospital. The discussion canvasses what is at stake morally and clinically in each of these cases and explores clinician-patient interactions, dynamics in relationships between consulting physicians and consultant psychiatrists, patient transference, and physician countertransference. The article defines legalism and countertransference and argues that an ethically and clinically important consequence of these phenomena for patients is distortion of clinicians' perceptions of patients' decisions and vulnerabilities. The discussion also describes how legalism and countertransference adversely affect how clinicians treat their psychiatrist colleagues. Finally, the article suggests how the effects of legalism and countertransference can be mitigated.

Rebates and spreads: pharmacy benefit management practices and corporate citizenship.

How ought we determine whether businesses in the health care sector profit fairly? One class of companies in the health care sector, pharmacy benefit managers (PBMs), deserves special consideration. We describe two specific revenue-generating practices--rebates and spread pricing--that account significantly for PBMs' profits but have been neglected in the bioethics and health policy literature as important sources of fiscal waste in our current health care system. We offer analyses of two common cases, consider employers' and employees' vulnerabilities, explore normative assumptions about how markets function, and raise questions about transparency in contract agreements between PBMs and employers. We consider ethical dimensions of PBMs' corporate citizenship in the health care sector and suggest how employers can negotiate more effectively with PBMs.

Moral damage to health care professionals and trainees: legalism and other consequences for patients and colleagues.

Health care professionals' and trainees' conceptions of their responsibilities to patients can change over time for a number of reasons: evolving career goals, desires to serve different patient populations, and changing family obligations, for example. Some changes in conceptions of responsibility are healthy, but others express moral damage. Clinicians' changes in their conceptions of what they are responsible for express moral damage when their responses to others express a meager, rather than robust, sense of what they owe others. At least two important expressions of moral damage in the context of health care are these: callousness and divestiture. Callousness describes the poor condition of a clinician's capacity for moral perception; when her capacity to accurately appreciate features of moral relevance that configure others' needs, vulnerabilities, and desert of care diminishes, such that she fails to respond with care to those for whom she has duties to care, she is callous. Callousness has been explored in detail elsewhere,1 and so the focus of this paper is divestiture. A clinician divests when the value of responding with care to others becomes less centrally and importantly constitutive of his personal and professional identity. Divestiture has important consequences for patients and health professions education, which I will explore here.

Third and fourth year medical students' attitudes about and experiences with callousness: the good, the bad and the ambiguous.

BACKGROUND: This study solicits third and fourth year medical students' attitudes about and experiences with callousness. METHODS: Medical students were asked to respond to an on-line survey assessing demographic information, their experiences with seeing callousness modeled by mentors and their attitudes about callousness. Participants included 74 students roughly split on gender and year in school. RESULTS: A 2 x 2 between-subjects MANOVA was conducted (dependent variables--attitudes about and experiences with callousness; independent variables--gender and year in school). Significant results were found for gender; follow-up analyses revealed that women hold more unfavorable attitudes about callousness than men. Although students generally regarded callousness as undesirable, they reported seeing callousness modeled by their mentors 20% of the time across a variety of situations. CONCLUSIONS: Students' attitudes about callousness are negative; women's attitudes are more negative than men's. Despite this, students (regardless of their demographic variations) regularly see it modeled by their mentors. Some students' narrative responses suggest they think being callous toward patients and colleagues can serve them well in some situations. The authors offer several questions to motivate further empirical and ethical inquiry into callousness and urge medical educators to consider its influence on students' conceptions of professionalism.

"Why aren't you doing what we want?" Cultivating collegiality and communication between specialist and generalist physicians and residents.

Developing residents' communication skills has been a goal of residency training programmes since the Accreditation Council for Graduate Medical Education codified it as a core competency. In this article, a case that features problematic communication between a generalist and specialist physician is drawn upon, and it is suggested how their communication might become open and effective through a practice of reason exchange. This is a practice of giving reasons, listening to reasons given by others, evaluating reasons and deciding which particulars of situations constitute reasons to act and reasons how to act. Drawing on recent literature in teaching communication to radiology residents, it is proposed that practices of reason exchange are part of the skill set generally referred to as "negotiation skills" that should be cultivated in all residents. Particularly, in cases in which generalist and specialist physicians disagree about the reasons to do something, not do something or do something this way or that way, how well physicians are trained to practice reason exchange depends on whether they can communicate effectively and negotiate disagreement collegially.

Should a good healthcare professional be (at least a little) callous?

The term "callous" has not, to this point, been studied empirically or considered philosophically in the context of healthcare professionalism. It should be, however, because its uses seem peculiar. Sometimes "callous" is used to suggest that becoming callous confers a benefit of some protection against emotional distress, which might be considered expedient in the healthcare work environment. But, "callous" also refers to a person's unappealing demeanor of hardened insensitivity. The tension between these different moral connotations of "callous" prompts several empirical, psychological, and moral questions; I introduce and entertain a few here. I also suggest a distinction between callousness and inurement and argue for why this distinction is important to appreciate and uphold in health professions education.