The Objective Structured Clinical Examination and student collusion: marks do not tell the whole truth.

OBJECTIVE: To determine whether the marks in the third year Objective Structured Clinical Examination (OSCE) were affected by the collusion reported by the students themselves on an electronic discussion board. DESIGN: A review of the student discussion, examiners' feedback and a comparison of the marks obtained on the 2 days of the OSCE. PARTICIPANTS: 255 third year medical students. SETTING: An OSCE consisting of 15 stations, administered on three sites over 2 days at a UK medical school. RESULTS: 40 students contributed to the discussion on the electronic discussion board. The main points raised were perceived inequity between students who did, or did not, have prior knowledge of the station content, and the lack of honesty and professionalism of their peers. Most contributors claimed to have received, or knew of others receiving, prior knowledge, but none confessed to passing on information. No significant difference (p = 0.16) was observed in the overall mark for the OSCE on day 1 (mean 390 (SD 37)) and day 2 (mean 397 (38)). On day 2, marks were considerably greater for four stations and markedly lower for three stations. It was not obvious why collusion should affect these station marks. A clear indication of the effects of collusion could only be obtained from a single subsection of an individual station (pathology) where 82 students on day 2 incorrectly gave the diagnosis from day 1. CONCLUSION: Marks do not provide a sound inference of student collusion in an OSCE and may mask the aspects of professional development of students.

Medical ethics: principles, persons, and perspectives: from controversy to conversation.

Medical ethics, principles, persons, and perspectives is discussed under three headings: History, Theory, and Practice. Under Theory, the author will say something about some different approaches to the study and discussion of ethical issues in medicine--especially those based on principles, persons, or perspectives. Under Practice, the author will discuss how one perspectives based approach, hermeneutics, might help in relation first to everyday ethical issues and then to public controversies. In that context some possible advantages of moving from controversy to conversation will be explored; and that will then be illustrated with reference to a current controversy about the use of human embryos in stem cell therapy research. The paper begins with history, and it begins in the author's home city of Edinburgh.

Implications of HIV infection and AIDS for medical education.

What implications on medical schools have HIV infection and AIDS, as the schools reshape their curricula to meet the General Medical Council's new requirements? (General Medical Council 1993). A recent Institute of Medical Ethics' (IME) enquiry suggests: (1) that each medical school should have a specific policy to coordinate teaching on HIV infection and AIDS, and to maximize students' clinical contact with patients who have the virus; and (2) that medical students should be encouraged to develop self-awareness and skills in communication and ethics.

HIV infection and AIDS: the ethics of medical confidentiality.

An Institute of Medical Ethics working party argues that an ethically desirable relationship of mutual empowerment between patient and clinician is more likely to be achieved if patients understand the ground rules of medical confidentiality. It identifies and illustrates ambiguities in the General Medical Council's guidance on AIDS and confidentiality, and relates this to the practice of different doctors and specialties. Matters might be clarified, it suggests, by identifying moral factors which tend to recur in medical decisions about maintaining or breaching confidentiality. The working party argues that two such factors are particularly important: the patient's need to exercise informed choice and the doctor's primary responsibility to his or her own patients.

The ethics of resource allocation.

KIE: Commenting on an article by John Habgood in the same issue of the Journal, Boyd contends that an analysis of the political, professional, and administrative considerations which entered into a resource allocation decision by the Newcastle Area Health Authority should have included two additional moral values. The decision involved acute versus chronic health care priorities. The values of equitable treatment of the most vulnerable patients--the acutely ill, and of the democratic political process itself, should have been considered.^ieng

Institute of Medical Ethics: working party report. HIV infection: the ethics of anonymised testing and of testing pregnant women.

An Institute of Medical Ethics working party supports the view that explicit permission should normally be sought in the case of testing for HIV antibody. It discusses this in relation to anonymised HIV testing for epidemiological purposes, concluding that this is to be welcomed, given certain safeguards. It next argues that pregnant women may have a greater and more immediate need than others to know their HIV status. It concludes that this need does not justify testing them without their permission, but can be met by voluntary diagnostic testing on an 'opting-out' basis, supported by adequate briefing.

Priorities in the allocation of scarce resources.

The authors report and comment on student reactions to a clinical example of moral choice in the microallocation of scarce resources. Four patients require dialysis simultaneously, but only one kidney machine is available. What moral, as opposed to clinical, criteria are available to determine who should have priority?

KIE: The authors discuss the reactions of the medical and nursing students in their ethics seminars to the moral choices posed by the microallocation of scarce medical resources, specifically how to choose among four patients requiring immediate renal dialysis when only one machine is available. In the absense of medical priority, questions concerning future quality of life, burdens to patients and family, and the ability and desirability of patient participation in the decision were raised. The students usually conclude that their rankings cannot be defended on rational moral grounds. Boyd and Potter conclude that, if the physician tries to realize society's goals in resource allocation, the physician patient relationship will be radically altered.

Research ethical committees in Scotland.

A questionnaire was sent to 41 ethical committees in Scotland requesting information about their constitution and supervision of clinical research. Thirty-four (83%) replies were received. Committees varied in size from one to 73 members, most of whom were medical. Ten had no nurse members and only three had lay members without direct NHS connections. Sixteen saw their role as advisory rather than supervisory. Thirteen had not met in the past year whereas two had held 10 or more meetings. Limited use (12) was made of standard protocols, and only six had formal procedures for monitoring research in progress. Only seven of 370 proposals were rejected outright. Risk/benefit dilemmas and difficulties relating to informed consent were the commonest problems encountered. The committees provide only limited safeguards for patients and research workers, and more effective, standardised procedures are indicated.