Is medical education asking too much of bioethics?

Daedalus

Volumn 128, Issue 4, 1999, Pages 1-25

  Fox, Renée C ^a  

^a UNIVERSITY OF PENNSYLVANIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BIOETHICS; HISTORY; MEDICAL EDUCATION; UNITED STATES;

BIOETHICS; EDUCATION, MEDICAL; HISTORY, 20TH CENTURY; UNITED STATES;

EID: 0033185834     PISSN: 00115266     EISSN: 15486192     Source Type: Journal    
DOI: None     Document Type: Article

References (55)

1. Abraham Flexner, Medical Education in the United States and Canada (Boston: The Merrymount Press, 1910).
2. Nicholas A. Christakis, Implicit Purposes of Proposals to Reform American Medical Education (Philadelphia, Pa.: Medical College of Pennsylvania Press, 1995), 36-38.
3. See also Nicholas A. Christakis, "The Similarity and Frequency of Proposals to Reform U.S. Medical Education: Constant Concerns," Journal of the American Medical Association 274 (9) (September 1995): 706-711.
4. Samuel W. Bloom, "Structure and Ideology in Medical Education: An Analysis of Resistance to Change," Journal of Health and Social Behavior 29 (5) (1988): 295.
5. W. C. Rappleye, Medical Education: Final Report of the Commission on Medical Education (New York: Association of American Medical Colleges, 1932), 228-229.
6. Dimitri A. Christakis and Chris Feudtner, "Ethics in a Short White Coat: The Ethical Dilemmas that Medical Students Confront," Academic Medicine 68 (4) (April 1993): 249-254.
7. Dimitri A. Christakis and Chris Feudtner, "Academic Medicine Ibid., 250.
8. Chris Feudtner, Dimitri A. Christakis, and Nicholas A. Christakis, "Do Clinical Clerks Suffer Ethical Erosion? Students' Perceptions of their Ethical Environment and Personal Development," Academic Medicine 69 (8) (August 1994): 670-679.
9. Frederick W. Hafferty and Ronald Franks, "The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education," American Medicine 69 (11) (November 1994): 861-871.
10. I was a member of the Columbia University Bureau of Applied Social Research team that conducted studies in the sociology of medical education throughout the 1950s at Cornell University Medical College, the University of Pennsylvania School of Medicine, the School of Medicine at Western Reserve University, and the University of Colorado School of Medicine. My major research for this project was located at Cornell University Medical College where I spent four years as a participant observer in direct fieldwork contact with the medical school socialization process.
11. The perspective on American bioethics that I present here, and numerous of the ideas accompanying it, have been progressively developed in some of my previously published papers. See, for example, Renée C. Fox and Judith P. Swazey, "Medical Morality Is Not Bioethics - Medical Ethics in China and the United States," Perspectives in Biology and Medicine 27 (4) (Spring 1984): 45-70;
12. Renée C. Fox, "The Sociology of Bioethics," in The Sociology of Medicine: A Participant Observer's View (Englewood Cliffs, N.J.: Prentice Hall, 1989), 224-276;
13. Renée C. Fox, "The Evolution of American Bioethics: A Social Perspective," in Social Science Perspectives on Medical Ethics, ed. George Weisz (Dordrecht, Boston, London: Kluwer Academic Publishers, 1990), 201-217;
14. and Renée C. Fox, "The Entry of U.S. Bioethics into the 1990s: A Social Analysis," in A Matter of Principles? Ferment in U.S. Bioethics, ed. Edwin R. DuBose, Ron Hamel, and Laurence J. O'Connell (Valley Forge, Pa.: Trinity Press, 1994), 21-71.
15. James F. Gustafson, "Ethics: An American Growth Industry," Key Reporter (Phi Beta Kappa), 56 (Spring 1991): 1-5.
16. James M. Gustafson, "Moral Disclosure About Medicine: A Variety of Forms," Journal of Medicine and Philosophy 15 (1990): 127.
17. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (New York: Oxford University Press, 1979;
18. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics 2d ed., 1983;
19. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics 3d ed., 1989;
20. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics 4th ed., 1994; 5th ed. forthcoming).
21. This phrase was coined by Donald W. Light and Glenn McGee in "On the Social Embeddedness of Bioethics," in Bioethics and Society: Constructing the Ethical Enterprise, ed. Raymond DeVries and Janardan Subedi (Upper Saddle River, N.J.: Prentice Hall, 1998), 2.
22. Daniel Callahan, "When Self-Determination Runs Amok," Hastings Center Report 22 (2) (March-April 1992): 52-55.
23. Ruth Macklin, Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine (New York and Oxford: Oxford University Press, 1999), 243.
24. Ruth Macklin, Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine Ibid., 54.
25. Ruth Macklin, Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine Ibid., 273-274.
26. Ruth Macklin, Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine Ibid., 249-274.
27. Ruth Macklin, Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine Ibid., 274.
28. Daniel Callahan, "Bioethics and the Culture Wars," The Nation (14 April 1997): 24.
29. Letter from Daniel Callahan to Arthur Kleinman, 25 February 1999.
30. Fox and Swazey, "Medical Morality Is Not Bioethics - Medical Ethics in China and the United States," 336, 360.
31. David Mechanic, "Managed Care as a Target of Distrust," Journal of the American Medical Association 277 (22) (11 June 1997): 1810.
32. Renée C. Fox, "More Than Bioethics," Hastings Center Report 28(6) (December 1996): 7.
33. Renée C. Fox, "The Human Condition of Health Professionals," Distinguished Lecturer Series, School of Health Studies, University of New Hampshire, Durham, N.H., 1980, 12.
34. Leon R. Kass, "'I Will Give No Deadly Drug': Why Doctors Must Not Kill," Bulletin of the American College of Surgeons 77 (3) (1992): 6-17.
35. James M. Gustafson, "Professions as 'Callings,'" Social Service Review 56 (4) (December 1982): 514.
36. Dimitri A. Christakis and Chris Feudtner, "Temporary Matters: The Ethical Consequences of Transient Social Relationships in Medical Training," Journal of the American Medical Association 278 (9) (3 September 1997): 743.
37. Leon Kass, "Practicing Ethics: Where's the Action?" Hastings Center Report 20 (1) (January-February 1990): 7.
38. Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (New York: Oxford University Press, 1999).
39. Renée C. Fox, "Training for Uncertainty," in The Student-Physician: Introductory Studies in the Sociology of Medical Education, ed. Robert K. Merton, George Reader, and Patricia L. Kendall (Cambridge, Mass.: Harvard University Press, 1957), 207-241.
40. The discussion of current patterns of medical uncertainty that follows is abstracted from Renée C. Fox, "Medical Uncertainty Revisited," in Handbook of Social Studies in Health and Medicine ed. Gary L. Albrecht, Ray Fitzpatrick, and Susan C. Scrimshaw (London: Sage Publications, forthcoming).
41. The discussion of prognostic uncertainty is based on Nicholas Christakis's book, Death Foretold: Prophecy and Prognosis in Medical Care (Chicago: University of Chicago Press, forthcoming).
42. Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: W. W. Norton & Company, 1998), 718.
43. Harold I. Lief and Renée C. Fox, "Training for 'Detached Concern' in Medical Students," in The Psychological Basis of Medical Practice, ed. Harold I. Lief, Victor F. Lief, and Nina R. Lief (New York: Harper and Row, 1963), 12-35.
44. Fox, The Sociology of Medicine: A Participant Observer's View, 85.
45. My discussion of the problems that American medical schools and academic health centers are presently facing, and the effects they are having on medical education, is deeply indebted to Kenneth M. Ludmerer's book, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, and also to the three-year project (1992-1995) on undergraduate medical education that Judith P. Swazey and I organized and co-directed under the auspices of the Acadia Institute and the Medical College of Pennsylvania.
46. See the report issued by the project, Fulfilling the Mission: Medical Schools and the Education of Medical Students (Philadelphia, Pa.: Medical College of Pennsylvania and Hahnemann University, 1996).
47. Ludmerer, Time to Heal.
48. During the ten-year period covering the academic years 1984-1985 through 1993-1994, there was an overall increase of 53.6 percent in the full-time medical school faculty. The number of medical students decreased by slightly less than 1 percent during that same period (Fulfilling the Mission, 12).
49. In the 1996-1997 academic year, a further 4.5 percent increase in the full-time medical school faculty members occurred. The first-year enrollment of medical students for the class entering in 1996 was 16,905, the lowest since 1990. Barbara Barzansky, Henry S. Jonas, and Sylvia I. Etzel, "Educational Programs in U.S. Medical Schools, 1996-1997," Journal of the American Medical Association 278 (9) (September 1997): 744, 746. In the 1997-1998 academic year, the number of full-time medical faculty increased once again, but this time only 1.2 percent over the previous year, from 95,568 to 96,773. Most of the increase took place in clinical departments; the number of full-time faculty members in the basic science departments remained virtually unchanged.
50. The number of enrolled medical students - 66,748 - also remained relatively constant. Barbara Barzansky, Henry S. Jonas, and Sylvia I. Etzel, "Educational Programs in U.S. Medical Schools, 1997-1998," Journal of the American Medical Association 280 (9) (2 September 1998): 803, 805.
51. Barzansky, Jonas, and Etzel, "Educational Programs in U.S. Medical Schools, 1997-1998," 803.
52. Steven R. Simon et al., "Views of Managed Care: A Survey of Students, Residents, Faculty, and Deans at Medical Schools in the United States," New England Journal of Medicine 340 (25 March 1999): 930.
53. Abigail Zuger, "Are Doctors Losing Touch with Hands-On Medicine?" New York Times, 13 July 1999, F1, F9.
54. Simon et al., "Views of Managed Care," 932-934.
55. Quoted in Cari Coleman, "Medical Schools Training for Reality of Managed Care," Association of American Medical Colleges Reporter 8 (9) (June 1999): 11.