Hundert E M, Douglas-Steele D, Bickel J
Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
Med Educ. 1996 Sep;30(5):353-64. doi: 10.1111/j.1365-2923.1996.tb00847.x.
As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the 'informal curriculum' that is so central to the moral development of medical students and residents. A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting 'the unwritten code' for medical students on a surgical clerkship and the senior residents' informal ways of producing a 'practical ethics of conduct' that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.
随着一些正规的生物伦理学教学在美国医学院校已成为常态，一种趋势已显现出来，即在生物伦理学教育和生物伦理决策中越来越关注背景情况。对经典困境和原则的教科书式知识的关注，正让位于之前的主导地位，以便能更详细地审视医学实际实践中的道德行为。在记录并分析了生物伦理学教育中这一新兴趋势及其在生物伦理学理论与研究中的类似情况之后，我们转向医学教育本身的背景，以超越正规的生物伦理学教学，去关注对医学生和住院医师道德发展至关重要的“非正规课程”。一种定性研究策略正被用于通过分析医学生和住院医师与他们在工作中的朋友及同事就与其职业发展相关问题进行的录音非正规谈话，来研究非正规课程。所呈现的数据记录了外科实习医学生的“不成文规范”以及高年资住院医师形成“实用行为伦理”的非正规方式，这种“实用行为伦理”塑造了对该外科科室中何为良好、熟练及正确行为的理解。恰当行为的观念是如何传达、奖励和约束的，这也揭示了职业行为是如何传授的，从而可以讨论哪些应该保留，哪些应该改变。出现伦理问题的背景情况增进了对医学伦理实践的理解。
