Historians of the future tracking the development of bioethics will note that the debates and arguments that have most engaged bioethicists thus far have been directed toward addressing the dilemmas attending physicians face as they interact with patients in the clinical setting. This is only to be expected, given the circumstances that gave birth to this burgeoning field. The preoccupation with clinical questions has, however, had an unfortunate consequence. Less examined by bioethicists are the significant behind-the-scenes ethical issues generated by, and specific to, the years of undergraduate and postgraduate medical training.

Ten years ago there was little talk about adding “professionalism” to the medical curriculum. Educators seemed to believe that professionalism was like the studs of a building—the occupants assume them to be present, supporting and defining the space in which they live or work, but no one talks much about them. Similarly, educators assumed that professional values would just “happen,” as trainees spent years working with mentors and role models, as had presumably been the case in the past. To continue the metaphor, when educators did discuss ethics and values, they tended to focus more on external building codes than on the nature of construction materials. Building codes are designed to ensure the public's safety by establishing procedures and standards. Likewise, the “new” bioethics of autonomy and informed consent that entered the medical curriculum in the 1970s and 1980s was oriented primarily toward protecting human rights (e.g., protecting patients from clinicians and clinicians from patients) by codification (e.g., who should decide and under what circumstances). In fact, educators explicitly warned students against acting on their personal or professional values in a misguided way—that is, in the absence of adequate ethical constraints, a type of behavior that came to be labeled, pejoratively, as paternalism.

Robert Coles' sentiment characterizes well the moral tenor of medical education today. Indeed, medical educators are frequently “seized by spasms of genuine moral awareness,” as they try to cope with the massive social and economic problems that face medical schools and teaching hospitals. The perception among educators that we currently fail to adequately teach several core aspects of doctoring, including professional values and behavior, constitutes one such spasm. In this case, the proposed remedy has generated considerable enthusiasm, but whether the “core competencies” curriculum will make a difference, or simply “accommodate to the prevailing rhythms of the world we inhabit,” remains to be seen.

Over the past 15 years, medical schools have paid some attention to the importance of developing students' communication skills as part of their medical education. Over the past decade, medical ethics has been added to the curriculum of most U.S. medical schools, at least on paper. More recently, there has been growing discussion of the importance of professionalism in medical education. Yet, the nature and content of these fields and their relationship to one another remains confused and vague, and that lack of clarity, in turn, impairs the effectiveness of medical education. This ambiguity invites serious contention over who should design and teach the curriculum as well as when, where, and how it should be taught.

High moral standards and adherence to a moral code have long been strong tenets of the profession of medicine, even though there have been occasional lapses that have led to renewed calls for a revitalization of moral integrity in medicine. Certainly, a moral component has generally been held to be an important aspect of the concept of a physician.

Given the money, prestige and power at stake in high-level sports, ethical lapses are hardly surprising. Nor are the rules, people, and organizations we entrust to punish infractions and ensure fair play. Similarly, the high stakes involved in medical education invite ethical slips. Yet, there are not only few referees in this all-important “game,” but also the subject itself has been almost entirely off-limits in the academic literature.

Medical residency—specialty training after the completion of medical school—is an essential component of medical education and is required in order to be a licensed, independent medical practitioner in most jurisdictions. As things currently stand in the United States, the match between medical school graduates and residency programs is governed by a match between rank-order lists prepared by candidates and residencies alike. An applicant picks a number of residency programs and ranks them according to order of interest. The residency program prepares a similar list, ranking the candidates it most wants in its program. A computer program compares the rankings and makes assignments according to a certain algorithm. Using these lists, the match system assigns approximately 24,000 applicants to approximately 21,000 training positions in pediatrics, obstetrics and gynecology, internal medicine, and the rest. These assignments are then announced to all parties on specific days. The system has been in place since 1952 and is overseen by the National Residency Match Program (NRMP), a nonprofit organization. This system has several advantages. First of all, it standardizes the timetable for decisions, and applicants are in no position to tie up offers while waiting to hear from other institutions. Institutions are not held captive, either, in making assignments while waiting to hear from particular parties.

In April of 2001 I published a brief commentary in the journal Academic Medicine questioning the current character and functioning of the National Residency Matching Program (or “the match,” as it is known in medical schools and teaching centers). The purpose of the article was to stimulate a rethinking of process. At 50 years old, the environment through which the match operates (and has helped to create) has changed, and as such I thought it time to ask ourselves whether or not the match, its algorithm, and, more important, the values it manifests might well need an overhaul.

Residents in long-term care facilities and rehab hospitals sometimes ask healthcare professionals (HCPs) to help them do things that HCPs judge to be on balance harmful. A person with respiratory problems may ask for a cigarette, a diabetic for alcohol, a dysphagiac for food or fluids by mouth, a person at risk for falling for her walker, and so on. These requests raise two kinds of problems. The first pits residents against HCPs. Should HCPs ever help residents do what they consider harmful? The second pits HCPs against HCPs. If HCPs disagree among themselves—some thinking that the resident should receive the assistance, others thinking not—what should be done?

Workplace bullying has been recognized as a major occupational stressor since the mid 1980s. A number of different terms have been used to describe it, including employee abuse, emotional abuse, mistreatment and neglect at work, mobbing, and harassment. In the United Kingdom, a number of reports from trades unions illustrating the pain, psychological distress, physical illness, and career damage suffered by the victims of bullying first drew attention to the issue. However, academic interest in the issue began only recently, and there are still few empirical studies. The most systematic research comes from Scandinavia, where there is strong public awareness and antibullying legislation.

Ethicists in American medical schools feel increasingly discouraged these days. In the 1960s, 1970s, and 1980s, society's enthusiasm for teaching about medical ethics flourished as new medical technologies posed new ethical perplexities. Americans eagerly sought ethics advice and looked to medical schools to provide it. As the sites where many of the new technologies were developed and future physicians were trained, medical schools were the logical place for medical ethicists to work and teach. A few schools recognized society's need and instituted explicit medical ethics teaching—allocating funds, hiring ethicists, creating departments, and trumpeting their accomplishments. But most schools responded to the need with indifference or even hostility. They distrusted outside “experts” and feared a zealous reform movement aimed at the character or practices of modern medicine. Yet even those schools were forced to create ethics programs to meet powerful accreditation requirements adopted around 1990. Complying reluctantly, these schools allocated few personnel and minimal budgets. The resulting programs struggled.

These CQ Sources were compiled by Bette Anton.

In their recent article, Glannon and Ross remind us that family members have obligations to help each other that strangers do not have. They argue, I believe correctly, that what creates moral obligations within families is not genetic relationship but rather a sharing of intimacy. For no one are these obligations stronger than they are for parents of young children. This observation leads the authors to the logical conclusion that organ donation by a parent to her child is not optional but rather a prima facie duty. However, Glannon and Ross go a step further by suggesting that because parent-to-child organ donation is a duty, it cannot be altruistic. They assert that “altruistic acts are optional, nonobligatory…supererogatory…. Given that altruism consists in purely optional actions presupposing no duty to aid others, any parental act that counts as meeting a child's needs cannot be altruistic.” Here I think the authors go too far.

It is inevitable that physicians in training will be exposed to behavior by supervising physicians that the trainees find unethical. By nature these events are rare. It is imperative within any residency training program that resident physicians have immediate access to a meaningful review process in cases of moral conflict with supervising physicians. Here, I discuss the reasons why this issue must be recognized and what it entails. Most important, I discuss the procedural steps that are essential for the training program to make this a meaningful safety mechanism in residency training. This issue is central to promoting conscious development of professionalism in clinical training. Physicians in training, especially resident physicians, need to be taught to value and protect their own professional integrity. The responsibility for fulfilling this ethical duty falls on the individual residency programs as well as the administrative organizations that regulate residency training. Thus, ensuring this process of review is an organizational ethical imperative. Availability of this process is fundamental to promoting and ensuring ethical behavior by all participants in residency training.

I am an M.D/Ph.D. student and work as a research assistant for the director of a division of the school of medicine who is an M.D. He assigned me to research a certain topic and gave me no guidelines or guidance as to how to do it. Nevertheless, I did the research and wrote it up. My supervisor liked the report and said that he thought it was so good that “I would like to offer you the opportunity to publish it and list you as the primary author.” Some bells went off when he so grandly offered to let me author the report for which I had done 100% of research and writing. I consulted some other people in the field and they said that, as long as I was the primary author, it was legitimate for him to list himself as secondary author if he did some editing later. After editing the abstract only, he e-mailed his revisions to me and in a note at the bottom he asked me what I thought of his revised author order. His name was first, mine second, and the name of his girlfriend (who had no part in this research or its revision) was third. I was shocked by what seemed to be a case of unethical author attribution and confronted him asking why he changed the order when we had agreed that I was primary author. He said that he had put in several hours of work.

Jennifer Radden's subtitle nicely summarizes the set of concerns that animate this rich and provocative book. Radden's aims are at once conceptual and normative. What degree of continuity (over time) or unity (at a time) do selves or persons really possess? And how ought healthcare professionals and others deal with individuals whose selves become “fragmented” or “divided” in various ways? Radden's analysis blends theoretical investigations in the philosophy of mind and metaphysics with key findings in abnormal psychology and psychotherapy to illuminate a nest of issues: Can we legitimately speak of one body housing or supporting more than one “person”? To what extent does our normatively charged notion of “person” presuppose a self that is integrated by continuities of memory, experience, and agency? Must legal conceptions of individual responsibility for civil or criminal wrongs be construed to require a continuous and unified “self” who is accountable? Are paternalistically motivated therapeutic interventions justifiable when dealing with dissociative-identity disorder on the grounds that they protect one “self” from another? Ought psychiatric advance directives be enforceable? What should be the normative goals of therapeutic practice with regard to individuals whose selves are fragmented?

Dr. Jodi Halpern has written a remarkable book articulating a view of clinical empathy that has practical and philosophical implications for all helping professionals, as well as for normative and relational ethics within the helping professions. Dr. Halpern first carefully deconstructs a detached insight view of empathy (an intellectualist view) and empathy as sympathetic merger between two persons.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.