H e a l t h C a r e Po l i c y a n d Q u a l i t y • O p i n i o n Camargo et al. Ethics Education and Radiology
Downloaded from www.ajronline.org by Cochin-Port Royal on 08/23/17 from IP address 193.51.85.197. Copyright ARRS. For personal use only; all rights reserved
Health Care Policy and Quality Opinion
Radiology and Ethics Education Aline Camargo1 Li Liu David M. Yousem Camargo A, Liu L, Yousem DM
OBJECTIVE. The purpose of this study is to assess medical ethics knowledge among trainees and practicing radiologists through an online survey that included questions about the American College of Radiology Code of Ethics and the American Medical Association Code of Medical Ethics. CONCLUSION. Most survey respondents reported that they had never read the American Medical Association Code of Medical Ethics or the American College of Radiology Code of Ethics (77.2% and 67.4% of respondents, respectively). With regard to ethics education during medical school and residency, 57.3% and 70.0% of respondents, respectively, found such education to be insufficient. Medical ethics training should be highlighted during residency, at specialty society meetings, and in journals and online resources for radiologists. n the past 3 decades, the teaching of medical ethics has garnered attention among educators at medical schools [1, 2]. Ethics education plays an essential role in building the professional character and self-understanding of physicians, both of which are fundamental qualities for establishing a safe and high-quality practice. Teaching medical ethics is also justified by the high incidence of ethical misbehavior that leads to disciplinary action, malpractice, insurance fraud, and the loss of physician licenses [3, 4]. On the basis of a review of the literature, we developed a self-administered questionnaire that was made available online through a research platform (Research Core, Qualtrics). On three separate occasions over a 6-week period, a link to the online questionnaire was e-mailed to 1569 radiologists and radiology trainees identified through a search of a database maintained by The Russell H. Morgan Department of Radiology and Radiological Science at Johns Hopkins Medical Institutions for continuing medical education purposes. The link to the questionnaire was also posted on social media sites, such as the Facebook, Twitter, and Instagram accounts of the authors and their institution, and the forums section of the Aunt Minnie website. In addition, the questionnaire was publicized on the Internet blogs of the American College of Radiology (ACR) and the Radiologi-
I
Keywords: ethics, radiology, residency, training DOI:10.2214/AJR.16.17779 Received December 4, 2016; accepted after revision February 1, 2017. D. M. Yousem receives royalty income from Elsevier, personal fees from medicolegal consulting, educational honoraria from the American College of Radiology, and royalty fees from CMEInfo.com, none of which have any bearing on this work. 1
All authors: Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287. Address correspondence to D. M. Yousem ([email protected]).
AJR 2017; 209:640–642 0361–803X/17/2093–640 © American Roentgen Ray Society
640
cal Society of North America. The link remained active between September 17, 2016, and October 31, 2016. A total of 424 radiologists and radiology trainees responded to the survey. The characteristics of the respondents are presented in Table 1. Because the survey allowed respondents to skip questions if they preferred, different numbers of respondents answered each question. Ten questions in the survey tested the respondents’ knowledge regarding the ACR’s Code of Ethics and the Code of Medical Ethics of the American Medical Association (AMA). Table 2 presents the responses for each survey question. Of the 346 respondents, only 10 (2.9%) answered all 10 questions correctly. Table 3 summarizes the survey responses regarding medical ethics education. Most respondents reported that they had never read the AMA Code of Medical Ethics (77.2%) or the ACR Code of Ethics (67.4%). Even though 72.1% of respondents received medical ethics training in medical school, they thought that their ethics education was not sufficient during medical school (196 respondents [57.3%]) and residency (238 respondents [70.0%]). The collected data revealed that 171 respondents (49.4%) do not actively seek to fill such a gap in their education by, for example, following discussions on medical ethics.
AJR:209, September 2017
Ethics Education and Radiology TABLE 1: Characteristics of Survey Respondents
No. (%) of Total No. of Correct Answers Respondents
Value
Ethics Topic (Correct Answer)
46 (33–60)
Charging a separate and distinct fee for the incidental administrative nonmedical service that the physician performs in securing the admission of a patient to a hospital is unethical. (True)
279 (66.3)
421
Male
256 (73.6)
424
92 (26.4)
History, diagnosis, prognosis, and the like acquired during the physician-patient relationship may be disclosed to an insurance company representative. (False)
268 (63.2)
Female
The AMA Code of Medical Ethics directly addresses disclosure of records to data collection companies. (True)
254 (61.5)
413
Payment by or to a physician solely for the referral of a patient is fee splitting. The Code of Medical Ethics of the AMA and the Code of Ethics of the ACR allow this practice, as long as the skills of the physician to whom the patient has been referred are guaranteed. (False)
362 (85.8)
422
Concerning the retention of medical records, the records of any patient covered by Medicare or Medicaid must be kept at least 5 years. (True)
349 (83.3)
419
134 (31.9)
420
Characteristic Age (y), median (IQR) (n = 336) Downloaded from www.ajronline.org by Cochin-Port Royal on 08/23/17 from IP address 193.51.85.197. Copyright ARRS. For personal use only; all rights reserved
TABLE 2: Overall Performance of Respondents
Sex (n = 348)
Years after completing residency, median (IQR) (n = 308)
14 (0–28)
Status (n = 308) Practicing radiologist
220 (71.4)
Trainee
88 (28.6)
Work setting (n = 342) Academic
231 (67.5)
Private practice
57 (16.7)
Hybrida
38 (11.1)
Government
8 (2.3)
Other
8 (2.3)
The Code of Medical Ethics prohibits the physician from accepting any in-kind gift from pharmaceutical, biotechnology, and medical device companies. (False)
415 (98.1)
423
334 (95.4)
Physicians should not recommend that a patient obtain a second opinion because this may harm the patient-physician r elationship. (False) A physician is not allowed to charge a patient for a missed appointment. (False)
293 (69.4)
422
Unethical conduct that violates state licensing provisions should be reported to the state licensing board. (True)
408 (97.6)
418
The AMA Code of Medical Ethics does not address sex d iscrimination in the medical profession. (False)
302 (72.6)
416
Country of practice (n = 350) United States Other
16 (4.6)
Country where medical school was attended (n = 276) United States
226 (81.9)
European countries and Canada
32 (11.6)
Other
18 (6.5)
Country where residency was completed (n = 276) United States
253 (91.7)
European countries and Canada
12 (4.4)
Other
11 (4.0)
Note—Except where otherwise indicated, data are number (%) of survey respondents. IQR = interquartile range. a Academic and private practice.
Previously published research studies showed that knowledge of ethics among residents and the confidence to deal with ethical situations increased when ethics education was included as part of the residency curriculum [5, 6]. Such findings highlight the statement by Perkins that “medical ethics (education) provides the conceptual tools necessary for residents to develop their own ethical decision-making frameworks” [7]. A previous Brazilian study that evaluated medical students revealed that less than onehalf of them considered ethics education in the core curriculum of medical school as instrumental in the formulation of their philosophy regarding ethics, and 41.4% reported that they
Note—AMA = American Medical Association, ACR = American College of Radiology.
had never read the nation-based code of medical ethics [8]. Similarly, we found that only 79 of the respondents (22.8%) had ever read the AMA Code of Medical Ethics, and only 113 (32.6%) had ever read the ACR Code of Ethics. On the basis of data from the ACR, the total number of Internet downloads of the Code of Ethics (including the Bylaws section) was only 723 in the 1-year period between June 1, 2015, and May 31, 2016, after the most recent update of the Code of Ethics occurred (Farmerie S, personal communication, January 26, 2017). Given that the ACR has more than 38,000 members, this finding suggests that if each download was intended for review by a single person, only 1.9% of those 38,000 members have viewed the most recent version of the ACR Code of Ethics. This finding highlights that many physicians do not consider ethics a critical educational subject but, rather, a personal concept based on their own perceptions. The perception that ethics might just be an intrinsic group of values that cannot be learned may justify the lack of interest in the pursuit of ethics knowledge from external sources, as re-
ported in the present study. Another possible explanation may be that respondents did not have an interest in the subject because they think that such educational material will not change their already established conduct and opinions. Our survey touched upon only a few issues associated with medical ethics knowledge. We chose the AMA Code of Medical Ethics as a focus for assessing the ethics knowledge base among our survey respondents because it is widely applied and available. However, every code of ethics has limitations in shaping appropriate responses to ethical dilemmas. Beauchamp and Childress stated, “Theory and principles are only starting points and general guides for the development of norms of appropriate conduct” [9]. Their theory assumed that deontologic absolute principles (i.e., rulesbased ethics) can govern ethical behavior. In contrast, a more pragmatic approach, known as casuistry, involves looking at each case individually and determining whether precedence has been established by similar examples elsewhere in society to determine what should be done. This approach is similar to the use of
AJR:209, September 2017 641
Camargo et al. TABLE 3: Responses to Survey Questions Regarding Medical Ethics Education
Downloaded from www.ajronline.org by Cochin-Port Royal on 08/23/17 from IP address 193.51.85.197. Copyright ARRS. For personal use only; all rights reserved
Ethics Topic
Yes Response
No Response
Total No. of Responses
Have you ever read the AMA Code of Medical Ethics?
79 (22.8)
268 (77.2)
347
Have you ever read the ACR Code of Ethics?
113 (32.6)
234 (67.4)
347
Did you have medical ethics training in medical school?
251 (72.1)
97 (27.9)
348
Do you think your medical ethics training in medical school was sufficient?
146 (42.7)
196 (57.3)
342
Did you have medical ethics training in your residency?
122 (35.1)
226 (64.9)
348
Did you think the medical ethics training in your residency was sufficient?
102 (30.0)
238 (70.0)
340
Do you follow discussions on medical ethics as part of your ongoing education or interest?
175 (50.6)
171 (49.4)
346
Note—Except where otherwise indicated, data are number (%) of responses. AMA = American Medical Association, ACR = American College of Radiology.
case law in the courts or case-based learning in medical education. In The Abuse of Casuistry: a History of Moral Reasoning, Jonsen and Toulmin stated that one should not be wedded to absolute principles (e.g., because two good principles, such as paternalism and individual freedom, often may contradict each other) [10]. They recommended assigning a moral issue to a taxonomy (i.e., a category of principles) and then resolving the dilemma on the basis of examples in that taxonomy that have already been adjudicated [10]. More studies are necessary to understand the current state of ethics education in medical schools and radiology residencies, to improve weaknesses and highlight the importance of the teaching of ethics. On the basis of our survey, we concluded that changes in medical ethics training and education in radiology residencies are required to promote ethical behavior in radiology practice. We recommend the following changes. First, just as the Accreditation Council for Graduate Medical Education added a business principles mandatory requirement to radiology residency education, we believe that a similar number of hours should be required for medical ethics education during residency.
642
Second, the ACR should solicit leaders in thought in this arena to provide an updated online program for radiology trainees and practitioners as part of the offerings of their Radiology Leadership Institute, and this program should be made accessible to all radiologists. Leadership demands ethical behavior. Third, ethics education for practicing radiologists should also be encouraged through the creation of specific materials by radiology subspecialty societies, including seminars at society meetings, with relevant case scenarios included for discussion. Fourth, radiology journals should add medical ethics–oriented articles for the edification of their readership. We believe that these changes in the approach toward medical ethics and its teaching will improve how radiologists deal with ethical situations and therefore will support professional integrity. References
1. Miles SH, Lane LW, Bickel J, Walker RM, Cassel CK. Medical ethics education: coming of age. Acad Med 1989; 64:705–714 2. Veatch RM, Sollitto S. Medical ethics teaching: report of a national medical school survey. JAMA
1976; 235:1030–1033 3. Wolfe SM, Williams C, Zaslow A. Public Citizen’s Health Research Group ranking of the rate of state medical boards’ serious disciplinary actions, 2009–2011. Public Citizen website. www. citizen.org/documents/2034.pdf. Published May 17, 2012. Accessed November 10, 2016 4. Silverberg LI. Survey of medical ethics in American medical schools: a descriptive study. J Am Osteopath Assoc 2000; 100:373–378 5. Sulmasy DP, Marx ES. Ethics education for medical house officers: long-term improvements in knowledge and confidence. J Med Ethics 1997; 23:88–92 6. Sulmasy DP, Geller G, Levine DM, Faden RR. A randomized trial of ethics education for medical house officers. J Med Ethics 1993; 19:157–163 7. Perkins HS. Teaching medical ethics during residency. Acad Med 1989; 64:262–266 8. Camargo A, de Almeida MAS, Morita I. Ethics and bioethics: what sixth year medical students have to say. Rev Bras Educ Med 2014; 38:182–189 9. Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed. New York: Oxford University Press, 2001:1–25 10. Jonsen AR, Toulmin S. The abuse of casuistry: a history of moral reasoning. Berkeley, CA: University of California Press, 1988
AJR:209, September 2017
Downloaded from www.ajronline.org by Cochin-Port Royal on 08/23/17 from IP address 193.51.85.197. Copyright ARRS. For personal use only; all rights reserved
Health Care Policy and Quality Opinion
Radiology and Ethics Education Aline Camargo1 Li Liu David M. Yousem Camargo A, Liu L, Yousem DM
OBJECTIVE. The purpose of this study is to assess medical ethics knowledge among trainees and practicing radiologists through an online survey that included questions about the American College of Radiology Code of Ethics and the American Medical Association Code of Medical Ethics. CONCLUSION. Most survey respondents reported that they had never read the American Medical Association Code of Medical Ethics or the American College of Radiology Code of Ethics (77.2% and 67.4% of respondents, respectively). With regard to ethics education during medical school and residency, 57.3% and 70.0% of respondents, respectively, found such education to be insufficient. Medical ethics training should be highlighted during residency, at specialty society meetings, and in journals and online resources for radiologists. n the past 3 decades, the teaching of medical ethics has garnered attention among educators at medical schools [1, 2]. Ethics education plays an essential role in building the professional character and self-understanding of physicians, both of which are fundamental qualities for establishing a safe and high-quality practice. Teaching medical ethics is also justified by the high incidence of ethical misbehavior that leads to disciplinary action, malpractice, insurance fraud, and the loss of physician licenses [3, 4]. On the basis of a review of the literature, we developed a self-administered questionnaire that was made available online through a research platform (Research Core, Qualtrics). On three separate occasions over a 6-week period, a link to the online questionnaire was e-mailed to 1569 radiologists and radiology trainees identified through a search of a database maintained by The Russell H. Morgan Department of Radiology and Radiological Science at Johns Hopkins Medical Institutions for continuing medical education purposes. The link to the questionnaire was also posted on social media sites, such as the Facebook, Twitter, and Instagram accounts of the authors and their institution, and the forums section of the Aunt Minnie website. In addition, the questionnaire was publicized on the Internet blogs of the American College of Radiology (ACR) and the Radiologi-
I
Keywords: ethics, radiology, residency, training DOI:10.2214/AJR.16.17779 Received December 4, 2016; accepted after revision February 1, 2017. D. M. Yousem receives royalty income from Elsevier, personal fees from medicolegal consulting, educational honoraria from the American College of Radiology, and royalty fees from CMEInfo.com, none of which have any bearing on this work. 1
All authors: Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287. Address correspondence to D. M. Yousem ([email protected]).
AJR 2017; 209:640–642 0361–803X/17/2093–640 © American Roentgen Ray Society
640
cal Society of North America. The link remained active between September 17, 2016, and October 31, 2016. A total of 424 radiologists and radiology trainees responded to the survey. The characteristics of the respondents are presented in Table 1. Because the survey allowed respondents to skip questions if they preferred, different numbers of respondents answered each question. Ten questions in the survey tested the respondents’ knowledge regarding the ACR’s Code of Ethics and the Code of Medical Ethics of the American Medical Association (AMA). Table 2 presents the responses for each survey question. Of the 346 respondents, only 10 (2.9%) answered all 10 questions correctly. Table 3 summarizes the survey responses regarding medical ethics education. Most respondents reported that they had never read the AMA Code of Medical Ethics (77.2%) or the ACR Code of Ethics (67.4%). Even though 72.1% of respondents received medical ethics training in medical school, they thought that their ethics education was not sufficient during medical school (196 respondents [57.3%]) and residency (238 respondents [70.0%]). The collected data revealed that 171 respondents (49.4%) do not actively seek to fill such a gap in their education by, for example, following discussions on medical ethics.
AJR:209, September 2017
Ethics Education and Radiology TABLE 1: Characteristics of Survey Respondents
No. (%) of Total No. of Correct Answers Respondents
Value
Ethics Topic (Correct Answer)
46 (33–60)
Charging a separate and distinct fee for the incidental administrative nonmedical service that the physician performs in securing the admission of a patient to a hospital is unethical. (True)
279 (66.3)
421
Male
256 (73.6)
424
92 (26.4)
History, diagnosis, prognosis, and the like acquired during the physician-patient relationship may be disclosed to an insurance company representative. (False)
268 (63.2)
Female
The AMA Code of Medical Ethics directly addresses disclosure of records to data collection companies. (True)
254 (61.5)
413
Payment by or to a physician solely for the referral of a patient is fee splitting. The Code of Medical Ethics of the AMA and the Code of Ethics of the ACR allow this practice, as long as the skills of the physician to whom the patient has been referred are guaranteed. (False)
362 (85.8)
422
Concerning the retention of medical records, the records of any patient covered by Medicare or Medicaid must be kept at least 5 years. (True)
349 (83.3)
419
134 (31.9)
420
Characteristic Age (y), median (IQR) (n = 336) Downloaded from www.ajronline.org by Cochin-Port Royal on 08/23/17 from IP address 193.51.85.197. Copyright ARRS. For personal use only; all rights reserved
TABLE 2: Overall Performance of Respondents
Sex (n = 348)
Years after completing residency, median (IQR) (n = 308)
14 (0–28)
Status (n = 308) Practicing radiologist
220 (71.4)
Trainee
88 (28.6)
Work setting (n = 342) Academic
231 (67.5)
Private practice
57 (16.7)
Hybrida
38 (11.1)
Government
8 (2.3)
Other
8 (2.3)
The Code of Medical Ethics prohibits the physician from accepting any in-kind gift from pharmaceutical, biotechnology, and medical device companies. (False)
415 (98.1)
423
334 (95.4)
Physicians should not recommend that a patient obtain a second opinion because this may harm the patient-physician r elationship. (False) A physician is not allowed to charge a patient for a missed appointment. (False)
293 (69.4)
422
Unethical conduct that violates state licensing provisions should be reported to the state licensing board. (True)
408 (97.6)
418
The AMA Code of Medical Ethics does not address sex d iscrimination in the medical profession. (False)
302 (72.6)
416
Country of practice (n = 350) United States Other
16 (4.6)
Country where medical school was attended (n = 276) United States
226 (81.9)
European countries and Canada
32 (11.6)
Other
18 (6.5)
Country where residency was completed (n = 276) United States
253 (91.7)
European countries and Canada
12 (4.4)
Other
11 (4.0)
Note—Except where otherwise indicated, data are number (%) of survey respondents. IQR = interquartile range. a Academic and private practice.
Previously published research studies showed that knowledge of ethics among residents and the confidence to deal with ethical situations increased when ethics education was included as part of the residency curriculum [5, 6]. Such findings highlight the statement by Perkins that “medical ethics (education) provides the conceptual tools necessary for residents to develop their own ethical decision-making frameworks” [7]. A previous Brazilian study that evaluated medical students revealed that less than onehalf of them considered ethics education in the core curriculum of medical school as instrumental in the formulation of their philosophy regarding ethics, and 41.4% reported that they
Note—AMA = American Medical Association, ACR = American College of Radiology.
had never read the nation-based code of medical ethics [8]. Similarly, we found that only 79 of the respondents (22.8%) had ever read the AMA Code of Medical Ethics, and only 113 (32.6%) had ever read the ACR Code of Ethics. On the basis of data from the ACR, the total number of Internet downloads of the Code of Ethics (including the Bylaws section) was only 723 in the 1-year period between June 1, 2015, and May 31, 2016, after the most recent update of the Code of Ethics occurred (Farmerie S, personal communication, January 26, 2017). Given that the ACR has more than 38,000 members, this finding suggests that if each download was intended for review by a single person, only 1.9% of those 38,000 members have viewed the most recent version of the ACR Code of Ethics. This finding highlights that many physicians do not consider ethics a critical educational subject but, rather, a personal concept based on their own perceptions. The perception that ethics might just be an intrinsic group of values that cannot be learned may justify the lack of interest in the pursuit of ethics knowledge from external sources, as re-
ported in the present study. Another possible explanation may be that respondents did not have an interest in the subject because they think that such educational material will not change their already established conduct and opinions. Our survey touched upon only a few issues associated with medical ethics knowledge. We chose the AMA Code of Medical Ethics as a focus for assessing the ethics knowledge base among our survey respondents because it is widely applied and available. However, every code of ethics has limitations in shaping appropriate responses to ethical dilemmas. Beauchamp and Childress stated, “Theory and principles are only starting points and general guides for the development of norms of appropriate conduct” [9]. Their theory assumed that deontologic absolute principles (i.e., rulesbased ethics) can govern ethical behavior. In contrast, a more pragmatic approach, known as casuistry, involves looking at each case individually and determining whether precedence has been established by similar examples elsewhere in society to determine what should be done. This approach is similar to the use of
AJR:209, September 2017 641
Camargo et al. TABLE 3: Responses to Survey Questions Regarding Medical Ethics Education
Downloaded from www.ajronline.org by Cochin-Port Royal on 08/23/17 from IP address 193.51.85.197. Copyright ARRS. For personal use only; all rights reserved
Ethics Topic
Yes Response
No Response
Total No. of Responses
Have you ever read the AMA Code of Medical Ethics?
79 (22.8)
268 (77.2)
347
Have you ever read the ACR Code of Ethics?
113 (32.6)
234 (67.4)
347
Did you have medical ethics training in medical school?
251 (72.1)
97 (27.9)
348
Do you think your medical ethics training in medical school was sufficient?
146 (42.7)
196 (57.3)
342
Did you have medical ethics training in your residency?
122 (35.1)
226 (64.9)
348
Did you think the medical ethics training in your residency was sufficient?
102 (30.0)
238 (70.0)
340
Do you follow discussions on medical ethics as part of your ongoing education or interest?
175 (50.6)
171 (49.4)
346
Note—Except where otherwise indicated, data are number (%) of responses. AMA = American Medical Association, ACR = American College of Radiology.
case law in the courts or case-based learning in medical education. In The Abuse of Casuistry: a History of Moral Reasoning, Jonsen and Toulmin stated that one should not be wedded to absolute principles (e.g., because two good principles, such as paternalism and individual freedom, often may contradict each other) [10]. They recommended assigning a moral issue to a taxonomy (i.e., a category of principles) and then resolving the dilemma on the basis of examples in that taxonomy that have already been adjudicated [10]. More studies are necessary to understand the current state of ethics education in medical schools and radiology residencies, to improve weaknesses and highlight the importance of the teaching of ethics. On the basis of our survey, we concluded that changes in medical ethics training and education in radiology residencies are required to promote ethical behavior in radiology practice. We recommend the following changes. First, just as the Accreditation Council for Graduate Medical Education added a business principles mandatory requirement to radiology residency education, we believe that a similar number of hours should be required for medical ethics education during residency.
642
Second, the ACR should solicit leaders in thought in this arena to provide an updated online program for radiology trainees and practitioners as part of the offerings of their Radiology Leadership Institute, and this program should be made accessible to all radiologists. Leadership demands ethical behavior. Third, ethics education for practicing radiologists should also be encouraged through the creation of specific materials by radiology subspecialty societies, including seminars at society meetings, with relevant case scenarios included for discussion. Fourth, radiology journals should add medical ethics–oriented articles for the edification of their readership. We believe that these changes in the approach toward medical ethics and its teaching will improve how radiologists deal with ethical situations and therefore will support professional integrity. References
1. Miles SH, Lane LW, Bickel J, Walker RM, Cassel CK. Medical ethics education: coming of age. Acad Med 1989; 64:705–714 2. Veatch RM, Sollitto S. Medical ethics teaching: report of a national medical school survey. JAMA
1976; 235:1030–1033 3. Wolfe SM, Williams C, Zaslow A. Public Citizen’s Health Research Group ranking of the rate of state medical boards’ serious disciplinary actions, 2009–2011. Public Citizen website. www. citizen.org/documents/2034.pdf. Published May 17, 2012. Accessed November 10, 2016 4. Silverberg LI. Survey of medical ethics in American medical schools: a descriptive study. J Am Osteopath Assoc 2000; 100:373–378 5. Sulmasy DP, Marx ES. Ethics education for medical house officers: long-term improvements in knowledge and confidence. J Med Ethics 1997; 23:88–92 6. Sulmasy DP, Geller G, Levine DM, Faden RR. A randomized trial of ethics education for medical house officers. J Med Ethics 1993; 19:157–163 7. Perkins HS. Teaching medical ethics during residency. Acad Med 1989; 64:262–266 8. Camargo A, de Almeida MAS, Morita I. Ethics and bioethics: what sixth year medical students have to say. Rev Bras Educ Med 2014; 38:182–189 9. Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed. New York: Oxford University Press, 2001:1–25 10. Jonsen AR, Toulmin S. The abuse of casuistry: a history of moral reasoning. Berkeley, CA: University of California Press, 1988
AJR:209, September 2017
