Volume 175 Issue 4

Medicine and the Community The physical, sexual and emotional violence history of middle-aged women: a community-based prevalence study Danielle Mazza, Lorraine Dennerstein, Corrine V Garamszegi and Emma C Dudley MJA 2001; 175: 199-201 Abstract - Methods - Questionnaire - Study participants - Statistical analysis - Results - Domestic violence - Unwanted sexual experiences with someone other than a husband or partner - Childhood abuse - Discussion - Acknowledgement - Reference - Authors' details - - More articles on Obstetrics & gynaecology and women's health - More articles on Social issues Abstract Objectives: To determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and compare these to figures obtained in a general practice setting. Design and methods: This research was part of the Melbourne Women's Midlife Health Project (MWMHP), an observational, longitudinal, population-based study of 438 Australian-born women conducted over nine years. In 1996, during the sixth year of the study, we asked the MWMHP participants to complete a self-administered "violence questionnaire", incorporating a modified Conflict Tactics Scale and questions on sexual abuse experienced during childhood and adult life. Results: Of the 395 women remaining in the sixth year of follow-up of the MWMHP, 362 (92%) completed the questionnaire. Overall, 28.5% (n = 101) of the women had experienced some form of domestic violence (physical, sexual or emotional) during their lifetime; 5.5% (n = 15) of women had experienced severe physical abuse in the past year at the hands of a partner; and 11.8% (n = 42) of the women had experienced rape or attempted rape between the age of 16 and the time of our survey. Regarding abuse in childhood, 8.9% (n = 32) of women had experienced physical abuse, 42.3% (n = 152) had experienced non-contact sexual abuse, and 35.7% (n = 128) contact sexual abuse. Compared with the general-practice-based study, rates of childhood physical abuse and penetrative sexual abuse were similar, but rates of less intrusive child sexual abuse were significantly higher in our study. Conclusions: Doctors in all areas of medicine who are dealing with middle-aged women need to be aware of the levels of violence sustained by women throughout their lives. Such experiences may have a substantial impact on women's physical and mental wellbeing. Over the past 20 years, the high prevalence of violence against women has been exposed by rigorous research. Women's Safety Australia,1 a large community-based survey of 6300 women undertaken by the Australian Bureau of Statistics, found that 2.6% of women who currently had partners had experienced an incident of physical violence in the previous 12-month period; 8.0% reported an incident of physical violence at some time during their current relationship; and 1.9% of women had experienced an incident of sexual violence during the 12 months prior to the survey. Mazza and colleagues2 examined the prevalence of physical, sexual and emotional violence experienced by women attending general practitioners in metropolitan Melbourne. Their study found that, of women aged 18 years and over who were in relationships, more than a quarter had been victims of physical or emotional abuse by a partner in the previous year, with one in 10 experiencing severe physical violence. In two Australian studies undertaken in hospital emergency departments,3,4 about 19% of female attendees disclosed histories of domestic violence. It is now recognised that domestic violence has an important influence on the morbidity and mortality of women. Increased utilisation of healthcare facilities,5 chronic pain (particularly pelvic pain),6,7 functional gastrointestinal disorders,8 drug and alcohol dependence or misuse,9-11 attempted suicide11 and psychopathology12-14 are all strongly associated with the experience of violence. The aims of our study were to determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and to compare these to figures obtained in a general practice setting in a previous study.2 Methods Questionnaire The "violence questionnaire" that was handed to participants for self-completion was the same as that used in a prevalence study of domestic violence experienced by women attending general practices in Melbourne,2 with which we wanted to compare our study data. The questionnaire incorporated the Conflict Tactics Scale,15 with the modification that respondents were asked whether the tactic had occurred never, once or more than once in the past year, and with the addition of questions on emotional abuse. Physical violence was classified as minor or severe.2 Questions about sexual abuse were derived from the studies of Wyatt16 and Russell,17 both of which used multiple screening questions to allow time for the respondent to become accustomed to the nature of the questions. Childhood sexual abuse was classified as "contact" abuse (involving physical contact) or "non-contact" abuse. (For the purposes of our study, a "child" was defined as a person under 16 years of age.) Study participants The subjects of our study were participants in the sixth year of the Melbourne Women's Midlife Health Project (MWMHP),18 a longitudinal study of a community-based cohort of Australian-born women aged 45-55 years at the beginning of the study. An initial cross-sectional study undertaken in 1991 of a randomly selected community-based sample of 2001 women gathered baseline information regarding women's health experiences and variables related to these experiences.19 The MWMHP study was approved by the Human Research Ethics Committee of the University of Melbourne. Eligibility for the longitudinal phase of the study included women who at baseline were premenopausal, were not taking the oral contraceptive pill or hormone therapy, and had an intact uterus. Of the 779 women eligible to enter the longitudinal study, 56% (n=438) chose to do so. Volunteers for the longitudinal study were more likely than non-participants to report better self-rated health, paid employment, more than 12 years of education, having ever had a Pap smear, exercising at least once a week, and having undergone dilatation and curettage.19 In the MWMHP study, women were interviewed annually face-to-face in their own homes by trained interviewers. Information was collected on a range of variables, including sociodemographic factors, health status, lifestyle behaviours, menopausal status and hormone therapy use. By 1996, when our study was conducted, the retention rate of MWMHP participants was 90% (n = 395). Of these women, 23 who had experienced surgical menopause were not given the violence questionnaire, and a further 10 women refused to complete the questionnaire, leaving 362 women who took part in our study. Statistical analysis The Statistical Package for the Social Sciences (SPSS)20 was used to analyse the sample and determine the prevalence of different forms of violence reported by the women. A statistical comparison was made between the results of our study and the data (previously unpublished) for the subset of women aged 50-69 years (n = 411) from an earlier, general-practice-based study of violence2(Box 1). Ninety-five per cent approximate confidence intervals were used. Results Of the 362 questionnaires available, there were missing data for eight women who did not answer questions on adult violence, four who did not complete the adult sexual abuse questions, and four who did not answer either one or more questions on childhood violence. At the time of completing the violence questionnaire the women were between 51 and 62 years of age (mean, 54.6; SD, 2.42). Sixty-six per cent (238/362) were in paid employment and 77% (277/362) were married or living with a partner. The median parity was 3 (range, 0-9), and 35% of the women had had more than 12 years' education. Domestic violence Overall, 28.5% (101/354) of the women in our study had experienced some form of physical or emotional violence over their lifetime (Box 2). A comparison between our sample and the general-practice-based sample with regard to prevalence of violence experienced in the past year is shown in Box 1. Unwanted sexual experiences with someone other than a husband or partner Overall, 40.8% (146/358) of respondents had, between the age of 16 years and the present, experienced either unwanted sexual advances or been in a situation in which the threat of sexual assault was associated with violence or threat of violence. This included one or more of the following: experiencing rape or attempted rape; encountering sexual advances from someone in authority; or narrowly missing being sexually assaulted. A comparison between the responses in our study and the general practice study is shown in Box 1. Childhood abuse Childhood physical abuse had been experienced by 8.9% (32/358) of the women in our study, and more than one in three women had experienced some form of childhood sexual abuse. Our study showed similar levels of physical abuse and penetrative sexual abuse in childhood, but significantly higher levels of less intrusive child sexual abuse, compared with the general practice sample (Box 1). Discussion Using a longitudinal cohort study such as the MWMHP provides many benefits in a prevalence study. Principal among these is that the women surveyed have been interacting with the research staff for over six years and have therefore built up a degree of trust and comfort with these people. This may facilitate disclosure of sensitive issues such as domestic violence and sexual abuse. A limitation of the study is that in order to obtain some comparative value with other work the questions were delivered by self-administered questionnaire, allowing no opportunity for clarification or exploration of the issues being recorded. Also, the additional questions about emotional abuse had not previously been validated. Of interest is the fact that, despite the participants being a self-selected group of relatively well-educated and health-conscious women, there is a considerable lifetime prevalence of domestic violence among them. The fact that our community-based survey results were similar to those of the general-practice-based survey2 confirms that violence affects the lives of all kinds of women and that it may be a very important contributor to concurrent morbidity occurring at the menopause. In the area of child abuse, our data show similar levels of physical abuse and penetrative abuse but significantly greater levels of less intrusive sexual abuse than those found in the general practice sample. This is surprising given that prevalence rates of most forms of abuse are usually lower in community-based settings than in general practice.2 The greater levels in our sample may reflect a cohort effect or may be owing to the long-term relationship developed over six years of follow-up that may have led to more disclosures. Many studies have demonstrated a relationship between experience of violence and long-term morbidity. Our findings of a high prevalence of violence experienced by women over their lifetime suggest that doctors practising in all areas of medicine need to recognise and explore violence issues when considering middle-aged women's reasons for presenting with ill health. Acknowledgement This study was funded by the National Health and Medical Research Council, the Victorian Health Promotion Foundation, and the Australasian Menopause Society. References Australian Bureau of Statistics. Women's Safety Australia 1996, Canberra: ABS, 1996. (Catalogue No. 4128.0.) Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. de Vries Robbe M, March L, Vinen J, et al. Prevalence of domestic violence among patients attending a hospital emergency department. Aust N Z J Public Health 1996; 20(4): 364-368. Roberts GL, O'Toole BI, Lawrence JM, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1993; 159: 307-310. Stark E, Flitcraft A, Zuckerman D, et al. Wife abuse in the medical setting: an introduction for health personnel. Monograph No. 7. Rockville, Maryland: National Clearinghouse on Domestic Violence, 1981. Schei B. Psycho-social factors in pelvic pain. A controlled study of women living in physically abusive relationships. Acta Obstet Gynecol Scand 1990; 69(1): 67-71. Walling MK, Recter RC, O'Hara MW, et al. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994; 84(2): 193-199. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1990; 113(11): 828-833. Burnam MA, Stein JA, Golding JM, et al. Sexual assault and mental disorders in a community population. J Consult Clin Psychol 1988; 56: 843-850. Winfield I, George LK, Swartz M, Blazer DG. Sexual assault and psychiatric disorders among a community sample of women. Am J Psychol 1990; 147: 335-341. McCauley J, Kern DE, Kolodner K, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123(10): 737-746. Gleason WJ. Mental disorders in battered women: an empirical study. Violence Vict 1993; 8(1): 53-68. Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women's mental health. Lancet 1988; 1: 841-845. Beitchman JH, Zucker KJ, Hood JE, et al. A review of the long-term effects of child sexual abuse. Child Abuse Negl 1992; 16: 101-118. Straus MA. Measuring intrafamily conflict and violence: the conflict tactics (CT) scales. J Marriage Fam 1979; 41(1): 75-88. Wyatt GE. The sexual abuse of Afro-American and white-American women in childhood. Child Abuse Negl 1985; 9: 507-519. Russell DEH. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl 1983; 7: 133-146. Dennerstein L, Smith A, Morse C, et al. Menopausal symptoms in Australian women. Med J Aust 1993; 159: 232-236. Burger HG, Dudley EC, Hopper JL, et al. The endocrinology of the menopausal transition: a cross-sectional study of a population-based sample. J Clin Endocrinol Metab 1995; 80(12): 3537-3545. SPSS for Windows. Statistical package for social sciences. Version 9.0. Chicago, Ill: SPSS Inc, 1999. (Received 2 Mar 2000, accepted 29 Mar 2001) Authors' details Office for Gender and Health, Department of Psychiatry, University of Melbourne, VIC. Danielle Mazza, MD, FRACGP, Research Fellow; Lorraine Dennerstein, AO, PhD, FRANZCP, Director; Corrine V Garamszegi, MWH, SRN, Research Assistant; Emma C Dudley, BSc(Hons), GradDip Epidemiol, Research Fellow. Reprints will not be available from the authors. Correspondence: Professor L Dennerstein, Office for Gender and Health, Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Charles Connibere Building, Parkville, VIC 3050. ldennATunimelb.edu.au Make a comment 1: Number of women experiencing various types of violence among MWMHP* participants compared with the number of women aged 50-69 years reporting these experiences in a general practice setting† Type of abuse MWMHP study (%) General practice study (%) Difference in prevalence between the 2 studies (95% CI) P Adult experience of violence Overall physical and/or emotional abuse by partner in the past year 57 (20.9%) 80 (29.6%) -8.7% (-16.0%, -1.4%) Minor physical abuse by partner in the past year 46 (16.9%) 61 (22.8%) -5.9% (-12.6%, +0.8%) 0.088 Severe physical abuse by partner in the past year 15 (5.5%) 18 (6.7%) -1.2% (-5.2%, +2.8%) 0.550 Emotional abuse by partner in the past year 31 (11.3%) 54 (20.0%) -8.7% (-14.8%, -2.6%) All forms of sexual assault between 16 years of age and the present 146 (40.8%) 135 (33.3%) +7.5% (+0.6%, +14.4%) Unwanted sexual experience between 16 years of age and the present 85 (23.7%) 79 (19.8%) +3.9% (-2.0%, +9.8%) 0.189 Rape or attempted rape between 16 years of age and the present 42 (11.8%) 43 (10.7%) +1.1% (-3.4%, +5.6%) 0.640 Childhood experience of violence Physical abuse 32 (8.9%) 34 (8.6%) +0.3% (-3.7%, +4.3%) 0.856 Non-contact sexual abuse 152 (42.3%) 103 (25.5%) +16.8% (+10.2%, +23.4%) Contact sexual abuse 128 (35.7%) 110 (27.2%) +8.5% (+1.9%, +15.1%) Penetrative sexual abuse 24 (6.7%) 17 (4.2%) +2.5% (-0.8%, +5.8%) 0.129 * MWMHP = Melbourne Women's Midlife Health Project (our study was based on the cohort of women participating in the MWMHP study18 in its sixth year). † The group of women aged 50-69 years was a subset (previously unpublished data, n=411) of the 2181 women aged over 18 years who took part in a general-practice-based study of violence against women.2 ‡ Missing data from incomplete questionnaires were excluded when calculating prevalences. Back to text 2: Lifetime prevalence of domestic violence among middle-aged women (MWMHP* participants) Type of abuse Number of women Prevalence† (95% CI) Overall physical 101 28.5% and/or emotional (23.8%-33.2%) abuse Minor physical 79 22.4% abuse (18.4%-26.2%) Severe physical 31 8.8% abuse (5.9%-11.8%) Emotional abuse 60 17.0% (13.1%-20.9%) * MWMHP = Melbourne Women's Midlife Health Project (our study was based on the cohort of women participating in the MWMHP study18 in its sixth year). † Missing data from incomplete questionnaires were excluded when calculating prevalences. Back to text

Danielle Mazza · Lorraine Dennerstein

Notable Cases Adult-to-adult living donor liver transplantation for fulminant hepatic failure The outcome of fulminant hepatic failure without timely liver transplantation is poor. We describe a 19-year-old woman with fulminant hepatic failure due to acute hepatitis B infection who received a living donor liver transplant from her sister. The donor's recovery was uneventful, allowing hospital discharge on Day 6. Two months after transplantation the recipient developed a biliary stricture requiring surgery. One year after transplantation, her liver function was normal. Anthony K House, Gary P Jeffrey, Katherine A Edyvane, Andrew P Barker, Martin D Chapman, George Garas, John Ferguson,Peter V van Heerden, Neville M Gibbs, Dugal I Heath and Andrew W Mitchell MJA 2001; 175: 202-204 For editorial comment, see McCaughan and Lynch Clinical record - Recipient details - Donor details - Donor surgery - Recipient surgery - Postoperative details - Discussion - References - Authors' details - - More articles on Gastroenterology Without liver transplantation, the prognosis for fulminant hepatic failure is extremely poor.1 A shortage of cadaver donors has resulted in some patients dying while waiting for a suitable donor.2 In Western Australia, our experience is that 60% of patients with fulminant hepatic failure die before a cadaver liver becomes available. Living donor liver transplantation was initially developed to circumvent waiting list deaths in children. The technique was subsequently expanded to include adult patients because of insufficient availability of cadaveric organs.3 While adult-to-child living donor liver transplantation is a relatively safe and accepted practice,4 adult-to-adult living donor liver transplantation is still controversial. The concern is that, because adult recipients require larger grafts, healthy adult donors may be at greater risk of death or complications.5 The world experience in adult-to-adult living donor liver transplantation is rapidly increasing, and many studies show recipient outcomes similar to those with whole-organ implants, as well as low donor risk.2,3,6-9 To date, there have been no reports of adult-to-adult living donor liver transplantation in Australia. We report such a case. The Sir Charles Gairdner Hospital Human Ethics Committee approved an adult-to-adult living donor transplantation program. Clinical record Recipient details The recipient was a previously well, 71 kg, 19-year-old mother of a 15-month-old son. She had acquired hepatitis B virus (HBV) infection. Her admission on 15 April 2000 was preceded by 2-3 weeks of worsening jaundice and constitutional symptoms. Physical examination revealed deep jaundice, but no signs of chronic liver disease. At admission, the patient had a serum bilirubin level of 474 µmol/L (normal, < 20 µmol/L), serum alanine transferase (ALT) level > 300 U/L (normal, < 40 U/L), and an international normalised ratio of prothrombin time (INR) of 1.9. She tested positive for hepatitis B surface antigen (HBsAg) and e antigen (HBeAg), and negative for antibodies to hepatitis C and HIV. On the fifth day (20 April 2000), there was a marked clinical deterioration, with the development of unresponsive coma requiring intubation and ventilation. The patient met three King's College Hospital criteria for poor prognosis in fulminant hepatic failure: a time interval of more than seven days between jaundice and the onset of encephalopathy; a major disturbance in coagulation; and a serum bilirubin level > 300 mmol/L. The presence of these criteria suggested the likelihood of recovery without transplantation was less than 7%.10 On transfer to Sir Charles Gairdner Hospital, the patient fulfilled the Australasian and New Zealand liver group criteria for urgent listing for orthotopic cadaver liver transplantation. In the event of no cadaver liver becoming available, the possibility of a living donor liver transplant was discussed with the family. The recipient's mother, grandmother and two sisters volunteered as donors. On blood typing, her grandmother and a sister were found to be ABO blood group compatible. The sister was the more suitable donor as the grandmother had cardiovascular comorbidities. Donor details The donor was a 64 kg, 24-year-old woman, with no significant medical history. She smoked four cigarettes a day, but drank no alcohol. Preoperative evaluation by an independent psychiatrist demonstrated no psychosocial impediment to liver donation. Serum electrolyte levels, liver function tests, full blood analysis, and coagulation studies were normal, and serology for HIV and hepatitis B and C viruses was negative. An abdominal computed tomography scan showed a normal liver with a total volume of 1512 mL. The right lobe volume was estimated at 1133 mL, giving an estimated graft-to-recipient body weight ratio of > 1.0%; this was adequate for transplantation.11,12 Preoperative angiography showed the right hepatic artery arising from the superior mesenteric artery, and the left originating from the coeliac axis. Endoscopic retrograde cholangiopancreatography had to be abandoned because of patient intolerance. A magnetic resonance imaging cholangiogram showed conventional biliary anatomy, with the right anterior and posterior ducts joining 5 mm from the confluence of the right and left hepatic ducts. Five counselling sessions were conducted over two days between medical staff and the donor (with and without members of her family). Informed consent was obtained from the donor, with the understanding that the donor or her family could stop the process at any time without giving a reason. On the fifth day after referral to the transplant unit, the living donor liver transplantation from sister to sister proceeded concurrently in adjacent operating theatres. Donor surgery Donor surgery was performed as previously described through a right subcostal incision with a midline extension to the xiphoid process. 6,13 Before the completion of the donor right lobectomy, the recipient hepatectomy was commenced. Final clamping of the donor right lobe vessels was undertaken when the recipient was ready to receive the graft. The donor's total estimated blood loss for the procedure was 2000 mL, replaced by two units of packed red blood cells and one unit of autologous blood perioperatively. The total procedure time was 6 h 15 min. Recipient surgery The recipient surgery was through a similar incision. The entire liver, which was atrophic, heavily bile stained and showed massive hepatic necrosis histopathologically, was removed. The donor right lobe was implanted, hepatic vein end-to-side to the inferior vena cava ("piggyback" style). The other vessels and the right hepatic bile duct were joined end-to-end to the recipient structures. The total operative time was 10 h 10 min and the total ischaemic time was 55 min. The recipient required six units of packed red blood cells, 18 units of platelets and 24 units of fresh frozen plasma perioperatively. Immunosuppression was initiated with cyclosporin and methylprednisolone, together with prophylaxis for hepatitis B virus infection with hepatitis B immunoglobulin infusions and lamivudine. Postoperative details The donor was extubated several hours after leaving the operating theatre and, after 24 hours in the intensive care unit, was transferred to the general ward. Recovery was complicated by right basal atelectasis, which was treated by intensive chest physiotherapy. All liver function tests were normal at discharge on Day 6. A staphylococcal infection in the drain wound required a two-day readmission, but responded to flucloxacillin treatment. The donor returned to normal full activities four weeks later. The recipient made a slower postoperative recovery. There was an immediate improvement, and extubation occurred on the fifth day after surgery, with transfer to the general ward on Day 7. At this time her serum bilirubin level was 242 µmol/L, serum ALT level was 262 U/L, and INR was 1.2, improved from the pre-surgery values of 670 µmol/L, 1060 U/L and 5.1, respectively. Her serum lactate level was 8.1 mmol/L (normal, < 1.3 mmol/L). Complications included Staphylococcus aureus septicaemia, right middle and lower lobe consolidation, and an episode of severe acute graft rejection. On the 33rd day after surgery, the recipient was discharged. Two months after transplantation, her serum bilirubin level was 341 µmol/L, serum alkaline phosphatase level was 374 U/L (normal, 35-135 U/L), and serum ALT level was 80 U/L. A stricture of the biliary anastomosis was stented at this time. Three months after transplantation, there was still no filling of the right posterior bile duct, necessitating laparotomy and reanastomosis of the duct. The patient made an uncomplicated recovery and was discharged on Day 7. Persisting abnormal liver function tests at five and a half months led to a liver biopsy. Moderately severe chronic rejection was diagnosed, and the immunosuppressive medication was changed from cyclosporin to tacrolimus. At 12 months, results of liver function tests were normal and the recipient had returned to normal activities. Discussion This case represents the first adult-to-adult living donor liver transplantation in Australia. To date, there has been one reported adult-to-child living donor liver transplantation in Australia.14 The outcome of fulminant hepatic failure is extremely poor.10 Liver transplantation is the only effective treatment, but must be timely as delays result in sicker patients and higher mortality rates.15 In our patient, an urgent adult-to-adult living donor liver transplantation was undertaken because of the lack of availability of a cadaver graft. The reported experience of living donor liver transplantation in the high-urgency or emergency setting is limited, but internationally the outcomes are reported to be similar to conventional cadaver liver transplantation. Emergency living donor liver transplantation in 15 adults with fulminant hepatic failure had an overall patient survival rate of 59%,9 which is in the range reported for urgent cadaver transplantation (50%-68% survival at one year).1,16 In another series, adult patients with acute or chronic liver failure who were listed for high-urgency transplantation and received either living right lobe or extended living left lobe grafts had a one-year survival rate of 85%.2 As living donor liver transplantation exposes essentially healthy individuals to a life-threatening procedure, the processes of informed consent and patient selection must be strictly adhered to. Our donor volunteered early in the selection process. In accordance with the principle of self-selection or free voluntarism,2 care was taken to ensure there was no undue pressure on the potential donor from other family members. All members of the family understood they could stop the process at any time. If a potential donor does decide to withdraw from the process, this should remain confidential, and a medical excuse should be made for the cancellation.17 In our case, the donor made a speedy and uneventful recovery, but the recipient's recovery was complicated by a stricture at the biliary anastomosis. Biliary complications occur in 10%-35% of whole-organ cadaver transplants.17,18 Strictures are usually anastomotic and develop more than one month after surgery.19 Presently, there appears no clear benefit in using duct-to-duct biliary anastomoses or choledochojejunostomy.17,19 Three months after transplantation, our patient had a stricture corrected surgically. Recently, much attention has focused on a decline in the number of cadaveric organs available for emergency and elective transplantation. In Japan and Hong Kong, where there are critical shortages of cadaveric donors because of religious, cultural or legislative impediments, living donor liver transplantation has become an important adjunct to cadaveric transplantation.2,3 Some transplant centres in Japan and the United States have also been successfully using living donor liver transplants in the non-emergency setting.6 In Australia, between 6% and 8% of patients waiting for cadaver liver transplantation die each year, compared with 10% in the United States.20,21 Most of these patients are adults, as the number of children on the waiting list has been reduced significantly by the use of split liver cadaveric and living donor liver transplantation.22,23 Following the worldwide experience with living donor liver transplantation, the Transplant Society of Australia and New Zealand21 has recently supported the use of living donor liver transplantation in emergency situations, but has questioned its elective role because of concerns about donor safety and inadequate data demonstrating a local need. To date, there have been three reported deaths in 2000 living liver donors, giving a mortality rate of 0.15%.24,25 Case-series reports also indicate minimal donor morbidity, with minimal operative blood loss, and average lengths of stay of one week.2,7,8 Donor morbidities include minor and major complications in 30%. Of these, biliary strictures and cholestasis are the more prevalent.25 Adult living donor liver transplantation is likely to be extended to waiting list patients when death while waiting increases to the proportions reported from Europe and North America and after procedures are in place for recipient and potential donor to be fully informed at transplant listing. Donor mortality and morbidities are a serious issue, but can be minimised by adequate donor work-up and selection. References Bismuth H, Samuel D, Castaing D, et al. Orthotopic liver transplantation in fulminant and subfulminant hepatitis. Ann Surg 1995; 222: 109-119. Lo CM, Fan ST, Liu CL, et al. Applicability of living donor liver transplantation to high-urgency patients. Transplantation 1999; 67: 73-77. Inomata Y, Uemoto S, Asonuma K, et al. Right lobe graft in living donor liver transplantation. Transplantation 2000; 69: 258-264. Grewal HP, Thistlethwaite JR, Loss GE, et al. Complications in 100 living-liver donors. Ann Surg 1998; 228: 214-219. Strong RW. Whither living donor liver transplantation? Liver Transplant Surg 1999; 5: 536-538. Marcos A, Fisher RA, Ham JM, et al. Right lobe living donor liver transplantation. Transplantation 1999; 68: 798-803. Fan ST, Lo CM, Liu CL, et al. Safety of donors in live donor liver transplantation using right lobe grafts. Arch Surg 2000; 135: 336-340. Marcos A, Fisher RA, Ham JM, et al. Selection and outcome of living donors for adult to adult right lobe transplantation. Transplantation 2000 (a); 69: 2410-2415. Uemoto S, Inomata Y, Sakuri T, et al. Living donor liver transplantation for fulminant hepatic failure. Transplantation 2000; 70: 152-157. O'Grady JG, Alexander GJM, Hayllar KM, et al. Early indicators of prognosis in fulminant hepatic failure. Gastroenterology 1997; 97: 439-445. Kiuchi T, Kasahara M, Uryuhara K, et al. Impact of graft size mismatching on graft prognosis in liver transplantation from living donors. Transplantation 1999; 67: 321-327. Marcos A, Fisher RA, Ham JM, et al. Liver regeneration and function in donor and recipient after right lobe adult to adult living donor liver transplantation. Transplantation 2000 (b); 69: 1375-1379. Wachs ME, Bak TE, Karrer FM, et al. Adult living donor liver transplantation using a right hepatic lobe. Transplantation 1998; 66: 1313-1316. Strong RW, Lynch SV, Ong TN, et al. Successful liver transplantation from a living donor to her son. N Engl J Med 1990; 322: 1505-1507. Shakil AO, Mazariegos GV, Kramer DJ. Fulminant hepatic failure. Surg Clin North America 1999; 79: 77-108. Washburn WK, Bradley J, Cosimi AB, et al. A regional experience with emergency liver transplantation. Transplantation 2000; 61: 235-239. Marcos A. Right lobe living donor liver transplantation: A review. Liver transplantation 2000; 6: 3-20. Jeffrey GP, Brind AM, Ormonde DG, et al. Management of biliary tract complications following liver transplantation. Aust N Z J Surg 1999; 69: 717-722. Mazariegos GV, Molmenti EP, Kramer DJ. Early complications after orthotopic liver transplantation. Surg Clin North America 1999; 79: 109-129. Kam I. Anatomical variations of the liver. Technical issues with Donors and Outcomes. The Second International Symposium Dedicated to Expanding the Donor Pool, Living Donor and Split Liver Transplantation; XVIII International Congress of the Transplantation Society 2000. Transplant Society of Australia and New Zealand (TSANZ). Live donor liver transplantation in Australia: Current recommendations. Liver Transplant Standing Committee. April 2000: Canberra, Australia. Rogier X, Broering DC, Mueller L, Living-donor liver transplantation in children. Langenbecks Arch Surg 1999; 384(6): 528-535. Reding R, de Goyet J de V, Delbeke I, et al. Paediatric liver transplantation with cadaveric or living related donors. Comparative results in 90 elective recipients of primary grafts. J Paediatr 1999; 134(3): 280-286. Schiano TD, Kim-Schluger L, Gondolesi G, Miller CM. Adult living donor transplantation. The hepatologist's perspective. Hepatology 2001; 33: 3-8. Renz JF, Roberts JP. Long-term complications of living donor liver transplantation. Liver Transpl 2000; 6 Suppl 2: 73-76. (Received 18 Apr 2001, accepted 22 Jun 2001) Authors' details Liver Transplant Service of Western Australia, Sir Charles Gairdner Hospital, Perth, WA. Anthony K House, MS, FRACS, Professor, Department of Surgery, University of Western Australia; Gary P Jeffrey, MD, FRACP, Associate Professor, Department of Medicine, University of Western Australia; Katherine A Edyvane, BM, BS, Registrar; Andrew P Barker, MB BS, FRACS, Surgeon; Martin D Chapman, MB BS, FRANZCP, Psychiatrist; George Garas, MB BS, FRACP, Hepatologist; John Ferguson, MB ChB, MRCP, Radiologist; Peter V van Heerden, Mmed, PhD, Intensivist; Neville M Gibbs, MD, FANZCA, Anaesthetist; Dugal I Heath, MD, FRACS, Surgeon and Senior Lecturer, Department of Surgery, University of Western Australia; Andrew W Mitchell, MB BS, FRACS, Senior Lecturer, Department of Surgery, University of Western Australia. Reprints will not be available from the authors. Correspondence: Professor A K House, University Department of Surgery, QEII Medical Centre, M Block, Verdun Road, Nedlands, WA 6907. akhouseATcyllene.uwa.edu.au Make a comment

Anthony K House · Gary P Jeffrey · Katherine A Edyvane · Andrew P Barker · Martin D Chapman · George Garas · John Ferguson · Neville M Gibbs

MJA 2001; 175: 205-210 For editorial comment, see Breen Abstract - Background to the development of our position statement - Content of a core curriculum - Knowledge - Skills - Attitudes - Teaching methods - Assessment - The challenge of implementing the curriculum - Conclusion - References - Authors' details - - More articles on Ethics - More articles on Education Abstract Teaching ethics incorporates teaching of knowledge as well as skills and attitudes. Each of these requires different teaching and assessment methods. A core curriculum of ethics knowledge must address both the foundations of ethics and specific ethical topics. Ethical skills teaching focuses on the development of ethical awareness, moral reasoning, communication and collaborative action skills. Attitudes that are important for medical students to develop include honesty, integrity and trustworthiness, empathy and compassion, respect, and responsibility, as well as critical self-appraisal and commitment to lifelong education. In recent years, an international consensus has emerged that ethics and health law should be essential components of medical curricula.1-3 In line with this, teachers of medical ethics and law in UK medical schools have recently published a model for a core ethics curriculum.4 In Australia, concern for ethics teaching has developed, in part, as a result of the findings of the Doherty Report5 and through the Australian medical school accreditation process. The Australian Medical Council's statement, Goals and objectives of basic medical education,6 specifies that graduates completing basic medical education "should have knowledge and understanding of the principles of ethics related to health care and the legal responsibilities of the medical profession", and that graduates should have "an appreciation of the complexity of ethical issues related to human life and death, including the allocation of scarce medical resources". There is, however, less consensus as to what ethics should be taught, how it should be taught and who should teach it. In part, this is because ethics offers not so much a discrete or limited area of content, but a place for the consideration of values and for dialogue across boundaries and between different perspectives. In addition, there are many different ways to think about and analyse ethical issues in practising medicine, from a "principlist" approach through to virtue ethics, narrative ethics and ethics of care (Box 1). Despite this diversity, there is a core of skills and knowledge related to ethics that is as fundamental to the practice of medicine as basic sciences or clinical skills. This core is concerned primarily with equipping students to recognise and understand important ethical issues, to know how to make decisions about those issues, and to have a better basis for knowing what should be done (in any given situation) and why. Consideration of questions such as "What are ethical reasons and how do they differ from other reasons?", "What does 'informed consent' mean and how does it work in practice?", and "How do people wish to die?" is an essential component of medical education that falls within the domain of ethics. As members of the Association of Teachers of Ethics and Law in Australian and New Zealand Medical Schools (ATEAM), we offer here a position statement on an ethics core curriculum for Australasian medical schools. We believe that this curriculum meets the goals outlined by the Australian Medical Council.6 Background to the development of our position statement Our outline of an ethics core curriculum arose out of a meeting in June 1999 of teachers of ethics and law in medicine from 10 universities in Australia and New Zealand. The meeting covered a wide range of issues, with participants exchanging views on the teaching of ethics, based on personal experiences and informal consultations within their own institutions. Following this meeting, three separate working parties developed statements on the knowledge, attitudes and skills considered desirable for students to acquire from an ethics curriculum. The whole group met again in July 2000 and agreed to develop and refine the initial statements from the working parties by an email exchange of views. The core curriculum outlined here is the consensus statement that resulted from this process. During our meetings and subsequent consultations, it became apparent that most of the existing Australasian ethics courses are strongly congruent with one another and with other existing statements, such as the consensus statement by teachers of medical ethics and law in UK medical schools.4 We see our consensus statement very much as a living document, open to challenges and revisions as changes in medicine and society raise new and different ethical questions and as medical education continues to evolve. Content of a core curriculum Knowledge A core curriculum of ethics knowledge must address both the foundations of ethics and specific topics in ethics (Box 2). We have made a distinction between basic ethical concepts and ethics in clinical settings to highlight the importance of understanding basic principles and terminology that apply to ethical problems irrespective of any clinical situation. For example, informed consent can not be understood adequately without an understanding of autonomy, individual rights and paternalism. Skills The construction of a knowledge base in medicine involves skills of problem-solving, reasoning, critical thinking, collaboration and the active use of knowledge.11 Specific learning outcomes, in terms of these transferable skills, are sought as part of the process of independent life-long learning. Such skills are as relevant in ethics as they are in other domains of medicine. More specific skills (those of ethical awareness, moral reasoning and ethical practice) are also required to translate this knowledge into practice. Ethical awareness relates to the ability to recognise ethical issues present in a medical setting. This requires students, in practising medicine, to maintain and develop sensitivity to issues involving their patients. Skills in moral reasoning involve the ability to analyse ethical issues in a medical setting, to construct arguments and counterarguments that are valid and sound, and to examine and interpret the arguments of others. The specifically moral nature of these arguments requires that students have some familiarity with ethical theory and principles. After weighing competing claims and interests, justification for a particular moral position can be offered. Skills of ethical practice concern a range of skills necessary for ethically sensitive practice. They include the ability to communicate about ethical issues with patients, their relatives and other healthcare professionals; effective negotiation and collaboration with patients, their families and other members of the healthcare team; and skills necessary to implement ethical decisions in the face of institutional constraints. Students' relative powerlessness in the medical hierarchy can often inhibit them from presenting a dissenting ethical view, and so they need to be able to recognise and analyse an institutional culture, with specific attention given to how students might act ethically in the face of it.12-14 Attitudes The traditional model of medical ethics education suggests that its goal is not to improve the moral character of future physicians, but to give those with already formed sound moral character "the knowledge and skills required to practice good medical care".15However, increasing concern about the dehumanising and detrimental effects of institutional practice and the medical education process itself has led to recognition of the importance of promoting humanistic qualities and behaviour in medical ethics education.16 A broad community consensus on unacceptable professional behaviour also exists. Awareness and discussion of professional values, attitudes and behaviours should be fostered among students and their teaching staff, both to minimise direct patient harm and to recognise and reduce individual and cultural factors that may erode professional trust. Attitudes that are important for medical students to develop are those that promote patients' interests through the doctor-patient relationship, the interests of colleagues through professional relationships, and students' own well-being (Box 3). These attitudes are core components of professional identity; placing them within the ethics curriculum does not imply ethical ownership, but is a mechanism to ensure explicit teaching in this area. Teaching methods It is imperative that ethics teaching be precise, challenging and clinically relevant. The curriculum should target students' needs,17 reflect the ethical issues encountered in clinical and professional practice,18 and take account of empirical research in ethics where appropriate. Ethics teaching should also consider the informal, "hidden" curriculum displayed in the values and behaviours of clinical and preclinical teachers and in the ways in which hospitals and medical schools are organised. The subtle messages students acquire from their teachers and institutions are, arguably, the most important determinant of what values are learnt, how they are learnt and the impact they have on practice and the profession. There is no single "best" method by which ethics should be taught and, indeed, the evolution of ethics education has profited enormously from curricular experimentation and innovation. However, all forms of teaching must remain cognisant of the centrality of the individual's experience, or narrative, and must also be committed to the notion of dialogue between individuals and between professions, perspectives and ideologies. This creates the basis for the incorporation of multiple perspectives and multiple teachers into ethics programs. Although the conceptual and theoretical knowledge of ethics can easily be introduced through readings, lectures, seminars or computer-assisted instruction, ethics education is fundamentally discursive, and thus it is essential to facilitate at least some learning of ethics knowledge in small groups. Small-group learning using case studies and problem-solving exercises can be used both to amplify and extend more didactic teaching methods and also to reinforce the relevance of ethics to medicine (Box 4).19 Professional, clinical and social issues can also be taught by integration with clinical teaching in a number of other settings, including: formal "ethics" ward rounds;20 formal "ethics" grand rounds and unit meetings; discussion of ethical issues within clinical seminars; ethics journal clubs. The teaching of attitudes deserves particular mention. The capacity to clarify and critically evaluate one's own values and to integrate personal and professional values in the life of the student and doctor should be an essential part of the medical school curriculum. Teaching methods that have been employed successfully to accomplish these tasks include: values journals or portfolios; discussion of cases, with particular emphasis on critical appraisal of personal and professional values and attitudes; debriefing sessions that allow for reflection and discussion of attitudes and behaviours encountered in the day-to-day experience of medical students. Role modelling by teachers is a crucial influence on the attitudes and behaviour of future doctors.21,22 The unconscious assimilation of professional culture and the ethical capitulations that have been seen as necessary for advancement within that culture can be better recognised and dealt with in educational programs that explicitly aim to include these elements. Teachers of ethics can play an important role in modelling the very nature of ethics: the teaching process should be perceived as being emotionally supportive and academically encouraging, should be tolerant of multiple perspectives, should be interdisciplinary, and should actively involve clinicians as co-instructors and as role models for students. This also underscores the responsibility of teachers to develop as an ethical community and be alert to, and respond to, unethical behaviour among themselves and their students. Deeper and more focused learning of specific issues through elective courses in ethics should also be available, either as part of the medical curriculum or through interfaculty cooperative arrangements. Advanced elective modules in ethics that may be taken during the degree are an efficient way to offer courses for students with a particular interest in ethics. Finally, although it is essential to introduce ethics within the medical curriculum, ethics may be best learnt when individuals are faced with real-life ethical issues in clinical practice. For this reason, education in ethics should continue through postgraduate and vocational training and continuing education. Ethical, legal and institutional issues are now addressed in structured-release sessions within the Commonwealth-supported National Curriculum for Junior Doctors in the Prevocational Years.23 Assessment It is important that ethical knowledge, skills and attitudes be assessed. This signals to students that their medical school regards ethics as important and acknowledges the fact that students give more attention to the areas that are assessed. Assessment also provides an opportunity to demonstrate the relevance and integral nature of ethics in basic sciences as well as in clinical and professional interactions. There is no single method for assessing ethics knowledge and skills. A number of methods have been used, including written case reports, objective structured clinical examinations24 and group assessment of students' self-directed, problem-based learning skills. Skills of problem-solving, cooperation and self-motivation may be assessed by such means as self- or peer-ratings, assessments by tutors, literature searches, diaries or portfolios.25,26 The critical issue is not so much the method of assessment, but whether the assessment instrument is well designed and appropriate to the task. The challenge for ethics educators is to develop valid, relevant, rigorous and reliable measures for assessing ethics and for evaluating the incorporation of ethics into practice. The challenge of implementing the curriculum The breadth and depth of ethics teaching and the time devoted to it vary considerably between Australasian medical schools. Given the integrated nature of many programs, it is difficult to assess the total number of hours devoted to ethics teaching, but the nominal number of hours per year varies between three and 20 (Box 5). Some medical schools already have dedicated staff teaching ethics with recognised allocation of curriculum time, while others face a number of challenges in reaching the aims we have outlined. These challenges include the following: (a) Shortage of skilled staff. There are no uniform qualifications for teaching ethics in medical schools. Staff require not only a good understanding of moral philosophy, but also familiarity with (and confidence in dealing with) the medical environment. It is difficult to stipulate specific qualifications required, but, as with all university teaching, a higher degree with a major focus on ethics or an appropriate topic is highly desirable. (b) Competition for curriculum time. Many Australasian medical schools have revised their curricula in recent years. There continues to be pressure of curriculum time on all aspects of medical teaching. We have not stipulated the number of contact hours required to successfully implement the core curriculum, as this will vary with methods of teaching, available staff and other factors. An integrated curriculum will incorporate many ethical issues into existing topics — for example, a clinical term in surgery should include teaching on ethical aspects of informed consent to surgical treatment. The issue is not so much competition for extra time, but judicious collaboration with clinical colleagues. Perhaps the greatest challenge facing implementation of a core curriculum in ethics is that of gaining recognition of the skills and expertise required to teach ethics. Until ethics is accepted as an essential domain in medicine, no less important or specialised than anatomy or pharmacology, support for an ethics core curriculum may be lacking. However, given the relatively recent recognition of the need for teaching of communication skills, we trust that support for teaching of ethics is not far behind. Conclusion In this position statement we have argued for the importance of a core curriculum in medical ethics. We believe that the curriculum we have presented meets the Australian Medical Council's medical ethics education goals. Moreover, there continues to be an essential flexibility in the interpretation and implementation of such a curriculum within diverse medical schools. We have also considered the challenges involved in delivering a medical ethics curriculum within an integrated teaching program. These challenges are not insurmountable. Educating the doctors of tomorrow in the ethical practice of medicine is surely a task deserving of our continued best efforts. References Royal College of Physicians and Surgeons of Canada. Bioethics curricula. available at: <http://rcpsc.medical.org/english/ethics>. Accessed 10 July 2001. The teaching of medical ethics: fourth consultation with leading medical practitioners. Geneva: World Health Organization, 1995. Culver CM, Clouser KD, Gert B, et al. Basic curricular goals in medical ethics. N Engl J Med 1985; 312(4): 253-256. Teaching medical ethics and law within medical education: a model for the UK core curriculum. J Med Ethics 1998; 24(3): 188-192. Doherty RL (chairman). Committee of Inquiry into Medical Education and Medical Workforce. Australian medical education and workforce into the 21st century. Canberra: AGPS, 1988. Australian Medical Council. Goals and objectives of basic medical education. Guidelines for assessment and accreditation of medical schools. Canberra: AMC, 2000. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press, 1994. Gillon R, Lloyd A, editors. Principles of health care ethics. Chichester: Wiley, 1994. Tovey P. Narrative and knowledge development in medical ethics. J Med Ethics 1998; 24: 176-181. Boyd KM, Higgs R, Pinching AJ, editors. The new dictionary of medical ethics. London: BMJ, 1997. Driscoll M. Psychology of learning for instruction. Boston: Allyn and Bacon, 1999. Christakis D, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993; 68(4): 249-254. Hicks LK, Lin Y, Robertson DW, et al. Understanding the clinical dilemmas that shape medical students' ethical development: questionnaire survey and focus group study. BMJ 2001; 322: 709-710. Doyal L. Closing the gap between professional teaching and practice. BMJ 2001; 322: 685-686. Miles SH, Lane LW, Bickel J, et al. Medical ethics education: coming of age. Acad Med 1989; 64: 705-713. Hafferty FW, Franks R. The hidden curriculum: ethics teaching and the structure of medical education. Acad Med 1994; 69: 861-871. Jacobson JA, Tolle BW, Stocking CB, Siegler M. Internal medicine residents' preferences regarding medical ethics education. Acad Med 1989; 64: 760-764. Pellegrino ED, Siegler M, Singer PA. Teaching clinical ethics. J Clin Ethics 1990; 1(3): 175-180. Parker M. Autonomy, problem-based learning and the teaching of medical ethics. J Med Ethics 1995; 21: 305-310. Siegler M. A legacy of Osler: teaching clinical ethics at the bedside. JAMA 1987; 239: 951-956. Wright S, Wong A, Newill C. The impact of role models on medical students. J Gen Intern Med 1997; 12: 53-56. Gordon JJ, Lyon PM. As others see us: students' role models in medicine. Med J Aust 1998; 169: 103-105. Postgraduate Medical Education Committee. Early postgraduate medical education. Available at: <http://meded.qmec.uq.edu.au/cpmec/index.asp>. Accessed 18 July 2001. Singer PA, Robb A, Cohen R, et al. Performance-based assessment of clinical ethics: the ethics objective clinical examination. Acad Med 1996; 71: 495-498. Savulescu J, Crisp R, Fulford KW, Hope T. Evaluating ethics competence in medical education. J Med Ethics 1999; 25: 367-374. Swanson D, Case S, Vleuten C. Strategies for student assessment. In: Boud D, Feletti G, editors. The challenge of problem-based learning. London: Kogan Page, 1991. Authors' details Department of Public Health, University of Adelaide, Adelaide, SA. Annette J Braunack-Mayer, BMedSci(Hons), PhD, Lecturer in Ethics. Centre for the Study of Health and Society, University of Melbourne, Melbourne, VIC. Lynn H Gillam, MA(Oxon), PhD, Lecturer in Health Ethics; and Research Fellow, Ethics Unit, Murdoch Children's Research Institute, Melbourne. Clinical School, St Vincent's Hospital, Melbourne, VIC. Edwina F Vance, MB BS, MBioethics, Fellow. Otago Bioethics Centre, University of Otago Medical School, New Zealand. Grant R Gillett, DPhil(Oxon), FRACS, Professor of Medical Ethics. Clinical Unit in Ethics and Health Law, University of Newcastle, Newcastle, NSW. Ian H Kerridge, MPhil, FRACP, Lecturer in Ethics; John McPhee, BCom (Hons)(Leg Stud), Consultant in Health Law; Peter Saul, FFICANZCA, MA, Clinical Lecturer in Ethics; David E Smith, MB BS, GradCertBioethics, General Medical Practitioner; Henry M Wellsmore, MAE, MSocSc, Lecturer in Ethics. School of Medicine, Flinders University, Adelaide, SA. Bogda Koczwara, FRACP, MBioethics, Coordinator, Personal and Professional Development; Wendy A Rogers, MRCGP, PhD, NHMRC, Sydney Sax Research Fellow, Department of General Practice; Brian F Stoffell, BA(Hons), PhD, Director of Medical Ethics. School of Community Medicine, University of New South Wales, Sydney, NSW. Paul M McNeill, LLB, PhD, Associate Professor of Ethics and Law in Medicine. School of Medicine, University of Tasmania, Hobart, TAS. Christopher J Newell, MA(Hons), PhD, Senior Lecturer. School of Medicine, University of Queensland, Brisbane, QLD. Malcolm H Parker, MB BS, MLitt(Hons), Senior Lecturer in Ethics and Professional Development. Department of Medical Education, University of Sydney, Sydney, NSW. Merrilyn Walton, BSW, MSW, Associate Professor of Ethical Practice. School of Medicine, James Cook University, Townsville, QLD. John S Whitehall, MB BS, FRACP, Associate Professor; and Domain Chair of Ethics and Personal Development, Director of Neonatology. Reprints will not be available from the authors. Correspondence: Dr A J Braunack-Mayer, Department of Public Health, University of Adelaide, SA 5005. annette.braunackmayerATadelaide.edu.au Make a comment 1: Approaches to ethics The "four principles" approach The "four principles" approach to ethics is based on principles of ethics articulated by Beauchamp and Childress.7 These principles are: Beneficence (the obligation to provide benefits); Non-maleficence (the obligation to avoid harm); Respect for autonomy (the obligation to respect the decision-making capacity of others); Justice (the obligation of fairness). It is claimed that these four principles encompass most, if not all, ethical issues in healthcare and provide a common set of moral commitments and a common language for discussing ethical issues.8 Narrative ethics Narrative ethics offers an alternative approach to principles, in which personal narrative, rather than a pre-identified framework, is central to any analysis and to decision-making. The emphasis is upon understanding the meaning of the situation for those involved. Narrative analysis draws upon skills of interpretation and reasoning by analogy to reach sound and defensible conclusions.8 This approach assumes that the most appropriate ethical solution can be reached through knowledge of the personal, cultural and social context of the individual.9 Ethics of care Ethics of care gives priority to caring as the most important moral principle in healthcare ethics, rejecting abstract and impersonal approaches to ethical analysis. In particular, care is contrasted with justice as a more appropriate moral principle. Like narrative ethics, ethics of care relies upon detailed information about the context of ethical decision-making in order to provide ethically sensitive and morally supportive care.10 Virtue ethics Virtue ethics starts with a consideration of particular qualities or virtues such as honesty, wisdom, or kindness rather than with concepts or rules. Becoming a good doctor involves learning through experience and from others and adopting an internal, value-based perspective, rather than following external rules or principles.10 This approach emphasises character and wisdom rather than focusing on the "right" result. Virtue ethicists believe that the intention to be a kind and compassionate person, rather than following a set of prescribed rules, results in a more integrated life with better-quality interactions. Back to text 2: Core knowledge for ethics in the medical curriculum FOUNDATIONS TOPICS Bioethical concepts Ethics in practice Disease, illness and suffering Models of the doctor-patient relationship Autonomy and agency Empathy, responsibility and accountability Personhood Determining capacity Competence and rationality Consent to and refusal of treatment Duty of care/beneficence Informed decision-making and disclosure Medical paternalism Legal aspects of the duty of care Vulnerability and trust Surrogate decision-making Medical veracity Involuntary treatment Harm Privacy and confidentiality issues Justice Compliance and adherence to treatment Life and death Futility/limiting, withdrawing treatment End-of-life decisions and causation of death Reproductive issues (including abortion) Professional ethical concepts Professionalism Professionalism, unprofessional conduct, self-regulation Professional issues for medical students and clinical governance Codes of ethics Student and physician impairments (eg, illness) Maintaining clinical competence Responding to clinical error Social ethical concepts Medical practice and research in society Individual and common good Cultural sensitivity in practice Individuals, families, societies and cultures Decision-making in conditions of uncertainty Human rights Resource allocation issues Models of healthcare delivery Public health ethics and legal obligations History and philosophy of medicine Evidence-based medicine and clinical judgement Status and uncertainties of science Ethical issues in complementary medicine Models of health, disease and care Commercialisation of medicine (including e-health) Medicalisation Human research ethics Goals and scope of medicine Issues in genetics and biotechnology Back to text 3: Core attitudes for ethics in the medical curriculum Honesty, integrity and trustworthiness Critical self-appraisal (including recognition of limitations and errors) Empathy and compassion Respect for (the dignity of) patients as people Respect for the roles of other healthcare professionals in the care of the patient Responsibilities of the medical professional towards the local and global community Responsibility and reliability Commitment to clinical competence and lifelong education Commitment to self-care Back to text 4: Examples of strategies for teaching ethics Scenarios incorporating ethical issues are used to prompt discussion, provide material for debate, or to set up role plays. Scenarios are used as triggers to explore issues. Students may be required to present their findings and understanding to others at a later time. This approach works in both "traditional" and "problem-based learning" courses. Students and their tutor discuss particular issues such as respect for colleagues and teachers, fidelity, promise-keeping and professional standards of behaviour, and how these concepts translate into a clinical setting. Issues of this sort may arise from the learning situation itself (eg, establishing and maintaining rules for attendance and commitment in shared tasks). Clinical situations are used as a prompt for students and staff to discuss ethical issues as they arise in the day-to-day practice of medicine. Students are required to keep a portfolio of current events as they are reported in the media, and to discuss this material in an essay and/or tutorial presentation. Students participate in a series of ethics tutorials, integrated with their clinical teaching, culminating in a group presentation to clinicians and students involving scripted role-plays on diverse ethical topics. Final-year students work on a statement of values that is incorporated into a declaration to be made during a prize-giving or graduation ceremony. Back to text 5: Ethics teaching in Australasian medical schools* University Year level taught Format Time allocated Adelaide All years† Lectures, seminars, PBL tutorials, self-directed learning, clinical modules Year 1: 10 hours Year 2: 10 hours Year 3: 25 hours Years 4-6: 3 hours/year Flinders All years Lectures, PBL tutorials, electives, web-based learning, portfolios, clinical teaching Year 1: 18 hours Year 2: 18 hours Year 3: 4 hours of formal lectures Melbourne All years Lectures, seminars, tutorials, PBL, self-directed learning, research projects, clinical teaching Year 1: 22 hours Year 2: 16 hours Year 3: 12 hours Years 4-6: 15 hours New South Wales All years Lectures, tutorials, workshops, clinical teaching Year 1: 6 hours Year 2: 35 hours Year 3: 28 hours Years 4-6: 5 hours/year Newcastle All years Seminars, tutorials, self-directed learning, clinical teaching Years 1-6: 40-50 hours Queensland All years† PBL tutorials, lectures, symposia, web-based learning, clinical teaching Years 1-2: 10% Years 3-4: 15% (% of curriculum) Sydney All years Lectures, theme sessions, PBL tutorials, portfolios, clinical teaching Years 1-3: weekly sessions Years 4-6: forum and integrated teaching Tasmania All years Lectures, tutorials, seminars, self-directed learning, electives, clinical teaching Years 1-6: 4 hours/year of formal lectures * As reported by ATEAM members. † Taught within EPPD stream. PBL = Problem-based learning. EPPD = Ethics, personal and professional development. Back to text

A Working Group, on behalf of the Association of Teachers of Ethics and Law in Australian and New Zealand Medical Schools (ATEAM)