While positive information in the context of clinical care can lead to placebo effects, negatively framed information can have negative or nocebo effects. Extant literature documents how doctor–patient encounters are fertile ground for suboptimal interactions leading to negative experiences for ethnoracial minority patients. In their _JME_ paper, Blease presents a critical perspective on the potential for patients’ access to their doctors’ clinical notes, ‘open notes’, to engender nocebo effects. 1 In this commentary, we affirm the central claim that nocebo effects (...) could emerge ‘via negative wording or framing of health information expressed by clinicians in documentation’. The advent of electronic health records (EHR) allowed patients the unprecedented opportunity to access personal clinical documentation, giving them a window into decision making around their health. This shift is undoubtedly complex, and thus warrants a more fulsome rendering of the unique challenges faced by ethnoracial minority patients. Herein, we highlight three... (shrink)

There is very little literature on the actual decision-making frameworks used by general practitioners with respect to ethical issues and virtually none on the impact of personal experiences of illness on this. This study aimed to investigate what these frameworks might be and if and how they were altered by doctors’ own illness experience. Twenty general practitioners were recruited, 10 having had a previous serious medical illness and 10 having no such history. They participated in a semi-structured interview, including case (...) vignettes, recorded and analysed using qualitative thematic analysis. Being a patient themselves altered general practitioners’ decision-making by enhancing physician empathy, increasing ease at discussing difficult topics, having a greater willingness to support patient choice and a wider ability to provide a greater diversity of therapeutic strategies, with the role of empathy being the most noticeable difference between the groups. Doctors who had not had a severe personal illnes... (shrink)

The ethics of treating the seriously and critically ill have not been static throughout the ages. Twentieth century medicine has inherited from the nineteenth century a science which places an inappropriate weight on diagnosis over prognosis and management, combined with a seventeenth century duty to prolong life. However other earlier ethical traditions, both Hippocratic and Christian, respected both the limitations of medicine and emphasised the importance of prognosis. This paper outlines some of the historical precedents for the treatment of the (...) critically ill, and also how the current paradigm limits clinical practice and causes ethical tensions. An understanding that other paradigms have been ethically acceptable in the past allows wider consideration and acceptance of alternatives for the future. However future alternatives will also have to address the role of technology, given its importance in this area of medicine. (shrink)

This study examines the processes ofdecision-making used by intensive care(critical care) specialists. Ninety-ninespecialists completed a questionnaire involvingthree clinical cases, using a novel methodologyinvestigating the role of uncertainty andtemporal-related factors, and exploring a rangeof ethical issues. Validation and triangulationof the results was done via a comparison studywith a medically lay, but highly informed groupof 37 law students. For both study groups,constructing reasons for a decision was largelyan interpretative and imaginative exercise thatwent beyond the data (as presented), commonlyresulting in different reasons supporting (...) thesame conclusions and similar reasons supportingopposite conclusions. The skills of ethicalimagination and interpretation were related toan individual''s prior lived experience,construed in the broadest sense. Application ofthese skills of ethical imagination andinterpretation always occurred, to some degree,in a state of uncertainty and almost alwaysinvolved temporal relationships.Using these results, a theory of ethicaldecision-making is proffered. Three levels ortypes of reasoning processes may be present.Type I decision-making involves the applicationof rules, usually in a deductive fashion. TypeII decision-making is characterised by aprocess where a plurality of reasons arebalanced, weighed and sifted with each other.Type III decision-making is intimately linkedwith respondents lived experiences and `crafts''the content of type I and II reasoningprocesses, via the application of ethicalimagination and interpretation. Relationshipsbetween these three types of reasoningprocesses, and with narrative ethics, are alsodiscussed. (shrink)

This article explores the psychological literature on rationalization and connects it with contemporary questions about the role of in-house lawyers in ethical dilemmas. Using the case study of AWB Ltd, the exclusive marketer of Australian wheat exports overseas, it suggests that rationalizations were influential in the perpetuation by in-house lawyers of AWB's payment of kickbacks to the Iraqi regime. The article explores how lawyers' professional rationalizations can work together with commercial imperatives to prevent in-house lawyers from seeing ethical issues as (...) those outside the organisation would see them. In particular, where lawyers over-identify with their client's commercial point of view and convince themselves that their role is primarily about providing 'technical' advice on commercial matters, wilful or unintended 'ethical blindness' can result. Lawyers can end up involved in or perpetuating serious misconduct by their client organizations. (shrink)

This paper is an adaptation of a paper presented at the British Educational Research Association Conference in Belfast, Northern Ireland, in August 1998. It reports on a study on reading pedagogy and metacognition in six classrooms in Leeds and six classrooms in Dublin. The evidence is based on 12 teacher interviews, 43 separate lesson observations and school/class, policy/lesson documents. The paper analyses the teachers' thinking and their classroom practices with reference to inter-related themes, tasks, texts and contexts, and it draws (...) out the implications for the development of metacognitive awareness among the g-year-old children that these teachers reach. It attempts to explain practice with reference to teachers' conceptions of teaching, the learner and reading. (shrink)

This paper compares the incidence of the diagnosis of Autistic Spectrum Disorders (ASD) among White and Asian children with reference to data obtained from thirteen local education authorities (LEAs) in England. It begins by outlining some of the theoretical debates associated with the definition, diagnosis and prevalence of ASD. The empirical component underpinning this work uses logistic modelling to ascertain whether the proportion of children with a statement of special educational need (SEN) for ASD is different for Asian and for (...) White children and whether the proportion of children with a statement of SEN for ASD varies between LEAs. The discussion speculates as to possible reasons for the differences found and identifies areas for further research. (shrink)