This target article focuses on dynamics that arise in three typical ethically complex cases in which psychiatric consultations are requested by physicians: a dying patient refuses life-prolonging treatment, an uncooperative patient demands to be allowed to go outside and smoke, and an angry patient demands to be admitted to the hospital. The discussion canvasses what is at stake morally and clinically in each of these cases and explores clinician-patient interactions, dynamics in relationships between consulting physicians and consultant psychiatrists, patient transference, and physician countertransference. The article defines legalism and countertransference and argues that an ethically and clinically important consequence of these phenomena for patients is distortion of clinicians' perceptions of patients' decisions and vulnerabilities. The discussion also describes how legalism and countertransference adversely affect how clinicians treat their psychiatrist colleagues. Finally, the article suggests how the effects of legalism and countertransference can be mitigated.

In this paper, we explore best practices for asynchronous discussions in graduate online bioethics education. We explain that online approaches have advantages and challenges in contrast to in-person discussions. Online challenges are lack of visual or auditory cues and technical access. Advantages include extended opportunities for specific focus, thoughtful reflection, and critical review. We found no significant review of related best practices in bioethics. Our more general literature review of graduate education and online approaches, plus experience in our own bioethics graduate program, suggest provisional best practices that we detail. We reason that online graduate discussion provisionally should aim for a Bcommunity of inquiry^framework that incorporates cognitive, social, and teaching Bpresences,^as well as a learning presence. However, we also note unresolved concerns about whether the framework sufficiently addresses learning, is complete, and captures communicative functions. Drawing further on the literature, we also suggest best practices for instructor feedback to students about their discussion performance, including that remarks should be timely and specific. two courses in our graduate bioethics program illustrate how we implement discussion strategies. Finally, we review assessment strategies and suggest that embedded formative assessments in discussion (i.e., instructor feedback, rubrics, etc.) support and demonstrate deeper learning. Limitations in generalizability include that our review targets asynchronous and text-based online discussion, our program assessments do not necessarily detail best practices, student expectations and approaches could be rather particular to our program, and specific bioethics content in principle could alter best practices.

Health care professionals' and trainees' conceptions of their responsibilities to patients can change over time for a number of reasons: evolving career goals, desires to serve different patient populations, and changing family obligations, for example. Some changes in conceptions of responsibility are healthy, but others express moral damage. Clinicians' changes in their conceptions of what they are responsible for express moral damage when their responses to others express a meager, rather than robust, sense of what they owe others. At least two important expressions of moral damage in the context of health care are these: callousness and divestiture. Callousness describes the poor condition of a clinician's capacity for moral perception; when her capacity to accurately appreciate features of moral relevance that configure others' needs, vulnerabilities, and desert of care diminishes, such that she fails to respond with care to those for whom she has duties to care, she is callous. Callousness has been explored in detail elsewhere,1 and so the focus of this paper is divestiture. A clinician divests when the value of responding with care to others becomes less centrally and importantly constitutive of his personal and professional identity. Divestiture has important consequences for patients and health professions education, which I will explore here.

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Students' attitudes about callousness are negative; women's attitudes are more negative than men's. Despite this, students (regardless of their demographic variations) regularly see it modeled by their mentors. Some students' narrative responses suggest they think being callous toward patients and colleagues can serve them well in some situations. The authors offer several questions to motivate further empirical and ethical inquiry into callousness and urge medical educators to consider its influence on students' conceptions of professionalism.