Messerschmitts

Mythic Dawn acolyte
10+ Year Member
Aug 29, 2005
997
38
36
Gilroy, CA
Status
Attending Physician
Apparently University of Cincinnati loves this question at interviews: If a child was dying and needed a blood transfusion and the parents refused (due to religious beliefs coherent with Jehova's Witness), what would you do?

The kicker is that Ohio law is apparently on the side of the parents, and they can successfully sue you (not sure if they can sue you so bad that you can loose your license though). What if it's down to saving the boy vs. losing your license? It's kind of a "damned if you do, damned if you don't" question, I don't want to sound cold-hearted, nor do I want to lose my license and be screwed after 4 gruelling years of med school plus ? years of residency. What's a good answer?
 

Toxic

Junior Member
10+ Year Member
5+ Year Member
Mar 29, 2005
23
0
Status
Interesting, I was always under the impression that parental decisions NOT in the best interests of the child could be challenged. I guess I am not familiar with the laws in specific states, but I would give the blood transfusion and I think you could fight it in court (and even if the state sided with the parents I doubt you would lose your liscense).

"Medical caretakers have an ethical and legal duty to advocate for the best interests of the child when parental decisions are potentially dangerous to the child's health, imprudent, neglectful, or abusive. When satisfactory resolution cannot be attained through respectful discussion and ethics consultation, seeking a court order for appropriate care might be necessary. "

This is from the UWSOM Bioethics website...it has some really good cases...hope that helps!!
 
OP
Messerschmitts

Messerschmitts

Mythic Dawn acolyte
10+ Year Member
Aug 29, 2005
997
38
36
Gilroy, CA
Status
Attending Physician
Toxic said:
Interesting, I was always under the impression that parental decisions NOT in the best interests of the child could be challenged. I guess I am not familiar with the laws in specific states, but I would give the blood transfusion and I think you could fight it in court (and even if the state sided with the parents I doubt you would lose your liscense).

"Medical caretakers have an ethical and legal duty to advocate for the best interests of the child when parental decisions are potentially dangerous to the child's health, imprudent, neglectful, or abusive. When satisfactory resolution cannot be attained through respectful discussion and ethics consultation, seeking a court order for appropriate care might be necessary. "

This is from the UWSOM Bioethics website...it has some really good cases...hope that helps!!
Awesome, thanks a lot! If they ask, I'll say that I'll give the transfusion, then fight tooth in nail in court! :p Cover all my bases. And that bioethics policy is gold too.
 

63768

Guest
10+ Year Member
Mar 5, 2005
2,202
4
Status
Medical Student
for jehovah witnesses, they are not allowed to consume blood according to the bible (genesis, acts, leviticus). if he/she refuses, you can explain to them that this is not consuming blood since it's similar to the blood exchange a baby receives from his/her mother. so through a technicality, they can receive blood transfusions.

in addition, i always thought the parents are allowed to make the decision for their child regardless if the child was unfit to decide for him/herself.
 

tacrum43

Behold the mighty echidna
10+ Year Member
7+ Year Member
Oct 19, 2004
3,130
3
36
Seattle, WA
Status
Resident [Any Field]
yourmom25 said:
for jehovah witnesses, they are not allowed to consume blood according to the bible (genesis, acts, leviticus). if he/she refuses, you can explain to them that this is not consuming blood since it's similar to the blood exchange a baby receives from his/her mother. so through a technicality, they can receive blood transfusions.

in addition, i always thought the parents are allowed to make the decision for their child regardless if the child was unfit to decide for him/herself.
I don't think they would buy that. Blood tranfusions are a big deal to devout Jehovah's Witnesses. Basically they take the verses in the Bible about eating blood to include "eating" it through your veins. And they think this is a horrible sin that you will certainly go to hell for. That's why they would object so strongly to their child receiving a transfusion.

Sometimes there are procedures that have been adapted so that they don't require a transfusion, so that might be an alternative to the court order, but I would say that the court order is the best way to go if there is no alternative. If it were an emergency situation though (and you didn't have time to get a court order), then I guess it's sort of up to the doctor how strongly they want to pursue giving the transfusion.
 

MrDreamWeaver

Senior Member
10+ Year Member
5+ Year Member
May 4, 2005
132
0
Status
Well it almost seems like the parents are holding up a knife to their children's throat sacrificing him/her for religion. So would you sit there and let the parent slowly cut their child, or would you actually do something?

Seems like the answer is obvious

You as a doctor are responsible for your patient's health.
 

rocketman

Member
10+ Year Member
5+ Year Member
Oct 7, 2005
66
0
Status
MrDreamWeaver said:
Well it almost seems like the parents are holding up a knife to their children's throat sacrificing him/her for religion. So would you sit there and let the parent slowly cut their child, or would you actually do something?

Seems like the answer is obvious

You as a doctor are responsible for your patient's health.
You as a doctor are also responsible for respecting the beliefs of others. I think the knife analogy is a stretch.
 

prncvegita

Member
10+ Year Member
5+ Year Member
Nov 7, 2005
38
0
Status
I think in general, you want to straddle the fence with any bioethics question. At the very least, doing so shows that you understand that things are more complicated than black and white.

I agree though that the child's life takes priority over the parent's religious wishes.

Off topic, here's a few interesting true bioethics cases I got from a friend in med school:
You diagnose a patient with a brain tumor. His mother died of a brain tumor years ago and he has vowed that if he gets a brain tumor, he will shoot himself rather than suffer a slow death. He was already treated for one brain tumor when he was in S. America - his doctors lied to him and told him he had a parasite to prevent him from shooting himself. As his physician in the U.S. what do you do?

A 15 year old boy comes into the AIDS clinic and tests negative. You discover, however, that he's been having sex for money with older men so that he can raise enough money to go back home to S. America. Reporting the situation will lead to his situation being dramatically worse (not exactly sure how other than loss of income, I think there may have been more to the story). Do you report it?

In case you're wondering what the physicians did for the first one, PM me. My friend said they're still deliberating on the 2nd one.


rocketman said:
You as a doctor are also responsible for respecting the beliefs of others. I think the knife analogy is a stretch.
 

tacrum43

Behold the mighty echidna
10+ Year Member
7+ Year Member
Oct 19, 2004
3,130
3
36
Seattle, WA
Status
Resident [Any Field]
prncvegita said:
I think in general, you want to straddle the fence with any bioethics question. At the very least, doing so shows that you understand that things are more complicated than black and white.

I agree though that the child's life takes priority over the parent's religious wishes.

Off topic, here's a few interesting true bioethics cases I got from a friend in med school:
You diagnose a patient with a brain tumor. His mother died of a brain tumor years ago and he has vowed that if he gets a brain tumor, he will shoot himself rather than suffer a slow death. He was already treated for one brain tumor when he was in S. America - his doctors lied to him and told him he had a parasite to prevent him from shooting himself. As his physician in the U.S. what do you do?

A 15 year old boy comes into the AIDS clinic and tests negative. You discover, however, that he's been having sex for money with older men so that he can raise enough money to go back home to S. America. Reporting the situation will lead to his situation being dramatically worse (not exactly sure how other than loss of income, I think there may have been more to the story). Do you report it?

In case you're wondering what the physicians did for the first one, PM me. My friend said they're still deliberating on the 2nd one.
These cases really happened? Especially the first one. I mean, what are the odds?
 

prncvegita

Member
10+ Year Member
5+ Year Member
Nov 7, 2005
38
0
Status
tacrum43 said:
These cases really happened? Especially the first one. I mean, what are the odds?
I dunno, one in 300,000,000 (roughly the population of the US?)
Actually more b/c if his mother had brain cancer, he's more likely to have brain cancer as well?

haha, yeah, these are true cases they discussed at my friend's med school. PM if you want to know where, I'm being paranoid, but not 100% sure what I'm allowed to disclose publicly.
 

Em1

Senior Member
10+ Year Member
5+ Year Member
Oct 9, 2005
569
1
Status
Medical Student
This probably wouldn't be my interview answer, but explain everything to the kid, provided he is old enough to understand, and get him to guilt trip the parents into letting him have the transfusion.

Even if that didn't work, the kid's support could only help you get a court order and/or defend your decision to override the parents.
 

RayhanS1282

perpetually percolated
10+ Year Member
15+ Year Member
Apr 8, 2004
2,030
1
Sucking long and hard in New York
Visit site
Status
yourmom25 said:
for jehovah witnesses, they are not allowed to consume blood according to the bible (genesis, acts, leviticus). if he/she refuses, you can explain to them that this is not consuming blood since it's similar to the blood exchange a baby receives from his/her mother. so through a technicality, they can receive blood transfusions.

in addition, i always thought the parents are allowed to make the decision for their child regardless if the child was unfit to decide for him/herself.

Yourmom, your avatars are getitng me hot and bothered. Who is that?
 

jackets5

Senior Member
10+ Year Member
Jan 20, 2005
1,189
11
Status
Id give the blood without any reservations. Religion is a choice, unlike being white or black if you decide you dont like the religion you can change it. With a child at the age of 6-8 he/she most likley has no clue about religion except what they know from their parents and has no opportunity to form their own opinoin about religion. Who knows the kid may grow up at the age of 18 and decide the jehova teachings are absurd to him and decide to not to practice the religion. I would definatley give the patient the benefit of the doubt in order to decide if he was indeed a jehova. No person should die from an easily treatable condition in the name of a religion that they are not old enough to make an informed decision about wether or not they wish to practice it. And this is coming from a republican/catholic
 

63768

Guest
10+ Year Member
Mar 5, 2005
2,202
4
Status
Medical Student
tacrum43 said:
I don't think they would buy that. Blood tranfusions are a big deal to devout Jehovah's Witnesses. Basically they take the verses in the Bible about eating blood to include "eating" it through your veins. And they think this is a horrible sin that you will certainly go to hell for. That's why they would object so strongly to their child receiving a transfusion.

Sometimes there are procedures that have been adapted so that they don't require a transfusion, so that might be an alternative to the court order, but I would say that the court order is the best way to go if there is no alternative. If it were an emergency situation though (and you didn't have time to get a court order), then I guess it's sort of up to the doctor how strongly they want to pursue giving the transfusion.
no, i also do not think they would buy it. but it's worth a try. it's taking their belief and twisting it. whether they buy it or not doesn't matter. basically, i'd give them the facts: if your kid doesn't receive this transfusion, his probability of death is much higher, and if he does get it, he'll probably be healed (or whatever that prognosis is).

if they still refuse and you've offered all you can, then it's their choice. a lot of people would step over their bounds and force the transfusion, but that is the way medicine used to be. now medicine includes the patient, and while many still believe the doctor should make the decision, we can only give them their options. they must make the decision. if the kid can't say anything, the parents must.
 

Nikki2002

Moderator Emeritus
10+ Year Member
7+ Year Member
Jun 16, 2005
13,152
2
Status
Medical Student
Messerschmitts said:
Apparently University of Cincinnati loves this question at interviews: If a child was dying and needed a blood transfusion and the parents refused (due to religious beliefs coherent with Jehova's Witness), what would you do?

The kicker is that Ohio law is apparently on the side of the parents, and they can successfully sue you (not sure if they can sue you so bad that you can loose your license though). What if it's down to saving the boy vs. losing your license? It's kind of a "damned if you do, damned if you don't" question, I don't want to sound cold-hearted, nor do I want to lose my license and be screwed after 4 gruelling years of med school plus ? years of residency. What's a good answer?
oh crap--that's ohio law....i gotta go look this up
 

63768

Guest
10+ Year Member
Mar 5, 2005
2,202
4
Status
Medical Student
jackets5 said:
Id give the blood without any reservations. Religion is a choice, unlike being white or black if you decide you dont like the religion you can change it.
but if the child is in no condition to respond or throws the responsibility of making such a decision to his/her parents, what do you do then? religion may be a choice, but it is a part of each patient. you cannot override the patient. if he/she chooses to let nature take its course, you have no right to bar that, just as we have no right to bar religion or beliefs.
 

prncvegita

Member
10+ Year Member
5+ Year Member
Nov 7, 2005
38
0
Status
yourmom25 said:
but if the child is in no condition to respond or throws the responsibility of making such a decision to his/her parents, what do you do then? religion may be a choice, but it is a part of each patient. you cannot override the patient. if he/she chooses to let nature take its course, you have no right to bar that, just as we have no right to bar religion or beliefs.
I definitely see both sides of the argument, but because the patient is a child and it is a life/death situation, I think the physician's discretion overrides the parents will in most states. I'm very surprised to hear that Ohio sides with the parents. What's the precedent for that?

Regardless of what the legal ramifications are, personally, I'd probably move for a court order to save the child's life, and even without one I'd probably override the parent's decision if it's an emergency situation. Again though, I think being straight-up with the parents is absolutely necessary and trying as best as possible to modify the procedure to conform to their beliefs is what's key.

Just my 2 cents.
 

63768

Guest
10+ Year Member
Mar 5, 2005
2,202
4
Status
Medical Student
prncvegita said:
Regardless of what the legal ramifications are, personally, I'd probably move for a court order to save the child's life, and even without one I'd probably override the parent's decision if it's an emergency situation. Just my 2 cents.
i'm trying to think about this in economic terms and it seems as if the legal costs and time would not be feasible for the doctor and/or the patient. in addition, i think if the hospital has one, an ethics committee is where you'd go to first.
 

MrDreamWeaver

Senior Member
10+ Year Member
5+ Year Member
May 4, 2005
132
0
Status
Everyone is saying "what if this, what if that?"

There is no clear-cut, correct answer to this. I personally think the better answer would be to save the child's life. That's your job.
 

jackets5

Senior Member
10+ Year Member
Jan 20, 2005
1,189
11
Status
Each patient. The parent is not the patient, a child that is unresponsive I would side with the idea that they would like to live rather than die. Again, at a real young age you really have no objective views on religion and the chance to make up your mind on the subject. I think the older the child gets the more complicated the situation. But if a child is real young 5-8 then i have no problem subsituting my views for the childs parents. Its better violate his possible future religious beliefs in favor of the child having a life than to let him die for something they may never grow to accept.

yourmom25 said:
but if the child is in no condition to respond or throws the responsibility of making such a decision to his/her parents, what do you do then? religion may be a choice, but it is a part of each patient. you cannot override the patient. if he/she chooses to let nature take its course, you have no right to bar that, just as we have no right to bar religion or beliefs.
 

PhotoMD

10+ Year Member
5+ Year Member
2+ Year Member
7+ Year Member
Dec 1, 2004
460
1
NYC
Status
Medical Student
Clearly you have to give the blood to the patient after obtaining a court order from a judge (which really can be done in a timely manner without regard to time of day). This is probably what you meant by "legally you have to respect the parents' wishes." The exception is a judge-signed court mandate, and it's your ethical obligation to obtain that order.
 

dynx

Yankee Imperialist
15+ Year Member
Jan 22, 2003
4,584
201
IN YOUR HEAD...let me out!
Visit site
Status
Fellow [Any Field]
PhotoMD said:
Clearly you have to give the blood to the patient after obtaining a court order from a judge (which really can be done in a timely manner without regard to time of day). This is probably what you meant by "legally you have to respect the parents' wishes." The exception is a judge-signed court mandate, and it's your ethical obligation to obtain that order.
yeah, here's the obvious answer.
while the spirit behind the "give him the blood to save his life...it's your job" sounds all great in theory its not going to keep you from being fired for giving the blood without a court order when the parents sue the hospital, you, the person who donated the blood and the guy that served them the hamburger in the cafeteria when you gave the blood.

BTW, at discharge, you should mention to any muslim patients that you have that heparin is a porcine product, wish them luck with that whole hell thing.
 

Chinorean

Senior Member
10+ Year Member
5+ Year Member
Jun 22, 2005
651
1
Status
Because it's a hypothetical question, I'd say to give the blood transfusion anyway. It doesn't matter if in that particular state there are such and such parental laws, because these are make believe parents who are never going to sue you.


It's good to be aware of different issues, but I would want a doctor who would fight for my life, not wave me away with a sad shrug. I think adcoms want incoming students to be somewhat starry-eyed and pro-saving people in the face of legal problems and real-world drama.
 

Hebrew Hammer

Registered Abuser
10+ Year Member
5+ Year Member
Jun 9, 2005
97
0
Red Sox Nation
Status
jackets5 said:
Id give the blood without any reservations. Religion is a choice, unlike being white or black if you decide you dont like the religion you can change it. With a child at the age of 6-8 he/she most likley has no clue about religion except what they know from their parents and has no opportunity to form their own opinoin about religion. Who knows the kid may grow up at the age of 18 and decide the jehova teachings are absurd to him and decide to not to practice the religion. I would definatley give the patient the benefit of the doubt in order to decide if he was indeed a jehova. No person should die from an easily treatable condition in the name of a religion that they are not old enough to make an informed decision about wether or not they wish to practice it. And this is coming from a republican/catholic
I completely agree with above poster. I would give the child the transfusion no matter what. The child is your patient, not the parents, and you must always give the patient the best medical care available regardless of what non-medical interests have to say. I am as PC generally as it gets, but I don't care at all if I am going against someones "beliefs" if I know that what I am doing is the right thing to do. I will gladly deal with the consequences later if it means doing the right thing now. I hope that all doctors would respond as such, and I am guessing that the adcom member would rather hear an impassioned response like this rather than someone straddling the line. Everyone posting seems to actually agree about this (amazing on SDN), so the difficult ethical situation doesn't actually seem that difficult, at least not to me.....
 

little_late_MD

Ready To Jump
10+ Year Member
5+ Year Member
Sep 26, 2005
446
3
38
South Florida
Status
Pre-Medical
Kick the parents out of the room.
One on one with the child ask "Do you want to live or do you want to die?"
If the child says "live" go with the tansfusion. If the child says "Die" follow the parents wishes.
Your patient has now told you the treatment option they would like to follow. Ethically, legally, and morally all your bases are covered.
 

prncvegita

Member
10+ Year Member
5+ Year Member
Nov 7, 2005
38
0
Status
Hebrew Hammer said:
I completely agree with above poster. I would give the child the transfusion no matter what. The child is your patient, not the parents, and you must always give the patient the best medical care available regardless of what non-medical interests have to say. I am as PC generally as it gets, but I don't care at all if I am going against someones "beliefs" if I know that what I am doing is the right thing to do. I will gladly deal with the consequences later if it means doing the right thing now. I hope that all doctors would respond as such, and I am guessing that the adcom member would rather hear an impassioned response like this rather than someone straddling the line. Everyone posting seems to actually agree about this (amazing on SDN), so the difficult ethical situation doesn't actually seem that difficult, at least not to me.....
I definitely agree that dealing with the consequences (i.e., losing your license, getting sued etc.) and what not shouldn't be the primary concern. The primary concern should be first the patient's well-being and second the family's interests, so personally I feel you'd be in the right by taking action. Just playing devil's advocate here though - you're making a very strong statement by saying you know what the "right thing to do" is. What if you're wrong? If you haven't already, you should definitely read "The Spirit Catches You and You Fall Down"... It's relates the story of when the medical community failed a young Hmong girl in California. Basically, our preconceived notions of what was best for the kid turned out to be wrong, whereas the basic love and care that the family gave, including completely botching the physician's treatment regiment b/c it conflicted with their beliefs, turned out to be significantly more beneficial.

People have their set of beliefs, doctors have their own, and when they come into conflict, it can be very nasty. IMHO, doctors need to do their best to understand and sympathize with their patient's beliefs and try to work within that framework.

Another question, say the kid is 16 or 17 (so, not of legal age), his parents refuse to have a blood transfusion, and the kid refuses it as well. Then what do you do? Just throwing this out there for more debate. Also, say the patient is of age and refuses the blood transfusion. Do you go against his wishes and do it anyways (ta hell with his beliefs!), or do you follow his requests and allow him to die the way he wishes to? Curious as to what most would say.
 

PittMedicine

Membership Revoked
Removed
10+ Year Member
Nov 4, 2005
201
0
CA
Status
Pre-Medical
Messerschmitts said:
Apparently University of Cincinnati loves this question at interviews: If a child was dying and needed a blood transfusion and the parents refused (due to religious beliefs coherent with Jehova's Witness), what would you do?

The kicker is that Ohio law is apparently on the side of the parents, and they can successfully sue you (not sure if they can sue you so bad that you can loose your license though). What if it's down to saving the boy vs. losing your license? It's kind of a "damned if you do, damned if you don't" question, I don't want to sound cold-hearted, nor do I want to lose my license and be screwed after 4 gruelling years of med school plus ? years of residency. What's a good answer?

VERY EASY ANSWER: Be logical when your in the interview. Tell the interview panel that you would take about the situation with the parents and try to convince them to allow you to give the transfusion. Obey the law, but never give up.
 

drgreeneatutk

Member
10+ Year Member
7+ Year Member
Apr 27, 2005
64
0
Pikeville
Status
Medical Student
prncvegita said:
I definitely agree that dealing with the consequences (i.e., losing your license, getting sued etc.) and what not shouldn't be the primary concern. The primary concern should be first the patient's well-being and second the family's interests, so personally I feel you'd be in the right by taking action. Just playing devil's advocate here though - you're making a very strong statement by saying you know what the "right thing to do" is. What if you're wrong? If you haven't already, you should definitely read "The Spirit Catches You and You Fall Down"... It's relates the story of when the medical community failed a young Hmong girl in California. Basically, our preconceived notions of what was best for the kid turned out to be wrong, whereas the basic love and care that the family gave, including completely botching the physician's treatment regiment b/c it conflicted with their beliefs, turned out to be significantly more beneficial.

People have their set of beliefs, doctors have their own, and when they come into conflict, it can be very nasty. IMHO, doctors need to do their best to understand and sympathize with their patient's beliefs and try to work within that framework.

Another question, say the kid is 16 or 17 (so, not of legal age), his parents refuse to have a blood transfusion, and the kid refuses it as well. Then what do you do? Just throwing this out there for more debate. Also, say the patient is of age and refuses the blood transfusion. Do you go against his wishes and do it anyways (ta hell with his beliefs!), or do you follow his requests and allow him to die the way he wishes to? Curious as to what most would say.
I am going to have to agree with the above poster on many things. I've considered this question for along time now, even sought advice from my pastor and physician that I know. It's one of the toughest "ethical" questions that I have come across. First I agree with the above poster on who decides on "what is the right thing to do". Several other poster have essentially said "screw the parents decision and do what's right" well what makes what you think is right more right than what someone else things is right. I personally agree that what I think is the correct thing to do is give the transfusion. However here is the tangled web we weave when we do that... What this question really comes down to is who has the right/responsability/obligation over this child? The parents or the doctor? If you choose the doctor (which most of you have), then you say that the doctor has authority over the parents of the child. If this is the case in this situation, then it will become the case in other situations as well (the slippery slope argument). Lets say a pregnant woman comes in with XX number of kids in the womb (XX= more than 3). What if medically speaking the "best" choice is to abort some to save the others and the mother and what if the mother refuses this option. Then can the doctor that the go ahead and abort as he sees fit as long as he thinks it's the "right thing to do or if he has a court order? I realize the parrallel here isn't exact but I hope I make my point. So for me, I again agree with the above post and say that I would try every means possible to talk the parents into consenting to the transfusion (this is all assuming the child cannot make the decision for himself, in which case it can make this situation even harder to deal with) but if in the end they refuse, regardless of your efforts, then I think I would begrudgingly respect their wishes. Now here's the kicker, if they did refuse in the end and the child did die, could they be charged with manslaughter? HHmmm...
I say all this in a very logical and academic sense, if you put me in the Dr. role (as I will be someday if things go as planned) and I'm next to the bed with the bleeding kid and I know all it takes is my word and the kid lives then actually allowing the kid to die would be EXTREMELY difficult for me to do and I can't be exactly sure how I'd react until I"m there.
 

CADreaming06

Senior Member
10+ Year Member
5+ Year Member
Jun 4, 2005
138
0
Status
prncvegita said:
I think in general, you want to straddle the fence with any bioethics question. At the very least, doing so shows that you understand that things are more complicated than black and white.

I agree though that the child's life takes priority over the parent's religious wishes.

Off topic, here's a few interesting true bioethics cases I got from a friend in med school:
You diagnose a patient with a brain tumor. His mother died of a brain tumor years ago and he has vowed that if he gets a brain tumor, he will shoot himself rather than suffer a slow death. He was already treated for one brain tumor when he was in S. America - his doctors lied to him and told him he had a parasite to prevent him from shooting himself. As his physician in the U.S. what do you do?

A 15 year old boy comes into the AIDS clinic and tests negative. You discover, however, that he's been having sex for money with older men so that he can raise enough money to go back home to S. America. Reporting the situation will lead to his situation being dramatically worse (not exactly sure how other than loss of income, I think there may have been more to the story). Do you report it?

In case you're wondering what the physicians did for the first one, PM me. My friend said they're still deliberating on the 2nd one.
interesting - - i was at a columbia interview and they specifically mentioned the second ethical situation (not as a question, but as an example of the types of cases that the students encounter in their courses).