Cultural competence, a clinical skill to recognise patients' cultural and religious beliefs, is an integral element in patient‐centred medical practice. In the area of death and dying, physicians' understanding of patients' and families' values is essential for the delivery of culturally appropriate care. Dementia is a neurodegenerative condition marked by the decline of cognitive functions. When the condition progresses and deteriorates, patients with advanced dementia often have eating and swallowing problems and are at high risk of developing malnutrition. Enteral tube (...) feeding is a conventional means of providing artificial nutrition and hydration to meet nutritional needs, but its benefits to the frail population are limitedly shown in the clinical evidence. Forgoing tube feeding is ethically challenging when patients are mentally incompetent and in the absence of an advance directive. Unlike some developed countries, like the United States of America, death and dying is a sensitive issue or even a taboo in some cultures in developing countries that forgoing enteral tube feeding is clinically and ethically challenging, such as China and Malaysia. This article in three parts 1) discusses the clinical and ethical issues related to forgoing tube feeding among patients with advanced dementia, 2) describes how Hong Kong Chinese, North American, and Malaysian Islamic cultures respond differently in the decision‐making patterns of forgoing tube feeding for patients with advanced dementia, and 3) reiterates the clinical implications of cultural competence in end‐of‐life care. (shrink)

This case describes an adolescent in a crisis of a chronic medical condition whose situation is complicated by substance abuse and mental illness. D. Micah Hester provides an analytic approach, teasing apart the multiple layers of medical, developmental, and moral issues at hand and describing possible responses and outcomes. Amy T. Campbell examines existing legal guidelines for adolescent decision making, arguing that greater space exists for clinical discretion in these matters than commonly thought. Cheryl D. Lew discusses the development of (...) agency in adolescent patients, the ideal of autonomous decision making in the context of impairment and chronic illness, and the obligation of healthcare teams to examine an adolescent patient’s decisions in relation to her identity. (shrink)

The editors welcome letters from readers, although we cannot guarantee that all will be published. To ensure timeliness, correspondents must respond to an article within seven weeks and not exceed two double‐spaced pages. Letters become the property of the editors and may be edited and shortened at our discretion.

This essay argues that normative judgments, in general, and moral judgments, in particular, are "truth apt" and can be objects of belief. Other main claims are: judgments about reasons, if interpreted as true, do not have metaphysical implications that are incompatible with a scientific view of the world. Two kinds of normative claims should be distinguished: substantive claims about what reasons people have and structural claims about what attitudes people must have insofar as they are rational. Employing this distinction, the (...) practical significance of substantive normative judgments is explained, and critical analysis of expressivist and Kantian views on this question is offered. (shrink)

The dilemma of whether and how to disclose a diagnosis of cancer or of any other terminal illness continues to be a subject of worldwide interest. We present the case of a 62-year-old Japanese woman afflicted with advanced gall bladder cancer who had previously expressed a preference not to be told a diagnosis of cancer. The treating physician revealed the diagnosis to the family first, and then told the patient: "You don't have any cancer yet, but if we don't treat (...) you, it will progress to a cancer". In our analysis, we examine the role of family consent, communication patterns (including ambiguous disclosure), and advance directives for cancer disclosure in Japan. Finally, we explore the implications for Edmund Pellegrino's proposal of "something close to autonomy" as a universal good. (shrink)

Many of the haemopoietic cell growth factors have now been purified to homogeneity and their structural genes cloned. Methods are also now available for obtaining pure populations of haemopoietic cells. The use of such cells, in combination with pure growth factors, has provided intriguing information about the biological activities and mode of action of the factors in faciliating survival, proliferation and differentiation of the haemopoietic cells.

Transoral laser microsurgery applies to the piecemeal removal of malignant tumours of the upper aerodigestive tract using the CO2 laser under the operating microscope. This method of surgery is being increasingly popularised as a single modality treatment of choice in early laryngeal cancers (T1 and T2) and occasionally in the more advanced forms of the disease (T3 and T4), predomi- nantly within the supraglottis. Thomas Kuhn, the American physicist turned philosopher and historian of science, coined the phrase ‘paradigm shift’ in (...) his groundbreaking book The Structure of Scientific Revolutions. He argued that the arrival of the new and often incompatible idea forms the core of a new paradigm, the birth of an entirely new way of thinking. This article discusses whether Steiner and col- leagues truly brought about a paradigm shift in oncological surgery. By rejecting the principle of en block resection and by replacing it with the belief that not only is it oncologically safe to cut through the substance of the tumour but in doing so one can actually achieve better results, Steiner was able to truly revolutionise the man- agement of laryngeal cancer. Even though within this article the repercussions of his insight are limited to the upper aerodigestive tract oncological surgery, his willingness to question other peoples’ dogma makes his contribution truly a genuine paradigm shift. (shrink)

PurposeThe main purpose of this study is to assess the effects of COVID-19 on the restaurant businesses of Bangladesh. It examines the socio-economic impacts of the humanitarian disaster of the COVID-19 pandemic from the perspective of restaurant owners. The study also intends to provide recommendations to mitigate effects on the restaurant business.Design/Methodology/ApproachA qualitative research approach was adopted to explore the effects of the COVID-19 pandemic on the restaurant businesses of Bangladesh. A total of 22 in-depth interviews were conducted with the (...) top-ranked restaurant owners in the Rajshahi City Corporation area of Bangladesh. Thematic analysis technique was applied for analyzing the collected data.FindingsThe study found that the restaurant owners were compelled to reduce their number of employees, and forced to ensure social distancing and proper sanitization which increased the expenses. Although online orders and home delivery services have increased significantly, restaurant business operation is gradually turning critical owing to the lack of financial support. Thus, restaurant owners urge the govenrment for financial assistance.Research Limitations/ImplicationsSince this research only focused on one city in Bangladesh, the outcomes of study may have a dearth of generalizability. Hence, the investigators are encouraged to extend the study area.Practical ImplicationsThis study will help restaurant owners and policymakers in formulating contemporary business policies and strategies. Thus, it will be supportive of improving the present condition of the restaurant businesses in developing countries like Bangladesh.Originality/ValueThis paper identified the truculent scenario of the restaurant business during the COVID-19 pandemic. (shrink)

Objectives To conduct an independent evaluation of the first phase of the Health Foundation’s Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design Mixed method evaluation involving five substudies, before and after design. Setting NHS hospitals in the United Kingdom. Participants Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention The SPI1 (...) was a compound (multi-component) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration—monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items)—there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for “difference in difference” 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from 17% (63) to 13% (49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening. (shrink)

This new translation of the first volume of Hegel's Lectures on the History of Philosophy is a welcome and valuable addition to the new translations of Hegel's works, and now appears in paperback for the first time. Hegel's History of Philosophy has been described as perhaps one of his greatest achievements, and also as the first systematic history of philosophy since Aristotle. The translation included material from lecture notes taken by Hegel's pupils in 1923-4, 1925-6, and 1927-8. This material was (...) not available to Haldane and Simson when they made their translation nearly 100 years ago. The present volume, which supersedes that earlier one, besides being indispensable for the professional student, will also introduce those unfamiliar with Hegel to his conception of philosophy. (shrink)

The public purse is responsible for funding almost all autism spectrum disorders (ASD) research in Canada (as per Canadian Institutes of Health Research [CIHR]) and for providing some of the existing services and supports for this population. In this article, we consider various reasons why Canada should be concerned to ensure a more equitable distribution of relevant public funding for ASD research than is currently the case to meet the express needs and interests of the diversity of autism stakeholders. As (...) such, we report data to show that CIHR-supported ASD research from the period of 2000–2010 demonstrates a bias focussed on the aetiology of the condition revealing a disproportionate emphasis on only two (Biomedical and Clinical) out of the four research pillars avowed by CIHR, with a comparative lack of fiscal resources committed to Health Systems and Services and Population and Public Health research. We advance certain normative and prudential reasons for funding more Health Systems and Services and Population and Public Health ASD research in Canada. In our view, this would seem to follow from CIHR’s official mandate ‘as a flexible mechanism that will continually align health research funding with changes in the manner in which health problems and opportunities are identified, understood and addressed’. (shrink)

Objective To assess parental permission for a neonate's research participation using the MacArthur competence assessment tool for clinical research (MacCAT-CR), specifically testing the components of understanding, appreciation, reasoning and choice. Study Design Quantitative interviews using study-specific MacCAT-CR tools. Hypothesis Parents of critically ill newborns would produce comparable MacCAT-CR scores to healthy adult controls despite the emotional stress of an infant with critical heart disease or the urgency of surgery. Parents of infants diagnosed prenatally would have higher MacCAT-CR scores than parents (...) of infants diagnosed postnatally. There would be no difference in MacCAT-CR scores between parents with respect to gender or whether they did or did not permit research participation. Participants Parents of neonates undergoing cardiac surgery who had made decisions about research participation before their neonate's surgery. Methods The MacCAT-CR. Results 35 parents (18 mothers; 17 fathers) of 24 neonates completed 55 interviews for one or more of three studies. Total scores: magnetic resonance imaging (mean 36.6, SD 7.71), genetics (mean 38.8, SD 3.44), heart rate variability (mean 37.7, SD 3.30). Parents generally scored higher than published subject populations and were comparable to published control populations with some exceptions. Conclusions The MacCAT-CR can be used to assess parental permission for neonatal research participation. Despite the stress of a critically ill neonate requiring surgery, parents were able to understand study-specific information and make informed decisions to permit their neonate's participation. (shrink)

The last chapter of Politian's first Miscellanea dealt with the amica silentia lunae through which the Greeks sailed back to Troy . He argued that the phrase should not be taken literally, as a statement that Troy fell at the new moon, but in an extended sense, as a poetic indication that the moon had not yet risen when the Greeks set sail. This reading had one merit: it explained how Virgil's moon could be silent while the Greeks were en (...) route but shine during the battle for the city . Yet Politian's effort to identify the phase of the moon described by Virgil was anything but clear: Non igitur aut sera fuerit aut pernox luna, tum nec lunae quidem omnino coitus, sed tempus arbitror potius quamdiu illa non luceret. Accordingly, though his arguments were sometimes repeated by commentators and teachers, they won little assent from scholars who occupied themselves seriously with the passage. In his Adversaria Turnebus took silentia lunae as referring ‘ad noctis taciturnitatem…non ad interlunium’. In the first chapter of his De rebus per epistolam quaesitis Giano Parrasio sharply criticised the fuzziness of Politian's explanation: ‘Ambages istae sunt, ambages’. More important, he quoted a line from the Little Iliad: νξ μν ην μέσση, λαμπρ δ' πέτελλε σελήνη. This he rendered ‘Nox erat intempesta, nitebat et aurea coelo Luna’, and inferred from it that the moon had been up when Troy fell. In his Virgilius collation scriptorum Graecorum illustratus, finally, Fulvio Orsini published a scholium on Euripides' Hecuba, one which quoted both the line from the Little Iliad and an analysis of it by the Peripatetic Callisthenes. He too took the line as refuting Politian. (shrink)

The last chapter of Politian's first Miscellanea dealt with the amica silentia lunae through which the Greeks sailed back to Troy. He argued that the phrase should not be taken literally, as a statement that Troy fell at the new moon, but in an extended sense, as a poetic indication that the moon had not yet risen when the Greeks set sail. This reading had one merit: it explained how Virgil's moon could be silent while the Greeks were en route (...) but shine during the battle for the city. Yet Politian's effort to identify the phase of the moon described by Virgil was anything but clear: Non igitur aut sera fuerit aut pernox luna, tum nec lunae quidem omnino coitus, sed tempus arbitror potius quamdiu illa non luceret. Accordingly, though his arguments were sometimes repeated by commentators and teachers, they won little assent from scholars who occupied themselves seriously with the passage. In his Adversaria Turnebus took silentia lunae as referring ‘ad noctis taciturnitatem…non ad interlunium’. In the first chapter of his De rebus per epistolam quaesitis Giano Parrasio sharply criticised the fuzziness of Politian's explanation: ‘Ambages istae sunt, ambages’. More important, he quoted a line from the Little Iliad: νξ μν ην μέσση, λαμπρ δ' πέτελλε σελήνη. This he rendered ‘Nox erat intempesta, nitebat et aurea coelo Luna’, and inferred from it that the moon had been up when Troy fell. In his Virgilius collation scriptorum Graecorum illustratus, finally, Fulvio Orsini published a scholium on Euripides' Hecuba, one which quoted both the line from the Little Iliad and an analysis of it by the Peripatetic Callisthenes. He too took the line as refuting Politian. (shrink)

Technical chronology establishes the structure of calendars and the dates of events; it is, as it were, the foundation of history, particularly ancient history. The chronologer must know enough philology to interpret texts and enough astronomy to compute the dates of celestial phenomena, above all eclipses, which alone provide absolute dates. Joseph Scaliger, so we are told, was the first to master and apply this range of technical skills: Of the mathematical principles on which the calculation of periods rests, the (...) philologians understood nothing. The astronomers, on their side, had not yet undertaken to apply their data to the records of ancient times. Scaliger was the first of the philologians who made use of the improved astronomy of the sixteenth century to get a scientific basis for historical chronology. So Mark Pattison. This verdict can be challenged on a number of grounds. The one relevant at present is simple: Scaliger himself claimed far less. He certainly said that technical chronology had been untouched in modern times — not an entirely fair judgement — but in antiquity it had been practised in exactly the manner he considered proper, or so he believed. In particular he singles out Censorinus, whose De die natali drew extensively on Varro's lost Antiquitates rerum humanarum, books 14–19, for information on chronology. Students of Varro have long appreciated the importance of Censorinus. His dry and compact treatise offers Varronian views on etymology, the human life-span, and the course of history itself, all couched in language so jejune as to suggest that he added little or nothing to what he read. (shrink)

Technical chronology establishes the structure of calendars and the dates of events; it is, as it were, the foundation of history, particularly ancient history. The chronologer must know enough philology to interpret texts and enough astronomy to compute the dates of celestial phenomena, above all eclipses, which alone provide absolute dates. Joseph Scaliger, so we are told, was the first to master and apply this range of technical skills: Of the mathematical principles on which the calculation of periods rests, the (...) philologians understood nothing. The astronomers, on their side, had not yet undertaken to apply their data to the records of ancient times. Scaliger was the first of the philologians who made use of the improved astronomy of the sixteenth century to get a scientific basis for historical chronology. So Mark Pattison. This verdict can be challenged on a number of grounds. The one relevant at present is simple: Scaliger himself claimed far less. He certainly said that technical chronology had been untouched in modern times — not an entirely fair judgement — but in antiquity it had been practised in exactly the manner he considered proper, or so he believed. In particular he singles out Censorinus, whose De die natali drew extensively on Varro's lost Antiquitates rerum humanarum, books 14–19, for information on chronology. Students of Varro have long appreciated the importance of Censorinus. His dry and compact treatise offers Varronian views on etymology, the human life-span, and the course of history itself, all couched in language so jejune as to suggest that he added little or nothing to what he read. (shrink)

We are printing in its entirety the discussion document which sets out a code of professional conduct for nurses published by the Royal College of Nursing in November 1976 together with commentaries by the Assistant Secretary of the British Medical Association, a professor of nursing studies, student nurses and a lawyer. The image of the nurse is still that of one of Florence Nightingale's young ladies or of a member of a religious order who is wholly dedicated to caring for (...) the sick. Today, as this document and the comments upon it show, 'dedication' is still part of the motive which leads a man or woman to become a nurse but in addition, and this is where the public may be ignorant or choose to be ignorant, nursing offers a career where intellectual achievement and the satisfaction of a demanding job bring their proper financial reward and place in the professional community. We are grateful to the Royal College of Nursing for permission to publish this document. (shrink)

We present a derivation of the homogeneous Lorentz transformations that arrives immediately at the general form without the usual specialization in thex direction.

We point out that the acceptance of the relativity principle together with the homogeneity and isotropy of space and the homogeneity of time inevitably leads to the Lorentz spacetime transformation with a universal limiting speed σ. Speculations on possible new four-dimensional symmetries involving a variable “speed of light” such as that proposed by Hsu must therefore be dismissed on such a basis alone. In this paper we draw attention to some logical inconsistencies in Hsu's attempt at establishing a new space-light (...) transformation law, and follow with a discussion on why such an attempt must necessarily fail. (shrink)

Objective: To determine cryopreservation-induced alterations in the cytoskeleton of metaphase II mouse oocytes and the implications of these alterations in functionality of the cytoskeleton and polyploidy after fertilization.Design: Comparative study.Setting: Clinical and academic research environment at a medical school teaching hospital.Intervention : Oocytes were frozen using a slow-cooling and slow-thawing protocol in 1.5 M dimethyl sulfoxide and 0.2 M sucrose and were analyzed before and after fertilization.Main Outcome Measure : Cytoskeletal alterations, fertilization, and polyploidy rates.Result : When analyzed immediately after (...) thawing, the oocytes displayed dramatic cytoskeletal alterations. Only slight recovery was observed upon removal of the cryoprotectants. However, incubation after thawing of 1 hour at 37oC completely reestablished a normal microfilament and microtubule pattern while partially restoring normal spindle morphology and chromosome alignment. Accordingly, insemination immediately after removal of cryoprotectants resulted in a significantly decreased fertilization rate and aberrant dynamics of cytoskeleton-dependent events, whereas oocytes inseminated after the post-thaw incubation displayed fertilization rates and cytoskeletal dynamics comparable to those in controls. Cryopreservation did not increase polyspermy but significantly increased digyny when the oocytes were inseminated after the post-thaw incubation. All digynic eggs displayed an abnormal spindle remnant in comparison with diploid or polyspermic eggs.Conclusion : A brief period of incubation after thawing allows recovery and positively affects fertilization and cytoskeletal dynamics. Cryopreservation does not impair the functionality of microfilaments and cytoplasmic microtubules during postfertilization events. Our findings suggest that the increased rate of digyny in cryopreserved oocytes may be related to the spindle disorganization, leading to failure in segregation of the chromosomes, rather than to direct malfunction of the microfilaments in polar body formation. (shrink)

How do we judge whether an action is morally right or wrong? If an action is wrong, what reason does that give us not to do it? Why should we give such reasons priority over our other concerns and values? In this book, T. M. Scanlon offers new answers to these questions, as they apply to the central part of morality that concerns what we owe to each other. According to his contractualist view, thinking about right and wrong is thinking (...) about what we do in terms that could be justified to others and that they could not reasonably reject. He shows how the special authority of conclusions about right and wrong arises from the value of being related to others in this way, and he shows how familiar moral ideas such as fairness and responsibility can be understood through their role in this process of mutual justification and criticism. Scanlon bases his contractualism on a broader account of reasons, value, and individual well-being that challenges standard views about these crucial notions. He argues that desires do not provide us with reasons, that states of affairs are not the primary bearers of value, and that well-being is not as important for rational decision-making as it is commonly held to be. Scanlon is a pluralist about both moral and non-moral values. He argues that, taking this plurality of values into account, contractualism allows for most of the variability in moral requirements that relativists have claimed, while still accounting for the full force of our judgments of right and wrong. (shrink)

The purpose of this qualitative study was to analyse nurses’ professional dignity in their everyday working lives. We explored the factors that affect nursing professional dignity in practice that emerge in relationships with health professionals, among clinical nurses working in hospitals and in community settings in central Italy. The main themes identified were: (i) nursing professional dignity perceived as an achievement; (ii) recognition of dignity beyond professional roles. These two concepts are interconnected. This study provides insights into professional dignity in (...) nursing being perceived as an achievement linked to the intrinsic dignity of every human being. The ‘nursing professional dignity perceived as an achievement’ was perceived as having declined in different social factors. Some factors of nursing professional dignity perceived as an achievement were attained more easily in community settings. ‘Recognition of dignity beyond professional roles’ underpins the intrinsic dignity as an expression of humanity, embedded in persons regardless of any profession, and values, such as: respect, moral integrity, humility, working conscientiously and kindness. (shrink)

We introduce a simple model for so-called spin-echo experiments. We show that the model is a mincing system. On the basis of this model we study fine-grained entropy and coarse-grained entropy descriptions of these experiments. The coarse-grained description is shown to be unable to provide an explanation of the echo signals, as a result of the way in which it ignores dynamically generated correlations. This conclusion is extended to the general debate on the foundations of statistical mechanics. We emphasize the (...) need for an appropriate mechanism to explain the gradual suppression over time of the correlations in a thermodynamic system. We argue that such a mechanism can only be provided by the interventionist approach, in which the interaction of the system with its environment is taken into account. Irreversible behavior is then seen to arise not as a result of limited measurement accuracy , but as a result of the fact that thermodynamic systems are limited systems which interact with their environment. A detailed discussion is given of recent objections to the interventionist approach in the literature. (shrink)

What are words? What makes two token words tokens of the same word-type? Are words abstract entities, or are they (merely) collections of tokens? The ontology of words tries to provide answers to these, and related questions. This article provides an overview of some of the most prominent views proposed in the literature, with a particular focus on the debate between type-realist, nominalist, and eliminativist ontologies of words.

The US neutrino community gathered at the Workshop on the Intermediate Neutrino Program at Brookhaven National Laboratory February 4-6, 2015 to explore opportunities in neutrino physics over the next five to ten years. Scientists from particle, astroparticle and nuclear physics participated in the workshop. The workshop examined promising opportunities for neutrino physics in the intermediate term, including possible new small to mid-scale experiments, US contributions to large experiments, upgrades to existing experiments, R&D plans and theory. The workshop was organized into (...) two sets of parallel working group sessions, divided by physics topics and technology. Physics working groups covered topics on Sterile Neutrinos, Neutrino Mixing, Neutrino Interactions, Neutrino Properties and Astrophysical Neutrinos. Technology sessions were organized into Theory, Short-Baseline Accelerator Neutrinos, Reactor Neutrinos, Detector R&D and Source, Cyclotron and Meson Decay at Rest sessions.This report summarizes discussion and conclusions from the workshop. (shrink)