Existing regulation of end-of-life care is flawed. Problems include poorly-designed laws, policies, ethical codes, training, and funding programs, which often are neither effective nor helpful in guiding decision-making. This leads to adverse outcomes for patients, families, health professionals, and the health system as a whole. A key factor contributing to the harms of current regulation is a siloed approach to regulating end-of-life care. Existing approaches to regulation, and research into how that regulation could be improved, have tended to focus on (...) a single regulatory instrument (e.g., just law or just ethical codes). As a result, there has been a failure to capture holistically the various forces that guide end-of-life care. This article proposes a response to address this, identifying “regulatory space” theory as a candidate to provide the much-needed holistic insight into improving regulation of end-of-life care. The article concludes with practical implications of this approach for regulators and researchers. (shrink)

Background Voluntary assisted dying became lawful in Victoria, the first Australian state to permit this practice, in 2019 via the Voluntary Assisted Dying Act 2017 (Vic). While conscientious objection by individual health professionals is protected by the Victorian legislation, objections by institutions are governed by policy. No research has been conducted in Victoria, and very little research conducted internationally, on how institutional objection is experienced by patients seeking assisted dying. Methods 28 semi-structured interviews were conducted with 32 family caregivers and (...) one patient about the experience of 28 patients who sought assisted dying. Participants were interviewed during August-November 2021. Data from the 17 interviews (all with family caregivers) which reported institutional objection were analysed thematically. Results Participants reported institutional objection affecting eligibility assessments, medication access, and taking the medication or having it administered. Institutional objection occurred across health settings and was sometimes communicated obliquely. These objections resulted in delays, transfers, and choices between progressing an assisted dying application and receiving palliative or other care. Participants also reported objections causing adverse emotional experiences and distrust of objecting institutions. Six mediating influences on institutional objections were identified: staff views within objecting institutions; support of external medical practitioners and pharmacists providing assisted dying services; nature of a patient’s illness; progression or state of a patient’s illness; patient’s geographical location; and the capability and assertiveness of a patient and/or caregiver. Conclusions Institutional objection to assisted dying is much-debated yet empirically understudied. This research found that in Victoria, objections were regularly reported by participants and adversely affected access to assisted dying and the wider end-of-life experience for patients and caregivers. This barrier arises in an assisted dying system that is already procedurally challenging, particularly given the limited window patients have to apply. Better regulation may be needed as Victoria’s existing policy approach appears to preference institutional positions over patient’s choice given existing power dynamics. (shrink)

In jurisdictions where voluntary assisted dying is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors’ involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this (...) protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture. There are no data in this work. (shrink)

ObjectiveTo increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility.SettingThree tertiary hospitals in metropolitan Brisbane, Australia.DesignQualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic (...) analysis.ResultsDoctors’ perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing.ConclusionsDoctors’ ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors’ role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making. (shrink)

This volume contains ten new essays on a priori knowledge by authors from Canada, the United States, Australia, & Europe Topics addressed include the nature, explanation, & indispensability of a priori knowledge, its connection with analytic truth, its place in mathematics, in logic, & in empirical theory, & the contribution of Kant & Quine to these topics. The focus is on twentieth-century contributions to these issues, but most essays also address earlier discussions at some length, & the essays that focus (...) on Kant also relate his views to more recent discussions. Contents: Introduction. A Rationalist Manifesto. Analyticity, Undeniability, & Truth. Analyticity & the A Priori. The Doubtful A Priori. Some Remarks on Indiscernibility. The Constitutive A Priori. Kant's A Priori Methods for Recognising Necessary Truths. EPR as A Priori Science. Gaps, Gluts, & Paradox. An Essay on Material Necessity. (shrink)

BackgroundThis paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources.MethodsAll publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation.ResultsFour resource-related themes were (...) identified: doctors’ ethical duties to consider resource allocation; balancing ethical obligations to patient and society; fair process and transparent resource allocation; and legal guidance on distributive justice as a rationale to limit life-sustaining treatment.ConclusionOf the policies that addressed resource allocation, this review found broad agreement about the existence of doctors’ duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment. (shrink)

Background Victoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to consider Objective To describe and analyse publicly available policy documents articulating an institutional objection to voluntary assisted dying in Victoria. Methods Policies were identified using a range of strategies, and those disclosing and discussing the nature of an institutional objection were thematically (...) analysed using the framework method. Results The study identified fifteen policies from nine policymakers and developed four themes: (1) extent of refusal to participate in VAD, (2) justification for refusal to provide VAD, (3) responding to requests for VAD, and (4) appeals to state-sanctioned regulatory mechanisms. While institutional objections were stated clearly, there was very little practical detail in most documents to enable patients to effectively navigate objections in practice. Conclusion This study demonstrates that despite having clear governance pathways developed by centralized bodies (namely, the Victorian government and Catholic Health Australia), many institutions’ public-facing policies do not reflect this guidance. Since VAD is contentious, laws governing institutional objection could provide greater clarity and regulatory force than policies alone to better balance the interests of patients and non-participating institutions. (shrink)

Background In June 2016, Canada legalized medical assistance in dying (MAiD). From the outset, some healthcare institutions (including faith-based and non-faith-based hospitals, hospices, and residential aged care facilities) have refused to allow aspects of MAiD onsite, resulting in patient transfers for MAiD assessments and provision. There have been media reports highlighting the negative consequences of these “institutional objections”, however, very little research has examined their nature and impact. Methods This study reports on findings from 48 semi-structured qualitative interviews conducted with (...) MAiD assessors and providers, MAiD team members (working to coordinate care and lead MAiD programs in institutions and health authorities), and family caregivers on their experiences with institutional objection. Participants were recruited from the Canadian provinces of British Columbia, Ontario, and Nova Scotia. Data were analyzed using inductive thematic analysis. Results Themes identified were: (1) basis for institutional objection (with objections commonly rooted in religious values and a particular philosophy of palliative care); (2) scope of objection (demonstrating a wide range of practices objected to); (3) lack of transparency regarding institutional position; (4) impacts on patients; (5) impacts on health practitioners; and (6) catalysts for change. Participants reported that many institutions’ objections had softened over time, lessening barriers to MAiD access and adverse impacts on patients and health practitioners. Participants attributed this positive change to a range of catalysts including advocacy by health practitioners and family members, policymaking by local health authorities, education, and relationship building. Nevertheless, some institutions, particularly faith-based ones, retained strong objections to MAiD, resulting in forced transfers and negative emotional and psychological impacts on patients, family members, and health practitioners. Conclusions This paper adds to the limited evidence base about the impacts of institutional objection and can inform practical and regulatory solutions in Canada and abroad. Reform is needed to minimize the negative impacts on patients, their caregivers, and health practitioners involved in MAiD practice. (shrink)

BackgroundJunior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors’ decision-making processes when treating people with dementia who have advance care directives, or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: their legal compliance and decision-making process related to treatment decisions; the factors influencing their clinical decision-making; and the factors (...) associated with accurate responses to one hypothetical vignette. MethodA cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: bacterial pneumonia; or suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette.ResultsOverall, 116 junior doctors responded. In Vignette 1, 58% of respondents selected the legally compliant option. Participants who chose the legally compliant option perceived ‘following patient wishes’ and ‘legal requirements to follow ACDs’ as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the ‘ACD is relevant in my decision-making process, but other factors are more relevant’. In Vignette 2, 72% of respondents indicated they would commence treatment and 18% selected they would not commence treatment.. Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario.ConclusionsThere are critical gaps in junior doctors’ compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors’ clinical decision-making and ensure compliance with the law is required. (shrink)

The ethical theory espoused by a philosopher is often dominated by certain implicit epistemological assumptions. These “ways of knowing” may in turn be dominated by personality preferences that give rise to certain preferred worldviews that undergird various philosophies. Such preferred worldviews are seen in We believe positions, stated or unstated. The meaning of these claims about the interconnections of unexamined assumptions and their philosophical implications may be seen through an example. This paper will examine certain crucial aspects of the thought (...) of John Doris, who promotes a form of situationist ethics. This example is intended to be suggestive rather than conclusive. It points to the need for an openness to other epistemological assumptions that might permit a more comprehensive appreciation of what moral agency involves, beyond what arises from the restricted methods of analytical philosophy and a positivist worldview. There have been other efforts to meet the situationist challenge to classical Aristotelian ethics, yet surprisingly little attention has been given to the role of implicit epistemologies and unexamined psychologies. This paper offers a critical examination of these prior We believe positions. (shrink)

Papers presented at a workshop held at the United Theological College, Bangalore, 1-12 June 1993 under the auspices of the Board of Theological Education of the Senate of Serampore College.

The present article addresses the logic of the sphere, or the Sphere Model of Consciousness developed by Patrizio Paoletti over three decades of research. M.E.D. Ed., 2002; Flussi, territori, luogo II. M.E.D. Ed., 2002; Fare il punto nave. M.E.D. Ed., 2005; In: Proceedings conference at Leslie and Susan Gonda Multidisciplinary Brain Research Center. Bar Ilan University. Faculty of Neuroscience, Israel, 2007; Osservazione—Quaderni di Pedagogia per il Terzo Millennio, Ed. 3P, 2011; Mediazione—Quaderni di Pedagogia per il Terzo Millennio, Ed. 3P, 2011). (...) The SMC model has been experimentally applied in the educational field and lies at the base of neuroscientific and psychoeducational research conducted by the Paoletti Foundation. In recent years, it has been studied by several researchers in the field of neuroscience. Following a logical-mathematical introduction regarding the properties of the spherical shape, we illustrate for the first time the structuring of the model and its neural foundations. We emphasize the central space of the sphere, defined by the geometric model and highlight its descriptive and heuristic properties in relation to the study of consciousness. Finally, we present educational applications of the model, particularly with respect to the center of the sphere, defined in the current context as the “place of pre-existence.”. (shrink)

The present article addresses the logic of the sphere, or the Sphere Model of Consciousness developed by Patrizio Paoletti over three decades of research. M.E.D. Ed., 2002; Flussi, territori, luogo II. M.E.D. Ed., 2002; Fare il punto nave. M.E.D. Ed., 2005; In: Proceedings conference at Leslie and Susan Gonda Multidisciplinary Brain Research Center. Bar Ilan University. Faculty of Neuroscience, Israel, 2007; Osservazione—Quaderni di Pedagogia per il Terzo Millennio, Ed. 3P, 2011; Mediazione—Quaderni di Pedagogia per il Terzo Millennio, Ed. 3P, 2011). (...) The SMC model has been experimentally applied in the educational field and lies at the base of neuroscientific and psychoeducational research conducted by the Paoletti Foundation. In recent years, it has been studied by several researchers in the field of neuroscience. Following a logical-mathematical introduction regarding the properties of the spherical shape, we illustrate for the first time the structuring of the model and its neural foundations. We emphasize the central space of the sphere, defined by the geometric model and highlight its descriptive and heuristic properties in relation to the study of consciousness. Finally, we present educational applications of the model, particularly with respect to the center of the sphere, defined in the current context as the “place of pre-existence.”. (shrink)

Ecological research and conservation practice frequently raise difficult and varied ethical questions for scientific investigators and managers, including duties to public welfare, nonhuman individuals (i.e., animals and plants), populations, and ecosystems. The field of environmental ethics has contributed much to the understanding of general duties and values to nature, but it has not developed the resources to address the diverse and often unique practical concerns of ecological researchers and managers in the field, lab, and conservation facility. The emerging field of (...) “ecological ethics” is a practical or scientific ethics that offers a superior approach to the ethical dilemmas of the ecologist and conservation manager. Even though ecological ethics necessarily draws from the principles and commitments of mainstream environmental ethics, it is normatively pluralistic, including as well the frameworks of animal, research, and professional ethics. It is also methodologically pragmatic, focused on the practical problems of researchers and managers and informed by these problems in turn. The ecological ethics model offers environmental scientists and practitioners a useful analytical tool for identifying, clarifying, and harmonizing values and positions in challenging ecological research and management situations. Just as bioethics provides a critical intellectual and problem-solving service to the biomedical community, ecological ethics can help inform and improve ethical decision making in the ecology and conservation communities. (shrink)

In the study of expertise, few debates come as big as that between constructivists and realists. This chapter discusses the signal debate between realists and constructivists about expertise. It sets out a view that includes aspects of both the constructivist and realist position to show that insights from what is often considered to be rival camps can be incorporated in a position that does justice to both. The chapter argues that, while expertise is real, there are two distinct social dimensions (...) to the concept of expertise. It attempts to demonstrate two distinct ways in which expertise has a social dimension. First, the chapter develops an account according to which 'is an expert' is a triadic predicate. Second, it considers the fact that attributions of expertise are often done by institutions, i.e. by medical boards certifying doctors, etc. Both dimensions can be acknowledged without undermining the basic case for realism about expertise. (shrink)

Kotzee and Smit explain why, if unicorns don't exist, then they could not possibly have existed. In fact, even if horned horses were discovered somewhere, they would not necessarily be unicorns. The key to understanding why this is so lies in understanding how so-called natural kind terms function.

Gabbay's separation theorem about linear temporal logic with past has proved to be one of the most useful theoretical results in temporal logic. In this paper, we establish an analogous statement a...

This study adjudicates between two opposing accounts of morphological productivity, using English past-tense as its test case. The single-route model posits that both regular and irregular past-tense forms are generated by analogy across stored exemplars in associative memory. In contrast, the dual-route model posits that regular inflection requires use of a formal “add -ed” rule that does not require analogy across regular past-tense forms. Children saw animations of an animal performing a novel action described with a novel verb. Past-tense forms (...) of novel verbs were elicited by prompting the child to describe what the animal “did yesterday.” Collapsing across age group, the likelihood of a verb being produced in regular past-tense form was positively associated with the verb's similarity to existing regular verbs, consistent with the single-route model only. Results indicate that children's acquisition of the English past-tense is best explained by a single-route analogical mechanism that does not incorporate a role for formal rules. (shrink)

Being Arising:. Review of Going on Bdngby Mark Epstein and The Positive Psychology of Buddhism and Yoga by Martin Levine.

This paper defends the view, put roughly, that to think that p is to guess that p is the answer to the question at hand, and that to think that p rationally is for one’s guess to that question to be in a certain sense non-arbitrary. Some theses that will be argued for along the way include: that thinking is question-sensitive and, correspondingly, that ‘thinks’ is context-sensitive; that it can be rational to think that p while having arbitrarily low credence (...) that p; that, nonetheless, rational thinking is closed under entailment; that thinking does not supervene on credence; and that in many cases what one thinks on certain matters is, in a very literal sense, a choice. Finally, since there are strong reasons to believe that thinking just is believing, there are strong reasons to think that all this goes for belief as well. (shrink)

This paper proposes several concepts of efficient solutions for multicriteria decision problems under uncertainty. We show how alternative notions of efficiency may be grounded on different decision ‘contexts’, depending on what is known about the Decision Maker's (DM) preference structure and probabilistic anticipations. We define efficient sets arising naturally from polar decision contexts. We investigate these sets from the points of view of their relative inclusions and point out some particular subsets which may be especially relevant to some decision situations.