As they age, many people are afraid that they might become a burden to their families and friends. In fact, fear of being a burden is one of the most frequently cited reasons for individuals who request physician aid in dying. Why is this fear so prevalent, and what are the issues underlying this concern? I argue that perceptions of individual autonomy, dependency, and dignity all contribute to the fear of becoming a burden. However, this fear is misplaced; common conceptions (...) of these values should be re-framed and re-examined. Practices that support a more community-centered type of autonomy can be found in dependency and dignity. This paper offers some practical examples of how to address common end-of-life situations that may cause anxiety to patients who are worried about being a burden. These practices include discussing expectations, both for care and how the relationship among the participants might change, and modeling respectful caregiving behaviors. Most difficult of all, though, includes cultural and societal attitude changes so that people recognize the good in receiving care and get used to the idea that they do not need to do anything to be valuable. (shrink)

BackgroundNarrative medicine is a well-recognized and respected approach to care. It is now found in medical school curricula and widely implemented in practice. However, there has been no analysis of the perception and usage of narrative medicine across different medical specialties and whether there may be unique recommendations for implementation based upon specialty. The aims of this study were to explore these gaps in research.MethodsFifteen senior physicians who specialize in internal medicine, pediatrics, or surgery (5 physicians from each specialty) were (...) interviewed in a semi-structured format about the utilization, benefits, drawbacks (i.e., negative consequences), and roles pertaining to narrative medicine. Qualitative content analysis of each interview was then performed.ResultsThree themes emerged from our analysis: roles, practice, and outcomes. Through these themes we examined the importance, utilization, barriers, benefits, and drawbacks of narrative medicine. There was consensus that narrative medicine is an important tool in primary care. Primary care physicians (general internists and general pediatricians) also believed that narrative medicine is not as important for non-primary care providers. However, non-primary care providers (surgeons) generally believed narrative medicine is valuable in their practice as well. Within specialties, providers’ choice of language varied when trying to obtain patients’ narratives, but choice in when to practice narrative medicine did not differ greatly. Among specialties, there was more variability regarding when to practice narrative medicine and what barriers were present. Primary care physicians primarily described barriers to eliciting a patient’s narrative to involve trust and emotional readiness, while surgeons primarily described factors involving logistics and patient data as barriers to obtaining patients’ narratives. There was broad agreement among specialties regarding the benefits and drawbacks of narrative medicine.ConclusionsThis study sheds light on the shared and unique beliefs in different specialties about narrative medicine. It prompts important discussion around topics such as the stereotypes physicians may hold about their peers and concerns about time management. These data provide some possible ideas for crafting narrative medicine education specific to specialties as well as future directions of study. (shrink)

Conley and colleagues (2023) conduct a fascinating analysis of how influential organizations in the global governance of human genome editing debate conceptualize and perform public engagement. Whi...

This article offers a critique of the recently revised BMA guidance on routine neonatal male circumcision and seeks to challenge the assumptions underpinning the guidance which construe this procedure as a matter of parental choice. Our aim is to problematise continued professional willingness to tolerate the non-therapeutic, non-consensual excision of healthy tissue, arguing that in this context both professional guidance and law are uncharacteristically tolerant of risks inflicted on young children, given the absence of clear medical benefits. By interrogating historical (...) medical explanations for this practice, which continue to surface in contemporary justifications of non-consensual male circumcision, we demonstrate how circumcision has long existed as a procedure in need of a justification. We conclude that it is ethically inappropriate to subject children—male or female—to the acknowledged risks of circumcision and contend that there is no compelling legal authority for the common view that male circumcision is lawful. (shrink)

This is a critical introduction to modern French philosophy, commissioned from one of the liveliest contemporary practitioners and intended for an English-speaking readership. The dominant 'Anglo-Saxon' reaction to philosophical development in France has for some decades been one of suspicion, occasionally tempered by curiosity but more often hardening into dismissive rejection. But there are signs now of a more sympathetic interest and an increasing readiness to admit and explore shared concerns, even if these are still expressed in a very different (...) idiom and intellectual context. Vincent Descombes offers here a personal guide to the main movements and figures of the last forty-five years. He traces over this period the evolution of thought from a generation preoccupied with the 'three H's' - Hegel, Husserl and Heidegger, to a generation influenced since about 1960 by the 'three masters of suspicion' - Marx, Nietzsche and Freud. In this framework he deals in turn with the thought of Sartre, Merleau-Ponty, the early structuralists, Foucault, Althusser, Serres, Derrida, and finally Deleuze and Lyotard. The 'internal' intellectual history of the period is related to its institutional setting and the wider cultural and political context which has given French philosophy so much of its distinctive character. (shrink)

Plasminogen activator inhibitor‐1 (PAI‐1) is a physiological inhibitor of urokinase (uPA), a serine protease known to promote cell migration and invasion. Intuitively, increased levels of PAI‐1 should be beneficial in downregulating uPA activity, particularly in cancer. By contrast, in vivo, increased levels of PAI‐1 are associated with a poor prognosis in breast cancer. This phenomenon is termed the “PAI‐1 paradox”. Many factors are responsible for the upregulation of PAI‐1 in the tumor microenvironment. We hypothesize that there is a breast cancer (...) predisposition to a more aggressive stage when PAI‐1 is upregulated as a consequence of Metabolic Syndrome (MetS). MetS exerts a detrimental effect on the breast tumor microenvironment that supports cancer invasion. People with MetS have an increased risk of coronary heart disease, stroke, peripheral vascular disease and hyperinsulinemia. Recently, MetS has also been identified as a risk factor for breast cancer. We hypothesize the existence of the “PAI‐1 cycle”. Sustained by MetS, adipocytokines alter PAI‐1 expression to promote angiogenesis, tumor‐cell migration and procoagulant microparticle formation from endothelial cells, which generates thrombin and further propagates PAI‐1 synthesis. All of these factors culminate in a chemotherapy‐resistant breast tumor microenvironment. The PAI‐1 cycle may partly explain the PAI‐1 paradox. In this hypothesis paper, we will discuss further how MetS upregulates PAI‐1 and how an increased level of PAI‐1 can be linked to a poor prognosis. BioEssays 29:1029–1038, 2007. © 2007 Wiley Periodicals, Inc. (shrink)

Do the conditions under which promises are made determine whether they ought to be kept? Philosophers have placed a number of conditions on promising which, they hold, must be met in order to make promise‐keeping obligatory. In so doing, they have distinguished valid promises from invalid promises and justified promises from promises that are not justified. Considering such conditions, one by one, we argue that they are mistaken. In the first place, the conditions they lay down are not necessary for (...) either valid or justified promise‐making. In the second place, promises need not meet such conditions in order to create moral obligations. In general, such analyses of promising fail because they suffer from a confusion between promise‐making and promise‐keeping. Philosophers have wrongly supposed that obligations to keep promises are dependent upon, or derivable from, the quality of the promises themselves, at the time they are made, instead of focusing on conditions that must be satisfied at the time when promises are supposed to be kept. It is not the quality of a promise that determines an obligation to keep it but the rightness or wrongness of performing the promised act. (shrink)

While there had still been an increasing flow of foreign direct investment (FDI) into China during the 2002 downturn in FDI globally, such investments have historically been only sporadically successful. Much writing has detailed and discussed problems associated with China FDI but several costs remain dangerously overlooked. One such cost is that of micro-monitoring plants for work conditions and employee treatment in violation of local Chinese laws and possible home country ethics. Further, a more personal cost is presented – the (...) personal cost associated with maintaining an investment in a facility that violates standards of ethical employee treatment. Background information related to these issues is presented, along with a general overview of FDI in China. (shrink)

\noindent\textbf{Introduction} Online interventions hold great potential for Therapeutic Change Process Research (TCPR), a field that aims to relate in-therapeutic change processes to the outcomes of interventions. Online a client is treated essentially through the language their counsellor uses, therefore the verbal interaction contains many important ingredients that bring about change. TCPR faces two challenges: how to derive meaningful change processes from texts, and secondly, how to assess these complex, varied and multi-layered processes? We advocate the use text mining and multi-level (...) models (MLMs): the former offers tools and methods to discovers patterns in texts; the latter can analyse these change processes as outcomes that vary at multiple levels. \noindent\textbf{Method} We (re-)used the data from \cite{Lamers2015} because it includes outcomes and the complete online intervention for clients with mild depressive symptoms. We used text mining to obtain basic text-variables from e-mails, that we analysed through MLMs. \noindent\textbf{Results} We found that we could relate outcomes of interventions to variables containing text-information. We conclude that we can indeed bridge text mining and MLMs for TCPR as it was possible to relate text-information (obtained through text mining) to multi-levelled TCPR outcomes (using a MLM). \noindent\textbf{Discussion} Text mining can be helpful to obtain change processes, which is also the main challenge for TCPR. We showed how MLMs and text mining can be combined, but our proposition leaves open how to obtain the most relevant textual operationalization of TCPR concepts. That requires interdisciplinary collaboration and discussion. The future does look bright: based on our proof-of-concept study we conclude that MLMs and text mining can indeed advance TCPR. (shrink)

Book reviewed in this article: The Social Dimensions of AIDS: Method and Theory. By Douglas A. Feldman & Thomas M. Johnson AIDS: Ethics and Public Policy. By Christine Pierce and Donald VanDeVeer.

Today’s panel is about the expanding boundary of population health policy, what that expanding boundary has to do with law, and what kinds of challenges and opportunities come out of it. What I want to do for the next few minutes is talk to you about the notion of population health as it exists where law and policy are made, rather than where it exists in a spectacular international theoretical literature. Then I want to introduce our panelists. In the process, (...) I will explain why the Honorable John Nilson, is not with us, which tells you a great deal about not only the real world of the politics of population health, but also about the kind of trouble you can get into if you are a first class lawyer involved in population health. (shrink)

Book reviewed in this article: The Social Dimensions of AIDS: Method and Theory. By Douglas A. Feldman & Thomas M. Johnson AIDS: Ethics and Public Policy. By Christine Pierce and Donald VanDeVeer.

Ethical guidance from the British Medical Association about treating doctor–patients is compared and contrasted with evidence from a qualitative study of general practitioners who have been patients. Semistructured interviews were conducted with 17 GPs who had experienced a significant illness. Their experiences were discussed and issues about both being and treating doctor–patients were revealed. Interpretative phenomenological analysis was used to evaluate the data. In this article data extracts are used to illustrate and discuss three key points that summarise the BMA (...) ethical guidance, in order to develop a picture of how far experiences map onto guidance. The data illustrate and extend the complexities of the issues outlined by the BMA document. In particular, differences between experienced GPs and those who have recently completed their training are identified. This analysis will be useful for medical professionals both when they themselves are unwell and when they treat doctor–patients. It will also inform recommendations for professionals who educate medical students or trainees. (shrink)

Today’s panel is about the expanding boundary of population health policy, what that expanding boundary has to do with law, and what kinds of challenges and opportunities come out of it. What I want to do for the next few minutes is talk to you about the notion of population health as it exists where law and policy are made, rather than where it exists in a spectacular international theoretical literature. Then I want to introduce our panelists. In the process, (...) I will explain why the Honorable John Nilson, is not with us, which tells you a great deal about not only the real world of the politics of population health, but also about the kind of trouble you can get into if you are a first class lawyer involved in population health. (shrink)

The medical humanities were organized, beginning in the late 1960s, by a small group of people who shared a critique of medical education and a commitment to vigorous action to change it. They proposed to create several demonstration programs in humanities education at American schools. Although the group began with a religious orientation, it soon acquired a broader, more secular mission. As a result of shrewd political organizing, the group attracted members from within medicine, and was awarded a grant to (...) promote the medical humanities. This paper describes these events and sets them in the context of the social and medical history of the 1960s and early 1970s. (shrink)