AimsThis study evaluates a protocol for early, routine ethics consultation for patients on extracorporeal membrane oxygenation to support decision-making in the context of clinical uncertainty with the aim of mitigating ethical conflict and moral distress.MethodsWe conducted a single-site qualitative analysis of EC documentation for all patients receiving ECMO support from 15 August 2018 to 15 May 2019. Detailed analysis of 20 ethically complex cases with protracted ethics involvement identifies four key ethical domains: limits of prognostication, bridge to nowhere, burden of (...) treatment and system-level concerns. There are three subthemes: relevant contextual factors, the role of EC and observed outcomes. Content analysis of transcripts from interviews with 20 members of the multidisciplinary ECMO team yields supplemental data on providers’ perceptions of the impact of the early intervention protocol.ResultsLimited outcome data for ECMO, unclear indications for withdrawal, adverse effects of treatment and an obligation to attend to programme metrics present significant ethical challenges in the care of this patient population. Upstream EC mitigates ethical conflict by setting clear expectations about ECMO as a time limited trial, promoting consistent messaging among multiple services and supporting surrogate decision-makers. When ECMO becomes a ‘bridge to nowhere’, EC facilitates decision-making that respects patient values yet successfully sets limits on non-beneficial use of this novel therapy.ConclusionData from this study support the conclusion that ECMO poses unique ethical challenges that necessitate a standardised protocol for early, routine EC—at least while this medical technology is in its nascent stages. (shrink)

Organ donation after a circulatory determination of death is possible in selected patients where consent is given to support donation and the patient has been legally declared dead by two doctors. The National Health Act (61 of 2003) and regulations provide strict controls for the certification of death and the donation of organs and tissues after death. Although the National Health Act expressly recognises that brain death is death, it does not prescribe the medical standards of testing for the determination (...) of brain death (neurological determination of death), circulatory death (circulatory determination of death) or for determination of death based on somatic criteria. However, in all cases of organ donation, including after circulatory death, the National Health Act mandates that two doctors certify the death, with one doctor possessing more than 5 years of experience. Additionally, both doctors must be independent from the transplant team. The standard for such determination, as for brain death, aligns with accepted medical standards. The Critical Care Society of Southern Africa has published South African (SA) Guidelines on Death Determination that outline rigorous standards for death determination in hospital settings by either a neurological or circulatory method. Legislation and the Health Professions Council of SA’s (HPCSA) professional guidance direct clinicians on obtaining informed consent for donation either from the patient or in cases of incapacity from their surrogate decision maker. Collectively, the legislation, regulations and professional guidelines in SA provide a robust ethical framework that supports organ donation after circulatory death. (shrink)

This article deals with nurses’ ethical concerns raised by the consequences of changes in governmental and institutional policies on nursing practice and patient care. The aims of this project were to explore perspectives of registered nurses who provide or manage direct patient care on policies that affect nursing and patient care, and to provide input to policy makers for the development of more patient-centred policies. Four focus groups were conducted with a total of 36 registered nurse participants. The project team (...) identified major themes that emerged in the analysis of transcripts of the focus group discussions. The four major themes were: effects of policy focused on cost containment, effects on quality of care, effects on patient education and access to needed services, and effects on nurses and nursing. The participants identified primarily negative effects of changes in national health policy and legislation that influence institutional policies on patient care and nursing practice. The effects of identified policy changes raised concerns about meeting nurses’ ethical obligations to patients and families. Participants specified key points for consideration by legislators and other policy makers. They viewed nurses who are involved in direct patient care as a critical resource for legislators and other policy makers in the development of public and institutional policies that affect nursing and patient care. (shrink)

Ethical challenges in public health can have a significant impact on the health of communities if they impede efficiencies and best practices. Competing needs for resources and a plurality of values can challenge public health policymakers and practitioners to make fair and effective decisions for their communities. In this paper, the authors offer an analytic framework designed to assist policymakers and practitioners in managing the ethical tensions they face in daily practice. Their framework is built upon the following set of (...) six considerations: determining population-level utility of the proposed action; demonstrating evidence of need and effectiveness of actions; establishing fairness of goals and proposed implementation strategies; ensuring accountability; and, assessing expected efficiencies and costs associated with the proposed action. Together, these considerations create a structured guide to assist decision-makers in identifying potential ethical challenges and in assessing the moral considerations that underlie public health practice - and possibly even, if the conditions are met, reduce the creation of ethical tension. Although the authors’empirical experiences provide the basis for the framework advanced here, their approach remains to be tested and evaluated by public health practitioners. (shrink)

Coastal ecosystems are increasingly dominated by humans. Consequently, the human dimensions of sustainability science have become an integral part of emerging coastal governance and management practices. But if we are to avoid the harsh lessons of land management, coastal decision makers must recognize that humans are one of the more coastally dependent species in the biosphere. Management responses must therefore confront both the temporal urgency and the very real compromises and sacrifices that will be necessary to achieve a sustainable coastal (...) ecosystem, one that is economically feasible, socially just, and ecologically sound. (shrink)

Genomic research projects that collect tissues from deceased organ and tissue donors must obtain the authorization of family decision makers under difficult circumstances that may affect the authorization process. Using a quasi-experimental design, the Ethical, Legal, and Social Issues (ELSI) substudy of the Genotype-Tissue Expression (GTEx) project compared the recall and understanding of the donation authorization process of two groups: family members who had authorized donation of tissues to the GTEx project (the comparison group) and family members who had authorized (...) organ and tissue donations in years previous, who subsequently participated in two different mock-authorization processes that mimicked the GTEx authorization process (the intervention groups). Participants in the comparison and intervention groups were matched on key demographic characteristics.We found that participants in the intervention groups who experienced a mock-authorization process demonstrated better recall of the tissue donation request than members of the comparison group. Our data indicate that the stress associated with the loss of a loved one limited the ability of family members to recall details about the GTEx project. However, we found a similar lack of knowledge in both the comparison and the intervention group participants, suggesting lack of knowledge may be due to the complexity and unfamiliarity of the information presented to them during the authorization process. We discuss these findings in the context of everyday clinical decision making in cognitively challenging conditions. (shrink)

Summary A study of the metallurgy and manufacturing techniques of a group of eight astrolabes (seven from Lahore, one attributed to India) using non-destructive methods has produced the earliest evidence for systematic use of high-zinc (α?+??) brass. To produce this alloy, the brass industry supplying the Lahore instrument makers must have co-melted metallic copper and zinc. This brass-making technology was previously believed to have been developed on an industrial scale in the nineteenth century in Europe. This work hypothesizes that this (...) technology was used in Lahore on an industrial scale as early as ad 1601. In addition, this work hypothesizes that the α?+?? brass alloy was used specifically for its ease in manufacturing the thin sheet brass required for astrolabe-component manufacture. (shrink)

Summary A study of the metallurgy and manufacturing techniques of a group of eight astrolabes using non-destructive methods has produced the earliest evidence for systematic use of high-zinc brass. To produce this alloy, the brass industry supplying the Lahore instrument makers must have co-melted metallic copper and zinc. This brass-making technology was previously believed to have been developed on an industrial scale in the nineteenth century in Europe. This work hypothesizes that this technology was used in Lahore on an industrial (...) scale as early as ad 1601. In addition, this work hypothesizes that the α + β brass alloy was used specifically for its ease in manufacturing the thin sheet brass required for astrolabe-component manufacture. (shrink)

Patient-reported outcomes are frequently used for medical decision making, at the levels of both individual patient care and healthcare policy. Evidence increasingly shows that PROs may be influenced by patients’ response shifts and dispositions. We identify how response shifts and dispositions may influence medical decisions on both the levels of individual patient care and health policy. We provide examples of these influences and analyse the consequences from the perspectives of ethical principles and theories of just distribution. If influences of response (...) shift and disposition on PROs and consequently medical decision making are not considered, patients may not receive optimal treatment and health insurance packages may include treatments that are not the most effective or cost-effective. We call on healthcare practitioners, researchers, policy makers, health insurers, and other stakeholders to critically reflect on why and how such patient reports are used. (shrink)

Bioethical decision‐making in pediatrics diverges from similar decisions in other medical domains because the young child is not an autonomous decision‐maker, while the teen is developing—and should be encouraged to develop—autonomy and decisional capacity. Thus the balance between autonomy and beneficence is fundamentally different in pediatrics than in adult medicine. While ethical dilemmas that reflect these fundamental issues are common, many pediatric physician and nursing training programs do not delve into the issues or offer specific training about how to (...) deal with borderline cases.To meet this need, the Children's Mercy Bioethics Center in Kansas City, Missouri, created a program specifically dedicated to serving practicing, experienced pediatric health professionals. Our students come from various professional disciplines: they are doctors, nurses, social workers, chaplains, lawyers, psychologists, counselors, and hospital administrators practicing in pediatrics. (shrink)

This paper is one of the four interrelated action agenda papers resulting from the National Summit on Public Health Legal Preparedness convened in June 2007 by the Centers for Disease Control and Prevention and multi-disciplinary partners. Each of the action agenda papers deals with one of the four core elements of public health legal preparedness: laws and legal authorities; competency in using those laws; coordination of law-based public health actions; and information. Options presented in this paper are for consideration by (...) policy makers and practitioners — in all jurisdictions and all relevant sectors and disciplines — with responsibilities for all-hazards emergency preparedness.Advancing and protecting the public's health depends upon the coordination of actions by many, diverse partners. For effective public health preparedness, there must be effective coordination of legal tools and law-based strategies across local, state, tribal, and federal jurisdictions, and also across sectors such as public health, health care, emergency management, education, law enforcement, community design, and academia. (shrink)

This paper is one of the four interrelated action agenda papers resulting from the National Summit on Public Health Legal Preparedness convened in June 2007 by the Centers for Disease Control and Prevention and multi-disciplinary partners. Each of the action agenda papers deals with one of the four core elements of public health legal preparedness: laws and legal authorities; competency in using those laws; coordination of law-based public health actions; and information. Options presented in this paper are for consideration by (...) policy makers and practitioners — in all jurisdictions and all relevant sectors and disciplines — with responsibilities for all-hazards emergency preparedness.Advancing and protecting the public's health depends upon the coordination of actions by many, diverse partners. For effective public health preparedness, there must be effective coordination of legal tools and law-based strategies across local, state, tribal, and federal jurisdictions, and also across sectors such as public health, health care, emergency management, education, law enforcement, community design, and academia. (shrink)

Background Empirical studies of surrogate decision-making tend to assume that surrogates should make only a 'substituted judgement'—that is, judge what the patient would want if they were mentally competent. Objectives To explore what people want in a surrogate decision-maker whom they themselves select and to test the assumption that people want their chosen surrogate to make only a substituted judgement. Methods 30 undergraduate students were recruited. They were presented with a hypothetical scenario about their expected loss of mental capacity (...) in the future and asked to answer some questions about their choice of surrogate. These data were analysed qualitatively using thematic content analysis. Results Most respondents talked about choosing someone who was caring and competent in certain ways, giving interesting evidence for their judgements. Surprisingly few highlighted how well they thought their chosen surrogate knew their preferences and would be able to make a substituted judgement. Moreover, few specified that their chosen surrogate had similar attitudes and values to their own and so would make a similar decision to theirs in the circumstances presented. Some respondents also referred to the social role of their chosen surrogate or the social dynamics of their situation which influenced their choices, as well as to ideas of reciprocity and characteristics of honesty and loyalty. Conclusion In the event that they lose mental capacity, many people will not select a surrogate to decide about medical treatments on their behalf solely on the basis that they expect their surrogate to make a substituted judgement. (shrink)

Introduction Stored human samples and the establishment of biobanks are increasing in the world. Along with this there are the questions of ethics that arise such as the correct method of obtaining informed consent for research on stored samples and the policies involved in collaborative research using collected samples. This study is an attempt to evaluate the researchers, academics and policy makers' views on these ethical aspects. Methods This was an anonymised study involving a Sri Lankan population of researchers, ethics (...) committee members, and policy makers. A self administered questionnaire was utilised as the study instrument. The questionnaire captured four major areas of interest: demographic characteristics of respondents, their attitudes on informed consent policy, their opinion on rights of collaborating researchers, their attitudes on dealing with international differences in regulatory frameworks. Results The study included 55 responders with 40/55 agreeing that donors should receive the option of giving informed consent for future research, with 31/55 considering multiple- type consent options most appropriate. Regarding the issue of shared samples in collaborative research majority agreed that source country ethics review committee approval was necessary 53/55. Conclusion The study concludes that sample donors should be given the option of giving advance consent to unspecified future research provided that future research is approved by an ethics committee. In collaborative research, it is necessary to involve ethics committees from donor countries in the research approval process. (shrink)

Architectural style is a medium for the promotion of cultural identities and cohesion. South Asian Association for Regional Cooperation nations provide a prism through which all forms of vernacular architecture can be viewed. This study is presented through the lens of the soul of the eye coupled with the power of technological probing. This synthesis affords a most appealing and lyrical exploration of the course of the development of cities within the SAARC nations. It showcases research results combining the above (...) stated synergy—starting from some of SAARC’s sophisticated historic cultures, cultures that ebbed and flowed along its shores and valleys. This paper shall touch upon unique cultural roots stretching back to the Dravidian civilization that flourished over 3500 years ago and also look at the grouping of houses within the Indus Valley Civilization in Lothal and the Sarasvati Valley Civilization in Kalibangan. The sensitivity underlying SAARC architecture and its traditions are seen in many communal settlements, profoundly so in the Indian subcontinent and in Sri Lanka. The paper shall showcase two specific, but nevertheless, distinct styles of communal functioning within unique architectural strongholds in the ancient Ratnagiri University in Odisha, India, and also touch upon a unique blend of styles of landscape architecture in Sri Lanka. The overarching emphasis of this study is that throughout SAARC’s history, architecture has been creatively adopted to the need of its users and the characteristics of its climate and location. It has always fulfilled the needs and nourished the spirit of its people, promoting cultural cohesion even today. In this context, it is interesting to explore traditional techniques of vernacular architecture in houses in Andhra, Tamil Nadu and Kerala. The common thread linking mass housing in Lothal, Kalibangan, Anuradhapura and Ratnagiri about 2 millennia ago, with present day housing patterns, is in the application of sustainable building practices using intelligent building forms, fabric and orientation. This paper explores this commonality from a modern perspective using CFD. As the SAARC countries still struggle to get a fuller understanding of their unique ecology and the complexity of their diverse cultures, revisiting the architectural legacy of their indigenous societies might prove insightful. The need for this revisit becomes even more relevant in the wake of the Paris Agreement and more recently the Kigali Agreement. The discourse on providing indoor thermal comfort to the SAARC people cannot be decoupled from the climate change story—heating, ventilation and cooling consume a large amount of energy and have a deep underlying link with the targets set at Paris and Kigali. The onus will be on a large number of stakeholders to meet these targets—engineers, architects, manufacturers, policy-makers, researchers and consumers. This paper aims at reminding the stakeholders of the richness and the usefulness of their vernacular architecture in upholding the ideal of sustainability. (shrink)

This is a study of a crucial and controversial topic in metaphysics and the philosophy of science: the status of the laws of nature. D. M. Armstrong works out clearly and in comprehensive detail a largely original view that laws are relations between properties or universals. The theory is continuous with the views on universals and more generally with the scientific realism that Professor Armstrong has advanced in earlier publications. He begins here by mounting an attack on the orthodox and (...) sceptical view deriving from Hume that laws assert no more than a regularity of coincidence between instances of properties. In doing so he presents what may become the definitive statement of the case against this position. Professor Armstrong then goes on to establish his own theory in a systematic manner defending it against the most likely objections, and extending both it and the related theory of universals to cover functional and statistical laws. This treatment of the subject is refreshingly concise and vivid: it will both stimulate vigorous professional debate and make an excellent student text. (shrink)

Breaking new ground in the debate about the relation of mind and body, David Armstrong's classic text - first published in 1968 - remains the most compelling and comprehensive statement of the view that the mind is material or physical. In the preface to this new edition, the author reflects on the book's impact and considers it in the light of subsequent developments. He also provides a bibliography of all the key writings to have appeared in the materialist debate.

In this important study D. M. Armstrong offers a comprehensive system of analytical metaphysics that synthesises but also develops his thinking over the last twenty years. Armstrong's analysis, which acknowledges the 'logical atomism' of Russell and Wittgenstein, makes facts the fundamental constituents of the world, examining properties, relations, numbers, classes, possibility and necessity, dispositions, causes and laws. All these, it is argued, find their place and can be understood inside a scheme of states of affairs. This is a comprehensive and (...) rigorously this-worldly account of the most general features of reality, argued from a distinctive philosophical perspective, and it will appeal to a wide readership in analytical philosophy. (shrink)

In this short text, a distinguished philosopher turns his attention to one of the oldest and most fundamental philosophical problems of all: How it is that we are able to sort and classify different things as being of the same natural class? Professor Armstrong carefully sets out six major theories—ancient, modern, and contemporary—and assesses the strengths and weaknesses of each. Recognizing that there are no final victories or defeats in metaphysics, Armstrong nonetheless defends a traditional account of universals as the (...) most satisfactory theory we have.This study is written for advanced students, but as Armstrong goes considerably beyond his earlier work on this topic, it will interest professional scholars as well. Carefully plotted and clearly written, Universals is both a paradigm of exposition and a case study on the value of careful analysis of fundamental issues in philosophy. (shrink)

A wide-ranging study of the central concepts in epistemology - belief, truth and knowledge. Professor Armstrong offers a dispositional account of general beliefs and of knowledge of general propositions. Belief about particular matters of fact are described as structures in the mind of the believer which represent or 'map' reality, while general beliefs are dispositions to extend the 'map' or introduce casual relations between portions of the map according to general rules. 'Knowledge' denotes the reliability of such beliefs as representations (...) of reality. Within this framework Professor Armstrong offers a distinctive account of many of the main questions in general epistemology - the relations between beliefs and language, the notions of proposition, concept and idea, the analysis of truth, the varieties of knowledge, and the way in which beleifs and knowledge are supported by reasons. The book as a whole if offered as a contribution to a naturalistic account of man. (shrink)

This is a collection of twenty-five papers and reviews by the leading analytic philosopher of our time. It adds to the papers on metaphysics and epistemology to be found in his previous two-volume collection published by Oxford University Press. One previously unpublished paper—“Why Conditionalize?”—is included. Australasian philosophers may note with some pride that eleven of the pieces were first published in the Australasian Journal of Philosophy.

First, The doctrine of naturalism, That reality is spatio-Temporal, Is defended. Second, The doctrine of materialism or physicalism, That this spatio-Temporal reality involves nothing but the entities of physics working according to the principles of physics, Is defended. Third, It is argued that these doctrines do not constitute a "first philosophy." a satisfactory first philosophy should recognize universals, In the form of instantiated properties and relations. Laws of nature are constituted by relations between universals. What universals there are, And what (...) relations hold between them, Must be discovered "a posteriori" by scientific investigation. (shrink)

Dispositions are essential to our understanding of the world. IDispositions: A Debate is an extended dialogue between three distinguished philosophers - D.M. Armstrong, C.B. Martin and U.T. Place - on the many problems associated with dispositions, which reveals their own distinctive accounts of the nature of dispositions. These are then linked to other issues such as the nature of mind, matter, universals, existence, laws of nature and causation.

D. M. Armstrong; II—Does Knowledge Entail Belief?, Proceedings of the Aristotelian Society, Volume 70, Issue 1, 1 June 1970, Pages 21–36, https://doi.org/10.109.

Argues that a set is the mereological whole of the singleton sets of its members (following Lewis's Parts of Classes), and that the singleton set of X is the state of affairs of X's having some unit-making property.

It is not certain when or by whom S0009838800011642_inline1 and S0009838800011642_inline2 were first technically distinguished as genus and species. The distinction does not appear in Plato's extant writings, whereas Aristotle seems to take it for granted in the Topics, which is usually regarded as among his earliest treatises. In his dialogues Plato seems able to use S0009838800011642_inline3 interchangeably to denote any group or division in a diairesis, including the group that is to be divided.

I want to defend a Combinatorialtheory of possibility. Such a view traces the very idea of possibility to the idea of the combinations – all the combinations which respect a certain simple form – of given, actual, elements. Combination is to be understood widely enough to cover the notions of expansion and contraction. The combinatorial idea is not new, of course. Wittgenstein gave a classical exposition of it in the Tractatus. Perhaps its charter is 3.4: ‘A proposition determines a place (...) in logical space. The existence of this logical place is guaranteed by the mere existence of the constituents’. There is a small additional combinatorial literature. I myself was converted to a combinatorial view by Brian Skyrms’ brief but fascinating article ‘Tractarian Nominalism.’. (shrink)

It is not certain when or by whomandwere first technically distinguished asgenusandspecies. The distinction does not appear in Plato's extant writings, whereas Aristotle seems to take it for granted in theTopics, which is usually regarded as among his earliest treatises. In his dialogues Plato seems able to useinterchangeably to denote any group or division in a diairesis, including the group that is to be divided.