Should mental health insurance cover only disorders found in DSM‐IV, or should it be extended to treatment for ordinary shyness, unhappiness, and other responses to life's hard knocks?

In 2012, a U.S. Institute of Medicine report called for a different approach to health care: “Left unchanged, health care will continue to underperform; cause unnecessary harm; and strain national, state, and family budgets.” The answer, they suggested, would be a “continuously learning” health system. Ethicists and researchers urged the creation of “learning health organizations” that would integrate knowledge from patient‐care data to continuously improve the quality of care. Our experience with an ongoing research study on atrial fibrillation—a trial known (...) as IMPACT‐AFib—gave us some insight into one of the challenges that will have to be dealt with in creating these organizations. Although the proposed educational intervention study placed no restrictions on what providers and health plans could do, the oversight team argued that the ethical principle of beneficence did not allow the researchers to be “bystanders” in relation to a control group receiving suboptimal care. In response, the researchers designed a “workaround” that allowed the project to go forward. We believe the experience suggests that what we call “bystander ethics” will create challenges for the kinds of quality improvement research that LHOs are designed to do. (shrink)

How can health plans make fair determinations about when “experimental” (and costly) treatments such as high dose chemotherapy with autologous bone marrow transplantation should be covered despite lack of clear clinical consensus about their benefits? Different models for managing “last chance” therapies evolving in some health plans offer promising examples of how issues of fairness and legitimacy in decisionmaking can be addressed.

"Cluster randomized trials," in which groups of patients are randomly assigned to different therapeutic interventions, provide a powerful way of evaluating drugs. CRTs have not been widely used, in good part because of concerns about whether patients must give informed consent to participate in them. A better understanding of how CRTs fit into clinical practice resolves the concerns.

In 2012, a U.S. Institute of Medicine report called for a different approach to health care: “Left unchanged, health care will continue to underperform; cause unnecessary harm; and strain national, state, and family budgets.” The answer, they suggested, would be a “continuously learning” health system. Ethicists and researchers urged the creation of “learning health organizations” that would integrate knowledge from patient‐care data to continuously improve the quality of care. Our experience with an ongoing research study on atrial fibrillation—a trial known (...) as IMPACT‐AFib—gave us some insight into one of the challenges that will have to be dealt with in creating these organizations. Although the proposed educational intervention study placed no restrictions on what providers and health plans could do, the oversight team argued that the ethical principle of beneficence did not allow the researchers to be “bystanders” in relation to a control group receiving suboptimal care. In response, the researchers designed a “workaround” that allowed the project to go forward. We believe the experience suggests that what we call “bystander ethics” will create challenges for the kinds of quality improvement research that LHOs are designed to do. (shrink)

Book reviewed in this article: Animal Experimentation: The Moral Issues. Edited by Robert M. Baird and Stuart E. Rosenbaum.

Although “rationing” continues to be a dirty word for the public in health policy discourse, Nir Eyal and colleagues handle the concept exactly right in their article in this issue of the Hastings Center Report. They correctly characterize rationing as an ethical requirement, not a moral abomination. They identify the key health policy question as how rationing can best be done, not whether it should be done at all. They make a cogent defense of what they call “rationing through (...) inconvenience” as a justifiable allocational technique. And they wisely call for research on the effectiveness and fairness of this approach and other methods of rationing. I fully agree with their approach to rationing and with their argument that the process they provocatively label “rationing through inconvenience” should not be rejected out of hand. But I believe they have underestimated two ways in which the practical impacts of rationing through inconvenience limit its potential usefulness: the asymmetry of its effect on patients and physicians and the way in which it reduces the capacity of health systems to learn from experience. (shrink)

Book reviewed in this article: Animal Experimentation: The Moral Issues. Edited by Robert M. Baird and Stuart E. Rosenbaum.

The essays range from Hegel and Modernism to Marcel Duchamp and the Avant-Garde, postmodern poetics, boredom and Proust, the romance of Arendt and Heidegger, ...

If dominating functions in ω ω are adjoined repeatedly over a model of GCH via a finite-support c.c.c. iteration, then in the resulting generic extension there are no long towers, every well-ordered unbounded family of increasing functions is a scale, and the splitting number s (and hence the distributivity number h) remains at ω 1.

We study the I-ultrafilters on ω, where I is a collection of subsets of a set X, usually R or ω 1 . The I-ultrafilters usually contain the P-points, often as a small proper subset. We study relations between I-ultrafilters for various I, and closure of I-ultrafilters under ultrafilter sums. We consider, but do not settle, the question whether I-ultrafilters always exist.

We study the $I$-ultrafilters on $\omega$, where $I$ is a collection of subsets of a set $X$, usually $\mathbb{R}$ or $\omega_1$. The $I$-ultrafilters usually contain the $P$-points, often as a small proper subset. We study relations between $I$-ultrafilters for various $I$, and closure of $I$-ultrafilters under ultrafilter sums. We consider, but do not settle, the question whether $I$-ultrafilters always exist.

Several canonical partition theorems are obtained, including a simultaneous generalization of Neumer's lemma and the Erdos-Rado theorem. The canonical partition relation for infinite cardinals is completely determined, answering a question of Erdos and Rado. Counterexamples are given showing that in several ways these results cannot be improved.

Let κ denote a regular uncountable cardinal and NS the normal ideal of nonstationary subsets of κ. Our results concern the well-known open question whether NS fails to be κ + -saturated, i.e., are there κ + stationary subsets of κ with pairwise intersections nonstationary? Our first observation is: Theorem. NS is κ + -saturated iff for every normal ideal J on κ there is a stationary set $A \subseteq \kappa$ such that $J = NS \mid A = \{X \subseteq (...) \kappa:X \cap A \in NS\}$ . Turning our attention to large cardinals, we extend the usual (weak) Mahlo hierarchy to define "greatly Mahlo" cardinals and obtain the following: Theorem. If κ is greatly Mahlo then NS is not κ + -saturated. Theorem. If κ is ordinal Π 1 1 -indescribable (e.g., weakly compact), ethereal (e.g., subtle), or carries a κ-saturated ideal, then κ is greatly Mahlo. Moreover, there is a stationary set of greatly Mahlo cardinals below any ordinal Π 1 1 -indescribable cardinal. These methods apply to other normal ideals as well; e.g., the subtle ideal on an ineffable cardinal κ is not κ + -saturated. (shrink)

One of the contemporary results of Germany’s memorial conundrum is the rise of its “counter-monuments”: brazen, painfully self-conscious memorial spaces conceived to challenge the very premises of their being. On the former site of Hamburg’s greatest synagogue, at Bornplatz, Margrit Kahl has assembled an intricate mosaic tracing the complex lines of the synagogue’s roof construction: a palimpsest for a building and community that no longer exist. Norbert Radermacher bathes a guilty landscape in Berlin’s Neukölln neighborhood with the inscribed light of (...) its past. Alfred Hrdlicka began a monument in Hamburg to counter—and thereby neutralize—an indestructible Nazi monument nearby. In a suburb of Hamburg, Jochen Gerz and Esther Shalev-Gerz have erected a black pillar against fascism and for peace designed to disappear altogether over time. The very heart of Berlin, former site of the gestapo headquarters, remains a great, gaping wound as politicians, artists, and various committees forever debate the most appropriate memorial for this site.4 4. The long-burning debate surrounding projected memorials, to the Gestapo-Gelände in particular, continues to exemplify both the German memorial conundrum and the state’s painstaking attempts to articulate it. For an excellent documentation of the process, see Topographie des Terrors: Gestapo, SS und Reichssicherheitshauptamt auf dem “Prinz-Albrecht-Gelände,” ed. Reinhard Rürup . For a shorter account, see James E. Young, “The Topography of German Memory,” The Journal of Art 1 : 30. James E. Young is assistant professor of English and Judaic studies at the University of Massachusetts, Amherst. He is the author of Writing and Rewriting the Holocaust: Narrative and the Consequences of Interpretation and The Texture of Memory: Holocaust Memorials and Meaning in Europe, Israel, and America , from which this essay is drawn. He is also the curator of “The Art of Memory,” an exhibition at the Jewish Museum of New York. (shrink)

We study various aspects of the size, including the cardinality, of closed unbounded subsets of [λ]<κ, especially when λ = κ+n for n ε ω. The problem is resolved into the study of the size of certain stationary sets. Relative to the existence of an ω1-Erdös cardinal it is shown consistent that ωω3 < ωω13 and every closed unbounded subsetof [ω3]<ω2 has cardinality ωω13. A weakening of the ω1-Erdös property, ω1-remarkability, is defined and shown to be retained under a large (...) class of Easton-like forcings applied to ω1-Erdös cardinals. A class of reverse-Easton forcings preserving α-Erdösness is also described, with special attention to the establishment of □-principles. Article Outline. (shrink)

This essay uses a mental files theory of singular thought—a theory saying that singular thought about and reference to a particular object requires possession of a mental store of information taken to be about that object—to explain how we could have such thoughts about abstract mathematical objects. After showing why we should want an explanation of this I argue that none of three main contemporary mental files theories of singular thought—acquaintance theory, semantic instrumentalism, and semantic cognitivism—can give it. I argue (...) for two claims intended to advance our understanding of singular thought about mathematical abstracta. First, that the conditions for possession of a file for an abstract mathematical object are the same as the conditions for possessing a file for an object perceived in the past—namely, that the agent retains information about the object. Thus insofar as we are able to have memory-based files for objects perceived in the past, we ought to be able to have files for abstract mathematical objects too. Second, at least one recently articulated condition on a file’s being a device for singular thought—that it be capable of surviving a certain kind of change in the information it contains—can be satisfied by files for abstract mathematical objects. (shrink)