Objective: To describe the frequency of support for terminal sedation among internists, determine whether support for terminal sedation is accompanied by support for physician assisted suicide , and explore characteristics of internists who support terminal sedation but not assisted suicide.Design: A statewide, anonymous postal survey.Setting: Connecticut, USA.Participants: 677 Connecticut members of the American College of Physicians.Measurements: Attitudes toward terminal sedation and assisted suicide; experience providing primary care to terminally ill patients; demographic and religious characteristics.Results: 78% of respondents believed that if (...) a terminally ill patient has intractable pain despite aggressive analgesia, it is ethically appropriate to provide terminal sedation . Of those who favoured terminal sedation, 38% also agreed that PAS is ethically appropriate in some circumstances. Along a three point spectrum of aggressiveness in end of life care, the plurality of respondents were in the middle, agreeing with terminal sedation but not with PAS. Compared with respondents who were less aggressive or more aggressive, physicians in this middle group were more likely to report having more experience providing primary care to terminally ill patients and attending religious services more frequently .Conclusions: Support for terminal sedation was widespread in this population of physicians, and most who agreed with terminal sedation did not support PAS. Most internists who support aggressive palliation appear likely to draw an ethical line between terminal sedation and assisted suicide. (shrink)

Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more complete understanding of clinical judgement (...) requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that ‘clinical judgement’ will merely express ‘the clinician's judgement.’. (shrink)

Background: Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians’ attitudes and practices regarding error discussions with colleagues.Methods: Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables.Results: Responses were received from 338 participants . In all, 73% of (...) respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision , wanting colleagues to learn from the mistake and wanting to receive support . Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm , minor harm or major harm . Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion .Conclusions: Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners. (shrink)

Background and objective: Code status discussions may fail to address patients’ treatment-related goals and their knowledge of cardiopulmonary resuscitation (CPR). This study aimed to investigate patients’ resuscitation preferences, knowledge of CPR and goals of care. Design, setting, patients and measurements: 135 adults were interviewed within 48 h of admission to a general medical service in an academic medical centre, querying code status preferences, knowledge about CPR and its outcome probabilities and goals of care. Medical records were reviewed for clinical information (...) and code status documentation. Results: 41 (30.4%) patients had discussed CPR with their doctor, 116 (85.9%) patients preferred full code status and 11 (8.1%) patients expressed code status preferences different from the code status documented in their medical record. When queried about seven possible goals of care, patients affirmed an average of 4.9 goals; their single most important goals were broadly distributed, ranging from being cured (n = 36; 26.7%) to being comfortable (n = 8; 5.9%). Patients’ mean estimate of survival to discharge after CPR was 60.4%. Most patients believed it was helpful to discuss goals of care (n = 95; 70.4%) and the chances of surviving inhospital CPR (n = 112; 83.0%). Some patients expressed a desire to change their code status after receiving information about survival following inhospital CPR (n = 11; 8.1%) or after discussing goals of care (n = 2; 1.5%). Conclusions: Doctors need to address patients’ knowledge about CPR and take steps to avoid discrepancies between treatment orders and patients’ preferences. Addressing CPR outcome probabilities and goals of care during code status discussions may improve patients’ knowledge and influence their preferences. (shrink)

Backround Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. Method We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. Results A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (...) (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). Conclusions Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying “ethical” issues, “professional” issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives. (shrink)

Christopher Meyers attempts a utilitarian defense of the deception of patients when the purported harms of truthful disclosure outweigh its benefits. He suggests that honesty i...

The Objective Of This Highly Rewarding Book Indian Philosophy Of Knowledge Is To Highlight The Main Purpose Of Gaining Knowledge. The Highest Knowledge In Vedas And Upanisads Is The Knowledge Of Brahman Which Leads To Liberation. The Sankhya System Promises Complete Cessation Of All Sorrows. The Yoga Is Entirely Devoted To The Attainment Of Kaivalya. Gautama, In His Nyayasutra Asserts That Their Knowledge Would Lead To The Attainment Of The Liberation. The Vaisesika And Mimamsa Begins With The Interpretation Of Dharma (...) As The Means For Attainment Of The Worldly As Well As Transcendental Well-Being. The Buddhists Aim Of Knowledge Is To Remove Passions And To Show The Path Of Nirvana. The Removal Of Karmic Matter Is The Main Theme Of Knowledge In Jaina Philosophy. (shrink)

The exact agreement between the Sommerfeld and Dirac results for the energy levels of the relativistic hydrogen atom (the “Sommerfeld Puzzle”) is analyzed and explained.

We review the equivalence of the two-flavor Skyrme-Witten model and the two-flavor large-N c quark model. The claimed equivalence for three flavorsbetween these two models is shown to be incorrectly given in the literature, and the properly equivalent extended three-flavor large-N c quark model is constructed and discussed.

This article explores egg freezing experiences of women in Turkey. Since 2014, it has been legal in Turkey to use egg freezing technology for ageing women, while it was previously allowed only for disease-related purposes. In cooperation with a private fertility clinic in Istanbul, the authors conducted 21 interviews with older, single women who held either professional or managerial positions and who were undergoing or had undergone the procedure. Drawing on a qualitative analysis of these interviews, the authors explore the (...) social context in which women postpone motherhood and decide to freeze their eggs. The study also looks at the women’s emotional responses to ageing that were triggered by the experience of egg freezing and their narratives of empowerment as a result of the procedure. (shrink)

Starting from simple topological arguments due to Dirac on the classical rotational properties of extended rigid bodies, we abstract the concept of a finite-size spinor (FSS). The FSS is a concept distinct from both point spinors (e.g., electrons) and composite spinors (e.g., nuclei), and suggests a new model for baryons. The FSS offers a natural explanation of “threeness” for the quarks, excludes the existence of free quarks, denies the operational definition of quark spin statistics, and, moreover, leads to the dual (...) model of hadronic interactions. (shrink)

Kramers's equation specialized to the Coulomb field is factored using a rotationally invariant, angular momentum based, algebra of three anticommuting operators. Comparing the explicit chiral two-component solutions for the factored equation to the two-component solutions defined by the Foldy-Wouthuysen series for the Dirac-Coulomb Hamiltonian, it is concluded that this series cannot converge.

We explore the developmental paradox of false belief understanding. This paradox follows from the claim that young infants already have an understanding of false belief, despite the fact that they consistently fail the elicited-response false belief task. First, we argue that recent proposals to solve this paradox are unsatisfactory because they (i) try to give a full explanation of false belief understanding in terms of a single system, (ii) fail to provide psychological concepts that are sufficiently fine-grained to capture the (...) cognitive requirements for the various manifestations of false belief understanding, and (iii) ignore questions about system interaction. Second, we present a dual-system solution to the developmental paradox of false belief understanding that combines a layered model of perspective taking with an inhibition-selection-representation mechanism that operates on different levels. We discuss recent experimental findings that shed light on the interaction between these two systems, and suggest a number of directions for future research. (shrink)

Die Staatshaushaltung der Athener, Boeckh von August. Dritte Auflage herausgegeben und mit Anmerkungen begleitet von Max Fränkel. 2 vols. Berlin. G. Reimer. 1886. 30 Mk.

The research presented in this volume demonstrates that it is no longer reasonable to ask whether or not synesthesia is real--we must now ask how we can account ...

Background Professional autonomy, which directly affects the quality of professional nursing in patient care, and cognitive flexibility, which is an important factor for adaptation to change and developing nursing roles, are important concepts for nursing. Research objectives This research was carried out to determine the effect of cognitive flexibility on attitudes towards professional autonomy in nurses. Research design This was a descriptive study. Participants and research context The research was conducted with 415 nurses working in a city hospital of a (...) province, meeting the inclusion criteria and agreeing to participate in the study. A questionnaire form, The Cognitive Flexibility Inventory (CFI), and the Attitude Toward Professional Autonomy Scale for Nurses (APASN) were used to collect data. Ethical considerations Ethical approval was obtained from the university ethics committee before starting the study. Institutional permission was obtained from the city hospital where the study was conducted. Electronic informed consent was obtained from the nurses included in the study. Findings In the study, the mean CFI score was 80.62 ± 11.55 and the mean APASN score was 70.42 ± 18.79. There was a weak positive correlation (r = 0.270; p < 0.05) between CFI and APASN scores. Moreover, the effect of the CFI mean score on the APASN mean score was found to be statistically significant (β = 0.278; p < 0.001). Furthermore, CFI explains 7.7% of APASN. Conclusion In the study, nurses’ attitudes towards professional autonomy and cognitive flexibility scores were found to be at a good level. Cognitive flexibility has a positive effect on attitudes towards professional autonomy. Interventional studies that will increase the level of cognitive flexibility are recommended in the development of nurses' attitudes towards professional autonomy. (shrink)