Evolution in Four Dimensions claims that epigenetic, behavioral, and symbolic inheritance systems should be considered equal partners to genetics in evolutionary biology. The evidence for, and applicable scope of, these additional inheritance systems is limited, particularly with regard to areas involving learning. It is unclear how including these extra dimensions in mainstream evolutionary thinking translates into testable hypotheses for a productive research program.

In his response to an earlier paper of ours Anton Killin takes issue with a certain aspect of our definition of an antique. He agrees with our view that the concept of an antique is an adjectival one and is at least happy to grant that those elements of the definition that relate to age are correct. But he takes issue with the idea that technical excellence is a necessary condition for being an antique. In addition to this, he also (...) criticizes us for largely excluding art objects from our discussion. In this rejoinder we focus mainly on defending the technical excellence criterion. But we will have something to say about art objects too, and we begin with a few words about them. (shrink)

Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind of epistemic (...) injustice has received limited treatment in bioethics. In this paper, we examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. We critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. We also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. We argue that providers ought to avoid epistemic injustice in pain management by striving toward epistemic humility. Epistemic humility, as a form of epistemic justice, may be the kind disposition required to correct the harmful prejudices that may arise through testimonial exchange in chronic pain management. (shrink)

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners’ opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive perceptions (...) of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted. (shrink)

Drawing on previous empirical research, we provide an exemplary narrative to illustrate how patients have experienced hospital care organized according to evidence‐based fast‐track programmes. The aim of this paper was to analyse and discuss if and how it is possible to include patients’ individual perspectives in an evidence‐based practice as seen from the point of view of nursing theory. The paper highlights two conflicting courses of development. One is a course of standardization founded on evidence‐based recommendations, which specify a set (...) of rules that the patient must follow rigorously. The other is a course of democratization based on patients’ involvement in care. Referring to the analysis of the narrative, we argue that, in the current implementation of evidence‐based practice, the proposed involvement of patients resembles empty rhetoric. We argue that the principles and values from evidence‐based medicine are being lost in the transformation into the current evidence‐based hospital culture which potentially leads to a McDonaldization of nursing practice reflected as ‘one best way’. We argue for reviving ethics of care perspectives in today's evidence practice as the fundamental values of nursing may potentially bridge conflicts between evidence‐based practice and the ideals of patient participation thus preventing a practice of ‘McNursing’. (shrink)

Prescription opioid abuse (POA) is an escalating clinical and public health problem. Physician worries about iatrogenic addiction and whether patients are ‘drug seeking’, ‘abusing’ and ‘diverting’ prescription opioids exist against a backdrop of professional and legal consequences of prescribing that have created a climate of distrust in chronic pain management. One attempt to circumvent these worries is the use of opioid contracts that outline conditions patients must agree to in order to receive opioids. Opioid contracts have received some scholarly attention, (...) with trust and trustworthiness identified as key values and virtues. However, few articles have provided a critical account of trust and trustworthiness in this context, particularly when there exists disagreement about their role in terms of enhancing or detracting from the patient–physician relationship. This paper argues that opioid contracts represent a misleading appeal to patient–physician trust. Assuming the patient is untrustworthy may wrongfully undermine the credibility of the patient's testimony, which may exacerbate certain vulnerabilities of the person in pain. However, misplaced trust in certain patients may render the physician vulnerable to the potential harms of POA. If patients distrust their physician, or feel distrusted by them, this may destabilise the therapeutic relationship and compromise care. A process of epistemic humility may help cultivate mutual patient–physician trust. Epistemic humility is a collaborative effort between physicians and patients that recognises the role of patients’ subjective knowledge in enhancing physicians’ self-understanding of their theoretical and practice frameworks, values and assumptions about the motivations of certain patients who report chronic pain. (shrink)

The paper defends the thesis that institutional virtue is properly modeled as a ‘‘consensual’’ property, along the lines of the Lehrer–Wagner model of consensus (LWC). In a first step, I argue that institutional virtue is not exhausted by duty-fulfilling, since institutions, contrary to natural individuals, are designed to fulfill duties. To avoid the charge of vacuity, virtue, if attributed to institutions, must be able to motivate supererogatory action. In a second step, I argue against dis- continuity of institutional virtue with (...) individual virtue. Two main arguments for discontinuity of collective properties display serious shortcomings when applied to virtues of institutions. Given that motivation for supererogatory action is neither inferred from statutory duties nor accommodates a right of reprobation, modeling institutional virtue on collective rationality or explaining it in terms of joint com-mitment both prove problematic. In a third step, I argue that LWC has the explanatory potential to account for institutional virtue. Due to its main features,iteration and evaluation, it provides a non-trivial analysis of continuity and thereby satisfies basic constraints on the notion of genuine institutional virtue. (shrink)

A significant amount of discussion in the bioethics community has been devoted to the question of whether individuals performing ethics consultations in healthcare institutions have any special expertise. In addition, articles in the lay press have questioned the “added value” that bioethicists bring to ethical dilemmas. Those at the forefront of the bioethics community have argued repeatedly that those doing ethics consults cannot simply be well-intentioned individuals, that some training in bioethics, group process, and facilitation is necessary to competently execute (...) a consult. As one bioethicist commented:if you approach any endeavor as an amateur activity, you will get, in the end, an amateurish version of the activity. Without a sufficient commitment of personnel, time, support, and financial resources, a healthcare organization will get the ‘ethics’ program … it set out to create: an inept, unskilled, inefficient, and highly risky ‘program’ in healthcare ethics and bioethics. (shrink)

A significant amount of discussion in the bioethics community has been devoted to the question of whether individuals performing ethics consultations in healthcare institutions have any special expertise. In addition, articles in the lay press have questioned the “added value” that bioethicists bring to ethical dilemmas. Those at the forefront of the bioethics community have argued repeatedly that those doing ethics consults cannot simply be well-intentioned individuals, that some training in bioethics, group process, and facilitation is necessary to competently execute (...) a consult. As one bioethicist commented:if you approach any endeavor as an amateur activity, you will get, in the end, an amateurish version of the activity. Without a sufficient commitment of personnel, time, support, and financial resources, a healthcare organization will get the ‘ethics’ program … it set out to create: an inept, unskilled, inefficient, and highly risky ‘program’ in healthcare ethics and bioethics. (shrink)

To the woman, God said, “I will greatly multiply your pain in child bearing; in pain you shall bring forth children, yet your desire shall be for your husband, and he shall rule over you.”Genesis 3:16There is now a well-established body of literature documenting the pervasive inadequate treatment of pain in this country. There have also been allegations, and some data, supporting the notion that women are more likely than men to be undertreated or inappropriately diagnosed and treated for their (...) pain.One particularly troublesome study indicated that women are more likely to be given sedatives for their pain and men to be given pain medication. Speculation as to why this difference might exist has included the following: Women complain more than men; women are not accurate reporters of their pain; men are more stoic so that when they do complain of pain, “it's real”; and women are better able to tolerate pain or have better coping skills than men. (shrink)

Dominant paradigms in science foster integration of research findings, but at what cost? Forcing convergence requires centralizing decision-making authority, and risks reducing the diversity of methods and contributors, both of which are essential for the breakthrough ideas that advance science.

State medical boards are beginning to take a more balanced approach to monitoring and disciplining for prescribing of pain medications, according to this survey of state medical boards across the country. Overall, respondents indicated that they are becoming more educated and more sophisticated in their approach to complaints of opioid overprescribing. In addition, their responses reflect a heightened awareness of the appropriateness of treating chronic pain with controlled substances.Yet, despite these inroads, boards generally demonstrate a continued tolerance of pain undertreatment, (...) the survey found. There is a discrepancy in the weight given to violation of standard of care, patient harm, and gross negligence for opioid overprescribing versus undertreatment of pain. Boards appear to have a higher threshold for patient harm in cases involving pain undertreatment — particularly for chronic nonmalignant pain. (shrink)

We report specific heat and μSR measurements on Th and/or B substituted UBe13. The specific heat data show that either Th or B substitution reduces the Kondo temperature TK and increases the entropy at the superconducting transition by almost 20%, indicating an enhanced density of states. However, whereas μSR shows clear evidence for magnetic correlations for Th substitutions, no magnetism is observed for B substitutions. The enhanced specific heat jump in the B-substituted material is associated with a change in the (...) superconducting properties as TK is reduced. (shrink)

This chapter contains sections titled: Introduction: Liberalism and Inclusiveness Liberalism: Political and Metaphysical Collaborating on Ideas of the Good Powers of Self‐Control Conclusion References.

Uncertainty regarding potential disciplinary action may give physicians pause when considering whether to accept a chronic pain patient or how to treat a patient who may require long-term or high doses of opioids. Surveys have shown that physicians fear potential disciplinary acrion for prescribing controlled substances and that physicians will, in some cases, inadequately prescribe opioids due to fear of regulatory scrutiny. Prescribing opioids for long-term pain management, particularly noncancer pain management, has been controversial; and boards have investigated and, in (...) some cases, disciplined physicians for such prescribing. While in virtually all of these cases the disciplinary actions were successfully appealed, news of the success was not often as well-publicized as news of the disciplinary actions, leaving some physicians confused about their potential liability when prescribing opioids for pain. The confusion has perhaps increased as a result of two relatively recent cases, one where a physician was successfully disciplined by a state medical board for undertreatment of his patients’ pain, and another where the physician was successfully sued for inadequate pain treatment. (shrink)

Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind of epistemic (...) injustice has received limited treatment in bioethics. In this paper, we examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. We critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. We also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. We argue that providers ought to avoid epistemic injustice in pain management by striving toward epistemic humility. Epistemic humility, as a form of epistemic justice, may be the kind disposition required to correct the harmful prejudices that may arise through testimonial exchange in chronic pain management. (shrink)

Using data from interviews, student work, and classroom observations in a “History of Race” course at a private predominantly White high school, this article examines the racialized tensions that led the teacher (first author) to create an unofficial affinity group for students of color that met outside of class. The authors argue that the teacher's attempt to implement a curriculum that was culturally affirming for students of color by de-centering Whiteness led to White students’ resistance that necessitated the creation of (...) an unofficial “safe space” outside of the classroom for the students of color. The need for such a group demonstrates the difficulties inherent in presenting a more honest account of the role of race and racism in the United States that challenges narratives of historical progress. The article concludes that while students of color ideally should have access to culturally affirming knowledge inside social studies classrooms, this experience demonstrates why that kind of knowledge can only be engaged effectively within learning spaces that challenge the norms of conventional social studies education. (shrink)

The American Journal of Bioethics, Volume 11, Issue 8, Page 33-35, August 2011.

Organizations are increasingly looking for ways to reap the benefits of cognitive diversity for problem solving. A major unanswered question concerns the implications of cognitive diversity for longer-term outcomes such as team learning, with its broader effects on organizational learning and productivity. We study how cognitive style diversity in teams—or diversity in the way that team members encode, organize and process information—indirectly influences team learning through collective intelligence, or the general ability of a team to work together across a wide (...) array of tasks. Synthesizing several perspectives, we predict and find that cognitive style diversity has a curvilinear—inverted U-shaped—relationship with collective intelligence. Collective intelligence is further positively related to the rate at which teams learn, and is a mechanism guiding the indirect relationship between cognitive style diversity and team learning. We test the predictions in 98 teams using ten rounds of the minimum-effort tacit coordination game. Overall, this research advances our understanding of the implications of cognitive diversity for organizations and why some teams demonstrate high levels of team learning in dynamic situations while others do not. (shrink)

The intersection of ethics, computing, and genetics plots a space not yet adequately mapped, despite its importance, indeed, its rapidly growing importance. Its subdomains are well-enough known: or the study of ethical issues in genetics and genomics, is part of core curricula everywhere. Ethics and computing is an established subfield. Computing and geneticshas in little more than a decade progressed from subsubspecialty to the sine qua non of contemporary biomedical research, and it bids fair to transform clinical practice. We must (...) prepare for the complete digitization of the genomes of individual patients and the storage of millions of these genomes in very large databases. (shrink)

El feedback correctivo escrito ha demostrado ser efectivo para el tratamiento de ciertas estructuras gramaticales ; sin embargo, persisten factores que dificultan realizar conclusiones categóricas al respecto. Algunos de estos corresponden al tipo de las formas que se benefician de un tratamiento como este, a los distintos contextos de aprendizaje investigados, a los diversos niveles de competencia lingüística de los participantes, entre otros. La presente investigación estudia dos estrategias de FCE indirecto; a saber, indirecto con indicación y localización e indirecto (...) con indicación, localización y explicación metalingüística, en el tratamiento de la forma comparativa de adjetivos en inglés a nivel escolar. Los objetivos son examinar la efectividad del FCE y robustecer la evidencia empírica en contextos de aprendizaje que han sido insuficientemente indagados. Este primer acercamiento constituye una aproximación inédita que contribuye al fortalecimiento y al aumento de la evidencia empírica existente en el ámbito del FCE. La muestra del estudio correspondió a 24 estudiantes de 8° año de enseñanza primaria con un nivel básico de competencia lingüística en el idioma inglés como lengua extranjera. Los resultados muestran que ambos tipos de feeback promueven el uso preciso de la forma estudiada pero el FCE indirecto con indicación y localización del error es el que consigue mayores logros que se mantienen en el tiempo. Estos antecedentes sugieren una acción facilitadora del FCE en el tratamiento de la forma gramatical apuntada. (shrink)

This article contends that theological training supported by effective mentoring can contribute to the shaping of theology students in terms of their spiritual growth, character development and ministry formation. It is further argued that mentoring as a supportive pedagogy needs to be an essential element of theological education. Subsequently, guidelines for making mentoring an effective pedagogy in theological training are proposed. A lot has been written about mentoring; however this article focuses on the use of mentoring as a supportive pedagogy (...) in denominational seminaries as a means of fostering the holistic development of theology students. (shrink)

Communities, scientists, policy-makers and industries are requiring farmers to address environmental and wellbeing challenges in their on-farm management, transitioning away from a productivity dominated focus towards a multi-faceted system focus that includes environmental and social values. This paper analyses how Miraka Ltd., an Aotearoa-New Zealand indigenous owned and operated milk company, has taken on the role of institutional entrepreneur to enable and support change towards a multi-faceted system amongst its supply farmers. Observations and interviews were carried out to: (i) identify (...) farmers’ changes in practices, beliefs and values over the last ten years; and (ii) identify how Miraka functions as an indigenous entrepreneur in the agricultural sector. Findings show that interviewees were initially guided by business and family-oriented values, beliefs and practices, but in response to the institutional entrepreneurship by Miraka, approximately half of the interviewees changed these values, beliefs and practices, by internalising people and environmental values. The main strategies employed by Miraka were mobilisation of material resources such as incentives and awards, creation of a rationale addressing environmental and social concerns in the dairy sector, and proactive connection with new actors. The research shows an indigenous owned small-medium enterprise can make changes in values, beliefs and practices amongst its supply farmers, but requires a stronger shared base of values to contribute to a wider economic change. The discussion connects these findings to wider literature on diverse economies and indigenous entrepreneurship to identify to what extent an indigenous small-medium enterprise can contribute to a system change. (shrink)

The paper discusses Bernard Bolzano’s epistemological approach to believing and knowing with regard to the epistemic requirements of an axiomatic model of science. It relates Bolzano’s notions of believing, knowing and evaluation to notions of infallibility, immediacy and foundational truth. If axiomatic systems require their foundational truths to be infallibly known, this knowledge involves both evaluation of the infallibility of the asserted truth and evaluation of its being foundational. The twofold attempt to examine one’s assertions and to do so by (...) searching for the objective grounds of the truths asserted lies at the heart of Bolzano’s notion of knowledge. However, the explanatory task of searching for grounds requires methods that cannot warrant infallibility. Hence, its constitutive role in a conception of knowledge seems to imply the fallibility of such knowledge. I argue that the explanatory task contained in Bolzanian knowing involves a high degree of epistemic virtues, and that it is only through some salient virtue that the credit of infallibility can distinguish Bolzanian knowing from a high degree of Bolzanian believing. (shrink)

On professional ethics of teachers and educational accountability for human development in Malaysia; collection of articles.

Patients who are dying of cancer usually give up eating and then stop drinking. This raises ethical dilemmas about providing nutritional support and fluid replacement. The decision-making process should be based on a knowledge of the risks and benefits of giving or withholding treatments. There is no clear evidence that increased nutritional support or fluid therapy alters comfort, mental status or survival of patients who are dying. Rarely, subcutaneous fluid administration in the dying patient may be justified if the family (...) remain distressed despite due consideration of the lack of medical benefit versus the risks. Some cancer patients who are not imminently dying become dehydrated from reversible conditions such as hypercalcaemia. This may mimic the effects of advanced cancer. These conditions should be sought and fluid replacement therapy should be given along with the specific treatments for the condition. (shrink)

Self-knowledge (SK) is a natural ability of the human cognitive system and is defined as a complex re-representation of knowledge subject has about her own internal states. It is composed of two basic representations: the representation of I and the representation of the experienced state. SK has a propositional (i.e. language-like) form and can be expressed in the form of self-reports like “I believe that I believe that p”. It has then the form of a second-order belief which, as a (...) re-representation, generates the following problem concerning false representations: if the first-order representations of the I or of experienced states can be false like in cases of self-illusions or disorders like somatoparaphrenia, then how can error in self-cognition inherited by the re-representation (i.e. by SK) be avoided? I claim that the re-representational model of SK is a useful but artificial tool for the description of the components of SK; however, it is misleading to think of it as capturing the truth about SK. I propose here a representational model of SK which reduces those beliefs constituting SK to first-order beliefs which are sufficient as constituents of SK. (shrink)

Working at the bedside and within communities as patient advocates, nurses frequently intervene to advance individuals’ health and well-being. However, the International Council of Nurses’ Code of Ethics asserts that nurses should expand beyond the individual model and also promote a rights-enabling environment where respect for human dignity is paramount. This article applies the results of an ethnographic human rights study with displaced populations in Rwanda to argue for a rights-based social advocacy role for nurses. Human rights advocacy strategies include (...) sensitization, participation, protection, good governance, and accountability. By adopting a rights-based approach to advocacy, nurses contribute to health agendas that include more just social relationships, equitable access to opportunities, and health-positive living situations for all persons. (shrink)

Background: After over 4 years since medical assistance in dying legalization in Canada, there is still much uncertainty about how this ruling has affected Canadian society. Objective: To describe the positive aspects of medical assistance in dying legalization from the perspectives of hospice palliative care providers engaging in medical assistance in dying. Design: In this qualitative descriptive study, we conducted an inductive thematic analysis of semi-structured interviews with hospice palliative care providers. Participants and setting: Multi-disciplinary hospice palliative care providers in (...) acute, community, residential, and hospice care in Vancouver and Toronto, Canada, who have engaged in end-of-life care planning with patients who have inquired about and/or requested medical assistance in dying. Ethical considerations: The research proposal was approved by University of British Columbia Research Ethics Board in Vancouver and University Health Network in Toronto. Participants were informed regarding the research goals, signed a written consent, and were assigned pseudonyms. Results: The 48 participants included hospice palliative care physicians, nurses, social workers, and allied health providers. The average interview length was 50 min. Positive aspects of medical assistance in dying legalization were identified at the individual level: a new end-of-life option, patients’ last chance to express control over their lives, patient and family comfort and relief, and a unique learning experience for hospice palliative care providers; the team level: supportive collegial relationships, broadened discussions about end-of-life and palliative care, and team debriefs provide opportunities for education and support; and the institutional level: improved processes to facilitate the implementation logistics. Conclusion: While being involved in the medical assistance in dying process is complex and challenging, this study sheds light on the positive aspects of medical assistance in dying legalization from the hospice palliative care provider’s perspectives. Medical Assistance in Dying legalization has resulted in improved end-of-life conversations between hospice palliative care providers, patients, and their families. Improved communication leads to a better understanding of patients’ end-of-life care plans and bridges some of the existing gaps between hospice palliative care and medical assistance in dying. (shrink)

In seeking to found a ‘new political logic’, Badiou argues that we can only retrieve the political sense of concrete negation through its subordination to a prior field of affirmation: i.e. the opening of a new possibility inside a given historical situation, or ‘the event’, that may be politically realised through the creation of a ‘new subjective body’ consisting in the social affirmation of those new possibilities. Revolutionary politics is therefore said to rest on a synthesis of, on the one (...) hand, democracy in the sense of spontaneous mass-political irruption, and, on the other, a prescriptive elaboration of the ramifications of the event. The discussion then turns to the question of strategy – outside and against the politically moribund State-form – and his reconfiguration of political universality vis-à-vis the formulations of classical Marxism. Badiou counterposes capitalist ideology’s implicit anthropology of self-interested animals to his own of subjects embodied in a generic truth-procedure and its concomitant model of political rights, where what is ultimately at stake is ‘the complete transformation of the form of... difference, of the way the difference exists’ rather than a materialist dialectics of antagonistic contradiction. The interview concludes with Badiou clarifying his relationship to Lacanian psychoanalysis as an essential but by no means exhaustive conceptual armoury for understanding the relation between subject and event. (shrink)

ABSTRACT Most pharmaceutical research carried out today is focused on the treatment and management of the lifestyle diseases of the developed world. Diseases that affect mainly poor people are neglected in research advancements in treatment because they cannot generate large financial returns on research and development costs. Benefit sharing arrangements for the use of indigenous resources and genetic research could only marginally address this gap in research and development in diseases that affect the poor. Benefit sharing as a strategy is (...) conceptually problematic, even if one, as we do, agrees that impoverished indigenous communities should not be exploited and that they should be assisted in improving their living conditions. The accepted concept of intellectual property protection envisages clearly defined originators and owners of knowledge, whereas the concept of community membership is fluid and indigenous knowledge is, by its very nature, open, with the originator(s) lost in the mists of time. The delineation of ‘community’ presents serious conceptual and practical difficulties as few communities form discrete, easily discernable groups, and most have problematic leadership structures. Benefit sharing is no substitute for governments’ responsibility to uplift impoverished communities. Benefit sharing arrangements may be fraught with difficulties but considerations of respect and equity demand that prior informed consent and consultation around commercialisation of knowledge take place with the source community and their government.1. (shrink)

Better memory, greater motivation and concentration lead to greater productivity, efficiency and performance, all of which are features that are highly valued in a modern society focused on productivity. In the effort for better cognitive abilities, otherwise healthy individuals use cognitive enhancers, medicines for the treatment of cognitive deficits of patients with various disorders and health problems, such as Alzheimer’s disease, schizophrenia, stroke, Attention Deficit Hyperactivity Disorder or ageing. The use of these is more common in professions with emphasised cognitive (...) abilities, or in occupations that require more attention, focus and alertness. Their use is also associated with the general working population, in that they are supposed to use them to alleviate the effects of sleep deprivation and to cope with increasing workloads. In the paper, we are addressing the ethical issue and the dilemmas of the use of pharmaceutical enhancements by healthy people who have no medical reason for taking such substances, in the context of improving their cognitive functions. (shrink)