“Clinical ethics consultants” have been practicing in the United States for about 50 years. Most of the earliest consultants—the “pioneers”—were “outsiders” when they first appeared at patients' bedsides and in the clinic. However, if they were outsiders initially, they acclimated to the clinical setting and became “insiders” very quickly. Moreover, there was some tension between traditional academics and those doing applied ethics about whether there was sufficient “critical distance” for appropriate reflection about the complex medical ethics dilemmas of the day (...) if one were involved in the decision making. Again, the pioneers deflected concerns by identifying and instituting safeguards to assure professional objectivity in clinical ethics consultation services. One might suggest that in moving inside and establishing normative practices, the pioneer clinical ethics consultants anticipated adoption of their routines and professionalization of the field. (shrink)

Interventions that are designed to stem plagiarism do not always override the motivation of individuals to cheat and, therefore, may not diminish misconduct. To inform more effective approaches, we conducted a systematic review to clarify the psychological causes of plagiarism. This review of 83 empirical papers showed that a specific blend of circumstances may foster plagiarism: an emphasis on competition and success rather than development and cooperation coupled with impaired resilience, limited confidence, impulsive tendencies, and biased cognitions. Fortunately, whenever students (...) feel their life and studies align to their future aspirations, many of these circumstances tend to dissipate. (shrink)

As clinical ethics consultants move toward professionalization, the process of certifying individual consultants or accrediting programs will be discussed and debated. With certification, some entity must be established or ordained to oversee the standards and procedures. If the process evolves like other professions, it seems plausible that it will eventually include a written examination to evaluate the core knowledge competencies that individual practitioners should possess to meet peer practice standards. The American Society for Bioethics and Humanities has published core knowledge (...) competencies for many years that are accepted by experts as the prevailing standard. Probably any written examination will be based upon the ASBH core knowledge competencies. However, much remains to be done before any examination may be offered. In particular, it seems likely that a recognized examining board must create and validate examination questions and structure the examination so as to establish meaningful, defensible parameters after dealing with such challenging questions as: Should the certifying examination be multiple choice or short-answer essay? How should the test be graded? What should the pass rate be? How may the examination be best administered? To advance the field of health care ethics consultation, thought leaders should start to focus on the written examination possibilities, to date unaddressed carefully in the literature. Examination models—both objective and written—must be explored as a viable strategy about how the field of health care ethics consultations can grow toward professionalization. (shrink)

A popular response to the Exclusion Argument for physicalism maintains that mental events depend on their physical bases in such a way that the causation of a physical effect by a mental event and its physical base needn’t generate any problematic form of causal overdetermination, even if mental events are numerically distinct from and irreducible to their physical bases. This paper presents and defends a form of dualism that implements this response by using a dispositional essentialist view of properties to (...) argue that the psychophysical laws linking mental events to their physical bases are metaphysically necessary. I show the advantages of such a position over an alternative form of dualism that merely places more “modal weight” on psychophysical laws than on physical laws. The position is then defended against the objection that it is inconsistent with dualism. Lastly, some suggestions are made as to how dualists might clarify the contribution that mental causes make to their physical effects. (shrink)

Informed consent is valid only if the person giving it is competent. Although allegedly informed consents are routinely tendered, there are nonetheless serious problems with the concept of competence as it stands. First, conceptual work upon competence is incomplete: the concept is unanalyzed and no logic of competence has been identified. It is thus virtually impossible to reliably discern who is competent. ;Traditional work on competence has explicated three dichotomies from which the necessary conditions for the possibility of competence will (...) be identified, viz., that competence is either a global or a specific notion; is present in varying degrees or in virtue of a threshold; and may or not include appeals to consequences. Past efforts have failed to notice a fourth dichotomy: competence as an affective or cognitive notion. Failure to designate the appropriate arms of these dichotomies is responsible for there being, at present, no reliable test for competence. The inadequacies of a highly regarded particular test for competence, the mental status examination, are examined in light of this failure. ;Competence is located within the rule-governed practice of informed consent. That practice and hence, competence, is justified through a Kantian analysis of respect for persons. This analysis reveals that the logic of competence requires assessment in terms of specific rather than global concerns; degrees of ability rather than a threshold; both cognitive and affective abilities; and no appeal to consequences. ;Based upon the analyses of consent as an example of decision making within the practice of informed consent and of respect for persons, the capacities which jointly comprise competence are identified. These are the capacities to receive, recognize, and retrieve information; to reason about, relate to oneself, and rank options; to choose among alternatives; and, under certain circumstances, to defend one's choice. ;Identification of the logic of competence and explication of and justification for the capacities that comprise competence to consent provide a conceptual foundation for the crucial concept of competence that the informed consent process currently lacks. It should facilitate construction of a test for competence. (shrink)

In jurisdictions where voluntary assisted dying is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors’ involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this (...) protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture. There are no data in this work. (shrink)

Existing regulation of end-of-life care is flawed. Problems include poorly-designed laws, policies, ethical codes, training, and funding programs, which often are neither effective nor helpful in guiding decision-making. This leads to adverse outcomes for patients, families, health professionals, and the health system as a whole. A key factor contributing to the harms of current regulation is a siloed approach to regulating end-of-life care. Existing approaches to regulation, and research into how that regulation could be improved, have tended to focus on (...) a single regulatory instrument (e.g., just law or just ethical codes). As a result, there has been a failure to capture holistically the various forces that guide end-of-life care. This article proposes a response to address this, identifying “regulatory space” theory as a candidate to provide the much-needed holistic insight into improving regulation of end-of-life care. The article concludes with practical implications of this approach for regulators and researchers. (shrink)

Background Voluntary assisted dying became lawful in Victoria, the first Australian state to permit this practice, in 2019 via the Voluntary Assisted Dying Act 2017 (Vic). While conscientious objection by individual health professionals is protected by the Victorian legislation, objections by institutions are governed by policy. No research has been conducted in Victoria, and very little research conducted internationally, on how institutional objection is experienced by patients seeking assisted dying. Methods 28 semi-structured interviews were conducted with 32 family caregivers and (...) one patient about the experience of 28 patients who sought assisted dying. Participants were interviewed during August-November 2021. Data from the 17 interviews (all with family caregivers) which reported institutional objection were analysed thematically. Results Participants reported institutional objection affecting eligibility assessments, medication access, and taking the medication or having it administered. Institutional objection occurred across health settings and was sometimes communicated obliquely. These objections resulted in delays, transfers, and choices between progressing an assisted dying application and receiving palliative or other care. Participants also reported objections causing adverse emotional experiences and distrust of objecting institutions. Six mediating influences on institutional objections were identified: staff views within objecting institutions; support of external medical practitioners and pharmacists providing assisted dying services; nature of a patient’s illness; progression or state of a patient’s illness; patient’s geographical location; and the capability and assertiveness of a patient and/or caregiver. Conclusions Institutional objection to assisted dying is much-debated yet empirically understudied. This research found that in Victoria, objections were regularly reported by participants and adversely affected access to assisted dying and the wider end-of-life experience for patients and caregivers. This barrier arises in an assisted dying system that is already procedurally challenging, particularly given the limited window patients have to apply. Better regulation may be needed as Victoria’s existing policy approach appears to preference institutional positions over patient’s choice given existing power dynamics. (shrink)

Nicholas Dixon’s Kantian argument for why mixed martial arts (MMA) is intrinsically immoral has received several critical responses. We offer an additional critical response. Unlike previous responses, ours does not rely on an interpretation of the categorical imperative that Dixon would find tendentious. Instead, we grant that Dixon’s views about what makes other sports consistent with the categorical imperative are correct and argue from this assumption that MMA is also consistent with the categorical imperative. Our argument focuses on Dixon’s claims (...) about certain cycling tactics, which we call ‘pain-leveraging cycling tactics’. We argue that MMA is consistent with the categorical imperative for the same sort of reasons that Dixon claims make pain-leveraging cycling tactics consistent with the categorical imperative. (shrink)

ObjectiveTo increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility.SettingThree tertiary hospitals in metropolitan Brisbane, Australia.DesignQualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic (...) analysis.ResultsDoctors’ perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing.ConclusionsDoctors’ ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors’ role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making. (shrink)

Objective Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient9s life. Design Semistructured in-depth interviews. Setting Three large tertiary public hospitals in Brisbane, Australia. Participants 96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling. (...) Results Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the _main_ reasons for futile care. Conclusions Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level. (shrink)

Over several decades, ethics and law have been applied to medical education and practice in a way that reflects the continuation during the twentieth century of the strong distinction between facts and values. We explain the development of applied ethics and applied medical law and report selected results that reflect this applied model from an empirical project examining doctors’ decisions on withdrawing/withholding treatment from patients who lack decision-making capacity. The model is critiqued, and an alternative “constitutive” model is supported on (...) the basis that medicine, medical law, and medical ethics exemplify the inevitable entanglement of facts and values. The model requires that ethics and law be taught across the medical education curriculum and integrated with the basic and clinical sciences and that they be perceived as an integral component of medical evidence and practice. Law, in particular, would rank as equal in normative authority to the relevant clinical scientific “facts” of the case, with graduating doctors having as strong a basic command of each category as the other. The normalization of legal knowledge as part of the clinician’s evidence base to be utilized in practice may provide adequate consolation for clinicians who may initially resent further perceived incursions on their traditional independence and discretion. (shrink)

Background Victoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to consider Objective To describe and analyse publicly available policy documents articulating an institutional objection to voluntary assisted dying in Victoria. Methods Policies were identified using a range of strategies, and those disclosing and discussing the nature of an institutional objection were thematically (...) analysed using the framework method. Results The study identified fifteen policies from nine policymakers and developed four themes: (1) extent of refusal to participate in VAD, (2) justification for refusal to provide VAD, (3) responding to requests for VAD, and (4) appeals to state-sanctioned regulatory mechanisms. While institutional objections were stated clearly, there was very little practical detail in most documents to enable patients to effectively navigate objections in practice. Conclusion This study demonstrates that despite having clear governance pathways developed by centralized bodies (namely, the Victorian government and Catholic Health Australia), many institutions’ public-facing policies do not reflect this guidance. Since VAD is contentious, laws governing institutional objection could provide greater clarity and regulatory force than policies alone to better balance the interests of patients and non-participating institutions. (shrink)

The Exclusion Argument for physicalism maintains that since (1) every physical effect has a sufficient physical cause, and (2) cases of causal overdetermination are rare, it follows that if (3) mental events cause physical events as frequently as they seem to, then (4) mental events must be physical in nature. In defence of (1), it is sometimes said that (1) is supported if not entailed by conservation laws. Against this, I argue that conservation laws do not lend sufficient support to (...) (1) to render its denial ‘unscientific’, and that those who accept (3) and deny (4) may consequently respond to the Exclusion Argument by denying (1) without thereby setting themselves at odds with current science. I also argue that conservation laws are compatible with (3) and the negation of (4), and that one can therefore accept conservation laws and (3) while denying both (1) and (4). (shrink)

This paper argues for a theory of phenomenal intentionality (herein referred to as ‘Structuralism’), according to which perceptual experiences only possess intentional content when their phenomenal components are appropriately related to one another. This paper responds to the objections (i) that Structuralism cannot explain why some experiences have content while others do not, or (ii) why contentful experiences have the specific contents that they have. Against (i), I argue that to possess content, an experience must present itself as an experience (...) of something distinct from itself, and that only experiences whose components are suitably structured satisfy this requirement. Against (ii), I argue that Structuralists can provide a deeper explanation of perceptual content than other theories of phenomenal intentionality by showing how the content-determining relations among our experiences depend on the selection pressures under which our perceptual systems developed. (shrink)

Objectives To determine the role played by law in medical specialists9 decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed. Design Cross-sectional postal survey of medical specialists. Setting The two largest Australian states by population. Participants 649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting. Main outcome measures Compliance with law and the impact of legal knowledge (...) on compliance. Results 649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge. Conclusions Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care. (shrink)

This paper proposes an analysis of statements about universals according to which such statements assert nothing more than that the evidence we’d take to confirm them obtains, where this evidence is understood to consist solely of patterns in the behavior of particulars that cannot be explained by other regularities in the way things behave. On this analysis, to say that a universal exists is simply to say that there is such a pattern in the behavior of certain particulars, and for (...) any predicate F that is presumed to correspond to a universal, to say that a particular is F is simply to say that its behavior exhibits a pattern of this sort. I argue that there is no theoretical work that we want postulations and ascriptions of universals to do that they’d be unfit for if analyzed in this way, and consequently that there is no reason to treat such statements as asserting anything more than what the proposed analysis suggests. (shrink)

Much of the commentary in the wake of the Charlie Gard litigation was aimed at apparent shortcomings of the law. These include concerns about the perceived inability of the law to consider resourcing issues, the vagueness of the best interests test and the delays and costs of having disputes about potentially life-sustaining medical treatment resolved by the courts. These concerns are perennial ones that arise in response to difficult cases. Despite their persistence, we argue that many of these criticisms are (...) unfounded. The first part of this paper sets out the basic legal framework that operates when parents seek potentially life-sustaining treatment that doctors believe is against a child’s best interests, and describes the criticisms of that framework. The second part of the paper suggests an alternative approach that would give decision-making power to parents, and remove doctors’ ability to unilaterally withhold or withdraw life-sustaining treatment that they regard is futile. This proposal is grounded in several values that we argue should guide these regulatory choices. We also contend that the best interests test is justifiable and since the courts show no sign of departing from it, the focus should be on how to better elucidate the underlying values driving decisions. We discuss the advantages of our proposed approach and how it would address some of the criticisms aimed at the law. Finally, we defend the current role that the judiciary plays, as an independent state-sanctioned process with a precedent-setting function. (shrink)

In this paper, we examine the lawfulness of a proposal to provide elective ventilation to incompetent patients who are potential organ donors. Under the current legal framework, this depends on whether the best interests test could be satisfied. It might be argued that, because the Mental Capacity Act 2005 (UK) (and the common law) makes it clear that the best interests test is not confined to the patient's clinical interests, but extends to include the individual's own values, wishes and beliefs, (...) the proposal will be in the patient's best interests. We reject this claim. We argue that, as things currently stand, the proposal could not lawfully be justified as a blanket proposition by reference to the best interests test. Accordingly, a modification of the law would be necessary to render the proposal lawful. We conclude with a suggestion about how that could be achieved. (shrink)

Chalmers’ meta-problem of consciousness is the problem of explaining “problem reports”; i.e. reports to the effect that phenomenal consciousness has the various features that give rise to the hard problem. Chalmers suggests that solving the meta-problem will likely “shed significant light on the hard problem.” Against this, I argue that work on the meta-problem will likely fail to make the hard problem any easier. For each of the main stances on the hard problem can provide an account of problem reports, (...) and we have no way of deciding which of these accounts gives the correct explanation of an individual’s problem reports without presupposing a stance on the hard problem. We thus cannot determine which of the available solutions to the meta-problem is correct without having already solved the hard problem. (shrink)

Fins and colleagues rightly note that “clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems” for which “progress in developing standards for q...

Setting aside all exclusion-style worries about the redundancy of postulating additional, non-physical mental causes for effects that can already be explained in purely physical terms, dualists who treat mental properties as supervening on physical properties still face a further problem: in cases of mental-to-mental causation, they cannot avoid positing an implausibly coincidental coordination in the timing of the distinct causal processes terminating, respectively, in the mental effect and its physical base. I argue that this problem arises regardless of whether one (...) treats the mental cause as causing both the mental effect and its physical base, or whether one treats the latter as having instead been caused by some physical state, and that the problem also does not depend on which theory of causation one adopts. A third option of treating the mental cause and its physical base as producing the mental effect and its physical base by a single causal process that they both contribute to is found to come up short as well. (shrink)

BackgroundThis paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources.MethodsAll publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation.ResultsFour resource-related themes were (...) identified: doctors’ ethical duties to consider resource allocation; balancing ethical obligations to patient and society; fair process and transparent resource allocation; and legal guidance on distributive justice as a rationale to limit life-sustaining treatment.ConclusionOf the policies that addressed resource allocation, this review found broad agreement about the existence of doctors’ duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment. (shrink)

The article by Professor Fiester (2015) expresses concern about the long-term moral distress or negative moral emotions, both aspects of moral residue, that linger in some stakeholders’ experiences...

Theories of phenomenal intentionality have been claimed to resolve certain worries about the indeterminacy of mental content that rival, externalist theories face. Thus far, however, such claims have been largely programmatic. This paper aims to improve on prior arguments in favor of phenomenal intentionality by using attention and Gestalt principles as specific examples of factors that influence the phenomenal character of perceptual experience in ways that thereby help determine perceptual content. Some reasons are then offered for rejecting an alternative interpretation (...) of these examples, according to which the phenomenal effects of attention and Gestalt principles play no role in the determination of perceptual content. (shrink)

This article argues that standard causal and functionalist definitions of realization fail to account for the realization of entities that cannot be individuated in causal or functional terms. By modifying such definitions to require that realizers also logically suffice for any historical properties of the entities they realize, one can provide for the realization of entities whose resistance to causal/functional individuation stems from their possession of individuative historical properties. But if qualia cannot be causally or functionally individuated, then qualia can (...) be physically realized only if the thesis that all things are physical or physically realized is insufficient for physicalism. (shrink)

Background In June 2016, Canada legalized medical assistance in dying (MAiD). From the outset, some healthcare institutions (including faith-based and non-faith-based hospitals, hospices, and residential aged care facilities) have refused to allow aspects of MAiD onsite, resulting in patient transfers for MAiD assessments and provision. There have been media reports highlighting the negative consequences of these “institutional objections”, however, very little research has examined their nature and impact. Methods This study reports on findings from 48 semi-structured qualitative interviews conducted with (...) MAiD assessors and providers, MAiD team members (working to coordinate care and lead MAiD programs in institutions and health authorities), and family caregivers on their experiences with institutional objection. Participants were recruited from the Canadian provinces of British Columbia, Ontario, and Nova Scotia. Data were analyzed using inductive thematic analysis. Results Themes identified were: (1) basis for institutional objection (with objections commonly rooted in religious values and a particular philosophy of palliative care); (2) scope of objection (demonstrating a wide range of practices objected to); (3) lack of transparency regarding institutional position; (4) impacts on patients; (5) impacts on health practitioners; and (6) catalysts for change. Participants reported that many institutions’ objections had softened over time, lessening barriers to MAiD access and adverse impacts on patients and health practitioners. Participants attributed this positive change to a range of catalysts including advocacy by health practitioners and family members, policymaking by local health authorities, education, and relationship building. Nevertheless, some institutions, particularly faith-based ones, retained strong objections to MAiD, resulting in forced transfers and negative emotional and psychological impacts on patients, family members, and health practitioners. Conclusions This paper adds to the limited evidence base about the impacts of institutional objection and can inform practical and regulatory solutions in Canada and abroad. Reform is needed to minimize the negative impacts on patients, their caregivers, and health practitioners involved in MAiD practice. (shrink)

This historic book may have numerous typos and missing text. Purchasers can usually download a free scanned copy of the original book (without typos) from the publisher. Not indexed. Not illustrated. 1752 edition. Excerpt:... to which the original Exclusion had been owing, the Points of two short and slender Hairs appear'd protruding themselves from its oval Surface. The thicker butoblong Bodies, from whose Extremities these grew, next forc'd themselves out, and it was evident to a-'n accustom'd Eye, that they were (...) the Antennze of a two wing'd Fly; next presented themselves the anterior Surfaces of two chequeffd Orbs, which were plainly the complex Eyes of anlnsect' of the same Species, separated by a plain Portion of a Forehead; and soon after the whole Head. This was no sooner all in View, than it swell'd to a Diameter equal to twice the Measure of that of the Breast. lt might have appear'd from the first, that the Head was growing under the Eye of the Observer, from the Extremity of the Thorax, but tho' a more rational Enquiry could not but produce for its Answer, that it was only now thrust forth out of the Cavity of the Breast in which it had before been lodg'd; it yet appear'd singular after this sudden Change in Size to conceive how a Thing should have been till that Moment lodg'd in a Cavityz not equal to half its own Diameter. P a The The Head was now entire and in its Place, and the Legs were firm, and supported the Body well, but the Wings did not yet appear. On examining the Place where they were to be expacted, I discover'd two irregular Protuberances of a wrinkled Surface, and considerably large, and under them the two oblong Pedicies which we see supporting the Balls under the Wings of all the two wing'd Flies. It was evident from this, that the Protuberances at the two Sides of the Base of the Thorax were the very Wings in their folded State, and this was soon prov'd by their expanding. The Wings in all this Race of Creatures are the last Part... (shrink)

BackgroundJunior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors’ decision-making processes when treating people with dementia who have advance care directives, or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: their legal compliance and decision-making process related to treatment decisions; the factors influencing their clinical decision-making; and the factors (...) associated with accurate responses to one hypothetical vignette. MethodA cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: bacterial pneumonia; or suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette.ResultsOverall, 116 junior doctors responded. In Vignette 1, 58% of respondents selected the legally compliant option. Participants who chose the legally compliant option perceived ‘following patient wishes’ and ‘legal requirements to follow ACDs’ as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the ‘ACD is relevant in my decision-making process, but other factors are more relevant’. In Vignette 2, 72% of respondents indicated they would commence treatment and 18% selected they would not commence treatment.. Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario.ConclusionsThere are critical gaps in junior doctors’ compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors’ clinical decision-making and ensure compliance with the law is required. (shrink)

Face transplantation—or, more properly, facial allograft transplantation —generates much public interest and academic debate. In this paper, we suggest that it is up to opponents of FAT to make the case for its impermissibility. We allow that there is a number of apparently strong arguments that might be deployed against FAT. However, all but one of these turn out not to be compelling after examination. The remaining argument is not so easily dismissed—but its central point is fairly workaday and certainly (...) does not tell us anything about FAT in particular. Therefore, qua argument about facial transplant surgery, it fails to hit its target. Overall, we conclude that a compelling case against FAT remains to be made. (shrink)

Through the analysis of forty ethical dilemmas drawn from real-life situations, _Ethics in Action_ guides the reader through a process of moral deliberation that leads to the resolution of a variety of moral dilemmas. Fosters critical thinking by evaluating the reasons people give to support their choices and actions Challenges the paradigm of moral relativism that often impedes efforts to resolve moral dilemmas Incorporates international perspectives often lacking in texts published for a U.S. audience.

Facial emotion recognition (FER) deficits interfere with interpretation of social situations and selection of appropriate responses. Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms are independently associated with social difficulties and might exacerbate the influence of deficient FER, because children with ADHD symptoms have fewer compensatory resources in social situations when they misinterpret emotions. Very few studies have tested this hypothesis in a community context, where child ADHD symptoms vary on a continuum. The current study extended this work by utilising a community sample (N (...) = 87) of boys and girls in middle childhood (M = 7.83 years) and testing for moderation of FER effects separately by ADHD symptom type (ADHD-I = inattentive, H = hyperactive/impulsive, C = combined) using linear regression. While lower FER was associated with more social problems, this relationship was qualified by the presence of ADHD symptoms. Specifically, only children with relatively high ADHD symptoms in our community sample showed this inverse relationship, which was clearest among children with elevated ADHD-C or ADHD-I symptoms. No gender differences were observed. These results support our primary hypothesis, extend prior findings to boys and girls in the community, and have implications for understanding how ADHD symptoms and FER influence youth social deficits. (shrink)

The practice of paying prisoners to for their participation in research has long been debated, and the controversy is reflected in the differing policies in the U.S. prison systems. Empirical study of financial payments to inmates who enroll in research has focused on whether this practice is coercive. In this study, we examined whether monetary incentives have the potential to be unduly influential among fifty HIV‐positive prisoners. The majority of prisoners surveyed believed that inmates should receive some compensation for their (...) involvement in research and disagreed with statements suggesting that the offer of payment constitutes undue influence. However, a sense of potentially being susceptible to undue influence was significantly higher among participants who had spent a longer time in prison and had less education. Overall, our findings suggest that most prisoners feel that they would be able to make a decision about research enrollment that is not solely based on an offer of monetary payment. (shrink)

Background and PurposeMany critically ill patients in intensive care units (ICUs) are unable to communicate their wishes about goals of care, particularly about the use of life-sustaining treatments. Surrogates and clinicians struggle with medical decisions because of a lack of clarity regarding patients’ preferences, leading to prolonged hospitalizations and increased costs. This project focused on the development and implementation of a tool to facilitate a better communication process by (1) assuring the early identification of a surrogate if indicated on admission (...) and (2) clarifying the decision-making standards that the surrogate was to use when participating in decision making. Before introducing the tool into the admissions routine, the staff were educated about its use and value to the decision-making process.Project and MethodsThe study was to determine if early use of a simple method of identifying a patient’s surrogate and treatment preferences might impact length of stay (LOS) and total hospital charges. A pre- and post-intervention study design was used. Nurses completed the surrogacy information tool for all patients upon admission to the neuroscience ICU. Subjects (total N=203) were critically ill patients who had been on a mechanical ventilator for 96 hours or longer, or in the ICU for seven days or longer. The project included staff education on biomedical ethics, critical communication skills, early identification of families and staff in crisis, and use of a simple tool to document patients’ surrogates and previously expressed care wishes. Data on hospital LOS and hospital charges were collected through a retrospective review of medical records for similar four-month time frames pre- and post-implementation of the assessment tool.ResultsSignificant differences were found between pre- and post-groups in terms of hospital LOS (F=6.39, p=.01) and total hospital charges (F=7.03, p=.009).ConclusionsProject findings indicate that the use of a simple admission assessment tool, supported by staff education about its completion, use, and available resources, can decrease LOS and lower total hospital charges. The reasons for the difference between the pre- and post-intervention groups remain unclear. Further research is needed to evaluate if the quality of communications between patients, their legally authorized representatives, and clinicians—as suggested in the literature—may have played a role in decreasing LOS and total hospital charges. (shrink)