Background Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians’ decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients’ ability to comprehend (...) complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored. Methods Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents’ perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test. Results Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient’s AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to “pass away in peace.” Few (17%) would forgo an AD following a family’s request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD. Conclusions Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient’s initial wishes and preferences expressed by the AD. (shrink)

Background Regarding controversial medical services, many have argued that if physicians cannot in good conscience provide a legal medical intervention for which a patient is a candidate, they should refer the requesting patient to an accommodating provider. This study examines what US physicians think a doctor is obligated to do when the doctor thinks it would be immoral to provide a referral. Method The authors conducted a cross-sectional survey of a random sample of 2000 US physicians from all specialties. The (...) primary criterion variable was agreement that physicians have a professional obligation to refer patients for all legal medical services for which the patients are candidates, even if the physician believes that such a referral is immoral. Results Of 1895 eligible physicians, 1032 (55%) responded. 57% of physicians agreed that doctors must refer patients regardless of whether or not the doctor believes the referral itself is immoral. Holding this opinion was independently associated with being more theologically pluralistic, describing oneself as sociopolitically liberal, and indicating that respect for patient autonomy is the most important bioethical principle in one's practice (multivariable ORs, 1.6–2.4). Conclusions Physicians are divided about a professional obligation to refer when the physician believes that referral itself is immoral. These data suggest there is no uncontroversial way to resolve conflicts posed when patients request interventions that their physicians cannot in good conscience provide. (shrink)

Starting with The Calculus of Consent James M. Buchanan published many books and articles emphasizing the importance of constitutional institutions and the promise of constitutional reforms. In this chapter I review some of these publications. The review begins with The Calculus, and then goes on to The Limits of Liberty, The Power to Tax, The Reason of Rules, Politics by Principle, Not Reason, and essays about the importance of constitutions in the European Union. The chapter closes with discussions of the (...) prospects of and impediments to constitutional reform in the United States and the European Union. (shrink)

In his critical study of Speusippus Leonardo Tarán (T.) expounds an interpretation of a considerable part of the controversial books M and N of Aristotle's Metaphysics. In this essay I want to consider three aspects of the interpretation, the account of Plato's ‘ideal numbers’ (section I), the account of Speusippus’ mathematical ontology (section II), and the account of the principles of that ontology (section III). T. builds his interpretation squarely on the work of Harold Cherniss (C.), to whom I will (...) also refer. I concentrate on T. because he has brought the ideas in which I am interested together and given them a concise formulation; he is also meticulous in indicating the secondary sources with which he agrees or disagrees, so that anyone interested in pursuing particular points can do so easily by consulting his book. (shrink)

Bazzocchi disposes the text of the Tractatus in a user-friendly manner, exactly as Wittgenstein's decimals advise. This discloses the logical form of the book by distinct reading units, linked into a fashioned hierarchical tree. The text becomes much clearer and every reader can enjoy, finally, its formal and literary qualities.

Theories of truth and vagueness are closely connected; in this article, I draw another connection between these areas of research. Gupta and Belnap’s Revision Theory of Truth is converted into an approach to vagueness. I show how revision sequences from a general theory of definitions can be used to understand the nature of vague predicates. The revision sequences show how the meaning of vague predicates are interconnected with each other. The approach is contrasted with the similar supervaluationist approach.

Background If trials of therapeutic interventions are to serve society's interests, they must be of high methodological quality and must satisfy moral commitments to human subjects. The authors set out to develop a clinical - trials compendium in which standards for the ethical treatment of human subjects are integrated with standards for research methods. Methods The authors rank-ordered the world's nations and chose the 31 with >700 active trials as of 24 July 2008. Governmental and other authoritative entities of the (...) 31 countries were searched, and 1004 English-language documents containing ethical and/or methodological standards for clinical trials were identified. The authors extracted standards from 144 of those: 50 designated as ‘core’, 39 addressing trials of invasive procedures and a 5% sample of the remainder. As the integrating framework for the standards we developed a coherent taxonomy encompassing all elements of a trial's stages. Findings Review of the 144 documents yielded nearly 15 000 discrete standards. After duplicates were removed, 5903 substantive standards remained, distributed in the taxonomy as follows: initiation, 1401 standards, 8 divisions; design, 1869 standards, 16 divisions; conduct, 1473 standards, 8 divisions; analysing and reporting results, 997 standards, four divisions; and post-trial standards, 168 standards, 5 divisions. Conclusions The overwhelming number of source documents and standards uncovered in this study was not anticipated beforehand and confirms the extraordinary complexity of the clinical trials enterprise. This taxonomy of multinational ethical and methodological standards may help trialists and overseers improve the quality of clinical trials, particularly given the globalisation of clinical research. (shrink)

Understanding risk factors for relationship dissolution and poor relationship adjustment among couples has been an active area of research in relationship science. One risk factor, non-marital cohabitation, has shown to predict higher rates of relationship dissolution and relationship instability in some samples, but the associations among German parents with children over time are less clear. In this study, we examined the links between non-marital cohabitation and 10-year outcomes in 220 German families with preschool-aged children at the initial assessment followed into (...) adolescence. Families were assessed 7 times over the 10 years and retention at the 10-year follow-up was over 92%. After accounting for multiple testing, only mother’s report of better initial interparental communication predicted whether parents were likely to stay together over the course of the 10 years. Adolescents of parents who cohabited were at higher risk for externalizing symptoms 10 years later compared to children of married parents. In addition, although there were no differences between cohabiting couples and married couples at the initial assessment in relationship adjustment, cohabiting mothers who stayed with their partner over the 10 years showed significantly greater declines in relationship adjustment over the 10 years compared to married mothers. Findings indicate the need for further research that explores family structure and dynamics over time to inform refinement of prevention programs targeting relationships and children’s mental health. (shrink)

In this paper I present a range of substructural logics for a conditional connective ↦. This connective was original introduced semantically via restriction on the ternary accessibility relation R for a relevant conditional. I give sound and complete proof systems for a number of variations of this semantic definition. The completeness result in this paper proceeds by step-by-step improvements of models, rather than by the one-step canonical model method. This gradual technique allows for the additional control, lacking in the canonical (...) model method, that is required. (shrink)

Since the BBS article in which Premack and Woodruff (1978) asked “Does the chimpanzee have a theory of mind?,” it has been repeatedly claimed that there is observational and experimental evidence that apes have mental state concepts, such as “want” and “know.” Unlike research on the development of theory of mind in childhood, however, no substantial progress has been made through this work with nonhuman primates. A survey of empirical studies of imitation, self-recognition, social relationships, deception, role-taking, and perspective-taking suggests (...) that in every case where nonhuman primate behavior has been interpreted as a sign of theory of mind, it could instead have occurred by chance or as a product of nonmentalistic processes such as associative learning or inferences based on nonmental categories. Arguments to the effect that, in spite of this, the theory of mind hypothesis should be accepted because it is more parsimonious than alternatives or because it is supported by convergent evidence are not compelling. Such arguments are based on unsupportable assumptions about the role of parsimony in science and either ignore the requirement that convergent evidence proceed from independent assumptions, or fail to show that it supports the theory of mind hypothesis over nonmentalist alternatives. Progress in research on theory of mind requires experimental procedures that can distinguish the theory of mind hypothesis from nonmentalist alternatives. A procedure that may have this potential is proposed. It uses conditional discrimination training and transfer tests to determine whether chimpanzees have the concept “see.” Commentators are invited to identify flaws in the procedure and to suggest alternatives. Key Words: apes; associative learning; concepts; convergence; deception; evolution of intelligence; folk psychology; imitation; mental state attribution; monkeys; parsimony; perspective-taking; primates; role-taking; self-recognition; social cognition; social intelligence; theory of mind. (shrink)

Sleep onset is associated with marked changes in behavioral, physiological, and subjective phenomena. In daily life though subjective experience is the main criterion in terms of which we identify it. But very few studies have focused on these experiences. This study seeks to identify the subjective variables that reflect sleep onset. Twenty young subjects took an afternoon nap in the laboratory while polysomnographic recordings were made. They were awakened four times in order to assess subjective experiences that correlate with the (...) (1) appearance of slow eye movement, (2) initiation of stage 1 sleep, (3) initiation of stage 2 sleep, and (4) 5 min after the start of stage 2 sleep. A logistic regression identified control over and logic of thought as the two variables that predict the perception of having fallen asleep. For sleep perception, these two variables accurately classified 91.7% of the cases; for the waking state, 84.1%. (shrink)

Among the scanty remains of poetry attributed to Eumelus of Corinth two lines 2 stand out as different from the rest, first because they are concerned not with the legendary past but with an actual, present occasion, and secondly because they are composed not for Corinthians but for Messenians. Our evidence comes from Pausanias and may be set out at the start.

Features include a comprehensive review of existing material, combined with new perspectives to equip students for the challenges in the work environment; chapter overviews and student learning objectives offer a solid and useful framework in which to organise study; diagrams and charts present overviews and contexts for the subject to act as useful revision aids; effective pedagogy including a review of the arguments considered, a menu of seminar topics, and questions in every chapter, serving as an ideal basis for seminar (...) study; and additional open-ended simulations to allow students to work through unfolding scenarios. (shrink)

The elegiac poem of eight lines discovered in the Ceramicus and published by by W. Peek is of considerable interest for the historian. Peek is surely right in maintaining that it was composed for the Athenians who fell under Tolmides at Coronea in 447 B.C., and his general exposition of the poem's meaning is convincing. The aim of this paper is to make some comments and supplements to his interpretation and then to consider some peculiarities in the thought and technique (...) of the poem. We may first set out a text and a translation:λμονες ℎοῖον γṑνα μχες ελσανες λπ[ο]φσχς δαιμονṐς ṑλσα' μ πολμοισὐν κακι χσετλελεσσε βροοῖσι δ πσι λοιπνφρζεσθαι λογṐν πιοσν ἔθκε λος. (shrink)

Vergil's plagiarism has been a theme for critics ever since Perellius Faustus made an anthology of his ‘furta’ and Quintus Octavius Avitus com-piled eight volumes of Оμоιóτησ, giving both the original passages and Vergil's adaptations of them . Much of this literature has survived in the commentary of Servius and in Book VI. of the Saturnalia of Macrobius. The study of his imitations and plagiarisms throws much light on Vergil's methods and aims of composition, and has frequently been attempted in (...) editions of his works. But one class of his plagiarisms differs considerably from the rest. Often in the Aenèid he incorporates phrases, either intact or slightly altered, from the Annales of Ennius. These differ from where he imitates Homer, because in them he does not have to translate from Greek into Latin and so remake the original into something new, and they differ, too, from his adaptations of some other earlier Latin poets, because Ennius was his only important forerunner who had written on the same heroic themes of war and the growth of Rome. (shrink)

Fractal time fluctuations of the spectral “1/f” form are universal in natural self-organizing systems. Neurobiology is uniquely infused with fractal fluctuations in the form of statistically self-similar clusters or bursts on all levels of description from molecular events such as protein chain fluctuations, ion channel currents and synaptic processes to the behaviors of neural ensembles or the collective behavior of Internet users. It is the thesis of this essay that the brain self-organizes via a vertical collation of these spontaneous events (...) in order to perceive the world and generate adaptive behaviors. REM sleep, which coalesces from self-similar clusters of burst-within-burst behavior during ontogeny, is essential to cognitive-emotional function, and has recurrent fractal organization. Empirical fMRI observations further support the association of fractal fluctuations in the temporal lobes, brainstem and cerebellum during the expression of emotional memory, spontaneous fluctuations of thought and meditative practice. Cognitive-emotional integration arises as amygdaloid-brainstem-cerebellar systems harmonize the vertical “1/f” symphony of coupled isochronous cortical oscillations in the pursuit of mindfulness. (shrink)

Oxidative damage to DNA has been associated with neurodegenerative diseases. Developmental exposure to lead has been shown to elevate the Alzheimer's disease related beta-amyloid peptide , which is known to generate reactive oxygen species in the aging brain. This study measures the lifetime cerebral 8-hydroxy-2'-deoxyguanosine levels and the activity of the DNA repair enzyme 8-oxoguanine DNA glycosylase in rats developmentally exposed to Pb. Oxo8dG was transiently modulated early in life , but was later elevated 20 months after exposure to Pb (...) had ceased, while Ogg1 activity was not altered. Furthermore, an age-dependent loss in the inverse correlation between Ogg1 activity and oxo8dG accumulation was observed. The effect of Pb on oxo8dG levels did not occur if animals were exposed to Pb in old age. These increases in DNA damage occurred in the absence of any Pb-induced changes in copper/zinc-superoxide dismutase , manganese-SOD , and reduced-form glutathion . These data suggest that oxidative damage and neurodegeneration in the aging brain could be impacted by the developmental disturbances. (shrink)

The revival of interest in Greek metre cannot be without an influence on the text of Pindar. In some ways this influence may have been for the good, but in one respect a theory based on insufficient evidence seems in danger of corrupting the text. The theory is briefly that in his dactylo-epitrite poems Pindar occasionally equated a choriamb — — with an epitrite — — — or — — —. This theory has been stated explicitly by two leading Pindaric (...) scholars, Otto Schröder and U. von Wilamowitz-Moellendorf. In the Prolegomena to his Editio Maior, p. 13, Schröder briefly states his case for what he calls ‘metathesis metrica.’ Moved by the fact that in iambic and Ionic metres a short syllable may be substituted for a long, and vice versa, he is convinced that the same applies to the metres of Pindar. (shrink)

In his Works of Pindar, Vol. II, p. xxiii, Dr. L. R. Farnell discusses the admission of metrical licences into Pindar's text, and pronounces that ‘the “Responsion-law” should not be pressed with over-strained severity.’ In general he agrees with Wilamowitz and Schroeder and disagrees with the stricter school of P. Maas. But none of these scholars have formulated the principles by which long syllables may be equated with short in Pindar's text, or even those by which two short syllables may (...) take the place of one long and vice versa. Such attempts were made by great scholars of the past, notably by Erasmus Schmid, Hermann and Boeckh, but recent developments in metric and textual criticism have created a new attitude towards metrical problems and provided a new vocabulary. It is time that Pindar's practice was re-examined. Only from it can we deduce what his rules of composition were and find out what licences he allowed and what not. The question is important both for the textual critic and for the student of Greek metric. If we can discover the principles on which Pindar used such metrical licences, we shall be more qualified to consider emendations which involve them and to understand the rules which he set before himself when composing an ode. (shrink)

One problem of interpreting research on subconscious processing is the possibility that participants are weakly conscious of the stimuli. Here, we compared the fMRI BOLD response in healthy adults to clearly visible single letters with the response to letters presented in the absence of any behavioural evidence of visibility . No letter catch trials served as a control condition. Forced-choice responses did not differ from chance when letter-to-background contrast was low, whereas they were almost 100% correct when contrast was high. (...) A comparison of fMRI BOLD signals for supraliminal and subliminal letters with the control trials revealed a signal increase in left BA 37 . Comparison of supraliminal with subliminal letters showed a significant increase in the right inferior frontal gyrus . Finally, a comparison of subliminal with supraliminal letters showed increases in the left middle temporal gyrus and the right extrastriate cortex. (shrink)