Moral distress has been covered extensively in the nursing literature and increasingly in the literature of other health professions. Cases that cause nurses’ moral distress that are mentioned most frequently are those concerned with prolonging the dying process. Given the standard of aggressive treatment that is typical in intensive care units (ICUs), much of the existing moral distress research focuses on the experiences of critical care nurses. However, moral distress does not automatically occur in all end-of-life circumstances, nor does every (...) critical care nurse suffer its damaging effects. What are the practices of these nurses? What specifically do they do to navigate around or through the distressing situations? The nursing literature is lacking an answer to these questions. This article reports a study that used narrative analysis to explore the reported practices of experienced critical care nurses who are skilled at and comfortable working with families and physicians regarding the withdrawal of aggressive treatment. A major finding was that these nurses did not report experiencing the dam-Moral Agency, Moral Imagination, and Moral Community: Antidotes to Moral Distress Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine Terri Traudt, MBC, MA, is a Communications Consultant specializing in bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis. [email protected] Joan Liaschenko, PhD, RN, FAAN, is a Professor at the Center for Bioethics and Nursing at the University of Minnesota. Cynthia Peden-McAlpine, PhD, ACNS, BC, is an Associate Professor in the School of Nursing at the University of Minnesota. © 2016 by The Journal of Clinical Ethics. All rights reserved. aging effects of moral distress as described in the nursing literature. The verbal communication and stated practices relevant to this finding are organized under three major themes: (1) moral agency, (2) moral imagination, and (3) moral community. Further, a total of eight subthemes are identified. The practices that constitute these themes and subthemes are further detailed and discussed in this article. Understanding these practices can help mitigate critical care nurses’ moral distress. (shrink)

Advance care planning (ACP) is a process that seeks to elicit patients’ goals, values, and preferences for future medical care. While most commonly employed in adult patients, pediatric ACP is becoming a standard of practice for adolescent and young adult patients with potentially life-limiting illnesses. The majority of research has focused on patients and their families; little attention has been paid to the perspectives of healthcare providers (HCPs) regarding their perspectives on the process and its potential benefits and limitations. Focus (...) groups were conducted with 15 physicians as part of a larger study of adolescent and young adult ACP in hematopoietic stem cell transplant (HSCT) patients. This study identified two categories important to the utility of ACP in pediatric HSCT patients; (1) the temporal context of ACP and decision making and (2) the limitations of pediatric ACP, with subcategories identified as (a) embodied and witnessed knowing, (b) the impact of clinical cascades—when the treatment of one organ system creates complications in another system that needs to be treated—and a creation of a “new normal” following complications of illness and its treatment in the pediatric intensive care unit (PICU), (c) the balancing of adolescents’ autonomy with their capacity to make informed medical decisions, and (d) the epistemological frames that differ between HCP and patients and their families. These findings support ACP in adolescent and young adult HSCT patients, with a number of implications for practice as this process becomes more common. (shrink)

Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine’s study contributes to a much-needed reorientation in thinking about and working with the challenges of moral distress. In providing a vital example of nurses able to navigate morally distressing situations in positive and constructive ways, and offering an analysis of the component elements of these nurses’ success, the study helps identify promising directions we might take in addressing the epidemic of moral distress. It also invites important questions, concerning the challenges (...) faced by clinicians who do not who work in healthy “moral communities,” who lack the ethical competencies, and who don’t have the presumptive authority and recognition enjoyed by the seasoned clinicians studied here. We explore some of these questions, and suggest ways we might build on the insights of Traudt and colleagues’ study. (shrink)

Can scientific evidence outstretch what scientists have mentally entertained, or could ever entertain? This article focuses on the plausibility and consequences of an affirmative answer in a special case. Specifically, it discusses how we may treat automated scientific data-gathering systems—especially AI systems used to make predictions or to generate novel theories—from the point of view of confirmation theory. It uses AlphaFold2 as a case study.

The phenomenological goal of grounding the content of conceptual thought in the background understanding of everyday, skillful coping was approached using evolutionary autonomous agent methodology. The behavior of an EAA evolved to perform a specified motor task was identified with skillful coping. Changes in the dynamics of the EAA controller occurred when the EAA encountered an unexpected obstacle with loss of longer time scale components in its hierarchical temporal organization. These temporal changes are consistent with the phenomenological changes which we (...) experience with breakdown during equipment use with our adoption of a more immediate, determinate stance. Since this latter experience is the basis of conceptual thought, the EAA paradigm goes some way in providing a naturalized explanation for the grounding of the content of conceptual thought in everyday, skillful coping in a manner that is physiologically plausible and phenomenologically accurate. (shrink)

The ecofeminist cosmologies of Indian scientist Vandana Shiva and Catholic theologian Ivone Gebara are examined. At the centre of each author’s discourse is their feminist epistemology that occasion a new way of knowing, incorporating each thinker’s social locations as nexus for authority. For Shiva, the feminine principle of Prakriti, or the awareness of nature as a living, interdependent force, is realized through the inclusion of women as sources of expertise and knowledge. Gebara rejects classical theology and philosophy as androcentric, anthropocentric, (...) and hierarchical. Instead Gebara envisions a revised epistemology of inclusivity with emphasis on multiplicity and unity initiated by an ecofeminist Trinitarian cosmology. Taken together Shiva and Gebara provide an epistemology that privileges the paradox of unity through diversity and difference as a solution to society’s current ecological crises. (shrink)

Surgery is an increasingly common and expensive mode of medical intervention. The ethical dimensions of the surgeon-patient relationship, including respect for personal autonomy and informed consent, are much discussed; but broader equity issues have not received the same attention. This paper extends the understanding of surgical ethics by considering the nature of evidence in surgery and its relationship to a just provision of healthcare for individuals and their populations.

The residency years comprise the last period of a physician’s formal training. It is at this stage that trainees consolidate the clinical skills required for independent practice and achieve a level of ethical development essential to their work as physicians, a process known as professional identity formation (PIF). Ethics education is thought to contribute to ethical development and to that end the Royal College of Physicians and Surgeons of Canada (RCPSC) requires that formal ethics education be integrated within all postgraduate (...) specialty training programs. However, a formal ethics curriculum can operate in parallel with informal and hidden ethics curricula, the latter being more subtle, pervasive, and influential in shaping learner attitudes and behavior. This paper reports on a study of the formal, informal, and hidden ethics curricula at two postgraduate psychiatry programs in Canada. Based on the analysis of data sources, we relate the divergences between the formal, informal, and hidden ethics curricula to two aspects of professional identity formation (PIF) during psychiatry residency training. The first is the idea of group membership. Adherence to the hidden curriculum in certain circumstances determines whether residents become part of an in-group or demonstrate a sense of belonging to that group. The second aspect of PIF we explore is the ambiguous role of the resident as a student and a practitioner. In ethically challenging situations, adherence to the messages of the hidden curriculum is influenced by and influences whether residents act as students, practitioners, or both. This paper describes the hidden curriculum in action and in interaction with PIF. Our analysis offers a complementary, empirical perspective to the theoretical literature concerning PIF in medical education. This literature tends to position sound ethical decision-making as the end result of PIF. Our analysis points out that the mechanism works in both directions: how residents respond to hidden curriculum in ethics can be a driver of professional identity formation. (shrink)

The confusion/non-consequential thinking explanation proposed by Newstead, Girotto, and Legrenzi (1995) for poor performance on Wason's THOG problem (a hypothetico-deductive reasoning task) was examined in three experiments with 300 participants. In general, as the cognitive complexity of the problem and the possibility of non-consequential thinking were reduced, correct performance increased. Significant but weak facilitation (33-40% correct) was found in Experiment 1 for THOG classification instructions that did not include the indeterminate response option. Substantial facilitation (up to 75% correct) was obtained (...) in Experiment 2 with O'Brien et al.'s (1990) one-other-THOG classification instruction. In Experiment 3, a revised version of O'Brien et al.'s pre-test problem format also led to substantial facilitation, even with the use of the standard three-choice THOG classification instruction. These findings are discussed in terms of Newstead et al.'s theoretical proposal and possible attentional factors. (shrink)

The contribution of this book to the field of reconciliation is both theoretical and practical, recognizing that good theory guides effective practice and practice is the ground for compelling theory. Using a Girardian hermeneutic as a starting point, a new conceptual Gestalt emerges in these essays, one not fully integrated in a formal way but showing a clear understanding of some of the challenges and possibilities for dealing with the deep divisions, enmity, hatred, and other effects of violence.

Research has established that exposure to a combination of diagnostic (i.e., relevant) and nondiagnostic (i.e., irrelevant) information results in predictions that are more regressive than predictions based on diagnostic information (Hackenbrack, 1992; Hoffman and Patton, 1997). This phenomenon has been labeled the dilution effect (e.g., Tetlock and Boettger, 1989) and has been documented when individuals make predictions. This study tests for the dilution effect when small groups make predictions, and examines the effect of using a procedure designed to reduce the (...) dilution effect. Results indicate that group predictions are influenced by nondiagnostic information in the same manner as are individual predictions, and allowing participants to rate the diagnosticity of information prior to making predictions does not reduce the dilution effect. (shrink)

In recent years, scholars have documented the racial disparities of mass incarceration. In this paper we argue that, although retributivism and deterrence theory appear to be race-neutral, in the contemporary U.S. context these seemingly contrary theories function jointly to rationalize racial inequities in the criminal justice system. When people of color are culturally associated with criminality, they are perceived as both irresponsible and hyperresponsible, a paradox that reflects their status as what Charles Mills calls subpersons. Following from this paradox, criminality (...) is understood as an atemporal characteristic of people of color, such that they are conceived as pre-criminals, criminals, or post-criminals. In Frantz Fanon’s account, overdetermination expresses this exclusion of people of color from full agency by capturing them within a rigid, immutable essence, which then controls the social meaning of their actions. The backward-looking quality of retribution and the forward-looking quality of deterrence then treat people of color as more deserving of punishment (and more severe punishment) and as threats to the social order who have to be restrained. We should read the racialization of mass incarceration as a symptom of how precariously people of color participate in the social contract and as reflections of how theories of punishment have been racially deployed. (shrink)

This is a translation of Hans-Georg Gadamer’s 1988 essay, “Musik und Zeit: Ein philosophisches Postscriptum.” The essay, although brief, is noteworthy in that it contains Gadamer’s philosophical reflections on music—reflections which are largely absent in his masterwork, Truth and Method. In the essay, one finds several important Gadamerian hermeneutical themes such as the notion of art as performance or enactment (Vollzug), the linguisticality of understanding, the importance of lingering with an artwork or text, and how our absorption in the work (...) gives rise to a particular experience of time. (shrink)

"Canada, like other industrial nations, is undergoing widespread social change at a faster pace than ever before. Many features of our basic institutions are being transformed and some of the values on which they were based are being weakened or swept away to be replaced by others. As this Royal Commission indicated in its first report, Challenges and Choices, the scope and implications of these changes call "into question basic assumptions, values, and institutions at every level of society, from the (...) shop floor to the cabinet room, to the international economic system," but while many values change, others endure."--. (shrink)

Essential skills and attitudes necessary for active citizenship need to be cultivated as early as prekindergarten. This exploratory study investigated if three and four-year olds could be actively engaged in social studies practices through inquiry learning in a school garden. Eleven children openly interacted and conducted personally-driven investigations on a daily basis in the school garden located on their playground over nine-months. Three interviews with children, teacher observation notes, and lesson plans were analyzed to discover whether NCSS preK-12 learning themes (...) (2010) for the social studies curriculum could be correlated with garden inquiries. Three prevalent NCSS themes surfaced from data analysis with Civic Ideals and Practices, People, Places, and Environments, and Time, Continuity, and Change being most prevalent. Results imply that working in a school garden through inquiry learning can foster the development of democratic competencies and thus, could be used to design C3 lessons for preschoolers in the garden. (shrink)

The long-running discourse on respect for human dignity and autonomy in the physician-patient relationship pertaining to persons with dementia (PwDs) is explored deeply in this paper through the use of a real-life case, to highlight the complex interplay between autonomy and best interest when it comes to a PwD's experiential and critical interests. Many scenarios and perspectives are described and applies to the case. However, there are a few perspectives, which are touched upon that could do with further scrutiny. Firstly, (...) it has been argued that rigid adherence to the advance directives of PwDs means that PwDs will be the only people who are not allowed to ever change their minds. This withdrawal of a fundamental freedom hardly accords with respect for human dignity, or for any residual autonomy that these individuals may still enjoy. Secondly, viewing this case through the lens of care ethics, and incorporating the recently proposed conceptual framework of anthropological vulnerability, may reveal valuable insights regarding care provision and caring physician-patient relationships. These perspectives would analyse the role of relational ontology, particularly in relation to significant others, significant communities, and caregivers. (shrink)

This short piece is a reply to the response Professor Menzel made to the Shelton and Geppert paper,The Limits of Advance Directives in Decision Making Around Food and Nutrition in Patients with Dementia, which appeared in the January 2024 issue of theJournal of Medical Ethics. We disagree with Professor Menzel’s response to our paper that we fail to address situations at the heart of the Dworkin/Dresser debate regarding the tension between critical and experimental interests. The purpose of our paper was (...) very practical: to delineate the types of situations in the progression of dementia when advance directives can be acted on and when they should not be acted on. Given that most patients, including many individuals with dementia, do not have advance directives, it is important for both healthcare providers and surrogate decision-makers to be keenly aware of their options for decision-making throughout the trajectory of dementia, especially if there is no advance directive. It is also important for all patients, especially ageing individuals, to understand the points at which advance directives are most important to have, as well as when they are less important, indeed sometimes how they are just not relevant to sound, ethical decision-making during the progression of dementia. Based on this analysis, it is important for individuals completing advance directives to know those limits and the stages of dementia at which they can and cannot be followed. (shrink)

BackgroundDonepezil, an acetylcholinesterase inhibitor used in the treatment of Alzheimer’s disease, has been widely cited in media and bioethics literature on cognitive enhancement (CE) as having the potential to improve the cognitive ability of healthy individuals. In both literatures, this claim has been repeatedly supported by the results of a small study published by Yesavageet al.in 2002 on non-demented pilots (30–70 years old). The factors contributing to this specific interpretation of this study’s results are unclear.MethodsWe examined print media and interdisciplinary (...) bioethics coverage of this small study, aiming to provide insight into how evidence from research may be shaped within different discourses, potentially influencing important policy, ethics, and clinical decisions. Systematic qualitative content analysis was used to examine how this study was reported in 27 media and 22 bioethics articles. Articles were analyzed for content related to: (1) headlines and titles; (2) colloquialisms; and, (3) accuracy of reporting of the characteristics and results of the study.ResultsIn media and bioethics articles referencing this small study, strong claims were made about donepezil as a CE drug. The majority of headlines, titles, and colloquialisms used enhancement language and the majority of these suggest that donepezil could be used to enhance intellectual ability. Further, both literatures moved between reporting the results of the primary study and magnifying the perceived connection between these results and the CE debate that was alluded to in the primary study. Specific descriptions of the results overwhelmingly reported an improvement in performance on a flight simulator, while more general statements claimed donepezil enhanced cognitive performance. Further, a high level of reporting accuracy was found regarding study characteristics of the original study, but variable levels of accuracy surrounded the presentation of complex characteristics (i.e., methods) or contentious properties of the CE debate (i.e., initial health status of the study subjects).ConclusionsHyped claims of CE effects cannot be completely accounted for by sheer inaccuracy in reporting. A complex interaction between the primary and secondary literature, and expectations and social pressures related to CE appears to drive enthusiastic reports. (shrink)

This book takes the principles of archetypal pedagogy and applies them in exciting new ways to fields as diverse as literary studies, therapy and, of course, teacher education.

Volume 20, Issue 7, July 2020, Page 145-147.

In the vertebrate spinal cord, motoneurons are clustered into longitudinal columns in agreement with the targets they innervate. Motoneurons within each column acquire properties early in development that ensure their axons navigate to appropriate targets, but how this target identity is specified is unknown. Recently, Tsuchida et al.(1) described the expression of putative regulatory genes within motor columns in the chicken spinal cord. Combinations of LIM‐family homeobox genes differentially mark columns that project to distinct target groups. Expression precedes column formation (...) and axon outgrowth, making these genes candidates for specifying the target identity of motoneuron groups. (shrink)

Extending and expanding Geiger and Feller’s analysis of increasing dispersion in R&D expenditures during the 1980s, the paper analyzes publication and citation counts as well as R&D expenditures for 194 top producers using Web of Science data. We find high and stable levels of inequality in the 1990s and 2000s, combined with robust growth both in the system and on individual campuses, considerable opportunities for short-range mobility and very limited opportunities for long-range mobility. Initial investments in research, private control, and (...) the capacity of wealthy institutions to attract productive faculty are associated with high levels of scientific output. New entrants to the system and those that leave the system are both clustered near the bottom of the hierarchy. (shrink)

ABSTRACT Genevieve Lloyd’s assessment of Spinoza’s rationalism shows how imagination and sensibility are integrated with reason in his metaphysics and equally makes clear how his philosophy illuminates a number of aesthetic works and political situations. This response considers the limitations of the aesthetic analogy she draws from Flaubert and also queries the contrast she sees between Spinoza’s account of reason and finitude and Pascal’s account of the same. Turning from Pascal, it concludes with a consideration of Spinoza’s response to Augustine’s (...) doctrine of original sin in the Political Treatise in order to indicate some problems that stem from a vision of politics grounded in a Spinozist metaphysics of multiplicity. (shrink)

In his recent book, John Norton has created a theory of inference to the best explanation, within the context of his "material theory of induction". I apply it to the problem of scientific explanations that are false: if we want the theories in our explanations to be true, then why do historians and scientists often say that false theories explained phenomena? I also defend Norton's theory against some possible objections.

David Armstrong argues that necessitation relations among universals are the best explanation of some of our observations. If we consequently accept them into our ontologies, then we can justify induction, because these necessitation relations also have implications for the unobserved. By embracing Armstrongian universals, we can vindicate some of our strongest epistemological intuitions and answer the Problem of Induction. However, Armstrong’s reasoning has recently been challenged on a variety of grounds. Critics argue against both Armstrong’s usage of inference to the (...) best explanation and even whether, by Armstrong’s own standards, necessitation relations offer a potential explanation of this explanandum, let alone the best explanation. I defend Armstrong against these particular criticisms. Firstly, even though there are reasons to think that Armstrong’s justification fails as a self-contained defence of induction, it can usefully complement several other answers to Hume. Secondly, I argue that Armstrong’s reasoning is consistent with his own standards for explanation. (shrink)

Evidentialists say that a necessary condition of sound epistemic reasoning is that our beliefs reflect only our evidence. This thesis arguably conflicts with standard Bayesianism, due to the importance of prior probabilities in the latter. Some evidentialists have responded by modelling belief-states using imprecise probabilities (Joyce 2005). However, Roger White (2010) and Aron Vallinder (2018) argue that this Imprecise Bayesianism is incompatible with evidentialism due to “inertia”, where Imprecise Bayesian agents become stuck in a state of ambivalence towards hypotheses. Additionally, (...) escapes from inertia apparently only create further conflicts with evidentialism. This dilemma gives a reason for evidentialist imprecise probabilists to look for alternatives without inertia. I shall argue that Henry E. Kyburg’s approach offers an evidentialist-friendly imprecise probability theory without inertia, and that its relevant anti-inertia features are independently justified. I also connect the traditional epistemological debates concerning the “ethics of belief” more systematically with formal epistemology than has been hitherto done. (shrink)

In this interview, Cynthia Hammond sits down with Marc Lafrance in order to discuss the 30-year sketching practice that led to her exhibition, Drawings for a Thicker Skin, in 2012. In this practice, Hammond made small, quick drawings of the clothes she would need for trips or key professional events. As she explains, the drawings were not just essential to knowing what to pack; they were essential to being able to pack. While she never conceived of the practice as (...) art, when invited to exhibit the drawings she found a way to relate this idiosyncratic and private practice to a larger set of ontological concerns. Clothing as a second skin is the key idea here, as Hammond and Lafrance explore what it means to navigate identity, idealized self-image, professional ‘passing’ and the skin ego. (shrink)

According to John D. Norton's Material Theory of Induction, all reasonable inductive inferences are justified in virtue of background knowledge about local uniformities in nature. These local uniformities indicate that our samples are likely to be representative of our target population in our inductions. However, a variety of critics have noted that there are many circumstances in which induction seems to be reasonable, yet such background knowledge is apparently absent. I call such absences ‘the frontiers of science', where background scientific (...) theories do not provide information about such local uniformities. I argue that the Material Theory of Induction can be reconciled with our intuitions in favour of these inductions. I adapt an attempted justification of induction in general, the Combinatoric Justification of Induction, into a more modest rationalisation at the less foundational level that the critics discuss. Subject to a number of conditions, we can extrapolate from large samples using our knowledge of facts about the minimum proportions of representative subsets of finite sets. I also discuss some of Norton's own criticisms of his theory and argue that he is overly pessimistic. I conclude that Norton's theory at least performs well at the frontiers of science. (shrink)

This article contributes to current discussions of the origins of modern sexuality by exploring an episode from Book II of Jean-Jacques Rousseau’s Confessions (1782), in the context of eighteenth-century childhood hygiene theory. In this episode, the sixteen-year-old Rousseau is the object of an aggressive sexual advance on the part of another young man, and witnesses this young man’s orgasm. By stressing his unusual immunity to understanding the sexual nature of this encounter, Rousseau places himself outside the cultural argument that moral (...) degradation was bringing on premature puberty (ejaculation, in males) and thus degradation of the human species in eighteenth-century Europe. (shrink)