The right to refuse medical intervention is well established, but it remains unclear how best to respect and exercise this right in life support. Contemporary ethical guidelines for critical care give ambiguous advice, largely because they focus on the moral equivalence of withdrawing and withholding care without confronting the very real differences regarding who is aware and informed of intervention options and how patient values are communicated and enacted. In withholding care, doctors typically withhold information about interventions judged too futile (...) to offer. They thus retain greater decision-making burden and face weaker obligations to secure consent from patients or proxies. In withdrawing care, there is a clearer imperative for the doctor to include patients in decisions, share information and secure consent, even when continued life support is deemed futile. How decisions to withhold and withdraw life support differ ethically in their implications for positive versus negative interpretations of patient autonomy, imperatives for consent, definitions of futility and the subjective evaluation of benefits and burdens of life support in critical care settings are explored. Professional reflection is required to respond to trends favouring a more positive interpretation of patient autonomy in the context of life support decisions in critical care. Both the bioethics and critical care communities should investigate the possibilities and limits of growing pressure for doctors to disclose their reasoning or seek patient consent when decisions to withhold life support are made. (shrink)

PURPOSE: To evaluate the effects of social support on comprehension and recall of consent form information in a study of Parkinson disease patients and their caregivers.DESIGN and METHODS: Comparison of comprehension and recall outcomes among participants who read and signed the consent form accompanied by a family member/friend versus those of participants who read and signed the consent form unaccompanied. Comprehension and recall of consent form information were measured at one week and one month respectively, using Part A of the (...) Quality of Informed Consent Questionnaire .RESULTS: The mean age of the sample of 143 participants was 71 years . Analysis of covariance was used to compare QuIC scores between the intervention group and control group . In the 1-week model, no statistically significant intervention effect was found . However, the intervention status by patient status interaction was statistically significant . In the 1-month model, no statistically significant intervention effect was found . Again, however, the intervention status by patient status interaction was statistically significant . At both time periods, intervention group patients scored higher on the QuIC than did intervention group caregivers, and control group patients scored lower on the QuIC than did control group caregivers.IMPLICATIONS: Social support played a significant role in enhancing comprehension and recall of consent form information among patients. (shrink)

Drawing on a landscape analysis of existing data-sharing initiatives, in-depth interviews with expert stakeholders, and public deliberations with community advisory panels across the U.S., we describe features of the evolving medical information commons. We identify participant-centricity and trustworthiness as the most important features of an MIC and discuss the implications for those seeking to create a sustainable, useful, and widely available collection of linked resources for research and other purposes.

SOME suggestions are here made for improvement of the text and understanding of Pliny's Eastern Aegean geography. The editions studied for the purpose are Detlefsen's special edition of the geographical books and Mayhoff's Teubner vol. i . The citations of MSS. readings given below are normally taken from Mayhoff's apparatus, which gives a fuller coverage than Detlefsen's. The MSS. are cited by the letters given them in Mayhoff's edition and the Budé Pliny book i , pp. 37 f. One further (...) MS., hitherto not collated in the geographical books, is here cited. Following Campbell, who first drew attention to it, I cite it as c. This MS., formerly in the Phillipps collection in Cheltenham and now in the Pierpont Morgan Library , is assigned to Lorsch and said to be of the first half of the ninth century. It seems thus to be somewhat older than A and E, and in that case is the oldest known surviving MS. of the geographical books. (shrink)

SOME suggestions are here made for improvement of the text and understanding of Pliny's Eastern Aegean geography. The editions studied for the purpose are Detlefsen's special edition of the geographical books and Mayhoff's Teubner vol. i. The citations of MSS. readings given below are normally taken from Mayhoff's apparatus, which gives a fuller coverage than Detlefsen's. The MSS. are cited by the letters given them in Mayhoff's edition and the Budé Pliny book i, pp. 37 f. One further MS., hitherto (...) not collated in the geographical books, is here cited. Following Campbell, who first drew attention to it, I cite it as c. This MS., formerly in the Phillipps collection in Cheltenham and now in the Pierpont Morgan Library, is assigned to Lorsch and said to be of the first half of the ninth century. It seems thus to be somewhat older than A and E, and in that case is the oldest known surviving MS. of the geographical books. (shrink)

Epilepsy surgery is the most effective therapeutic approach for children with drug resistant epilepsy. Recent advances in neurosurgery, such as the Laser Interstitial Thermal Therapy, improved the safety and non-invasiveness of this method. Electric and magnetic source imaging plays critical role in the delineation of the epileptogenic focus during the presurgical evaluation of children with DRE. Yet, they are currently underutilized even in tertiary epilepsy centers. Here, we present a case of an adolescent who suffered from DRE for 16 years (...) and underwent surgery at Cook Children's Medical Center. The patient was previously evaluated in a level 4 epilepsy center and treated with multiple antiseizure medications for several years. Presurgical evaluation at CCMC included long-term video electroencephalography, magnetoencephalography with simultaneous conventional EEG and high-density EEG in two consecutive sessions, MRI, and fluorodeoxyglucose - positron emission tomography. Video long-term EEG captured nine focal-onset clinical seizures with a maximal evolution over the right frontal/frontal midline areas. MRI was initially interpreted as non-lesional. FDG-PET revealed a small region of hypometabolism at the anterior right superior temporal gyrus. ESI and MSI performed with dipole clustering showed a tight cluster of dipoles in the right anterior insula. The patient underwent intracranial EEG which indicated the right anterior insular as seizure onset zone. Eventually LITT rendered the patient seizure free. Retrospective analysis of ESI and MSI clustered dipoles found a mean distance of dipoles from the ablated volume ranging from 10 to 25 mm. Our findings highlight the importance of recent technological advances in the presurgical evaluation and surgical treatment of children with DRE, and the underutilization of epilepsy surgery in children with DRE. (shrink)

I have argued that there is a philosophical problem posed by a need to determine the reference of expressions which seem to refer to kinds of stuff or matter and to make identity claims about it (e.g., ‘the gold’, ‘the same clay’). Ordinary sortal expressions such as ‘lump’, and ‘piece’ have been shown to be inadequate to the task of providing reference for the expressions in question. What is necessary is an expression which does not have an ordinary sortal use (...) and which meets certain other conditions which I have enumerated. There does not seem to be an expression in ordinary language which fits these conditions. The technical term, ‘quantity’, as defined by Helen Cartwright, meet the conditions. ‘Parcel’, suggested V. C. Chappell, fails to meet the conditions. Another technical term, ‘m-elements’, coined by Laycock, comes close to meeting the conditions, but has a number of difficulties. Mose of these difficulties stem from the fact that counting (rather than measuring, as with quantities) is behind the application of ‘m-elements’, and stuff is as a matter of fact measured, rather than counted, in most situations. I have also considered a possible difficulty with ‘quantity’ (that in most cases in which someone talks of ‘same stuff’ strictly speaking we don't have the same quantity of stuff) and shown it not to be a genuine difficulty. (shrink)

The aim of this study is to explore how nurses perceive patient participations of patients over 75 years old undergoing hemodialysis treatment in dialysis units, and of their next of kin. Ten nurses told stories about what happened in the dialysis units. These stories were analyzed with critical discourse analysis. Three discursive practices are found: (1) the nurses’ power and control; (2) sharing power with the patient; and (3) transferring power to the next of kin. The first and the predominant (...) discursive practice can be explained with an ideology of paternalism, in which the nurses used biomedical explanations and the ethical principle of benefice to justify their actions. The second can be explained with an ideology of participation, in which the nurses used ethical narratives as a way to let the patients participate in the treatment. The third seemed to involve autonomous decision-making and the ethical principle of autonomy for the next of kin in the difficult end-of-life decisions. (shrink)

Is God's foreknowledge compatible with human freedom? One of the most attractive attempts to reconcile the two is the Ockhamistic view, which subscribes not only to human freedom and divine omniscience, but retains our most fundamental intuitions concerning God and time: that the past is immutable, that God exists and acts in time, and that there is no backward causation. In order to achieve all that, Ockhamists distinguish ‘hard facts’ about the past which cannot possibly be altered from ‘soft facts’ (...) about the past which are alterable, and argue that God's prior beliefs about human actions are soft facts about the past. (shrink)

In this article, I examine the moral dimensions of gender affirmation. I argue that the moral value of gender affirmation is rooted in what Iris Murdoch called loving attention. Loving attention is central to the moral value of gender affirmation because such affirmation is otherwise too fragile or insincere to have such value. Moral reasons to engage in acts that gender affirm derive from the commitment to give and express loving attention to trans people as a way of challenging their (...) marginalization. In the latter part of the paper, I will discuss how my arguments bear on recent arguments by Robin Dembroff and Daniel Wodak (2018) on the use of gender-neutral language. They argue that we have a duty not to use gender-specific pronouns for anyone. Their conclusion turns, in part, on a rejection of gender affirmation as a moral duty. The value of gender affirmation, rooted in our moral perception of trans people, should make us skeptical of this conclusion, in favor of a more nuanced and pluralistic approach to the ethics of gendering. (shrink)

This book is an extensive survey and critical examination of the literature on the use of expert opinion in scientific inquiry and policy making. The elicitation, representation, and use of expert opinion is increasingly important for two reasons: advancing technology leads to more and more complex decision problems, and technologists are turning in greater numbers to "expert systems" and other similar artifacts of artificial intelligence. Cooke here considers how expert opinion is being used today, how an expert's uncertainty is or (...) should be represented, how people do or should reason with uncertainty, how the quality and usefulness of expert opinion can be assessed, and how the views of several experts might be combined. He argues for the importance of developing practical models with a transparent mathematic foundation for the use of expert opinion in science, and presents three tested models, termed "classical," "Bayesian," and "psychological scaling." Detailed case studies illustrate how they can be applied to a diversity of real problems in engineering and planning. (shrink)

This is a welcome reprint of a book that continues to grow in importance.

Integrated developmental and elemental information in teeth provide a unique framework for documenting breastfeeding histories, physiological disruptions, and neurotoxicant exposure in humans and our primate relatives, including ancient hominins. Here we detail our method for detecting the consumption of mothers’ milk and exploring health history through the use of laser ablation‐inductively coupled plasma‐mass spectrometry (LA‐ICP‐MS) mapping of sectioned nonhuman primate teeth. Calcium‐normalized barium and lead concentrations in tooth enamel and dentine may reflect milk and formula consumption with minimal modification during (...) subsequent tooth mineralization, particularly in dentine. However, skeletal resorption during severe illness, and bioavailable metals in nonmilk foods, can complicate interpretations of nursing behavior. We show that explorations of the patterning of multiple elements may aid in the distinction of these important etiologies. Targeted studies of skeletal chemistry, gastrointestinal maturation, and the dietary bioavailability of metals are needed to optimize these unique records of human health and behavior. (shrink)

There are two aims of this paper: (1) to explore the affective dimensions of moral shock and how it relates to normative marginalization of those furthest from dominant society, but also, more specifically; (2) to articulate the trans experience of constantly being under moral attack because the dominant “world” normatively defines you out of existence. Toward these ends, I build on Katie Stockdale’s recent work on moral shock, arguing that moral shock needs to be contextualized to “worlds” of sense to (...) understand how marginalized people affectively experience shocking events. My focus is the trans experience of moral shock due to the way trans people are positioned outside of dominant society, creating the conditions to experience cyclical, chronic shock. These affective conditions point to a collective responsibility to ease the affective stress that the most marginalized experience. (shrink)

Student nurses are confronted by many ethical challenges in clinical practice. The aim of the study was to explore Malawian students’ experiences of ethical problems during their clinical placement. A phenomenological hermeneutic design comprising interviews and qualitative content analysis was used. Ten students were interviewed. Three main themes emerged: 1) Conflict between patient rights and the guardians’ presence in the hospital; 2) Conflict between violation of professional values and patient rights caused by unethical behaviour; and 3) Conflict between moral awareness (...) and the ideal course of action. The students had difficulties ensuring patient rights and acting in accordance with western norms and values which are not always appropriate in the Malawian context. The students require role models who demonstrate professional attitudes towards patients’ rights and values. There is a need to create pedagogical strategies in which a caring attitude and ethical reflection can be learned and cultivated in clinical practice. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Imagined Apotheoses: Drake, Harriot, and Ralegh in the AmericasWilliam M. HamlinPerhaps the two best known stories of Europeans being taken for gods by non-European peoples are those of Hernan Cortés in Mexico and Captain James Cook in Hawaii. Separated by two hundred sixty years, five thousand miles, and vast differences in cultural and linguistic context, these two incidents nonetheless share many traits in the conventional telling. Cortés and (...) Cook were both strong leaders, for instance, both capable of inspiring devotion among their subordinates. Both men became amateur ethnographers during their lengthy sojourns away from Europe, both sought to promote an image of respectful rather than rapacious foreign incursion, and both are said to have been taken for returning gods by the native peoples among whom they landed: Cortés for the Toltec culture-hero and demigod Quetzalcoatl, Cook for the Hawaiian deity Lono. Click for larger view View full resolutionFigure 1.“The Far Side” cartoon by Gary Larson. Courtesy of Chronicle Features, San Francisco.Recent scholarly studies and debates—among them the rather strident dispute between Gananath Obeyesekere and Marshall Sahlins over the alleged deification of Cook by eighteenth-century Hawaiians—have opened up these returning-god theories to skeptical critique and detailed justification; but such discussions have had little, if any, impact on popular imagination. 1 [End Page 405] Indeed, the idea that redoubtable European explorers can be (and often are) perceived as supernatural beings by non-European “primitives” has been uncritically perpetuated to this day by filmmakers, fantasists, writers of popular history, and purveyors of cultural literacy. E. D. Hirsch, Jr., for instance, informs our children that Caribbean islanders encountered by Columbus “asked if he had come from heaven”—the implication being, of course, that they took him for a god. 2 And in the recent film, 1492: Conquest of Paradise, we hear the indefatigable Admiral (played by Gerard Depardieu) claim that “on every island the natives welcome us with great generosity and trust.... Because of our appearance, we have been mistaken for gods, and are treated accordingly.” 3 Fortunately, we also have a “Far Side” parody of the cultural conceit on which such ideas in part rely, but the cartoon serves as well to demonstrate just how thoroughly the conceit has permeated our collective awareness (see figure 1). 4 Click for larger view View full resolutionFigure 2.“It’s against my programming to impersonate a deity.” From The Return of the Jedi, dir. Richard Marquand, Lucasfilm, Ltd., 1983. All Rights Reserved. Courtesy of Lucasfilm, Ltd.Let me offer just one other example. Near the end of the popular 1983 film The Return of the Jedi, the forest-dwelling Ewoks begin to chant and salaam upon first glimpsing the golden robot C-3PO, who in turn tells his captured comrades, “I do believe they think I am some sort of god.” When Han Solo sarcastically asks the robot to use his “divine influence” to help extricate them from their predicament, C-3PO replies that such an action would be improper: “It’s against my programming to impersonate a deity.” Here we see, embedded within a film romance, both the classic trope of the apotheosized foreigner and the related motif of the foreigner’s reluctance to [End Page 406] play the god-role (see figure 2). It is worth noting, however, that while C-3PO may be unwilling to exploit the Ewoks’ misperception, Luke Skywalker is not; he uses the “Force” to convince the Ewoks of the robot’s magical prowess and, more to the point, to perpetuate their misapprehension. 5What I wish to suggest in this essay is that certain habitual Western assumptions or conceits regarding cross-cultural encounters—assumptions which have been usefully termed “myth models” inasmuch as they condition human perception and find frequent discursive expression—coexist easily but in fact disjunctively with certain other ideological structures in many early modern travel narratives and colonial accounts. Obeyesekere, in his provocative book on the supposed deification of Captain Cook in Hawaii, has linked such myth models to the conceptual structures of the longue durée as characterized by Fernand Braudel, and it is possible that they may also be... (shrink)

MORALITY is an area of culture that is highly susceptible to philosophical skepticism. This has been so at least since the time of the Greek Sophists. But modern Western civilization seems to be especially prone to philosophical doubts about the moral enterprise because of widely shared assumptions and views in the modern age about the knowledge-yielding powers of the human mind. This particular trouble spot in the culture has received extensive philosophical attention ever since the seventeenth century, but activity in (...) moral philosophy has never been greater than in our own time. (shrink)