The dilemma of whether and how to disclose a diagnosis of cancer or of any other terminal illness continues to be a subject of worldwide interest. We present the case of a 62-year-old Japanese woman afflicted with advanced gall bladder cancer who had previously expressed a preference not to be told a diagnosis of cancer. The treating physician revealed the diagnosis to the family first, and then told the patient: "You don't have any cancer yet, but if we don't treat (...) you, it will progress to a cancer". In our analysis, we examine the role of family consent, communication patterns (including ambiguous disclosure), and advance directives for cancer disclosure in Japan. Finally, we explore the implications for Edmund Pellegrino's proposal of "something close to autonomy" as a universal good. (shrink)

Quality improvement (QI) is fundamental to maintaining high standards of health care. Significant debate exists concerning the necessity for an ethical approval system for those QI projects that push the boundaries, appearing more similar to research than QI. The authors discuss this issue identifying the core ethical issues in family medicine (FM), drawing upon the fundamental principles of medical ethics, including principles of autonomy, utility, justice and non-maleficence. Recent debate concerning the application of QI ethics boards is discussed with relevance (...) to primary care and issues such as general practitioner (GP) intentions, the impact of QI on patients and the use of confidential patient data and the impact of dissemination. The authors conclude that a system of QI ethical approval leaves many issues unresolved and potentially creates several barriers to implementing QI. To ensure ethical QI work is generated within FM it is essential for GPs to learn about and engage in more ethical reflection so that they can better judge and resolve these issues. (shrink)

In this article I introduce a new reading of Jean-Paul Sartre's account of bad faith. The reading contrasts with previous accounts by denying that states of bad faith are exhausted by attitudes towards transcendence and facticity. Instead, I argue that bad faith can involve attitudes to many other aspects of the human being. I also respond to an argument which claims that affirmations of freedom are inconsistent with the motivations behind bad faith. The inconsistency is here resolved by demonstrating how (...) in bad faith we can still affirm a restricted version of freedom which avoids us acknowledging the unpleasant aspects of our full freedom. (shrink)

Patient decision aids enable patients to be better informed about the potential benefits and harms of their healthcare options. Certification of patient decision aids at the national level in the United States is a critical step towards responsible governance—primarily as a quality measure that increases patients’ safety, as mandated in the U.S. Patient Protection and Affordable Care Act (PPACA). Certification would provide a verification process to identify conflicts of interest that may otherwise bias the scientific evidence presented in decision aids. (...) Certification also benefits clinicians who may otherwise face malpractice claims based on harm to patients caused by possible reliance on patient decision aids that are inaccurate, incomplete, or presented in a manner that biases the patient’s decision. Existing work by the International Patient Decision Aid Standards Collaboration could guide the establishment of a certification process within the U.S. This article argues for national certification of patient decision aids and discusses how that may be achieved. (shrink)

Wallace became a full-time naturalist in 1848, the year when he and Bates set out on their journey to South America. Wallace was twenty-five at the time and over half of his life had been spent in various parts of Wales, the land of his birth. Commentators have tended to gloss over or ignore any formative influences from this early period of his life or even to dismiss them as non-existent. This is surprising as it was during the eight or (...) so years in Wales leading up to 1848 that Wallace's interest in natural history emerged. ‘The importance of this early period in Wallace's life can scarcely be over-emphasized’ wrote Durant in his account of the development of the Wallace personality, but he omitted any specific reference to the significance of the early period in Wales. Those seeking a simple unitary cause for Wallace's conversion to natural history usually locate this in his visit to Leicester in 1844 and his meeting there with H. W. Bates. ‘The odyssey began … in 1844, in Leicester’ wrote Brooks, adding that ‘the more remote parts of … southern Wales had offered little reading material…’ This, and similar claims, are presumably founded primarily on Wallace's belief—expressed sixty years later—that it was at Leicester that he first familiarized himself with Malthus'Essay on the Principles of Populationand Humboldt'sPersonal Narrative of Travels in South America.There is, however, evidence that Wallace was probably familiar with at least one of these books some time before his visit to Leicester and that it was during his period in southern Wales that his interest in natural history emerged and developed. (shrink)

Background Population based genetics studies are dependent on large numbers of individuals in the pursuit of small effect sizes. Recruiting and consenting a large number of participants is both costly and time consuming. We explored whether an online consent process for large-scale genetics studies is acceptable for prospective participants using an example online genetics study. Methods We conducted semi-structured interviews with 42 members of the public stratified by age group, gender and newspaper readership (a measure of social status). Respondents were (...) asked to use a website designed to recruit for a large-scale genetic study. After using the website a semi-structured interview was conducted to explore opinions and any issues they would have. Responses were analysed using thematic content analysis. Results The majority of respondents said they would take part in the research (32/42). Those who said they would decline to participate saw fewer benefits from the research, wanted more information and expressed a greater number of concerns about the study. Younger respondents had concerns over time commitment. Middle aged respondents were concerned about privacy and security. Older respondents were more altruistic in their motivation to participate. Common themes included trust in the authenticity of the website, security of personal data, curiosity about their own genetic profile, operational concerns and a desire for more information about the research. Conclusions Online consent to large-scale genetic studies is likely to be acceptable to the public. The online consent process must establish trust quickly and effectively by asserting authenticity and credentials, and provide access to a range of information to suit different information preferences. (shrink)

Promoting patient autonomy has become a key imperative in health service encounters. We will examine the potential negative effects of over-promoting patient autonomy and consider the impact on patient access, their experience and the provision of equitable services by focusing on an extreme manifestation of this trend, i.e. calls for patient involvement in health care decision making to be mandatory. Advocates of mandatory autonomy hold that patients have a duty to themselves, to society and to the medical system to make (...) decisions on their health care independently. Models of mandatory autonomy may be contrasted to those of optional autonomy that seek to ascertain patients’ decisional preferences and to understand wider limitations on their freedom to choose. Where choice as decisional responsibility becomes mandatory it ceases to promote agency and where autonomous choice is understood as an individualistic practice it will contribute to the cultural dominance of Western values. Moreover, taking a view that principlist ethics needs to take account of the social and cultural contexts of individual lives, we argue that if mandatory autonomy were to be over-emphasised as part of an ongoing move towards patient choice in UK National Health Service (NHS), educated and affluent people would be more able to exercise choices at the expense of people who are experienced in asserting preferences and who have the resources to make use of choices. We will argue that the promotion of autonomy needs to be tempered by steps to enable less powerful social, cultural and economic groups to contribute to decision making and to support individuals who may feel abandoned by having decisional responsibility transferred to them. Until constraints on individual choice can be understood and addressed, we advocate the model of optional autonomy used in shared decision making and make recommendations for practice, policy, education and research. (shrink)

Objective The UK Human Papillomavirus (HPV) vaccine programme commenced in the autumn of 2008 for year 8 (age 12–13 years) schoolgirls. We examine whether the vaccine should be given when there is a difference of opinion between daughters and parents or guardians. Design Qualitative study using semi-structured interviews. Participants A sample of 25 stakeholders: 14 professionals involved in the development of the HPV vaccination programme and 11 professionals involved in its implementation. Results Overriding the parents' wishes was perceived as problematic (...) and could damage the relationship between school and parents. A number of practical problems were raised in relation to establishing whether parents were genuinely against their daughter receiving the vaccine. Although many respondents recognised that the Gillick guidelines were relevant in establishing whether a girl could provide consent herself, they still felt that there were significant problems in establishing whether girls could be assessed as Gillick competent. In some areas school nurses had been advised not to give the vaccine in the absence of parental consent. None of the respondents suggested that a girl should be vaccinated against her consent even if her parents wanted her to have the vaccine. Conclusions While the Gillick guidelines provide a legal framework to help professionals make judgements about adolescents consenting to medical treatment, in practice there appears to be variable and confused interpretation of this guidance. Improved legal structures, management procedures and professional advice are needed to support those who are assessing competence and establishing consent to vaccinate adolescents in a school setting. (shrink)

Elwyn Richardson’s work at Oruaiti School from 1949 to 1962 has been almost exclusively interpreted as a unique experiment in art and craft education, partially as a result of impact of his book, In The Early World. The book is viewed as evidence of innovative departmental policies that allowed teachers wide latitude for experimentation, access to ample high-quality art materials and professional support. This interpretation of his work is, however, limiting as it obscures the scientific basis of Richardson’s approach. (...) The art and craft work at Oruaiti arose directly out of a scientific foundation that was shaped more by Richardson’s interest in environmental study than by the dominant ideas about child art. (shrink)

This article was written as the final presentation to be delivered at our day of reflection on the educational work of Elwyn Richardson. As such, the tone is somewhat different to that which is usual for this journal, but I elect to leave it substantially the same as it was when delivered. I address first the question of what we do when we mourn or remember someone like Elwyn Richardson, who made an important contribution to New Zealand’s educational (...) history. Then I turn to a ‘whakapapa’ or genealogy of progressivist ideas in education in New Zealand, and finally look to where we might take the spirit of these ways of thinking in the future. (shrink)

As educators we are haunted. This haunting takes place on several levels, through our personal histories, through key theoretical ideas we have encountered on our journeys, and by those significant educators who have gone before. This paper highlights how Elwyn S. Richardson continues to haunt education in New Zealand. Also how Elwyn, in turn, was haunted by ‘Wal’ and John Dewey. Rubbing up against neo-liberal reform, philosophers such as Elwyn, give us permission to develop our own personal (...) educational philosophy. Through employing an arts-based autoethnography, we explore how our educational journeys have been haunted by Elwyn. And by drawing on Jacques Derrida’s directive, ‘speak to the ghost’, we summon up Elwyn. To do this we write a series of fictional letters which enable us to reflect on one author’s memories. Through analysis of these letters we demonstrate the importance of the Arts as a method to critically reflect upon, and rise above, the dominant neo-liberal ideology we work within. We speculate here that a strong personal philosophy has the potential to disrupt and engage educators critically with an institutional philosophy that continues to dominate much of mainstream education in New Zealand. (shrink)

Les Prolegomenes a la Philosophie de Platon sont un manuel d'ecole neoplatonicien. Il s'inspire d'un modele dont Proclus a du etre l'auteur, mais l'origine de ce texte est presque surement alexandrine et doit dater de la premiere moitie du Vle siecle. Cette oeuvre est essentielle pour comprendre comment etait diffuse l'enseignement platonicien, et pour mieux saisir le mouvement des idees de l'Antiquite finissante. Dans une importante introduction, L. O. Westerink a retrace l'histoire de l'ecole d'Alexandrie et celle du genre litteraire (...) de ces introductions a Platon et a Aristote. (shrink)