The study of complexity in chronic care is an emergent discipline that has not yet developed a consistent theoretical framework. Thinking in the field of complexity encompasses complexity science and complexity theories, which represent a convergence of different types of ideas and theories that focus on the interactions of individual parts that make up a complex system. In this context, an important distinction is to be made between "complex" and "complicated." If a system—despite the fact that it may consist of (...) a huge number of components— can be given a complete description in terms of its individual constituents, such a system is merely complicated. An example could be computers. In a complex system, on the .. (shrink)

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called (...) early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care. (shrink)

Rationale In Belgium, several policies regulating reimbursement of acid suppressant drugs and evidence-based recommendations for clinical practice were issued in a short period of time, creating a unique opportunity to observe their effect on prescribing. Aims and objectives To describe the evolution of prescriptions for acid suppressants and explore the interaction of policies and practice recommendations with prescribing patterns. Method Monthly claims-based data for proton pump inhibitors (PPIs) and H-2-antihistamines by general practitioners, internists and "astroenterologists were obtained from the Belgian (...) national health insurance database (1997-2005). The evolution of reimbursed defined daily doses and expenses after introduction of reimbursement regulations and dissemination of practice recommendations was explored. Results Recommendations had no impact on prescribing. All changes can be related to concomitant policies. Lifting reimbursement restrictions for cheaper products did not control growth or save costs in the Iona term. Only restricting reimbursement of all PPIs managed to curb the growth. We observed an unintended increase of non-omeprazole PPIs by gastroenterologists. Conclusions Reimbursement policies influence prescribing, but their effect can be unintended. A dialogue between policymakers and guideline developers, and evidence-based policies that are linked to clinical guidelines, could be an effective way to pursue both cost-containment and quality of care. (shrink)

The introduction of non-invasive prenatal testing in healthcare systems around the world offers an opportunity to reconsider funding policies for prenatal screening. In some countries with universal access healthcare systems, pregnant women and their partners are asked to pay for NIPT. In this paper, we discuss two important rationales for charging women for NIPT: to prevent increased uptake of NIPT and to promote informed choice. First, given the aim of prenatal screening, high or low uptake rates are not intrinsically desirable (...) or undesirable. Using funding policies to negatively affect uptake, however, is at odds with the aim of screening. Furthermore, copayment disproportionally affects those of lower socioeconomic status, which conflicts with justice requirements and impedes equal access to prenatal screening. Second, we argue that although payment models may influence pregnant women’s choice behaviours and perceptions of the relevance of NIPT, the copayment requirement does not necessarily lead to better-informed choices. On the contrary, external influences on women’s personal choices for or against prenatal screening should ideally be avoided. To improve informed decision-making, healthcare systems should instead invest in adequate non-directive, value-focused pretest counselling. This paper concludes that requiring copayments for NIPT in universal access healthcare systems fails to promote reproductive autonomy and is unfair. (shrink)

The Roberta Kevelson Seminar on Law and Semiotics is integrated in the regular program of a US Law School and student enrollment is honored with credit points. Hitherto, the study of Legal Semiotics has mainly been located outside the Law Schools in the US and the Faculties of Law in the EU. Two important questions within the more general theme of Legal Semiotics and Legal Education arose: (1) the program requirements in an education context, and (2) the attention and interests (...) of the students. This IJSL issue offers essays presented during the Round Table which closed the Seminar, provides some experience-based suggestions for a Seminar program and discusses how to deal with the pragmatic attitude of law students. It interests how those topics relate to legal and semiotic literature and how they focus globally important viewpoints, as can be concluded in the example of the legal semiotics of family structures. (shrink)

Wat is de plaats van het recht in de samenleving? Hoe fungeert het juridisch discours? Wie is de mens van het recht? Waartoe leiden de semantische transformaties die het recht tot een eigen discours maken? Hoe gaat de maatschappij met het juridisch discours om? Hoe verhoudt het rechtsbeleid zich tot de rechtswetenschap? Hoe verhouden de verschillende vakgebieden binnen het recht zich tot elkaar? Deze en andere vragen tussen rechtsfilosofie, rechtstheorie en rechtspraktijk worden in een collectie wetenschappelijke teksten geconfronteerd met kritische (...) interdisciplinaire benaderingen. Het boek biedt in die zin een kleine encyclopedie van de juridische discipline, gelieerd aan overwegingen van algemene cultuur. (shrink)

Deception is part of the natural repertoire of adaptive behaviours in many organisms. In humans we see it in all domains of human activity including health care. Within health care, deception can be a matter of concern, but it is also used to protect patients, for instance against overwhelming and negative diagnostics. This paper demonstrates that deception and self‐deception are closely interlinked and that self‐deception facilitates deception. Furthermore, self‐deception tends to be used to reduce the discomfort we feel when we (...) are dishonest (cognitive dissonance). The paper includes references to core psychological mechanisms and ethical aspects. (shrink)

The American Journal of Bioethics, Volume 11, Issue 6, Page 29-31, June 2011.

Prenatal screening pathways, as nowadays offered in most Western countries consist of similar tests. First, a risk‐assessment test for major aneuploides is offered to pregnant women. In case of an increased risk, invasive diagnostic tests, entailing a miscarriage risk, are offered. For decades, only conventional karyotyping was used for final diagnosis. Moreover, several foetal ultrasound scans are offered to detect major congenital anomalies, but the same scans also provide relevant information for optimal support of the pregnancy and the delivery.Recent developments (...) in prenatal screening include the application of microarrays that allow for identifying a much broader range of abnomalities than karyotyping, and non‐invasive prenatal testing (NIPT) that enables reducing the number of invasive tests for aneuploidies considerably. In the future, broad NIPT may become possible and affordable.This article will briefly address the ethical issues raised by these technological developments. First, a safe NIPT may lead to routinisation and as such challenge the central issue of informed consent and the aim of prenatal screening: to offer opportunity for autonomous reproductive choice. Widening the scope of prenatal screening also raises the question to what extent ‘reproductive autonomy’ is meant to expand. Finally, if the same test is used for two different aims, namely detection of foetal anomalies and pregnancy‐related problems, non‐directive counselling can no longer be taken as a standard. Our broad outline of the ethical issues is meant as an introduction into the more detailed ethical discussions about prenatal screening in the other articles of this special issue. (shrink)

Lawyers write, blog and are otherwise producers of words; they structure public life through legal discourse and integrate all issues that reinforce legal reasoning. Even if one is inclined not to justify the power of their words in the context of a democratic theory, one is hardly able to challenge its public acceptance. But semiotic analyses harden the question whether these emperors wear nothing but robes. That attitude intensifies where medicine becomes increasingly relevant for legal discourse, as becomes clear where (...) for instance US political viewpoints bring bioethical issues to the Courts. One major theme in today’s medicine pertains to identity in its psychological, philosophical and social dimensions. Identity thus becomes a groundbreaking semiotic issue in law and medicine; both discourses are particular important to the otherness of the other. A US criminal law case interests here (Harrington v. State of Iowa, 2003; cited as: 659N.W.2d 509). The case is decided with “information about what the person has stored in his brain”. A chain of signs is involved: from “brain-function” to “brain-storage” via “brain-scan” to “brain-fingerprint”, for which the case became famous. A long series of signs and meanings belong here to intertwined discourses. Central is a particular sign in each discourse: “brain” means brain scan, and “fingerprint” means law! The two display trading mechanisms, which determine the otherness of the other and the self! The chain of signs in the Harrington case shows inter-disciplinarity in law and inter-discursivity among law and medicine. The trading itself underlines the semiotic dimensions in cyberspace, in particular the semiotics of the virtual (Hayles, Kurzweil) and their effects on legal discourse. (shrink)

One vivid description of folktale research, still applicable although more than a half century old, reads, “Folktale study is like a desert journey, where the only landmarks are the bleached bones of earlier theories.” Because theories have proven to be so ephemeral in comparison with the tales themselves , it might seem prudent to place more stock in the tales and less in the theories or at least to take an eclectic approach toward theorizing so as to hedge bets; but (...) not all scholars of folktales exercise more circumspection now than their predecessors did fifty years ago. For example, in Little Red Riding Hood: A Casebook Alan Dundes — one of the most prominent American folklorists of our day — adduces no material dated from before 1697 that is related to the tale “Little Red Riding Hood” but manages nonetheless to question sharply the very notion of valuing early written evidence. By scrutinizing a short Latin poem written in the first quarter of the eleventh century, I hope to refute Dundes's dismissal of literary evidence and to underscore the pertinence of studying medieval literature in coming to grips with that beautiful and elusive phenomenon to which English-speakers give the name “fairy tale.”. (shrink)

Peirce shows how he presupposes that a ‘most general science of semeiotic’ is entirely a matter of culture. Semiotics unfolds even beyond the debate on specific differences between nature and culture. The expression ‘semiotics of culture’ entails all components of a true pleonasm. Pierce finds his parallel in the philosophy of Hegel and both philosophers consider the close ties between expressiveness and consciousness as a specifically human, cultural and spiritual activity. That viewpoint leads not only to linguistic but also to (...) other expressive phenomena, among which the body. Faces are perhaps the most outstanding bodily carriers of expression, so that Peirce’s analyses of Thirdness relate to the human face, not as a natural but as a cultural datum, in particular an artifice. A face-to-face relationship is embedded in a regulative discourse rather than an ethical appeal or other metaphysical dimensions. Three cases show various degrees of artificiality with different semiotic implications: Tilda Swinton’s appearance at the recent 2008 Oscar ceremony, the body art of Orlan and the first 2005 facial transplant of Isabelle Dinoire. The three do not only show how the human face is an artifice, but also how realities can appear to be fictitious within patterns of semiotic nature. Any sign can be a correlative to a fictitious world! (shrink)

Die hier vorgelegte Arbeit enthält drei inhaltlich zusammenhängende erkenntnistheoretische Untersuchungen über Probleme des Verstehens und Interpretierens von Rede und Text. Das _Ziel der Untersuchungen besteht jeweils darin, die von unterschiedlichen Autoren vorgebrachten Behauptungen einer erfahrungsunabhängigen Geltung der Prinzipien des Verstehens und Interpretierens einer eingehenden Prüfung zu unterziehen_ – sei es im Zusammenhang mit der im Rahmen der Sozialen Erkenntnistheorie geführten Diskussion über den Status von menschlichen Zeugnissen, sei es in Form einer Kritik des von Karl Popper im Kontext seiner Situationslogik (...) vertretenen Rationalitätsprinzips oder auch in der eingehenden Analyse der Argumente, die von analytischen Philosophen zugunsten einer erfahrungsunabhängigen Geltung des_ principle of charity_ vorgebracht wurden. Diese kritische Ausrichtung der Arbeit im Sinne der Zurückweisung der genannten Behauptungen hat jedoch auch eine konstruktive Dimension: Sie zeigt die Möglichkeit einer naturalistischen Hermeneutik, d.h. einer Verstehenslehre, die konsequent auf die Beanspruchung apriorischen Wissens verzichtet. (shrink)

Pediatric oncology has a strong research culture. Most pediatric oncologists are investigators, involved in clinical care as well as research. As a result, a remarkable proportion of children with cancer enrolls in a trial during treatment. This paper discusses the ethical consequences of the unprecedented integration of research and care in pediatric oncology from the perspective of parents and physicians. An empirical ethical approach, combining (1) a narrative review of (primarily) qualitative studies on parents' and physicians' experiences of the pediatric (...) oncology research practice, and (2) comparison of these experiences with existing theoretical ethical concepts about (pediatric) research. The use of empirical evidence enriches these concepts by taking into account the peculiarities that ethical challenges pose in practice. Analysis of the 22 studies reviewed revealed that the integration of research and care has consequences for the informed consent process, the promotion of the child's best interests, and the role of the physician (doctor vs. scientist). True consent to research is difficult to achieve due to the complexity of research protocols, emotional stress and parents' dependency on their child's physician. Parents' role is to promote their child's best interests, also when they are asked to consider enrolling their child in a trial. Parents are almost never in equipoise on trial participation, which leaves them with the agonizing situation of wanting to do what is best for their child, while being fearful of making the wrong decision. Furthermore, a therapeutic misconception endangers correct assessment of participation, making parents inaccurately attribute therapeutic intent to research procedures. Physicians prefer the perspective of a therapist over a researcher. Consequently they may truly believe that in the research setting they promote the child's best interests, which maintains the existence of a therapeutic misconception between them and parents. Due to the integration of research and care, their different ethical perspectives become intertwined in the daily practice of pediatric oncology. Increasing awareness of what this means for the communication between parents and physicians is essential. Future research should focus on efforts that overcome the problems that the synchronicity of research and care evokes. (shrink)

Faces challenge the sender-receiver model as the major scheme of thought for appropriately understanding interaction between human individuals. The openness and indeterminacy of faces lead to establish a semiotically relevant distinction between interaction and interactivity. The latter is our proposed articulation of the dynamic energy that thrives through the existence of signs and the uses of a semiotics. Facial expressions sustain and express the vital dynamism of making meaning in life. This often occurs at a bewildering distance to legal life (...) and discourses established by legal terminologies. (shrink)

There are many ways to assess face perception skills. In this study, we describe a novel task battery FEAST (Facial Expression Action Stimulus Test) developed to test recognition of identity and expressions of human faces as well as stimulus control categories. The FEAST consists of a neutral and emotional face memory task, a face and object identity matching task, a face and house part-to-whole matching task, and a human and animal facial expression matching task. The identity and part-to-whole matching tasks (...) contain both upright and inverted conditions. The results provide reference data of a healthy sample of controls in two age groups for future users of the FEAST. (shrink)

die Behandlungsweise kann jedoch sehr verschieden sein. Diese letztere charakterisiert nicht nur eine bestimmte Auffassung von Philosophie, sondern ebenso den Philosophen, der sie anwendet. In dem Sinne ist jede Erörterung eines philosophischen Gedankens zugleich eine bio graphische Notiz. Der erfahrungswissenschaftliche Charakter der in diesem Band ge sammelten philosophische Gedankengänge entstammt zu einem er heblichen Teil der Kenntnisnahme der (ursprünglich amerikanischen) Kulturanthropologie. Ihr Schöpfen aus den Initiativen der alther kömmlichen Ethnologie wie auch aus der vergleichenden Völkerkunde hat, zusammen mit dem fruchtbaren (...) «:field-work», auf einer anthropo logischen Basis neue und neuartige Erfahrungen über den Menschen hervorgehoben. Dadurch ist mehr als ein bloßes Kooperieren von Philosophie und Wissenschaft gewachsen: hier hat sich der Charakter des Philosophischen selbst gewandelt. Diese Kooperation, ja vielmehr tiefgreifende Verschränkung ist ein Merkmal moderner Philosophie. Besonders im Denken von Hermann Wein ist dieses Charakteristikum zu einem fruchtbaren philosophischen Ausgangspunkt geworden. Das wäre sowohl für seine philosophisch-anthropologischen wie auch für seine sprachphilosophischen Erörterungen nachzuweisen. Eben in der Abschätzung und Durchdenkung jener Bereiche bekommt die Idee der Erfahrung ihre Gestaltungskraft. Als Grundmotiv wäre diese Idee zu betrachten - nicht als ein regelmässig wiederkehrender Hinweis oder die Formulierung irgendeiner Wünschbarkeit in philosophicis. Betrachtet man unsere Philosophie der Gegenwart, so ergibt sich, dass ein solcher Ausgangspunkt außer in anthropologischen und be stimmten sprachphilosophischen Erwägungen auch in ethischen Frage stellungen fruchtbar geworden ist - wir weisen auf die amerikanischen und anderen. (shrink)

This study aims to contribute to emerging human-robot interaction research by adding longitudinal findings to a limited number of long-term social robotics home studies. We placed 70 robots in users’ homes for a period of up to six months, and used questionnaires and interviews to collect data at six points during this period. Results indicate that users’ evaluations of the robot dropped initially, but later rose after the robot had been used for a longer period of time. This is congruent (...) with the so-called mere-exposure effect, which shows an increasing positive evaluation of a novel stimulus once people become familiar with it. Before adoption, users focus on control beliefs showing that previous experiences with robots or other technologies allows to create a mental image of what having and using a robot in the home would entail. After adoption, users focus on utilitarian and hedonic attitudes showing that especially usefulness, social presence, enjoyment and attractiveness are important factors for long-term acceptance. (shrink)