Health care is provided in many contexts—not just hospitals, clinics, and community health settings. Different institutional settings may significantly influence the design and delivery of health care and the ethical obligations and practices of health care practitioners working within them. This is particularly true in institutions that are established to constrain freedom, ensure security and authority, and restrict movement and choice. We describe the results of a qualitative study of the experiences of doctors and nurses working within two women’s prisons (...) in the state of New South Wales (NSW), Australia. Their accounts make clear how the provision and ethics of health care may be compromised by the physical design of the prison, the institutional policies and practices restricting movement of prisoners and practitioners, the focus on maintaining control and security, and the very purpose of the prison and prison system itself. The results of this study make clear the impact that context has on professional practice and illustrate the importance of sociology and anthropology to bioethics and to the development of a more nuanced account of professional ethics. (shrink)

The success of deep brain stimulation (DBS) for movement disorders and the improved understanding of the neurobiologic and neuroanatomic bases of psychiatric diseases have led to proposals to expand current DBS applications. Recent preclinical and clinical work with Alzheimer's disease and obsessive-compulsive disorder, for example, supports the safety of stimulating regions in the hypothalamus and nucleus accumbens in humans. These regions are known to be involved in addiction and overeating associated with obesity. However, the use of DBS targeting these areas (...) as a treatment modality raises common ethical considerations, which include informed consent, coercion, enhancement, threat to personhood, and manipulation of the reward center. Pilot studies for both of these conditions are currently investigational. If these studies show promise, then there is a need to address the ethical concerns related to the initiation of clinical trials including the reliability of preclinical evidence, patient selection, study design, compensation for participation and injury, cost-effectiveness, and the need for long-term follow-up. Multidisciplinary teams are necessary for the ethical execution of such studies. In addition to establishing safety and efficacy, the consideration of these ethical issues is vital to the adoption of DBS as a treatment for these conditions. We offer suggestions about the pursuit of future clinical trials of DBS for the treatment of addiction and overeating associated with obesity and provide a framework for addressing ethical concerns related to treatment. (shrink)

In this article the author argues that nursing is best understood as a vocational occupation. Using Blum’s model of vocations it is argued that such occupations are socially expressed within practices embodying traditions, norms and a range of meanings: industrial, social, personal and moral. Vocational workers are those who identify in certain ways with these traditions, norms and meanings. One problem with the vocational model, as it has historically applied to nursing, is that it has been articulated through concepts of (...) motherhood. Nursing was a vocation precisely because the character of the nurse was identified as feminine. The author argues that the vocational model for nursing can be conceptually disentangled from its identification with ideals of motherhood and femininity. It is nursing work and the identification with the moral and social meaning of nursing that give nursing its vocational status, not the feminized character of the nurse. (shrink)

Exploratory studies employing volunteer subjects are especially vulnerable to race and class bias. This article illustrates how inattention to race and class as critical dimensions in women's lives can produce biased research samples and lead to false conclusions. It analyzes the race and class background of 200 women who volunteered to participate in an in-depth study of Black and White professional, managerial, and administrative women. Despite a multiplicity of methods used to solicit subjects, White women raised in middle-class (...) families who worked in male-dominated occupations were the most likely to volunteer, and White women were more than twice as likely to respond to media solicitations or letters. To recruit most Black subjects and address their concerns about participation required more labor-intensive strategies involving personal contact. The article discusses reasons for differential volunteering and ways to integrate race and class into qualitative research on women. (shrink)

This publication features the stories and experiences of pharmacy professionals who identify as members of historically underrepresented groups. This collection of personal essays presents significant events in the lives of those in the pharmacy community whose experiences have been shaped by their race, ethnicity, gender or gender presentation, sexual orientation, ability, language, mental health, or other factors. The perspectives from the narratives highlight the importance of diversity, equity, and inclusion in the healthcare sector. The authors of the narratives also reflect (...) on their experience to consider what they wish would have happened in the experience, to offer advice for others that may be faced with similar situations. Access to these stories will deepen the collective understanding among pharmacy colleagues, patients, and society of the experiences that individuals from historically underrepresented groups within pharmacy have experienced. (shrink)

The sudden emergence of the COVID-19 pandemic brought global disruption to every aspect of society including healthcare, supply chain, the economy, and social interaction. Among the many emergent considerations were the safety and public health of the public, patients, essential workers, and healthcare professionals. In certain locations, clinical research was halted—or terminated—in deference to the immediate needs of patient care, and clinical trials focusing on the treatment and prevention of coronavirus infection were prioritized over studies focusing on other diseases. Difficult (...) decisions were made rapidly; flexibility and reconsideration were necessary not only because the intensity and severity of infection varied over time and by locale but also because knowledge of the disease and understanding of its treatment grew. Here we discuss the ethical challenges in decision-making and competing ethical tensions during the pandemic in an effort to advance future preparedness. (shrink)

Online digital archives have allowed researchers to explore the past as never before. Arguably without the search technology offered by online digital archives the lives of many individuals would have remained in obscurity. Furthermore, the level of detail that can be quickly gleaned about individuals from the past, particularly when multiple digital archives are accessed, raises ethical questions. For example, when reporting findings researchers could be disclosing personal information that is unknown to descendants, and if it relates to a sensitive (...) topic then there is the potential for the researcher to cause distress. However, the rapid growth in digital archives has meant there has been little consideration of what ethical concerns digital archives might generate. This article reflects upon research using one digital archive and the importance of the researcher’s relationship with the material they retrieve when searching this type of source. (shrink)

One barrier to optimal pain management in the neonatal intensive care unit is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are vulnerable to pain and harm, and completely dependent on others for (...) pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate’s family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers. (shrink)

In these essays Stephen White examines the forms of psychological integration that give rise to self-knowable and self-conscious individuals who are responsible, concerned for the future, and capable of moral commitment. The essays cover a wide range of basic issues in philosophy of mind, metaphysics, moral psychology, and political philosophy, providing a coherent, sophisticated, and forcefully argued view of the nature of the self. Beginning with mental content and ending with Rawls and utilitarianism, each essay argues a distinctive line. (...) Together they are a unified and powerful philosophical position of considerable scope, one that provides a unique vision of the mind, consciousness, personhood, and morality. White argues that the unity of the self revealed in personal identity and moral responsibility is best understood in normative terms. Basic to such features of the self are the patterns of self-concern in which they are characteristically displayed and the internal justification that supports such concern. The treatment of intentionality and consciousness that grounds this account emphasizes privileged selfknowledge and practical rationality and their corresponding contributions to the unity of the self. A final source of unity emerges from the analysis of our fundamental commitments, an analysis that ensures a central place in moral theory for the notion of the self. (shrink)

In this paper I distinguish three alternatives to the functionalist account of qualitative states such as pain. The physicalist-functionalist holds that (1) there could be subjects functionally equivalent to us whose mental states differed in their qualitative character from ours, (2) there could be subjects functionally equivalent to us whose mental states lacked qualitative character altogether and (3) there could not be subjects like us in all objective respects whose qualitative states differed from ours. The physicalist-functionalist holds (1) and (3) (...) but denies (2). The transcendentalist holds (1) and (2) and denies (3). I argue that both versions of physicalist-functionalism inherit the problem of property dualism which originally helped to motivate functionalist theories of mind. I also argue that neither version of physicalist-functionalism can distinguish in a principled way between those neurophysiological properties of a subject which are relevant to the qualitative character of that subject's mental states and those which are not. I conclude that the only alternative to a functionalist account of qualitative states is a transcendentalist account and that this alternative is not likely to appeal to the critics of functionalism. (shrink)

This chapter defends the property dualism argument. The term “semantic premise” mentioned is used to refers to an assumption identified by Brian Loar that antiphysicalist arguments, such as the property dualism argument, tacitly assume that a statement of property identity that links conceptually independent concepts is true only if at least one concept picks out the property it refers to by connoting a contingent property of that property. It is argued that, the property that does the work in explaining the (...) possibility of a posteriori identities need not be a first-order property of the referent in question. On his view, the property dualism argument requires only a weaker semantic premise, which allows that the property in question be a higher order property. A refined version of the property dualism argument is formulated, which uses the weaker premise, and defends the argument against various objections. (shrink)

During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift—to some degree—from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by “crisis standards of care,” but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude (...) certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities. (shrink)

Raven10 years in Mexico. The mean IQs in relation to a British mean of 100 obtained from the 1979 British standardization sample and adjusted for the estimated subsequent increase were: 98·0 for whites, 94·3 for Mestizos and 83·3 for Native Mexican Indians.

This research merges literature from organizational behavior and marketing to garner insight into how organizations can maximize the benefits of Corporate Social Responsibility for enhanced CSR and organizational engagement of employees. Across two field experiments, the authors demonstrate that the effectiveness of employee co-creation activities in increasing employees’ positive CSR perceptions is moderated by self-construal. In particular, the positive effect of co-creation on CSR perceptions emerges only for employees with a salient interdependent self-construal. Moreover, the results demonstrate that increased positive (...) CSR perceptions then predict increased CSR engagement and organizational engagement. The research thus highlights the need to consider self-construal when trying to utilize co-creation to predict CSR engagement and organizational engagement, via CSR perceptions. (shrink)

RationaleSurrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.ObjectiveTo determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.MethodsThis was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth semistructured (...) interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.Measurements and main resultsThere was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.ConclusionsFamily members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs. (shrink)

The question whether epistemological concepts are closed under deduction is an important one since many skeptical arguments depend on closure. Such skepticism can be avoided if closure is not true of knowledge (or justification). This response to skepticism is rejected by Peter Klein and others. Klein argues that closure is true, and that far from providing the skeptic with a powerful weapon for undermining our knowledge, it provides a tool for attacking the skeptic directly. This paper examines various arguments in (...) favor of closure and Klein's attempted use of closure to refute skepticism. Such a refutation of skepticism is mistaken. But the closure principle is in any case false, so the skepticism that depends on it is undermined. The appeal of the closure principle derives from a failure to recognize an important feature of our epistemological concepts, namely, their context relativity. (shrink)

There is a well-known line of thought, associated with Donald Davidson, that connects the notion of a perceptual given—of non-linguistic or non-conceptual experience of the world—with skepticism. Against this, I argue that the notion of what is given in perception leads to skepticism only on certain interpretations. I argue, in fact, that there must be perceptual experience such that there is “something it is like” to have it, or that would provide the subject of a phenomenological analysis, if we are (...) to block skepticism in its most radical forms. In particular, I claim that there is a distinctive phenomenology of the experience of agency. These phenomenological claims are conclusions of a transcendental argument according to which our having such experience is a condition of our having a meaningful language. Moreover, the same transcendental argument is sufficient to show the incoherence of radical skepticism about the external world. And I argue that the proper understanding of perceptual experience—as object involving—renders the standard objections to transcendental arguments ineffective. (shrink)

The Monographs produced by the International Agency for Research on Cancer (IARC) apply rigorous procedures for the scientific review and evaluation of carcinogenic hazards by independent experts. The Preamble to the IARC Monographs, which outlines these procedures, was updated in 2019, following recommendations of a 2018 expert Advisory Group. This article presents the key features of the updated Preamble, a major milestone that will enable IARC to take advantage of recent scientific and procedural advances made during the 12 years since (...) the last Preamble amendments. The updated Preamble formalizes important developments already being pioneered in the Monographs Programme. These developments were taken forward in a clarified and strengthened process for identifying, reviewing, evaluating and integrating evidence to identify causes of human cancer. The advancements adopted include strengthening of systematic review methodologies; greater emphasis on mechanistic evidence, based on key characteristics of carcinogens; greater consideration of quality and informativeness in the critical evaluation of epidemiological studies, including their exposure assessment methods; improved harmonization of evaluation criteria for the different evidence streams; and a single-step process of integrating evidence on cancer in humans, cancer in experimental animals and mechanisms for reaching overall evaluations. In all, the updated Preamble underpins a stronger and more transparent method for the identification of carcinogenic hazards, the essential first step in cancer prevention. (shrink)

Background: People with traumatic brain injury face a range of mental health challenges during the adjustment process post-injury, but access to treatment can be difficult, particularly for those who live in regional and remote regions. eHealth provides the potential to improve access to evidence-based psychological therapy for people with a severe TBI. The aim of the current study is to assess the efficacy of a psychological intervention delivered via video consulting to reduce psychological distress in people with TBI.Methods: This paper (...) outlines the protocol for a multi-center, three-arm, parallel, non-inferiority randomized controlled trial of an evidence-based manualized psychological intervention, ACT-Adjust. ACT-Adjust provides nine sessions for adults with a moderate to severe TBI experiencing clinical levels of psychological distress. Fifty-six participants referred from Brain Injury Rehabilitation Units across New South Wales and the NSW icare scheme will be randomly allocated to three conditions; video consulting, face-to-face and, a waitlist control.Discussion: This is the first RCT to evaluate the efficacy of a psychological therapy delivered via video consulting for individuals with a moderate to severe TBI.Trial Registration:www.anzctr.org.au, Australian New Zealand Clinical Trials Registry ANZCTRN2619001602112. (shrink)

Introduction Patients require an accurate knowledge about placebos and their possible effects to ensure consent for placebo-controlled clinical trials is adequately informed. However, few previous studies have explored patients’ baseline levels of understanding and knowledge about placebos. The present online survey aimed to assess knowledge about placebos among patients with a history of back pain. Design A 15-item questionnaire was constructed to measure knowledge about placebos. Additional questions assessed sociodemographic characteristics, duration and severity of back pain, and previous experience of (...) receiving placebos. Setting Participants recruited from community settings completed the study online. Results 210 participants completed the questionnaire. 86.7% had back pain in the past 6 months, 44.3% currently had back pain. 4.3% had received a placebo intervention as part of a clinical trial and 68.1% had previously read or heard information about placebos. Overall knowledge of placebos was high, with participants on average answering 12.07 of 15 questions about placebos correctly. However, few participants correctly answered questions about the nocebo effect and the impact of the colour of a placebo pill. Conclusions The findings identified key gaps in knowledge about placebos. The lack of understanding of the nocebo effect in particular has implications for the informed consent of trial participants. Research ethics committees and investigators should prioritise amending informed consent procedures to incorporate the fact that participants in the placebo arm might experience adverse side effects. (shrink)

Hilary Putnam and John McDowell have each argued against representational realist theories of perception and in favor of direct realist (or “common-sense realist”) alternatives. I claim that in both cases they beg the question against their representational realist opponents. Moreover, in neither case has any alternative been offered to the representational realist position where the solution to perceptual or demonstrative versions of Frege’s problem is concerned. In this paper I present a transcendental argument that some of our perceptions of external (...) objects must be direct in the sense that we perceive them and there is nothing else we perceive in virtue of which we do so. I also present a reply to standard objections to the claim that transcendental arguments can be used to support conclusions about the world and not simply about our own use of concepts. Finally, I present a theory in terms of which the relevant Frege problems can be solved without appeal to any of the sorts of representations in terms of which representational realism is defined. (shrink)

It has normally been assumed that whatever empirical and metaphysical problems it may raise, mind-body dualism would satisfy a number of deeply engrained intuitions about the mental for which nondualist theories have no plausible account. In what follows I shall argue that this is true only for a special class of dualist theories. I distinguish transcendental dualism from the other forms that dualist theories may take. And I argue that where the intuitions about subjectivity that have seemed to motivate and (...) support dualism are concerned, only transcendental dualism has an advantage over nondualist theories; nontranscendental versions of dualism are open to the same objections that have made nondualist accounts of the mind seem implausible. Moreover, I argue that the usual objections to transcendental dualism are inconclusive. I shall argue, however, that with regard to a crucial intuition concerning the subjective point of view - that we have a form of privileged access to our own qualitative mental states - transcendental dualism is at a disadvantage relative to some nondualist and nontranscendental theories. And I shall argue that if a theory fails to satisfy this intuition, its other advantages carry very little weight. Thus I claim that transcendental versions of dualism do not offer viable alternatives to nontranscendental theories of mind. (shrink)

This article describes the spiritual formation training program for counseling students at Richmont Graduate University, an evangelical institution providing Master’s-level instruction for counselors and ministers. This model of spiritual formation has a dual foundation which includes the centrality of love to the Christian life and the importance of attachment to the development of persons. The training is intentionally designed to invite students to pursue a more secure attachment to God, healthier relationships with others, and a more grace-based self-awareness. Integrative and (...) clinical instruction, and experiences that foster establishment of secure attachment are described. Co-curricular efforts in research and student advisement focus on grace and wellness, as well as opportunities for service, and these serve to further contribute to a supportive environment for spiritual formation. (shrink)

The dominant paradigm of experiments in the social and behavioral sciences views an experiment as a test of a theory, where the theory is assumed to generalize beyond the experiment's specific conditions. According to this view, which Alan Newell once characterized as “playing twenty questions with nature,” theory is advanced one experiment at a time, and the integration of disparate findings is assumed to happen via the scientific publishing process. In this article, we argue that the process of integration is (...) at best inefficient, and at worst it does not, in fact, occur. We further show that the challenge of integration cannot be adequately addressed by recently proposed reforms that focus on the reliability and replicability of individual findings, nor simply by conducting more or larger experiments. Rather, the problem arises from the imprecise nature of social and behavioral theories and, consequently, a lack of commensurability across experiments conducted under different conditions. Therefore, researchers must fundamentally rethink how they design experiments and how the experiments relate to theory. We specifically describe an alternative framework, integrative experiment design, which intrinsically promotes commensurability and continuous integration of knowledge. In this paradigm, researchers explicitly map the design space of possible experiments associated with a given research question, embracing many potentially relevant theories rather than focusing on just one. Researchers then iteratively generate theories and test them with experiments explicitly sampled from the design space, allowing results to be integrated across experiments. Given recent methodological and technological developments, we conclude that this approach is feasible and would generate more-reliable, more-cumulative empirical and theoretical knowledge than the current paradigm – and with far greater efficiency. (shrink)

In another tumultuous term of the United States Supreme Court in 2022-2023 a series of critical cases implicate instant and forthcoming changes in multiple fronts that collectively shift the national public health law and policy environment.

Darwinian Evolution and Classical Liberalism brings together a collection of new essays that examine the multifaceted ferment between Darwinian biology and classical liberalism.

As the United States emerges from the worst public health threat it has ever experienced, the Supreme Court is poised to reconsider constitutional principles from bygone eras. Judicial proposals to roll back rights under a federalism infrastructure grounded in states’ interests threaten the nation’s legal fabric at a precarious time. This column explores judicial shifts in 3 key public health contexts — reproductive rights, vaccinations, and national security — and their repercussions.

In many research studies, tumor biopsies are an unavoidable requirement for achieving key scientific aims. Yet some commentators view mandatory research biopsies as coercive and suggest they should be optional, or at least optional until further data are obtained regarding their scientific usefulness. Further complicating the ethical picture is the fact that some research biopsies offer a potential for clinical benefit to trial participants. We interviewed and surveyed a convenience sample of participants in phase I clinical trials at a single (...) institution. Our primary aim was to describe phase I participants’ understanding of whether a research biopsy offered them the prospect of medical benefit. We also endeavored to describe participants’ views about biopsies—specifically, the benefits of biopsies, if any, and whether biopsies were acceptable, risky, or discouraged trial participation. Finally, we collected data on demographics and attitudes to see if any strong correlations with misunderstanding, acceptability, or riskiness existed. Overall, the respondents tended to view research biopsies as acceptable, though they did not succeed in identifying the lack of benefit of a research biopsy. These findings call for renewed efforts in consent conversations and documents to carefully describe the benefits, or lack thereof, of research biopsies. (shrink)