Are clinical practice guidelines a means for improving the quality of health care? For saving money in the health care system? For solving the malpractice problem? For making the health care system work better for all? Or, are they a recipe for disaster? This overview sets out conceptual, definitional, and practical aspects of clinical practice guidelines as a broad framework for reflecting on the issue of what guidelines are and why they count. It draws mainly on work done since 1990 (...) at the Institute of Medicine and focuses on five questions. First, what are guidelines, and who develops them? Second, what criteria or principles should be used to create good guidelines? Third, what problems or pitfalls exist in developing and disseminating guidelines? Fourth, in what ways can guidelines help improve medical care, and in what ways will they not be as practical or useful, particularly with respect to quality of care? Finally, what ethical context might guide deliberations on this topic? (shrink)

In this comment, we propose a short exploration of the differences among the declaration of death, the determination of death, and the concept of death, and how they relate to the ethics and practi...

Are clinical practice guidelines a means for improving the quality of health care? For saving money in the health care system? For solving the malpractice problem? For making the health care system work better for all? Or, are they a recipe for disaster? This overview sets out conceptual, definitional, and practical aspects of clinical practice guidelines as a broad framework for reflecting on the issue of what guidelines are and why they count. It draws mainly on work done since 1990 (...) at the Institute of Medicine and focuses on five questions. First, what are guidelines, and who develops them? Second, what criteria or principles should be used to create good guidelines? Third, what problems or pitfalls exist in developing and disseminating guidelines? Fourth, in what ways can guidelines help improve medical care, and in what ways will they not be as practical or useful, particularly with respect to quality of care? Finally, what ethical context might guide deliberations on this topic? (shrink)

Hegel and the Symbolic Mediation of Spirit examines the role of the symbol and the sign in Hegel's philosophy. Of the relatively few commentators who have concerned themselves at all with the role of the symbol or the sign in Hegel's philosophy, most have restricted themselves to either his discussion of theoretical spirit, in which he presents symbol-making as an act of the imagination that must be surpassed by abstract thought, or to his consideration of the symbolic form of art, (...) which he describes as the mere precursor to art's ideal form. As a result, these commentators have tended to assume that Hegel's philosophy asserts a simple preference for the sign over the symbol. Hegel and the Symbolic Mediation of Spirit contests this assumption by considering these passages in light of Hegel's entire philosophy of spirit and logical method. Through close analyses of the various ways in which the symbol and the sign serve the development of theoretical and absolute spirit, this dissertation demonstrates how the symbol is of "absolute" importance to Hegel's notion of spirit as wholly self-determining. Although spirit's necessary recourse to the symbolic--to that which is ambiguous and displacing--appears to compromise its act of self-determination, this work shows how spirit's symbolic experience actually conditions and completes its self-determining activity. At the same time, besides leading to a new understanding of spirit, this comprehensive consideration of Hegel's discussions of the symbol and the symbolic leads to a unique position on some of the most widely-debated issues of Hegelian scholarship. It serves, for example, to delineate the relationship between language and thought, to illuminate the paradox of art's simultaneous absolute and derivative status, and to display philosophy's ultimate dependence upon artistic and religious conceptions of reality. (shrink)

Whether they realize it or not, most stakeholders in the debate about using animals for research agree on the common goal of seeking an end to research that causes animals harm. The central issues in the controversy are about how much effort should be devoted to that goal and when we might reasonably expect to achieve it. Some progress has already been made: The number of animals used for research is about half what it was in the 1970s, and biomedical (...) research has reached the point where we can reasonably begin to envision a time when it could advance without causing harm to animals. With some effort and aggressive development of new biomedical research technologies, full replacement of animals in harmful research is within our grasp. The goal will not be reached all at once, however, and phasing out invasive research on all nonhuman primates should be the priority. (shrink)

This article investigates the online information practices of persons grieving and mourning via Facebook. It examines how, or whether, these practices and Facebook’s terms of use policies have implications for the bereaved and/or the memory of the deceased. To explore these questions, we compared traditional publicly recorded asynchronous modes of grieving (i.e., obituaries) with Facebook’s asynchronous features (i.e., pages, photos, messages, profiles, comments). Additionally, by applying observational techniques to Facebook memorial pages and Facebook profiles, conducting a survey, and interviewing respondents (...) as a follow-up to the survey, we examined the benefits of and issues surrounding online information sharing via Facebook when coping with the loss of another. We found that the immediacy of publishing comments, messages, wall posts, and photos provides Facebook mourners with a quick outlet for their emotions and a means of timely group support; however, these actions directly affect the online curation of the deceased’s self and memory and also create an environment of competition among mourners. The aforementioned benefits and complications of using Facebook during bereavement are shaped by the policies outlined by the social media platform. (shrink)

Testosterone fluctuates in response to competitive social interactions, with the direction of change typically depending on factors such as contest outcome. Watching a competition may be sufficient to activate T among fans and others who are invested in the outcome. This study explores the change in T associated with vicarious experiences of competition among combat sport athletes viewing a teammate win or lose and assesses how individual differences in social identification with one’s team relates to these patterns of T reactivity. (...) Twenty-six male combat athletes completed a social identity questionnaire on a neutral day. Later, salivary samples were obtained before and after athletes viewed a video of a teammate engaged in a formal contest. T reactivity to viewing a teammate compete varied among participants in both the magnitude and direction of change, independent of contest outcome. Individual differences in cognitive centrality, a core feature of social identification, showed a strong positive relationship with T reactivity, particularly if their teammate won. Initial findings suggest that dominance-linked androgen responses associated with watching a teammate win a competition might depend on the belief that team membership is central to one’s own identity. These exploratory results in a small sample of combat athletes should be interpreted with caution. Uncovering the role of social group dynamics in influencing T responses to competition is particularly important in light of the evolutionary history of coalitional combat in humans. (shrink)

This qualitative study describes the lived experience of physicians who work in communities that have experienced a public mass shooting. Semi-structured interviews were conducted with seventeen physicians involved in eight separate mass casualty shooting incidents in the United States. Four major themes emerged from constant comparative analysis: The psychological toll on physicians: “I wonder if I'm broken”; the importance of and need for mass casualty shooting preparedness: “[We need to] recognize this as a public health concern and train physicians to (...) manage it”; massive media attention: “The media onslaught was unbelievable”; and commitment to advocacy for a public health approach to firearm violence: “I want to do whatever I can to prevent some of these terrible events.”. (shrink)

Physiologically accurate mouse models of cancer are critical in the pre‐clinical development of novel cancer therapies. However, current standardized animal‐housing temperatures elicit chronic cold‐associated stress in mice, which is further increased in the presence of tumor. This cold‐stress significantly impacts experimental outcomes. Data from our lab and others suggest standard housing fundamentally alters murine physiology, and this can produce altered immune baselines in tumor and other disease models. Researchers may thus underestimate the efficacy of therapies that are benefitted by immune (...) responses. A potential mediator, norepinephrine, also underlies stress pathways common in mice and humans. Therefore, research into mechanisms connecting cold‐stress and norepinephrine signaling with immune depression in mice could highlight new combination therapies for humans to simultaneously target stress while stimulating anti‐tumor immunity. (shrink)

Studies on associations between music training and cognitive abilities typically focus on the possible benefits of music lessons. Recent research suggests, however, that many of these associations stem from niche-picking tendencies, which lead certain individuals to be more likely than others to take music lessons, especially for long durations. Because the initial decision to take music lessons is made primarily by a child's parents, at least at younger ages, we asked whether individual differences in parents' personality predict young children's duration (...) of training. Children between 7 and 9 years of age ( N = 170) with varying amounts of music training completed a measure of IQ. Their parents provided demographic information as well as ratings of their own and their child's Big Five personality dimensions. Children's personality traits predicted duration of music training even when demographic variables and intelligence were held constant, replicating findings reported previously with 10- to 12-year-olds and 17-year-olds. A novel finding was that parents' openness-to-experience predicted children's duration of training, even when characteristics that pertained to children (demographic variables, intelligence, and personality) were controlled statistically. Our findings are indicative of passive and active gene-environment correlations, whereby genetic predispositions influence the likelihood that a child will have certain experiences, such as music training. (shrink)

RÉSUMÉKant affirme que nous exigeons l'accord des autres quand nous rendons des jugements de goût. Je soutiens que cette affirmation fait partie d'une explication de la façon dont la phénoménologie des jugements esthétiques familiers appuie son affirmation selon laquelle les jugements de goût sont universels. La théorie esthétique de Kant n'est plausible que si nous rejetons l'affirmation répandue selon laquelle cette exigence est normative. Je propose une lecture non normative des jugements de goût kantiens basée sur une étude des textes, (...) puis je conteste les trois interprétations normatives importantes, qui nous obligent à attribuer à Kant une position qu'il n'acceptait pas. (shrink)

© 2015, Springer-Verlag Berlin Heidelberg.Genetic studies have identified single nucleotide polymorphisms associated with the risk of prostate cancer. It remains unclear whether such genetic variants are associated with disease aggressiveness. The NCI-SPORE Genetics Working Group retrospectively collected clinicopathologic information and genotype data for 36 SNPs which at the time had been validated to be associated with PC risk from 25,674 cases with PC. Cases were grouped according to race, Gleason score and aggressiveness. Statistical analyses were used to compare the frequency (...) of the SNPs between different disease cohorts. After adjusting for multiple testing, only PC-risk SNP rs2735839 was significantly and inversely associated with aggressive and high-grade disease in European men. Similar associations with aggressive and high-grade disease were documented in African-American subjects. The G allele of rs2735839 was associated with disease aggressiveness even at low PSA levels in both European and African-American men. Our results provide further support that a PC-risk SNP rs2735839 near the KLK3 gene on chromosome 19q13 may be associated with aggressive and high-grade PC. Future prospectively designed, case-case GWAS are needed to identify additional SNPs associated with PC aggressiveness. (shrink)

La conviction que la modernité occidentale soit un monde sécularisé, athée, dans lequel la religion ne domine plus la sphère publique, n’est qu’une présomption. Autrement dit : une transformation, à partir d’un monde où le sens réside en dehors de lui, vers un monde où le sens se situe en lui-même. Si nous suivons la pensée du philosophe français Jean-Luc Nancy, présentée dans ses livres Le Sens du Monde et La déclosion, nous devons penser le monde non pas comme ayant (...) un sens en soi, mais comme étant le sens lui-même. Vivre dans un monde laïque signifie vivre dans un monde qui est sens, un monde devenu responsable pour soi-même mais qui ne s’enferme pas sur soi-même. Nancy, s’inspirant de Martin Heidegger, affirme que, dans un monde laïque, il n’est plus question de savoir si le monde a un sens, mais si le monde est sens. Pour être athée aujourd’hui, conclut Nancy, nous n’avons plus à faire à la question « pourquoi est-il quelque chose en général ? », mais à la réponse « il y a quelque chose, et cela en soi fait sens ». (shrink)

A study was done with incoming freshmen, sophomore, senior, and graduate business students (n = 185) to assess the effects of moral development, gender, education level, and context on the moral choices in a simulated business situation, a potential hostile takeover of a fictional company. The results indicated that level of moral development did affect the decisions of students; however, main effects for gender, the level of education, and context were not significant. Theresults did find significant interaction effects between context (...) and moral development and gender and moral development. Students with lower levels of moral development were less likely to consider the contextual situation when making their decisions. The effect of moral development was more pronounced for female business students than for male business students. The implications of these results for ethics education in business schools are discussed. (shrink)

A study was done with incoming freshmen, sophomore, senior, and graduate business students (n = 185) to assess the effects of moral development, gender, education level, and context on the moral choices in a simulated business situation, a potential hostile takeover of a fictional company. The results indicated that level of moral development did affect the decisions of students; however, main effects for gender, the level of education, and context were not significant. Theresults did find significant interaction effects between context (...) and moral development and gender and moral development. Students with lower levels of moral development were less likely to consider the contextual situation when making their decisions. The effect of moral development was more pronounced for female business students than for male business students. The implications of these results for ethics education in business schools are discussed. (shrink)

PurposeAdolescents develop their decision-making ability as they transition from childhood to adulthood. Participation in their medical care should be encouraged through obtaining assent, as recommended by the American Academy of Pediatrics (AAP). In this research, we aim to define the current knowledge of AAP recommendations and surgeon practices regarding assent for elective reconstructive procedures.MethodsAn anonymous electronic survey was distributed to North American paediatric surgeons and fellows through the American Pediatric Surgical Association (n=1353).ResultsIn total, 220 surgeons and trainees responded (16.3%). Fifty (...) per cent of the surgeons who are familiar with the concept of assent had received formal training; 12% of the respondents had not heard of assent before the survey. Forty-seven per cent were aware of the 2016 AAP policy statement regarding assent in paediatric patients. Eighty-nine per cent always include adolescents as part of the consent discussion. Seventy-seven per cent solicit an expression of willingness to accept the proposed care from the patient. The majority (74%) of the surgeons perceived patient cooperation/understanding as the biggest barrier to obtaining assent. Over half of the respondents would consider proceeding with elective surgery despite the adolescent patient’s refusal. Reasons cited for proceeding with elective surgery include surgeons’ perception of medical necessity, perceptions of disease urgency, and lack of patient maturity.ConclusionPaediatric surgeons largely acknowledge the importance of assent, but variably practice the principles of obtaining assent from adolescent patients undergoing elective reconstructive procedures. Fewer surgeons are explicitly aware of formal policy statements or received formal training. Additional surgeon education and institutional policies are warranted to maximise inclusion of adolescents in their medical care. (shrink)

Do free will beliefs influence moral judgments? Answers to this question from theoretical and empirical perspectives are controversial. This study attempted to replicate past research and offer theoretical insights by analyzing World Values Survey data from residents of 46 countries (n = 65,111 persons). Corroborating experimental findings, free will beliefs predicted intolerance of unethical behaviors and support for severe criminal punishment. Further, the link between free will beliefs and intolerance of unethical behavior was moderated by variations in countries’ institutional integrity, (...) defined as the degree to which countries had accountable, corruption-free public sectors. Free will beliefs predicted intolerance of unethical behaviors for residents of countries with high and moderate institutional integrity, but this correlation was not seen for countries with low institutional integrity. Free will beliefs predicted support for criminal punishment regardless of countries’ institutional integrity. Results were robust across different operationalizations of institutional integrity and with or without statistical control variables. (shrink)

Importance Informed consent is essential to ethical, rigorous research and is important to recruitment and retention in cancer trials.Objective To examine cancer clinical trial (CCT) participants’ perceptions of informed consent processes and variations in perceptions by cancer type.Design and Setting and Participants Cross-sectional survey from mixed-methods study at National Cancer Institute–designated Northeast comprehensive cancer center. Open-ended and forced-choice items addressed: (1) enrollment and informed consent experiences and (2) decision-making processes, including risk-benefit assessment. Eligibility: CCT participant with gastro-intestinal or genitourinary, hematologic-lymphatic (...) malignancies, lung cancer, and breast or gynecological cancer (N = 334).Main Outcome Measures Percentages satisfied with consent process and information provided; and assessing participation’s perceptions of risks/benefits. Multivariable logistic or ordinal regression examined differences by cancer type.Results Most patient-participants felt well informed by the consent process (more than 90% overall and by cancer type) and. most (87.4%) reported that the consent form provided all the information they wanted, although nearly half (44.8%) reported that they read the form somewhat carefully or less. More than half (57.9%) said that talking to research staff (i.e., the consent process) had a greater impact on participation decisions than reading the consent form (2.1%). A third (31.1%) were very sure of joining in research studies before the informed consent process (almost half of lung cancer patients did—47.1%). Most patients personally assessed the risks and benefits before consenting. However, trust in physicians played an important role in the decision to enroll in CCT.Conclusions and Relevance Cancer patients rely less on written features of the informed consent process than on information obtained from the research staff and their own physicians. Research should focus on information and communication strategies that support informed consent from referring physicians, researchers, and others to improve patient risk-benefit assessment and decision-making. (shrink)

Psychiatric diagnostic covariation suggests that the underlying structure of psychopathology is not one of circumscribed disorders. Quantitative modeling of individual differences in diagnostic patterns has uncovered several broad domains of mental disorder liability, of which the Internalizing and Externalizing spectra have garnered the greatest support. These dimensions have generally been estimated from lifetime or past-year comorbidity patters, which are distal from the covariation of symptoms and maladaptive behavior that ebb and flow in daily life. In this study, structural models are (...) applied to daily diary data ( Median = 94 days) of maladaptive behaviors collected from a sample ( N = 101) of individuals diagnosed with personality disorders (PDs). Using multilevel and unified structural equation modeling, between-person, within-person, and person-specific structures were estimated from 16 behaviors that are encompassed by the Internalizing and Externalizing spectra. At the between-person level (i.e., individual differences in average endorsement across days) we found support for a two-factor Internalizing–Externalizing model, which exhibits significant associations with corresponding diagnostic spectra. At the within-person level (i.e., dynamic covariation among daily behavior pooled across individuals) we found support for a more differentiated, four-factor, Negative Affect-Detachment-Hostility-Disinhibition structure. Finally, we demonstrate that the person-specific structures of associations between these four domains are highly idiosyncratic. (shrink)

Understanding cognitive effort expended during assessments is essential to improving efficiency, accuracy, and accessibility within these assessments. Pupil dilation is commonly used as a psychophysiological measure of cognitive effort, yet research on its relationship with effort expended specifically during language processing is limited. The present study adds to and expands on this literature by investigating the relationships among pupil dilation, trial difficulty, and accuracy during a vocabulary test. Participants (n = 63, Mage = 19.25) completed a subset of trials from (...) the Peabody Picture Vocabulary Test while seated at an eye‐tracker monitor. During each trial, four colored images were presented on the monitor while a word was presented via audio recording. Participants verbally indicated which image they thought represented the target word. Words were categorized into Easy, Medium, and Hard difficulty. Pupil dilation during the Medium and Hard trials was significantly greater than during the Easy trials, though the Medium and Hard trials did not significantly differ from each other. Pupil dilation in comparison to trial accuracy presented a more complex pattern, with comparisons between accurate and inaccurate trials differing depending on the timing of the stimulus presentation. These results present further evidence that pupil dilation increases with cognitive effort associated with vocabulary tests, providing insights that could help refine vocabulary assessments and other related tests of language processing. (shrink)