Patient and public involvement is widely thought to be important in the improvement of health care delivery and in health equity. Purpose: The article examines the role of experiential knowledge in service co-production in order to develop opiate substitution treatment services (OST) for high-risk opioid users. Method: Drawing on social representations theory and the concept of social identity, we explore how experts’ by experience and registered nurses’ understandings of OST contain discourses about the social representations, identity, and (...) citizenship of the participants and the effects these may have on developing or hindering inclusive and bottom-up forms of patient and public involvement. Results: The meeting sessions that potentially offer room for creativity and problem-solving fail to provide any new propositions for fixing the system. The health care professionals primarily identify themselves as regulators who protect the correctness of their actions and show little interest in considering experiential knowledge on opioid addiction. Conclusion: The participation of patients has been one of the prominent reforms implemented in health care. The goal of client-centered thinking is often emphasised; however, the implementation is not simple due to the strongly institutionalised knowledge and related working patterns and practices in health care. (shrink)

Through a fieldwork study of the practice of methadone substitution at a French addiction clinic, the classic ‘theory of action’ is criticized and an alternative one proposed. A sketch of the debates among French drug specialists, drug users and legislators shows the pertinence for these practitioners of such a theoretical question; further, the ethnographic data suggest that they can be seen as actually trying out an alternative to this ‘theory of action’.

Concerns that cash payments to people who inject drugs (PWID) to reimburse research participation will facilitate illicit drug purchases have led some ethical authorities to mandate department store/supermarket vouchers as research reimbursement. To examine the relative efficacy of the two forms of reimbursement in engaging PWID in research, clients of two public opioid substitution therapy clinics were invited to participate in a 20–30 min, anonymous and confidential interview about alcohol consumption on two separate occasions, 4 months apart. Under the (...) crossover design, at Time 1, clients of Clinic 1 were offered $A20 cash as reimbursement, while clients of Clinic 2 were offered an $A20 voucher; at Time 2, the form of reimbursement was reversed. Using clinic records to determine the denominator (number of clients dosed), we found that compared with clients offered a voucher, a significantly higher proportion of clients who were offered cash participated in the survey (58% (139/241) vs 74% (186/252); χ2=14.27; p=0.0002). At first participation, respondents most commonly reported planning to purchase food/drinks/groceries (68%), cigarettes (21%) and transport/fuel (11%) with their payments, with those reimbursed in cash more likely to report planning to fund transport/fuel (19% vs 1%; p<.01) and less likely to report planning to purchase food/drinks/groceries (62% vs 76%; p=0.02). Just three out of 155 cash participants reported planning to purchase illicit drugs with their payment. Results demonstrate that modest cash payments enhanced recruitment of this group, an important consideration given the challenges of delineating the parameters of a population defined by illegal activity, seemingly without promoting excessive additional drug use. (shrink)

In many countries around the world, people who inject drugs remain at high risk of HIV acquisition not because effective forms of prevention are unknown, nor because they find effective prevention undesirable, but because those in charge, mainly politicians but also bureaucrats, find evidence-based practice politically unacceptable. The evidence for preventive efficacy of harm reduction strategies, most prominently needle and syringe programmes but also treatment programmes such as opiate substitution, is irrefutable.1 However, political responses to drug use (...) issues are varied and complex, so the will to implement appropriate harm reduction programmes in the interests of public health remains lacking in too many jurisdictions. As a consequence, the discussion of how best, in the context of research, to reduce HIV incidence in populations of people who inject drugs but are not offered comprehensive access to known prevention strategies is—tragically—an important one. Dawson et al 2 focus on access to sterile injecting equipment and recognise that this should remain the ‘default’ standard of prevention for HIV prevention trials involving people for whom injecting drug use is the primary risk factor for HIV acquisition. ‘Standard of prevention’ means the background or minimal HIV risk reduction interventions offered to all participants in a trial, regardless of what other investigational interventions they are assigned to receive. The standard of prevention concept is grounded in the ethical principle of beneficence—that researchers and sponsors are obliged to maximise benefits and minimise risks to participants in research studies.3 …. (shrink)

It is commonly thought that when a patient is unable to make a treatment decision for herself, patient autonomy should be respected by consulting the views of a patient surrogate, normally either the next-of-kin or a person previously designated by the patient. On one view, the task of this surrogate is to make the treatment decision that the patient would have made if competent. But this so-called ‘substituted judgment standard’ (SJS) has come in for has come in for (...) a good deal of criticism recently. For instance, some question whether surrogates are able to reliably predict what the patient would have chosen. Others wonder how respecting a patient's counter-factual, rather than actual, choices is supposed to respect her autonomy. Such concerns have lead some to reject the SJS and argue for alternative characterisations of the role of surrogate decision-makers. (shrink)

An increasing amount of twenty-first century metaphysics is couched in explicitly hyperintensional terms. A prerequisite of hyperintensional metaphysics is that reality itself be hyperintensional: at the metaphysical level, propositions, properties, operators, and other elements of the type hierarchy, must be more fine-grained than functions from possible worlds to extensions. In this paper I develop, in the setting of type theory, a general framework for reasoning about the granularity of propositions and properties. The theory takes as primitive the notion of a (...) substitution on a proposition (property, etc.) and, among other things, uses this idea to elucidate a number of theoretically important distinctions. A class of structures are identified which can be used to model a wide range of positions about the granularity of reality; certain of these structures are seen to receive a natural treatment in the category of M-sets. (shrink)

A primary goal of clinical practice is to respect patient autonomy. To promote this goal for patients who have lost the ability to make their own decisions, commentators recommend that surrogates make their treatment decisions based on the substituted judgment standard. This standard is commonly interpreted as directing surrogates to make the decision the patient would have made in the circumstances, if the patient were competent. However, recent commentators have argued that this approach—attempting to make the decision the patient (...) would have made if competent—is theoretically problematic, practically infeasible, and ignores the interests of the patient9s family and loved ones. These commentators conclude that the substituted judgment standard should be revised significantly, or abandoned altogether. While this response would avoid the cited problems, it also would require substantial changes to clinical practice and would raise significant problems of its own. The present paper thus considers the possibility that the criticisms do not point to problems with the substituted judgment standard itself; instead, they point to problems with the way it is most commonly interpreted. This analysis suggests that the substituted judgment standard need not be dramatically revised or abandoned. Instead, it should be interpreted in a way that effectively promotes respect for the autonomy of incompetent patients. The ‘endorsed life’ interpretation described here helps clinicians and surrogates to achieve this important goal. To clarify this approach, we explain how it differs from three other recently proposed alternatives to the standard interpretation of the substituted judgment standard. (shrink)

In this essay, I propose an analysis of Quine’s example ’Giorgione was so-called because of his size’, grounded on the idea of an obstinate demonstrative. In the first sections, I discuss the advantages and drawbacks of the demonstrative and logophoric treatments of ‘so called’, I highlight certain parallelisms with Davidson’s paratactic view of quotation, and I introduce independent considerations in favor of the idea of an obstinate demonstrative. In the second half of my essay, I apply this notion to Quine’s (...) example, and I discuss its consequences with respect to the principle of substitutivity of coreferential singular terms. (shrink)

Substituted judgement is often used in the absence of advanced directives to guide decision-making when patients lack decisional capacity. We present a remarkable case of family members exercising substituted misjudgement for a 42-year-old man hospitalized with multiorgan failure on life support. Feeling that their loved one would rather die than face severe disability, they elected to withdraw life support. Although this was done, the patient remained alive and recovered enough to clearly indicate his preference for life, even with severe disability. (...) This case suggests that in instances of unusual quality-of-life judgements where the patient's wishes cannot be known with reasonable certainty, families and physicians should be very wary using substituted judgement to refuse life support. Unless there are strong considerations based on the patient's prior statements, actions and values to decline life support, it would seem ethically appropriate to continue treatment, even with substantial disability the likely outcome. (shrink)

This article seeks to consider the ways in which substitutes for religion have been found both through a discussion of the treatment of religion in the classical sociological theories of Weber; Durkheim and Marx and then the way in which in modern societies alternative sets of belief and practices which fulfi l the same function as religion have been developed in the Communist and the postCommunist and Western worlds.

The 'substitution argument' purports to demonstrate the falsity of Russellian accounts of belief-ascription by observing that, e.g., these two sentences: (LC) Lois believes that Clark can fly. (LS) Lois believes that Superman can fly. could have different truth-values. But what is the basis for that claim? It seems widely to be supposed, especially by Russellians, that it is simply an 'intuition', one that could then be 'explained away'. And this supposition plays an especially important role in Jennifer Saul's defense (...) of Russellianism, based upon the existence of an allegedly similar contrast between these two sentences: (PC) Superman is more popular than Clark. (PS) Superman is more popular than Superman. The latter contrast looks pragmatic. But then, Saul asks, why shouldn't we then say the same about the former? The answer to this question is that the two cases simply are not similar. In the case of (PC) and (PS), we have only the facts that these strike us differently, and that people will sometimes say things like (PC), whereas they will never say things like (PS). By contrast, there is an argument to be given that (LS) can be true even if (LC) is false, and this argument does not appeal to anyone's 'intuitions'. The main goal of the paper is to present such a version of the substitution argument, building upon the treatment of the Fregan argument against Russellian accounts of belief itself in "Solving Frege's Puzzle". A subsidiary goal is to contribute to the growing literature arguing that 'intuitions' simply do not play the sort of role in philosophical inquiry that so-called 'experimental philosophers' have supposed they do. (shrink)

Substituted judgment has increasingly become the accepted standard for rendering decisions for incapacitated adults in the USA. A broad exception exists with regard to patients with diminished capacity secondary to depressive disorders, as such patients’ previous wishes are generally not honoured when seeking to turn down life-preserving care or pursue aid-in-dying. The result is that physicians often force involuntary treatment on patients with poor medical prognoses and/or low quality of life as a result of their depressive symptoms when similarly (...) situated incapacitated patients without such depressive symptoms would have their previous wishes honoured via substituted judgment. This commentary argues for reconsidering this approach and for using a substituted judgment standard for a subset of EMP/LQL patients seeking death. (shrink)

Patients who are incompetent need a surrogate decision maker to make treatment decisons on their behalf. One of the main ethical questions that arise in this context is what standard ought to govern such decision making. According to the Substituted Judgment Standard, a surrogate ought to make the decision that the patient would have made, had he or she been competent. Although this standard has sometimes been criticized on the grounds of being difficult to apply, it has found wide (...) appeal, since it it is alleged to protect incompetent patients? right to autonomy. The main purpose of the thesis is to evaluate SJS, from a conceptual and ethical perspective. It argues that the traditional formulation of SJS is seriously incomplete, and discusses alternative ways of completing it. Moreover, it questions the received view on how SJS should be morally justified, by offering arguments against the view that decision making in accordance with this standard extends the patient's opportunities for self-determination. Instead it suggests a virtue-ethical approach according to which the moral point of SJS-based decision making is not to protect the patient's interests, but to express respect for person. The thesis also critically assesses empirical studies according to which surrogates often fail to correctly predict patients? actual treatment preferences. It is shown that such results cannot, for a number of reasons, support the conclusion drawn that surrogates are ill-equipped to make decisions that comply with SJS. (shrink)

Expressivism is a blossoming meta-semantic framework sometimes relying on what Carter and Chrisman call “the core expressivist maneuver.” That is, instead of asking about the nature of a certain kind of value, we should be asking about the nature of the value judgment in question. According to expressivists, this question substitution opens theoretical space for the elegant, economical, and explanatorily powerful expressivist treatment of the relevant domain. I argue, however, that experimental work in cognitive psychology can shed light (...) on how the core expressivist maneuver operates at the cognitive level and that this: raises worries about the aptness of the expressivist question substitution and supports an evolutionary debunking argument against expressivism. Since evolutionary debunking arguments are usually run in favor of expressivism, this creates an obvious puzzle for expressivists. I wrap up by briefly responding to the objection that the debunking argument against expressivism overgeneralizes and, therefore, should be rejected. (shrink)

The first section introduces a distinction between 2 families of cognitive operations, called System 1 and System 2. The second section presents an attribute-substitution model of heuristic judgment, which elaborates and extends earlier treatments of the topic. The third section introduces a research design for studying attribute substitution. The fourth section discusses the controversy over the representativeness heuristic. The last section situates representativeness within a broad family of prototype heuristics, in which properties of a prototypical exemplar dominate global (...) judgments concerning an entire set. (shrink)

On a traditional interpretation of the substituted judgement standard a person who makes treatment decisions on behalf of a non-competent patient ought to decide as the patient would have decided had she been competent. I propose an alternative interpretation of SJS in which the surrogate is required to infer what the patient actually thought about these end-of-life decisions. In clarifying SJS it is also important to differentiate the patient's consent and preference. If SJS is part of an autonomy ideal (...) of the sort found in Kantian ethics, consent seems more important than preference. From a utilitarian perspective a preference-based reading of SJS seems natural. I argue that the justification of SJS within a utilitarian framework will boil down to the question whether a non-competent patient can be said to have any surviving preferences. If we give a virtue-ethical justification of SJS the relative importance of consent and preferences depends on which virtue one stresses-respect or care. I argue that SJS might be an independent normative method for extending the patient's autonomy, both from a Kantian and a virtue ethical perspective. (shrink)

Obwohl die Substitutionsbehandlung nachweislich den Gesundheitszustand opiatabhängiger Patienten verbessern und die Beschaffungskriminalität reduzieren kann, bestehen enge gesetzliche Regelungen, die die Therapiefreiheit der behandelnden Ärzte stark begrenzen: So werden durch das Betäubungsmittelgesetz und die zugehörigen Verordnungen nicht nur das Behandlungsziel (Abstinenz) sondern auch notwendige Therapiebausteine definiert, die darauf ausgerichtet sind, die Therapietreue des Patienten zu kontrollieren. Deutsche Ärzte, die die strengen Auflagen nicht strikt befolgten, wurden zu Gefängnisstrafen verurteilt. Wie der Artikel zeigt, fördern die bestehenden Gesetze eine „kontrollierende“ statt einer motivierenden (...) ärztlichen Behandlung, ohne wichtige Ziele, wie den Schutz der Allgemeinheit vor einer illegalen Verbreitung illegaler Opioide, vollständig zu erreichen. Zusammenfassend zeigt der Artikel, dass eine stärker am Wohl der Patienten ausgerichtete Substitutionsbehandlung (einschließlich notwendiger Kontrolluntersuchungen) mit hoher Wahrscheinlichkeit auch die Öffentlichkeit wirksamer vor den potenziellen Gefahren einer illegalen Verbreitung von gefährlichen Opioiden schützt als die Befolgung abstrakter, restriktiver gesetzlichen Normen. (shrink)

When making substituted judgments for incapacitated patients, surrogates often struggle to guess what the patient would want if they had capacity. Surrogates may also agonize over having the (sole) responsibility of making such a determination. To address such concerns, a Patient Preference Predictor (PPP) has been proposed that would use an algorithm to infer the treatment preferences of individual patients from population-level data about the known preferences of people with similar demographic characteristics. However, critics have suggested that even if (...) such a PPP were more accurate, on average, than human surrogates in identifying patient preferences, the proposed algorithm would nevertheless fail to respect the patient’s (former) autonomy since it draws on the ‘wrong’ kind of data: namely, data that are not specific to the individual patient and which therefore may not reflect their actual values, or their reasons for having the preferences they do. Taking such criticisms on board, we here propose a new approach: the Personalized Patient Preference Predictor (P4). The P4 is based on recent advances in machine learning, which allow technologies including large language models to be more cheaply and efficiently ‘fine-tuned’ on person-specific data. The P4, unlike the PPP, would be able to infer an individual patient’s preferences from material (e.g., prior treatment decisions) that is in fact specific to them. Thus, we argue, in addition to being potentially more accurate at the individual level than the previously proposed PPP, the predictions of a P4 would also more directly reflect each patient’s own reasons and values. In this article, we review recent discoveries in artificial intelligence research that suggest a P4 is technically feasible, and argue that, if it is developed and appropriately deployed, it should assuage some of the main autonomy-based concerns of critics of the original PPP. We then consider various objections to our proposal and offer some tentative replies. (shrink)

In this journal, Dr Daniel Daly, an American bioethicist, uses a principlist approach (respect for autonomy, non-maleficence, beneficence and justice) to argue that intravenous opiate users should not be denied repeat heart valve replacements if these are medically indicated, ‘unless the valve replacement significantly violates another’s autonomy or one or more of the three remaining principles’.1 In brief outline, the paper seeks to use a widely accepted ethical theory—‘principlism’ as developed by Beauchamp and Childress over the last 40 plus (...) years and eight editions of their ground-breaking book Principles of Biomedical Ethics2—to resolve clinical disagreement about the ethics of denying medically indicated life-prolonging treatment to patients who continue or resume intravenous opiate use. The argument Dr Daly's argument in very brief summary is that in the context of contemporary American medical practice, such treatment is ethically justified—perhaps even ethically required—if requested or accepted by an adequately autonomous patient and thus respects the patient’s autonomy, if it is not harmful to the patient, if it is beneficial to the patient, and if it is fair and just in terms of Aristotle’s formal theory of justice according to which equals should be treated equally while unequals should be treated unequally in proportion to the morally relevant inequality or inequalities. Dr Daly focuses his argument around a typical case description where these conditions are met and therefore where, he concludes, repeat heart valve replacements ought to be provided. As Dr Daly notes, principlism ‘is not without its problems; nonetheless it does provide a viable set of principles that are widely held by medical ethicists and inform the work of ethics committees at many secular medical facilities’. DOI (declaration of interest): The writer of this editorial is a career-long supporter and defender of the use of ‘principlism’ or ‘the four principles …. (shrink)

Normal 0 false false false EN-MY X-NONE AR-SA Normal 0 false false false EN-MY X-NONE AR-SA /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin-top:24.0pt; mso-para-margin-right:0cm; mso-para-margin-bottom:0cm; mso-para-margin-left:0cm; mso-para-margin-bottom:.0001pt; text-align:justify; line-height:200%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:Arial; mso-bidi-theme-font:minor-bidi;} /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin-top:24.0pt; mso-para-margin-right:0cm; mso-para-margin-bottom:0cm; mso-para-margin-left:0cm; mso-para-margin-bottom:.0001pt; text-align:justify; line-height:200%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; (...) mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:Arial; mso-bidi-theme-font:minor-bidi;}This study explores the significance of the family factors on drug use and its effects on relapse. In this respect, the effects of parental substance use , family conflict , and family structure are discussed in this research. The family, as a fundamental social unit of society, can be expected to exert remarkable influences on the development of social behaviors such as adolescent substance use and also relapse ADDIN EN.CITE Rouholamini 2002 90 90 90 32 Rouholamini,S Formative research on familial characteristics of drug users in Iran Master 2002 New Haven Yale (Rouholamini, 2002) . Since nearly 90% of drug abusers in Iran live with a family member ADDIN EN.CITE Mokri 2002 6 6 6 17 Mokri, A A brief overview of the status of drug abuse in Iran Archives of Iranian Medicine 184-190 5(3) 2002 (Mokri, 2002) , therefore family has an important role to reduce the high rates of relapse after detoxification. Therefore, this study considers three factors: Parental substance use , Family Conflict , and Family Structure. The objective of this study is to examine the effects of family factors on relapse behavior among male adolescent opiate users in Kerman. In this research 226 adolescents between the ages of 13 to 20 were selected based on ten rehabilitation centers to answer the Self-administered questionnaire. Results showed that there were important relationships between these factors with relapse in adolescents. The study proposes some suggestions in order to prevent relapse after treatment in adolescents. (shrink)

Introduction Substitute decision making on behalf of incapable patients is based on the ethical principle of ‘respect for autonomy’. This study was conducted to assess patients' wishes and preferences in terms of a substitute decision maker and determinants of such preferences. Methods The authors conducted a cross-sectional study and selected samples randomly from patients presenting at Farabi Eye Hospital clinics who were 18 years of age or older. Questionnaires were completed through interviews. Results 200 patients between the ages of 18 (...) and 83 years were interviewed. About 52% (N=105) were men and 73% (N=77) were married. Among married patients, the spouse was chosen as the substitute decision maker in only 51% of cases. Single men preferred their father first in 36% (N=9) of cases, while single girls chose their father in 5.6% (N=1) of cases and their most prevalent choice was other unmentioned people (33.3%, N=6). Most patients (93.5%) wished to be asked about their substitute decision maker when hospitalised. Conclusion The results of this study show that the people we usually consult for decisions concerning patient treatment are significantly different from the patients' preferred substitute decision makers. The authors suggest patients be allowed to choose their substitute decision maker while conscious. (shrink)

Persons of diminished capacity, especially those who are still legally competent but are de facto incompetent should still be able to participate in moderately risky research projects that benefit the class of persons with similar diseases. It is argued that this view can be supported with a modified communitarianism, a philosophy ofmedicine that holds that health care is a joint responsibility that meets foundational human needs. The mechanism for obtaining a substituted consent I call ``community consent,'' and distinguish this from (...) the usual family or surrogate consent for treatment. Care givers are included in the community that might consent for an individual who has no identifiable family members. (shrink)

In 'A Puzzle about Belief' Saul Kripke appeals to a principle of disquotation that allows us to infer a person's beliefs from the sentences to which she assents (in certain conditions). Kripke relies on this principle in constructing some famous puzzle cases, which he uses to defend the Millian view that the sole semantic function of a proper name is to refer to its bearer. The examples are meant to undermine the anti-Millian objection, grounded in traditional Frege-cases, that truth-value is (...) not always maintained when co-referential names are intersubstituted in belief reports. I argue here that our disquotational practice is sensitive to certain shifts in conversational context, and it is only if we overlook these shifts - if we 'misdisquote' - that we can draw the conclusions Kripke wants to draw from his examples. In the wake of this conclusion, I provide a 'contextualist' treatment of Kripke's puzzle cases. I show how this treatment is motivated by certain norms of rationality, and I defend these norms against an intriguing 'anti-Cartesian' theory of mind. Throughout the paper, I develop the larger implications that my treatment of Kripke's argument has for the semantic theory of names and belief reports, and, more generally, for our picture of the relation between linguistic behaviour and our states of mind. (shrink)

According to what we propose to call “the competence model,” competence is a necessary condition for valid informed consent. If a person is not competent to make a treatment decision, the decision must be made by a substitute decision-maker on her behalf. Recent reports of various United Nations human rights bodies claim that article 12 of the Convention on the Rights of Persons with Disabilities involves a wholesale rejection of this model, regardless of whether the model is based on (...) a status, outcome, or functional approach to competence. The alleged rationale of this rejection is that denying persons the right to make their own treatment decisions based on an assessment of competence necessarily discriminates against persons with mental disorders. Based on a philosophical account of the nature of discrimination, we argue that a version of the competence model that combines supported decision-making with a functional approach to competence does not discriminate against persons with mental disorders. Furthermore, we argue that status- and outcome-based versions of the competence model are discriminatory. (shrink)

Semanticists face substitution challenges even outside of contexts commonly recognized as opaque. Jennifer M. Saul has drawn attention to pairs of simple sentences - her term for sentences lacking a that-clause operator - of which the following are typical: -/- (1) Clark Kent went into the phone booth, and Superman came out. (1*) Clark Kent went into the phone booth, and Clark Kent came out. -/- (2) Superman is more successful with women than Clark Kent. (2*) Superman is more (...) successful with women than Superman. -/- She challenges us to explain why the upper and lower sentences in each pair differ, or at least appear to differ, in their truth-values and hence truth-conditions. This appearance of substitution failure is inherently puzzling. Moreover, it is taken by Saul to generate a dilemma for anyone hostile to direct reference accounts of that-clause constructions. Direct reference theorists regard the appearance of substitution failure in that-clause contexts as mere appearance, to be dealt with pragmatically rather than semantically. -/- Critics of such accounts need to say something about simple-sentence cases. If they choose to allow that intuitions of substitution failure can be over-ridden and explained away pragmatically in simple-sentence cases but not in that-clause cases, they lay themselves open to the charge of operating a double standard. But if they do not choose this option, they must offer a semantic explanation of apparent substitution failure in simple-sentence cases - no easy task, it turns out. Other respondents to Saul's challenge have sought to provide elaborate semantic treatments. In contrast, this paper proposes a far simpler pragmatic explanation of intuitions of substitution failure in simple sentences, an explanation that deploys no more resources than are to be found in Grice's 'Logic and Conversation'. Ironically, this proposal turns out to be incompatible with a direct reference perspective. So if it is, as I maintain, the most plausible treatment of simple-sentence cases available, Saul's initial thought gets turned around 180 degrees: the phenomenon she has drawn attention to ends up representing a challenge to supporters of direct reference theories. (shrink)

The standard by which we apply decision-making for those unable to do so for themselves is an important practical ethical issue with substantial implications for the treatment and welfare of such individuals. The approach to proxy or surrogate decision-making based upon substituted judgement is often seen as the ideal standard to aim for but suffers from a need to provide a clear account of how to determine the validity of the proxy's judgements. Proponents have responded to this demand by (...) providing the truth-conditions for the substituted judgement in terms of counterfactual reasoning using a possible worlds semantics. In this paper, I show how these underpinnings fail to support the substituted judgement approach as a reasonable standard for decision-making. Firstly, I show how this counterfactual element has been poorly interpreted. I then explain how various accounts have failed to reflect problems and limitations associated with providing an interpretation of their truth-conditions using counterfactuals. Finally, I argue that, even when we attend to the initial problems of providing a counterfactual analysis, it still deeply problematic as a means of determining the validity of substituted judgements for two main reasons. Firstly, making determinate judgements as to the truth-value of these judgements will often not be possible and, secondly, there is a strong requirement when interpreting many counterfactual claims to charitably accede to their being true. I conclude that substituted judgements, as interpreted through counterfactual reasoning and possible worlds semantics, do not therefore provide an adequate standard for surrogate decision-making. (shrink)

Recent research, especially with functional brain imaging, demonstrated cases where the administration of a placebo produces objective effects in tissues that are indistinguishable from those of the real therapeutic agents. This phenomenon has been shown in treatments of pain, depression, Parkinsonism, and more. The main ethical complaint against placebo treatment is that it is a kind of deception, where supposedly we substitute what works just psychologically for a real drug that actually works on the tissue level. We claim that (...) the scientific findings bring to a new level the seeming deconstruction of the distinction between “placebo” and “real” drugs, and that instances of placebo treatment which fulfill this criterion should be recognized as a unique category—we call it “comparable placebo treatment” (CPT). The paper uses an analysis of the notion of deception to argue that CPT does not amount to deception; that it can preserve patient autonomy; and that it is therefore morally legitimate. (shrink)

The adaptive BCI known as ‘closed-loop deep brain stimulation’ (clDBS) is a device that stimulates the brain in order to prevent pathological neural activity and automatically adjusts stimulation levels based on computational algorithms that detect or predict those pathological processes. One of the prominent ethical concerns raised by clDBS is that, by inhibiting or modulating the undesirable neural states of a cognitive agent automatically, the device potentially undermines her autonomy. It has been argued that clDBS is not a threat because (...) autonomy is fundamentally relational, i.e., it essentially depends on external (e.g., social or cultural) factors. If the relational approach to autonomy includes human-computer interaction, then the mechanisms of clDBS, even if external to the brain and exerting some degree of control over the individual, may support her autonomy. However, DBS applications are substantially different from one another, each involving a specific neurological or psychiatric condition, neural target, mechanism and symptom(s), and therefore at least some of them may not fit into the relational analysis. I examine different clDBS applications for treatment resistant depression and claim that while internal capsule/ventral striatum (VC/VS) clDBS is a case of relational autonomy, subgenual cingulate gyrus (Cg25) clDBS is not. Autonomy (relational or otherwise) requires some degree of self-regulation of our motivational states, which is supported by VC/VS DBS but is absent in Cg25 DBS. In Cg25 DBS the device itself directly influences motivational states, thus substituting or overriding (instead of supporting) the auto-regulatory cognitive processes required for autonomous action. (shrink)

Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or “authentic” self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, (...) when that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a “restorative representation” model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their “truest self” would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient’s treatment refusal and previously undiagnosed depression led to difficulty determining the patient’s authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions. (shrink)

The urgency of the resuscitation and the impaired ability of the patient to make a reasonable autonomous decision both conspire against adequate consideration of the principles of medical ethics. Informed consent is usually not possible for these reasons and this leads many to consider that consent is not required for resuscitation, because resuscitation brings benefit and prevents harm and because the patient is not in a position to give or withhold consent. However, consent for resuscitation is required and the common (...) models employed for this purpose are presumed consent or consent from a patient proxy. However, if we are to honour the principles of respect for patient autonomy, as well as beneficence and non-maleficence, when starting and continuing resuscitation we must try and achieve the best balance between benefit and harm from the patient's perspective. The concept of professional substituted judgment involves the resuscitators gathering as much information about the patient as they possibly can, including any previously expressed attitudes towards such a situation, and combining this with their acquired professional knowledge of the likely benefits and harms of the resuscitation endeavour and then exercising their moral imagination, imagining themselves as the patient, and asking "would I want this treatment?" By employing professional substituted judgment resuscitators should recognise when the balance of benefit and harm becomes unfavourable from the patient's perspective and at this point they have a moral obligation to withdraw resuscitation as they can no longer presume the patient's consent. In this way the principles of beneficence, non-maleficence and respect for patient autonomy are more favourably balanced than under other resuscitation decision making processes. (shrink)

In this article, it is argued that it is problematic to construe the debate around the process labelled ‘surrogacy’ as a form for infertility treatment. Firstly, this way of defining what happens opens up a new form of medical desire where a growing number of people wish to have children through ‘surrogacy’. This medicalizes childlessness and creates pressure within health services to respond to the desires of an ever-growing group of patients. Secondly, this labels the woman who carries the (...) child as a ‘surrogate’ and defines her as a core element in a ‘treatment method’. This way of phrasing and defining what happens puts the woman carrying the child in an unacceptable moral position within the health system. Thirdly, by viewing the woman carrying the child as a ‘substitute’ for a mother or as a ‘temporary custodian’ ignores the unique relationship between the foetus and the pregnant woman. To keep the ethical issues in focus in the ‘surrogacy’ process, it is necessary for health professionals to always... (shrink)

Background: The increasing number of elderly people in nursing homes with failing competence to give consent represents a great challenge to healthcare staff’s protection of patient autonomy in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation. The lack of national guidelines and internal routines can threaten the protection of patient autonomy. Objectives: To place focus on protecting patient autonomy in the decision-making process by studying how relatives experience their role as substitute decision-makers. Design: A qualitative descriptive design with (...) analysis of the contents of transcribed in-depth interviews with relatives. Participants: Fifteen relatives of 20 patients in 10 nursing homes in Norway. Results and Interpretations: The main findings reveal deficient procedures for including relatives in decision-making processes. Relatives have poor knowledge about the end of life, and there is little discussion about their role as substitute decision-makers for patients who are not competent to give consent. Few relatives understand the concept of patient autonomy. In Norway the treating physician is responsible for patient treatment. When relatives are included in discussions on treatment, they perceive themselves as responsible for the decision, which is a burden for them afterwards. This qualitative study describes relatives’ experiences, thus providing important information on the improvement potential with the main objective of safeguarding patient autonomy and caring for relatives. Conclusion: The study reveals failing procedures and thus a great potential for improvement. Both ethical and legal aspects must be addressed when considering patient autonomy. (shrink)

According to one prominent strand of mainstream logic and metaphysics, identity is indistinguishability. Priest has recently argued that this permits counterexamples to the transitivity and substitutivity of identity within dialetheic metaphysics, even in paradigmatically extensional contexts. This paper investigates two alternative regimentations of indistinguishability. Although classically equivalent to the standard regimentation on which Priest focuses, these alternatives are strictly stronger than it in dialetheic settings. Both regimentations are transitive, and one satisfies substitutivity. It is argued that both regimentations provide better (...) candidates to occupy the core theoretical role of numerical identity than does the standard regimentation. (shrink)

Background: Biological products are widely used in the treatment of burns, chronic wounds, and other forms of acute injury. However, the religious and ethical issues, including consent, arising from their use have never been addressed in the medical literature.Aims: This study was aimed to ascertain the views of religious leaders about the acceptability of biological products and to evaluate awareness among healthcare professionals about their constituents.Methods: The religious groups that make up about 75% of the United Kingdom population were (...) identified and a questionnaire on 11 biological products was sent to its leaders. Another questionnaire concerning 17 products was sent to 100 healthcare professionals working in seven specialist units in the UK.Results: All religious leaders replied, some after consultation with international bodies. Among them, 77% said that patients should be informed of the constituents of the biological products and consent obtained. Some leaders expressed concerns about particular products including the transmission of viral and prion diseases, cruelty to animals, and material derived from neonates. None of the healthcare professionals surveyed knew the constituents of all the products correctly.Conclusion: Ignoring religious sensitivities and neglecting consent in the usage of biological products could have very serious implications, including litigation. Hospitals and manufacturers should take immediate measures to enlighten healthcare professionals of the constituents of these products so that they can obtain informed consent from patients. (shrink)

Background Doctors sometimes encounter parents who object to prescribed treatment for their children, and request suboptimal substitutes be administered instead. Previous studies have focused on parental refusal of treatment and when this should be permitted, but the ethics of requests for suboptimal treatment has not been explored. Methods The paper consists of two parts: an empirical analysis and an ethical analysis. We performed an online survey with a sample of the general public to assess respondents’ thresholds for (...) acceptable harm and expense resulting from parental choice, and the role that religion played in their judgement. We also identified and applied existing ethical frameworks to the case described in the survey to compare theoretical and empirical results. Results Two hundred and forty-two Mechanical Turk workers took our survey and there were 178 valid responses. Respondents’ agreement to provide treatment decreased as the risk or cost of the requested substitute increased. More than 50% of participants were prepared to provide treatment that would involve a small absolute increased risk of death for the child and a cost increase of US$<500, respectively. Religiously motivated requests were significantly more likely to be allowed. Existing ethical frameworks largely yielded ambiguous results for the case. There were clear inconsistencies between the theoretical and empirical results. Conclusion Drawing on both survey results and ethical analysis, we propose a potential model and thresholds for deciding about the permissibility of suboptimal treatment requests. (shrink)

BackgroundJunior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors’ decision-making processes when treating people with dementia who have advance care directives, or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: their legal compliance and decision-making process related to treatment decisions; the factors influencing their clinical decision-making; and (...) the factors associated with accurate responses to one hypothetical vignette. MethodA cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: bacterial pneumonia; or suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette.ResultsOverall, 116 junior doctors responded. In Vignette 1, 58% of respondents selected the legally compliant option. Participants who chose the legally compliant option perceived ‘following patient wishes’ and ‘legal requirements to follow ACDs’ as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the ‘ACD is relevant in my decision-making process, but other factors are more relevant’. In Vignette 2, 72% of respondents indicated they would commence treatment and 18% selected they would not commence treatment.. Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario.ConclusionsThere are critical gaps in junior doctors’ compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors’ clinical decision-making and ensure compliance with the law is required. (shrink)

Thirty-three physicians, bioethicists, and medical economists from ten different countries met at Lawrence University, Appleton, Wisconsin, to create The Appleton Consensus: International Guidelines for Decisions to Forego Medical Treatment. The guidelines deal with four specific decision-making circumstances: 1. Five guidelines were created for decisions involving competent patients or patients who have executed an advance directive before becoming incompetent, and those guidelines fell into three categories. 2. Thirteen guidelines were created for decisions involving patients who were once competent, but are (...) not now competent, who have not executed an advance directive. 3. Seven guidelines were created for decisions involving patients who are not now and never have been competent, for whom 'no substituted judgement' can be rendered. 4. Eleven guidelines were created for decisions involving the scarcity of medical resources, which exists in all communities. Five concepts were identified as being critical in the establishment of priorities, given the reality of scarce health resources (1). The term 'physician' is used in the American sense, synonymous with 'medical practitioner'. (shrink)

B. Readings (University in Ruins. Cambridge: Harvard University Press, 1996) argued that universities have abandoned their original project of promoting a national culture and have tried to substitute by embracing globalization, but the vagueness and incoherence of the concept has failed to return purpose to the University. The academic treatment of corporate social responsibility illustrates this dilemma. For a generation after H.R. Bowen (Social Responsibilities of the Businessman. New York: Harper & Row, 1953) founded the field, scholars struggled to (...) fit the concept within a national system of pluralistic power-sharing among a variety of institutions that would define and enforce standards of responsibility necessary for the general good of American society. That understanding changed in the nineteen eighties, shortly after corporate executives had united to an unprecedented degree to direct the power of government in their interests, influence the public agenda, and roll back the power of unions. In response, business ethicists began to reformulate corporate social responsibility as a voluntary practice on the part of these same executives. Since the Kantian and Lockean principles upon which this approach was based were themselves problematic, it is not surprising that the experience gained over the last generation casts doubt on the efficacy of this reliance on voluntary restraint and personal initiative. However, circumstances that include the failure of globalization to deliver on its promises may have changed sufficiently in recent years to revive interest in approaches that acknowledge the importance of countervailing power for encouraging greater corporate social responsibility. (shrink)

OBJECTIVE: This paper addresses the question of the circumstances which lead clinicians to use legal coercion in the management of patients with severe anorexia nervosa, and explores similarities and differences between such formal coercion and other forms of 'strong persuasion' in patient management. METHOD: Logistic regression and other statistical analysis was undertaken on 75 first admissions for anorexia nervosa from a sample of 117 successive admissions to an eating disorder facility in New South Wales, Australia, where an eating disorder was (...) the primary diagnosis. Admissions with other primary diagnoses, such as bulimia nervosa (25 episodes), and entries with a co morbid diagnosis (e.g. depression or opiate overdose), were discarded, leaving 96 admissions by 75 individuals. RESULTS: Resort to measures of legal coercion into treatment was found to be associated with three main indicators: the patient's past history (number of previous admissions); the complexity of their condition (the number of other psychiatric co morbidities); and their current health risk (measured either by Body Mass Index or the risk of re-feeding syndrome). CONCLUSIONS: Our study is consistent with the few earlier studies about indicators for legal coercion in anorexia nervosa management, and suggests that clinicians use legal coercion very sparingly, distinguishing legal coercion from other forms of close clinical management of patients. (shrink)

Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization (...) in the event of pneumonia. (shrink)

Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization in (...) the event of pneumonia. (shrink)

OBJECTIVE: To describe the issues faced, and how they were addressed, by the University of Toronto Critical Care Medicine Program/Joint Centre for Bioethics Task Force on Appropriate Use of Life-Sustaining Treatment. The clinical problem addressed by the Task Force was dealing with requests by patients or substitute decision makers for life-sustaining treatment that their healthcare providers believe is inappropriate. DESIGN: Case study. SETTING: The University of Toronto Joint Centre for Bioethics/Critical Care Medicine Program Task Force on Appropriate Use (...) of Life-Sustaining Treatment. PARTICIPANTS: The 24-member Task Force included physician and nursing leaders from five critical care units, bioethicists, a legal scholar, a health administration expert, a social worker, and a hospital public relations professional. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Our specific lessons learned include a) a policy focus on process; b) use of a negotiation and mediation model, rather than a hospital ethics committee model, for this process; and c) the policy development process is itself a negotiation, so we recommend equal involvement of interested groups including patients, families, and the public. CONCLUSIONS: This article describes the key issues faced by the Task Force while developing its policy. It will provide a useful starting point for other groups developing policy on appropriate use of life-sustaining treatment. (shrink)

This paper examines a patient with borderline mental capacity, where the healthcare team is conflicted about how to proceed. This case demonstrates the complicated intersection between undue influence and mental capacity, allowing us to explore how the law is applied in clinical practice. Patients have the right to decline or accept medical treatments offered to them. In Singapore, family members perceive a right to be involved in the decision-making process for sick and elderly patients. Elderly patients, dependent on mainly family (...) members for care and support, sometimes submit to their overbearing influence resulting in decisions that fail to protect the patients’ own best interests. However, the clinicians’ own well-intentioned influence, driven by a desire for the best medical outcome can also be undue, and neither influence should seek to be a substitution for the patient’s decision. Following Re BKR [2015] SGCA 26, we are now obliged to examine how mental capacity can be affected by undue influence. A lack of capacity can be found when a patient fails to appreciate the presence of undue influence or is susceptible to undue influence due to their mental impairment causing their will to be overborne. This then paves the way for the health care team to decide based on best interests, because the patient is determined to be lacking in mental capacity. (shrink)

This paper draws a correlation between processes of research and drawing by analyzing the formation of emotional content and stylistic representation in art. The paper suggests that research process fundamentally involves a systematic development of understanding on a particular issue through a process of rational inquiry. The research outcome or an intellectual understanding is therefore nothing more than a thoroughly investigated form of a hypothesis/ premise/ theory/ idea that has undergone a careful process of scrutiny, comparison and evaluation. On similar (...) grounds, drawing process also involves a systematic development of form in which adjustments are made with the help of nonverbal reasoning till the final form is evolved. The development of form in drawing becomes a systematic rational process but operates at a subconscious plane; reason is substituted by aesthetic sensibility. It is suggested that aesthetic sensibility is a judgment that the human mind tailors through the use of non-verbal criteria of evaluating the beautiful and ugly. The paper develops a theoretical model in the light of above and then applies it to analyze various drawing conventions used by Sadequain in figurative treatment. (shrink)

The accuracy of proxies when they interpret advance directives or apply substituted decision-making criteria has been called into question. It therefore became important to know if the Andalusian Advance Directive Form (AADF) can help to increase the accuracy of proxies' predictions. The aim of this research was to compare the effect of the AADF on the accuracy of proxies' predictions about patients' preferences with that gained from informative and deliberative sessions about end-of-life decision making. A total of 171 pairs of (...) patients and their proxies were randomized to three groups. The control group's answers to the Life Sustaining Preferences Questionnaire (LSPQ) were compared with their proxies' answers to the same questionnaire. In one intervention group, the patients had already completed the AADF and given it to their proxies, who used it to guide their own answers to the LSPQ. In the second intervention (discussion) group, both patients and proxies attended two educative sessions guided by trained nurses and later filled in the LSPQ. Comparisons of accuracy and other variables showed a strong association with the discussion group. The findings show that promoting communication between patients and their proxies improves the accuracy of proxies' predictions much more than isolated use of the AADF form. (shrink)