Sildenafil citrate (Viagra) and other newly released pharmaceuticals that assist erectile dysfunction may be one of the most important categories of drugs released in the past decade. Sildenafil is distinctive because it creates a new therapeutic relationship not only between patient and physician, but also with sexual partner(s). Physicians must first evaluate the patient comprehensively, addressing not only erectile function and sexual performance, but overall physical and mental health. Since the drug does impact others, an expanded model for informed consent (...) needs to be considered. Three models to consider include the public health one, ethically justified limits on confidentiality, and a biopsychosocial one. The biopsychosocial model may be preferred because it expands the patient-physician dyad to directly include others. Physicians also need to distinguish between professional, role-related obligations and personal conscience when treating patients whose sexual beliefs and practices differ from their own. Other ethical issues include inappropriate prescribing over the Internet, dealing with unrealistic patient expectations, and fairness in paying for treatment for sexual conditions in both men and women. With these proposed guidelines, physicians can continue to provide steady, reliable guidance for patients while working with yet another scientific advance in medicine. (shrink)

Today in Japan psychoactive drugs are widely prescribed for various psychiatric disorders including so-called ‘functional’ disorders. They are undoubtedly effective in relieving various psychological and behavioral symptoms. However, Japan has yet to address some basic questions: (1) uncertainty concerning the cause of various psychiatric functional disorders; (2) unknown factors that affect the function of psychotropic drugs in patients; (3) the difficulty in obtaining objective data concerning the effects of these medications * both on the brain and the psychological symptoms (behavior); (...) and most importantly, (4) due to both the behavioral and organic (brain and CNS) effects of psychoactive drugs, the difficulty in evaluating the risk/benefit ratio between the behavioral (primary) effect and the organic (side) effect. In addition, there are bioethical problems, since these uncertainties tend to permit too broad a range of intention and too many modes of intervention in (a) prescribing and (b) taking psychoactive drugs on the part of therapists and patients, respectively. Though the increased risk of the inappropriate use of these drugs – the non-therapeutic uses, and their over-prescription – has been indicated in other industrialized countries, it has not yet been fully recognized and adequately discussed in Japan. Moreover, it is necessary to establish a sound basis for the ‘somato-psychic’ evaluation of these effects in the context of the physician-patient relationship, including the patient's family and even the broader society. Keywords: bioethics, pharmacological treatment, primary and secondary effects, psychiatric-functional disorders, risk/benefit ratio CiteULike Connotea Del.icio.us What's this? (shrink)

Prescribing drugs for uses that the FDA has not approved — off-label drug use — can sometimes be justified but is typically not supported by substantial evidence of effectiveness. At the root of inappropriate off-label drug use lie perverse incentives for pharmaceutical firms and flawed oversight of prescribing physicians. Typical reform proposals such as increased sanctions for manufacturers might reduce the incidence of unjustified off-label use, but they do not remove the source of the problem. Public policy (...) should address the cause and control the practice. To manage inappropriate off-label drug use, off-label prescriptions must be tracked in order to monitor the risks and benefits and the manufacturers’ conduct. Even more important, reimbursement rules should be changed so that manufacturers cannot profit from off-label sales. When off-label sales pass a critical threshold, manufacturers should also be required to pay for independent testing of the safety and effectiveness of off-label drug uses and for the FDA to review the evidence. Manufacturers should also finance, under FDA supervision, programs designed to warn physicians and the public about the risks of off-label drug use. (shrink)

Through the 1960s, many people claimed that drug advertising was educational and physicians often relied on it. Continuing Medical Education (CME) was developed to provide an alternative. However, because CME relied on grants, industry funders chose the subjects offered. Now policymakers worry that drug firms support CME to promote sales and that commercial support biases prescribing and fosters inappropriate drug use. A historical review reveals parallel problems between advertising and industry-funded CME. To preclude industry influence and improve CME, (...) we should ensure independent funding by taxing medical industries, facilities and physicians. Independent public and professional authorities should create CME curricula. An independent agency should allocate all funds to educational institutions for approved curricula. (shrink)

The Food and Drug Administration authorizes the marketing of a drug only for uses that the manufacturer has demonstrated to be safe and effective, based on evidence from at least two clinical trials. However, the FDA does not regulate the practice of medicine, so physicians may prescribe drugs in any manner they choose. Prescribing drugs in ways that deviate from the uses specified in the FDA-approved drug label, package insert, and marketing authorization is referred to as off-label prescribing. (...) This occurs when physicians prescribe a drug for a therapeutic purpose other than the one approved by the FDA; treat patients in a different age cohort or gender than the population on which it was tested; or prescribe a different dose, for a different duration of use, or a different mode of administration than indicated on the label. (shrink)

Despite advances in medical knowledge regarding pain management, pain continues to be significantly undertreated in the United States. There are many drug and nondrug treatments, but the use of controlled substances, particularly the opioid analgesics, is universally accepted for the treatment of pain from cancer. Although opioid analgesics are safe and effective in treating chronic pain, there is continued research and discussion about patient selection and long-term effects. A number of barriers in the health care and drug regulatory systems account (...) for the gap between what is known about pain management and what is practiced. Among the barriers are physicians’ fears of being disciplined by state regulatory boards for inappropriate prescribing.State medical boards are in a unique position not only to address physicians’ concerns about being investigated, but also to encourage pain management. Prior to 1989, a few state medical boards had policies relating to controlled substances or pain. Subsequently, state medical boards began adopting policies regarding the prescribing of opioids for the treatment of pain; many of these specifically addressed physicians’ fear of regulatory scrutiny. (shrink)

Despite advances in medical knowledge regarding pain management, pain continues to be significantly undertreated in the United States. There are many drug and nondrug treatments, but the use of controlled substances, particularly the opioid analgesics, is universally accepted for the treatment of pain from cancer. Although opioid analgesics are safe and effective in treating chronic pain, there is continued research and discussion about patient selection and long-term effects. A number of barriers in the health care and drug regulatory systems account (...) for the gap between what is known about pain management and what is practiced. Among the barriers are physicians’ fears of being disciplined by state regulatory boards for inappropriate prescribing.State medical boards are in a unique position not only to address physicians’ concerns about being investigated, but also to encourage pain management. Prior to 1989, a few state medical boards had policies relating to controlled substances or pain. Subsequently, state medical boards began adopting policies regarding the prescribing of opioids for the treatment of pain; many of these specifically addressed physicians’ fear of regulatory scrutiny. (shrink)

Deprescribing is the term used to describe the process of withdrawal of an inappropriate medication supervised by a clinician. This article presents a discussion of how the Four Principles of biomedical ethics that may guide medical practitioners’ prescribing practices apply to deprescribing medications in older adults. The view of deprescribing as an act creates stronger moral duties than if viewed as an omission. This may explain the fear of negative outcomes which has been reported by prescribers as a (...) barrier to deprescribing. Respecting the autonomy of older adults is complex as they may not wish to be active in the decision-making process; they may also have reduced cognitive function and family members may therefore have to step in as surrogate decision-makers. Informed consent is intended as a process of information giving and reflection, where consent can be withdrawn at any time. However, people are rarely updated on the altered risks and benefits of their long-term medications as they age. Cessation of inappropriate medication use has a large financial benefit to the individual and the community. However, the principle of justice also dictates equal rights to treatment regardless of age. (shrink)

Many factors contribute to the inappropriate use of medicines, including not only a lack of information but also inaccurate and misleading promotional information. This review examines how the promotion of pharmaceuticals directly affects the prescribing and use of medicines. We define promotion broadly as all actions taken directly by pharmaceutical companies with the aim of enhancing product sales. We look in greater detail at promotion techniques aimed at prescribers, such as sales representatives, pharmaceutical advertisements in medical journals and (...) use of key opinion leaders, along with the quality of information provided and the effects thereof. We also discuss promotion to the public, through direct-to-consumer advertising, and its effects. Finally, we consider initiatives to regulate promotion that come from industry, government and nongovernmental organizations. (shrink)

Rationale, aims and objectives: Appropriate use of diagnostic and treatment modalities are essential for rational use of resources. The aim of this study is to evaluate the use of diagnostic modalities and different treatment options and their economic impacts following an acute ankle distortion resulting from an occupational accident. We evaluated the type-of-treatment impact on the victims' course of recovery as well as its impact on the associated accident costs. Research was carried out in Belgium. Methods: An ankle distortion victims' (...) database consisting of 200 cases of (Belgian) occupational accidents during the period 2005-2007 was analysed. Results: Patients who were prescribed immobilization or the use of adjuvant support or physical therapy (118 cases) were not employed during a period of 37 days on average, with a mean total cost of 3140.14 Euros caused by the ankle sprain. Patients without any adjuvant therapy (82 cases) were characterized by an unemployment rate of 15 days on average, and a total cost of 1077.86 Euros. Cast immobilization, although its application is not supported by evidence-based literature, was still applied in 36% of the population studied and resulted in the longest average absence of work of 42 days with an obvious significant increase in medical and total costs. Conclusions: Our results show a high rate of inappropriate use of cast immobilizations for ankle distortions. From an economic point of view and for the same clinical endpoint (being full resumption of the occupational activities), simple conventional treatment, consisting of rest, ice, compression and elevation at diagnosis with allowance of early weight bearing in the further clinical course, leads to the quickest full resumption of activities in combination with the lowest medical costs, if compared with any other kind of treatment. (shrink)

A dearth of clinical research involving children has resulted in off-licence and sometimes inappropriate medications being prescribed to the paediatric population. In this environment, recent years have seen the introduction of a raft of regulation aimed at increasing the involvement of children in clinical trials research and generating evidence-based medicinal preparations for their use. However, this regulation pays scant attention to the autonomy of competent minors. In particular, it makes no provision for the ability of competent minors to consent (...) to participate in medical research and is therefore at odds with best ethical practice. This article explores the tensions between law and ethics in relation to clinical research involving minors and concludes that greater respect should be given to the autonomy of those minors who are competent to decide for themselves. (shrink)

An increasing number of community physicians are involved in clinical research.Indeed, 60 of industry-funded research is now spent on community based trials. This surge in community based clinical trials has increased the number of clinical trials applications submitted to the drug regulatory agencies by pharmaceutical sponsors. Many have argued that the commercial interests connected to the conduct and outcome of these trials also increases the potential for conflicts of interest for participating physicians. The context in which these trials take place (...) increases the potential for a host of practices that infringe on ethical, legal and clinical obligations of physicians For example, financial recruitment incentives may lead to violations of the inclusion criteria and the consent process. It may result in inappropriate recruitment of patient participants and a blurring of the ethically significant distinctions between treatment and research. In some cases, it may be hard to distinguish research from the marketing of new products and attempts to influencing prescribing patterns. (shrink)

An increasing number of community physicians are involved in clinical research.Indeed, 60 of industry-funded research is now spent on community based trials. This surge in community based clinical trials has increased the number of clinical trials applications submitted to the drug regulatory agencies by pharmaceutical sponsors. Many have argued that the commercial interests connected to the conduct and outcome of these trials also increases the potential for conflicts of interest for participating physicians. The context in which these trials take place (...) increases the potential for a host of practices that infringe on ethical, legal and clinical obligations of physicians For example, financial recruitment incentives may lead to violations of the inclusion criteria and the consent process. It may result in inappropriate recruitment of patient participants and a blurring of the ethically significant distinctions between treatment and research. In some cases, it may be hard to distinguish research from the marketing of new products and attempts to influencing prescribing patterns. (shrink)

ABSTRACT A key selling point of pharmacogenetics is the genetic stratification of either patients or diseases in order to target the prescribing of medicine. The hope is that genetically ‘tailored’ medicines will replace the current ‘one‐size‐fits‐all’ paradigm of drug development and usage. This paper is concerned with the relationship between difference and justice in the use of pharmacogenetics. This new technology, which facilitates the identification and use of difference, has, we shall argue, the potential to lead to injustice either (...) by the inappropriate use of difference or through the inappropriate failure to use difference. We build on empirical data from a detailed study of the range of options for the development of pharmacogenetics to present a consideration of the ethical issues that surround patient and disease stratification. In it we explore the ways in which the use of pharmacogenetics may lead to the creation of new, genetically stratified, forms of difference and new forms of injustice based on these divisions. We also examine the ways in which existing forms of difference and social stratification may interact with the use of pharmacogenetics. In conclusion, we suggest how an understanding of these ethical issues could usefully inform future policy discussions. (shrink)

The ‘scaling up’ objection says non-representational ecological-enactive accounts will be unable to explain ‘representation hungry’ cognition. Obsessive-compulsive disorder presents a paradigmatic instance of this objection, marked as it is by ‘representation hungry’ obsessive thoughts and compulsive behavior organized around them. In this paper I provide an ecological-enactive account of OCD, thereby demonstrating non-representational frameworks can ‘scale up’ to explain ‘representation hungry’ cognition. First, I outline a non-representational account of mind— a predictive processing operationalization of Sean Kelly’s theory of perception. This (...) account explains the ‘tensions’ and ‘pulls’ which guide and constrain our action-oriented and affect-laden perceptual ‘grip’ upon the world to be underwritten by an imperative to minimize prediction error. I then argue that OCD is best understood as ‘grip gone awry’— malformed predictive models signal inappropriately high error, and this results in extremely strong ‘tensions’ and ‘pulls’ which prescribe actions. Thus, I arrive at the idea that OCD is primarily constituted by ‘not just right’ feelings caused by high error signaling. Finally, I explain that this account provides a causal explanation of the non-representational existential feeling fundamental to OCD. Compulsions are considered manifestations of non-representational grip responsive to this feeling, whilst obsessions are explained to play a meta-role in the condition, being formulated by subjects in a bid to make their ‘not just right’ feeling intelligible. I explain that the meta-role obsessions play makes their representational status largely irrelevant to OCD, and so leave this an open question. Consequently, I provide a non-representational account of OCD, thereby demonstrating that ecological-enactive approaches can respond to the ‘scaling up’ objection. (shrink)

Adequate treatment of pain is essential to alleviate suffering, yet studies show that patients with terminal or serious illness receive inadequate pain relief. In the case of terminally ill patients, adequate palliation of pain may be likely to reduce requests for physician-assisted suicide. This issue of the journal addresses barriers to effective pain relief and suggests how treatment of pain can be improved. The symposium features the Pain Relief Act, which is designed to provide practitioners who prescribe controlled substances for (...) pain with protection from inappropriate legal sanctions. The Act is the product of the Project on Legal Constraints on Access to Effective Pain Relief, whose principal investigators were Nancy Neveloff Dubler, LL.B., Sandra H. Johnson, J.D., LL.M., Robert J. Levine, M.D., and Benjamin W. Moulton, J.D., M.P.H.The Project was supported by the Mayday Fund and the Emily Davie and Joseph S. Kornfeld Foundation. (shrink)

Adequate treatment of pain is essential to alleviate suffering, yet studies show that patients with terminal or serious illness receive inadequate pain relief. In the case of terminally ill patients, adequate palliation of pain may be likely to reduce requests for physician-assisted suicide. This issue of the journal addresses barriers to effective pain relief and suggests how treatment of pain can be improved. The symposium features the Pain Relief Act, which is designed to provide practitioners who prescribe controlled substances for (...) pain with protection from inappropriate legal sanctions. The Act is the product of the Project on Legal Constraints on Access to Effective Pain Relief, whose principal investigators were Nancy Neveloff Dubler, LL.B., Sandra H. Johnson, J.D., LL.M., Robert J. Levine, M.D., and Benjamin W. Moulton, J.D., M.P.H.The Project was supported by the Mayday Fund and the Emily Davie and Joseph S. Kornfeld Foundation. (shrink)

Singh's study of 150 UK and US children diagnosed with attention deficit hyperactivity disorder and prescribed psychotropic medication concludes on the basis of interviews with the children that ‘stimulants improve their capacity for moral agency … an ability to meet normative expectations’.1 Reinterpreted in lay language, she finds that, when taking Ritalin, the children conform to the wishes and expectations of their parents and teachers. They get better grades at school and show less ‘oppositional-defiance’. This is not surprising as it (...) is precisely what Ritalin is supposed to do. However, it begs a number of crucial questions. Might it not be that the failure of the child to conform to the expected norms in the non-medicated state is a legitimate expression of the child's own moral agency, rebelling against what he/she experiences as inappropriate …. (shrink)

This paper argues that it is morally irresponsible for modern medical providers or health care institutions to support and advocate the integration of CAM practices (i.e. homeopathy, acupuncture, energy healing, etc.) with conventional modern medicine. The results of such practices are not reliable beyond that of placebo. As a corollary, it is argued that prescribing placebos perceived to stand outside the norm of modern medicine is morally inappropriate. Even when such treatments do no direct physical harm, they create (...) unnecessary barriers to patients' informed understanding of their health. (shrink)

Among the many explanations for antibiotic overprescription, some doctors cite the risk of malpractice liability if they deny a patient's request for an antibiotic and the patient's condition worsens. In this paper, I examine the merits of this concern—i.e., whether physicians could, in fact, face malpractice liability for refusing to prescribe an antibiotic when, from a public health perspective, the use of the antibiotic would be considered inappropriate. I conclude that the potential for liability cannot be dismissed entirely, but (...) the risk is remote—even in cases where there is a chance that the antibiotic might have benefited the patient. (shrink)

Lithuania was one of the first states in Europe to approve a comprehensive list of patients’ duties under a special Law on the Rights of Patients of 2010. The approval of the catalogue of patients’ duties at the level of a law is based on the restatement of the principle of equal rights of the parties participating in health care relations, and the prevention of consumerism in these relations. The paper distinguishes between general and special patients’ duties. The general duties (...) include the duty to exercise the patient’s rights in good faith, the ban to abuse them, the duties of cooperation and looking after one’s health, as well as the duty of treatment with due respect. The norms that entrench duties of ethical nature should serve to prevent any inappropriate behaviour of patients in health care institutions. Nevertheless, legal application of these provisions and proving the infringements in practice is likely to be complicated. The special duties include: the duty to familiarise oneself against signature with the internal regulations of the health care institution as presented to him or her, other documents prescribed by the health care institution; the duty to present the documents confirming identity; the duty upon receiving information about the health care services prescribed for him or her to confirm in writing his or her consent or refusal with regard to the provision of such health care services in the cases specified by the law; the duty to provide health care professionals with any information about one’s health, to follow the prescriptions and recommendations of health care professionals, to inform health care professionals about any deviations from the prescriptions or the prescribed treatment regime which he or she has accepted. The legal analysis of the contents of the duties has revealed certain unsubstantial obscurities. The analysis of the provision that enables to take sanctions against the patient infringing their duties has revealed that the health care institution may only terminate provision of health care services to the patient if one of the two alternative conditions is fulfilled. I.e. if a person violates his or her duties and thereby causes danger to their own and other patients’ health and life, or prevents them from receiving high quality health care services. The conclusions show that application of this provision may be problematic: first, due to the juridical technique of the wording of the norm; second – due to complicated substantiating that the patient prevented or prevents other patients from receiving high quality health care services; third – due to the conflict of this provision with the provision of the Law of the Republic of Lithuania on Medical Practice, which provides that a doctor may refuse provision of health care services in cases of real threat to his or her own life; and fourth – the norm does not provide for the right to terminate the provision of services in cases of threat to health and/or life of health care workers (non-specialists). (shrink)

Studies on participation and spatial orientations of college students have examined aspects of university life, as projected through language, from a reportorial or narrative perspective, but hardly any one of these studies has been devoted exclusively to how students' participation structure, together with the activities participants orient to at the participation space, evokes shared socio-academic backgrounds and cultural constraints, a major way to gain access into the students' cognitive and pragmatic tendencies. This research, thus, addresses itself to Nigerian college students' (...) participation configuration, their participant roles, and the illocutionary goals of their encounters within the Goffmanian participation framework and discourse pragmatic parameters. For data, 100 interactions amongst students of the Faculty of Arts, University of Ibadan, Nigeria, were taped and scrutinised for participation forms and spatial descriptions. Two types of participation structure are manifest in the interactions, namely, unmarked and marked participations. The unmarked participation structure is the regular frame in which Goffman's ratification and non-ratification framework is strictly observed. The marked participation configuration, an unexpected interactional frame which bifurcates into accommodated and non-accommodated structures, takes interruptions by unaccredited participants as appropriate or inappropriate. The paper contends that participation configuration and contextual elements prescribe participant roles together with the pragmatic functions assigned to language and actions in the interactions. Thus, the illocutionary goals of participants, rooted in socio-academic matters and enabled by participation structures, spatial orientations and body language manipulations are contextually negotiated. (shrink)

Deprescribing is the term used to describe the process of withdrawal of an inappropriate medication supervised by a clinician. This article presents a discussion of how the Four Principles of biomedical ethics that may guide medical practitioners’ prescribing practices apply to deprescribing medications in older adults. The view of deprescribing as an act creates stronger moral duties than if viewed as an omission. This may explain the fear of negative outcomes which has been reported by prescribers as a (...) barrier to deprescribing. Respecting the autonomy of older adults is complex as they may not wish to be active in the decision-making process; they may also have reduced cognitive function and family members may therefore have to step in as surrogate decision-makers. Informed consent is intended as a process of information giving and reflection, where consent can be withdrawn at any time. However, people are rarely updated on the altered risks and benefits of their long-term medications as they age. Cessation of inappropriate medication use has a large financial benefit to the individual and the community. However, the principle of justice also dictates equal rights to treatment regardless of age. (shrink)

Flaws, biases, and ethical problems surrounding research and diagnosis may lead to inappropriate or inequitable treatments that exacerbate or fail to improve the misery that some individuals face due to their psychiatric conditions. Possible androcentric biases in the choice and definition of categories for diagnosis available in DSM-III-R may in turn influence the approaches of therapists to clients, particularly male therapists towards female clients. Androcentric bias in diagnosis, which may also be reflected in the values of the psychiatrist, may (...) lead to treatment regimens designed to make clients fit into roles, positions, and norms prescribed by a culture reflecting patriarchal values. Some acceptance of attempts by feminists to correct androcentrism are beginning to emerge in psychiatric diagnosis. Keywords: androcentrism, bias, feminist, psychiatry of biology CiteULike Connotea Del.icio.us What's this? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My Ability to FlourishPaulette KoehlerIn twenty years of convulsions, I’ve never heard a neurologist mention the word “epilepsy.” Over this time, the intensity of my original simple partial seizures, “simple” signifying retained consciousness and “partial” indicating disturbances restricted to a specific area of my brain, grew to the complex level on my left temporal lobe. I believe this development was influenced by my use of prescribed medications. Several neurologists (...) from Los Angeles to San Francisco directed various electroencephalograms (EEGs), including a week–long, prescription–free EEG in the hospital; magnetic resonance imaging tests (MRIs); computed tomography (CT) scans anywhere from forty–five minutes to four hours each; and blood profiles to help determine my situation. For legal reasons, one neurologist even had me sign a release stating that he was not able to diagnose my situation.Test results present limited information about my brain and without ever saying, “I don’t know,” these neurologists communicated my test results by utilizing technical terms and thus not always answering my questions. After explaining that my head turns to the left while my right hand shakes, symptoms that have been recognized and reported by several friends and family members, my doctor replied that a seizure on the left side of my brain should cause my head to turn to the right and then changed the subject. I felt like asking, “Am I doing it wrong?”The brain is different from other parts of our anatomy in that it can’t be replaced like a kidney, heart or other organ. It cannot be removed like tonsils, an appendix or even a limb. It can be physically studied or repaired while functioning but the resulting percentage of survival or proper operation of the body after surgery is minimal and the number of people requiring such attention is so low that the amount is scanty. A dead brain limits the analysis of its functions.My “disabilities” involve spontaneous uncontrolled loss of consciousness, exhaustion, mood swings, and the suspension of driving privileges. Activity interference, extra naps, losing friends and not being able to get around are definite disadvantages. However, everyone needs to manage personal problems. No one is perfect.Public transit schedules and directions don’t always offer me the transportation I need. Fortunately, the combination of a bus ride with walking or running can serve my needs while also helping me to keep physically healthy.Limited benefits include discounted transit and the option to ride instead of walking or running. A trip to Nana’s on the train is always a treat.I’d rather not be branded “disabled” even though those who understand my situation address me with compassionate, sympathetic attention, [End Page E4] always asking how I physically feel. I feel fine. A seizure is only a quick, conscious loss of time and an occasional scrape on the knee. I’m more annoyed when I notice strangers looking suspiciously at my public transport discount card as if I don’t really deserve it.Like the “disability” brand, the medications I’ve taken, Dilantin, Neurontin, Depakote, Keppra and Lamictal, among others, all of which produced serious side effects without reducing the frequency of my seizures have only been a cover–up, preventing a search for the true cause and effective treatment of my seizures. Being identified as disabled has only limited my daily schedule. I am not disabled, as society has unfortunately characterized me.My seizures began in 1993, the year our FDA started approving rBGH, recombinant bovine growth hormone, man–made for the use on dairy cows to enhance their milk production. As a result, milk on the market increased while keeping the price from rising, as demonstrated in Economics I. Can the use of rBGH act on my brain in any way?One neurologist, in order to avoid the responsibility of inappropriate recommendations, presented his thoughts in the form of questions, encouraging me to consider options.“You’ve tried all of these medications?”“Has your diet alteration made any difference in your seizures?”“Have you tried organic foods?”His inquiries persuaded me to contemplate whether drugs are an answer to my problem, pay attention to differences in my life and... (shrink)

The paper discusses inappropriate (futile) treatment by analyzing the casuistics of palliative patients in the terminal stage of illness who are hospitalized at the Department of Internal Medicine and Geriatrics of the Faculty hospital with policlinic (FNsP). Our research applies the principles of palliative care in the context of bioethics. The existing clinical conditions of healthcare in Slovakia are characteristic of making a taboo of the issues of inappropriate treatment of palliative patients. Inductive-deductive and normative clinical bioethics methods (...) of palliative care and ethical strategy are applied for defining issues found in inappropriate hemodialysis treatment. An algorithm of hemodialysis treatment requires the definition of those lege artis criteria which, in the context of a patient’s autonomy and his/her decision, precondition the avoidance of the situation in which hemodialysis treatment is inappropriate (futile). Futile treatment in a terminal condition is ethically inappropriate medical treatment that extends the suffering of patients and their relatives. Its definition is determined by the relevant legislation and the methods of bioethics. An active palliative strategy is aimed at managing the process of incurable diseases in the patient’s bio-psycho-socio-spiritual continuity in the process of special bioethics. The global bioethical objective of general bioethics for palliative care is based on the paradigm of social harmony and solidarity in the context of an authentic modus of the patient’s existence as a constitutive principle for the phenomenon of the patient’s being to finite being (death). (shrink)

It is conventional wisdom among political philosophers that ideal principles of justice must guide our attempts to design institutions to avert actual injustice. Call this the ideal guidance approach. I argue that this view is misguided— ideal principles of justice are not appropriate "guiding principles" that actual institutions must aim to realize, even if only approximately. Fortunately, the conventional wisdom is also avoidable. In this paper, I develop an alternative approach to institutional design, which I call institutional failure analysis. The (...) basic intuition of this approach is that our moral assessment of institutional proposals is most effective when we proceed from a detailed understanding of the causal processes generating problematic social outcomes. Failure analysis takes the institutional primary design task to be obviating or averting institutional failures. Consequently, failure analysis enables theorists to prescribe more effective solutions to actual injustice because its focuses on understanding the injustice, rather than specifying an ideal of justice. (shrink)

Joshua Parker’s article on green inhaler prescribing is important and timely. I agree with much of it, specifically regarding the institutional duty to make climate-friendly changes (from environmentally expensive prescriptions to ‘greener,’ similarly effective ones). The challenge, however, comes in determining how that institutional obligation impacts the rights and duties of patients. In this commentary, I want to offer a friendly alternative to Parker’s view of individual patient obligation, which I suggest is important for reasons that go beyond this (...) one case. Parker’s broad view is that, because metered-dose inhalers (MDIs) emit far more greenhouse gases (GHG) than do dry powder inhalers (DPIs), and the two are equally effective for most patients, the healthcare system should switch most patients on MDIs to DPIs, and the patients have a pro tanto duty to accept this change.1 The problem is that no individual inhaler use causes harmful climate change, and so it is difficult to explain a duty not to use MDIs. It seems that my individual behaviour ‘makes no difference’ to climate change, so familiar more principles have a difficult time justifying a prohibition of such behaviour. Parker’s response to this worry fits into the consequentialist tradition,2 3 as he argues that each individual contribution to climate change causes some amount of ‘expected harm,’ because it contributes a little bit to future climate changes which will cause harm. And since we have a duty to minimise expected harm, we have a duty not to make such small contributions to climate change. I think we should be sceptical of this sort of argument. It makes the most sense if we endorse a bathtub metaphor, in which the atmosphere is like a bathtub, and once it is full, every …. (shrink)

A growing body of work argues that we should reform problematic emotions like anxiety, anger, and shame: doing this will allow us to better harness the contributions that these emotions can make to our agency and wellbeing. But feminist philosophers worry that prescriptions to correct these inappropriate emotions will only further marginalize women, minorities, and other members of subordinated groups. While much in these debates turns on empirical questions about how we can change problematic emotion norms for the better, (...) to date, little has been done by either side to assess how we might do this, much less in ways that are responsive to the feminists’ worries. Drawing on research in cognitive science, this paper argues that though the feminists’ worries are real, the leading proposals for remedying them are inadequate. It then develops an alternative strategy for reshaping problematic emotion norms—one that’s sensitive to the feminists’ concerns. (shrink)

The general aim of this work is to show the importance of the adressee's mind as planned by the author of a speech act or of a norm; in particular, how important are the expected motivations for goal adoption. We show that speech acts differ from one another for the different motivations the speaker is attempting to obtain from the hearer. The description of the participants' social positions is not sufficient. Important conflicts can arise which are not relative to what (...) to do, but to the different motives requested by the speaker. This view is applied to norms, pointing out that what is required by a norm is not only a behaviour but also a mental attitude, and that the prescribed mind might be even more important than the prescribed behaviour. Norms don't want just behavioural conformity, but also that this conformity implies an acknowledgement and a reinforcement of both the authority and the norm itself. Norms ask for submission. Any form of norm is aimed at influencing the addressee by changing his or her mind. (shrink)

Teachers are no longer simply being told what to teach, but also how to teach it. It is important therefore to examine whether some prescriptions of teaching methods are acceptable while others are not, and to justify opposition to certain forms of prescription. I show that some attempts to prescribe teaching methods are either empty, or incompatible with holding teachers to account for the pupil learning which is supposed to result. My argument does not depend on making any value assumptions (...) about ultimate educational aims. Examples from the National Literacy and Numeracy Strategies are discussed. (shrink)

This paper trials new experimental methods for the analysis of natural language reasoning and the development of critical ordinary language philosophy in the wake of J.L. Austin. Philosophical arguments and thought experiments are strongly shaped by default pragmatic inferences, including stereotypical inferences. Austin suggested that contextually inappropriate stereotypical inferences are at the root of some philosophical paradoxes and problems, and that these can be resolved by exposing those verbal fallacies. This paper builds on recent efforts to empirically document (...) class='Hi'>inappropriate stereotypical inferences that may drive philosophical arguments. We demonstrate that previously employed questionnaire-based output measures do not suffice to exclude relevant confounds. We then report an experiment that combines reading time measurements with plausibility ratings. The study seeks to provide evidence of inappropriate stereotypical inferences from appearance verbs that have been suggested to lie at the root of the influential ‘argument from illusion’. Our findings support a diagnostic reconstruction of this argument. They provide the missing component for proof of concept for an experimental implementation of critical ordinary language philosophy that is in line with the ambitions of current ‘evidential’ experimental philosophy. (shrink)

Teachers are no longer simply being told what to teach, but also how to teach it. It is important therefore to examine whether some prescriptions of teaching methods are acceptable while others are not, and to justify opposition to certain forms of prescription. I show that some attempts to prescribe teaching methods are either empty, or incompatible with holding teachers to account for the pupil learning which is supposed to result. My argument does not depend on making any value assumptions (...) about ultimate educational aims. Examples from the National Literacy and Numeracy Strategies are discussed. (shrink)

This chapter deals with one of the common fallacies in Western philosophy, inappropriate appeal to authority (IAA). IAA has many different facets. At its core, it is a fallacy that assumes that because someone is an authority, we should listen to that person. The problem with IAA is that it ignores content in favor of credentials and power. There are a few different ways in which IAA can occur. IAA seems to be the result of a flaw in human (...) thinking. Social cognitive theory, a theory that helps explain human action, notes that humans tend to act like each other. The tendency to listen to authorities who are not authorities explains why celebrities are able to sell us stuff. The important thing to remember about IAA is that it is not just a fallacy that comes up in arguments that do not matter. (shrink)

Kihlbom has recently argued that a system of seeking negatively informed consent might be preferable in some cases to the ubiquitous informed consent model. Although this theory is perhaps not powerful enough to supplant informed consent in most settings, it lends strength to Evans’ and Hungin’s proposal that it can be ethical to prescribe placebos rather than "active" drugs. This paper presents an argument for using negatively informed consent for the specific purpose of authorising the use of placebos in clinical (...) contexts. (shrink)

In Good White People: The Problem with Middle-Class White Anti-Racism, Shannon Sullivan considers: "What can white people do to help end racial injustice?". As one response to this question, Sullivan argues that prescribing "white shame" and "white guilt" is useless, since promoting these ideas leads to self-hate and inaction on the part of white people. In this paper, I agree with Sullivan, but for different reasons. I argue that assuming that white people can feel ashamed simply about being white (...) within our current society is unfounded. I will maintain that the project of "promoting white shame" is fraught to begin with, and show the significance of this finding for conversations about white people's role in... (shrink)

... and the baby has a large VSD. Otherwise appears well, gaining weight, smiling. No apnea, never been on ventilator. Local cardiac surgeon refused to operate, saying that surgery would be inappropriate. Have reached out to other centers, and some state that they never perform what they said was “futile” heart surgery on children with Trisomy 18, while other sites say they have and will continue to perform these operations. Can someone explain to me what is going on? In (...) the realm of medical care—given enough patients, clinicians, and time—conflict is inevitable. Someone will want to do something, such as give a drug or start a new form of technologic support, and someone else will think that this is a... (shrink)

This paper reframes the futility debate, moving away from the question “Who decides when to end what is considered to be a medically inappropriate or futile treatment?” and toward the question “How can society make policy that will best account for the multitude of values and conflicts involved in such decision-making?” It offers a pragmatist moral epistemology that provides us with a clear justification of why it is important to take best standards, norms, and physician judgment seriously and a (...) clear justification of why ample opportunity must be made for patients, families, and society to challenge those standards and norms. (shrink)

Actions expressing strong emotions such as anger can be appropriate responses when an agent judges a serious injustice to have been committed. Certainly, a woman can experience these conditions and express herself through actions such as gesturing aggressively, gritting her teeth, or lashing out verbally. If she is consequently labeled “crazy,” “hysterical,” or “a bitch,” what has gone awry? This paper offers an analysis of the common charge of inappropriateness in the case of women’s actions expressing emotion. To begin, I (...) will present core normative distinctions that define appropriate emotional expression. Following this, the “double-bind” of women’s actions expressing emotion will be explored with reference to the conflicting normative practices outlined in the first section of the paper. Put briefly, when a female agent surpasses gendered behavioral expectations, she is seen as having failed what can be called the first test of social coping. The perception of this failure shuts down further avenues for interpreting her behavior. Instead, the social inappropriateness of her emotion is used as further proof of irrationality. The arguments of the second section leave no doubt that gendered norms in the case of actions expressing emotions must be rejected both on epistemological and moral grounds. The final section of the paper explores epistemically and ethically viable alternatives for deciding the rational appropriateness of actions expressing emotion. (shrink)

A distinguished political philosopher with years of experience teaching in undergraduate liberal arts programs, Anderson shows how the ideal of practical reason can reconcile academia’s research aims with public expectations for universities: the preparation of citizens, the training of professionals, the communication of a cultural inheritance. It is not good enough, he contends, to simply say that the university should stick to the great books of the classic tradition, or to denounce this tradition and declare that all important questions are (...) a matter of personal or cultural choice. By applying the methods of practical reason, instead, teachers and students will think critically about the essential purposes of any human activity and the underlying arguments of any text. (shrink)

A distinguished political philosopher with years of experience teaching in undergraduate liberal arts programs, Anderson shows how the ideal of practical reason can reconcile academia’s research aims with public expectations for universities: the preparation of citizens, the training of professionals, the communication of a cultural inheritance. It is not good enough, he contends, to simply say that the university should stick to the great books of the classic tradition, or to denounce this tradition and declare that all important questions are (...) a matter of personal or cultural choice. By applying the methods of practical reason, instead, teachers and students will think critically about the essential purposes of any human activity and the underlying arguments of any text. (shrink)

What is good prescribing? In this paper we will look at the kinds of criteria which are relevant to evaluating prescribing. In particular we wish to challenge, or at least re-frame, the picture of prescribing as an essentially technical process. In so doing we hope to indicate something more general about the power, and limitations, of technical rationality in health care, and to contribute something to work in health care technology assessment. Finally we hope this discussion will (...) act as a stimulus towards a much needed revision of the way ‘good’ prescribing is defined by current policies, guidelines and protocols. (shrink)

Name der Zeitschrift: Kant-Studien Jahrgang: 105 Heft: 4 Seiten: 491-508.

In many Western jurisdictions cannabis, unlike most other psychoactive drugs, cannot be prescribed to patients even in cases where medical professionals believe that it would ease the patient’s pain or anxiety. The reasons for this prohibition are mostly ideological, although medical and moral arguments have been formulated to support it. In this paper, it is argued that freedom, properly understood, provides a sound ethical reason to allow the use of cannabis in medicine. Scientific facts, appeals to harm and autonomy, and (...) considerations of symbolic value cannot consistently justify prohibitions. (shrink)

BackgroundMany genetic counseling studies have focused on anxiety status because clients of GC often feel anxious during their visits. Metacognition is known to be one of the causes of having an inappropriate thinking style. In this study, we examined the relationship between anxiety and the metacognitive status of GC clients according to their characteristics.MethodsThe participants were 106 clients who attended their first GC session in our hospital from November 2018 to March 2021. The survey items were the clients’ characteristics, (...) anxiety status at the time of the visit, and metacognitive status.ResultsHigh state anxiety and high trait anxiety were observed in 34.9 and 11.3% of clients, respectively. Clients who were a relative or had a family history were significantly more likely to have high state anxiety. As for metacognitive status, only negative beliefs about thoughts concerning uncontrollability and danger were associated with having an anxiety status. Furthermore, multivariate analysis showed that negative beliefs about thoughts concerning uncontrollability and danger were an independent determinant of higher state anxiety, but not being a relative or having a family history. Metacognitive status scores were significantly lower in clients than in the control group.ConclusionState anxiety was shown to be more dependent on negative beliefs about thoughts concerning uncontrollability and danger of GC clients than their characteristics such as being a relative or having a family history. The results of this study will contribute to the development of new GC psychosocial support measures to address the anxiety of GC clients. (shrink)