The National Health Service (NHS) was the first healthcare system globally to declare ambitions to become net carbon zero. To achieve this, a shift away from metered-dose inhalers which contain powerful greenhouse gases is necessary. Many patients can use dry powder inhalers which do not contain greenhouse gases and are equally effective at managing respiratory disease. This paper discusses the ethical issues that arise as the NHS attempts to mitigate climate change. Two ethical issues that pose a barrier to moving (...) away from metered-dose inhalers are considered: patients who decline an inhaler with a smaller carbon footprint and increased cost. I argue that while a patient is not morally justified in refusing a more environmentally sustainable inhaler due to the expected harms, a doctor may still prescribe a metered-dose inhaler if they believe that switching without consent might undermine trust or substantially worsen the patient’s health. Turning to cost, I argue that the imperative to combat climate change means the NHS should accept small increased financial costs for lower carbon inhalers, even though this provides no additional direct benefit for the patient. I then go on to consider the implications of the preceding analysis for policy and practice. I argue for a policy that minimises the impact of inhalers on the climate by advocating for a principle of environmental prescribing and explore decision-making in practice. While the arguments here pertain primarily to inhalers, the discussion has broader implications for debates around healthcare’s responsibility to be environmentally sustainable. (shrink)

Medical cannabis is widely available in the USA and legalisation is likely to expand. Despite the increased accessibility and use of medical cannabis, physicians have significant knowledge gaps regarding evidence of clinical benefits and potential harms. We argue that primary care providers have an ethical obligation to develop competency to provide cannabis to appropriate patients. Furthermore, specific ethical considerations should guide the recommendation of medical cannabis. In many cases, these ethical considerations are extensions of well-established principles of beneficence and nonmaleficence, (...) which indicate that providers should recommend cannabis only for conditions that have the strongest evidence base. Additionally, the contested status of cannabis in American culture raises specific issues related to shared decision-making and patient education, as well as continuing clinical education. (shrink)

There are marked differences between countries with regard to reimbursement decision-making, yet few studies have tried to understand this process and its consequences by a detailed analysis of the local context and decision-making structure. This article describes reimbursement decision-making and subsequent prescribing patterns of new pharmaceuticals by means of a case study on glitazones in treatment of type 2 diabetes mellitus patients in Denmark. The study shows that institutional arrangements, providing the context in which evidence is (...) used, are highly important for understanding the reimbursement decision-making process. In particular the Danish Medicines Agency (DMA) has shaped the decision to reimburse glitazones on the basis of physician-mediated requests of individual patients. Relatively few patients have been prescribed glitazones since their introduction in 2000, suggesting that individual reimbursement may be an effective instrument in controlling overall expenditure of selected pharmaceuticals, although in the case of glitazones this has likely been achieved at the expense of equality in access to the products. The discussion focuses on the generalizability of the findings to both other pharmaceuticals in the individual reimbursement scheme in Denmark, and to other countries that are trying to balance the need to control overall pharmaceutical care expenditure with the need to secure equality in access to new drugs with therapeutic added value. (shrink)

Davis Lewis describes that decision theory is no more than a systematic account of an ordinary, common sense philosophy of mind. It is a tool applied to the task of coming to know ourselves and others as persons. The aim is to extend the value function from individual words to propositions so that it gives a measure of degrees of desire. Decision theorists agree that desirability is to be explicated as expected value. They agree that insofar as (...) class='Hi'>decision theory is a normative enterprise, it prescribes that one choose so as to maximize expected value. They agree that the notion of expected value involves the notion of revision of degrees of belief. Desire‐as‐belief implies near‐opinionation or indifference. The author thinks that there is no small irony in the fact that the greatest contemporary defender of Humeanism is also one of the co‐founders of the only version of decision theory. (shrink)

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause (...) dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria. (shrink)

I apply some of the lessons from quantum theory, in particular from Bell’s theorem, to a debate on the foundations of decision theory and causation. By tracing a formal analogy between the basic assumptions of causal decision theory (CDT)—which was developed partly in response to Newcomb’s problem— and those of a local hidden variable theory in the context of quantum mechanics, I show that an agent who acts according to CDT and gives any nonzero credence to some possible (...) causal interpretations underlying quantum phenomena should bet against quantum mechanics in some feasible game scenarios involving entangled systems, no matter what evidence they acquire. As a consequence, either the most accepted version of decision theory is wrong, or it provides a practical distinction, in terms of the prescribed behaviour of rational agents, between some metaphysical hypotheses regarding the causal structure underlying quantum mechanics. (shrink)

The concept of transformative decision rules provides auseful tool for analyzing what is often referred to as the`framing', or `problem specification', or `editing' phase ofdecision making. In the present study we analyze a fundamentalaspect of transformative decision rules, viz. permutability. A setof transformative decision rules is, roughly put, permutable justin case it does not matter in which order the rules are applied.It is argued that in order to be normatively reasonable, sets oftransformative decision rules have to (...) satisfy a number ofstructural conditions that together imply permutability. Thisformal result gives support to a non-sequential theory of framing,i.e., a theory which prescribes no uniform order in which differentsteps in the framing process have to be performed. (shrink)

The objective of this paper is to construct an implementable theory of rational decision-making for cognitive agents subject to realistic resource constraints. It is argued that decision-making should select actions indirectly by selecting plans that prescribe them. It is also argued that although expected values provide the tool for evaluating plans, plans cannot be compared straightforwardly in terms of their expected values, and the objective of a realistic agent cannot be to find optimal plans. The theory of Locally (...) Global planning is proposed as a realistic alternative to standard "maximizing" theories of rational decision-making. (shrink)

Without doctors being able to explain medical decisions to patients, I argue their use of black box AIs would erode the effective and respectful care they provide patients. In addition, I argue that physicians should use AI black boxes only for patients in dire straits, or when physicians use AI as a “co-pilot” (analogous to a spellchecker) but can independently confirm its accuracy. I respond to A.J. London’s objection that physicians already prescribe some drugs without knowing why they work.

The following definitions and explanations are decisions formulated arbitrarily in a sense. However, the underlying assumptions serving as a guide to their formulation are found in both pragmatism and logical positivism. Yet there has been some confusion of the difference between definitions, axioms, postulates, etc., and as a result there is a confusion of certain phases of formal and factual knowledge. For example, one notices in C. I. Lewis' works that all formal statements are thought of as “definitive.” A more (...) effective word, I believe, is “prescriptive.” Axioms are prescriptive, yet, as will be seen below, they are not definitions, and no one in practice conceives of them as such, as can be seen in mathematical works. Axioms prescribe the logical relationship between two or more concepts or words. If interpreted, the factual referents of the words, whose logical relations have been prescribed in axioms, are different. This is not the case with definitions. (shrink)

The Sharī‘ah ‘Committee is a board which is independent in directing, reviewing and supervising an Islamic Financial Institution. It consists of those who are specialised in Fiqh Mu‛āmalāt or those who know it with expertise in other fields. In conjunction with IFIs emergence, the Accounting and Auditing Organization for Islamic Financial Institutions was established and has issued numerous standards on accounting, auditing and also governance for IFIs. The researchers intend to review the duties and decision-making guidelines of the Sharī‘ah (...) Committee prescribed by the AAOIFI in 2010. The review undergoes a thorough search and critical analysis of any related content about the topic throughout the whole standard. Some important results are: AAOIFI mentions directly the duties of the Sharī‘ah Committee along with the definition of this Sharī‘ah Committee. These duties are directing, reviewing and supervising. On the other hand, decision-making guidelines are indicated indirectly and they are scattered throughout the AAOIFI governance standards. (shrink)

Combined oral contraceptives have been demonstrated to have significant benefits for the treatment and prevention of disease. These medications also are associated with untoward health effects, and they may be directly contraceptive. Prescribers and users must compare and weigh the intended beneficial health effects against foreseeable but unintended possible adverse effects in their decisions to prescribe and use. Additionally, those who intend to abide by Catholic teachings must consider prohibitions against contraception. Ethical judgments concerning both health benefits and contraception are (...) approached in this essay through an overview of the therapeutic, prophylactic, untoward, and contraceptive effects of COC and discussion of magisterial and traditional Catholic teachings from natural law. Discerning through the principle of double effect, proportionate reason, and evidence gathered from the sciences, medical and moral conclusions are drawn that we believe to be fully compliant with good medicine and Catholic teaching. (shrink)

Background: The American Medical Association, the British Medical Association and the Canadian Medical Association have guidelines that specifically discourage physicians from self-prescribing or prescribing to family members, but only the BMA addresses informal prescription requests between colleagues. Objective: To examine the practices of paediatric providers regarding self-prescribing, curbsiding colleagues, and prescribing and refusing to prescribe to friends and family. Methods: 1086 paediatricians listed from the American Academy of Paediatrics 2007 web-based directory were surveyed. Results: 44% of (...) eligible survey respondents returned usable surveys. Almost half of respondents had prescribed for themselves. An equal number had informally requested a prescription from a colleague. Three-quarters stated they had been asked to prescribe a prescription drug for a first-degree or second-degree relative, and 51% had been asked by their spouse. Eighty-six per cent stated that they had refused to write a prescription on at least one occasion for a friend or family member. The following reasons “strongly influenced” their decision to refuse a prescription request: outside of provider’s expertise ; patient’s need for his or her own physician ; not medically indicated ; need for a physical examination. Conclusion: These data confirm that most physicians have engaged in self-prescribing or curbside requests for prescriptions. It can be argued that curbsiding is more morally problematic than self-prescribing because it implicates a third party, and should be discouraged regardless of whether the requester is a colleague, family member or friend. (shrink)

In this paper I argue that resource allocation in publicly funded medical systems cannot be done using a purely substantive theory of justice, but must also involve procedural justice. I argue further that procedural justice requires institutions and that these must be “local” in a specific sense which I define. The argument rests on the informational constraints on any non-market method for allocating scarce resources among competing claims of need. However, I resist the identification of this normative account of local (...) justice with the actual approach to local decision-making taken within the UK National Health Service. I illustrate my argument with reference to the case of provision of In Vitro Fertilisation within the UK NHS. (shrink)

The objective of this book is to produce a theory of rational decision making for realistically resource-bounded agents. My interest is not in “What should I do if I were an ideal agent?”, but rather, “What should I do given that I am who I am, with all my actual cognitive limitations?” The book has three parts. Part One addresses the question of where the values come from that agents use in rational decision making. The most comon view (...) among philosophers is that they are based on preferences, but I argue that this is computationally impossible. I propose an alternative theory somewhat reminiscent of Bentham, and explore how human beings actually arrive at values and how they use them in decision making. Part Two investigates the knowledge of probability that is required for decision-theoretic reasoning. I argue that subjective probability makes no sense as applied to realistic agents. I sketch a theory of objective probability to put in its place. Then I use that to define a variety of causal probability and argue that this is the kind of probability presupposed by rational decision making. So what is to be defended is a variety of causal decision theory. Part Three explores how these values and probabilities are to be used in decision making. In chapter eight, it is argued first that actions cannot be evaluated in terms of their expected values as ordinarily defined, because that does not take account of the fact that a cognizer may be unable to perform an action, and may even be unable to try to perform it. An alternative notion of “expected utility” is defined to be used in place of expected values. In chapter nine it is argued that individual actions cannot be the proper objects of decision-theoretic evaluation. We must instead choose plans, and select actions indirectly on the grounds that they are prescribed by the plans we adopt. However, our objective cannot be to find plans with maximal expected utilities. Plans cannot be meaningfully compared in that way. (shrink)

BackgroundIn cancer care, do not resuscitate orders are common in the terminal phase of the illness, which implies that the responsible physician in advance decides that in case of a cardiac arrest neither basic nor advanced Coronary Pulmonary Rescue should be performed. Swedish regulations prescribe that DNR decisions should be made by the responsible physician, preferably in co-operation with members of the team. If possible, the patient should consent, and significant others should be informed of the decision. Previous studies (...) have shown that physicians and nurses can experience ethical dilemmas in relation to DNR decisions, but knowledge about what ethical reasoning they perform is lacking. Therefore, the aim was to describe and explore what ethical reasoning physicians and nurses apply in relation to DNR-decisions in oncology and hematology care.MethodsA qualitative, descriptive and explorative design was used, based on 287 free-text comments in a study-specific questionnaire, answered by 216 physicians and nurses working in 16 oncology and hematology wards in Sweden. Comments were given by 89 participants.ResultsThe participants applied a situation-based ethical reasoning in relation to DNR-decisions. The reasons given for this were both deontological and utilitarian in kind. Also, expressions of care ethics were found in the material. Universal rules or guidelines were seen as problematic. Concerning the importance of the subject, nurses to a higher extent underlined the importance of discussing DNR-situations, while physicians described DNR-decisions as over-investigated and not such a big issue in their daily work.ConclusionThe study revealed that DNR-decisions in oncology and hematology care gave rise to ethical considerations. Important ethical values described by the participants were to avoid doing harm and to secure a peaceful and “natural” death with dignity for their dying patients. A preference for the expression “allow for natural death” instead of the traditional term “do not resuscitate” was found in the material. (shrink)

There have been many attempts during the history of applied ethics that have tried to develop a theory of moral reasoning. The goal of this paper is to explicate one aspect of the debate between various attempts of offering a specific method for resolving moral dilemmas. We contrast two kinds of deliberative methods: deliberative methods whose goal is decision-making and deliberative methods that are aimed at gaining edifying perspectives. The decision-making methods assessed include the traditional moral theories like (...) utilitarianism and Kantianism, as well as second order principles, such as principlism and specified principlism. In light of this assessment, we suggest taking a closer look at two perceptive models, casuistry and particularism. These models are used for dealing with moral dilemmas that provide for edifying perspectives rather than decision-making. These perceptive models, though less scientific and not as good at prescribing an action, are more human in the sense that they enrich our moral sensibilities and enhance our understanding of the meaning of the situation. (shrink)

A constructive proof is given which shows that every nonrecursive r.e. many-one degree is represented by the family of decision problems for partial implicational propositional calculi whose well-formed formulas contain at most two distinct variable symbols.

Background Cancer patients are at risk of developing blood clots in their veins - venous thromboembolism - which often takes the form of a pulmonary embolism or deep vein thrombosis. The risk increases with advanced disease. Evidence based treatment is low molecular weight heparin by daily subcutaneous injection. The aim of this research is to explore the barriers for doctors in the UK when diagnosing and treating advanced cancer patients with VTE. Method Qualitative, in-depth interview study with 45 doctors. Doctors (...) were from three specialties: oncology, palliative medicine and general practice, with a mixture of senior and junior staff. Framework analysis was used. Results Doctors opinions as to whether LMWH treatment was ethically appropriate for patients who were symptomatic from VTE but at end of life existed on a shifting continuum, largely influenced by patient prognosis. A lack of immediate benefit coupled with the discomfort of a daily injection had influenced some doctors not to prescribe LMWH. The point at which LMWH injections should be stopped in patients at the end of life was ambiguous_._ Some perceived ‘overcaution’ in their own and other clinicians’ treatment of patients_._ Viewpoints were divergent on whether dying of a PE was considered a “good way to go”. The interventionalism and ethos of palliative medicine was discussed. Conclusions Decisions are difficult for doctors to make regarding LMWH treatment for advanced cancer patients with VTE. Treatment for this patient group is bounded to the doctors own moral and ethical frameworks. (shrink)

Evidence accumulation has been the core component in recent development of perceptual and value-based decision-making theories. Most studies have focused on the evaluation of evidence between alternative options. What remains largely unknown is the process that prepares evidence: how may the decision-maker sample different sources of information sequentially, if they can only sample one source at a time? Here we propose a normative framework in prescribing how different sources of information should be sampled proactively to facilitate the (...) decision process: beliefs for different noisy sources are updated in a Bayesian manner and participants can proactively allocate resource for sampling (i.e. saccades) among different sources to maximize the information gain in such process. We show that our framework can account for human participants’ actual choice and saccade behaviors in a two-alternative value-based decision-making task. Moreover, our framework makes novel predictions about the empirical eye movement patterns. (shrink)

Higher education institutions have access to higher volumes and a greater variety and granularity of student data, often in real-time, than ever before. As such, the collection, analysis and use of student data are increasingly crucial in operational and strategic planning, and in delivering appropriate and effective learning experiences to students. Student data – not only in what data is collected, but also how the data is framed and used – has material and discursive effects, both permanent and fleeting. We (...) have to critically engage claims that artificial intelligence and the ever expansive/expanding systems of algorithmic decision-making provide speedy, accessible, revealing, panoramic, prophetic and smart analyses of students' risks, potential and learning needs. We need to pry open the black boxes higher education institutions use to admit, steer, predict and prescribe students’ learning journeys. (shrink)

The present study aimed at investigating the heavy metals concentrations in the soils around “Larga de Sus” abandoned mine (Zlatna, Romania), evaluating the potential ecological risk of heavy metal pollution and highlighting ethical aspects related to risk assessment, ecological restoration, and soil remediation. The results of the chemical analysis showed that the soil in the study area is highly polluted with heavy metals since the average concentrations of Pb (32.4–2318.1 mg/kg), and Ni (321.6–562.8 mg/kg) in soil exceed their corresponding threshold (...) established by the Romanian legislation. The potential ecological risk index method developed by Hakanson was used to assess the potential risk of heavy-metal pollution. The results indicated that Pb and Ni showed severe and considerable potential ecological risk, while Cr had lightly ecological risk. In this case, remediation should be focused only on Pb or on all heavy metals even if they have lightly ecological risk? A scientific management technique cannot logically prescribe which choices should be selected. The interaction between human activity and the environment is complicated and difficult to quantify and risk management cannot and should not be based simply on risk assessment results. What is needed to make the right choice of the most appropriate alternative that fits our personality, culture, religion, and desires? The moral and ethical implications of ecological restoration and soil remediation (e.g. tolerance of uncertainty, responsibility, moral duty, etc.) have to be incorporated within the decision-making process in order to make optimum sustainable decisions and to achieve real environmental protection. (shrink)

Since USA constitutional precedent established in 1976, adolescents have increasingly been afforded the right to access contraception without first obtaining parental consent or authorisation. There is general agreement this ethically permissible. However, long-acting reversible contraception methods have only recently been prescribed to the adolescent population. They are currently the most effective forms of contraception available and have high compliance and satisfaction rates. Yet unlike other contraceptives, LARCs are associated with special procedural risks because they must be inserted and removed by (...) trained healthcare providers. It is unclear whether the unique invasive nature of LARC changes the traditional ethical calculus of permitting adolescent decision-making in the realm of contraception. To answer this question, we review the risk–benefit profile of adolescent LARC use. Traditional justifications for permitting adolescent contraception decision-making authority are then considered in the context of LARCs. Finally, analogous reasoning is used to evaluate potential differences between permitting adolescents to consent for LARC procedures versus for emergency and pregnancy termination procedures. Ultimately, we argue that the invasive nature of LARCs does not override adolescents’ unique and compelling need for safe and effective forms of contraception. In fact, LARCs may oftentimes be in the best interest of adolescent patients who wish to prevent unintended pregnancy. We advocate for the specific enumeration of adolescents’ ability to consent to both LARC insertion and removal procedures within state policies. Given the provider-dependent nature of LARCs and the stigma regarding adolescent sexuality, special political and procedural safeguards to protect adolescent autonomy are warranted. (shrink)

In this paper, we investigate some implications of recent results about salience on loan decisions. Using the framework of focus-weighted utility we show that consumers might take out loans even when that yield them negative utility due to the focusing bias. We suggest, however, that this can be counterbalanced and consumers might be more prudent in their decisions and less likely to take out such loans when the usual fixed-installments plan is coupled with an equivalent decreasing-installments option. Moreover, we show (...) that this is true even for loans with prepayment options or when borrowers take default into consideration. We argue that harmful loan consumption could be decreased if a policy would prescribe presentation of loan repayment schedules in a way that employs this effect. (shrink)

The body of this book contains four original papers, comments, and author's replies, from a conference on the Logic of Decision and Action held at the University of Pittsburgh in March 1966. The principal authors are Herbert Simon, N. Rescher, Donald Davidson, and G. H. von Wright. Commentators are R. Ackermann, A. R. Anderson, N. D. Belnap, R. Binkley, H. N. Castañeda, R. Chisholm, J. Robison, and the late E. J. Lemmon. As appendices, there are articles by A. R. (...) Anderson "The Formal Analysis of Normative Systems," and Rescher's very brief scheme for the classifications of "actions" according to five key generic elements. Problems of decision and action are important for all philosophical critique of norms; in ethics, philosophy of science, of the social sciences, and so forth. The task of a comprehensive logic of action is to describe or prescribe the rules that govern reasoning about the occasions for action, the discovery of action alternatives, and the choice of action. In "The Logic of Heuristic Decision Making," Herbert Simon continues to support the view presented in his earlier work, that "ordinary mathematical reasoning, hence the ordinary logic of declarative statements, is all that is required," as relevant imperatives can be brought into normative systems via correspondence rules for conversion of existential statements. In "Semantic Foundations for the Logic of Preference," Rescher starts from the familiar semantical notion of a "possible world," offering the valuation-measure for such worlds as a determinant of preferabilities, and hoping to show that divergent approaches to problems of preference may be reconciled in this way. Davidson's article, "The Logical Form of Action Sentences" analyzes concepts of agency and intentionality. G. H. von Wright sees a logic of change to be necessary in order to formulate a logic of action. His essay elaborates some of the ideas in his book Norms and Action, but also gives essential modifications of his earlier views.--M. B. M. (shrink)

Background: Cancer patients are at risk of developing blood clots in their veins - venous thromboembolism(VTE) - which often takes the form of a pulmonary embolism or deep vein thrombosis. Therisk increases with advanced disease. Evidence based treatment is low molecular weightheparin (LMWH) by daily subcutaneous injection. The aim of this research is to explore thebarriers for doctors in the UK when diagnosing and treating advanced cancer patients withVTE.MethodQualitative, in-depth interview study with 45 doctors (30 across Yorkshire, England and 15across (...) South Wales). Doctors were from three specialties: oncology, palliative medicine andgeneral practice, with a mixture of senior and junior staff. Framework analysis was used. Results: Doctors opinions as to whether LMWH treatment was ethically appropriate for patients whowere symptomatic from VTE but at end of life existed on a shifting continuum, largelyinfluenced by patient prognosis. A lack of immediate benefit coupled with the discomfort of adaily injection had influenced some doctors not to prescribe LMWH. The point at whichLMWH injections should be stopped in patients at the end of life was ambiguous. Someperceived overcaution in their own and other clinicians treatment of patients. Viewpointswere divergent on whether dying of a PE was considered a "good way to go". Theinterventionalism and ethos of palliative medicine was discussed. Conclusions: Decisions are difficult for doctors to make regarding LMWH treatment for advanced cancerpatients with VTE. Treatment for this patient group is bounded to the doctors own moral andethical frameworks. (shrink)

The present study aimed at investigating the heavy metals concentrations in the soils around “Larga de Sus” abandoned mine, evaluating the potential ecological risk of heavy metal pollution and highlighting ethical aspects related to risk assessment, ecological restoration, and soil remediation. The results of the chemical analysis showed that the soil in the study area is highly polluted with heavy metals since the average concentrations of Pb, and Ni in soil exceed their corresponding threshold established by the Romanian legislation. The (...) potential ecological risk index method developed by Hakanson was used to assess the potential risk of heavy-metal pollution. The results indicated that Pb and Ni showed severe and considerable potential ecological risk, while Cr had lightly ecological risk. In this case, remediation should be focused only on Pb or on all heavy metals even if they have lightly ecological risk? A scientific management technique cannot logically prescribe which choices should be selected. The interaction between human activity and the environment is complicated and difficult to quantify and risk management cannot and should not be based simply on risk assessment results. What is needed to make the right choice of the most appropriate alternative that fits our personality, culture, religion, and desires? The moral and ethical implications of ecological restoration and soil remediation have to be incorporated within the decision-making process in order to make optimum sustainable decisions and to achieve real environmental protection. (shrink)

"ACT Administrative Appeals Tribunal Decisions." Ethos: Official Publication of the Law Society of the Australian Capital Territory, (200), pp. 42.

Clear guidelines addressing the ethically appropriate use of anti-infectives in the setting of hospice care do not exist. There is lack of understanding about key treatment decisions related to infection treatment for patients who are eligible for hospice care. Ethical concerns about anti-infective use at the end of life include: (1) delaying transition to hospice, (2) prolonging a dying process, (3) prescribing regimens incongruent with a short life expectancy and goals of care, (4) increasing the reservoir of potential resistant (...) pathogens, (5) placing unreasonable costs on a capitated hospice system. Although anti-infectives are thought to be relatively safe, they can place a burden on patients and be inconsistent to particular care plans. The current complex, and at times fragmented, medical care often fails to address these issues in decision-making. In many ways, the ethics governing the end of life decisions related to dialysis, hydration/nutrition, and hypercalcemia parallel those of anti-infectives. In this article we articulate important elements in ethical decision-making in the application of anti-infectives for patients who are eligible for hospice care, and we point to the need for prospective studies to help refine particular guidelines in these cases. (shrink)

ABSTRACT Clear guidelines addressing the ethically appropriate use of anti‐infectives in the setting of hospice care do not exist. There is lack of understanding about key treatment decisions related to infection treatment for patients who are eligible for hospice care. Ethical concerns about anti‐infective use at the end of life include: (1) delaying transition to hospice, (2) prolonging a dying process, (3) prescribing regimens incongruent with a short life expectancy and goals of care, (4) increasing the reservoir of potential (...) resistant pathogens, (5) placing unreasonable costs on a capitated hospice system. Although anti‐infectives are thought to be relatively safe, they can place a burden on patients and be inconsistent to particular care plans. The current complex, and at times fragmented, medical care often fails to address these issues in decision‐making. In many ways, the ethics governing the end of life decisions related to dialysis, hydration/nutrition, and hypercalcemia parallel those of anti‐infectives. In this article we articulate important elements in ethical decision‐making in the application of anti‐infectives for patients who are eligible for hospice care, and we point to the need for prospective studies to help refine particular guidelines in these cases. (shrink)

The general public and environmental policy makers often perceive management actions of environmental managers as “science,” when such actions are, in fact, value judgments about when to intervene in natural processes. The choice of action requires ethical as well as scientific analysis because managers must choose a normative outcome to direct their intervention. I examine a management case study involving prescribed burning of sagebrush (Artemisia tridentata) communities in south-central Montana (USA) to illustrate how to teach students to ethically evaluate a (...) management action by precisely identifying: 1) the proposed management action, 2) the deficiency of the system to be remedied by the action, 3) the stakeholders affected by the action, and 4) the category and type of values affirmed in the management action. Through such analysis, students are taught to recognize implicit and explicit value judgments associated with management actions, identify stakeholders to whom managers have legitimate ethical obligations, and practice a general method of ethical analysis applicable to many forms of environmental management. (shrink)

Spanish legislation on insurance and reinsurance mediation stipulates that intermediary can only receive commissions and fees for the management of their policies and prohibits any other form of remuneration. However, it is possible that financial intermediaries who manage larger risks wait until the end of the legal deadline to settle with insurance companies. This common practice in the insurance market hides additional remuneration in defiance of the law. It also means that the risk is not covered within the prescribed period (...) and would, involve a commercial payment to the client, and, on the other hand, affect sustainable claims management. (shrink)

The general public and environmental policy makers often perceive management actions of environmental managers as science, when such actions are, in fact, value judgments about when to intervene in natural processes. The choice of action requires ethical as well as scientific analysis because managers must choose a normative outcome to direct their intervention. I examine a management case study involving prescribed burning of sagebrush (Artemisia tridentata) communities in south-central Montana (USA) to illustrate how to teach students to ethically evaluate a (...) management action by precisely identifying: 1) the proposed management action, 2) the deficiency of the system to be remedied by the action, 3) the stakeholders affected by the action, and 4) the category and type of values affirmed in the management action. Through such analysis, students are taught to recognize implicit and explicit value judgments associated with management actions, identify stakeholders to whom managers have legitimate ethical obligations, and practice a general method of ethical analysis applicable to many forms of environmental management. (shrink)

BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians (...) use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education. (shrink)

The Medication Event Monitoring System (MEMS) is a relatively new device designed to overcome some of the disadvantages of traditional adherence-measuring techniques. MEMS has also been found useful in tracking adherence behaviour without the need to visit patients frequently. In this study each patient was given a pre-filled, labelled MEMS bottle and cap. Patients were monitored for 24 weeks. For patients specifically studied, there were periods when drug levels may have been low and some exhibited erratic medication-taking behaviour. It is (...) concluded that MEMS can measure adherence behaviour objectively, and so might be used to improve prescribing decisions, identify drug wastage and improve carer support. Further research is needed before the routine use of electronic medication monitoring can be recommended. (shrink)