This paper explores the ethical and conceptual implications of the findings from an empirical study (reported elsewhere) of decision-making capacity in anorexia nervosa. In the study, ten female patients aged thirteen to twenty-one years with a diagnosis of anorexia nervosa, and eight sets of parents, took part in semistructured interviews. The purpose of the interviews was to identify aspects of thinking that might be relevant to the issue of competence to refuse treatment. All the patient-participants were also tested using the (...) MacArthur Competence Assessment Tool—Treatment test of competence. This is a formalized, structured, interviewer-administered test of competence, which is a widely accepted clinical tool for determining capacity. The young women also completed five brief, self-administered questionnaires to assess their levels of psychopathology. The issues identified from the interviews are described under two headings: difficulties with thought processing and changes in values. The results suggest that competence to refuse treatment may be compromised in people with anorexia nervosa in ways that are not captured by traditional legal approaches. (shrink)

It feels like there’s two of you inside—like there’s another half of you, which is my anorexia, and then there’s the real K [own name], the real me, the logic part of me, and it’s a constant battle between the two. The anorexia almost does become part of you, and so in order to get it out of you I think you do have to kind of hurt you in the process. I think it’s almost inevitable. We came to the (...) concept of authenticity belatedly, one might say. We had been talking to people who had a diagnosis of anorexia nervosa about their experiences of living with their condition, and though we had not raised issues of authenticity or identity ourselves, they often did. They struggled with questions of .. (shrink)

Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we argue that conceptualizing anorexia (...) nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals. (shrink)

Enhancing body awareness has been described as a key element or a mechanism of action for therapeutic approaches often categorized as mind-body approaches, such as yoga, TaiChi, Body-Oriented Psychotherapy, Body Awareness Therapy, mindfulness based therapies/meditation, Feldenkrais, Alexander Method, Breath Therapy and others with reported benefits for a variety of health conditions. To better understand the conceptualization of body awareness in mind-body therapies, leading practitioners and teaching faculty of these approaches were invited as well as their patients to participate in focus (...) groups. The qualitative analysis of these focus groups with representative practitioners of body awareness practices, and the perspectives of their patients, elucidated the common ground of their understanding of body awareness. For them body awareness is an inseparable aspect of embodied self awareness realized in action and interaction with the environment and world. It is the awareness of embodiment as an innate tendency of our organism for emergent self-organization and wholeness. The process that patients undergo in these therapies was seen as a progression towards greater unity between body and self, very similar to the conceptualization of embodiment as dialectic of body and self described by some philosophers as being experienced in distinct developmental levels. (shrink)

Picking up the question of what FLaK might be, this editorial considers the relationship between openness and closure in feminist legal studies. How do we draw on feminist struggles for openness in common resources, from security to knowledge, as we inhabit a compromised space in commercial publishing? We think about this first in relation to the content of this issue: on image-based abuse continuums, asylum struggles, trials of protestors, customary justice, and not-so-timely reparations. Our thoughts take us through the different (...) ways that openness and closure work in struggles against violence, cruel welcomes, and re-arrangements of code and custom. Secondly, we share some reflections on methodological openness and closure as the roundtable conversation on asylum, and the interview with Riles, remind us of #FLaK2016 and its method of scattering sources as we think about how best to mix knowledges. Thirdly, prompted by the FLaK kitchen table conversations on openness, publishing and ‘getting the word out’, we respond to Kember’s call to ‘open up open access’. We explain the different current arrangements for opening up FLS content and how green open access, the sharedit initiative, author request and publisher discretion present alternatives to gold open access. Finally drawing on Franklin and Spade, we show how there are a range of ‘wench tactics’—adapting gifts, stalling and resting—which we deploy as academic editors who are trying to have an impact on the access, use and circulation of our journal, even though we do not own the journal we edit. These wench tactics are alternatives to the more obvious or reported tactic of resignation, or withdrawing academic labour from editing and reviewing altogether. They help us think about brewing editorial time, what ambivalence over our 25th birthday might mean, and how to inhabit painful places. In this, we respond in our own impure, compromised way to da Silva’s call not to forget the native and slave as we do FLaK, and repurpose shrapnel, in our common commitments. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Decision-Making as a Broader ConceptJacinta O. A. Tan (bio), Anne Stewart (bio), and Tony Hope (bio)KeywordsCompetence, decision-making, capacity, anorexia nervosa, autonomy, values, identityWe thank Demian Whiting for the thoughtful critique of aspects of our paper (Tan et al. 2006a). A primary aim of our research was to provide empirical grounds on which to stimulate discussion about the nature of decision-making capacity (DMC). Whiting criticizes in particular the concept of (...) 'pathological values' that we suggested might be relevant in the assessment of DMC and in the related issue of deciding when a patient's refusal of beneficial treatment should be overridden.Whiting's central concern is with DMC. Whiting argues that the absence of pathological values should not be a criterion for DMC. We are unclear whether he is also arguing that pathological values do not provide a reason of any kind for overriding treatment refusal. At the end of the paper he writes: "we cannot justify compulsory treatment of patients who have pathological values... on the grounds that these patients lack DMC" (2009, XX). This seems to leave open the possibility that we may be able to justify compulsory treatment of patients who have pathological values on grounds other than that they lack DMC. As we wrote in our response to the discussants of our original paper, "The primary issue for us is whether the reasons for refusal to which we draw attention provide grounds for overriding refusal, and if they do how they can be characterized in such a way as to avoid the ever-present danger of simply overriding autonomy in a patient's best interests" (Tan et al. 2006b, 300).In deciding on whether to use compulsory treatment, there are other relevant factors that may need to be considered, such as the seriousness of the decision, which determines the threshold for competence. However, in this response we consider three issues. First, we argue that the current concept of DMC is by no means so clear cut or generally agreed upon as Whiting implies, and that some of the lack of clarity relates to pathological values. Second, that the concept of DMC is itself dependent on accounts of autonomy, and that it is plausible that pathological values can affect autonomy. Third, we directly consider the question of whether a coherent account of pathological values might be given based on a concept of authenticity.The Current Criteria for DMCWhiting argues that the current criteria for DMC are correct and that an additional criterion along the lines of absence of pathological values should not be added. This argument assumes that there is a clear and agreed understanding of the current criteria. We believe this is not the case for three reasons.(i) Whiting begins his account of DMC by saying that it is normally taken to include: "(1) [End Page 345] understanding (and appreciation)" (2009, 341). Already there is an area of dispute, and the use of parentheses reflects this. The concept of 'appreciation' was developed by Grisso and Applebaum (Grisso, Appelbaum, and Hill-Fotouhi 1997). It is not included in either English common law development, for example (ReC), nor in the criteria specified in the Mental Capacity Act 2005. More important, Grisso and Appelbaum in their comment on our original paper (2006) argue that our work advances thinking about 'appreciation' rather than requiring that we add new elements. The implication is that they believe that what we have called pathological values are relevant to the assessment of capacity and are already included in an account of capacity that incorporates the criterion of 'appreciation.' In our response, we argued that pathological values are not entirely captured within the account of appreciation that Grisso and Appelbaum had previously given. We do not want to revisit that issue here, but the point of relevance is that on one view (that of Grisso and Appelbaum) pathological values are already included in the current criteria for DMC as part of the concept of appreciation, whereas on Whiting's view they are not.(ii) Even if there were agreement over the wording and concepts relevant to DMC there is a further important issue: how are those concepts... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Studying Penguins to Understand BirdsJacinta O. A. Tan (bio), Anne Stewart (bio), Ray Fitzpatrick (bio), and Tony Hope (bio)Keywordsanorexia nervosa, treatment decision-making, competence, valuesWe are grateful to Grisso, Appelbaum, Charland, and Vollmann for their thoughtful commentaries on our paper. We would like to respond by picking up on some of the points they make, although we do not address all the issues raised.Our general aims in the paper are (...) less immediately pragmatic than are the central concerns of Grisso and Appelbaum. Our interest is primarily in a number of ethical, and related conceptual, issues that arise from empirical data. In the long run, of course, we believe that these ethical and conceptual issues are important to the care of people with mental disorders, but our focus is philosophical.Our central interest is what justifies overriding treatment refusal. We are unhappy with a "status" approach according to which, for example, the mere fact that a person suffers a mental disorder provides grounds for overriding her wishes. Such an approach, it seems to us, fails to identify reasons, and discriminates against those with mental disorder, a view shared by the Law Commission (The Law Commission 1995). We are, on the other hand, attracted by the approach that grounds any overriding of treatment refusal on lack of capacity (or competence) to make treatment decisions. The concept of capacity has been well developed through legal cases and conceptual analysis, not least by Grisso and Appelbaum themselves. We were struck, however, first through clinical experience, and subsequently from the pilot study reported in our paper, that many patients with anorexia nervosa who refuse treatment do not necessarily lack capacity, using the current criteria, and yet show features or give reasons that raise serious doubts as to whether it is right to respect their refusal of treatment.To avoid reliance on a "status" approach, the issue with which we are grappling is whether the concept of capacity (and therefore lack of capacity) can be developed to encompass some of our findings, and whether it is ethically right to do so. Charland makes the important point that the concept of competence, or capacity, has both a descriptive and a prescriptive component. It is for this reason that the question of whether, for example, we should extend the criteria for capacity is part of the question of when it is morally right to override treatment refusal.Grisso and Appelbaum suggest that our work advances "our thinking about appreciation, rather than requiring that we add new elements" (2006, 297). From our perspective, and at this stage, it is a secondary issue whether we are suggesting a development of appreciation, or a new element (e.g., "pathological values"). The primary issue for us is whether the reasons for refusal to which we draw attention provide grounds for overriding refusal, and if they do how they can be characterized in [End Page 299] such a way as to avoid the ever-present danger of simply overriding autonomy in a patient's best interests.We chose to study anorexia nervosa for various reasons, but we expect that the issues raised have a more general relevance (such as to substance abuse and impulse control disorders as Grisso and Appelbaum and Charland suggest). We do not expect the results to be relevant to all, or even most, mental disorders. Our main interest is not the specific management of people with anorexia, but how the data challenge, and help to develop, the concept of capacity, and the ethical analysis of overriding patient refusal of treatment. Our paper aims to address what we understand Charland to be referring to by the "pretheoretical desiderata" (2006, 283) of the concept of capacity. One reason why we chose anorexia as the focus of this work is because it is different from many mental disorders in the issues that it raises. In this it is, perhaps, rather like studying penguins to better understand the concept of bird just because penguins, although clearly birds, have unusual features.We agree, therefore, with Grisso and Appelbaum's caution that it would be unwise to jump in and change the MacCAT-T on the basis of the results... (shrink)

The term “social world” is increasingly familiar in philosophy and political theory. Rawls uses it quite often, especially in his later works. But there has been little explicit discussion of the term and the idea of social worlds. My aim in this paper is to show that political philosophers, Rawlsian or not, should think seriously about social worlds and the roles these things play and ought to play in their work. The idea of social worlds can help political philosophers think (...) about what they do in new and fruitful ways and enrich debates about the roles, aims, and methodology of political philosophy. I begin by analyzing Rawls’s uses of “social world.” I then propose a broadly Rawlsian conception of social worlds as logically possible closed networks of social relations between agents. Next, I put this conception to work, arguing that the idea of navigating the landscape of social worlds can help us better understand the four apparently disparate roles of political philosophy that Rawls presents. Moving beyond Rawls interpretation, I use the idea of social worlds to develop an analogy and distinction between world-oriented and principle-oriented approaches to political philosophy. While principle-oriented approaches grant centrality and importance to engagement with principles of justice, legitimacy, or other political concepts, world-oriented approaches grant centrality and importance to engagement with social worlds. I propose two examples of world-oriented approaches, political philosophy as navigation and political philosophy as world-building, and argue that they are viable and worthy of further consideration. (shrink)

The statesman, scientist, and philosopher Francis Bacon (1561-1626) lived a divided life. Was he a noble scholar, or a conniving political crook? Was he a homosexual? Lisa Jardine and Alan Stewart draw upon previously untapped sources to create a controversial nuanced portrait of the quintessential "Renaissance man", one whose achievements, while enormous, were nonetheless sadly circumscribed by his class and station.

ABSTRACTThe recognition of emotional facial expressions is often subject to contextual influence, particularly when the face and the context convey similar emotions. We investigated whether spontaneous, incidental affective theory of mind inferences made while reading vignettes describing social situations would produce context effects on the identification of same-valenced emotions as well as differently-valenced emotions conveyed by subsequently presented faces. Crucially, we found an effect of context on reaction times in both experiments while, in line with previous work, we found evidence (...) for a context effect on accuracy only in Experiment 1. This demonstrates that affective theory of mind inferences made at the pragmatic level of a text can automatically, contextually influence the perceptual processing of emotional facial expressions in a separate task even when those emotions are of a distinctive valence. Thus, our novel findings suggest that language acts as a contex... (shrink)

The growth of non-ideal theory and of political realism has had a profound influence on methodological inquiry in political philosophy. It is now the norm for authors defending ideal theory to take special care to show that it can relate to the real world in the right sort of way. Two recent books—David Estlund’s Utopophobia: On the Limits (If Any) of Political Philosophy ( 2020 ), and Ben Laurence’s Agents of Change: Political Philosophy in Practice ( 2021 )—fit this mold. (...) Both authors argue that ideal theory can be practical, and Estlund additionally argues that it can be valuable even if it lacks practical value. In this commentary, I argue that something important is missing from these defenses of ideal theory: they both fail to be realistic in a “second-order” way. I suggest that other recent work comes closer to meeting this standard. (shrink)

Adolescence methamphetamine use is an issue of considerable concern due to its correlation with later delinquency, divorce, unemployment and health problems. Understanding how adolescents initiate methamphetamine abuse is important in developing effective prevention programs. We formulate a mathematical model for the spread of methamphetamine abuse using nonlinear ordinary differential equations. It is assumed that susceptibles are recruited into methamphetamine use through imitation. An epidemic threshold value, Ra\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\mathcal {R}}_a$$\end{document}, termed the abuse reproduction (...) number, is proposed and defined herein in the drug-using context. The model is shown to exhibit the phenomenon of backward bifurcation. This means that methamphetamine problems may persist in the population even if Ra\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\mathcal {R}}_a$$\end{document} is less than one. Sensitivity analysis of Ra\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\mathcal {R}}_a$$\end{document} was performed to determine the relative importance of different parameters in methamphetamine abuse initiation. The model is then fitted to data on methamphetamine users less than 20 years old reporting methamphetamine as their primary substance of abuse in the treatment centres of Cape Town and parameter values that give the best fit are chosen. Results show that the proportion of methamphetamine users less than 20 years old reporting methamphetamine as their primary substance of abuse will continue to decrease in Cape Town of South Africa. The results suggest that intervention programs targeted at reducing adolescence methamphetamine abuse, are positively impacting methamphetamine abuse. (shrink)

Postmodern claims for the lack of general coherence in social life and therefore in social research are merely a version of recurrent attempts to accept incoherence as adequate in explanations. Incoherence, however, is less sharply distinguished from the synthetic and generalizing theories that it is held to have replaced than its proponents and critics suppose. Generalizing approaches, in fact, were built around contradictions that contributed to their instability and facilitated postmodern fragmentation. In this paper we demonstrate the central contradictions in (...) social theory, showing their common occurrence in apparently opposed positions. Both postmodernism and what it seeks to replace are features of a conservative and unproductive social science. We trace the contradictory continuities through major modern schools of social theory in order to clear the ground for a progressive social science which accepts contradictions as problems that must be solved creatively in the practice of social research. (shrink)

This paper concerns the special ethical problems in child and adolescent psychiatry which relate to the child as a developing being. Two themes are discussed--the sense of responsibility in the child, and the therapist's responsibility towards the child. As a background to understanding the former, ideas on moral and cognitive development are reviewed. The therapist's responsibility is discussed in relation to different styles of therapy and the ethical issues they raise. The article concludes with a number of suggested ethical principles.

It is now rather over a century since the marble statue of a youth in Naples was recognised as a copy of the Doryphoros of Polykleitos, and the first attempt made to extract from it the mathematical principles of the Polykleitan canon. Periodic warnings uttered on the subject by such scholars as Gardner and Furtwängler failed to deter further speculation, which culminated in Anti's monumental publication of 1921. Understandably enough, this seems effectively to have checked research in the field, with (...) only one or two exceptions, for a number of years. In the past decade or so, however, the pendulum, apparently never stable for long, has swung back again: a spate of books and articles on Polykleitos and his school has appeared, including no fewer than four major attempts to recover the principles of the canon from the surviving copies of his works. Again, murmurings to the contrary have passed unheeded, the gulf between believers and unbelievers now, it seems, having become virtually unbridgeable. With this in mind, and considering that Polykleitan studies have undergone a quiet revolution in the last year or two through the identification of fragments of casts of the Doryphoros and an Amazon among those recently discovered at Baiae, it seems an opportune moment to try to restate a few principles, basic but all too often ignored, and to indicate a number of directions that further research might take. (shrink)

We are grateful for these two insightful commentaries, which both see novelty and value in the manner in which we invoke the hypothesis that anorexia nervosa is a passion, to help explain data from the Anorexia Experiences Study, which provides the basis of our inquiry. In this response, we wish to clarify and elaborate on our hypothesis; in particular, the difference between passions and moods, the manner in which our hypothesis touches on issues of authenticity and identity, and the compelling (...) parallel with addiction. We also wish to emphasize that, in proposing the hypothesis that anorexia nervosa is a passion, our primary aim is not so much to exclude or replace alternative theoretical approaches. Our focus, really, is to argue that the hypothesis that anorexia nervosa is a passion adds something rich and unique to our current understanding of that condition, which is not fully or adequately captured by alternative accounts... (shrink)

Alan Stewart - Francis Bacon and the Transformation of Early-Modern Philosophy - Journal of the History of Philosophy 40:4 Journal of the History of Philosophy 40.4 542-543 Book Review Francis Bacon and the Transformation of Early-Modern Philosophy Stephen Gaukroger. Francis Bacon and the Transformation of Early-Modern Philosophy. New York: Cambridge University Press, 2001. Pp. xii + 249. Cloth, $59.95. Paper, $21.95. In Stephen Gaukroger's new study, Francis Bacon is lauded all too familiarly as the inaugurator of "the transformation of philosophy (...) into science, and philosophers into scientists" . But it's far from the old story: Gaukroger sees Bacon not as progenitor of the Scientific Revolution or revered Father of Modern Science, but as launching "the first systematic, comprehensive attempt to transform the early-modern.. (shrink)

Insulin is stored within the pancreas in an inactive Zn2+‐bound hexameric form prior to release. Similarly, clinical insulins contain Zn2+ and form multimeric complexes. Upon release from the pancreas or upon injection, insulin only becomes active once Zn2+ disengages from the complex. In plasma and other extracellular fluids, the majority of Zn2+ is bound to human serum albumin (HSA), which plays a vital role in controlling insulin pharmacodynamics by enabling removal of Zn2+. The Zn2+‐binding properties of HSA are attenuated by (...) non‐esterified fatty acids (NEFAs) also transported by HSA. Elevated NEFA concentrations are associated with obesity and type 2 diabetes. Here we present the hypothesis that higher NEFA levels in obese and/or diabetic individuals may contribute to insulin resistance and affect therapeutic insulin dose‐response profiles, through modulation of HSA/Zn2+ dynamics. We envisage this novel concept to have important implications for personalized treatments and management of diabetes‐related conditions in the future. (shrink)

This volume captures the individuality, the national and personal identity, the cultural exchange, and the self-consciousness that have long been sensed as peculiarly potent in the Hellenistic world. The fields of history, literature, art, philosophy, and religion are each presented using the format of two essays followed by a response. Conveying the direction and focus of Hellenistic learning, eighteen leading scholars discuss issues of liberty versus domination, appropriation versus accommodation, the increasing diversity of citizen roles and the dress and gesture (...) appropriate to them, and the accompanying religious and philosophical ferment. The result is an arresting view of the incredible and unprecedented diversity of the Hellenistic world. (shrink)

Tomasello's account of the origins and nature of moral obligation rightly emphasises the key roles of social relations and a cooperative sense of “we.” However, we suggest that it overlooks the complexity of those social relations and the resulting prevalence of a divided “we” in moral social groups. We argue that the social identity dynamics that arise can lead to competing obligations in a single group, and this has implications for the evolution of obligation.

Conditional information can be equally asserted in the forms if p, then q (e.g., ?if I am ill, I will miss work tomorrow?) and q, if p (e.g., ?I will miss work tomorrow, if I am ill?). While this type of clause order manipulation has previously been found to have no influence on the ultimate conclusions participants draw from conditional rules, we used self-paced reading to examine how it affects the real time incremental processing of everyday conditional statements. Experiment 1 (...) revealed that clause order interacts with presuppositional congruency as readers hypothetically represent counterfactual statements. When if p, then q counterfactuals contained a presupposition that was incongruent with prior context, these statements took longer to read than when the presupposition was congruent, but for q, if p conditionals there was no such congruency effect. Experiment 2 revealed that reading times were influenced by the subjective probability of an indicative conditional regardless of clause order, with a penalty observed for low-probability statements relative to high-probability statements in both conditional clause orders. These data reveal a dissociation whereby clause order mediates the effect of suppositional congruency on reading times, but does not mediate the effect of subjective probability. (shrink)

In the past two decades, feminist scholars have produced an abundance of theoretical writing in humanities and social science disciplines. The result is a body of work that is extraordinarily rich, hard to keep up with, and extremely difficult to teach.With the appearance of Theorizing Feminism: Parallel Trends in the Humanities and Social Sciences, the first genuinely interdisciplinary anthology of significant contributions to feminist theory, teachers will finally have a volume that does justice to their topic. Creatively edited, with insightful (...) introductory material, this timely reader illuminates the historical development of feminist theory as well as the current state of the field.Emphasizing common themes and interests in the humanities and social sciences, the editors have chosen those topics that have been central to feminist theory in many disciplines, that remain relevant to current debates, and that reflect the interests of a diverse community of thinkers.The contributors include leading figures from psychology, literary criticism, sociology, philosophy, anthropology, art history, law, and economics. This is the ideal text for any advanced course on interdisciplinary feminist theory, one that fills a long-standing gap in feminist pedagogy. (shrink)

Measures are designed to evaluate the processes and outcomes of care associated with the delivery of clinical (and non-clinical) services. They allow for intra- and interorganizational comparison to be used continuously to improve patient health outcomes. The use of performance measures always means to abstract the complex reality (medical scenarios and procedures) in order to provide an understandable and comparable output. Measures can focus on global performance. The more detailed data are available the more specific judgements with respect to the (...) appropriateness of clinical decision-making and implementation of evidence are feasible. Externally reported measures are intended both to inform and lead to action. By providing this information, deficiencies in patient care and unnecessary variations in the care process can be uncovered. Such variations have contributed to disparities in morbidity and mortality. The developments in information technology, especially world-wide interconnectivity, standards for electronic data exchange and facilities to store and manage large amounts of data, offer the opportunity to analyse health-relevant information in order to make the delivery of healthcare services more transparent for consumers and providers. Global performance measures, such as the overall life expectancy (mortality) in a country, can give a rough orientation of how well health systems perform but they do not offer general solutions nor spe-cific insights into care processes that have to be improved. In contrast to population-based measures, case-based performance measures use a defined group of patients depending on specific patient characteristics and features of disease. By means of these measures we are able to compare the number of patients that receive a necessary medical procedure against those patients who do not. The use of case-based measures is a bottom-up approach to improve the overall performance in the long run. They are not only a tool for global orientation but can offer a straightforward link to the areas of deficient care and the underlying procedures. Performance measures are relevant to providers as well as consumers, from their own individual perspective. Cased-based measures focus on the management of individual patient. This approach to performance measurement can inform physicians in a meaningful and constructive way by monitoring their individual performance and by pointing out possible areas of improvement. (shrink)

The Australian Aborigines' environmental culture and the "double bind" approach used in the program of Alcoholics Anonymous are considered as a source for the generation of a new strategy for dealing with the ecological problems of our day. The strategy aims at achieving a negotiated outcome in issues of high societal risk related to waste management in the Hawkesbury region of Sydney, Australia.