It has often been argued that if a clinician cannot decide which of two treatments to offer, a trial may be ethical, but it is unethical if she/he has a preference. Since individual clinicians usually have a preference, most trials could be judged unethical according to this line of argument. A recent important article in the New England Journal of Medicine argued that individual preferences are not as important as the collective uncertainty of informed clinicians. If clinicians are equally divided, (...) there is a state of collective equipoise and a trial is ethical. However, clinicians will seldom be exactly equally divided. We conducted an ethometric study to find out how much collective equipoise can be disturbed before the potential subjects in a trial think that it is unethical. Half of our subjects perceived a trial as unethical when equipoise was disturbed beyond 70:30. In other words, when 70 per cent of experts favour one treatment, 50 per cent of subjects would prefer that treatment to be administered rather than subjected to critical assessment. When equipoise is disturbed beyond 80:20, less than 3 per cent of subjects would consider human trials morally justifiable. (shrink)

OBJECTIVE: To ascertain attitudes to different methods of obtaining informed consent for randomised clinical trials (RCTs). DESIGN: Structured interviews with members of the public, medical secretaries and medical students. SETTING: The public were approached in a variety of public places. Medical secretaries and students were approached in their place of work. SUBJECTS: Fifty members of the public, 25 secretaries and 25 students. MAIN OUTCOME MEASURES: Views on RCTs were elicited, with particular emphasis on how subjects thought the concept of randomisation (...) should be explained. Each participant was presented with descriptions of proposed clinical trials and asked to select his or her preference from a range of options. RESULTS: Written information was preferred over verbal information in 91% of replies. Most respondents (86%) would prefer to sign a consent form. Of the seven statements explaining randomisation, a significant difference was found in favour of explanations that were less explicit about the play of chance (ANOVA; p = 0.0004). Eighty-three per cent of participants thought that randomised trials were morally acceptable when there was no prior medical preference between treatments. However, over half (55%) thought they would find it upsetting to be offered entry in such a trial and a quarter thought the outcome of treatment might be adversely affected. CONCLUSIONS: Our results offer some support for the idea that "economy with truth" is less unsettling than a frank description of the stark reality of what randomisation means. It is a matter of debate as to whether, if we are correct, autonomy should have precedence over beneficence. The offer of entry in a clinical trial is likely to affect the experience of care for many people, especially if the process of randomisation is described explicitly. Potential participants should be given a detailed written explanation of the rationale for the trial and be asked to sign a consent form if they agree to take part. (shrink)

Objectives To conduct an independent evaluation of the first phase of the Health Foundation’s Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design Mixed method evaluation involving five substudies, before and after design. Setting NHS hospitals in the United Kingdom. Participants Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention The SPI1 (...) was a compound (multi-component) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration—monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items)—there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for “difference in difference” 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from 17% (63) to 13% (49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening. (shrink)

Patient safety has only recently been subjected to wide-spread systematic study. Healthcare differs from other high risk industries in being more diverse and multi-contextual, and less certain and regulated. Also many patient safety problems are low-frequency events associated with many, varied contributing factors. The subject of this paper is the epistemology of patient safety (the science of the method of finding out about patient safety). Patient safety research is considered here on the background of a risk management framework which requires (...) researchers to: • Understand the context - as a subset of healthcare quality, services and systems research, with technical and human behavioural (cultural) components and a range of external and internal organisational influences, a wide range of research disciplines is necessary • Identify the risks - identify the things that go wrong and the frequency and nature of different types of incidents from sources such as medical record review, observational studies, audit, incident and medico-legal reports • Analyse the risks - deconstruct the things that go wrong, identifying contributing factors and trying to detect trends and patterns in contributing factors, detection, mitigation factors, ameliorating factors and actions taken to reduce risk • Evaluate the risks - decide on priorities, identifying preventive and corrective strategies and judging the risk- and cost-benefit of potential corrective strategies such as standardisation or simplification of a process or device • Manage the risk - evaluate and scope preventive and/or corrective strategies and then implement these, or place the problem on a risk register pending solution, or accept that what is needed is unaffordable • Communicate and consult - use interactive sessions, audit, on-going feedback, reminders and patient mediated prompts • Monitor and review the state of the problem - get baseline trends and patterns so that changes can be tracked and properly attributed to an intervention A hierarchy of levels of evidence has been proposed for clinical research and we argue that insufficient weighting has been given to lower ranked levels of research and to qualitative research, although critical interpretive synthesis is now gaining acceptance in mainstream thinking (e.g. by the Cochrane Collaboration). Fundamental challenges remain including how to grasp the elusive concept of patient safety, how to quantify, characterise and cost the problems, how to judge the extent to which harm can be attributed to errors, violations or system failures, how to identify contributing factors and the extent to which they can be implicated, how to judge whether incidents or their precursors are preventable, how to generate strong evidence to make healthcare safer and how to translate research into practice. Future directions include addressing the mundane as well as rare, dramatic events, and developing further research in non-hospital settings and in developing countries. In summary, a mixture of qualitative and quantitative methods, using information from all available data sources and combining retrospective, real time and prospective study designs, is necessary to address some of the more difficult patient safety problems. (shrink)

Since the English translation first appeared in 1923, Rudolf Otto's volume has established itself as a classic in the field of religious philosophy. It offers an in-depth inquiry into the non-rational factor in the idea of the divine and its relation to the rational.

In the face of environmental crises such as climate change, pollution and biodiversity loss—which all adversely impact on health—Gils-Schmidt and Salloch explore whether physicians can be justified in taking climate issues into account in clinical care.1 While their approach centres on the ‘climate-sensitive’ decisions, physicians can carry out on the micro-level of clinical decision-making, they encourage further discussions on how climate-related issues can be included across different levels of decision-making in healthcare. We propose a list of tasks and a model (...) to assist with navigating the range of factors and structural elements an environmentally sensitive ethics must address. Stephen Gardiner’s notion of a perfect moral storm is central to understanding these issues.2 Gardiner describes how a perfect moral storm occurs in the centre of three overlapping conditions for human action and policymaking in the face of climate change. This storm is driven by: (1) a lack of interest among current generations to meet global needs and accommodate the well-being of future generations, (2) a lack of ecological concerns for other parts of nature than humans and (3) weak ethical and political theories and institutions shaping policy decisions on issues with severe implications across borders and generations. Moreover, these conditions are embedded in the existing, complex world of ethically unjustified power imbalances and social injustice. The growing awareness of healthcare’s climate footprint has amplified and accelerated global, grassroots action to make healthcare more environmentally friendly. This includes incorporating environmental impacts into quality improvement methodologies, building communities of practice to explore how to make …. (shrink)

Hermann von Helmholtz’s work on perceptual science had a fundamental impact on Neo-Kantian movements in the late nineteenth century, and his influence continues to be felt in psychology and analytic philosophy of perception. As is widely acknowledged, Helmholtz denied that we can perceive mind-independent properties of external objects, a view I label Ignorance. Given his commitment to Ignorance, Helmholtz might seem to be committed to a subjectivism according to which we only perceive properties of our own representations. Against this, I (...) argue that for Helmholtz, the properties we perceive are not monadic properties of either the subject or the object. Rather, Helmholtz endorsed a relationalism about the properties we perceive: the properties of objects we perceive are all relational properties. I then suggest that once we take into account oft-neglected terminological distinctions in Helmholtz’s corpus, we are better able to make sense of his commitment to relationalism. (shrink)

Heidegger’s early project aims to articulate the form of our being as Dasein, and he says that for this usually hidden form to become accessible, a certain kind of “mood” is required of the philosopher. This “ground-mood” he identifies in Sein und Zeit as anxiety. He also, however, presents anxiety as a mood anyone, philosopher or not, experiences when there is some significant breakdown in the living of her life. I argue here that there are largely unrecognized problems with this (...) conflation of methodological and “existential” moods, but that there is nevertheless a compelling methodological account of anxiety that can be teased apart from the existentialist one: methodologically understood, anxiety is a self-affected state of the ontologist, one that results from her asking ontological questions of herself, and, by imagining crisis or breakdown, withdrawing from her determinate situation to a position where she can see the form of her own activity as questioner and imaginer. I draw out some consequences this has for how we should understand the place of ontological understanding in living one’s life, and I conclude by briefly showing how my reading helps us see Heidegger as developing key elements in the work of Descartes and Kant. (shrink)

In this, the first of two ground-breaking volumes on the nature of language in the light of the way it evolved, James Hurford looks at how the world first came to have a meaning in the minds of animals and how in humans this meaning eventually came to be expressed as language. He reviews a mass of evidence to show how close some animals, especially primates and more especially apes, are to the brink of human language. Apes may not talk (...) to us but they construct rich cognitive representations of the world around them, and here, he shows, are the evolutionary seeds of abstract thought - the means of referring to objects, the memory of events, even elements of the propositional thinking philosophers have hitherto reserved for humans. What then, he asks, is the evolutionary path between the non-speaking minds of apes and our own speaking minds? Why don't apes communicate the richness of their thoughts to each other? Why do humans alone have a unique disposition to reveal their thoughts in complex detail? Professor Hurford searches a wide range of evidence for the answers to these central questions, including degrees of trust, the role of hormones, the ability to read minds, and the willingness to cooperate. Expressing himself congenially in consistently colloquial language the author builds up a vivid picture of how mind, language, and meaning evolved over millions of years. His book is a landmark contribution to the understanding of linguistic and thinking processes, and the fullest account yet published of the evolution of language and communication."A wonderful read - lucid, informative, and entertaining, while at the same time never talking down to the reader by sacrificing argumentation for the sake of 'simplicity'. Likely to be heralded as the major publication dealing with language evolution to date. Frederick J. Newmeyer, University of Washington. (shrink)

Further examines the sense in which moral judgements are universalizable. Distinguishes between moral and logical theses of universalizability and shows how the moral does not follow from the logical. Universalizability, in the form maintained in this book, is a logical, not a moral, thesis; furthermore, nothing substantially moral follows from the logical thesis. The chapter presents the exact import of the thesis and considers the role of moral principles.

On the example of the online game Akinator, the basic principles on which programs of this type are built are considered. Effective technics have been proposed by which artificial intelligence systems can build logical inferences that allow to identify an unknown subject from its description. To confirm the considered hypotheses, the terminological analysis of definition of the program "Akinator" offered by the author is carried out. Starting from the assumptions given by the author's definition, the article complements their definitions presented (...) by other researchers and analyzes their constituent theses. Finally, some proposals are made for the next steps in improving the program. The Akinator program, at one time, became one of the most famous online games using artificial intelligence. And although this was not directly stated, it was clear to the experts in the field of artificial intelligence that the program uses the techniques of expert systems and is built on inference rules. At the moment, expert systems have lost their positions in comparison with the direction of neural networks in the field of artificial intelligence, however, in the case considered in the article, we are talking about techniques using both directions – hybrid systems. Games for filling semantics interact with the user, expanding their semantic base and use certain strategies to achieve the best result. The playful form of such semantics filling programs is beneficial for researchers by involving a large number of players. The article examines the techniques used by the Akinator program, and also suggests possible modifications to it in the future. This study, first of all, focuses on how the knowledge base of the Akinator program is built, it consists of incomplete sets, which can be filled and adjusted as a result of further iterations of the program launches. It is important to note our assumption that the order of questions used by the program during the game plays a key role, because it determines its strategy. It was identified that the program is guided by the principles of nonmonotonic logic – the assumptions constructed by the program are not final and can be rejected by it during the game. The three main approaches to acquisite semantics proposed by Jakub Šimko and Mária Bieliková are considered, namely, expert work, crowdsourcing and machine learning. Paying attention to machine learning, the Akinator program using machine learning to build an effective strategy in the game presents a class of hybrid systems that combine the principles of two main areas in artificial intelligence programs – expert systems and neural networks. (shrink)

William Hasker and I have a friendly disagreement over the doctrine of the Trinity. We both reject classical theistic attributes like divine timelessness and divine simplicity. Instead, we affirm that God is temporal and unified. Further, we reject so-called Latin models of the Trinity, and prefer social models of the Trinity. Where we disagree is over the doctrine of the processions of the Trinitarian persons. In this essay, I articulate some problems for the doctrine of the processions.

Discusses an important objection to the view that moral judgements are prescriptive: the existence of cases in which people act in ways that they know to be wrong. The objection is that if moral judgements are prescriptive, it is impossible to accept a moral judgement and yet act contrary to it; therefore prescriptivism must be wrong. It is argued that cases of moral weakness do not constitute a counterexample to prescriptivism.

Leslie Graves, Barbara Horan and Alex Rosenberg (1999) have argued that the process of evolution is really deterministic, so we should be instrumentalists about our probabilistic evolutionary theory. I criticize the consistency of their view. I argue that because they are realists towards multiple theories (quantum mechanics and macrophysics) their arguments against realism for another scientific theory fail. The main point of this paper is critical, but in order to set up this criticism I explore the ramifications of realism for (...) multiple theories. Finally, I offer a brief metaphysical justification for realism about multiple theories. This view justifies realism for evolutionary theory, which has been defended by Robert Brandon and Scott Carson (1996). (shrink)