Purpose: Physicians are often reluctant to discuss “Do Not Resuscitate” orders with patients. Although perceived self-efficacy is a known prerequisite for behavioural change, little is understood about the confidence of physicians regarding DNR discussions.Subjects and methods: A survey of 217 internal medicine attendings and 132 housestaff at two teaching hospitals about their attitudes and confidence regarding DNR discussions.Results: Participants were significantly less confident about their ability to discuss DNR orders than to discuss consent for medical procedures , and this was (...) true for both attendings and housestaff . In a multivariate logistic model of confidence regarding DNR discussions, women were less confident than men ; house officers were less confident than attendings , those who were less confident of their ability to discuss medical procedures were less confident discussing DNR , and those who found talking to patients about DNR orders very difficult reported less confidence than those who did not .Conclusion: We conclude that physicians’ confidence regarding DNR discussions is low compared with their confidence regarding other medical discussions and that confidence varies by sex and perceived difficulty of the task. Efforts to improve DNR discussions should explore the need to tailor educational interventions to fit these characteristics. (shrink)

Many medical ethicists accept the thesis that there is no moral difference between withholding and withdrawing life-sustaining therapy. In this paper, we offer an interesting counterexample which shows that this thesis is not always true. Withholding is distinguished from withdrawing by the simple fact that therapy must have already been initiated in order to speak coherently about withdrawal. Provided that there is a genuine need and that therapy is biomedically effective, the historical fact that therapy has been initiated entails a (...) claim to continue therapy that cannot be attributed to patients who have not yet received therapy. This intrinsic difference between withholding and withdrawing therapy is of moral importance. In many instances, patients will waive this claim. But when one considers withdrawing therapy from one patient to help another in a setting of scarce resources, this intrinsic moral difference comes into sharp focus. In an era of shrinking medical resources, this difference cannot be ignored. (shrink)

OBJECTIVE: To examine the long-term effects of an innovative curriculum on medical house officers' (HOs') knowledge, confidence, and attitudes regarding medical ethics. DESIGN: Long term cohort study. The two-year curriculum, implemented by a single physician ethicist with assistance from other faculty, was fully integrated into the programme. It consisted of monthly sessions: ethics morning report alternating with didactic conferences. The content included topics such as ethics vocabulary and principles, withdrawing life support, informed consent, and justice. Identical content was offered simultaneously (...) at the largest affiliated community hospital. SETTING: A multi-hospital university training programme from July, 1992 to June, 1994. PARTICIPANTS: Thirty-nine HOs responded in 92. Thirty HOs from the same cohort responded in 94 (response rates = 83% v 71%; P = 0.19). RESULTS: The curriculum was well received, with 96% of HOs finding the sessions stimulating. Previously validated scales of knowledge and confidence were administered at baseline and at follow-up. The average knowledge score improved 14% (P < 0.001). Confidence also improved, rising from 3.3 to 3.8 on a 5-point Likert scale (P < 0.001). These findings were independent of age, gender, religion, and prior education. The only attitudinal change was an increase in the proportion of residents who thought that ethics should be a required part of residency training (57% v 80%, P = 0.05). CONCLUSION: This curriculum appears practical, popular, and effective. It should be readily transferable to other institutions. (shrink)

We report the results of a randomized trial to assess the impact of an innovative ethics curriculum on the knowledge and confidence of 85 medical house officers in a university hospital programme, as well as their responses to a simulated clinical case. Twenty-five per cent of the house officers received a lecture series, 25 per cent received lectures and case conferences, with an ethicist in attendance, and 50 per cent served as controls. A post-intervention questionnaire was administered. Knowledge scores did (...) not differ among the groups. Confidence regarding ethical issues was significantly greater in the aggregate intervention group compared to the control group. Confidence regarding procedural issues related to ethics was significantly higher for the EI group than for the controls. Responses to a simulated case showed that significantly fewer house officers in the EI group would intubate a patient for whom such therapy would be futile. We conclude that ethics education can have an impact on house officers' confidence and their responses to a simulated case, and that the EI was more effective than the LI. Such results have implications regarding the implementation of ethics education during residency. (shrink)

OBJECTIVES: To study the accuracy of reviewing ward notes (chart review) as a measure of the quality of care rendered to patients with "Do Not Resuscitate" (DNR) orders. DESIGN: We reviewed the charts of 19 consecutive, competent inpatients with DNR orders for evidence that the staff addressed a broad range of patient care needs called Concurrent Care Concerns (CCCs), such as withholding treatments other than resuscitation itself, and attention to patient comfort needs. We then interviewed the patient, consultant physician, house (...) officer, and primary nurse and compared the ward notes with the understandings of these staff members. SETTING: The medical service of an urban university medical centre. RESULTS: The average number of documented CCCs addressed per DNR order was 1.1. The ward notes generally agreed with the perceptions of patients, house officers, and nurses (% agreement with notes = 79%, 77%, and 82%; kappa = 0.43, 0.40, 0.50). Consultant physicians' understandings were poorly reflected in the ward notes (% agreement = 59%; kappa = 0.18). They overestimated attention to CCCs compared with the notes (P < 0.0001) and with other observers (P < 0.0001). CONCLUSION: Chart review for attention to CCCs accurately reflects the understandings of patients, house officers, and nurses, but consultant physicians report more attention to CCCs than is recorded in the ward notes or understood by other observers. Better communication regarding end-of-life care plans should be encouraged. (shrink)

The National Conference of Catholic Bishops has argued for significant government involvement in health care in order to assure respect for what they regard as the right to health care. Critics charge that the bishops are wrong because health care is not a right. In this article, it is argued that these critics are correct in their claim that health care is not a right. However, it is also argued that the premise that health care is not a right does (...) not imply that the market is the most equitable and just system for providing health care. Natural law arguments in the tradition of Roman Catholic social teaching lead to the conclusion that a just and prosperous society has a moral obligation to provide health care even if there is no such right. Further, there are strong moral grounds for concluding that the bishops are correct in their claim that health care ought not to be considered a market commodity. It is argued that if health care ought not to be considered a commodity, then national health insurance is the best available alternative for fulfilling the social obligation to distribute health care resources justly and fairly at this time in American history. The bishops' case for government involvement can be made on the strength of the Catholic tradition in theological argumentation, independent of the claim that health care is a right. (shrink)

Aim: Patients with advanced cancer need information about end-of-life treatment options in order to make informed decisions. Clinicians vary in the frequency with which they initiate these discussions.Patients and methods: As part of a long-term longitudinal study, patients with an expected 2-year survival of less than 50% who had advanced gastrointestinal or lung cancer or amyotrophic lateral sclerosis were interviewed. Each patient’s medical record was reviewed at enrollment and at 3 months for evidence of the discussion of patient wishes concerning (...) ventilator support, artificial nutrition and hydration , resuscitation and hospice care. A Kaplan–Meier analysis was also performed and 2-year survival calculated.Results: 60 cancer and 32 ALS patients were enrolled. ALS patients were more likely than cancer patients to have evidence of discussion about their wishes for ventilator support , ANH , DNR and hospice care . At 6 months, 91% of ALS patients were alive compared with 62% of cancer patients; at 2 years, 63% of ALS patients were alive compared with 23% of cancer patients .Conclusions: Cancer patients were less likely than ALS patients to have had documented advanced care planning discussions despite worse survival. This may reflect perceptions that ALS has a more predictable course, that advanced cancer has a greater number of treatment options, or differing views about hope. Nevertheless, cancer patients may be less adequately prepared for end-of-life decision-making. (shrink)

Introduction: The use of human samples in genomic research has increased ethical debate about informed consent (IC) requirements and the information that subjects should receive regarding the results of the research. However, there are no quantitative data regarding researchers’ attitudes about these issues. Methods: We present the results of a survey of 104 US and 100 Spanish researchers who had published genomic epidemiology studies in 61 journals during 2006. Results: Researchers preferred a broader IC than the IC they had actually (...) obtained in their published papers. US authors were more likely than their Spanish colleagues to support obtaining a broad IC, covering either any future research project or any projects related to a group of diseases (67.6% vs 43%; adjusted OR = 4.84, 95% CI, 2.32 to 10.12). A slight majority of researchers (55.8%) supported informing participants about individual genomic results only if the reliability and clinical validity of the information had been established. Men were more likely than women to believe that patients should be informed of research results even if these conditions were not met (adjusted OR = 2.89, 95% CI = 1.46 to 5.72). Conclusions: This study provides evidence of a wide range of views among scientists regarding some controversial ethical issues related to genomic research, suggesting the need for more study, debate and education. In the interim, journals might consider including the investigators’ policies regarding these ethical issues in the papers they publish in the field of genomic epidemiology. (shrink)

Unrealistic optimism is a bias that leads people to believe, with respect to a specific event or hazard, that they are more likely to experience positive outcomes and/or less likely to experience negative outcomes than similar others. The phenomenon has been seen in a range of health-related contexts—including when prospective participants are presented with the risks and benefits of participating in a clinical trial. In order to test for the prevalence of unrealistic optimism among participants of early-phase oncology trials, we (...) conducted a survey with patients over 18 years of age who were enrolled in a phase I, phase I/II, or phase II clinical cancer trial in the New York City area between August 2008 and October 2009. Participants in our study were asked to compare their own chances of experiencing a range of risks and benefits related to the trial they were enrolled in with the chances of the other trial participants. We found a significant optimistic bias in their responses. Respondents tended to overestimate the benefits of the trial they were enrolled in and underestimate its risks. In addition, we found no significant relationship between respondents’ understanding of the trial’s purpose and how susceptible they were to unrealistic optimism. Our findings suggest that improving the consent process for oncology studies requires more than addressing deficits in understanding. (shrink)

Purpose Recent research has found unrealistic optimism among patient-subjects in early-phase oncology trials. Our aim was to investigate the cognitive and motivational factors that evoke this bias in this context. We expected perceptions of control to be a strong correlate of unrealistic optimism. Methods A study of patient-subjects enrolled in early-phase oncology trials was conducted at two sites in the USA. Respondents completed questionnaires designed to assess unrealistic optimism and several risk attribute variables that have been found to evoke the (...) bias in other contexts. Results One hundred and seventy-one patient-subjects agreed to be interviewed for our study. Significant levels of perceived controllability were found with respect to all nine research-related questions. Perceptions of control were found to predict unrealistic optimism. Two other risk attribute variables, awareness of indicators and mental image, were correlated with unrealistic optimism. However, in multivariate regression analysis, awareness and mental image dropped out of the model and perceived controllability was the only factor independently associated with unrealistic optimism. Conclusion Patient-subjects reported that they can, at least partially, control the benefits they receive from participating in an early-phase oncology trial. This sense of control may underlie unrealistic optimism about benefiting personally from trial participation. Effective interventions to counteract unrealistic optimism may need to address the psychological factors that give rise to distorted risk/benefit processing. (shrink)

Dear Norm,Thank you for sharing such a personal and heartfelt essay. I have been asked by the editors to comment. Reading it inspires me to do so in a similarly heartfelt way. Although I don't know you well, I thought I'd write to you as if you were my patient.I share your sense that Alzheimer disease is a terrible scourge. I've seen much of this disease over a lifetime of practice, and I deeply understand its ravages and the debility and (...) suffering it causes. But what you propose is not a good solution for the problems that Alzheimer disease poses for patients, families, and society. It will ultimately do far more harm than good. Please let me try to explain. (shrink)

The ethical treatment of cancer patientsparticipating in clinical trials requiresthat patients are well-informed about thepotential benefits and risks associated withparticipation. When patients enrolled in phaseI clinical trials report that their chance ofbenefit is very high, this is often taken as evidence of a failure of the informed consent process. We argue, however, that some simple themes from the philosophy of language may make such a conclusion less certain. First, the patient may receive conflicting statements from multiple speakers about the expected (...) outcome of the trial. Patients may be reporting the message they like best. Second, there is a potential problem of multivocality. Expressions of uncertainty of the frequency type can be confused with expressionsof uncertainty of the belief type. Patients may be informed using frequency-type statements and respond using belief-type statements. Third, each speech episode involving the investigator and the patient regarding outcomes may subservemultiple speech acts, some of which may beindirect. For example, a patient reporting ahigh expected benefit may be reporting a beliefabout the future, reassuring family members,and/or attempting to improve his or her outcome by apublic assertion of optimism. These sources oflinguistic confusion should be considered injudging whether the patient's reported expectation isgrounds for a bioethical concern that there hasbeen a failure in the informed consent process. (shrink)

Traditional epistemic and doxastic logics cannot deal with inconsistent beliefs nor do they represent the evidence an agent possesses. So-called ‘evidence logics’ have been introduced to deal with both of those issues. The semantics of these logics are based on neighbourhood or hypergraph frames. The neighbourhoods of a world represent the basic evidence available to an agent. On one view, beliefs supported by evidence are propositions derived from all maximally consistent collections evidence. An alternative concept of beliefs takes them to (...) be propositions derivable from consistent partitions of one’s inconsistent evidence; this is known as Schotch-Jennings Forcing. This paper develops a modal logic based on the hypergraph semantics to represent Schotch-Jennings Forcing. The modal language includes an operator U(φ1,…,φn;ψ)\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$U(\varphi _1, \ldots, \varphi _n;\psi )$$\end{document} which is similar to one introduced in Instantial Neighbourhood Logic. It is of variable arity and the input formulas enjoy distinct roles. The U operator expresses that all evidence at a particular world that supports ψ\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\psi $$\end{document} can be supported by at least one of the φi\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\varphi _i$$\end{document}s. U can then be used to express that all the evidence available can be unified by the finite set of formulas φ1,…,φn\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\varphi _1,\ldots, \varphi _n$$\end{document} if ψ\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\psi $$\end{document} is taken to be ⊤\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\top $$\end{document}. Future developments will then use that semantics as the basis for a doxastic logic akin to evidence logics. (shrink)

Recent studies in semantics of modal and superintuitionistic predicate logics provided many examples of incompleteness, especially for Kripke semantics. So there is a problem: to find an appropriate possible- world semantics which is equivalent to Kripke semantics at the propositional level and which is strong enough to prove general completeness results. The present paper introduces a new semantics of Kripke metaframes' generalizing some earlier notions. The main innovation is in considering "n"-tuples of individuals as abstract "n"-dimensional vectors', together with some (...) transformations of these vectors. Soundness of the semantics is proved to be equivalent to some non- logical properties of metaframes; and thus we describe the maximal semantics of Kripke- type. (shrink)

In 1885, during initial discussions of J. C. Maxwell's celebrated thermodynamic demon, Whiting (1) observed that the demon-like velocity selection of molecules can occur in a gravitationally bound gas. Recently, a gravitational Maxwell demon has been proposed which makes use of this observation [D. P. Sheehan, J. Glick, and J. D. Means, Found. Phys. 30, 1227 (2000)]. Here we report on numerical simulations that detail its microscopic phase space structure. Results verify the previously hypothesized mechanism of its paradoxical behavior. This (...) system appears to be the only example of a fully classical mechanical Maxwell demon that has not been resolved in favor of the second law of thermodynamics. (shrink)

A laboratory-testable, solid-state Maxwell demon is proposed that utilizes the electric field energy of an open-gap p-n junction. Numerical results from a commercial semiconductor device simulator (Silvaco International–Atlas) verify primary results from a 1-D analytic model. Present day fabrication techniques appear adequate for laboratory tests of principle.

In any competition for monuments of wasted labour the collection of accidental acrostics in Latin poets published by I. Hilberg would stand a good chance of a prize. But amongst his examples of ‘neckische Spiele des Zufalls’ is one I am gullible enough to believe may be more significant. In Aeneid 7. 601–15 Vergil describes the custom of opening the gates of war in a long anacoluthic sentence, the first four lines of which run: Mos erat Hesperio in Latio, quern (...) protinus urbes Albanae coluere sacrum, nunc maxima rerum Roma colit, cum prima movent in proelia Mortem, Sive Getis inferre manu lacrimabile bellum…. (shrink)

In a recent article in this journal our unit was accused of a number of errors of judgment in applying covert video surveillance (CVS) to infants and children suspected of life-threatening abuse. The article implied, that on moving from the Royal Brompton Hospital in London to North Staffordshire Hospital, we failed to present our work to the Research Ethics Committee (REC). We did send our protocol to the REC though we did not consider that, after a total of 16 patients (...) had been documented as being the subject of life-threatening abuse, this was research. The REC in Staffordshire agreed with us. We were also accused of undertaking work that should be pursued by the Police. We agree with this. However, unlike the Metropolitan Police the Staffordshire Police would not undertake CVS. We fail to agree that 'working together' with parents is necessarily practical or safe when trying to protect children from life-threatening abuse of this kind. (shrink)

In 2000, a simple, foundational thermodynamic paradox was proposed: a sealed blackbody cavity contains a diatomic gas and a radiometer whose apposing vane surfaces dissociate and recombine the gas to different degrees (A $_{2} \rightleftharpoons $ 2A). As a result of differing desorption rates for A and A $_{2}$ , there arise between the vane faces permanent pressure and temperature differences, either of which can be harnessed to perform work, in apparent conflict with the second law of thermodynamics. Here we (...) report on the first experimental realization of this paradox, involving the dissociation of low-pressure hydrogen gas on high-temperature refractory metals (tungsten and rhenium) under blackbody cavity conditions. The results, corroborated by other laboratory studies and supported by theory, confirm the paradoxical temperature difference and point to physics beyond the traditional understanding of the second law. (shrink)