Adults who are incapacitated and alone, having no surrogates, may be known as “unbefriended.” Decision-making for these particularly vulnerable patients is a common and vexing concern for healthcare providers and hospital ethics committees. When all other avenues for resolving the need for surrogate decision-making fail, patients who are incapacitated and alone may be referred for “public guardianship” or guardianship of last resort. While an appropriate mechanism in theory, these programs are often under-staffed and under-funded, laying the consequences of inadequacies on (...) the healthcare system and the patient him or herself. We describe a qualitative study of professionals spanning clinical, court, and agency settings about the mechanisms for resolving surrogate consent for these patients and problems therein within the state of Massachusetts. Interviews found that all participants encountered adults who are incapacitated and without surrogates. Four approaches for addressing surrogate needs were: work to restore capacity; find previously unknown surrogates; work with agencies to obtain surrogates; and access the guardianship system. The use of guardianship was associated with procedural challenges and ethical concerns including delays in care, short term gains for long term costs, inabilities to meet a patient’s values and preferences, conflicts of interest, and ethical discomfort among interviewees. Findings are discussed in the context of resources to restore capacity, identify previously unknown surrogates, and establish improved surrogate mechanisms for this vulnerable population. (shrink)

Adults who are incapacitated and alone, having no surrogates, may be known as “unbefriended.” Decision-making for these particularly vulnerable patients is a common and vexing concern for healthcare providers and hospital ethics committees. When all other avenues for resolving the need for surrogate decision-making fail, patients who are incapacitated and alone may be referred for “public guardianship” or guardianship of last resort. While an appropriate mechanism in theory, these programs are often under-staffed and under-funded, laying the consequences of inadequacies on (...) the healthcare system and the patient him or herself. We describe a qualitative study of professionals spanning clinical, court, and agency settings about the mechanisms for resolving surrogate consent for these patients and problems therein within the state of Massachusetts. Interviews found that all participants encountered adults who are incapacitated and without surrogates. Four approaches for addressing surrogate needs were: work to restore capacity; find previously unknown surrogates; work with agencies to obtain surrogates; and access the guardianship system. The use of guardianship was associated with procedural challenges and ethical concerns including delays in care, short term gains for long term costs, inabilities to meet a patient’s values and preferences, conflicts of interest, and ethical discomfort among interviewees. Findings are discussed in the context of resources to restore capacity, identify previously unknown surrogates, and establish improved surrogate mechanisms for this vulnerable population. (shrink)

Summary Although Sir William Forbes of Pitsligo's An Account of the Life and Writings of James Beattie has long served as an invaluable resource for those interested in Beattie's life and thought, there has been little scholarship on the genesis of Forbes's book. This article considers the role played by Dugald Stewart—as well as that of his friend, Archibald Alison—in the making of Forbes's Life of Beattie. It also examines the reasons for Forbes's decision not to print Stewart's letter in (...) its entirety in the Life of Beattie and explores the letter's significance for understanding Stewart's philosophical development. (shrink)

BACKGROUND: Hallucinations and delusions that complicate Parkinson’s disease could lead to nursing home placement and are linked to increased mortality. Cognitive impairments are typically associated with the presence of hallucinations but there are no data regarding whether such a relationship exists with delusions. OBJECTIVE: We hypothesized that hallucinations would be associated with executive and visuospatial disturbance. An exploratory examination of cognitive correlates of delusions was also completed to address the question of whether they differ from hallucinations. METHODS: 144 PD subjects (...) completed a neuropsychological battery to assess cognition and the SAPS to examine psychosis. Correlational analyses assessed associations between hallucinations and delusions with cognitive domains. RESULTS: 48 subjects reported psychotic symptoms: 25 experienced hallucinations without delusions, 23 had symptoms dominated by delusions. Severity and/or number of hallucination subtypes were significantly correlated with lower scores in language, memory, attention, executive functioning, and visuospatial ability. Correlations with delusions were non-significant. Tests of differences in the size of the correlations between groups revealed a significant relationship between language and visuospatial performance with hallucinations. CONCLUSIONS: Cognitive correlates of hallucinations and delusions appear to be different in PD, suggesting distinct pathogenic mechanisms and possibly anatomical substrates. Hence, delusions may not share the same associations with dementia as hallucinations. Since this is a new finding, further studies will be needed to confirm our results. (shrink)

The self-disorder model provides a phenomenological framework for understanding how the core symptoms of Schizophrenia Spectrum Disorders (SSDs) are rooted in an instability of minimal selfhood. This instability involves a range of “anomalous experiences”: transformations in an individual’s perceptual field and sense of being an agent of action. The explanatory value of this theoretical model can be summarized in two claims about the role of anomalous experiences in self-disorders: (1) anomalous experiences express a common trait-like disturbance that is characteristic of (...) SSDs, and (2) anomalous experiences contribute to explanations regarding how self-disorders progress into SSDs. While hypotheses consistent with the first claim have been substantiated in several studies, hypotheses consistent with the second claim remain underexamined. We argue that attending to this gap in the literature requires considering which methodological strategies are best suited for investigating if and how anomalous experiences contribute to the development of self-disorders into SSDs and psychotic states. Network modeling is discussed as one such strategy suitable for examining the role of anomalies of lived-world in the maintenance of paranoid delusions in SSDs. (shrink)

As John Henry Newman reflected on 'The Idea of a University' more than a century and a half ago, Bradley C. S. Watson brings together some of the nation's most eminent thinkers on higher education to reflect on the nature and purposes of the American university today. Their mordant reflections paint a picture of the American university in crisis. This book is essential reading for thoughtful citizens, scholars, and educational policymakers.

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)

While outcomes for children with T-cell acute lymphoblastic leukemia have improved dramatically, survival rates for patients with relapsed/refractory disease remain dismal. Prior studies indicate that glucocorticoid resistance is more common than resistance to other chemotherapies at relapse. In addition, failure to clear peripheral blasts during a prednisone prophase correlates with an elevated risk of relapse in newly diagnosed patients. Here we show that intrinsic GC resistance is present at diagnosis in early thymic precursor T-ALLs as well as in a subset (...) of non-ETP T-ALLs. GC-resistant non-ETP T-ALLs are characterized by strong induction of JAK/STAT signaling in response to interleukin-7 stimulation. Removing IL7 or inhibiting JAK/STAT signaling sensitizes these T-ALLs, and a subset of ETP T-ALLs, to GCs. The combination of the GC dexamethasone and the JAK1/2 inhibitor ruxolitinib altered the balance between pro- and anti-apoptotic factors in samples with IL7-dependent GC resistance, but not in samples with IL7-independent GC resistance. Together, these data suggest that the addition of ruxolitinib or other inhibitors of IL7 receptor/JAK/STAT signaling may enhance the efficacy of GCs in a biologically defined subset of T-ALL.Leukemia advance online publication, 30 May 2017; doi:10.1038/leu.2017.136. (shrink)

Central to Thomas Sprat's History of the Royal Society was the description and justification of the method adopted and advocated by the Fellows of the Society, for it was thought that it was their method which distinguished them from ancients, dogmatists, sceptics, and contemporary natural philosophers such as Descartes. The Fellows saw themselves as furthering primarily a novel method, rather than a system, of philosophy, and the History gave expression to this corporate self-perception. However, the History's description of their method (...) was not necessarily accurate. Rather, as will be argued below, by a combination of subtle misrepresentation and selective exposition, Sprat portrayed a method which would further the aims of social and ecclesiastical stability and material prosperity, essential for the Royal Society since its continued existence depended upon the creation of a social basis for the institutionalized pursuit of natural philosophy. Some link had to be forged between the activities of the Society and the intellectual and social aspirations of the Restoration. To understand the intent and meaning of Sprat's History and the method there portrayed, we must therefore look to the institutional needs which it fulfilled. (shrink)

The reception of Buffon's Histoire Naturelle in the Enlightenment has not received the historical attention it deserves. Drawing primarily on archival sources, this paper examines Aberdeen reactions to the Histoire during the period c. 1750–1800. As pedagogues, the Aberdonians endeavoured to maintain intellectual orthodoxy, and hence they attacked Buffon for his apparent materialism and atheism. Moreover, the Aberdonians rejected Buffon's critique of taxonomy because they based their natural history courses on classifications of the three kingdoms of nature, and because they (...) attempted to use classification systems in nosology and the study of the human mind. Finally, in the 1790s Aberdeen readings of the Histoire were profoundly affected by the fears aroused by the French Revolution. (shrink)

Although the University of Leeds has attained something of a reputation for the quality of its scholarship in the history of science, few historians are aware of the impressive collection of early scientific and medical books and manuscripts to be found in the University libraries. In order to make the library resources more widely known, we embarked on a systematic survey of the contents of the main historical collections. We wanted not only to give a general impression of the particular (...) strengths and distinctive features of each collection, but also to mention the interesting or rare copies of individual works to be found in them. We have, therefore, examined every book related to the history of science and medicine in the relevant collections, and in doing so we have uncovered a number of important items. For example, we have identified a book which was once in Newton's library, and a previously unrecorded copy of Joseph Black's chemical lectures. More generally, we had not suspected the true size and range of the Chaston Chapman Collection, which makes it a valuable resource for the history of alchemy and early chemistry; nor were we initially aware of the strength of the Historical Collection of the Medical and Dental Library. The wealth of the legacies to the Brotherton and Special Collections also impressed us. (shrink)

Mark Schroeder has argued that all reasonable forms of inconsistency of attitude consist of having the same attitude type towards a pair of inconsistent contents (A-type inconsistency). We suggest that he is mistaken in this, offering a number of intuitive examples of pairs of distinct attitudes types with consistent contents which are intuitively inconsistent (B-type inconsistency). We further argue that, despite the virtues of Schroeder's elegant A-type expressivist semantics, B-type inconsistency is in many ways the more natural choice in developing (...) an expressivist account of moral discourse. We close by showing how to adapt ordinary formality-based accounts of logicality to define a B-type account of logical inconsistency and distinguish it from both semantic and pragmatic inconsistency. In sum, we provide a roadmap of how to develop a successful B-type expressivism. (shrink)

In a recent article Duncan Purves, Ryan Jenkins, and B. J. Strawser argue that in order for a decision in war to be just, or indeed the decision to resort to war to be just, it must be the case that the decision is made for the right reasons. Furthermore, they argue that this requirement holds regardless of how much good is produced by said action. In this essay I argue that their argument is flawed, in that it mistakes what (...) makes an agent morally good for what makes an act morally good. I argue that the main thrust of Purves et al.’s argument in fact undermines the conclusion they wish to draw, and that the reasons for one’s action do not make an in principle difference to the morality of actions in war. I further argue that this position undermines the traditional ad bellum just war constraint of right intention, and that the morality of actions in war is, at core, only concerned with outcomes. I conclude by clarifying that one’s reasons for action do in fact matter when deciding to enter war or kill in war, but only because one’s reasons significantly impact the way in which one acts. The purpose of this paper is to clear the theoretical space by showing why intentions/reasons do not in principle matter when assessing the morality of war (or killing), but this should not be taken as an argument that we should ignore intentions/reasons altogether. (shrink)

Wood informs the reader that Buber rejected "isms," hard and fast rules and principles, and systems, but he goes on to systematize Buber's thought nonetheless. The result is often enlightening. I and Thou, which Wood considers the central work of the philosopher's thought, is finely broken down and analyzed in its component parts. In this manner it is less formidable to the uninitiated, and the reader who is puzzled by a particular passage can find in Wood's book an authoritative, well-researched (...) explanation. There are also excellent biographical data woven in with glimpses of Buber's voluminous works and the influences on them, and a complete bibliography that is as definitive as any published to date. But Buber's thought does not lend itself to systematization. One cannot substitute Ontology for Metaphysics and then proceed to dissect a philosophy which declares itself to be beyond metaphysics, and which points to the existential meeting of a person here and now with another person and/or with God. Wood provides a diagram showing the structure of I and Thou which may be useful for locating selections in the book as they relate to a certain code, but at the same time it illustrates what Buber describes as objectification, an I-it relationship with a person or his work, which is far from the I-Thou relationship.--S. J. B. (shrink)

Immanuel Kant’s _Groundwork for the Metaphysics of Morals _is_ _one of the most important texts in the history of ethics. In it Kant searches for the supreme principle of morality and argues for a conception of the moral life that has made this work a continuing source of controversy and an object of reinterpretation for over two centuries. This new edition of Kant’s work provides a fresh translation that is uniquely faithful to the German original and more fully annotated than (...) any previous translation. There are also four essays by well-known scholars that discuss Kant’s views and the philosophical issues raised by the _Groundwork. _J.B. Schneewind defends the continuing interest in Kantian ethics by examining its historical relation both to the ethical thought that preceded it and to its influence on the ethical theories that came after it; Marcia Baron sheds light on Kant’s famous views about moral motivation; and Shelly Kagan and Allen W. Wood advocate contrasting interpretations of Kantian ethics and its practical implications. (shrink)

Rachel Carson begins her revolutionary book Silent Spring with a quote from E.B. White that reads 'we would stand a better chance of survival if we accommodated ourselves to this planet and viewed it appreciatively'. While White's advice can account for an instrumental relationship towards nature, I believe that the more important relationship offered in his recommendation is one of appreciation or gratitude. But how are we to understand gratitude as appreciating Nature non-instrumentally when it has traditionally always been understood (...) as a response to a benefit received? My motivation is to modify our traditional conception of gratitude alongside Simon Hailwood's account of the 'Otherness of Nature' to see how we can truly show gratitude for Nature rather than simply reflecting on how Nature serves human interests. (shrink)

Richard Rufus of Cornwall was educated as a philosopher at Paris where he was a master of arts.Thomas Eccleston, De adventu Fratrum minorum in Angliam c. 6 (Manchester: Manchester University Press, 1951), p. 30. In 1238, after lecturing on Aristotle’s libri naturales, Rufus became a Franciscan and moved to Oxford to study theology, becoming the Franciscan master of theology in about 1256 and probably dying not long after 1259.A. Little, “The Franciscan School at Oxford in the Thirteenth Century,” Archivum Franciscanum (...) Historicum 19 (1926): 842–45. Wills and Inventories, Surtees Society Publications 2 (London: J.B. Nichols, 1835), pp. 10–11. Cf. A. Little, The Grey Friars in Oxford (Oxford: Clarendon Press, 1892), p. 143. (shrink)

Kraus’s book is both deep and wide-ranging. My comments focus on her account of Kant on self-awareness – both a priori and empirical apperception. Basic to her account is what she calls the hylomorphism of mental faculties in Kant. Kraus distinguishes her ‘reflexive’ account of apperception from both ‘logical’ and ‘psychological’ accounts. An inevitable question is: Does Kant think we have an empirical cognition of the self? Kraus seems to want to say yes, but I question this answer. Cognition requires (...) both intuition and conception. My claim is that it requires intuition in both space and time, but inner empirical self-awareness is apparently in time only. Kant’s Refutation of Idealism in B, as developed later in the Kiesewetter essays, makes awareness of our body essential to time determination. (shrink)

This latest in attempts to collect statements from living American philosophers presents thoughts and interests of those writing in the "middle decades," the fifty years from 1920 to 1970. The editor has restricted himself to America’s senior philosophers asking each to reflect on "the things that matter most," or "to share the motifs in their work and to present concerns about their world". Although some influential elders are missing from this collection, an interesting variety of viewpoints and styles of American (...) philosophizing are represented. Especially interesting are the reflections of Brand Blanshard, Edwin Burtt, Herbert Feigl, Charles Hartshorne, Stephen Pepper, Roy Wood Sellars, and Herbert Spiegelberg. Blanshard traces his development from the influences upon him of Bradley, and describes his own rationalist ethics and humanist religion. Herbert Feigl in an even more autobiographical vein relates how he came under the important influence of Moritz Schlick and to be a member of the Vienna Circle. Also included in his article is a summary of his views on the issues of induction, scientific explanation, the mind-body problem, determinism, and some matters of practical philosophy. Pepper explains how he originated the idea of world hypotheses, and how he believes these hypotheses themselves originate and function, and Spiegelberg sketches an intriguing "ethics for fellows in the fate of existence." In his essay Hartshorne mixes comments on pragmatism, idealism, and the "linguistic turn," with explanations of his own "neoclassical metaphysics."—B.M. (shrink)

IN A RECENT AND PHILOSOPHICALLY RICH STUDY, David Wood has undertaken the deconstruction of time through an engagement with the thought of Nietzsche, Husserl, Heidegger, and, of course, Derrida. The present essay is not intended to offer a sustained criticism of Wood's arguments or to canvass what he says about the quartet of philosophers noted above; rather, with his book as background, the essay's purpose is to say something about only one of the four philosophers--Edmund Husserl--and particularly about the place (...) of presence and absence in Husserl's phenomenology of time and the consciousness of time. The results may supply ammunition both to those inclined to criticize Husserl from a deconstructive point of view and to those bold enough to defend him. In any event, what Husserl has to say about these matters is worth considering for its own sake. His discussion of the different ways in which presence and absence enter into our temporal experience is subtle and nuanced. He draws delicate distinctions and points to continuities and discontinuities that deserve the philosopher's careful and sympathetic attention. I will focus on a few of these, hoping that they will suggest something of the rich resources for reflection on this topic that are present in Husserl's texts. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Excited DeliriumWhat’s Psychiatry Got to do With It?Paul B. Lieberman, MDIf in life we are surrounded by death, so too in the health of our intellect by madness.—WittgensteinDelirium is a medical syndrome defined as “a relatively acute decline in cognition that fluctuates over hours or days” whose primary manifestation is a deficit of attention. It is common, estimated to occur in 10% to more than 50% of hospitalized patients, (...) with higher prevalence rates among people in nursing homes and at the end of life. It is often fatal, with a mortality rate in the hospital estimated to be 25% to 33%. Caused by a wide variety of conditions and frequently difficult to diagnose, it lacks characteristic postmortem pathology (Josephson & Miller 2018)‘Excited delirium,’ as Byju and Friesen forcefully argue (Byju & Friesen, 2023), is, if nothing else, an excuse. The ‘diagnosis’ has not been empirically validated and remains controversial (American Psychiatric Association, 2020). And while delirium is usually treated by internists and emergency medicine physicians, psychiatrists should also be concerned about the misuse of a putative medical diagnosis and join actively in discussion about it. For one thing, patients mis-diagnosed with this condition, as Byju and Friesen’s examples suggest, may actually have another psychiatric condition and, so, be people for whose safety we should advocate. Moreover, the kinds of police interventions which Byju and Friesen document as involving excited delirium also befall patients with other psychiatric problems in whom the issue of delirium does not arise.There are at least two broad ways in which psychiatrists are qualified and obligated to engage with this issue. As physicians, we should join our medical colleagues in carefully but persistently telling the scientific, medical truth. As psychiatrists, we should bring psychiatric knowledge into the discussion, for example, by explaining what can happen when people who do not, apparently, have a diagnosable mental disorder interact under stress with other people who, apparently, do.Delirium is a clinical diagnosis, made when characteristic signs and symptoms are present which should not be made ‘by exclusion’ when, as may happen, other causes are not found. There is no evidence of delirium in any of the three clinical descriptions Byju and Friesen provide. Perhaps such evidence exists which is not in their brief reports, but these three people appear to have had, either, another psychiatric condition, such as psychosis or drug intoxication, or perhaps no [End Page 353] diagnosis at all. Psychiatrists are particularly wellpositioned to make this point since patients with mental health problems are often misdiagnosed when they seek medical attention and are told, and treated as if, “it’s all (“just”!) psychological.”Excited delirium, if it exists, is fatal in 10% of cases (Gonin, Beysard, Hersin, & Carron, 2018) and, although this is lower than the rate for delirium in general, it is still high. Medical personnel must be available to evaluate and ensure the safety of patients in custody.The potential conflict between protecting the patient and protecting the public should not be overstated. Although physical trauma and excessive administration of medications, including ketamine 500 mg IV (Orhurhu, Vashicht, Claus, & Cohen, 2023) can be lethal, mechanical restraint by itself is not (Chieze et al., 2019; Gleerup et al., 2019): something else is necessary, such as asphyxiation (Evans, Wood, & Lambert, 2003). Nor is restraint necessary in many cases in which ‘de-escalation’ techniques can be equally effective (Garriga et al., 2016; Fernández-Costa, 2020). Perhaps these points are best made by law enforcement leaders—and they have been—but psychiatrists can add that safe management of potential violence can be provided for agitated people with psychiatric conditions.Although it is not clear what kind of strength ‘superhuman’ strength might be (certainly not medical), relative imperviousness to pain is clinically described. Its locus classicus is Beecher’s observation, during World War II, that injured soldiers awaiting return home from the front, required lower than usual doses of analgesics (Beecher, 1946). And it’s a common experience, scientifically confirmed, that physical trauma may not become painful until sometime after the injury (Melzack, Wall, & Ty, 1982). But pain is a warning. Its absence is not a license, but a caution... (shrink)