The data emerging from the clinical and brain studies described above suggest that, in the case of OCD, there are two pertinent brain mechanisms that are distinguishable both in terms of neuro dynamics and in terms of the conscious experiences that accompany them. These mechanisms can be characterized, on anatomical and perhaps evolutionary grounds, as a lower level and a higher level mechanism. The clinical treatment has, when successful, an activating effect on the higher level mechanism, and a suppressive effect (...) on the lower level one. (shrink)
Objective: There are benefits and risks of giving patients more granular control of their personal health information in electronic health record (EHR) systems. When designing EHR systems and policies, informaticists and system developers must balance these benefits and risks. Ethical considerations should be an explicit part of this balancing. Our objective was to develop a structured ethics framework to accomplish this. -/- Methods: We reviewed existing literature on the ethical and policy issues, developed an ethics framework called a “Points to (...) Consider” (P2C) document, and convened a national expert panel to review and critique the P2C. -/- Results: We developed the P2C to aid informaticists designing an advanced query tool for an electronic health record (EHR) system in Indianapolis. The P2C consists of six questions (“Points”) that frame important ethical issues, apply accepted principles of bioethics and Fair Information Practices, comment on how questions might be answered, and address implications for patient care. -/- Discussion: The P2C is intended to clarify whatis at stake when designers try to accommodate potentially competing ethical commitments and logistical realities. The P2C was developed to guide informaticists who were designing a query tool in an existing EHR that would permit patient granular control. While consideration of ethical issues is coming to the forefront of medical informatics design and development practices, more reflection is needed to facilitate optimal collaboration between designers and ethicists. This report contributes to that discussion. (shrink)
Ethics should guide the design of electronic health records (EHR), and recognized principles of bioethics can play an important role. This approach was adopted recently by a team of informaticists designing and testing a system where patients exert granular control over who views their personal health information. While this method of building ethics in from the start of the design process has significant benefits, questions remain about how useful the application of bioethics principles can be in this process, especially when (...) principles conflict. For instance, while the ethical principle of respect for autonomy supports a robust system of granular control, the principles of beneficence and non-maleficence counsel restraint due to the danger of patients being harmed by restrictions on provider access to data. Conflict between principles has long been recognized by ethicists and has even motivated attacks on approaches that state and apply principles. In this paper we show how using ethical principles can help in the design of EHRs by first, explaining how ethical principles can and should be used generally, and then by, discuss how attention to details in specific cases can show that the tension between principles is not as bad as it initially appeared. We conclude by suggesting further ways in which the application of these (and other) principles can add value to the ongoing discussion of patient involvement in their health care. This is a new approach to linking principles to informatics design that we expect will stimulate further interest. (shrink)
Most people do not know there are different kinds of medical studies; some are conducted on people who already have a disease or medical condition, and others are performed on healthy volunteers who want to help science find answers. No matter what sort of research you are invited to participate in, or whether you are a patient when you are asked, it’s entirely up to you whether or not to do it. This decision is important and may have many implications (...) for your health and well-being, as well as those of other patients now and in the future. Making a good decision – the right one for you – requires you to become educated about topics you may not have thought about before, some of which may be quite complicated. This chapter explains the key issues to help you make a good decision. (shrink)
Although there is a growing recognition that older adults and those with extensive comorbid conditions undergo cancer screening too frequently, there is little information about patients’ perceptions regarding cessation of cancer screening. Information on older adults’ views of screening cessation would be helpful both for clinicians and for those designing interventions to reduce overscreening.
Backdating of stock options is an example of an agency problem. It has emerged despite all the measures (i.e., new regulations and additional corporate governance mechanisms) aimed at addressing such problems? Beyond such negative controlling measures, a more positive empowering approach based on ethics may also be necessary. What ethical measures need to be taken to address the agency problem? What values and norms should guide the board of directors in protecting the shareholders' interests? To examine these issues, we first (...) discuss the role values and norms can play with respect to underlying corporate governance and the proper role of directors, such as transparency, accountability, integrity (which is reflected in proper mechanisms of checks and balances), and public responsibility. Second, we discuss various stakeholder approaches (e.g., government, directors, managers, and shareholders) by which conflicts of interest (i.e., the agency problem) can be addressed. Third, we assess the practice of backdating stock options, as an illustration of the agency problem, in terms of whether the practice is legally acceptable or ethically justifiable. Fourth, we proceed to an analysis of good corporate governance practice involving backdating options based on a series of ethical standards including: (1) trustworthiness; (2) utilitarianism; (3) justice; and (4) Kantianism. We conclude that while executive compensation schemes (e. g., stock options) were originally intended to help remedy the agency problem by tying together the interests of the executives and shareholders, these schemes may have actually become "part of the problem," and that the solution ultimately depends upon whether directors and executives accept that all of their actions must be based on a set of core ethical values. (shrink)
In this Issue Content Type Journal Article Pages 7-9 Authors Jason M. Wirth Michael Schwartz Journal Comparative and Continental Philosophy Online ISSN 1757-0646 Print ISSN 1757-0638 Journal Volume Volume 4 Journal Issue Volume 4, Number 1 / 2012.
Digital medicine is a medical treatment that combines technology with drug delivery. The promises of this combination are continuous and remote monitoring, better disease management, self-tracking, self-management of diseases, and improved treatment adherence. These devices pose ethical challenges for patients, providers, and the social practice of medicine. For patients, having both informed consent and a user agreement raises questions of understanding for autonomy and informed consent, therapeutic misconception, external influences on decision making, confidentiality and privacy, and device dependability. For providers, (...) digital medicine changes the relationship where trust can be verified, clinicians can be monitored, expectations must be managed, and new liability risks may be assumed. Other ethical questions include direct third-party monitoring of health treatment, affordability, and planning for adverse events in the case of device malfunction. This article seeks to lay out the ethical landscape for the implementation of such devices in patient care. (shrink)
A study was conducted in order to examine the relationship between corporate codes of ethics and behaviour. Fifty-seven interviews of employees, managers, and ethics officers were conducted at four large Canadian companies. The study found that codes of ethics are a potential factor influencing the behaviour of corporate agents. Reasons are provided why codes are violated as well as complied with. A set of eight metaphors are developed which help to explain how codes of ethics influence behaviour.
What might a theory of mental imagery look like, and how might one begin formulating such a theory? These are the central questions addressed in the present paper. The first section outlines the general research direction taken here and provides an overview of the empirical foundations of our theory of image representation and processing. Four issues are considered in succession, and the relevant results of experiments are presented and discussed. The second section begins with a discussion of the proper form (...) for a cognitive theory, and the distinction between a theory and a model is developed. Following this, the present theory and computer simulation model are introduced. This theory specifies the nature of the internal representations (data structures) and the processes that operate on them when one generates, inspects, or transforms mental images. In the third, concluding, section we consider three very different kinds of objections to the present research program, one hinging on the possibility of experimental artifacts in the data, and the others turning on metatheoretical commitments about the form of a cognitive theory. Finally, we discuss how one ought best to evaluate theories and models of the sort developed here. (shrink)
Introduction: Previous studies have measured individuals’ willingness to share personal information stored in an electronic health record (EHR) with healthcare providers. But none have measured preferences when patients’ choices determine access by healthcare providers. -/- Methods: Patients were given the ability to control the access of doctors, nurses or other staff in a primary care clinic to personal information stored in an EHR. Patients could restrict access to all personal data or to specific types of sensitive information, and could restrict (...) access for a specific time period. Patients also completed a survey regarding their understanding and opinions regarding the process. -/- Results: Of 139 eligible patients who were approached, 105 (75.5%) were enrolled and preferences were collected from 105 of them (100%). Sixty patients (57%) did not restrict access by any providers. Of the 45 patients (43%) who chose to limit the access of at least 1 provider, 36 restricted access only to all personal information in the EHR, while 9 restricted access of some providers to a subset of the their personal information. Thirty-four (32.3%) patients blocked access to all personal information by all doctors, nurses, and/or other staff; 26 (24.8%) blocked access by all doctors and/or nurses, and 5 (4.8%) denied access to alldoctors, nurses, and staff. -/- Conclusions: A significant minority of patients chose to restrict access by their primary care providers to personal information contained in an EHR, and few chose to restrict access to specific types of information. More research is needed to identify patient goals and understanding when facing decisions of this sort, and to identify the impact of educating patients regarding information contained in the EHR and its use in clinical care. (shrink)
Neuropsychological research on the neural basis of behaviour generally posits that brain mechanisms will ultimately sufﬁce to explain all psychologically described phenomena. This assumption stems from the idea that the brain is made up entirely of material particles and ﬁelds, and that all causal mechanisms relevant to neuroscience can therefore be formulated solely in terms of properties of these elements. Thus, terms having intrinsic mentalistic and/or experiential content (e.g. ‘feeling’, ‘knowing’ and ‘effort’) are not included as primary causal factors. This (...) theoretical restriction is motivated primarily by ideas about the natural world that have been known to be fundamentally incorrect for more than three-quarters of a century. Contemporary basic physical theory differs profoundly from classic physics on the important matter of how the consciousness of human agents enters into the structure of empirical phenomena. The new principles contradict the older idea that local mechanical processes alone can account for the structure of all observed empirical data. Contemporary physical theory brings directly and irreducibly into the overall causal structure certain psychologically described choices made by human agents about how they will act. This key development in basic physical theory is applicable to neuroscience, and it provides neuroscientists and psychologists with an alternative conceptual framework for describing neural processes. Indeed, owing to certain structural features of ion channels critical to synaptic function, contemporary physical theory must in principle be used when analysing human brain dynamics. The new framework, unlike its classic-physics-based predecessor, is erected directly upon, and is compatible with, the prevailing principles of physics. It is able to represent more adequately than classic concepts the neuroplastic mechanisms relevant to the growing number of empirical studies of the capacity of directed attention and mental effort to systematically alter brain function.. (shrink)
Some experts have argued that patients should routinely be told the specific magnitude and absolute probability of potential risks and benefits of screening tests. This position is motivated by the idea that framing risk information in ways that are less precise violates the ethical principle of respect for autonomy and its application in informed consent or shared decisionmaking. In this Perspective, we consider a number of problems with this view that have not been adequately addressed. The most important challenges stem (...) from the danger that patients will misunderstand the information or have irrational responses to it. Any initiative in this area should take such factors into account and should consider carefully how to apply the ethical principles of respect for autonomy and beneficence. (shrink)
To address growing concerns about academic integrity, college students (n?=?758) at honor system and non-honor system institutions were presented with eight scenarios to determine the influence of an honor system on their perceptions of and responses to academic dishonesty. Main effects for honor code status emerged. Students from traditional honor system schools considered the behaviors to be more dishonest, and were more likely to respond that they would report the incident when compared to students attending modified and non-honor system institutions. (...) Findings suggest traditional honor systems, with specific rules and regulations in place, are more effective at cultivating academic integrity among students; modified honor systems may not be as effective as previous research suggests. (shrink)
While several tests and strategies are recommended for colorectal cancer (CRC) screening, studies suggest that primary care providers often recommend colonoscopy without providing information about its risks or alternatives. These observations raise concerns about the quality of informed consent for screening colonoscopy.
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)
The status of constructivism as a metaethical or metanormative theory is unclear partly due to the lack of a clear semantics for central normative terms such as ‘reason’ and ‘ought’. In a series of recent papers, Sharon Street has attempted to clarify the central commitments of constructivism by focusing on the idea of a practical point of view and what follows from it. We improve upon the informal understanding provided by Street and attempt to provide a semantics for ‘ought’. Our (...) semantics respects the core intuition of the constructivist that normative claims are made true because of our practical commitments as agents and also reflects the constructivist’s commitment to the centrality of practical deliberation to normative truth. On our view, a normative claim of the form ⌜S ought to ϕ⌝ is true if ϕ is entailed from S’s set of evaluative attitudes. We argue that a virtue of our definition is that it allows us to see precisely what is distinctive about constructivism as opposed to realism and expressivism. (shrink)
Obsessive-compulsive disorder is a commonly occurring neuropsychiatric condition characterized by bothersome intrusive thoughts and urges that frequently lead to repetitive dysfunctional behaviours such as excessive handwashing. There are well-documented alterations in cerebral function which appear to be closely related to the manifestation of these symptoms. Controlled studies of cognitive-behavioural therapy techniques utilizing the active refocusing of attention away from the intrusive phenomena of OCD and onto adaptive alternative activities have demonstrated both significant improvements in clinical symptoms and systematic changes in (...) the pathological brain circuitry associated with them. Careful investigation of the relationships between the experiential and putative neurophysiological processes involved in these changes can offer useful insights into volitional aspects of cerebral function. (shrink)
Health care professionals who travel from their home countries to participate in humanitarian assistance or development work experience distinctive ethical challenges in providing care and services to populations affected by war, disaster or deprivation. Limited information is available about organizational practices related to preparation and support for health professionals working with non-governmental organizations. In this article, we present one component of the results of a qualitative study conducted with 20 Canadian health care professionals who participated in international aid work. The (...) findings reported here relate to expatriate clinicians’ experiences and perceptions of ethics preparation, training and support. The strategies examined include pre-departure training and preparation, in-field supports and retrospective debriefing of ethical issues. Participants experienced a range of training and supports as beneficial for addressing ethical challenges in humanitarian assistance and development work. Participants also expressed ambivalence or scepticism about the benefits offered by specific modalities. This analysis can contribute to informing discussions of how organizations and individual practitioners can best develop, implement and utilize ethics training and support for international aid work. (shrink)
Humanitarian health care practitioners working outside familiar settings, and without familiar supports, encounter ethical challenges both familiar and distinct. The ethical guidance they rely upon ought to reflect this. Using data from empirical studies, we explore the strengths and weaknesses of two ethical models that could serve as resources for understanding ethical challenges in humanitarian health care: clinical ethics and public health ethics. The qualitative interviews demonstrate the degree to which traditional teaching and values of clinical health ethics seem insufficient (...) for addressing all the realities of health care practice during humanitarian missions. They equally suggest that greater good orientations of public health ethics can thwart the best intentions of health care professionals wanting to attend to the interests of individual patients. Even though neither is complete on its own for helping guide health professionals on field missions, taken together these models have much to offer. At the same time, the narratives of the humanitarian health care workers illustrate how some of the crucial differences between public health ethics and clinical ethics generate tensions in humanitarian health practice. We offer an analysis of some of the complexities this creates for humanitarian health care ethics, and consider ways of adjudicating between the two models. (shrink)
This article explores the accounts of Canadian-trained health professionals working in humanitarian and development organizations who considered not treating a patient or group of patients because of resource limitations. In the narratives, not treating the patient(s) was sometimes understood as the right thing to do, and sometimes as wrong. In analyzing participants’ narratives we draw attention to how medications and equipment are represented. In one type of narrative, medications and equipment are represented primarily as scarce resources; in another, they are (...) represented as patient care. In the contexts respondents were working, medications and equipment were often both patient care interventions and scarce resources. The analytic point is that health professionals tend to emphasize one conceptualization over the other in coming to assert that not treating is right, or wrong. Rendering tacit ethical frameworks more explicit makes them available for reflection and debate. (shrink)
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role (...) of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances. (shrink)
: The Bush administration's military war on terrorism is a blunt, ineffective, and unjust response to the threat posed to innocent civilians by terrorism. Decentralized terrorist networks can only be effectively fought by international cooperation among police and intelligence agencies representing diverse nation‐states, including ones with predominantly Islamic populations. The Bush administration's allegations of a global Islamist terrorist threat to the national interests of the United States misread the decentralized and complex nature of Islamist politics. Undoubtedly there exists a “combat (...) fundamentalist” element within Islamism. But the threat posed to U.S. citizens by Islamist terrorism neither necessitates nor justifies as a response massive military invasions of other nations. Not only does the Bush administration's war on alleged “terrorist states” violate the doctrine of just war, but in addition these wars arise from a new, unilateral, imperial foreign‐policy doctrine of “preventive wars.” Such a doctrine will isolate the United States from international institutions and long‐standing allies. The weakening of these institutions and alliances will only weaken the ability of the international community to deter terrorism. (shrink)
In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further (...) questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined. (shrink)
Introduction: Variation across research ethics boards in conditions placed on access to medical records for research purposes raises concerns around negative impacts on research quality and on human subject protection, including privacy.Aim: To study variation in REB consent requirements for retrospective chart review and who may have access to the medical record for data abstraction.Methods: Thirty 90-min face-to-face interviews were conducted with REB chairs and administrators affiliated with faculties of medicine in Canadian universities, using structured questions around a case study (...) with open-ended responses. Interviews were recorded, transcribed and coded manually.Results: Fourteen sites required individual patient consent for the study to proceed as proposed. Three indicated that their response would depend on how potentially identifying variables would be managed. Eleven sites did not require consent. Two suggested a notification and opt-out process. Most stated that consent would be required if identifiable information was being abstracted from the record. Among those not requiring consent, there was substantial variation in recognising that the abstracted information could potentially indirectly re-identify individuals. Concern over access to medical records by an outside individual was also associated with requirement for consent. Eighteen sites required full committee review. Sixteen allowed an external research assistant to abstract information from the health record.Conclusions: Large variation was found across sites in the requirement for consent for research involving access to medical records. REBs need training in best practices for protecting privacy and confidentiality in health research. A forum for REB chairs to confidentially share concerns and decisions about specific studies could also reduce variation in decisions. (shrink)
BackgroundThe amount of research utilizing health information has increased dramatically over the last ten years. Many institutions have extensive biobank holdings collected over a number of years for clinical and teaching purposes, but are uncertain as to the proper circumstances in which to permit research uses of these samples. Research Ethics Boards (REBs) in Canada and elsewhere in the world are grappling with these issues, but lack clear guidance regarding their role in the creation of and access to registries and (...) biobanks.MethodsChairs of 34 REBS and/or REB Administrators affiliated with Faculties of Medicine in Canadian universities were interviewed. Interviews consisted of structured questions dealing with diabetes-related scenarios, with open-ended responses and probing for rationales. The two scenarios involved the development of a diabetes registry using clinical encounter data across several physicians' practices, and the addition of biological samples to the registry to create a biobank.ResultsThere was a wide range of responses given for the questions raised in the scenarios, indicating a lack of clarity about the role of REBs in registries and biobanks. With respect to the creation of a registry, a minority of sites felt that consent was not required for the information to be entered into the registry. Whether patient consent was required for information to be entered into the registry and the duration for which the consent would be operative differed across sites. With respect to the creation of a biobank linked to the registry, a majority of sites viewed biobank information as qualitatively different from other types of personal health information. All respondents agreed that patient consent was needed for blood samples to be placed in the biobank but the duration of consent again varied.ConclusionParticipants were more attuned to issues surrounding biobanks as compared to registries and demonstrated a higher level of concern regarding biobanks. As registries and biobanks expand, there is a need for critical analysis of suitable roles for REBs and subsequent guidance on these topics. The authors conclude by recommending REB participation in the creation of registries and biobanks and the eventual drafting of comprehensive legislation. (shrink)
Humanitarian healthcare work presents a range of ethical challenges for expatriate healthcare professionals, including tragic choices requiring the selection of a least-worst option. In this paper we examine a particular set of tragic choices related to the prioritization of care and allocation of scarce resources between individuals in situations of widespread and urgent health needs. Drawing on qualitative interviews with clinicians, we examine the nature of these choices. We offer recommendations to clinical teams and aid organizations for preparing and supporting (...) frontline clinicians in their efforts to determine the least-worst option, and in their responsibility for making such choices. (shrink)