“At-own-risk discharges” or “self-discharges” evidences an irretrievable breakdown in the patient–clinician relationship when patients leave care facilities before completion of medical treatment and against medical advice. Dissolution of the therapeutic relationship terminates the physician’s duty of care and professional liability with respect to care of the patient. Acquiescence of an at-own-risk discharge by the clinician is seen as respecting patient autonomy. The validity of such requests pivot on the assumptions that the patient is fully informed and competent to (...) invoke an at-own-risk discharge and that care up to the point of the at-own-risk discharge meets prevailing clinical standards. Palliative care’s use of a multidisciplinary team approach challenges both these assumptions. First by establishing multiple independent therapeutic relations between professionals in the multidisciplinary team and the patient who persists despite an at-own-risk discharge. These enduring therapeutic relationships negate the suggestion that no duty of care is owed the patient. Second, the continued employ of collusion, familial determinations, and the circumnavigation of direct patient involvement in family-centric societies compromises the patient’s decision-making capacity and raises questions as to the patient’s decision-making capacity and their ability to assume responsibility for the repercussions of invoking an at-own-risk discharge. With the validity of at-own-risk discharge request in question and the welfare and patient interest at stake, an alternative approach to assessing at-own-risk discharge requests are called for. The welfare model circumnavigates these concerns and preserves the patient’s welfare through the employ of a multidisciplinary team guided holistic appraisal of the patient’s specific situation that is informed by clinical and institutional standards and evidenced-based practice. The welfare model provides a robust decision-making framework for assessing the validity of at-own-risk discharge requests on a case-by-case basis. (shrink)

“At-own-risk discharges” or “self-discharges” evidences an irretrievable breakdown in the patient–clinician relationship when patients leave care facilities before completion of medical treatment and against medical advice. Dissolution of the therapeutic relationship terminates the physician’s duty of care and professional liability with respect to care of the patient. Acquiescence of an at-own-risk discharge by the clinician is seen as respecting patient autonomy. The validity of such requests pivot on the assumptions that the patient is fully informed and competent to (...) invoke an at-own-risk discharge and that care up to the point of the at-own-risk discharge meets prevailing clinical standards. Palliative care’s use of a multidisciplinary team approach challenges both these assumptions. First by establishing multiple independent therapeutic relations between professionals in the multidisciplinary team and the patient who persists despite an at-own-risk discharge. These enduring therapeutic relationships negate the suggestion that no duty of care is owed the patient. Second, the continued employ of collusion, familial determinations, and the circumnavigation of direct patient involvement in family-centric societies compromises the patient’s decision-making capacity and raises questions as to the patient’s decision-making capacity and their ability to assume responsibility for the repercussions of invoking an at-own-risk discharge. With the validity of at-own-risk discharge request in question and the welfare and patient interest at stake, an alternative approach to assessing at-own-risk discharge requests are called for. The welfare model circumnavigates these concerns and preserves the patient’s welfare through the employ of a multidisciplinary team guided holistic appraisal of the patient’s specific situation that is informed by clinical and institutional standards and evidenced-based practice. The welfare model provides a robust decision-making framework for assessing the validity of at-own-risk discharge requests on a case-by-case basis. (shrink)

Preterm discharge effects: Relationship between the maternal experience and newborn's psychobiological regulation The purpose of this study is to investigate how the past experiences of mothers and their potentially traumatic events during pregnancy may have influenced the processes of psychobiological self-regulation and cognitive development in a child born preterm. Eighty children who had a gestational age of < 32 weeks were examined at the 9th month of the corrected age. The mothers and children were divided in two groups: (...) multipara mothers and their children and the primipara mothers and their children. These children were examined on the basis of sleep disorders, nutritional problems and mental development. Perinatal data from clinical observations and data from standardized developmental tests were used to describe the differences. The children of primipara mothers who had unexpected preterm delivery presented major incidences of sleep disorders while the children of primipara mothers, who programmed preterm delivery, presented a major incidences of nutrition problems. The predictability of preterm delivery has a major influence on the capacity of newborns for self-regulation in the case of primipara mothers. (shrink)

The purpose of this study is to investigate the current state of post-traumatic growth and identify its influencing factors in discharged COVID-19 patients. PTG refers to individual experiences of significant positive change arising from the struggle with a major life crisis. This descriptive cross-sectional study used the convenient sampling method to recruit 140 discharged COVID-19 patients in Hunan, China. The results show that the PTG of the discharged COVID-19 patients was positively correlated with self-esteem, post-traumatic stress disorder, coping style (...) tendency, and social support, but negatively correlated with the time from onset to diagnosis. Our findings could provide guidance on improving the psychological state and well-being of discharged COVID-19 patients. (shrink)

An ethically sound discharge from the hospital can be impeded by a number of factors, including a lack of payor for a patient’s care, a lack of appropriate discharge options, and a lack of authority to sign a patient into a long-term facility. In some cases, the primary barrier involves the patient’s lack of financial decision-making capacity.When a patient’s income comes primarily from government assistance, financial decision making is connected to both the individual’s well-being and to fair allocation (...) of resources. Taking away another person’s financial independence is a substantial intrusion on autonomy and should not be considered lightly. However, poor management of funds can lead to homelessness, medical noncompliance, vulnerability to financial exploitation, and other threats to human flourishing. As with medical decision-making capacity, poor decisions alone do not invalidate an individual’s right to self-determination. And as with medical decision-making capacity, such determinations should not be made ad hoc or be capricious, but should rely on sound assessment criteria. When there are justified concerns that a patient may be vulnerable due to limited financial decision-making capacity, an evaluation should be completed and a surrogate payee be sought, when appropriate. (shrink)

The evaluations involved in shame are, intuitively at least, of many different sorts. One feels ashamed when seen by others doing something one would prefer doing alone (social shame). One is ashamed because of one’s ugly nose (shame about permanent traits). One feels ashamed of one’s dishonest behavior (moral shame), etc. The variety of evaluations in shame is striking; and it is even more so if one takes a cross-cultural perspective on this emotion. So the difficulty – the “unity problem” (...) of shame- turns out to be the following: is there a common trait shared by all shame evaluations that will allow us to differentiate these evaluations from those that feature in other negative self-reflexive emotions like anger at oneself or self disappointment? Some progress is perhaps accomplished if we say that, in shame, a given trait or behavior is evaluated as degrading or as revealing one’s lack of worth. Still, even if we agree with this last claim, truth is that these answers are less illuminating than we might wish. A theory of shame should surely further elucidate the aspect of one’s identity relevant for shame, namely, the self of shame. In this connexion, philosophers have referred to “self-esteem,” “self-respect” or the “social self,” significantly disagreeing thus on which aspect of one’s identity is at stake in shame. After critically discussing the different solutions to the problem, we offer our own. Shame, we claim, consists in an awareness of a distinctive inability to discharge a commitment that goes with holding self-relevant values. This conception solves the unity problem while illuminating other aspects of this emotion. (shrink)

BackgroundSocial support plays an important role for health outcomes. Support for those living with chronic conditions may be particularly important for their health, and even for their survival. The role of support for the survival of cancer patients after receiving an allogeneic hematopoietic cell transplant is understudied. To better understand the link between survival and support, as well as different sources and functions of support, we conducted two studies in alloHCT patients. First, we examined whether social support is related to (...) survival. Second, we examined who provides which support and which specific support-related functions and tasks are fulfilled by lay caregivers and healthcare professionals.MethodsIn Study 1, we conducted a retrospective chart review of alloHCT patients and registered availability of a dedicated lay caregiver and survival. In Study 2, we prospectively followed patients after alloHCT from the same hospital, partly overlapping from Study 1, who shared their experiences of support from lay caregivers and healthcare providers in semi-structured in-depth interviews 3 to 6 months after their first hospital discharge.ResultsPatients with a dedicated caregiver had a higher probability of surviving to 100 days than patients without a caregiver, OR = 2.84, p = 0.042. Study 2 demonstrated the importance of post-transplant support due to patients’ emotional needs and complex self-care regimen. The role of lay caregivers extended to many areas of patients’ daily lives, including support for attending doctor’s appointments, managing medications and financial tasks, physical distancing, and maintaining strict dietary requirements. Healthcare providers mainly fulfilled medical needs and provided informational support, while lay caregivers were the main source of emotional and practical support.ConclusionThe findings highlight the importance of studying support from lay caregivers as well as healthcare providers, to better understand how they work together to support patients’ adherence to recommended self-care and survival. (shrink)

David Hume and Adam Smith are often regarded as founding fathers of modern social science and champions of self-interested material acquisitiveness. Against this view I argue that their moral and political philosophies are better understood as modern installments in the classical tradition of virtue ethics. By focusing on Hume and Smith's conception of self-love and particularly on their distinction of self-love from self-interest, I demonstrate their dedication to encouraging virtues beyond the instrumental virtues of the market. (...) ;Hume and Smith regard egoism as a natural and inescapable element of human nature, but they also believe that egoism is educable. Untrained egoism manifests itself in such basic forms of selfishness as vanity and ambition, but a properly educated and elevated egoism heightens our sensitivity to the well-being of others. Through a careful analysis of their dialectical rhetoric, I show how Hume and Smith educate the egoism of their readers in their moral works. By so doing I demonstrate that the Scots understood themselves not merely as advocates of the pursuit of wealth, but as moral educators aspiring to introduce their readers to a life beyond the furious pursuit of external goods. Their portraits of magnanimous statesmen and wise and virtuous sages serve as models of this higher life, a life distinguished by the pursuit of moral nobility through beneficent activity. By tracing the Aristotelian and Ciceronian origins of their understanding of the relationship of self-love to benevolence, I thus show that far from celebrating commercial self-interest and denigrating virtue, Hume and Smith draw on classical sources in their attempts to ennoble modern liberalism and encourage decency and respect for the dignity of others. And by focusing particularly on their conception of the proper magnanimity for modernity, that of the wise and virtuous man, I argue that Hume's and Smith's practical writings on history, politics and economics are best regarded as attempts to discharge the beneficent duties they describe in their moral philosophy, and thereby claim wisdom and virtue for themselves. (shrink)

This paper has its roots in qualitative analysis of accounts produced by an Italian serial killer. Theoretical references are related to symbolic interactionism and its developments in the field of psychology and criminology. The whole contribution is aimed to twofold purposes: A) to provide a set of criteria specifically addressed to study deviant action as system of meanings into two related contexts: the single action itself and the whole life history. According this point, paper introduces the concept of “deviant career” (...) and it explains its development and steps; it also provides some psychological social points of views and contributions that scientific works offers. B) to think about potentialities of accounting interviews as powerful tools in clinical practice and empirical research too.Specifically, we discuss narrative about behaviour and life story as a resource in order to take suggestions about meanings, goals and rules of action. It also suggests something about functions that crime discharges in the whole pathway of one's life. Juridical case analysis, run by means of the software ATLAS.ti, is aimed to demonstrate theoretical reasoning proposed. (shrink)

There has recently been emphasis put on providing two-factor accounts of monothematic delusions. Such accounts would explain (1) whether a delusional hypothesis (e.g. someone else is inserting thoughts into my mind) can be understood as a prima facie reasonable response to an experience and (2) why such a delusional hypothesis is believed and maintained given its implausibility and evidence against it. I argue that if we are to avoid obfuscating the cognitive mechanisms involved in monothematic delusion formation we should split (...) the first factor (1 above) into two factors: how abnormal experience can give rise to a delusional ‘proto-hypothesis’ and how a ‘proto-hypothesis’ in consort with normal experiences and background information, can be developed into a delusional hypothesis. In particular I will argue that a schizophrenic is faced with the unusual requirement of having to identify an introspectively accessible thought as one's own, and that this requirement of identification is the central experiential abnormality of thought insertion, auditory verbal hallucination, and alien control (i.e. passivity symptoms). Additionally, I will consider non-experiential factors which are required for the formation of a delusional hypothesis. (shrink)

O debate consigo mesmo é um fenômeno corriqueiro. Diariamente tomamos decisões – sejam elas importantes ou triviais, teóricas ou práticas – em questões nas quais temos que escolher entre pelo menos duas opções. Para fazê-lo confrontamos uma com a outra seja deliberando pausadamente a respeito dos méritos de cada uma, seja impulsiva-mente adotando uma delas e descartando as demais. Os auto-debates que mais têm cha-mado a atenção dos filósofos são aqueles em que pareceria que a racionalidade é violada: do wishful (...) thinking ao auto-engano, passando pela akrasia e outras formas aparentemente paradoxais do pensar e do agir. Servindo-se de concepções da racionalidade e do debate desenvolvidas pelo autor, este artigo procura analisar a natureza do auto-debate e seus tipos, e mostrar que a irracionalidade que se costuma atribuir a alguns de seus exemplos típicos só se justifica devido a uma concepção que limita a racio-nalidade a seu modelo lógico-dedutivo.The debate with oneself is a common phenomenon. We make decisions every day – important or trivial, theoretical or practical – concerning issues in which we have to choose among at least two options. In order to do that we have to compare these options either by quietly reflecting about the merits of each one, or impulsively adopting one of them and discharging the others. The kinds of self-debate that have most attracted philosophers' attention are those in which rationality is apparently violated: from wishful thinking to self-deception, including akrasia and other apparently para-doxical forms of thinking and of acting. This paper tries to analyze the nature and differ-ent kinds of self-debate using the conceptions of rationality and of debate developed by the author, and tries to show that the irrationality that is usually attributed to some of its typical examples is only justified due to a conception that limits rationality to its logical-deductive model. (shrink)

The model for capacity assessment in the United States and much of the Western world relies upon the demonstration of four skills including the ability to communicate a clear, consistent choice. Yet such assessments often occur at only one moment in time, which may result in the patient expressing a choice to the evaluator that is highly inconsistent with the patient’s underlying values and goals, especially if a short-term factor (such as frustration with the hospital staff) distorts the patient’s preferences (...) momentarily. These challenges are particularly concerning in cases, which arise frequently in hospital settings, in which patients demand immediate self-discharge, often during off-hours, while faced with life-threatening risks. This paper examines the distinctive elements that shape such cases and explores their ethical implications, ultimately offering a model for such situations that can be operationalized. (shrink)

Recent neuro-psychoanalytic literature has emphasized the view that our subjective identity rests on ancient subcortical neuro-psychic processes expressing unthinking forms of experience, which are “affectively intense without being known” (Solms and Panksepp, 2012). Devoid of internal representations, the emotional states of our “core-Self” (Panksepp, 1998b) are entirely “projected” towards the external world and tend to be discharged through instinctual action-patterns. However, due to the close connections between the subcortical and the cortical midline brain, the emotional drives may also find (...) a way to be reflected within an intrinsic self-referential processing, evident when the organism is not actively engaged with the external world. Thanks to such endogenous functioning, the core-Self emotional dispositions are not overtly executed, but they are organized within coherent dynamic mental structures, called “feeling-toned complexes” by C.G. Jung and “unconscious phantasies” by Melanie Klein. The intrinsic self-referential dynamism of the ‘brainmind’ originated from REM sleep arousal and then evolved in the resting-state activity of a complex of cortico-limbic midline brain structures (CMS), also called Default Mode Network (DMN). From our neuro-ethological perspective, it is sustained by an “introverted” SEEKING activity leading to the subjective exploration of internally constructed virtual scenarios. This “mind wandering” function, implicated in dreaming, fantasy processing, remembering and thinking, is the essence of the imaginative function and constitutes the first form of reflection, where intentions and drives gain a primordial form of conscious (but not self-conscious) representation. During postnatal development, this original (“archetypal”) imaginative function is slowly attuned in a relational “transitional” space and may be expressed first in non-verbal and eventually in abstract-verbal social communicative patterns. Our view has noticeable implications for psychotherapy. Instead of trying to directly modify interpersonal, extrinsic relationships (a top-down approach), dysfunctional emotional-relational patterns may be modified by a process in which the patient is helped to let-go of the perceived feeling-objects in favor of an immersion, via the actual feeling, from the superficial level of perception towards a void feeling-state, empty of images. Only starting from this “anoetic” feeling-state, the deep imaginal creative and re-structuring self-referential activity may be reactivated by a process of spontaneous imagination. (shrink)

In many countries the military still threatens to punish personnel that disobey orders for the sake of self‐preservation. The Uniform Code of Military Justice (UCMJ) in the U.S., for instance, makes it a crime for a soldier to refuse a directive from a superior unless what that order requires is “patently unlawful”. This qualification is usually interpreted narrowly to cover orders to commit war crimes or to victimize civilians, not orders that would require sacrifice of life or limb. In (...) other words, soldiers are afforded some right of conscientious disobedience, but no right of non‐conscientious, self‐regarding disobedience.We would not think it morally justifiable for any civilian employer to demand and enforce obedience unto death. In most countries it is not legally justifiable, either. The U.S. Occupational Safety and Health Act (1970), for instance, grants workers a right to disobey an instruction and request an official workplace inspection if ever ever they believe that an “imminent danger” exists, where this is defined in terms of a reasonable expectation “of death or serious physical harm.” 5 The Act protects employees who exercise this right from discharge or retaliation. If it is not permissible for civilian employers to enforce compliance with such “imminently dangerous” directives, then why is it permissible for the military? This paper consider a number of possible responses to this question. (shrink)

The desire to self-improve is probably as old as humanity: most of us want to be smarter, more athletic, more beautiful, or more talented. However, in the light of an ever increasing array of possibilities to enhance our capacities, clarity about the purpose and goal of such efforts becomes crucial. This is especially true when decisions are made for children, who are exposed to their parents’ plans and desires for them under a notion of increasing wellbeing. In recent years, (...) cognitive enhancement has become a popular candidate for the promotion of wellbeing; welfarists even impose a moral duty on parents to cognitively enhance their children for the sake of their wellbeing. In this article, I aim to show that welfarists are mistaken in inferring such a moral obligation from the potential benefit of cognitive enhancement. In support of this, I offer three arguments: the vagueness of wellbeing as a theoretical concept means it becomes impossible to apply in practice; the link between cognition and wellbeing is far from unequivocal; and quantification issues with regard to cognition make a duty impossible to discharge. In conclusion, I reject the welfarist approach as a justification for a parental moral obligation to cognitively enhance children. (shrink)

However, Stein's self-images are more than appropriations of a male identity and masculine interests. Several of them are irrelevant to categories of sex and gender. In part, Stein is an obsessive psychologist, a Euclid of behavior, searching for "bottom natures," the substratum of individuality. She also tries to diagram psychic genotypes, patterns into which all individuals might fit. Although she plays with femaleness/maleness as categories, she also investigates an opposition of impetuousness and passivity, fire and phlegm; a variety of (...) regional and national types; and the dualism of the "dependent independent," who tends to resist. In part, as she puzzles her way towards knowing and understanding, she presents herself as engaged in aural and oral acts, listening and hearing before speaking and telling. That sense of perception as physical also emerges in a passage in which she, as perceiver/describer, first incorporates and then linguistically discharges the world: "Mostly always when I am filled up with it I tell it, sometimes I have to tell it, sometimes I like to tell it, sometimes I keep on with telling it."1 · 1. The Making of Americans: Being a History of a Family's Progress , p. 325. Catharine R. Stimpson, associate professor of English at Barnard College, is the editor of Signs: Journal of Women in Culture and Society and the author of J.R.R. Tolkien as well as other essays and fiction. See also: "Visual Rhetoric in The Autobiography of Alice B. Toklas" by Paul K. Alkon in Vol. 1, No. 4; "Gertrude Stein, the Cone Sisters, and the Puzzle of Female Friendship" by Carolyn Burke in Vol. 8, No. 3. (shrink)

While principle-based ethics is well known and widely accepted in psychiatry, much less is known about how decisions are made in clinical practice, which case scenarios exist, and which challenges exist for decision-making. Protocols of the central ethics committee responsible for four psychiatric hospitals over 7 years (N=17) were analysed. While four cases concerned suicide risk in the case of intended hospital discharge, the vast majority (N=13) concerned questions of whether the responsible physician should or should not initiate the (...) use of coercion in patients lacking mental capacity. The committee’s recommendations were non-uniform. Forced feeding and electroconvulsive therapy were endorsed in each one case. In two cases of intermittent loss of capacity due to heavy drinking or intermittent severe suicidal ideation, a self-binding contract was recommended and the use of coercion was considered as justified for a very limited period. In all other cases, most of which involved involuntary treatment, the use of coercion was not endorsed. Without exception, the recommendations were accepted with relief by the physicians and their treatment teams, who feared liability in the event of harm to the patient. Eventually, a model of a decision algorithm was derived from the ethical arguments in the protocols. (shrink)

Clinicians and administrators have a professional obligation to contribute to improvement of healthcare quality. At the same time, participation in embedded research poses risks to healthcare institutions. Disclosure of an institution’s sensitive information could endanger relationships with patients and undermine its reputation. The existing ethical framework for learning healthcare systems does not address the conflict between the OTC and institutional interests. Ethical guidance and policy regulation are needed to create a safe environment for embedded research. In this article we analyse (...) the EF for LHSs and the concept of professionalism. We suggest that the EF should be supplemented with an obligation to protect provider’s legitimate interests. We define legitimate interests as those that enable providers to discharge their primary duties. We argue that both the OTC and the obligation to protect legitimate interests are grounded in the concept of medical professionalism and can be understood as a matter of contract between a democratic society and medical professionals. The proposed supplemented EF can be implemented into a regulatory system in three different ways: the self-regulating: where providers decide themselves how to balance the ethical claims, the centralised: where a governmental institution decides the right balance between providers’ interests and interests of a health system; and the mediating: where medical professionals, the state and patients negotiate their interests. Our article contributes to the discussion on ethical relevance of providers’ interests and the regulatory model for weighing opposite interests in LHSs. (shrink)

Dignity of risk is a simple concept that is surprisingly hard to enact, honor, and prioritize in health care. The term was coined 50 years ago by Robert Perske in an article entitled "The Dignity of Risk and the Mentally Retarded". And as I have written in "Discharge Decisions and the Dignity of Risk", "the concept involves respect for persons, self-determination, and attempts to minimize paternalism or parentalism". Most simply, the dignity of risk embraces respecting or honoring an (...) individual's choices or decisions even in the face of potential harms.The central tension between safety/protection and autonomy/self-determination is at the core of the concept, but it also involves appraisals... (shrink)

Victims of injustice are prominent protagonists in efforts to resist injustice. I argue that they have a duty to do so. Extant accounts of victims’ duties primarily cast these duties as self-regarding duties or duties based on collective identities and commitments. I provide an account of victims’ duties to resist injustice that is grounded in the duty to assist. I argue that victims are epistemically privileged with respect to injustice and are therefore uniquely positioned to assist fellow victims. Primarily, (...) they discharge this duty through testimony: victims alert other actors to the need for assistance and initiate and coordinate resistance efforts. I briefly provide an account of oppression that ranges from persecution to structural injustice. Through the examples of torture and ‘manterrupting’, I illustrate the duty and its limits. I outline shortcomings in victims’ epistemic privilege and explore means by which these can be overcome. I respond to objections from demandingness and fairness, arguing that victims have an essential, albeit circumscribed, role to play in defeating injustice. (shrink)

This paper explores the moral responsibility a manager has toward a worker. The primary focus is upon those relationships whereworkers have been led to trust their managers. I argue that in such circumstances, models of the employment relationship based on rational self-interest fail to adequately describe the behavior of the actors. Rather, I show through case studies how trust operates in these environments to supercede pure, self-interested behavior. I then explore the moral implications of this finding relative to (...) those managers who lead their workers to trust them. I make the claim that these managers cannot adequately discharge their moral obligations unless they take on positive moral obligations. I cast this responsibility as one of positive care for some portion of worker welfare and briefly discuss what this might mean in practice. (shrink)

Background:The concept of patient advocacy is still poorly understood and not clearly conceptualized. Therefore, there is a gap between the ideal of patient advocacy and the reality of practice. In order to increase nursing actions as a patient advocate, a comprehensive and clear definition of this concept is necessary.Research objective:This study aimed to offer a comprehensive and clear definition of patient advocacy.Research design:A total of 46 articles and 2 books published between 1850 and 2016 and related to the concept of (...) patient advocacy were selected from six databases and considered for concept analysis based on Rodgers’ evolutionary approach.Ethical considerations:This study was approved by the Research Ethics Committee of Tarbiat Modares University.Findings:The attributes of patient advocacy are safeguarding (track medical errors, and protecting patients from incompetency or misconduct of co-workers and other members of healthcare team), apprising (providing information about the patient’s diagnosis, treatment, and prognosis, suggesting alternatives of healthcare, and providing information about discharge program), valuing (maintaining self-control, enabling patients to make decisions freely, maintaining individualization and humanity, maintaining patient privacy, and acting in the patients’ values, culture, beliefs, and preferences), mediating (liaison between patients, families, and healthcare professionals, being patients’ voice, and communicate patient preferences and cultural values to members of the healthcare team), and championing social justice in the provision of healthcare (confronting inappropriate policies or rules in the healthcare system, identifying and correcting inequalities in delivery of health services, and facilitating access to community health services and health resources).Discussion and conclusion:The analysis of this concept can help to develop educational or managerial theories, design instruments for evaluating the performance of nurses in patient advocacy, develop strategies for enhancing patient advocacy, and improve the safety and quality of nursing care in the community and healthcare system. (shrink)

In this paper, I do several things. First, I present a definition of ‘corruption’ as ‘abuse of power that builds or maintains the abuser’s power’, arguing that this definition is more generally applicable than other definitions offered in the literature and that it highlights a crucial property of corruption, namely its tendency to metastasise, presenting a more and more serious danger to society. To defend the emphasis I place on this tendency, I then argue that corruption (as commonly understood) frequently (...) produces three mechanisms pushing it to reproduce: self-perpetuation by the corrupt actors to protect themselves, formation of networks between corrupt actors which ensnare new participants, and normalisation of specific kinds of abuse of power in the corrupt actors’ social environments. From here, I turn to political parties, arguing that they present fertile soil for the mechanisms just described. In their stead, I argue for sortition—a system whereby legislators are randomly selected from the population at large. I make the case that each of the three metastatic mechanisms I have described would have much more difficulty taking root in a sortitional-democratic system than in an electoral-democratic one, before concluding by responding to a major potential objection to such a proposal’s feasibility—namely, that sortitional juries would be less competent than elected legislatures—and presenting a sketch of a sortitional-democratic system setting out how it could discharge the government’s executive functions, in addition to the legislative functions already covered. The paper as a whole, in addition to its explicit arguments, may be considered to make an implicit case for non-ideal over ideal theory, in that it attempts to show the importance of that quintessentially non-ideal factor, corruption, to the nature of any political order. (shrink)

I shall draw on my experience of being an ICU patient to make some practical, ethical, and philosophical points about the care of the critically ill. The recurring theme in this paper is ICU psychosis. I suggest that discharged patients ought to be educated about it; I discuss the obstacles in the way of accurately measuring it; I argue that we must rethink autonomy in light of it; and I suggest that the self disintegrates in the face of it.

In this essay, we examine the grounds, nature and content, status, acquisition and role, and justification of gratitude in Kant's ethical system, making use of student notes from Kant's lectures on ethics. We are especially interested in questions about the significance of gratitude in Kant's ethics. We examine Kant's claim that gratitude is a sacred duty, because it cannot be discharged, and explain how this claim is consistent with his insistence that “ought” implies “can.” We argue that for Kant a (...) proper understanding of self-esteem is importantly related to, if not necessary for, possession of the virtue of gratitude. (shrink)

The aim of this study was to assess the opinions and role of intensive care unit (ICU) nurses regarding the distribution of ICU beds. We conducted this research among 30% of the attendees at two ICU congresses in Turkey. A self-administered questionnaire was used, which included 13 cases and allocation criteria. Of the total (136 nurses), 53.7% participated in admission/discharge decisions. The most important criterion was quality of life as viewed by the physician; the least important was the (...) patient’s social status. According to the findings, the nurses thought that medical benefit and avoiding discrimination were important. On the other hand their ignorance of patients’ autonomous preferences arouses suspicions about these nurses’ role in advocating for patients’ rights. For this reason, nurses’ role in allocation decisions should be clearly described and should also be the basis on which intensive care nurses’ duties in allocation decisions should be determined. (shrink)

Concern for NGO accountability has been intensified in recent years, following the growth in the size of NGOs and their power to influence global politics and curb the excesses of globalization. Questions have been raised about where the sector embraces the same standards of accountability that it demands from government and business. The objective of this paper is to examine one aspect of NGO accountability, its discharge through annual reporting. Using Habermas’ theory of communicative action, and specifically its validity (...) claims, the research investigates whether NGOs use their annual reporting process to account to the host societies in which they operate or steer stakeholder actions toward their own self-interests. The results of the study indicate that efforts by organizations to account are characterized by communicative action through the provision of truthful disclosures, generally appropriate to the discharge of accountability and in a manner intended to improve their understandability. At the same time, however, some organizations exhibit strategically oriented behaviors in which the disclosure content is guided by the opportunity to present organizations in a particular light and there appears a lack of rhetor authenticity. The latter findings cast doubt on the ethical inspiration of NGOs and the values they demand from business communities, and questions arise as to why such practices exist and what lessons can be learnt from them. (shrink)

Equity is clearly central to Hobbes’s theory of the laws of nature, and it has an important place in his doctrine of the duties and exercise of sovereignty. It is also prominent in his general theory of law, especially as it is articulated in the late Dialogue between a Philosopher and a Student of the Common Laws of England. Still, it is not more central to Hobbes’s ethics, politics and legal philosophy than his concept of justice, or even as central. (...) On the contrary, his theory of justice is presupposed by his views about equity – in the sense that fidelity to a social contract is a condition of adjudication and definitive interpretation of law. Nor does equity contribute to a genuinely anti-authoritarian strand in Hobbes’s political philosophy. It is not as if, between the lines of that philosophy, Hobbes is a liberal. He does not think that the sovereign should exercise self-restraint because liberty and autonomy are good and sovereign self-restraint creates a space for both. Rather, he thinks that heavy-handed rule saps initiative, wealth and other resources from the people, making them less able to participate in or finance military action or internal state security. In other words, heavy-handed rule can make it harder for the sovereign to discharge the principal duty of sovereignty – ensuring public safety. (shrink)

This article both defines and shows the limits of settler shame for achieving decolonialized justice. It discusses the work settler shame does in “healing” the nation and delivering Canadians into a new sense of pride, thus maintaining the myth of the peacekeeping Canadian. This kind of shame does so, somewhat paradoxically, by making people feel good about feeling bad. Thus, the contiguous relationship of shame and recognition in a settler colonial context produces a form of pernicious self-recognition. Drawing on (...) the work of Sara Ahmed and Glen Coulthard, this article shows that a politics of recognition informed by settler shame has done little to actually see or hear Indigenous peoples on their own terms. Since settler shame is a self-directed emotion that seeks to be discharged through reconciliatory processes that are dependent on liberal recognition, it remains a mere optics of justice wedded to settler ignorance. The dependence on insufficient recognition renders the reconciliatory drive in Canada similarly insufficient, even harmful. Settler shame, then, is dangerous in relationship with recognition and reconciliation in Canada today, maintains settler colonialism, and forestalls Indigenous futurity and resurgence. (shrink)

In 1964, anesthesiologists at Harvard Medical School studied a group of patients about to undergo major abdominal surgery. Half the patients got the standard preoperative visit. The other half received an enhanced visit dealing with postoperative pain. That half were told that pain is normal and expected, that they would receive medications as ordered by their physicians, that they could also use several self-help techniques to relieve pain, and that nurses and physicians would be standing by to assist them (...) if needed. The enhanced-visit group ended up requesting half as many opioid analgesics as the other group, and they were discharged an average of two days earlier, despite successful blinding (Egbert et al.... (shrink)

Moral relativism is often rejected on grounds that it is either descriptively inadequate, at best, or self-defeating, at worst. In this essay, I swim against the predominant anti-relativistic philosophical tide. My minimal aim is to show that relativism is neither descriptively inadequate nor self-defeating. My maximal aim is to outline the beginnings of an argument that relativism is a truth resting on deep facts about the human normative predicament. And I shall suggest that far from being a source (...) of cultural degeneracy, the fact of relativism has the potential to ground a culture that is deeply life-affirming. My argument against the twin charges of descriptive inadequacy and self- defeat turns on a distinction between tolerant and intolerant relativism. I concede that many of the standard arguments against relativism do have force against tolerant relativism. But against intolerant relativism, those arguments are entirely unavailing. The crucial difference between the tolerant and intolerant relativist is that although the intolerant relativist agrees with the tolerant relativist that norms are relative, she insists that agents are sometimes entitled to hold others to norms by which they are not bound. I shall argue that just because the intolerant relativist allows that we are sometimes entitled to hold others to norms by which we are bound but they are not, she is able to escape both the charge of descriptive inadequacy and the charge of self- defeat. In particular, I shall show that the intolerant relativist has a coherent and satisfying account of the nature of moral disagreement and moral argument. Establishing the ultimate truth of relativism, however, would take more than showing that one form of relativism escapes certain standard arguments against relativism. Though I do not pretend to conclusively discharge the burden of showing that relativism is true in the space of this essay, I do sketch the beginnings of an account of what I call the bindingness of norms that has intolerant relativism as more or less straight-forward downstream consequence. If there are independent grounds for accepting that account of bindingness, then there are independent grounds for accepting intolerant moral relativism. (shrink)

What we perceive is the product of an intrinsic process and not part of external physical reality. This notion is consistent with the philosophical position of transcendental idealism but also agrees with physiological findings on the thalamocortical system. -Frequency rhythms of discharge activity from thalamic and cortical neurons are facilitated by cholinergic arousal and resonate in thalamocortical networks, thereby transiently forming assemblies of coherent oscillations under constraints of sensory input and prefrontal attentional mechanisms. Perception and conscious experience may be (...) based on such assemblies and sensory input to thalamic nuclei plays merely a constraining role in their formation. In schizophrenia, the ability of sensory input to modulate self-organisation of thalamocortical activity may be generally reduced. If during arousal thalamocortical self-organisation is underconstrained by sensory input, then attentional mechanisms alone may determine the content of perception and hallucinations may arise. (shrink)

Having been involved in a slew of recent scandals, many of the world’s largest technology companies embarked on devising numerous codes of ethics, intended to promote improved standards in the conduct of their business. These efforts have attracted largely critical interdisciplinary academic attention. The critics have identified the voluntary character of the industry ethics codes as among the main obstacles to their efficacy. This is because individual industry leaders and employees, flawed human beings that they are, cannot be relied on (...) voluntarily to conform with what justice demands, especially when faced with powerful incentives to pursue their own self-interest instead. Consequently, the critics have recommended a suite of laws and regulations to force the tech companies to better comply with the requirements of justice. At the same time, they have paid little attention to the possibility that individuals acting within the political context, e.g. as lawmakers and regulators, are also imperfect and need not be wholly compliant with what justice demands. This paper argues that such an omission is far from trivial. It creates a heavy argumentative burden on the part of the critics that they by and large fail to discharge. As a result, the case for Big Tech regulation that emerges from the recent literature has substantial lacunae and more work needs to be done before we can accept the critics’ calls for greater state involvement in the industry. (shrink)

Transcranial magnetic stimulation, EEG, and behavioral studies by our group implicate spurious activation of speech perception neurocircuitry in the genesis of auditory hallucinations in schizophrenia. The neurobiological basis of these abnormalities remains uncertain, however. We review our ongoing studies, which suggest that altered cortical coupling underlies speech processing in schizophrenia and is expressed via disrupted gamma resonances and impaired corollary discharge function of self-generated verbal thought.

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChua Hong Choon, Adjunct Associate ProfessorThe case for commentary describes a difficult, and yet not uncommon, clinical situation faced by clinicians at the Institute of Mental Health (IMH) in the course of their work. Based on the information provided on the case, the patient is likely to be suffering from the paranoid subtype of schizophrenia, and his illness is characterised by hostile and aggressive behaviour during episodes of (...) relapse.Although aggressive behaviour is known to be associated with young, male patients with paranoid delusions, auditory hallucinations and lack of insight,1 it is still necessary to exclude other causes of aggressive behaviour in this young man. Two causes of aggressive behaviour that are sometimes misattributed to schizophrenia are antisocial personality disorder and substance abuse. However, Mr. T did not have a history of conduct or behavioural problems prior to the onset of his psychotic illness, and he was also not reported to be violent or disruptive during the periods when he was on regular medication. There was also no history of illicit drug use.The initial onset of Mr. T’s illness while he was serving his National Service is a fairly common presentation of the first episode of schizophrenia in Singaporean males. While traits apparent prior to National Service such as his academic difficulties and inability to make friends are associated with the development of schizophrenia,2 the stress of regimented life and military drills might be more closely associated with his initial full-blown psychotic episode with prominent paranoid (and persecutory) delusions.The systematised nature of Mr. T’s delusions and the prominent threatening auditory hallucinations significantly increase his risk of [End Page 217] dangerousness,3 and when his wife became “incorporated” into his delusional beliefs, he began to threaten her physically during episodes of relapse. Despite being only 28 years old, Mr. T has already been hospitalised numerous times for inpatient treatment, due to frequent relapses of his illness. While relapses in schizophrenia may be attributed to various factors, including lack of social support, substance abuse, poor (or partial) response to medication and psychosocial stressors, Mr. T’s multiple relapses were primarily due to the stopping of his medication and his refusal to continue with any form of psychiatric treatment.The key problem to be addressed in this case is therefore the patient’s severe lack of insight which leads to recurrent episodes of treatment non-adherence and subsequent relapses.Mr. T’s wife has come to the clinic to ask for medication to secretly put into his food. Although the patient is apparently in remission of his condition (having just been treated and discharged from hospital), he has again stopped his medication, and she is justifiably afraid that he will become unwell again. Recognising that the patient’s lack of insight is the main (and possibly only) reason for his refusal to take medication, it would be prudent to first consider if all possible actions had been taken to create an awareness and to help the patient gain insight into his illness and the need to take medication. This may yet be possible in the window of opportunity that exists when the patient is in remission of his illness (and is therefore not disturbed by the symptoms of his psychotic disorder).Recent studies have demonstrated that psycho-education is able to reduce self-stigmatisation in individuals with schizophrenia, and also significantly improve insight 4 (as measured by the Birchwood’s Psychosis Insight Scale). A 2011 Cochrane Review 5 also concluded psycho-education does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stays in patients with schizophrenia. In this case, psycho-education could be given to Mr. T even after he has been discharged from hospital; he might not want to continue with medication, but he might consider seeing a trained clinician (case manager, nurse or medical social worker) to make sense of his life experiences. Engaging Mr. T through psycho-education may result in sufficient insight for him to consider resuming medication voluntarily, at least in the short term.Although there is a paucity of studies examining specific psycho-therapies (including cognitive behavioural therapy... (shrink)

This study set out to investigate the influence of male circumcision and other factors on sexually transmitted infections in Botswana. A syndromic approach, which diagnoses a sexually transmitted infection based on the presence of urethral discharge or genital ulcers rather than on laboratory tests, was used. The data were from the 2001 Botswana AIDS Impact Survey where a nationally representative, randomly selected sample of men and women aged 1064 years who had ever had sexual intercourse. The logistic regression technique (...) was executed to examine the association between male circumcision and self-reported urethral discharge or genital ulcers, while controlling for all other independent variables in the analysis. The main finding of this study was that among men who are circumcised, the odds for self-reported urethral discharge or genital ulcers are significantly lower than for those men who are not circumcised in both urban and rural Botswana. The analysis also showed that the odds in favour of self-reported urethral discharge or genital ulcers, for men who drink alcohol, are twice as large as those for men who do not drink alcohol, controlling for all other independent variables in the analysis. Religion and ethnicity also came through as factors exerting a protective influence against self-reported symptoms of sexually transmitted infections. The conclusion is that while male circumcision appears to be significantly associated with the risk for self-reported urethral discharge or genital ulcers, it is man’s behaviour, irrespective of ethnicity or religious dictates, that continues to play a vital role in protection against self-reported symptoms of sexually transmitted infections in Botswana. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Carmen MirandaJessica LesCarmen Miranda, she called herself today. She suffered from decades of schizoaffective disorder and now more recently, end–stage renal disease from uncontrolled diabetes. I first met Carmen two weeks prior when she had been brought to the hospital on a 72 hour psychiatric hold for self–harm. She failed to go to dialysis for a week, an act that would kill her if allowed to continue. Now (...) she was here again, for the same reason.Everyone of competent mind has the right to refuse medical treatment. Unfortunately, Carmen’s mind was not currently grounded in reality. So against her will, our family medicine team admitted her to the hospital and arranged for dialysis early the next morning. None of us liked doing this. Fortunately, when the time came for the dialysis tech to insert the dialysis catheter into her shunt, Carmen agreed peacefully. After her dialysis, we had no right to keep her in the hospital because her life was no longer in danger, at least until the next week. We discharged her to home. However the question remained, what about next time?To navigate this ethical gray zone, we called an ethics committee meeting. An ethicist, nurses, hospital social workers, the inpatient family medicine resident team, and most importantly, two people who knew her very well—her caseworker and long–term psychiatrist—discussed her case for an [End Page 103] hour. Our medicine team learned that in her last period of clarity two months prior, Carmen made contradictory statements regarding her wishes. Carmen told her caseworker she was tired of dialysis and being sick and stated it was time to let herself go. During the same lucid week she told her psychiatrist that she was grateful she had been forced to complete dialysis against her wishes after a run of non–adherence while suffering psychosis a couple of months prior. Now months later she was in a downward spiral, exacerbated by the deterioration of her mentally ill husband. If she missed a dialysis treatment here and there, it was okay, but when she went on a run missing several treatments, it was slow suicide.The ethics meeting concluded that Carmen needed to complete an advanced directive and select a power of attorney other than her gravely incompetent husband as soon as she was deemed competent. If she did not become lucid again, her psychiatric team should apply for conservatorship, a legally appointed person who serves as guardian for a gravely disabled mentally ill person. However, conservatorship would take months. In the interim, the ethics committee ruled that our medicine team would continue to provide lifesaving treatment for her, against her wishes if necessary.The ethics meeting adjourned but our medicine team remained in a gray area. To what length should we go to treat her? If she continued to refuse dialysis would we hold her in the hospital until she became sufficiently docile by inevitable uremia that we could peacefully dialyze her? Possibly. Would we go so far as to put her under anesthesia to complete her dialysis? Personally, I hoped not.Just three days after the ethics committee meeting, her caseworker found Carmen yelling nonsensical phrases through the front door of her home while her husband held the door shut with his beer belly and good shoulder. After gaining entry later in the day, Carmen’s caseworker found their mutual medication collection strewn in the bathtub and no food in the house. He placed Carmen on a psychiatric hold and transported her to the hospital. The emergency department paged me when Carmen arrived. I braced myself for the possibilities that lay ahead. When I reached Carmen, she was sitting in a room reserved for psychiatric patients and under watch by a friendly police officer accustomed to these situations.“Hi, Carmen,” I said, one step into her room. She sat on the edge of the gurney, wrapped in three blankets.“Cold,” she said.The police officer spoke from behind my shoulder, “She has been requesting cup after cup of ice water, she won’t take anything else.”“Let’s get you more comfortable.” I returned with a warm blanket and draped it over her... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Coward Conscience and Bad Conscience in Shakespeare and NietzscheSandra BonettoGeorge Bernard Shaw once observed that the whole of Nietzsche was expressed in three lines that Shakespeare puts into the mouth of one of his greatest villains, Richard III 1 : "Conscience is but a word that cowards use / Devised at first to keep the strong in awe / Our strong arms be our conscience; swords, our law" (5.6). (...) More specifically, perhaps, these lines invite a comparison between Shakespeare's repeated association of conscience with cowardice in Richard III, 2 and Nietzsche's negative evaluation of bad conscience, notably in On the Genealogy of Morals. 3 The aim of this article is to offer such a comparative analysis in order to demonstrate that Shakespeare's coward conscience anticipates Nietzsche's understanding of the bad conscience (das schlechte Gewissen) as "the consciousness of guilt" (GM, II, p. 67), including its involvement with the notions of debt, sin, punishment, and God.INietzsche devoted the Second Essay of his Genealogy to the discussion of bad conscience, its origins, and related matters, notably guilt (Schuld) and its relation to duty (Pflicht) and debt (Schuld). The German term Schuld denotes both guilt and debt, and both senses are inextricably linked in Nietzsche's analysis. The bad conscience as consciousness of guilt is also [End Page 512] the consciousness of a debt owed—to another individual, society, and above all to the Christian God. The debt owed to God is one that can never be repaid, so that Christian morality necessitates guilt as "eternal punishment" for man's original transgression (see GM, II, pp. 91–92). Thus, Nietzsche argues, the descriptive equivalent of bad conscience, in the language of Christianity, is sin—"this is the priestly name for the... bad conscience" (GM, III, p. 140). In other words, sin is essentially a debt contracted with God. This is evident, for instance, in the substitution of the word "sin" for "debt" (ophéilema) in the formula of the Our Father as found in St. Luke. Even in the more general description, e.g. in the passage of St. Matthew where Jesus is explaining the implications of the petition "Forgive us or debts as we forgive our debtors," where the expressions paràptoma (fault, error) and armatia (aberration, failing, defect in relation to a norm or whole) are the more common terms used to denote sin, the sense of debt is implicit—we only accept our failure in relation to the Christian norm or whole if we accept that we "owe it to God" to live up to that norm in the first place. Moreover, the notion of debt brings with it the debtor's fear of failing to repay the creditor, so that a fear of punishment results from the sense of not living up to the contractual relationship with God.According to Nietzsche, the basis for the bad conscience and guilt, which he further defines as "anger directed against the self" (GM, I, p. 45), is cruelty, a natural human disposition that is displayed unabashedly in punishment. Bad conscience, he argues, is cruelty turned inward and essentially amounts to self-punishment or "psychical cruelty"—a form of subliminal suffering we impose on ourselves. Speaking of the "psychology of conscience," Nietzsche emphasises therefore that conscience "is not 'the voice of God in man'—it is rather the instinct of cruelty that turns back after it can no longer discharge itself externally" (GM, "A Polemic," p. 312). Bad conscience, or sin, is cruelty directed backwards, at oneself. In short, Nietzsche holds that the bad conscience, experienced by us as the "bite" or "sting" of conscience (morsus conscientiae; Gewissensbiss), results from the internalisation of instincts, notably the instincts to cruelty. Rather than acting on natural impulses, man has come to stifle and repress them: "Hostility, cruelty, joy in persecuting, in attacking, in change, in destruction—all this turned against the possessors of such instincts: that is the origin of the "'bad conscience'" (GM, II, p.85).Anticipating Freud's theory of repression and pre-empting his psychological interpretation of conscience as superego (Über-Ich), Nietzsche argues, "all instincts that do not discharge themselves outwardly turn [End Page 513... (shrink)

Regina R. is a 12-year-old girl with recently diagnosed insulin-dependent diabetes. Before discharging her from the hospital, her family physician and consulting diabetes specialist try to instruct the girl and her parents in the appropriate program of treatment, including diet, insulin, and regular self-monitoring. However, the parents become upset when they learn what is involved in insulin treatment and inform the family physician they plan to employ the services of an alternative healing clinic that promises to cure their daughter (...) with a combination of herbal potions, macrobiotics, aroma therapy, therapeutic touch, Ayurveda, homeopathy, and guided imagery. (shrink)

This guide accompanies the following article(s): ‘Full Disclosure of the “Raw Data” of Research on Humans: Citizens’ Rights, Product Manufacturer’s Obligations and the Quality of the Scientific Database.’Philosophy Compass 6/2 (2011): 90–99. doi: 10.1111/j.1747‐9991.2010.00376.x Author’s Introduction Securing consent (and informed consent) from patients and research study participants is a key concern in patient care and research on humans. Yet, the legal doctrines of consent and informed consent differ in their applications. In patient care, the judicial doctrines of consent and informed (...) consent are disclosure doctrines based on the obligation of physicians to inform their patients of the following types of information: the nature of the procedure the physician is recommending in the patent’s care (P), the alternatives to the physician‐recommendation (A), and the risks of procedure and its alternatives (R). In addition, the physician must provide truthful answers to the patient’s questions (Q) to the best of the physician’s abilities. In research on humans, the onus of disclosure by study sponsors and principal investigators is much greater than in patient care precisely because the purpose of research is not patient care. The purpose of research is the identification and development of new generalizable knowledge. Thus, participation in a research study or trial may not benefit the study volunteer at all. In addition, the participant may carry a heavy risk burden in relationship to any testing of a newly designed drug or device as part of their experiences in the research study. Presently, despite the risks borne by the research study participant, the raw data collected from volunteers in research trials are treated by courts as if they were the private property of the study sponsor rather than generally owed to the public as would be expected by an effort like research participation aimed at contributing to the development of generalizable knowledge. This paper reviews the obligations that study sponsors owe to their study participants based on the very definition of research as a systematic activity whose purpose is to develop generalizable knowledge to help all humans. Author Recommends Court cases Canterbury v. Spence, United States Court of Appeals, District of Columbia Circuit 464 F.2d 772 (1972). (Federal appellate decision heard in the District of Columbia, USA) Reibl v. Hughes, 2 S.C.R. 880 (1980). (Supreme Court of Canada) Rogers v. Whitaker, 175 C.L. R. 479 (1992). (High Court of Australia) Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others. 1 A.C. 871 (1985) (House of Lords) Canterbury v. Spence is the landmark Federal informed consent case in the United States heard in the District of Columbia. In this case, Judge Spottswood Robinson articulated the reasonable person standard of informed consent. This standard was subsequently adopted by the Supreme Court of Canada (Reibl v. Hughes, 2 S.C.R. 880 (1980)) and the High Court of Australia (Rogers v. Whitaker, 175 C.L. R. 479 (1992)). The House of Lords rejected the reasonable person standard in England in Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others. 1 A.C. 871 (1985). Book Mazur, Dennis J. The Science and Ethics of Research on Humans. Baltimore, MD: Johns Hopkins University Press, 2007. This book is a detailed guide for the review of scientific and ethical aspects of research on humans contained in the research study protocols and research informed consent forms which need to be submitted by study sponsors and principal investigators to institutional review boards (IRBs) for IRB review before a research study can receive approval to be conducted within a human study population in those institutions over which the IRB has authority. It also presents basic definitions in the area of research on humans and basic approaches to help conduct a deep review of the underlying scientific and ethical issues that are present within a research study protocol and its accompanying research informed consent form. Report National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Guidelines for the Protection of Human Subjects of Research. Washington, DC: DHEW Publications, 1978 (78‐0012). This U.S. National Commission in the Belmont Report argued for the necessity of a reasonable volunteer standard in research on humans in the United States. Arguing that the professional standard and the reasonable person standard of consent and informed consent were insufficient to base a disclosure standard in research on humans, this National Commission developed the reasonable volunteer standard where a study participant is to be approached in research informed consent with that information that a reasonable volunteer would want to know. Online Materials Belmont Report: Syllabus Topics for Lecture and Discussion Week I: Introduction and Overview Readings: Rogers v. Whitaker, 175 C.L.R. 479 (1992). (High Court of Australia) Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others. 1 A.C. 871 (1985) (House of Lords) Week II: The Different Standards of Consent and Informed Consent Readings: Canterbury v. Spence, 464 F.2d 772 (1972). (Federal appellate opinion heard in the District of Columbia) Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others. 1 A.C. 871 (1985) (House of Lords) Week III: Definition of Research Reading: Mazur, Dennis J. The Science and Ethics of Research on Humans. Baltimore, MD: Johns Hopkins University Press, 2007. (Especially Chapters 2 and 3) Week IV: How to Review a Research Study Protocol and Research Informed Consent Form Reading: Mazur, Dennis J. The Science and Ethics of Research on Humans. Baltimore, MD: Johns Hopkins University Press, 2007. (Especially Chapters 4–6, 10, and 12–14) Week V: Obligations in Research of Humans Versus Patient Care Reading: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Guidelines for the Protection of Human Subjects of Research. Washington, DC: DHEW Publications, 1978 (78‐0012). Focus Questions • How do the judicial doctrines of consent in England and Australia compare to the judicial doctrines of informed consent in the United States and Canada? • How does a professional standard of disclosure differ from a reasonable person standard of disclosure? • What is the definition of research? • How is a research study (study proposal and research informed consent form) reviewed from scientific and ethical bases for considerations of approval by an IRB? • How do the obligations of a study sponsor, a principal investigator, and a research team conducting a research trial on human study participants differ from the obligations of a physician caring for a patient? • Should all raw data of research derived from humans be made available to the public for use in developing generalizable knowledge to help others, or should raw data be considered the private property of the study sponsors (for example, prescription drug manufacturers), who fund the research trials? Seminar/project Idea Draw a timeline of the development of the basic concepts of consent and informed consent in patient care and in patient research. On this timeline, first place the dates of the key court cases in England, the United States, Canada, and Australia on consent and informed consent. Then place the date of the development of the Belmont Report. Why do differences exist between these four countries in terms of the legal requirements of informedness of a patient (in medical care) and a study participant (in medical research)? What roles if any do the concepts of self‐determination and self‐decision have in consent and informed consent in patient care and in informed consent in research on humans among the four countries of interest? What are the realities of research on human participants that require a new standard of informed consent, the reasonable volunteer standard, to be developed beyond the two standards in patient care, the professional standard, and the reasonable person standard? Counterpoint Arguments The following are counterpoint arguments that need to be appreciated to more fully understand the concepts that impact the thesis that ‘raw data’ should be open to the public to allow the opportunity of checking of the results of its associated scientific paper and for further analysis. De‐Identified (Anonymized) Raw Data A current approach to identifying (anonymizinig) raw data is based on the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104‐191). HIPAA was enacted by the U.S. Congress in 1996 to keep a person’s medical information private. In a research study, a person’s private medical information can become research data. HIPAA’s Privacy Rule allows a covered entity to de‐identify data by removing all 18 elements that could be used to identify the individual or the individual’s relatives, employers, or household members; these elements are enumerated in the Privacy Rule. The covered entity must also have no actual knowledge that the remaining information could be used alone or in combination with other information to identify the individual who is the subject of the information. Under this method, the identifiers that must be removed are the following: 1 Names. 2 All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP Code, and their equivalent geographical codes, except for the initial three digits of a ZIP Code if, according to the current publicly available data from the Bureau of the Census: 2a. The geographic unit formed by combining all ZIP Codes with the same three initial digits contains more than 20,000 people. 2b. The initial three digits of a ZIP Code for all such geographic units containing 20,000 or fewer people are changed to 000. 3 All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, and date of death, and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older. 4 Telephone numbers. 5 Facsimile numbers. 6 Electronic mail addresses. 7 Social security numbers. 8 Medical record numbers. 9 Health plan beneficiary numbers. 10 Account numbers. 11 Certificate/license numbers. 12 Vehicle identifiers and serial numbers, including license plate numbers. 13 Device identifiers and serial numbers. 14 Web universal resource locators (URLs). 15 Internet protocol (IP) address numbers. 16 Biometric identifiers, including fingerprints and voiceprints. 17 Full‐face photographic images and any comparable images. 18 Any other unique identifying number, characteristic, or code, unless otherwise permitted by the Privacy Rule for re‐identification. Even though ‘raw data’ can be de‐identified (anonymized) so that there is no way to trace back the data to the study participant from which it was drawn, there are still questions whether the ‘de‐identified raw data’ can be given to other researchers or made public without the original study participant’s approval. It may be the case that this approval could be done at the start of any research study where the individual considering study participation would be counseled on what the process of de‐identification consists of and would be asked whether the participant would allow use of the data by other researchers or made available to the public in a de‐identified state. However, there may be questions of the study participants as to whether the data are truly de‐identified and untraceable back to the study participant since the participant would not be able to see the process actually being carried out in detail in all relevant circumstances. Using Raw Data in Context Simply being in possession of raw data is never enough to build on that data from a research perspective. Researchers need to understand the context of the scientific research study in which the data were collected. This research context includes (but is not limited to): (i) the scientific hypothesis of the research study, (ii) the inclusion and exclusion criteria selected by the research designers of the study to determine which study participants were included and which were excluded from the study, (iii) the methods used to collect the data and possibilities of errors in the data collection processes, and (iv) answers to questions regarding whether any data were excluded from the study data and why these data were excluded. Ownership Rights Over Data There are ownership rights over data. Ownership rights include court decision making related to the question which parties are to be considered as the owners of the data. Possible owners here include (but are not limited to) (i) the study sponsor whose only role was to fund that study, (ii) the principal investigator(s) who developed the scientific hypothesis, and (iii) individual study participants through special contracts made by individual participants who negotiate such contracts with study sponsors and principal investigators to share in the ownership of data. Examples of such data are participant sources of unique gene lines or unique cell lines to be used in future research. Objections to Data Sharing Finally, individual researchers may simply object to sharing data. A researcher’s arguments here may be simply stating that he or she has a right to fully analyze the data since the collection of the data was the researchers’ idea in the first place. These researchers may argue that they have the right to mine the data as fully as they can before deciding to make the data open to the public for others to analyze. Works Cited 1 Kaiser, J. ‘Making Clinical Data Widely Available.’Science 322.5899 (10 Oct. 2008): 217–8. 2 de Lusignan, S., J.F. Metsemakers, P. Houwink, V. Gunnarsdottir, and J. van der Lei. ‘Routinely Collected General Practice Data: Goldmines for Research? A Report of the European Federation for Medical Informatics Primary Care Informatics Working Group (EFMI PCIWG) from MIE2006, Maastricht, The Netherlands.’Informatics in Primary Care 14.3 (2006): 203–9. 3 Sim, I. ‘Human Studies Database Project’, CTSA Data Repositories Symposium (17 Oct. 2008). 23 Nov. 2010. 4 Sim, I., C.G. Chute, H. Lehmann, R. Nagarajan, M. Nahm, and R.H. Scheuermann. ‘Keeping Raw Data in Context.’Science 323.5915 (6 Feb. 2009): 713. 5 U.S. Department of Health and Human Services, National Institutes of Health, HIPAA Privacy Rule, Information for Researchers. 13 Nov. 2010. 6 Wilczynski, N.L., R.B. Haynes, and Hedges Team. ‘EMBASE Search Strategies for Identifying Methodologically Sound Diagnostic Studies for Use by Clinicians and Researchers.’BMC Medicine 29.3 (March 2005): 7. (shrink)

This guide accompanies the following article(s): ‘Full Disclosure of the “Raw Data” of Research on Humans: Citizens’ Rights, Product Manufacturer’s Obligations and the Quality of the Scientific Database.’Philosophy Compass 6/2 (2011): 90–99. doi: 10.1111/j.1747‐9991.2010.00376.x Author’s Introduction Securing consent (and informed consent) from patients and research study participants is a key concern in patient care and research on humans. Yet, the legal doctrines of consent and informed consent differ in their applications. In patient care, the judicial doctrines of consent and informed (...) consent are disclosure doctrines based on the obligation of physicians to inform their patients of the following types of information: the nature of the procedure the physician is recommending in the patent’s care (P), the alternatives to the physician‐recommendation (A), and the risks of procedure and its alternatives (R). In addition, the physician must provide truthful answers to the patient’s questions (Q) to the best of the physician’s abilities. In research on humans, the onus of disclosure by study sponsors and principal investigators is much greater than in patient care precisely because the purpose of research is not patient care. The purpose of research is the identification and development of new generalizable knowledge. Thus, participation in a research study or trial may not benefit the study volunteer at all. In addition, the participant may carry a heavy risk burden in relationship to any testing of a newly designed drug or device as part of their experiences in the research study. Presently, despite the risks borne by the research study participant, the raw data collected from volunteers in research trials are treated by courts as if they were the private property of the study sponsor rather than generally owed to the public as would be expected by an effort like research participation aimed at contributing to the development of generalizable knowledge. This paper reviews the obligations that study sponsors owe to their study participants based on the very definition of research as a systematic activity whose purpose is to develop generalizable knowledge to help all humans. Author Recommends Court cases Canterbury v. Spence, United States Court of Appeals, District of Columbia Circuit 464 F.2d 772 (1972). (Federal appellate decision heard in the District of Columbia, USA) Reibl v. Hughes, 2 S.C.R. 880 (1980). (Supreme Court of Canada) Rogers v. Whitaker, 175 C.L. R. 479 (1992). (High Court of Australia) Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others. 1 A.C. 871 (1985) (House of Lords) Canterbury v. Spence is the landmark Federal informed consent case in the United States heard in the District of Columbia. In this case, Judge Spottswood Robinson articulated the reasonable person standard of informed consent. This standard was subsequently adopted by the Supreme Court of Canada (Reibl v. Hughes, 2 S.C.R. 880 (1980)) and the High Court of Australia (Rogers v. Whitaker, 175 C.L. R. 479 (1992)). The House of Lords rejected the reasonable person standard in England in Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others. 1 A.C. 871 (1985). Book Mazur, Dennis J. The Science and Ethics of Research on Humans. Baltimore, MD: Johns Hopkins University Press, 2007. This book is a detailed guide for the review of scientific and ethical aspects of research on humans contained in the research study protocols and research informed consent forms which need to be submitted by study sponsors and principal investigators to institutional review boards (IRBs) for IRB review before a research study can receive approval to be conducted within a human study population in those institutions over which the IRB has authority. It also presents basic definitions in the area of research on humans and basic approaches to help conduct a deep review of the underlying scientific and ethical issues that are present within a research study protocol and its accompanying research informed consent form. Report National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Guidelines for the Protection of Human Subjects of Research. Washington, DC: DHEW Publications, 1978 (78‐0012). This U.S. National Commission in the Belmont Report argued for the necessity of a reasonable volunteer standard in research on humans in the United States. Arguing that the professional standard and the reasonable person standard of consent and informed consent were insufficient to base a disclosure standard in research on humans, this National Commission developed the reasonable volunteer standard where a study participant is to be approached in research informed consent with that information that a reasonable volunteer would want to know. Online Materials Belmont Report: Syllabus Topics for Lecture and Discussion Week I: Introduction and Overview Readings: Rogers v. Whitaker, 175 C.L.R. 479 (1992). (High Court of Australia) Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others. 1 A.C. 871 (1985) (House of Lords) Week II: The Different Standards of Consent and Informed Consent Readings: Canterbury v. Spence, 464 F.2d 772 (1972). (Federal appellate opinion heard in the District of Columbia) Sidaway v. Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others. 1 A.C. 871 (1985) (House of Lords) Week III: Definition of Research Reading: Mazur, Dennis J. The Science and Ethics of Research on Humans. Baltimore, MD: Johns Hopkins University Press, 2007. (Especially Chapters 2 and 3) Week IV: How to Review a Research Study Protocol and Research Informed Consent Form Reading: Mazur, Dennis J. The Science and Ethics of Research on Humans. Baltimore, MD: Johns Hopkins University Press, 2007. (Especially Chapters 4–6, 10, and 12–14) Week V: Obligations in Research of Humans Versus Patient Care Reading: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Guidelines for the Protection of Human Subjects of Research. Washington, DC: DHEW Publications, 1978 (78‐0012). Focus Questions • How do the judicial doctrines of consent in England and Australia compare to the judicial doctrines of informed consent in the United States and Canada? • How does a professional standard of disclosure differ from a reasonable person standard of disclosure? • What is the definition of research? • How is a research study (study proposal and research informed consent form) reviewed from scientific and ethical bases for considerations of approval by an IRB? • How do the obligations of a study sponsor, a principal investigator, and a research team conducting a research trial on human study participants differ from the obligations of a physician caring for a patient? • Should all raw data of research derived from humans be made available to the public for use in developing generalizable knowledge to help others, or should raw data be considered the private property of the study sponsors (for example, prescription drug manufacturers), who fund the research trials? Seminar/project Idea Draw a timeline of the development of the basic concepts of consent and informed consent in patient care and in patient research. On this timeline, first place the dates of the key court cases in England, the United States, Canada, and Australia on consent and informed consent. Then place the date of the development of the Belmont Report. Why do differences exist between these four countries in terms of the legal requirements of informedness of a patient (in medical care) and a study participant (in medical research)? What roles if any do the concepts of self‐determination and self‐decision have in consent and informed consent in patient care and in informed consent in research on humans among the four countries of interest? What are the realities of research on human participants that require a new standard of informed consent, the reasonable volunteer standard, to be developed beyond the two standards in patient care, the professional standard, and the reasonable person standard? Counterpoint Arguments The following are counterpoint arguments that need to be appreciated to more fully understand the concepts that impact the thesis that ‘raw data’ should be open to the public to allow the opportunity of checking of the results of its associated scientific paper and for further analysis. De‐Identified (Anonymized) Raw Data A current approach to identifying (anonymizinig) raw data is based on the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104‐191). HIPAA was enacted by the U.S. Congress in 1996 to keep a person’s medical information private. In a research study, a person’s private medical information can become research data. HIPAA’s Privacy Rule allows a covered entity to de‐identify data by removing all 18 elements that could be used to identify the individual or the individual’s relatives, employers, or household members; these elements are enumerated in the Privacy Rule. The covered entity must also have no actual knowledge that the remaining information could be used alone or in combination with other information to identify the individual who is the subject of the information. Under this method, the identifiers that must be removed are the following: 1 Names. 2 All geographic subdivisions smaller than a state, including street address, city, county, precinct, ZIP Code, and their equivalent geographical codes, except for the initial three digits of a ZIP Code if, according to the current publicly available data from the Bureau of the Census: 2a. The geographic unit formed by combining all ZIP Codes with the same three initial digits contains more than 20,000 people. 2b. The initial three digits of a ZIP Code for all such geographic units containing 20,000 or fewer people are changed to 000. 3 All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, and date of death, and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older. 4 Telephone numbers. 5 Facsimile numbers. 6 Electronic mail addresses. 7 Social security numbers. 8 Medical record numbers. 9 Health plan beneficiary numbers. 10 Account numbers. 11 Certificate/license numbers. 12 Vehicle identifiers and serial numbers, including license plate numbers. 13 Device identifiers and serial numbers. 14 Web universal resource locators (URLs). 15 Internet protocol (IP) address numbers. 16 Biometric identifiers, including fingerprints and voiceprints. 17 Full‐face photographic images and any comparable images. 18 Any other unique identifying number, characteristic, or code, unless otherwise permitted by the Privacy Rule for re‐identification. Even though ‘raw data’ can be de‐identified (anonymized) so that there is no way to trace back the data to the study participant from which it was drawn, there are still questions whether the ‘de‐identified raw data’ can be given to other researchers or made public without the original study participant’s approval. It may be the case that this approval could be done at the start of any research study where the individual considering study participation would be counseled on what the process of de‐identification consists of and would be asked whether the participant would allow use of the data by other researchers or made available to the public in a de‐identified state. However, there may be questions of the study participants as to whether the data are truly de‐identified and untraceable back to the study participant since the participant would not be able to see the process actually being carried out in detail in all relevant circumstances. Using Raw Data in Context Simply being in possession of raw data is never enough to build on that data from a research perspective. Researchers need to understand the context of the scientific research study in which the data were collected. This research context includes (but is not limited to): (i) the scientific hypothesis of the research study, (ii) the inclusion and exclusion criteria selected by the research designers of the study to determine which study participants were included and which were excluded from the study, (iii) the methods used to collect the data and possibilities of errors in the data collection processes, and (iv) answers to questions regarding whether any data were excluded from the study data and why these data were excluded. Ownership Rights Over Data There are ownership rights over data. Ownership rights include court decision making related to the question which parties are to be considered as the owners of the data. Possible owners here include (but are not limited to) (i) the study sponsor whose only role was to fund that study, (ii) the principal investigator(s) who developed the scientific hypothesis, and (iii) individual study participants through special contracts made by individual participants who negotiate such contracts with study sponsors and principal investigators to share in the ownership of data. Examples of such data are participant sources of unique gene lines or unique cell lines to be used in future research. Objections to Data Sharing Finally, individual researchers may simply object to sharing data. A researcher’s arguments here may be simply stating that he or she has a right to fully analyze the data since the collection of the data was the researchers’ idea in the first place. These researchers may argue that they have the right to mine the data as fully as they can before deciding to make the data open to the public for others to analyze. Works Cited 1 Kaiser, J. ‘Making Clinical Data Widely Available.’Science 322.5899 (10 Oct. 2008): 217–8. 2 de Lusignan, S., J.F. Metsemakers, P. Houwink, V. Gunnarsdottir, and J. van der Lei. ‘Routinely Collected General Practice Data: Goldmines for Research? A Report of the European Federation for Medical Informatics Primary Care Informatics Working Group (EFMI PCIWG) from MIE2006, Maastricht, The Netherlands.’Informatics in Primary Care 14.3 (2006): 203–9. 3 Sim, I. ‘Human Studies Database Project’, CTSA Data Repositories Symposium (17 Oct. 2008). 23 Nov. 2010. 4 Sim, I., C.G. Chute, H. Lehmann, R. Nagarajan, M. Nahm, and R.H. Scheuermann. ‘Keeping Raw Data in Context.’Science 323.5915 (6 Feb. 2009): 713. 5 U.S. Department of Health and Human Services, National Institutes of Health, HIPAA Privacy Rule, Information for Researchers. 13 Nov. 2010. 6 Wilczynski, N.L., R.B. Haynes, and Hedges Team. ‘EMBASE Search Strategies for Identifying Methodologically Sound Diagnostic Studies for Use by Clinicians and Researchers.’BMC Medicine 29.3 (March 2005): 7. (shrink)

SUMMARYThis Study reviews the prevalent concepts of maturation and motivation, and develops the following points :1. Developmental and clinical child Psychology are held apart less because of à differing focus of interests than because of differing concepts of maturation and motivation.2. Maturation is à term applied in biology and Psychology to, the development of the individual by growth processes, as distinguished from development by exercise and learning. It is defined in terms of à sequence or order of phases.3. Sequences can (...) be affected by conditioning. It is suggested that only the groundplan of life, the order of phases from birth through maturity and reproduction to death, is unalterable. Maturation is but one contributing factor, or principle, which co‐determines the more complex process of development.4. The goal‐determining factor in the individuals striving is called motivation. There are two major categories of motivation changes : the basic tendency of life is to establish the individuals equilibrium. From this point of view, all changes of direction are due to environmental influences which call for adaptation to reestablish equilibrium . The second category, the thesis of this Study, is that life is expansion , à process involving the homeostatic mechanism. In the course of the expansive as well as of the adaptive process, the individual changes its direction. Direction changes may be experienced in the act of reproduction when the individual transmits energies to new life; again, in the act of self‐limitation when the productive energies have been exhausted; another change of direction is that from flight movements to experimentation with and mastery of stimuli.5. Three developmental theories have been forwarded. The first, based on the concept of evolution, is à structuralization theory of development. The second, à biogenic theory of development, is related to the growth process and hypothecates à parallel of physical and Psychological development. The third developmental theory describes development as à change of motivation– an adaptation process resulting from the individuals dynamic relationship to his environment.The three theories emphasize three indispensable aspects of the developmental process: organization, content and form, Dynamics and objectives.6. Only the last of these three theories explained the fact of personality immaturity in relationship to the physical maturation, since the adaptive and the physical growth process could be conceived of as relatively independent from each other.7. Objections are raised against this theory of adaptation, to the extent that it claims adaptation to be identical with development.8. Objections are raised against the definition of the discharge principle as the basic tendency of the organism and against the identification of the discharge with the homeostasis principle.9. Since homeostasis is defined as an optimal tension level, and not as its lowest possible level, there must be states of tension which are overly‐low as well as overly‐high. In states of too‐low tension, charging must be à basic tendency of the organism.10. The main properties of life are growth and reproduction– that is, expansion, in which the environment is being exploited, adapted to life, mastered by the living being. Adaptation to the environment is only à partial aspect of life, and may be used as à detour to the opposite goal.11. All living beings have à course of life during which they develop structures that anticipate future needs. Theľ work with reserves. Anľ given need of à living being must be considered as related to the present, past and future of its life. As à consequence, it is impossible to assume that à tendency related only to the moment plays à basic role in the life of the individual. The acute release tendency relates only to acute phases or features of the needs of the immediate present.12. Consequently, deferral occurs not onlt in the course of adaptation, and as an imposed phenomenon; deferral may also occur as unimposed, unlearned behavior whenever the individual is not quite prepared for à desired experience.13. Motivation during growth and during decline is described and analyzed.14. Creativity is defined as constructive activity, à process which has its biological substratum in growth and reproduction. It consists of forming new products which develop, first, from experimentation with materials, and second, from the masterful handling of those materials.15. The probability of the processes of unlearned cooperation is presented.16. Neurosis is found to originate in connection with feelings of guilt and remorse over failing oneself as well as over failing others.17. The aim of life is seen in the contribution of biologically and/or culturally constructive products which can be utilized in the building process of life and of culture. (shrink)

The spatial dynamics of the optical emission from an array of 50 times 50 individual microcavity plasma devices is investigated. The array is operated in argon and argon-neon mixtures close to atmospheric pressure with an ac voltage. The optical emission is analysed with phase and space resolution. It has been found that the emission is not continuous over the entire ac period, but occurs once per half period. Each of the observed emission phases shows a self-pulsing of the (...) class='Hi'>discharge, with several bursts of emission of fixed width and repetition rate. The number of emission bursts depends on applied voltage and frequency. Spatially resolved measurements prove that the emission bursts are formed by overlapping emission pulses from single discharge cavities. Intensity differences between positive and negative half-wave can be interpreted through spatially resolved measurements of single discharge cavities. (shrink)

This paper argues that Chris Marker's 1982 film Sans Soleil derives its affective force from doublings and ‘faces’ of horror and beauty that reveal a twofold synthesis of actual and virtual. While a focus upon the material, ever in relation to transient yet lingering sensations, cannot discharge the power and force of the film, this paper endeavours nevertheless to assess and evoke Marker and Deleuze's own interrogative methods that thoroughly explore, in the manner of a revelatory ‘schizoanalysis’ or empiricism, (...) molecular and variable operations beneath our ‘molar’ structures and organisations. As Sans Soleil's voiceover states, ‘If they don't see happiness in the picture, at least they'll see the black’, a provocative remark that invokes indefinable singularities and the darkness of a wound, cracking of time and splitting of self in film, life and death. Considerations of death, consciousness and subjectivity extend this paper's examinations. (shrink)

Background:The theoretical framework of Jϋrgen Habermas suggests that effective communication requires competent participants with an objective attitude that complies with the rules and worlds designated as objective, social and subjective. This situation determines communicative action, which stimulates the search for mutual understanding and results in a process of interaction that promotes self-determination.Objectives:In this study, the discharge letters of patients with myocardial infarction were explored regarding the provision of information. The patient’s right to information and the duty of informing (...) were analysed according to the perspective of Jϋrgen Habermas.Research design:This was a cross-sectional analysis (from a broader longitudinal study) of all discharge letters that were directly related to nursing interventions regarding the provision of information to 106 patients. In this major study, the difficulties faced by patients who experienced a myocardial infarction and the changes in their lifestyles were analysed based on the type of information received.Ethical considerations:The hospital Ethics Committee approved the study, which complied with ethical principles and required informed consent.Findings:In the nursing letters, interventions related to the provision of information were conducted at an average of 3.59 interventions per patient. For 8.5% of the patients, however, no interventions related to the provision of information were performed. The most common area of information during hospitalisation was related to the management of signs and symptoms and applied to 90.6% patients.Discussion:The nursing interventions did not cover patient education, transition processes or awareness of the disease. Thus, the right to information can be questioned.Conclusion:Information is a right, and communication is extremely important. Health professionals should be aware of this importance regarding both care management and the satisfaction guarantee. The sharing of information by health professionals based on their competency is essential for patients to exercise their right to self-determination and decision-making. (shrink)

Design: Qualitative interview study. Participants: Fifty-nine patients with a family history of cancer who attend a regional cancer genetics clinic in the UK were interviewed about their current and previous research experiences. Findings: Interviewees gave a range of explanations for research participation. These were categorised as social—research participation benefits the wider society by progressing science and improving treatment for everyone; familial—research participation may improve healthcare and benefit current or future generations of the participant’s family; and personal—research participation provides therapeutic or (...) non-therapeutic benefits for oneself. Conclusions: We discuss the distinction drawn between motives for research participation focused upon self and others, and observe that personal, social and familial motives can be seen as interdependent. For example, research participation that is undertaken to benefit others, particularly relatives, may also offer a number of personal benefits for self, such as enabling participants to feel that they have discharged their social or familial obligations. We argue for the need to move away from simple, static, individualised notions of research participation to a more complex, dynamic and inherently social account. (shrink)

This article argues that contemporary accounts of justice miss a relational dimension of justice, which focuses on the terms private individuals’ interactions must meet for them to constitute relationships among equal, self-determining persons. The article develops the argument that the justice requirement to respect others as substantively free and equal individuals can sometimes be adequately discharged only if the relevant private persons are held responsible for its realization. It further elaborates the normative framework of relational justice to explain the (...) generic structure, content, and scope of such a requirement. (shrink)

Just-war theory has a long and distinguished history that stretches back to the Christian theologians of medieval Europe. Yet principles of just war must develop alongside social norms, standards of military practice and technology, and civilian-military relationships. Since World War II, and especially since American involvement in Vietnam, military ethics has developed into an academic cottage industry. As commonly taught to undergraduates and military practitioners, contemporary just-war theory seeks to ensure the political sovereignty and territorial integrity of nation-states. The theory (...) insists that the only just wars are defensive ones and forbids wars of national aggrandizement. On this view, because of the right to collective self-determination, wars must not seek to remake the world order, as that would undermine state sovereignty.In recent decades, however, cosmopolitan philosophers have challenged various aspects of the traditional edifice in an attempt to use just-war theory to enhance the protection of human rights around the world. Scholars have argued for greater scope for humanitarian intervention to protect individuals against their own government, for principles of justice after war to ensure that all states are legitimate, and most radically, for the responsibility of ordinary combatants to assess for themselves the justice of their military's cause. On this last argument, because combatants whose cause is just have done nothing to lose their immunity from harm, attacking them is unjust, and combatants whose cause is unjust cannot fight with discrimination.This publication surveys these recent developments, and it finds that they provide a radical challenge to both the theory and the practice of contemporary warfare. Of particular importance is its insistence on the need to strengthen international institutions, so as to provide combatants with an impartial perspective on their side's cause, and to strengthen military ethics education; and its suggestion that policies on dishonorable discharge be rethought. However, this monograph also challenges certain aspects of the new approach, suggesting important connections between military ethics and democratic theory and practice. (shrink)

[ES] Gottlob Frege posiblemente era el primer filósofo analítico. La exégesis de su doctrina quedó durante varias décadas restringida casi naturalmente al ámbito de la filosofía analítica y angloparlante. El método que Frege heredó a la filosofía analítica se basa en el análisis abstracto y formal, y la aprehensión de su doctrina se desarrolló bajo el supuesto –tomado casi por autoevidente- que éste método es el único correcto para dar cuenta de los problemas filosóficos más fundamentales, muy particularmente el de (...) desarrollar una teoría de significado. Igualmente se asumía y asume todavía con cierto automatismo que las preocupaciones filosóficas de Frege son fundamentalmente las mismas de la filosofía analítica y las que no caben en este supuesto se desechan fácilmente como anacrónicas o absurdas. Este acercamiento al pensamiento de Frege exclusivamente bajo los supuestos de la filosofía analítica, sus méritos no obstante, no toma en cuenta el ambiente anti-naturalista y neo-kantiano en el cual Frege formó sus convicciones fundamentales. Algunos aspectos contenciosos como, por ejemplo, el principio de contexto, una posible jerarquía de sentidos indirectos o la suposición, casi tácita, de que la doctrina de Frege es una teoría sobre expresiones referenciales, aparecen en una luz diferente si nos damos cuenta de que su intento de construir un sistema es, en cuanto a filosofía, en el fondo una respuesta a problemas que Frege encontró en el sistema de Kant. [EN] Gottlob Frege was quite possibly the first analytical philosopher. For several decades the study of his teachings restricted itself almost naturally to the sphere of analytical and English speaking philosophy. The very method which Frege might have impressed upon analytical philosophy takes off with abstract and formal analysis and the apprehension of his doctrine developed under the assumption –taken to be almost self-evident- that this method is the only one capable of correctly accounting for the most fundamental philosophical problems, especially bringing forth a comprehensive theory of meaning. Hence it was taken for granted with certain automatism that the Frege´s philosophical worries were initially identical in its origins with those of contemporary analytical philosophy and those not amenable to easy adoptions are discharged as absurd anachronisms when viewed against current doctrines. Approaching Fregean thought exclusively under the assumptions of analytical philosophy, while having merit, does not take into account the anti-naturalist and neo-Kantian background which influenced the modelling of Frege’s fundamental convictions. Some contentious aspects like for example the context principle, a possible hierarchy of indirect senses or the almost tacit assumption that Frege’s doctrine is a theory about referential expressions appear in a different light, once we become aware that his attempt at system-construction, as far as it concerns philosophy, is fundamentally an answer to problems which Frege found in Kant’s system. (shrink)