Culture, defined as shared behavior or information within a community acquired through some form of social learning from conspecifics, is now suggested to act as a second inheritance system. Cultural processes are important in a wide variety of vertebrate species. Birdsong provides a classic example of cultural processes: cultural transmission, where changes in a shared song are learned from surrounding conspecifics, and cultural evolution, where the patterns of songs change through time. This form of cultural transmission of information has features (...) that are different in speed and form from genetic transmission. More recently, culture, vocal traditions and an extreme form of song evolution has been documented in cetaceans. Humpback whale song ‘revolutions’, where the single population-wide shared song type is rapidly replaced by a new, novel song type introduced from a neighbouring population, represents an extraordinary example of ocean basin-wide cultural transmission rivalled in its geographic extent only by humans. In this review, we examine the cultural evolutions and revolutions present in some birdsong and whale song, respectively. By taking a comparative approach to these cultural processes, we review the existing evidence to understand the similarities and differences for their patterns of expression and the underlying drivers, including anthropogenic influences, which may shape them. Finally, we encourage future studies to explore the role of innovation vs. production errors in song evolution, the fitness information present in song, and how human-induced changes in population sizes, trajectories and migratory connections facilitating cultural transmission may be driving song revolutions. (shrink)

Focus on the evolutionary origins of musicality has been neglected relative to attention on language, so these new proposals are welcome stimulants. We argue for a broad comparative approach to understanding how the elements of musicality evolved, and against the use of overly simplistic evolutionary accounts.

Normothermic Regional Perfusion, or NRP, is a method of donated organ reperfusion using cardiopulmonary bypass or a modified extracorporeal membrane oxygenation (ECMO) circuit after circulatory death while leaving organs in the dead donor’s corpse. Despite its potential, several key ethical issues remain unaddressed by this technology.

The Patient Self Determination Act of 1991 brought much needed attention to the importance of advance care planning and surrogate decision-making. The purpose of this law is to ensure that a patient’s preferences for medical care are recognized and promoted, even if the patient loses decision-making capacity. In general, patients are presumed to have DMC. A patient’s DMC may come under question when distortions in thinking and understanding due to illness, delirium, depression or other psychiatric symptoms are identified or suspected. (...) Physicians and other healthcare professionals working in hospital settings where medical illness is frequently comorbid with depression, adjustment disorders, demoralization and suicidal ideation, can expect to encounter ethical tension when medically sick patients who are also depressed or suicidal request do not resuscitate orders. (shrink)

This article is a longitudinal analysis of the relation between gendered labour divisions and new data processing technologies at the Dutch Central Bureau of Statistics. Following social-constructivist and evolutionary economic approaches, the authors hold that the relation between technology and work organization is a two-way process. This means that technology does not only affect the relations between men and women at work, but that these relations also influence technological choices. The proportional numbers of men and women on the labour market (...) and changing conceptions of which work is deemed appropriate for women have been important factors in the strongly varying extent to which women participated in office work. They have also been important factors in determining the course of technological development. Shortages of women on the labour market have even determined search heuristics for new technological solutions in specific directions. (shrink)

Upon entering the examination room, Caitlyn encounters a woman sitting alone and in distress. Caitlyn introduces herself as the hospital ethicist and tells the woman, Mrs. Dennis, that her aim is to help her reach a decision about whether to perform an autopsy on her recently deceased husband. Mrs. Dennis begins the encounter by telling the ethicist that she has to decide quickly, but that she is very torn about what to do. Mrs. Dennis adds, “My sons disagree about the (...) autopsy.” As a standardized patient, a specialized actor, the woman playing Mrs. Dennis has already delivered the same opening lines several times to different learners practicing their clinical ethics consultation skills. An SP encounter is a simulated patient encounter used for educational purposes that requires the standardization of verbal and behavioral responses. In the encounter, the simulator, or “patient,” uses a scripted medical history to enable the learner to employ a certain skill, say, the ability to perform a neurological exam. The use of standardized patients in the evaluation of clinical skills has become a staple in medical education. To tackle the challenge of teaching clinical ethics consultation skills, we have incorporated SP encounters into the curriculum of the Bioethics Program of The Union Graduate College and the Icahn School of Medicine at Mount Sinai. SP encounters are incorporated into one of our onsite classes, the Onsite Clinical Ethics Practicum, and they are part of the capstone examination, which all of our graduates must complete successfully. The inclusion of simulated encounters into the curriculum is one way in which we equip our students with the core competencies specified by the American Society for Bioethics and Humanities Task Force for clinical ethicists. (shrink)

Communities often unite during a crisis, though some cope by ascribing blame or stigmas to those who might be linked to distressing life events. In a preregistered two-wave survey, we evaluated the dehumanization of Asians and Asian Americans during the COVID-19 pandemic. Our first wave revealed dehumanization was prevalent, between 6.1% and 39% of our sample depending on measurement. Compared to non-dehumanizers, people who dehumanized also perceived the virus as less risky to human health and caused less severe consequences for (...) infected people. They were more likely to be ideologically Conservative and believe in conspiracy theories about the virus. We largely replicated the results 1 month later in our second wave. Together, many Americans dehumanize Asians and Asian Americans during the COVID-19 pandemic with related perceptions that the virus is less problematic. Implications and applications for dehumanization theory are discussed. (shrink)

Purpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools. Method: An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses. Results: Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were (...) deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most (n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer (n = 37, 60%) provided faculty training for teaching ethics. Conclusions: Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices. (shrink)

Objective Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians’ attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus. Design, Setting, Participants A survey of resident/fellow physicians and internal medicine (...) attendings at an academic medical center, May to August 2013. Measurements We used a 24-item, internet-based survey assessing physician-respondents’ demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected. Main Results A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/ fellows. Only 32 percent of the respondents indicated that a surrogate’s consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate’s objection. Those who self-reported as “knowledgeable” about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VAECMO over a surrogate’s objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005). Conclusions Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/ critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians’ hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study. (shrink)

A 1999–2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to “best informants” in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The (...) median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC. (shrink)

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners’ opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive perceptions (...) of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted. (shrink)

BackgroundWhile previous research has examined various aspects of ethics consultation (EC) in U.S. hospitals, certain EC practices have never been systematically studied.MethodsTo address this gap, we surveyed a random stratified sample of 600 hospitals about aspects of EC that had not been previously explored.ResultsNew findings include: in 26.0% of hospitals, the EC service performs EC for more than one hospital; 72.4% of hospitals performed at least one non-case consultation; in 56% of hospitals, ECs are never requested by patients or families; (...) 59.0% of case consultations involve conflict; the usual practice is to visit the patient in all formal EC cases in 32.5% of hospitals; 56.6% of hospitals do not include a formal meeting in most EC cases; 61.1% of hospitals do not routinely assess ethics consultants’ competencies; and 31.6% of hospitals belong to a bioethics network. We estimate the total number of non-case consultations performed in U.S. hospitals to be approximately one half the number of case consultations; we estimate the total number of ECs performed in U.S. hospitals, including both case and non-case consultations, to be just over 100,000 per year.ConclusionsThese findings expand our current understanding of EC in U.S. hospitals, and raise several concerns that suggest a need for further research. (shrink)

The annual volume of ethics consultations (ECs) has been a topic of interest in the bioethics literature, in part because of its presumed relationship to quality. To better understand factors associated with EC volume, we used multiple linear regression to model the number of case consultations performed in the last year based on a national survey. We found that hospital bed size, academic affiliation, and urban/rural location were all associated with EC volume, but were not the primary drivers. Instead, these (...) variables affected EC volume through three other variables, all of which relate to ethics staffing: the percentage of case consultations performed by a single individual; whether the survey respondent’s main role at the hospital contained the word “ethics”; and especially, the number of full-time ethics program staff. We conclude that EC is an example of supply-sensitive care, and further research is needed to determine the optimal level of EC activity. (shrink)

The first-ever compilation of articles that highlights the intersection of Derridean and feminist theories--a work that represents the extensive and diverse response feminist theorists have had to Derrida, particularly to the issues of gender, identity, and the construction of the subject.

The past two decades of psychoanalytic discourse have witnessed a marked transformation in the way we think about women and gender. The assignment of gender carries with it a host of assumptions, yet without it we can feel lost in a void, unmoored from the world of rationality, stability and meaning. The feminist analytic thinkers whose work is collected here confront the meaning established by the assignment of gender and the uncertainty created by its absence. The contributions brought together in (...) _Psychoanalytic Reflections on a Gender-free Case_ address a cross-section of significant issues that have both chronicled and facilitated the changes in feminist psychoanalysis since the mid 1980s. Difficult issues which have previously been ignored are considered first. The book goes on to address family perspectives as they interact and shape the child’s experience of growing up male or female. Other topics covered are the authority of personal agency as influenced by the language and theory of patriarchy, male-centred concepts that consistently define women as inferior, and the concept of gender as being co-constructed within a relationship. The gender-free case presented here will fascinate all psychoanalysts interested in exploring ways of grappling with the elusive nature of gender, as well as those studying gender studies. (shrink)

‘It feels like I have lost a part of myself’ is frequently uttered by those grieving the death of a loved one. Despite the ubiquity of such utterances, and the palpable sense that they express something true, few philosophers have considered what, if anything, accounts for their truth. Here, I develop a suggestion from Donald Baxter according to which Composition as Identity provides us a means to understand the grief utterances literally. In doing so, I identify and develop a version (...) of Leibniz's Law required for Composition as Identity to account for the truth of the grief utterances. In turn, this principle helps shed light on Composition as Identity's central claim: that the parts are identical to the whole. By considering objections to the resulting view, I construct a list of desiderata for other philosophers interested in accounting for the grief utterances. (shrink)

Background: The factors influencing parents’ willingness to enroll their children in biobanks are poorly understood. This study sought to assess parents’ willingness to enroll their children, and their perceived benefits, concerns, and information needs under different consent and data-sharing scenarios, and to identify factors associated with willingness. Methods: This large, experimental survey of patients at the 11 eMERGE Network sites used a disproportionate stratified sampling scheme to enrich the sample with historically underrepresented groups. Participants were randomized to receive one of (...) three consent and data-sharing scenarios. Results: In total, 90,000 surveys were mailed and 13,000 individuals responded (15.8% response rate). 5737 respondents were parents of minor children. Overall, 55% (95% confidence interval 50–59%) of parents were willing to enroll their youngest minor child in a hypothetical biobank; willingness did not differ between consent and data-sharing scenarios. Lower educational attainment, higher religiosity, lower trust, worries about privacy, and attitudes about benefits, concerns, and information needs were independently associated with less willingness to allow their child to participate. Of parents who were willing to participate themselves, 25% were not willing to allow their child to participate. Being willing to participate but not willing to allow one’s child to participate was independently associated with multiple factors, including race, lower educational attainment, lower annual household income, public health care insurance, and higher religiosity. Conclusions: Fifty-five percent of parents were willing to allow their youngest minor child to participate in a hypothetical biobank. Building trust, protecting privacy, and addressing attitudes may increase enrollment and diversity in pediatric biobanks. (shrink)

Short overview of the From Small Beginnings Project and its relevance for resisting eugenics in contemporary society.

Numerous articles in the popular press together with an examination of websites associated with the medical, legal, engineering, financial, and other professions leave no doubt that the role of professions has been impacted by the Internet. While offering the promise of the democratization of expertise – expertise made available to the public at convenient times and locations and at an affordable cost – the Internet is also driving a reexamination of the concept of professional identity and related claims of expertise (...) and standards of integrity. This paper begins with a presentation of case studies illustrating the ease by which impostors infiltrate the ranks of professionals. Reports of individuals masquerading as professionals via the Internet often reveal that these imposters cause harm to the unwary victims who rely on assertions of professional expertise. Such reports motivated the authors to examine the origins and evolution of the traditional roles of professions and professionals in today’s society, as well as question how, or whether, the standards for professional practice have been adapted to the challenges posed by technology, i.e., do statements of professional ethics provide a ‘guiding light’ for practitioners and their clients in the cyber age? The authors challenge the professions to consider the notion that technology forces a confrontation between the guild-like aspects of a profession that have served, on the one hand, to protect a profession from encroachment and, on the other hand, have purportedly protected the public. (shrink)

In Grief: A Philosophical Guide, Michael Cholbi presents a compelling account of the nature of grief. To further illustrate how fruitful the philosophical study of grief, and Cholbi’s account of it is, I present three sets of comments. The first regards the extent to which Cholbi’s account of grief also provides an account of vicarious grief. The second concerns the paradox of grief and the good of grief, and suggests one reason we may recommend grief is that grieving is healthy. (...) The final set of comments pertains to the duty to grieve, and whether this duty may extend to other emotionally rich activities, such as falling in love. (shrink)

The development of T cells and B cells from pluripotent hematopoietic precursors occurs through a stepwise narrowing of developmental potential that ends in lineage commitment. During this process, lineage-specific genes are activated asynchronously, and lineage-inappropriate genes, although initially expressed, are asynchronously turned off. These complex gene expression events are the outcome of the changes in expression of multiple transcription factors with partially overlapping roles in early lymphocyte and myeloid cell development. Key transcription factors promoting B-cell development and candidates for this (...) role in T-cell development are discussed in terms of their possible modes of action in fate determination. We discuss how a robust, stable, cell-type–specific gene expression pattern may be established in part by the interplay between endogenous transcription factors and signals transduced by cytokine receptors, and in part by the network of effects of particular transcription factors on each other. BioEssays 21:726–742, 1999. © 1999 John Wiley & Sons, Inc. (shrink)

This study explores the association between different types of morally challenging interactions during military deployment and response strategies, as well as the mediating role of moral emotions. Interviews with Dutch servicemen who participated in military operations were content coded. We found a relationship between local-cultural and team-related interactions and moral justification; these effects were mediated by other-condemning emotions. Similarly, other-condemning emotions mediated the relationship between local-cultural interactions and relativism. This study points at the importance of other-condemning emotions in shaping military (...) reactions to frequently occurring morally challenging interactions. (shrink)

BackgroundAdherence to widely accepted practice standards is a frequently used measure of healthcare quality. In the U.S., the most widely recognized authoritative source of practice standards for ethics consultation (EC) is the second edition of the American Society for Bioethics and Humanities’ Core Competencies for Healthcare Ethics Consultation report.MethodsTo determine the extent to which EC practices in U.S. hospitals adhere to these practice standards, we developed and analyzed 12 evaluative measures from a national survey.ResultsOnly three of the 12 standards achieved (...) over 75% adherence with reported EC practices: allowing anyone involved in a case to request an EC (100%), not requiring an attending physician’s permission to conduct an EC (97.6%), and having at least one person on the ethics consultation service (ECS) with advanced level EC proficiency (79.3%).ConclusionsImplications are discussed for achieving consensus on EC standards as they continue to evolve. (shrink)

BackgroundAs hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs (HCEPs) that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.MethodsBased on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.ResultsAmong 372 hospitals whose informants responded to an online survey, 97% (...) of hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership (35.7%), regulatory compliance (29.0%), business ethics (26.2%), and research ethics (12.6%). HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff (77.0%), nurses (59.9%), staff physicians (49.0%), hospital leadership (44.2%), medical residents (20.3%) and the community/general public (18.4%). HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents’ strategies for managing challenges include staff training and additional funds.ConclusionsWhile this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs. (shrink)

The multifaceted work of the late Susan Leigh Star is explored through a selection of her writings and essays by friends and colleagues. Susan Leigh Star (1954–2010) was one of the most influential science studies scholars of the last several decades. In her work, Star highlighted the messy practices of discovering science, asking hard questions about the marginalizing as well as the liberating powers of science and technology. In the landmark work Sorting Things Out, Star and Geoffrey Bowker revealed the (...) social and ethical histories that are deeply embedded in classification systems. Star's most celebrated concept was the notion of boundary objects: representational forms—things or theories—that can be shared between different communities, with each holding its own understanding of the representation. Unfortunately, Leigh was unable to complete a work on the poetics of infrastructure that further developed the full range of her work. This volume collects articles by Star that set out some of her thinking on boundary objects, marginality, and infrastructure, together with essays by friends and colleagues from a range of disciplines—from philosophy of science to organization science—that testify to the wide-ranging influence of Star's work. Contributors Ellen Balka, Eevi E. Beck, Dick Boland, Geoffrey C. Bowker, Janet Ceja Alcalá, Adele E. Clarke, Les Gasser, James R. Griesemer, Gail Hornstein, John Leslie King, Cheris Kramarae, Maria Puig de la Bellacasa, Karen Ruhleder, Kjeld Schmidt, Brian Cantwell Smith, Susan Leigh Star, Anselm L. Strauss, Jane Summerton, Stefan Timmermans, Helen Verran, Nina Wakeford, Jutta Weber. (shrink)

Metaphors abound in descriptions of the COVID-19 pandemic: it is described, among other things, as a war, a flood, and a marathon. However, not all metaphors may resonate equally well with members...

BackgroundTo help inform the development of more accessible, acceptable, and effective ethics consultation (EC) training programs, we conducted an EC training needs assessment, exploring ethics practitioners’ opinions on: the relative importance of various EC practitioner competencies; the potential market for EC training (that is, how many individuals would benefit and how much individuals and hospitals would be willing to pay); and the preferred content, format, and characteristics of EC training.MethodsAs part of a multipart study, we surveyed “best informants” who self-identified (...) as the person most actively involved in EC or healthcare ethics in a random sample of 600 U.S. general hospitals, stratified for bed size.ResultsThe competency that was ranked most important for a lead or solo ethics consultant was knowledge of ethics, while common sense was ranked least important. The median estimated number of individuals at each hospital who would benefit from EC training was six at the basic level, three at the advanced level, and two for EC management training. In 19.1 percent of hospitals, respondents thought their hospital would not be willing to pay anything for EC training within the next two years. Respondents thought potential trainees would be likely to participate in EC training on multiple different topics. Opinions varied widely on preferred formats. Most respondents thought it very important to be able to interact with instructors and with other trainees, practice EC skills, receive a certificate for completing EC training, and complete EC training during work hours.ConclusionsThese findings provide U.S. population data that may be useful to healthcare educators and bioethics leaders in their efforts to develop EC training programs and products that match trainees’ preferences and needs. (shrink)

This article describes some potential uses of Bayesian estimation for time-series and panel data models by incorporating information from prior probabilities in addition to observed data. Drawing on econometrics and other literatures we illustrate the use of informative “shrinkage” or “small variance” priors while extending prior work on the general cross-lagged panel model. Using a panel dataset of national income and subjective well-being we describe three key benefits of these priors. First, they shrink parameter estimates toward zero or toward each (...) other for time-varying parameters, which lends additional support for an income → SWB effect that is not supported with maximum likelihood. This is useful because, second, these priors increase model parsimony and the stability of estimates and thus improve out-of-sample predictions and interpretability, which means estimated effect should also be more trustworthy than under ML. Third, these priors allow estimating otherwise under-identified models under ML, allowing higher-order lagged effects and time-varying parameters that are otherwise impossible to estimate using observed data alone. In conclusion we note some of the responsibilities that come with the use of priors which, departing from typical commentaries on their scientific applications, we describe as involving reflection on how best to apply modeling tools to address matters of worldly concern. (shrink)

Western media coverage of female genital modifications in Africa has been hyperbolic and one-sided, presenting them uniformly as mutilation and ignoring the cultural complexities that underlie these practices. Even if we ultimately decide that female genital modifications should be abandoned, the debate around them should be grounded in a better account of the facts.

Volume 20, Issue 7, July 2020, Page W15-W16.