In the face of mounting criticism against advance directives, we describe how a novel, computer-based decision aid addresses some of these important concerns. This decision aid, Making Your Wishes Known: Planning Your Medical Future , translates an individual's values and goals into a meaningful advance directive that explicitly reflects their healthcare wishes and outlines a plan for how they wish to be treated. It does this by (1) educating users about advance care planning; (2) helping individuals identify, clarify, and prioritize (...) factors that influence their decision-making about future medical conditions; (3) explaining common end-of-life medical conditions and life-sustaining treatment; (4) helping users articulate a coherent set of wishes with regard to advance care planning—in the form of an advance directive readily interpretable by physicians; and (5) helping individuals both choose a spokesperson, and prepare to engage family, friends, and health care providers in discussions about advance care planning. (shrink)

PurposeAdvance directives have been criticized for failing to help physicians make decisions consistent with patients’ wishes. This pilot study sought to determine if an interactive, computer-based decision aid that generates an advance directive can help physicians accurately translate patients’ wishes into treatment decisions.MethodsWe recruited 19 patient-participants who had each previously created an advance directive using a computer-based decision aid, and 14 physicians who had no prior knowledge of the patient-participants. For each advance directive, three physicians were randomly assigned to review (...) the advance directive and make five to six treatment decisions for each of six (potentially) end-of-life clinical scenarios.From the three individual physicians’ responses, a “consensus physician response” was generated for each treatment decision (total decisions = 32). This consensus response was shared with the patient whose advance directive had been reviewed, and she/he was then asked to indicate how well the physician translated his/her wishes into clinical decisions.ResultsPatient-participants agreed with the consensus physician responses 84 percent (508/608) of the time, including 82 percent agreement on whether to provide mechanical ventilation, and 75 percent on decisions about cardiopulmonary resuscitation (CPR).Across the six vignettes, patient-participants’ rating of how well physicians translated their advance directive into medical decisions was 8.4 (range = 6.5-10, where 1 = extremely poorly, and 10 = extremely well). Physicians’ overall rating of their confidence at accurately translating patients’ wishes into clinical decisions was 7.8 (range = 6.1-9.3, 1 = not at all confident, 10 = extremely confident).ConclusionFor simulated cases, a computer-based decision aid for advance care planning can help physicians more confidently make end-of-life decisions that patients will endorse. (shrink)

Mr. Galanas, an eighty‐six‐year‐old man, intentionally shot himself in the chest and abdomen. Surprisingly, the bullet damaged only his distal pancreas and part of his colon, requiring a diverting colostomy to prevent leakage of bowel fluids into his abdomen. After being admitted, he lies intubated in the intensive care unit awaiting surgery to repair his colon. He is responsive but does not demonstrate clear decision‐making capacity. He grudgingly accepts pain medications but refuses antibiotics and antidepressants. He has a living will (...) that gives his wife durable power of attorney and also explicitly states a desire to refuse all medical interventions if he is permanently unconscious or in an end‐stage condition. Mrs. Galanas reports frequent conversations in which her husband said he would not want to be sustained on life support. She also says that he often mentioned he would not want an ostomy bag—a likely, albeit temporary, outcome of the proposed surgery. His physicians are nervous about withholding medical interventions when Mr. Galanas's injury is the result of a suicide attempt and his prognosis is good. Should the care team surgically repair his injured colon, regardless of the patient's capacity, his advance directive, and his wife's statement that he would not want surgery or other life‐sustaining treatment? (shrink)

The adage “an ounce of prevention is worth a pound of cure” is widely used in healthcare settings and can be applied to the work of institutional clinical ethics committees. The model of clinical ethics consultation, however, is inherently reactive: a crisis or question emerges, and ethics experts are called to help. In an effort to employ a proactive component to the model of clinical ethics consultation (as well as to standardize our educational interventions), we developed ethics pocket cards. The (...) purpose of this article is to: (1) describe the rationale for using ethics pocket cards, (2) provide examples of our cards, and (3) begin a dialogue about the potential uses of ethics pocket cards. In doing so, we hope to explore how such portable, economical devices can advance the goals of ethics consultation as well as the educational aims of ethics committees. (shrink)

Background: Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians’ attitudes and practices regarding error discussions with colleagues.Methods: Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables.Results: Responses were received from 338 participants . In all, 73% of (...) respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision , wanting colleagues to learn from the mistake and wanting to receive support . Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm , minor harm or major harm . Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion .Conclusions: Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners. (shrink)

Christopher Caudwell’s The Crisis in Physics is a stylish and readable analysis of the lines of connection between scientific theories and economic realities. Caudwell provides a trenchant critique of mechanism and positivism. In the words of J.B.S. Haldane, The Crisis in Physics offers a “quarry of ideas” for future philosophers: a wealth of insights and arguments that demands continuing critical reflection.

We report the identification of a recurrent, 520-kb 16p12.1 microdeletion associated with childhood developmental delay. The microdeletion was detected in 20 of 11,873 cases compared with 2 of 8,540 controls and replicated in a second series of 22 of 9,254 cases compared with 6 of 6,299 controls. Most deletions were inherited, with carrier parents likely to manifest neuropsychiatric phenotypes compared to non-carrier parents. Probands were more likely to carry an additional large copy-number variant when compared to matched controls. The clinical (...) features of individuals with two mutations were distinct from and/or more severe than those of individuals carrying only the co-occurring mutation. Our data support a two-hit model in which the 16p12.1 microdeletion both predisposes to neuropsychiatric phenotypes as a single event and exacerbates neurodevelopmental phenotypes in association with other large deletions or duplications. Analysis of other microdeletions with variable expressivity indicates that this two-hit model might be more generally applicable to neuropsychiatric disease. © 2010 Nature America, Inc. All rights reserved. (shrink)

In this paper I take Hempel’s raven paradox as the claim that statements of the form ‘∼Ru v Bu’, ‘u is not a raven or u is black,’ confirm the hypothesis h ‘(x)(Rx → Bx)’, ‘All ravens are black.’ Although Hempel discusses this using a criterion of confirmation expressed wholly in terms of deductive logic (see 1965, pp. 35-9), it has become more common to articulate criteria of confirmation using concepts of probability and, in particular, to employ the positive relevance (...) criterion of confirmation which says that, given background knowledge k, (i) e confirms h if and only if P(h/e.k)>P(h/k); (ii) e disconfirms h if and only if P(h/e.k)shrink)

On April 26, 1995, the United States Supreme Court limited the reach of the preemption provision of ERISA in New York State Conference of Blue Cross & Blue Shield Plans v. Tavelers Insurance Co. ). In Travelers, the Supreme Court upheld the validity of a New York statute requiring hospitals to collect surcharges from patients covered by commercial insurers and requiring health maintenance organizations to pay a surcharge to the state's general fund that varies depending on the number of Medicaid-eligible (...) HMO members enrolled. Neither patients insured by Blue Cross/Blue Shield plans nor the plans themselves are similarly charged under the statute. Several commercial insurers and HMOs claimed the surcharges should be preempted under ERISA because they are levied on patients whose insurance or HMO membership premiums are purchased by an ERISA plan.The ERISA preemption clause means that federal regulation, or lack thereof, supersedes state regulation that is related to employee pension and benefit plans. This preemption clause prevents states from changing health care and benefit law for a significant portion of state residents. (shrink)

"Every word, like a sacred object, has its place. No _précis_ is possible. This extraordinary book must be read."—Edmund Carpenter, _New York Times Book Review _ "No outline is possible; I can only say that reading this book is a most exciting intellectual exercise in which dialectic, wit, and imagination combine to stimulate and provoke at every page."—Edmund Leach, _Man _ "Lévi-Strauss's books are tough: very scholarly, very dense, very rapid in argument. But once you have mastered him, human history (...) can never be the same, nor indeed can one's view of contemporary society. And his latest book, _The Savage Mind_, is his most comprehensive and certainly his most profound. Everyone interested in the history of ideas _must_ read it; everyone interested in human institutions _should _read it."—J. H. Plumb, _Saturday Review_ "A constantly stimulating, informative and suggestive intellectual challenge."—Geoffrey Gorer, _The Observer_, London. (shrink)

My object in this paper is to suggest a few reflections on some themes in Bentham's work which others as well as I have noted, without perhaps developing them as fully as might with advantage be done. There will be nothing like full development in the limited compass of what is said here, but what is said may at least indicate possible directions for further exploration. The greater part of the paper will be concerned with the notion of natural authority; (...) but I want to begin by taking a broader, though no doubt rather superficial, view of the role in Bentham's thinking of the concepts of ‘nature’ and ‘the natural’. (shrink)

The object of this article is to examine, with the work of Jeremy Bentham as the principal example, one strand in the complex pattern of European social theory during the second half of the eighteenth century. This was of course the period not only of the American and French revolutions, but of the culmination of the movements of thought constituting what we know as the Enlightenment. Like all great historical episodes, the Enlightenment was both the fulfilment of long-established processes and (...) the inauguration of new processes of which the fulfilment lay in the future. Thus the seminal ideas of seventeenth-century rationalism realized and perhaps exhausted their potentialities in the eighteenth-century Enlightenment. The ideas with which this article is concerned, however—conveniently grouped and labelled as the ideas of utilitarianism—only began to achieve systematic development in these later decades of the eighteenth century. Within that period—during the first half and more of Bentham's long life—attempts to apply those ideas to the solution of social problems met largely with failure and frustration. Yet unrealized potentialities remained, the realization of which was reserved for a time when the world of the philosophes no longer existed. The movements for social and political reform which have played so large a part in modern history since the French Revolution may be judged in widely differing ways; but whatever the verdict, these movements surely cannot be understood without due consideration of that part of their origins which lies in eighteenth-century utilitarianism. (shrink)

The author argues that there is a sharp contrast between Plato's earlier teleological explanation of nature and his later conception. In the Phaedo Anaxagoras' νοṽς as a teleological principle is rejected, the forms taking its place, in the Philebus the existence of a νοṽς explaining order and finality in nature, is strictly demonstrated. After that nature and consequences of this new doctrine are briefly discussed : the ineffable character of the transcendent cause of the world ; the reduction of the (...) number of the Forms to those of substances in nature ; the causality of νοṽς as an immanent and intermediate one ; the foundation of a mathematical science of nature. Thirdly the author makes an effort to reconstruct the philosophical grounds of this development, starting from the three theses, on which the argumentation of the Philebus is based. 1) νοṽς can only exist in a soul. It is argued that the dynamic conception of soul in the Phaedrus logically leads to the conclusion, that νοṽς also is movement . 2) To explain cosmic order and finality a νοṽς has to be accepted. This new idea occurs for the first time in the Sophistes and in the myth of the Politicus. 3) Cosmic order has a mathematical and astronomical character. This aspect is absent before the Philebus and seems to have been a consequence of Plato's discovery of the regularity in the planitary motions . Finally the author thinks he can indicate in the Sophistes the turning-point in the theory of Forms, as a result of the extension of the notion of being. (shrink)

A total of 944 expressed sequence tags generated 2212 EST loci mapped to homoeologous group 1 chromosomes in hexaploid wheat. EST deletion maps and the consensus map of group 1 chromosomes were constructed to show EST distribution. EST loci were unevenly distributed among chromosomes 1A, 1B, and ID with 660, 826, and 726, respectively. The number of EST loci was greater on the long arms than on the short arms for all three chromosomes. The distribution of ESTs along chromosome arms (...) was nonrandom with EST clusters occurring in the distal regions of short arms and middle regions of long arms. Duplications of group 1 ESTs in other homoeologous groups occurred at a rate of 35.5%. Seventy-five percent of wheat chromosome 1 ESTs had significant matches with rice sequences, where large regions of conservation occurred between wheat consensus chromosome 1 and rice chromosome 5 and between the proximal portion of the long arm of wheat consensus chromosome 1 and rice chromosome 10. Only 9.5% of group 1 ESTs showed significant matches to Arabidopsis genome sequences. The results presented are useful for gene mapping and evolutionary and comparative genomics of grasses. (shrink)