Recent efforts to introduce competition, consistent with microeconomic theory, into the United States health care system raise questions of distributive justice. Similarities between microeconomic theory and libertarian philosophy suggest the possibility of confusing economic goals of efficiency and cost containment with social goals of equity of access to care. This paper raises the fear that if the two are confused, society may unwittingly abandon any serious effort to ensure that the poor have access to essential types of medical care, because (...) libertarian philosophy cannot justify placing any constraints, however beneficient, on the actual distribution of benefits and burdens of illness resulting from free trade. (shrink)

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, fee-for-service medical practice creates incentives to (...) provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, “managed care, by its nature, places the good of the patient into conflict with … the good of all the other patients served by the plan; the good of the plan and the organization, themselves…; and the self-interest of the physician. (shrink)

The increased competition for a share of the market of insured patients, which arose in the wake of failed comprehensive health care reform, has provoked questions about what, if any, standards will govern new “competitive” health care organizations. Managed care arrangements, which typically shift to providers and patients some or all of the financial risk for patient care, are of special concern because they can create incentives to withhold beneficial care from patients. Of course, fee-for-service medical practice creates incentives to (...) provide unnecessary services, and managed care can avoid that type of harm. Still, as Edmund Pellegrino has noted, “managed care, by its nature, places the good of the patient into conflict with … the good of all the other patients served by the plan; the good of the plan and the organization, themselves…; and the self-interest of the physician. (shrink)

Following the seemingly endless debate over managed care liability, I cannot suppress thoughts of Yeats’s poem, “The Second Coming.” It is not the wellknown phrase, “Things fall apart; the centre cannot hold,” that comes to mind; although that could describe the feeling of a health-care system unraveling. The poem’s depiction of lost innocence — “The best lack all conviction, while the worst/Are full of passionate intensity” — does not allude to the legislature, the industry, the public, or the medical or (...) legal profession. What resonates is the poem’s evocation of humanity’s cyclical history of expectation and disappointment, with ideas as grand as justice and occupations as pedestrian as managed care. Writing in 1919, Yeats described the end of an era with images of war’s destructive forces. The poem expresses a universal desire for some miraculous rebirth or resolution of all problems: “Surely some revelation is at hand.” But instead, the brutish Sphinx-like creature emerges, possibly the Antichrist. New gods displace old gods in the cycle of civilization, and man must muddle on. (shrink)

Following the seemingly endless debate over managed care liability, I cannot suppress thoughts of Yeats’s poem, “The Second Coming.” It is not the wellknown phrase, “Things fall apart; the centre cannot hold,” that comes to mind; although that could describe the feeling of a health-care system unraveling. The poem’s depiction of lost innocence — “The best lack all conviction, while the worst/Are full of passionate intensity” — does not allude to the legislature, the industry, the public, or the medical or (...) legal profession. What resonates is the poem’s evocation of humanity’s cyclical history of expectation and disappointment, with ideas as grand as justice and occupations as pedestrian as managed care. Writing in 1919, Yeats described the end of an era with images of war’s destructive forces. The poem expresses a universal desire for some miraculous rebirth or resolution of all problems: “Surely some revelation is at hand.” But instead, the brutish Sphinx-like creature emerges, possibly the Antichrist. New gods displace old gods in the cycle of civilization, and man must muddle on. (shrink)

The men and women who serve in the armed forces, in the words of Major General Joseph Caravalho, “sign a blank check, co-signed by their families, payable to the Army, Navy, Air Force, or Marines, up to and including their lives.” It is human nature to consider such a pact in polarized terms; the pact concludes in either a celebratory homecoming or funereal mourning. But in reality, surviving catastrophic injury may incur the greatest debt. The small but real possibility of (...) losing the ability to bear biological children due to genitourinary combat injury has been a topic of discussion in hushed tones, behind closed doors. But as policy changes move the conversation into the open, we must be fully aware of the far-reaching and long-term impacts of decisions on those who have sustained genitourinary injury. In January 2016, Secretary of Defense Ashton Carter outlined a set of reforms that would improve the quality of life for military families by recognizing the importance of maintaining fertility, even in the face of severe injury. This first promising step could build a solid foundation of insuring fertility preservation for wounded service members with genitourinary injury, and it could set a precedent beyond the military for insuring treatment for people who have lost their reproductive capacity. Thus, the ethical challenges raised by the new policy require careful analysis. (shrink)

Ocean biology helps regulate global climate by fixing atmospheric CO2 and exporting it to deep waters as sinking detrital particles. New observations demonstrate that particle fragmentation is the principal factor controlling the depth to which these particles penetrate the ocean's interior, and hence how long the constituent carbon is sequestered from the atmosphere. The underlying cause is, however, poorly understood. We speculate that small, particle‐associated copepods, which intercept and inadvertently break up sinking particles as they search for attached protistan prey, (...) are the principle agents of fragmentation in the ocean. We explore this idea using a new marine ecosystem model. Results indicate that explicitly representing particle fragmentation by copepods in biogeochemical models offers a step change in our ability to understand the future evolution of biologically‐mediated ocean carbon storage. Our findings highlight the need for improved understanding of the distribution, abundance, ecology and physiology of particle‐associated copepods. (shrink)

We critically engage two traditional views of scientific data and outline a novel philosophical view that we call the pragmatic-representational view of data. On the PR view, data are representations that are the product of a process of inquiry, and they should be evaluated in terms of their adequacy or fitness for particular purposes. Some important implications of the PR view for data assessment, related to misrepresentation, context-sensitivity, and complementary use, are highlighted. The PR view provides insight into the common (...) but little-discussed practices of iteratively reusing and repurposing data, which result in many datasets’ having a phylogeny—an origin and complex evolutionary history—that is relevant to their evaluation and future use. We relate these insights to the open-data and data-rescue movements, and highlight several future avenues of research that build on the PR view of data. (shrink)

_An illuminating record of dialogues between the Dalai Lama and some of today’s most prominent scientists, philosophers, and contemplatives_ In 2013, during a historic six-day meeting at a Tibetan monastery in southern India, the Dalai Lama gathered with leading scientists, philosophers, and monks for in-depth discussions on the nature of reality, consciousness, and the human mind. This eye-opening book presents a record of those spirited and wide-ranging dialogues, featuring contributions from prominent scholars like Richard Davidson, Matthieu Ricard, Tania Singer, and (...) Arthur Zajonc as they address such questions as: Does nature have a nature? Do you need a brain to be conscious? Can we change our minds and brains through meditation? Throughout, the contributors explore the exciting and sometimes surprising commonalities between Western scientific and Tibetan Buddhist methods of perceiving, investigating, and knowing. Part history, part state-of-the-field, part inspiration for the future, this book rigorously and accessibly explores what these two investigative traditions can teach each other, and what that can tell us about ourselves and the world. (shrink)

Many health care systems include programs that allow patients in exceptional circumstances to access medical interventions of as yet unproven benefit. In this article we consider the ethical justifications for—and demands on—these special access programs (SAPs). SAPs have a compassionate basis: They give patients with limited options the opportunity to try interventions that are not yet approved by standard regulatory processes. But while they signal that health care systems can and will respond to individual suffering, SAPs have several disadvantages, including (...) the potential to undermine regulatory and knowledge-generation structures that constitute significant public goods. The “balance” between these considerations depends in part on how broadly SAPs are used, but also on whether SAPs can be made to contribute to the generation of knowledge about the effects of health interventions. We argue that patients should usually be required to contribute outcome data while using SAPs. (shrink)

In this paper, we examine recent critiques of the debate about defining disease, which claim that its use of conceptual analysis embeds the problematic assumption that the concept is classically structured. These critiques suggest, instead, developing plural stipulative definitions. Although we substantially agree with these critiques, we resist their implication that no general definition of “disease” is possible. We offer an alternative, inductive argument that disease cannot be classically defined and that the best explanation for this is that the concept (...) is structured as a cluster. We further argue that we do not need to reject the possibility of defining the general concept “disease” to legitimate developing stipulative definitions of disease that are relative to particular purposes. A cluster definition of disease is compatible with contextually motivated definitions, which may be considered précisifications of the more general cluster concept. (shrink)

This article reports the findings of a qualitative study that explored the organizational influences on moral distress for health professionals working in pediatric intensive care units across Canada. Participants were recruited to the study from PICUs across Canada. The PICU is a high-tech, fast-paced, high-pressure environment where caregivers frequently face conflict and ethical tension in the care of critically ill children. A number of themes including relationships with management, organizational structure and processes, workload and resources, and team dynamics were identified. (...) This study provides a rare and important multi-disciplinary perspective on this topic and the findings have implications for administrators and leaders who seek to improve the moral climate of healthcare delivery. (shrink)

Throughout March and April 2020, debate raged about how best to allocate limited intensive care unit resources in the face of a growing COVID-19 pandemic. The debate was dominated by utility-based arguments for saving the most lives or life-years. These arguments were tempered by equity-based concerns that triage based solely on prognosis would exacerbate existing health inequities, leaving disadvantaged patients worse off. Central to this debate was the assumption that ICU admission is a valuable but scarce resource in the pandemic (...) context.In this paper, we argue that the concern about achieving equity in ICU triage is problematic for two reasons. First, ICU can be futile and prolong or exacerbate suffering rather than ameliorate it. This may be especially true in patients with COVID-19 with emerging data showing that most who receive access to a ventilator will still die. There is no value in admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. Second, the focus on ICU admission shifts focus away from important aspects of COVID-19 care where there is greater opportunity for mitigating suffering and enhancing equitable care.We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to culturally safe care in the following interlinked areas: palliative care, communication and decision support and advanced care planning. (shrink)

Various analytical tools originally developed for theories of mechanistic explanation have recently been imported into the ongoing debate on the hypothesis of extended cognition. One such tool that appears particularly relevant to that debate is Craver’s mutual manipulability account of constitution, most of all because it promises to settle the debate on experimental grounds. This paper investigates whether it is possible to deliver on that promise. We first find that, far from grounding an experimental evaluation of HEC, MM is conceptually (...) incompatible with both internalist and externalist accounts of cognition. Next, we propose a suitable modification of MM, MM*, but it turns out that MM* presupposes rather than produces clarity on the extension of cognition. Moreover, subject to MM* the inference to constitution is radically empirically underdetermined. Finally, we argue that our results can be generalized and conclude that, for principled reasons, it is impossible to experimentally determine whether cognitive processes have extracerebral constituents. Determining the extension of cognition is an inherently pragmatic matter. (shrink)

Recently, concerns have been raised about the phenomenon of ‘overdiagnosis’, the diagnosis of a condition that is not causing harm, and will not come to cause harm. Along with practical, ethical, and scientific questions, overdiagnosis raises questions about our concept of disease. In this paper, we analyse overdiagnosis as an epistemic problem and show how it challenges many existing accounts of disease. In particular, it raises ques- tions about conceptual links drawn between disease and dysfunction, harm, and risk. We argue (...) that ‘disease’ should be considered a vague concept with a non-classical structure. On this view, overdiagnosed cases are ‘borderline’ cases of disease, falling in the zone between cases that are clearly disease, and cases that are clearly not disease. We then develop a pre ́cising definition of disease designed to provide practical help in preventing and limiting overdiagnosis. We argue that for this purpose, we can define disease as dysfunction that has a significant risk of causing severe harm to the patient. (shrink)

In this essay I explore the economic, social, environmental and cultural changes taking place in Bolsena, Italy, where agricultural livelihoods have rapidly diminished in the last two decades. I examine how gender dynamics have shifted with the changing values and livelihoods of Bolsena through three women’s narratives detailing their gendered experiences of environment, community and self. I reflect on these changes with Sabrina, who is engaged in a feminist community-based organization; Anna, who is running an alternative wine bar; and Isabella, (...) a jeweler, who is engaged in ecofeminist practices. My analysis is based on concepts developed by feminist political ecology: specifically, the theory of rooted networks from Dianne Rocheleau, Donna Haraway’s concept of naturecultures (and the work of J. K. Gibson-Graham on new economic imaginaries emerging from the politics of place. I aim to think with, reflect upon and provoke from the “otherwise”, taking into account the lived relations entwining nature and gender. My article looks at the interconnections of gender, environment and livelihoods, attentive to the daily needs, embodied interactions and labours of these three women as part of a reappropriation, reconstruction and reinvention of Bolsena’s lifeworld. By listening to the stories of their everyday lives and struggles, I show the dynamic potential of the politics of place and the efforts to build diverse economies and more ethical economic and ecological relationships based on gender-aware subjectivities and values. (shrink)

Gelfand quantales are complete unital quantales with an involution, *, satisfying the property that for any element a, if a b a for all b, then a a* a = a. A Hilbert-style axiom system is given for a propositional logic, called Gelfand Logic, which is sound and complete with respect to Gelfand quantales. A Kripke semantics is presented for which the soundness and completeness of Gelfand logic is shown. The completeness theorem relies on a Stone style representation theorem for (...) complete lattices. A Rasiowa/Sikorski style semantic tableau system is also presented with the property that if all branches of a tableau are closed, then the formula in question is a theorem of Gelfand Logic. An open branch in a completed tableaux guarantees the existence of an Kripke model in which the formula is not valid; hence it is not a theorem of Gelfand Logic. (shrink)

Synthetic biology is a broad term covering multiple scientific methodologies, technologies, and practices. Pairing biology with engineering, synbio seeks to design and build biological systems, either through improving living cells by adding in new functions, or creating new structures by combining natural and synthetic components. As with all new technologies, synthetic biology raises a number of ethical considerations. In order to understand what these issues might be, and how they relate to those covered in ethics literature on synbio, we conducted (...) an interview study with practicing synthetic biologists affiliated with a synthetic biology centre in Australia. Scientists identified a range of ethical challenges germane to the field, including precarious employment, pressures from industry, gender inequity, and the negative effects of the hyping of synbio. These challenges differed markedly from those identified in the ethics literature, whose treatment of the harms and benefits of synbio remains largely speculative and abstract. In our discussion of the pragmatic, every day ethical issues synthetic biologists face, we illustrate how issues of waste or research integrity play pivotal roles in everything from lived experiences in the laboratory, to long-term research trajectories guiding the field. In a confirmation of the ethical relevance of our participant’s views on the field, we argue that the subjects they raise must be included in any ethical analysis of synbio as a field. (shrink)

Recently, concerns have been raised about the phenomenon of 'overdiagnosis', the diagnosis of a condition that is not causing harm, and will not come to cause harm. Along with practical, ethical, and scientific questions, overdiagnosis raises questions about our concept of disease. In this paper, we analyse overdiagnosis as an epistemic problem and show how it challenges many existing accounts of disease. In particular, it raises questions about conceptual links drawn between disease and dysfunction, harm, and risk. We argue that (...) "disease" should be considered a vague concept with a nonclassical structure. On this view, overdiagnosed cases are 'borderline' cases of disease, falling in the zone between cases that are clearly disease, and cases that are clearly not disease. We then develop a précising definition of disease designed to provide practical help in preventing and limiting overdiagnosis. We argue that for this purpose, we can define disease as dysfunction that has a significant risk of causing severe harm to the patient. (shrink)

Background: Limited knowledge of the experiences of conflicts of conscience found in nursing literature. Objectives: To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta. Research design: Interpretive description was selected to help situate the findings in a meaningful clinical context. Participants and research context: Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta. Ethical consideration: Ethics approval from the Health Research Ethics Board at the University of Alberta. Findings: Three common (...) themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse’s voice, and the unique proximity of nurses. Discussion and conclusion: The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection. (shrink)

Although health and disease occupy opposite ends of a spectrum, distinguishing between them can be difficult. This is the “line-drawing” problem. The papers in this special issue engage with this challenge of delineating the boundaries of disease. The authors explore different views as to where the boundary between disease and nondisease lies, and related questions, such as how we can identify, or decide, what counts as a disease and what does not; the nature of the boundary between the two categories; (...) and what sorts of considerations could justify the location of that boundary. In exploring these questions, the papers draw on detailed clinical examples, provide theoretical critiques of existing approaches to disease definition, and offer new ways to conceptualize key features in debates about disease, including harm and biological dysfunction. (shrink)

: Catharine Macaulay's first political pamphlet, "Loose remarks on certain positions to be found in Mr. Hobbes's philosophical rudiments of government and society with a short sketch for a democratical form of government in a letter to Signor Paoli," published in London in 1769, has received no significant scholarly attention in over two hundred years. It is of primary interest because of the light it sheds on Macaulay's critique of patriarchal politics, which helps to establish a new line of thinking (...) about the historian as an early feminist writer. It appears she was working from an unauthorized edition of the Thomas Hobbes's De Cive (1647) entitled Philosophicall Rudiments of Government and Society, printed by a royalist bookseller in London 1651. Some errors in this translation may explain Macaulay's skewed understanding of Hobbes's argument in support of the premises of monarchy. Her intriguing analysis of paternal authority in "Loose Remarks" anticipates recent feminist explorations of Hobbesian political thought. (shrink)

Corporate community involvement is often regarded as means of development in developing countries. However, CCI is often criticised for patronage and insensitivity both to context and local priorities. A key concern is the extent of 'community participation' in corporate social decision-making. Community participation in CCI offers an opportunity for these criticisms to be addressed. This paper presents findings of research examining community participation in CCI governance undertaken by Magadi Soda Company in Kenya. We draw on socio-political governance and interaction theories (...) to examine the institutionalisation of participatory decision-making and its impact on changing governing roles and social action in CCI over time. (shrink)

An increasing number of patients receive diagnoses of disease without having any symptoms. These include diseases detected through screening programs, as incidental findings from unrelated investigations, or via routine checks of various biological variables like blood pressure or cholesterol. In this article, we draw on narrative identity theory to examine how the process of making sense of being diagnosed with asymptomatic disease can trigger certain overlooked forms of harm for patients. We show that the experience of asymptomatic disease can involve (...) ‘mismatches’ between one’s beliefs about one’s health status on the one hand, and bodily sensations or past experience on the other. Patients’ attempts to integrate these diagnoses into their self-narratives often involve either forming inaccurate beliefs about bodily sensations and/or past experience, or coming to believe that feelings and experience do not necessarily track or predict health status, leading to an ongoing sense of vulnerability to ill health. These resulting alterations in self-understanding can sometimes be considered harmful, in view of their implications for ascriptions of responsibility and ongoing anxiety. (shrink)

BackgroundSchool violence and bullying are prevalent problems that affect health in general, especially through the development of emotional and behavioral problems, and can result in the deterioration of the academic performance of the student victim. The objective of this study was to determine the prevalence rates of aggressive behaviors according to types of school violence and bullying, sociodemographic characteristics, and variation by department, region, and time in the period between 2014 and 2018 in Peru.MethodsThe design was observational and cross-sectional based (...) on data from the Specialized System for Reporting Cases of School Violence in Peru, which covers a population of 23,641 students at the initial, primary, and secondary levels of Basic Regular Education [Educación Básica Regular ], for the 2014–2018 period. The prevalence rates of the different types of school violence and bullying, the sociodemographic characteristics, and the variation by department, region, and time in the period between 2014 and 2018 were estimated.ResultsPsychological violence/bullying occurred at higher prevalence rates. Women from public institutions reported greater sexual violence, mostly by teachers than by other students. The Selva region had the highest prevalence rate of sexual violence. The departments of Tacna and Piura had the highest and lowest rates of psychological/verbal violence and bullying in 2018.ConclusionPsychological/verbal violence and bullying is highly prevalent among students; women report being victims of sexual violence by administrative personnel of public institutions. The Selva region had the highest rate of sexual violence, and Piura and Tacna had the highest and lowest rates of violence and psychological/verbal bullying. Based on these results, it is suggested to conduct evidence-based prevention programs in Peruvian schools to reduce these social problems. (shrink)

Positive claims about narrative approaches to healthcare suggest they could have many benefits, including supporting person-centred healthcare (PCH). Narrative approaches have also been criticised, however, on both theoretical and practical grounds. In this paper we draw on epistemological work on narrative and knowledge to develop a conception of narrative that responds to these concerns. We make a case for understanding narratives as accounts of events in which the way each event is described as influenced by the ways other events in (...) the narrative are described. This view of narratives recognises that they can contribute knowledge of different kinds of connections between events: not just causal, and not just of patient’s perspectives. Additionally, narratives can add further epistemic value by suggesting potentially useful lines of inquiry. We take narrative approaches to healthcare to include clinicians considering both patients’ informational offerings and their own professional understandings as narratives. On this understanding, our account is able to overcome the major theoretical and practical criticisms that have been levelled against the use of narrative approaches in healthcare, and can help to explain why and how narrative approaches are consistent with PCH. (shrink)

Peer review of manuscripts has recently become a subject of academic research and ethical debate. Critics of the review process argue that it is a means by which powerful members of the scientific community maintain their power, and achieve their personal and communal aspirations, often at others' expense. This qualitative study aimed to generate a rich, empirically‐grounded understanding of the process of manuscript review, with a view to informing strategies to improve the review process. Open‐ended interviews were carried out with (...) 35 journal editors and peer reviewers in the United Kingdom, the USA and Australia. It is clear from this research that relations of power and epistemic authority in manuscript review are complex and dynamic, and may have positive and negative features, and that even where power is experienced as controlling, restrictive and illegitimate, it can also be resisted. In conclusion, the manuscript review process is best thought of not in terms of simple dominance of reviewers and editors over authors, but rather as a shifting “net” of power relations. These complex power relations need to be understood if reviewers are to be encouraged to participate in the process and to do so in the the most ethical and effective manner. (shrink)

Evidence-based medicine has been rapidly and widely adopted because it claims to provide a method for determining the safety and efficacy of medical therapies and public health interventions more generally. However, as others have noted, EBM may be riven through with cultural bias, both in the generation of evidence and in its translation. We suggest that technological and scientific advances in medicine accentuate and entrench these cultural biases, to the extent that they may invalidate the evidence we have about disease (...) and its treatment. This creates a significant ethical, epistemological and ontological challenge for medicine. (shrink)