BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians (...) use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education. (shrink)

Context Opioid treatment agreements (OTAs) are documents that clinicians present to patients when prescribing opioids that describe the risks of opioids and specify requirements that patients must meet to receive their medication. Notwithstanding a lack of evidence that OTAs effectively mitigate opioids’ risks, professional organizations recommend that they be implemented, and jurisdictions increasingly require them. We sought to identify the jurisdictions that require OTAs, how OTAs might affect the outcomes of lawsuits that arise when things go wrong, and instances in (...) which the law permits flexibility for clinicians and health care institutions to adopt best practices. -/- Methods We surveyed the laws and regulations of all 50 states and the District of Columbia to identify which jurisdictions require the use of OTAs, the circumstances in which OTA use is mandatory, and the terms OTAs must include (if any). We also surveyed criminal and civil judicial decisions in which OTAs were discussed as evidence on which a court relied to make its decision to determine how OTA use influences litigation outcomes. -/- Findings Results show that a slight majority (27) of jurisdictions now require OTAs. With one exception, the jurisdictions’ requirements for OTA use are triggered at least in part by long-term prescribing. There is otherwise substantial variation and flexibility within OTA requirements. Results also show that even in jurisdictions where OTA use is not required by statute or regulation, OTA use can inform courts’ reasoning in lawsuits involving patients or clinicians. Sometimes, but not always, OTA use legally protects clinicians from liability. -/- Conclusions -/- Our results show that OTA use is entwined with legal obligations in various ways. Clinicians and health care institutions should identify ways for OTAs to enhance clinician–patient relationships and patient care within the bounds of relevant legal requirements and risks. (shrink)

Abstract:During recent years, the principle and practice of employment-at-will have been under attack. While progress has been made in eroding the practice, the principle still governs the philosophical assumptions underlying employment practices in the United States, and, indeed, EAW has been promulgated as one of the ways to address economic ills in other countries. This paper will briefly review the major critiques of EAW. Given the failure of these arguments to erode the underpinnings of EAW, we shall suggest new avenues (...) for approaching employment issues to achieve the desirable goal of employee dignity and respect. (shrink)

This article presents a response to Richard Rorty's paper "Is Philosophy Relevant to Business Ethics?" The author questions Rorty's views on the depreciation of the role of philosophy in applied ethics, and outlines four reasons why philosophy retains its relevance. The author addresses the role of moral reasoning in the development of the moral imagination. The author also concludes that humans have the means necessary to make moral progress and are capable of moral reasoning, and need only to develop a (...) strong moral imagination. (shrink)

Major depression (MD) is a highly heterogeneous diagnostic category. Diverse symptoms such as sad mood, anhedonia, and fatigue are routinely added to an unweighted sum-score, and cutoffs are used to distinguish between depressed participants and healthy controls. Researchers then investigate outcome variables like MD risk factors, biomarkers, and treatment response in such samples. These practices presuppose that (1) depression is a discrete condition, and that (2) symptoms are interchangeable indicators of this latent disorder. Here I review these two assumptions, elucidate (...) their historical roots, show how deeply engrained they are in psychological and psychiatric research, and document that they contrast with evidence. Depression is not a consistent syndrome with clearly demarcated boundaries, and depression symptoms are not interchangeable indicators of an underlying disorder. Current research practices lump individuals with very different problems into one category, which has contributed to the remarkably slow progress in key research domains such as the development of efficacious antidepressants or the identification of biomarkers for depression. The recently proposed network framework offers an alternative to the problematic assumptions. MD is not understood as a distinct condition, but as heterogeneous symptom cluster that substantially overlaps with other syndromes such as anxiety disorders. MD is not framed as an underlying disease with a number of equivalent indicators, but as a network of symptoms that have direct causal influence on each other: insomnia can cause fatigue which then triggers concentration and psychomotor problems. This approach offers new opportunities for constructing an empirically based classification system and has broad implications for future research. (shrink)

Objective: To examine current research payment practices and to inform development of clearer guidelines for researchers and ethics committees.Design: Exploratory email based questionnaire study of current research participant reimbursement practices. A diverse sample of organisations and individuals were targeted.Setting: Australia.Participants: Contacts in 84 key research organisations and select electronic listservers across Australia. A total of 100 completed questionnaires were received with representations from a variety of research areas .Main measurements: Open-ended and fixed alternative questions about type of research agency; type (...) of research; type of population under study; whether payment is standard; amounts and mechanisms of payment; factors taken into account when deciding on payment practices; and whether payment policies exist.Results: Reimbursement practice is highly variable. Where it occurs it is largely monetary and is for time and out-of-pocket expenses. Ethics committees were reported to be often involved in decision making around reimbursement.Conclusions: Research subject payment practices vary in Australia. Researchers who do provide payments to research participants generally do so without written policy and procedures. Ethics committees have an important role in developing guidelines in this area. Specific guidelines are needed considering existing local policies and procedures; payment models and their application in diverse settings; case study examples of types and levels of reimbursement; applied definitions of incentive and inducement; and the rationale for diverse payment practices in different settings. (shrink)

The ways in which knowledge relates to power have been much discussed in radical education theory. New emphasis on the role of gender and the growing debate about subjectivity have deepened the discussion, while making it more complex. In Getting Smart , Patti Lather makes use of her unique integration of feminism and postmodernism into critical education theory to address some of the most vital questions facing education researchers and teachers.

This analysis tests the influence of personal, job, and family status characteristics on maternal employment. We use the Merged Child/mother File from the National Longitudinal Survey of Youth to examine employment patterns of mothers who gave birth between 1979 and 1986. Logistic regression is used to estimate the probabilities; proportional hazards techniques are used to estimate rates of leaving and return to employment after childbirth. We find that family status factors and the proportion of the family income the mother earns (...) are consistently important in predicting maternal employment. Human capital factors are more significant in predicting employment exits and the rate of exit than the rate of return or employment status one year after a birth. (shrink)

Introduction to the Institutional Logics Perspective -- Precursors to the Institutional Logics Perspective -- Defining the Inter-institutional System -- The Emergence, Stability and Change of the Inter-institutional System -- Micro-Foundations of Institutional Logics -- The Dynamics of Organizational Practices and Identities -- The Emergence and Evolution of Field-Level Logics -- Implications for Future Research.

In Frege's Conception of Logic Patricia A. Blanchette explores the relationship between Gottlob Frege's understanding of conceptual analysis and his understanding of logic.

This paper examines the relationship between organizational ethical culture in two large international CPA firms, auditors'' personal values and the ethical orientation that those values dictate, and judgments in ethical dilemmas typical of those that accountants face. Using an experimental task consisting of multiple judgments designed to vary in "moral intensity" (Jones, 1991), and unique as well as tried-and-true approaches to variable measurements, this study examined the judgments of more than three hundred participants in our study. ANCOVA and path analysis (...) results indicate that: (1) Ethical judgments in situations of high moral intensity are affected by personal values and by environmental variables, such as the professional code of conduct (direct and indirect effects) and previous ethics instruction (direct effect only). (2) Corporate ethical culture, and a relatively strong firm rules-orientation, affect auditors'' idealism but not relativism, and therefore indirectly affect ethical judgments. Jones'' (1991) moral intensity argument is supported: differences in the characteristics of specific judgment tasks apparently result in different decision processes. (shrink)

Habit and Embodiment in Merleau-PontyIntroductionMerleau-Ponty (French phenomenological philosopher, born in 1908 and deceased in 1961) refers to habit in various passages of his Phenomenology of Perception as a relevant issue in his philosophical and phenomenological position. Through his exploration of this issue he explains both the pre-reflexive character that our original linkage with the world has, as well as the kind of “understanding” that our body develops with regard to the world. These two characteristics of human existence bear a close (...) relation with the vision of an embodied mind sustained by Gallagher and Zahavi in their work The Phenomenological Mind: An Introduction to Philosophy of Mind and Cognitive Science. Merleau-Ponty uses concepts like those of the lived or own body and of lived space in order to emphasize, from a first-person perspective, the co-penetration that exists between subject and world.Gallagher and Zahavi have regained the experience of phenomenology, especially that of Merleau-Ponty and Sartre, to contribute to the development of the cognitive sciences. Via the phenomenological approach to the reality of habit, a new understanding of the body becomes possible for us, such that it becomes characterized “as subject, as experiencer, as agent”, and at the same time we can understand “the way the body structures our experience” (Gallagher and Zahavi, 2008). Additionally, the idea of a pre-reflexive understanding is conceived of by these authors... (shrink)

In Emotions and Reasons, Patricia Greenspan offers an evaluative theory of emotion that assigns emotion a role of its own in the justification of action. She analyzes emotions as states of object-directed affect with evaluative propositional content possibly falling short of belief and held in mind by generalized comfort or discomfort.

Husserl’s writings on sociality have received increasing attention in recent years. Despite this growing interest, Husserl’s reflections on the specific role of communication remain underexplored. In this paper, we aim to fill this gap by reconstructing the various ways in which Husserl draws systematic connections between communication and communalization. As will become clear, Husserl’s analysis converges with much more recent ideas defended by Margaret Gilbert and Naomi Eilan.

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest (...) have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma. (shrink)

Introduction : schizoanalysis, digital screens and new brain circuits -- Schizoid minds, delirium cinema and powers of machines of the invisible -- Illusionary perception and powers of the false -- Surveillance screens and powers of affect -- Signs of time : meta/physics of the brain-screen -- Degrees of belief : epistemology of probabilities -- Powers of creation : aesthetics of material-force -- The open archive : cinema as world-memory -- Divine in(ter)vention : micropolitics and resistance -- Logistics of perception 2.0 (...) : multiple screens as affective weapons -- Conclusion : the neuro-image : brain-screens from the future. (shrink)

Last year, the Joint Commission on Accreditation of Healthcare Organizations for the first time included provisions in its Hospital Accreditation Manual requiring institutions to have mechanisms in place to consider ethical issues arising in the care of patients and to educate care givers and patients on bioethical issues. This new requirement is notably vague. There is no indication of what type of mechanisms would be appropriate or how those involved in considering ethical issues should conduct themselves. This vagueness is by (...) no means accidental, but it reflects a recognition that clinical bioethics is still in its formative stages and that there are currently almost as many different mechanisms for dealing with bioethical issues in the healthcare setting as there are institutions that have such mechanisms. The Joint Commission's action, however, also implies that the time for experimentation will soon be over. (shrink)

In 2004, drug user representatives lobbied against the now stalled $17.5m Australian government Retractable Needle and Syringe Technology Initiative due to concerns about inadequate consultation and potential health risks to participants.1 Some drug user organisations have also recently withdrawn support for the Australian Illicit Drug Reporting System , ….

A dialogue between virtue and care ethics is formed as a step towards meeting Pellegrino's challenge to create a more comprehensive moral philosophy. It is also a dialogue between nursing and medicine since each practice draws on the Greek Virtue Tradition and the Judeo-Christian Tradition of care differently. In the Greek Virtue Tradition, the point of scrutiny lies in the inner character of the actor, whereas in the Judeo-Christian Tradition the focus is relational, i.e. how virtues are lived out in (...) specific relationships, particularly unequal relationships where vulnerability of one of the members is an issue. In a care ethic relational qualities such as attunement rather than inner qualities are the point of scrutiny. A dialogue between these two traditions makes it possible to consider the relational virtues and skills of openness and responsiveness that are required for a respectful meeting of the other. (shrink)

Neurophenomenological (NP) methods integrate objective and subjective data in ways that retain the statistical power of established disciplines (like cognitive science) while embracing the value of first-person reports of experience. The present paper positions neurophenomenology as an approach that pulls from traditions of cognitive science but includes techniques that are challenging for cognitive science in some ways. A baseline study is reviewed for “lessons learned,” that is, the potential methodological improvements that will support advancements in understanding consciousness and cognition using (...) neurophenomenology. These improvements, we suggest, include (1) addressing issues of interdisciplinarity by purposefully and systematically creating and maintaining shared mental models among research team members; (2) making sure that NP experiments include high standards of experimental design and execution to achieve variable control, reliability, generalizability, and replication of results; and (3) conceiving of phenomenological interview techniques as placing the impetus on the interviewer in interaction with the experimental subject. (shrink)

Parmenides of Elea was the most important and influential philosopher before Plato. He rejected as impossible the scientific inquiry practiced by the earlier Presocratic philosophers and held that generation, destruction, and change are unreal and that only one thing exists. In this book, Patricia Curd argues that Parmenides sought to reform rather than to reject scientific inquiry, and she offers a more coherent account of his influence on later philosophers._ _The Legacy of Parmenides_ examines Parmenides' arguments, considering his connection (...) to earlier Greek thought and how his account of what-is could have served as a model for later philosophers. Curd also explores the theories of his successors, including the Pluralists, the Atomists, the later Eleatics, and the later Presocratics. She concludes with a discussion of the importance of Parmenides' work to Plato's _Theory of Forms._ _The Legacy of Parmenides_ challenges traditional views of early Greek philosophy and provides new insights into the work of Parmenides. "_The Legacy of Parmenides_ represents a milestone... of Parmenides' interpretation. It is full of ideas and tells a coherent story about Parmenides and early Greek thought." --_ Alexander Nehamas, Princeton University___ "Professor Curd offers a genuinely original and possibly correct interpretation of the core thesis of the poem of Parmenides in a field so well worked over that saying something both new and true is profoundly difficult, this is a notable achievement." --_ Thomas M. Robinson, University of Toronto___ "This will be a substantial book in the story of early Greek philosophy, and future writers on the tradition from Thales through Plato will not be able to ignore it without missing an important interpretive alternative. It will be of value to students of Presocratic philosophy or the Greek tradition, as well as to students of the scientific revolution, cosmology, the origins of logic, or comparative mysticism." --_ Scott W. Austin, Texas A&M University___ PATRICIA CURD_ is professor at Purdue University where she works primarily in Ancient Philosophy. She is a co-editor of _Readings in Ancient Greek Philosophy_, and is the editor of _A Presocratics Reader._. (shrink)