In their forthcoming article, ‘What makes a medical intervention invasive?’ De Marco, Simons, and colleagues explore the meaning and usage of the term ‘invasive’ in medical contexts. They describe a ‘Standard Account’, drawn from dictionary definitions, which defines invasiveness as ‘incision of the skin or insertion of an object into the body’. They then highlight cases wherein invasiveness is employed in a manner that is inconsistent with this account (eg, in describing psychotherapy) to argue that the term invasiveness is often (...) used to explicitly or implicitly reference interventions that do not fall under the standard account. The authors offer an alternative ‘schematic’ definition of invasiveness, whereby medical interventions entail an underlying context-independent property of ‘basic invasiveness’ and may be understood both relative to each other and to a context-specific threshold of what is ‘invasive’.1 We propose that the meaning of terms such as ‘invasiveness’ is necessarily heterogeneous, and that what is implied by its usage will certainly depend on context, particularly in medical settings. Hence, the creation of a unifying definition is less critical than clarification of the implied and intended meanings of each instance of the term’s use. We further argue that interpreting the use of terms like ‘invasiveness’ in medical practice is complicated by the embedding of each use of this term in a different ‘language game’, whereby words and their meanings are understood by an in-group familiar with …. (shrink)

Objective: To examine the role of explainability in machine learning for healthcare (MLHC), and its necessity and significance with respect to effective and ethical MLHC application. Study Design and Setting: This commentary engages with the growing and dynamic corpus of literature on the use of MLHC and artificial intelligence (AI) in medicine, which provide the context for a focused narrative review of arguments presented in favour of and opposition to explainability in MLHC. Results: We find that concerns regarding explainability are (...) not limited to MLHC, but rather extend to numerous well-validated treatment interventions as well as to human clinical judgment itself. We examine the role of evidence-based medicine in evaluating unexplainable treatments and technologies, and highlight the analogy between the concept of explainability in MLHC and the related concept of mechanistic reasoning in evidence-based medicine. Conclusion: Ultimately, we conclude that the value of explainability in MLHC is not intrinsic, but is instead instrumental to achieving greater imperatives such as performance and trust. We caution against the uncompromising pursuit of explainability, and advocate instead for the development of robust empirical methods to successfully evaluate increasingly inexplicable algorithmic systems. (shrink)

The aim of a theoretically ideal process of informed consent is to promote the autonomy of the patient and to limit unethical physician paternalism. However, in practice, the nature of the medical profession requires physicians to act as ontological decision architects—based on the medical knowledge that they acquire through their experience and training, physicians ontologically determine a subset of viable courses of action for their patient. What is observed is not an unethical physician limitation or biasing of the patient towards (...) certain treatment options that violates patient autonomy or consciously undermines informed consent, but rather a more foundational paternalism that is necessarily inherent to the physician–patient relationship. In this article we argue for a recognition of this underlying physician paternalism and posit that this necessary paternalism is not a foil to patient autonomy, but rather a foundational aspect of the duties of the medical professional within the physician–patient relationship. (shrink)

The aim of a theoretically ideal process of informed consent is to promote the autonomy of the patient and to limit unethical physician paternalism. However, in practice, the nature of the medical profession requires physicians to act as ontological decision architects—based on the medical knowledge that they acquire through their experience and training, physicians ontologically determine a subset of viable courses of action for their patient. What is observed is not an unethical physician limitation or biasing of the patient towards (...) certain treatment options that violates patient autonomy or consciously undermines informed consent, but rather a more foundational paternalism that is necessarily inherent to the physician–patient relationship. In this article we argue for a recognition of this underlying physician paternalism and posit that this necessary paternalism is not a foil to patient autonomy, but rather a foundational aspect of the duties of the medical professional within the physician–patient relationship. (shrink)

Over the past two decades ethics committees have proliferated in healthcare institutions across the country. Catalysts for this growth include the endorsement of ethics committees by the New Jersey Supreme Court in the Quinlan case, by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research in its report entitled Deciding to Forgo Life Sustaining Medical Treatment, by the U.S. Department of Health and Human Services in its 1985 “Baby Doe” regulations, by numerous other courts in (...) treatment decisionmaking opinions issued after Quinlan, and more recently by the Joint Commission on Accreditation of Healthcare Organizations. (shrink)

In many jurisdictions, legal frameworks afford patients the opportunity to make prospective medical decisions or to create directives that contain a special provision forfeiting their own ability to object to those decisions at a future time point, should they lose decision‐making capacity. These agreements have been described with widely varying nomenclatures, including Ulysses Contracts, Odysseus Transfers, Psychiatric Advance Directives with Ulysses Clauses, and Powers of Attorney with Special Provisions. As a consequence of this terminological heterogeneity, it is challenging for healthcare (...) providers to understand the terms and uses of these agreements and for ethicists to engage with the nuances of clinical decision‐making with such unique provisions surrounding patient autonomy. In theory, prospective self‐binding agreements may safeguard patient's “authentic” wishes from future “inauthentic” changes of mind. In practice, it is unclear what may be comprised within these agreements or how—and to what effect—they are used. The primary focus of this integrative review is to curate the existing literature describing Ulysses Contracts (and analogous decisions) used in the clinical arena, in order to empirically synthesize their shared essence and provide insights into the traditional components of these agreements when used in practice, the requirements of their consent processes, and the outcomes of their utilization. (shrink)

Unrealistic optimism is a bias that leads people to believe, with respect to a specific event or hazard, that they are more likely to experience positive outcomes and/or less likely to experience negative outcomes than similar others. The phenomenon has been seen in a range of health-related contexts—including when prospective participants are presented with the risks and benefits of participating in a clinical trial. In order to test for the prevalence of unrealistic optimism among participants of early-phase oncology trials, we (...) conducted a survey with patients over 18 years of age who were enrolled in a phase I, phase I/II, or phase II clinical cancer trial in the New York City area between August 2008 and October 2009. Participants in our study were asked to compare their own chances of experiencing a range of risks and benefits related to the trial they were enrolled in with the chances of the other trial participants. We found a significant optimistic bias in their responses. Respondents tended to overestimate the benefits of the trial they were enrolled in and underestimate its risks. In addition, we found no significant relationship between respondents’ understanding of the trial’s purpose and how susceptible they were to unrealistic optimism. Our findings suggest that improving the consent process for oncology studies requires more than addressing deficits in understanding. (shrink)

Purpose Recent research has found unrealistic optimism among patient-subjects in early-phase oncology trials. Our aim was to investigate the cognitive and motivational factors that evoke this bias in this context. We expected perceptions of control to be a strong correlate of unrealistic optimism. Methods A study of patient-subjects enrolled in early-phase oncology trials was conducted at two sites in the USA. Respondents completed questionnaires designed to assess unrealistic optimism and several risk attribute variables that have been found to evoke the (...) bias in other contexts. Results One hundred and seventy-one patient-subjects agreed to be interviewed for our study. Significant levels of perceived controllability were found with respect to all nine research-related questions. Perceptions of control were found to predict unrealistic optimism. Two other risk attribute variables, awareness of indicators and mental image, were correlated with unrealistic optimism. However, in multivariate regression analysis, awareness and mental image dropped out of the model and perceived controllability was the only factor independently associated with unrealistic optimism. Conclusion Patient-subjects reported that they can, at least partially, control the benefits they receive from participating in an early-phase oncology trial. This sense of control may underlie unrealistic optimism about benefiting personally from trial participation. Effective interventions to counteract unrealistic optimism may need to address the psychological factors that give rise to distorted risk/benefit processing. (shrink)

In this article, we explore how deep brain stimulation (DBS) devices designed to “close the loop”—to automatically adjust stimulation levels based on computational algorithms—may risk taking the individual agent “out of the loop” of control in areas where (at least apparent) conscious control is a hallmark of our agency. This is of particular concern in the area of psychiatric disorders, where closed-loop DBS is attracting increasing attention as a therapy. Using a relational model of identity and agency, we consider whether (...) DBS designed for psychiatric regulation may require special attention to agency. To do this, we draw on philosophical work on relational identity and agency, connecting it with reports from people using first-generation DBS devices for depression and obsessive-compulsive disorder. We suggest a way to extend a notion of relational agency to encompass neural devices. (shrink)

Family members can provide crucial support to individuals participating in clinical trials. In research on the “newest frontier” of Deep Brain Stimulation (DBS)—the use of DBS for psychiatric conditions—family member support is frequently listed as a criterion for trial enrollment. Despite the significance of family members, qualitative ethics research on DBS for psychiatric conditions has focused almost exclusively on the perspectives and experiences of DBS recipients. This qualitative study is one of the first to include both DBS recipients and their (...) family members as interview participants. Using dyadic thematic analysis—an approach that takes both the individuals and the relationship as units of analyses—this study analyzes the complex ways in which family relationships can affect DBS trial participation, and how DBS trial participation in turn influences family relationships. Based on these findings, we propose ways to improve study designs to better take family relationships into account, and better support family members in taking on the complex, essential roles that they play in DBS trials for psychiatric conditions. (shrink)

Between 1998 and 2006, a new style of television news consumption was born: “news grazing.” With remote control devices in hand, “grazers” flip through TV news channels in order to find interesting news stories. Approximately three‐fifths of the public graze, and this group tends to be younger than non‐grazers. Grazers are less likely than the rest of the public to follow “hard” news about politics and economics, and, not surprisingly, they are even less knowledgeable about public affairs than most people (...) are. (shrink)

What happens at the end of a clinical trial for an investigational neural implant? It may be surprising to learn how difficult it is to answer this question. While new trials are initiated with increasing regularity, relatively little consensus exists on how best to conduct them, and even less on how to ethically end them. The landscape of recent neural implant trials demonstrates wide variability of what happens to research participants after an neural implant trial ends. Some former research participants (...) continue to receive support for their devices (e.g., battery and component replacements, software updates, etc.). Others, when safe, have their neural implants removed through surgical explantation. Still others continue to live with a deactivated neural implant embedded in their body. In the United States, there are no uniform requirements to provide services, of any kind, after an neural implant study ends, and other nations are similarly facing this challenge. The existence of a post-trial gap in an expanding neural implant research ecosystem invites obvious questions: What is owed to neural implant research participants post-trial, and why has providing it been so difficult to accomplish in practice? To take a step forward on this difficult issue, we assembled one group of stakeholders – researchers funded for neuroethics grants by the National Institutes of Health – to explore possible starting points on one topic: ethical guidance for post-trial care of research participants in neural implant trials. Based on shared concerns discussed in the expert workshop the current paper is a call to action. It reports the key areas of convergence from the meeting and highlights important next steps towards developing much needed guidance. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:277 HUME'S IMPRESSIONS OF BELIEF Introduction Hume's theory of belief is often taken to be fully stated in his opening remarks on the subject in A Treatise of Human Nature, Book I, Part III, Section VII: "An opinion, therefore, or belief may be most accurately defin'd, A LIVELY IDEA RELATED TO OR ASSOCIATED WITH A PRESENT IMPRESSION."1 Taking this definition as Hume's final account leaves the reader with many (...) problems. What is it for an idea to be lively? How is an idea related to or associated with an impression? Is belief really so simple a phenomenon? I argue that Hume's theory of belief is much more complex than this, and that the Treatise contains only a rough, preliminary account of belief. By the time he wrote An Enquiry Concerning the Human Understanding, Hume had developed his theory in full detail. As I show, in this latter account a belief is an intentional state involving a combination of Humean ideas and impressions. The nature of these ideas and impressions allows the mind to take note of a belief as something quite different from its other perceptions. In the Treatise, however, Hume did not have a clear understanding of how the mind could distinguish beliefs from other perceptions. He could only go so far as to say that an idea believed is livelier than other ideas. He argued that a present impression is capable of calling to mind an idea of something that has been associated with that impression in the past, and of transferring some of its own vivacity to that idea. As we look at the account of belief in the Treatise, we will see how the preliminary concepts of force and liveliness and a transference of vivacity lay the foundation for his 278 final account, yet point to a need for a fuller explication of the difference the mind notes between beliefs and other perceptions. We will see that in the Appendix to the Treatise Hume tried to work out this difference in terms of 'feeling' but this was unsuccessful without the notion of an intentional act. Finally, we will see that Hume concluded in the Enquiry that a belief is an intentional state in which a new impression of reflection arises about the idea believed. This new impression is the feeling of belief by which beliefs are distinguished from other 2 perceptions of the mind. The Account in the Treatise We begin our explication of Hume's theory of belief by looking at the account in A Treatise of Human Nature. Here Hume maintains that it is ideas which are believed, and that these beliefs differ from other ideas only in their "force and vivacity" (T 96). This force and vivacity is a result of the believed idea's relation to an impression. These theses lead us to the familiar Treatise definition of belief as "A LIVELY IDEA RELATED TO OR ASSOCIATED WITH A PRESENT IMPRESSION" (T 96). Hume begins his analysis of belief in Section VII of the Treatise by stating that "the idea of an object is an essential part of the belief of it, but not the whole" (T 94). The suggestion is that there is more to being in a state of belief than merely entertaining the idea believed. The simple phrase "belief o_f_ an object" leads us to presume that it is ideas that are believed, or that we have beliefs o_f ideas. We will need to examine Hume's meaning of 'idea' in enough depth to understand the role it plays in the theory of belief. 279 Hume gives some examples of the way we may conceive ideas without believing them: Suppose a person present with me, who advances propositions, to which I do not assent, that Caesar dy'd in his bed, that silver is more fusible than lead, or mercury heavier than gold; 'tis evident, that notwithstanding my incredulity, I clearly understand his meaning, and form all the same ideas, which he forms (T 95). Note that Hume says one may form all the same ideas as another. Yet the ideas one forms are just what Hume had earlier called the propositions one... (shrink)

Human rights instruments exist to respond to serious dangers that human beings routinely face, what Henry Shue terms ‘standard threats.’ According to Shue’s influential account of the structure of a moral right, these threats are ‘the targets of the social guarantees for the enjoyment of … a right.’ They are ‘common, or ordinary, and serious but remediable.’ Yet for individuals who struggle daily against serious, remediable threats that are common to their peer group, but do not routinely threaten mainstream society, (...) this oversight has enormous implications for their security, subsistence, freedom, and dignity. This paper examines the three elements of Shue’s standard threat. It concludes by making the case that if we are to deploy this element of the structure of moral rights to justify social guarantees of protection, and to craft them in a way that takes proper account of human diversity, then we must ask: Standard for whom? (shrink)

This article explores the connection between the Heng Xian and the Changes of Zhou tradition, especially the “Tuan” and “Attached Verbalizations” commentaries. Two important Heng Xian terms—heng 恆 and fu 復—are also Changes of Zhou hexagrams and possible connections are explored. Second, the Heng Xian account of the creation of names is compared with the “Attached Verbalizations” account of the creation of the Changes of Zhou system. Third, the roles played by knowing and desire in both Heng Xian and the (...) Changes of Zhou tradition are explored, with particular focus on potential points of similarity. Finally, insights gained through these comparisons are used to interpret the Heng Xian advice on initiating action. (shrink)

Overdiagnosis is an emerging problem in health policy and practice: we address its definition and ethical implications. We argue that the definition of overdiagnosis should be expressed at the level of populations. Consider a condition prevalent in a population, customarily labelled with diagnosis A. We propose that overdiagnosis is occurring in respect of that condition in that population when the condition is being identified and labelled with diagnosis A in that population ; this identification and labelling would be accepted as (...) correct in a relevant professional community; but the resulting label and/or intervention carries an unfavourable balance between benefits and harms. We identify challenges in determining and weighting relevant harms, then propose three central ethical considerations in overdiagnosis: the extent of harm done, whether harm is avoidable and whether the primary goal of the actor/s concerned is to benefit themselves or the patient, citizen or society. This distinguishes predatory, misdirected and tragic overdiagnosis; the degree of harm moderates the justifiability of each type. We end with four normative challenges: methods for adjudicating between professional standards and identifying relevant harms and benefits should be procedurally just; individuals, organisations and states are differently responsible for addressing overdiagnosis; overdiagnosis is a matter for distributive justice: the burdens of both overdiagnosis and its prevention could fall on the least-well-off; and communicating about overdiagnosis risks harming those unaware that they may have been overdiagnosed. These challenges will need to be addressed as the field develops. (shrink)

When two people move in synchrony, they become more social. Yet it is not clear how this effect scales up to larger numbers of people. Does a group need to move in unison to affiliate, in what we term unitary synchrony; or does affiliation arise from distributed coordination, patterns of coupled movements between individual members of a group? We developed choreographic tasks that manipulated movement synchrony without explicitly instructing groups to move in unison. Wrist accelerometers measured group movement dynamics and (...) we applied cross-recurrence analysis to distinguish the temporal features of emergent unitary synchrony and distributed coordination. Participants’ unitary synchrony did not predict pro-social behavior, but their distributed coordination predicted how much they liked each other, how they felt toward their group, and how much they conformed to each other's opinions. The choreography of affiliation arises from distributed coordination of group movement dynamics. (shrink)

In his 1981 article "What is 'business ethics'"? Peter Drucker maintains that the then current business ethics literature is a form of casuistry, and it provides an illegitimate argument for business apologists, while it also unjustly bashes business. I agree with W. Michael Hoffman's and Jennifer Mills Moore's criticisms of Drucker's article. However, by limiting themselves to this article, rather than considering Drucker's management works, they have missed an opportunity to benefit from his acknowledged practical wisdom. In this paper, I (...) seize the opportunity to show that Drucker takes business ethics seriously, and I develop his position on business morality. His view of business management responsibility and the related notion of a just organization is seen to be essentially Platonic. (shrink)

For over a decade, managed care has profoundly altered how healthcare is delivered in the United States. There have been concerns that the patient-physician relationship may be undermined by various aspects of managed care, such as restrictions on physician choice, productivity requirements that limit the time physicians may spend with patients, and the use of compensation formulas that reward physicians for healthcare dollars not spent. We have previously published data on the effects of managed care on the physician-patient relationship from (...) the physician's perspective. In 1999, we collected data on the impact of managed care arrangements on the physician-patient relationship from the patient's perspective. This article discusses our collective findings. (shrink)

Over the past several years, healthcare has been profoundly altered by the growth of managed care. Because managed care integrates the financing and delivery of healthcare services, it dramatically alters the roles and relationships among providers, payers, and patients. While analysis of this change has focused on whether and how managed care can control costs, an increasingly important concern among healthcare providers and recipients is the impact of managed care on the physicianpatient relationship, but little data have been collected and (...) analyzed. We designed a survey for distribution to Wisconsin physicians to analyze the prevalence and types of managed care arrangements in the state, and the impact of these arrangements on physicians and their relationships with patients. (shrink)

A causal-comparative, mixed methods design was used to study a partnership between a university and school district formed with the goal of improving history teachers’ United States history content knowledge to raise student engagement and achievement. Data were collected from middle and high school history teachers including teacher interviews, classroom observations, and student work. Student engagement surveys and academic performance data were also collected. Student academic performance was positively impacted and changes in classroom practice were found in the treatment group. (...) However, differences in student engagement between groups were not found to be statistically significant. (shrink)

The purpose of the current study was to examine the reliability and validity of the RESTQ-Sport-36 for use in the collegiate student-athlete population. A total of 494 collegiate student-athletes competing in National Collegiate Athletic Association Division I, II, or III sanctioned sport completed the RESTQ-Sport-36 and Brief Profile of Mood States. Structural equation modeling procedures were used to compare first order to hierarchical model structures. Results of a confirmatory factor analysis and exploratory structural equation modeling analysis indicated that the first (...) order 12-factor structure demonstrated the best fit of all models tested. Support was not observed for the fit of any hierarchical model. Moderate to strong correlations were observed between stress and recovery subscales and mood states, thus supporting the construct validity of the abbreviated RESTQ measurement model. The current findings provide support for the measure’s use in this population and give pause as it relates to the scoring and interpretation of hierarchical factors such as Total Stress and Total Recovery. Overall, the current results indicate that the RESTQ-Sport-36 may be a useful tool for collegiate student-athlete training load and competition monitoring. (shrink)

Where do you begin the important conversation about professionalizing early childhood education (ECE) as a field of practice? This book is the tool you need to advance the conversation and shape the future of ECE. Professionalizing Early Childhood Education As a Field of Practice provides an overview of the topic, a participant guide, a conversation workbook, and a facilitator guide to move the conversation forward. Each section supports deep thought and creative discussions to make the overall conversation meaningful and productive (...) for the entire profession. Don't just sit back and listen; be a part of this important conversation.Stacie Goffin is a widely recognized authority in early childhood education with a passion for raising the competence of ECE as a field of practice. She received a degree in child development from the University of Massachusetts Amherst, followed by her master's in early childhood from George Washington University and her executive education certification from Harvard. Stacie currently serves as Principal of the Goffin Strategies Group, where she uses her experience consulting with educational programs to improve effectiveness and services for young children. (shrink)

The currently standard approach to fiction is to define it in terms of imagination. I have argued elsewhere that no conception of imagining is sufficient to distinguish a response appropriate to fiction as opposed to non-fiction. In her contribution Kathleen Stock seeks to refute this objection by providing a more sophisticated account of the kind of propositional imagining prescribed by so-called ‘fictive utterances’. I argue that although Stock's proposal improves on other theories, it too fails to provide an adequate criterion (...) of fictionality. I conclude by sketching an alternative account according to which fiction is a genre. (shrink)

Joan Tronto’s new paradigm of caring democracy bases citizenship on the need to ensure that all people receive and provide care equitably. But how exactly are citizens motivated to take up these caring responsibilities? The writings of Alcoholics Anonymous (AA) co-founder William ‘Bill’ Wilson provide one answer: he pathologizes the alcoholic – dooming him to inevitable relapse and death – to compel AA members to accept shared vulnerability and mutual care as the bedrock of sobriety and AA society. Wilson returns (...) repeatedly to the threat of death to convince AA members to carry out their newfound caring and democratic responsibilities. We use Wilson’s thinking, as well as Michel Foucault’s work on biopower, to forward the concept of biocaring democracy, in which the acceptance of shared pathology compels people to care for each other but also limits their democratic responsibilities. More broadly, our analysis suggests how hinging democracy to shared vulnerability may constrain the radical possibilities that Tronto envisions. (shrink)