For all of the emphasis on quality improvement—as well as the acknowledged overlap between assessment of the quality of healthcare services and clinical ethics—the quality of clinical ethics consultation has received scant attention, especially in terms of empirical measurement. Recognizing this need, the second edition of Core Competencies for Health Care Ethics Consultation identified four domains of ethics quality: (1) ethicality, (2) stakeholders’ satisfaction, (3) resolution of the presenting conflict/dilemma, and (4) education that translates into knowledge. This study is the (...) first, to our knowledge, to directly measure all of these domains. Here we describe the quality improvement process undertaken at a tertiary care academic medical center, as well as the tools developed to measure the quality of ethics consultation, which include post-consultation satisfaction surveys and weekly case conferences. The information gained through these tools helps to improve not only the process of ethics consultation, but also the measurement and assurance of quality. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Living Organ Donors’ Stories: (Unmet) Expectations about Informed Consent, Outcomes, and CareElisa J. Gordon, Symposium EditorKeywordsEthics, informed consent, kidney, liver, living donor, narrative, transplantationLiving donor organ transplantation has become standard treatment for patients with end-stage kidney or end-stage liver disease. Live donors comprised approximately 5,769 (34%) and 247 (4%) of all kidney and liver transplants in 2011, respectively (OPTN/UNOS). The reasons why people donate, the perception that donating (...) does not entail a decision per se, and the attendant fears and anxieties living donors feel about donating, have all been previously well investigated (Lennerling, Forsberg, Meyer, & Nyberg, 2004; Papachristou, Walter, Frommer, & Klapp, 2010). But much less is known about how donors experienced the overall donation process including the donor evaluation, preparation, appreciation of risks, decision-making, informed consent, post-operative, recovery processes, and the impact of donating on all aspects of their life, from their point of view. Thus, a narrative approach is essential for gaining insights into these less well known phenomena.There is good reason to remain concerned about the safety and ethical basis of living donation considering that living donors undergo serious health risks for no direct medical benefit to themselves (Ethics Committee of the Transplantation Society, 2004; Laird, 2012; Neergaard, 2011; Ratner & Sandoval, 2010; Shelton, 2011). The situation raises serious ethical questions specifically about nonmaleficence and informed consent, and more broadly about using people as a means to an end. The absence of long-term information may not undermine a willing donor’s commitment to save a loved one’s life, but is certainly cause for concern among transplant clinicians who want to be sure to disclose information that may be material for donors in order to provide adequate informed consent. In other words, the disjuncture between what transplant clinicians find important to disclose to donors and what prospective donors need to know—which follows along the lines of what Elliot Mishler referred to as the ‘voice of medicine’ versus the ‘voice of the lifeworld’(1984)—seems to complicate donors’ preparation for donation. Donors’ stories are important for addressing these concerns by identifying risks that typically do not get reported in the scientific literature—perhaps owing to a different [End Page 1] conceptualization of what should be construed as noteworthy risks—as well as by demonstrating how personal situations can enhance or detract from the experience overall.This issue of Narrative Inquiry in Bioethics (NIB) affords a unique entrée into both the often heard and unheard stories of living organ donors. A set of topical areas were presented for the authors’ consideration that relate to the donation process in general and the informed consent process more specifically: whether donors were prepared to donate; comprehended what they were told; could have understood the process better, as well as, the impact of donation on health, employment, finances, and personal relationships (Table 1). When soliciting donors’ stories, every effort was made to include a full range of experiences—both good and bad—from a variety of donors: kidney donation, liver donation, adult-to-adult and adult-to-child donation, related, unrelated, directed and anonymous (also known as ‘altruistic’ or ‘good Samaritan’ donors), paired chain exchange, and list exchange (Table 2)—in order to present a balanced perspective on live donation. Additionally, this issue includes a full breadth of stories about the donor experience, ranging from positive to mixed to negative (Table 3). While donors were given tremendous leeway in what stories they told, they were asked to focus their narratives on the lesser known dimensions of donation—the experience of it. While additional stories from liver donors would have helped to underscore common concerns among liver donors, we only received a few. Some of the donors are themselves health care professionals, active in the United Network for Organ Sharing (UNOS) or their local OPO, or have leveraged their experiences to help others by becoming a donor buddy or donor advocate. Given that we received more stories than Click for larger view View full resolutionTable 1.Topical areas to address[End Page 2] Click for larger view View full resolutionTable 2.Forms of Living Donation Click for larger view View... (shrink)

A 'Kripke-style' semantics is given for combinatory logic using frames with a ternary accessibility relation, much as in the Tourley-Meyer semantics for relevance logic. We prove by algebraic means a completeness theorem for combinatory logic, by proving a representation theorem for 'combinatory posets.' A philosophical interpretation is given of the models, showing that an element of a combinatory poset can be understood simultaneously as a set of states and as a set of actions on states. This double interpretation allows (...) for one such element to be applied to another . Application turns out to be modeled the same way as 'fusion' in relevance logic.We also introduce 'dual combinators' that apply from the right. We then explore relationships to some well-known substructural logics, showing that each can be embedded into the structurally free. non-associative Lambek calculus, with the embedding taking a theorem ω to a statement of the form Γ ⊨ ω, where Γ is some fusion of the combinators needed to justify the structural assumptions of the given substructural logic. This builds on earlier ideas from Belnap and Meyer about a Gentzen system wherein structural rules are replaced with rules for introducing combinators. We develop such a system and prove a cut theorem. (shrink)

Certain species of fish have recently become important model systems in comparative genomics and in developmental biology, in certain instances because of their small genome sizes (e.g., in the pufferfish) and, in other cases, because of the opportunity they provide to combine an easily accessible and experimentally manipulable embryology with the power of genetic approaches (e.g., in the zebrafish). The resulting accumulation of genomic information indicates that, surprisingly, many gene families of fish consist of more members than in mammals. Most (...) modern fish, including the zebrafish and medakka, are diploid organisms; however, the greater number of genes in fish was possibly caused by additional ancient genome duplications which happened in the lineage leading to modern ray-finned fishes but not along the lineage leading to tetrapods. Since these two lineages shared their last common ancestor (in the Devonian about 360 million years ago) individual duplicated members of gene families were later lost in fish. Interestingly, comparative data indicate that, in some cases, genes in mammals even serve somewhat different functions than their homologues in fish, highlighting that the degree of evolutionary relatedness of genes is not always a reliable predictor of their evolutionary conservation and their similarity of function. Since fish are phenotypically probably not more complex than mammals, it is possible that evolution took alternative paths to the “economics of genomics” through alternative solutions to gene regulation. It is suggested that the more complex genomic architecture of fish permitted them to adapt and speciate quickly in response to changing selective regimes. BioEssays 20:511–515, 1998. © 1998 John Wiley & Sons, Inc. (shrink)

Ageing is a complex phenomenon which remains a major challenge to modern biology. Although the evolutionary biology of ageing is well understood, the mechanisms that limit lifespan are unknown. The isolation and analysis of single‐gene mutations which extend lifespan (Age mutations) is likely to reveal processes which influence ageing. Caenorhabditis elegans is the only metazoan in which Age mutations have been identified. The Age mutations not only prolong life, but also confer a complex array of other phenotypes. Some of these (...) phenotypes provide clues to the evolutionary origins of these genes while others allude to mechanisms of lifespan‐extension. Many of the Age genes interact and share a second common phenotype, that of stress resistance. Rather than invertebrate ageing being determined by a ‘clock mechanism’, a picture is emerging of ageing as a non‐adaptive process determined, in part, by resistance to intrinsic stress mediated by stress‐response genes. (shrink)

The report of the President's Council on Bioethics, Human Cloning and Human Dignity, addresses the central ethical, political, and policy issue in human embryonic stem cell research: the moral status of extracorporeal human embryos. The Council members were in sharp disagreement on this issue and essentially failed to adequately engage and respectfully acknowledge each others' deepest moral concerns, despite their stated commitment to do so. This essay provides a detailed critique of the two extreme views on the Council (i.e., embryos (...) have full moral status or they have none at all) and then gives theoretical grounding for our judgment about the intermediate moral status of embryos. It also supplies an account of how to address profound moral disagreements in the public arena, especially by way of constructing a middle ground that deliberately pays sincere respect to the views of those with whom it has deep disagreements. (shrink)

Consider the following situation. It is the first day of school, and the new third-grade students file into the classroom to be shown to their seats for the coming year. As they enter, the third-grade teacher notices one small boy who is particularly unkempt. He looks to be in desperate need of bathing, and his clothes are dirty, torn and tight-fitting. During recess, the teacher pulls aside the boy's previous teacher and asks about his wretched condition. The other teacher informs (...) her that he always looks that way, even though the boy's family is quite wealthy. The reason he appears as he does, she continues, is that the family observes an odd practice according to which the children do not receive many important things – food, clothing, bathing, even shelter – unless they specifically request them. Since the boy, like many third-graders, has little interest in bathing and clean clothes, he just never asks for them. (shrink)

Using practical formalism a deontological ethical analysis of peer relations in organizations is developed. This analysis is composed of two types of duties derived from Kant's Categorical Imperative: negative duties to refrain from the use of peers and positive duties to provide help and assistance. The conditions under which these duties pertain are specified through the development of examples and conceptual distinctions. A number of implications are then discussed.

Developmental Coordination Disorder and Attention-Deficit/Hyperactivity Disorder are unique neurodevelopmental disorders with overlaps in executive functions and motor control. The conditions co-occur in up to 50% of cases, raising questions of the pathological mechanisms of DCD versus ADHD. Few studies have examined these overlaps in adults with DCD and/or ADHD. Therefore, to provide insights about executive functions and motor control between adults with DCD, ADHD, both conditions, or typically developed controls, this study used a stop-signal task and parallel EEG measurement. We (...) assessed executive performance via go accuracy and go reaction time, as well as motor response inhibition via stop-signal reaction time. This was complemented with analysis of event-related potentials. Based on existing investigations of adults with DCD or ADHD, we expected groups would not differ in behavioral performance on stop and go trials, but differences in ERPs, particularly in components N200 and P300 would be evident. The sample included N = 50 adults with DCD, ADHD, DCD + ADHD, and control participants. We replicated that there were no between-group differences for behavioral-level executive performance and motor response inhibition. However, on a physiological level, ERP components N200 and P300 differed between groups, particularly during successful response inhibition. These ERPs reflect potential endophenotypic differences not evident in overt behavior of participants with ADHD and/or DCD. This suggests a disorder specific employment of inhibition or general executive functions in groups of adults with DCD, DCD + ADHD, ADHD, or control participants. (shrink)

No crucial experiment demonstrates that four hue categories are needed to describe color appearance. Instead, converging lines of evidence suggest that the terms red, yellow, green, and blue are sufficient and precise enough for deriving color discrimination functions and for a useful model constraining relations between color appearance and neuronal responses. Such a model need not be based on linguistic universals. Until something better is available, this holds.

Tradition is a central concern for a wide range of academic disciplines interested in problems of transmitting culture across generations. Yet, the concept itself has received remarkably little analysis. A substantial literature has grown up around the notion of 'invented tradition,' but no clear concept of tradition is to be found in these writings; since the very notion of 'invented tradition' presupposes a prior concept of tradition and is empty without one, this debunking usage has done as much to obscure (...) the idea as to clarify it. In the absence of a shared concept, the various disciplines have created their own vocabularies to address the subject. Useful as they are, these specialized vocabularies (of which the best known include hybridity, canonicity, diaspora, paradigm, and contact zones) separate the disciplines and therefore necessarily create only a collection of parochial and disjointed approaches. Until now, there has been no concerted attempt to put the various disciplines in conversation with one another around the problem of tradition. Combining discussions of the idea of tradition by major scholars from a variety of disciplines with synoptic, synthesizing essays, Questions of Tradition will initiate a renewal of interest in this vital subject. (shrink)

On page 1 of his classic text, Millsap states, “Measurement invariance is built on the notion that a measuring device should function the same way across varied conditions, so long as those varied conditions are irrelevant [emphasis added] to the attribute being measured.” By construction, measurement invariance techniques require not only detecting varied conditions but also ruling out that these conditions inform our understanding of measured domains. In fact, measurement invariance techniques possess great utility when theory and research inform their (...) application to specific, varied conditions that, if not detected, introduce measurement biases, and, thus, depress measurement validity. Yet, we see emerging bodies of work where scholars have “put the cart before the horse” when it comes to measurement invariance, and they apply these techniques to varied conditions that, in fact, may reflect domain-relevant information. These bodies of work highlight a larger problem in measurement that likely cuts across many areas of scholarship. In one such area, youth mental health, researchers commonly encounter a set of conditions that nullify the use of measurement invariance, namely discrepancies between survey reports completed by multiple informants, such as parents, teachers, and youth themselves. In this paper, we provide an overview of conceptual, methodological, and measurement factors that should prevent researchers from applying measurement invariance techniques to detect informant discrepancies. Along the way, we cite evidence from the last 15 years indicating that informant discrepancies reflect domain-relevant information. We also apply this evidence to recent uses of measurement invariance techniques in youth mental health. Based on prior evidence, we highlight the implications of applying these techniques to multi-informant data, when the informant discrepancies observed within these data might reflect domain-relevant information. We close by calling for a moratorium on applying measurement invariance techniques to detect informant discrepancies in youth mental health assessments. In doing so, we describe how the state of the science would need to fundamentally “flip” to justify applying these techniques to detect informant discrepancies in this area of work. (shrink)