NYC RECOVERS, an alliance of organizations concerned with New York CityYear of Recovery’, September 2001 to December 2002. This paper describes the concepts, techniques and accomplishments of NYC RECOVERS, and discusses potentials of the model, as well as obstacles to its implementation.

Industrial agriculture has extensive environmental and social costs, and efforts to create alternative farming systems are widespread if not yet widely successful. This study explored how a set of grain farmers and rotational graziers in Iowa transitioned to agroecological management practices. Our focus on the resources and strategies that farmers mobilized to develop opportunities for, and overcome barriers to, transitioning to alternative practices allows us to go beyond the existing literature focused on why farmers transition. We attend to both the (...) ecological and socioeconomic context of innovation by comparing processes of technical change in two contrasting regions of Iowa. Farmers cultivated farm-level biodiversity and enterprise diversity, developed new cognitive and psychological competencies, and overcame barriers to innovation by developing external network linkages with peers, knowledge organizations, and federal policies. Our research provides insights into how biophysical, cognitive, structural and market considerations can be integrated into research efforts that aim to make sense of innovation toward sustainable agriculture. (shrink)

Background: Ethics consultants (ECs) are increasingly expected to possess core knowledge and skills. Few data address whether ECs actually possess recommended core knowledge. We aimed to measure pediatric ECs’ understanding of ethical principles, identify knowledge gaps, and explore associations between experience/training and knowledge in pediatric ethics consultations. Methods: We identified the 2 ECs most knowledgeable in pediatric ethics from each of 45 freestanding children's hospitals and an equal number of general teaching hospitals in the United States. This yielded a sample (...) of 159 eligible pediatric ECs. Pediatric ECs were sent a survey measuring ethics training, characteristics of the ethics consultation service, and EC knowledge, as assessed by a previously validated scale entitled the Test of Residents’ Ethics Knowledge for Pediatrics (TREK-P). Of 102 completed surveys received, 99 were used in the analysis. Results: Seventy-three percent of ECs had completed ≥1 formal training modality, most commonly bioethics mini-courses, master's degrees, or certificate programs (20–30% each). Respondents infrequently received salary support (32%) or had a budget (28%) to support ethics work. The median TREK-P score was 19 (interquartile range [IQR] 17–21). Forty percent of subjects scored ≥20, surpassing the threshold of adequate performance proposed in previous work. Median scores were significantly higher among ECs with formal training in ethics but did not differ significantly by other variables. In secondary analyses, high scores (≥20) were significantly more common among ECs receiving salary support (55% vs. 33%, p = 0.04) and who had formal ethics training (47% vs. 22%, p = 0.02). Items pertaining to privacy, genetic testing, and assent, were answered incorrectly by >33% of ECs. Conclusions: High scores on a validated ethics knowledge scale were more common among ECs with salary support or formal ethics training. The study highlights knowledge gaps that warrant consideration as EC becomes a professionalized endeavor. (shrink)

Philosophers have developed three theories of luck: the probability theory, the modal theory, and the control theory. To help assess these theories, we conducted an empirical investigation of luck attributions. We created eight putative luck scenarios and framed each in either a positive or a negative light. Furthermore, we placed the critical luck event at the beginning, middle, or end of the scenario to see if the location of the event influenced luck attributions. We found that attributions of luckiness were (...) significantly influenced by the framing of the scenario and by the location of the critical event. Positively framing an event led to significantly higher lucky ratings than negatively framing the same exact event. And the closer a negative event was placed toward the end of a scenario, the more unlucky the event was rated. Overall, our results raise the possibility that there is no such thing as luck and thereby pose serious challenges to the three prominent theories of luck. We instead propose that luck may be a cognitive illusion, a mere narrative device used to frame stories of success or failure. (shrink)

ABSTRACTWe conducted two studies to determine whether there is a relationship between dispositional optimism and the attribution of good or bad luck to ambiguous luck scenarios. Study 1 presented five scenarios that contained both a lucky and an unlucky component, thereby making them ambiguous in regard to being an overall case of good or bad luck. Participants rated each scenario in toto on a four-point Likert scale and then completed an optimism questionnaire. The results showed a significant correlation between optimism (...) and assignments of luck: more optimistic people rated the characters in the ambiguous scenarios as more lucky while more pessimistic people rated the same characters in the same scenarios as more unlucky. Study 2 separated the good and bad luck components of the study 1 scenarios and presented the components individually to a new group of participants. Participants rated the luckiness of each component on the same four-point scale and then completed the optimism questionnaire. We found... (shrink)

ObjectiveTo evaluate the relationship between recently trained paediatricians' ethics knowledge and exposure to a formal ethics or professionalism curriculum during residency.MethodsWe conducted a cross-sectional survey of recently trained paediatricians which included a validated 23-item instrument called the Test of Residents' Ethics Knowledge for Pediatrics. The sample included paediatricians who completed medical school in 2006–2008, whose primary specialty was paediatrics or a paediatric subspecialty, and who completed paediatric residency training in 2010–2011. This sample was stratified based on residency programme variables: presence (...) of a formal curriculum in ethics or professionalism, programme size and American Board of Pediatrics certifying exam passage rate. Paediatricians were randomly selected from each stratum for survey participation.ResultsAmong the 370 responding paediatricians (55%), the mean knowledge score was 17.3 (SD 2.2) out of a possible 23. Presence of a formal curriculum in ethics and/or professionalism was not significantly associated with knowledge. Knowledge was lowest on items about parental requests for a child to undergo genetic testing (2 items, 44% and 85% incorrect), preserving patient confidentiality over email (55% incorrect), decision-making regarding life-sustaining technologies (61% incorrect), and decision-making principles such as assent and parental permission (2 items, 47% and 49% incorrect).ConclusionsThis study highlights several areas in which paediatricians' knowledge may be low and that are amenable to targeted educational interventions. These findings should prompt discussion and research among ethicists and educators about how ethics and professionalism curricula can more consistently influence paediatricians' knowledge. (shrink)

Who are the best subjects for judgment tasks intended to test grammatical hypotheses? Michael Devitt ( [2006a] , [2006b] ) argues, on the basis of a hypothesis concerning the psychology of such judgments, that linguists themselves are. We present empirical evidence suggesting that the relevant divide is not between linguists and non-linguists, but between subjects with and without minimally sufficient task-specific knowledge. In particular, we show that subjects with at least some minimal exposure to or knowledge of such tasks tend (...) to perform consistently with one another—greater knowledge of linguistics makes no further difference—while at the same time exhibiting markedly greater in-group consistency than those who have no previous exposure to or knowledge of such tasks and their goals. (shrink)

Michael Devitt ([2006a], [2006b]) argues that, insofar as linguists possess better theories about language than non-linguists, their linguistic intuitions are more reliable. (Culbertson and Gross [2009]) presented empirical evidence contrary to this claim. Devitt ([2010]) replies that, in part because we overemphasize the distinction between acceptability and grammaticality, we misunderstand linguists' claims, fall into inconsistency, and fail to see how our empirical results can be squared with his position. We reply in this note. Inter alia we argue that Devitt's focus (...) on grammaticality intuitions, rather than acceptability intuitions, distances his discussion from actual linguistic practice. We close by questioning a demand that drives his discussion—viz., that, for linguistic intuitions to supply evidence for linguistic theorizing, a better account of why they are evidence is required. (shrink)

In “Mindsets, Informed Consent and Research,” Lynn Jansen opens a promising new window onto consent for early‐phase cancer trials. She hypothesizes that patients who have agreed to take part in these trials, most of whom have incurable cancers, adopt different cognitive orientations or mindsets during the predecisional “deliberative” phase than they do during the postdecisional “implementation” phase. The different objectives that individuals hold during these phases—choosing among courses of action during the former, implementing the chosen action during the latter—lead to (...) the adaptive and preconscious application of different cognitive and attentional filters. If this is the case, then the prevalent practice of using surveys and interviews with postdecisional research participants, who on average markedly overestimate the potential for benefit that these trials offer, to extrapolate to the ethically central but much less studied deliberative phase, is methodologically suspect. As Jansen correctly notes, her thesis has numerous implications for the theory and study of informed consent. Three, in particular, deserve further discussion. (shrink)

ABSTRACT With few exceptions, the effectiveness of continuing education mandates has been measured by self-report assessments of the professional psychologists who fulfill them. The present investigation provided a longitudinal look at the number of approved CE providers and the incidence of licensing board complaints across a succession of two-year cycles prior to, and following, the 2012 implementation of CE mandates in the State of Illinois. Findings showed a substantial increase in the number of CE providers across that time, though no (...) significant change in the incidence of licensing board complaints, suggesting that the increased availability of CE did not translate into lower complaint rates. Possible reasons for these findings are noted, and recommendations for future work are detailed in support of an evidence-based approach to CE that better articulates and aligns its objectives with its outcomes in an era of renewed accountability in the health professions. (shrink)

The purpose of the study was to develop an understanding of how nursing students gained perspective on nursing care of diverse populations through watching documentaries in a cultural diversity course. The basis of this paper is our analyses of students’ written responses and reactions to documentaries viewed in class. The guiding theoretical frameworks for the course content and the study included postcolonial feminism, Foucauldian thought, and cultural safety. Krathwohl's Taxonomy of the Affective Domain was used to identify themes and determine (...) how undergraduate nursing students were progressing in achieving learning outcomes. Our findings suggest that while the use of documentaries serves as a tool for deepening students’ understanding of the realities of various populations, this activity, in the absence of critical reflection, may inadvertently promote stereotypes and further marginalize different people groups. Even though nursing students reflected on the importance of cultural safety in nursing, our findings indicate that their actions may not reflect this, especially since these students are in the early stages of the nursing program. Students need to be provided with a space where they can explore implicit biases evoked by exposure to new information about different people groups as a way of enhancing culturally safe care. (shrink)

A research project by the Schools of Theology and Psychology of Australia’s Charles Sturt University surveyed a large sample of Salvation Army officers. This article considers survey responses to two questions relating to end-of-life care: the use of pain medications that may shorten life, and the cessation of fluid and food intake. The results of the analyses are evaluated in terms of Michael Banner’s proposal that moral theology should more assiduously converse with ‘patient ethnographic study’, which the survey instantiates to (...) some extent. Banner’s proposal and the results of the survey are contrasted to Peter Singer’s analytical moral philosophical dictums on end-of-life care. The results are also compared to a metastudy by Andrea Rodríguez-Prat and Evert van Leeuwen of 14 ethnographic studies of those who wish to hasten death at the end of life. We conclude that respondents exemplify a form of moral reasoning that is embedded within Christian spirituality; counters the assumptions of Singer’s approach; contrasts the diminishment of ‘meaning’ at the end of life, as seen in Rodríguez-Prat and van Leeuwen; and deserves further respectful ethnographic study. (shrink)

We conducted a narrative review of existing literature to identify the knowledge, skills, and abilities necessary for officers who police in democratic societies to successfully manage potentially volatile police–public interactions. This review revealed 10 such KSAs that are frequently discussed in the literature. These KSAs include: knowledge of policies and laws; an understanding of mental health-related issues; an ability to interact effectively with, and show respect for, individuals from diverse community groups; awareness and management of stress effects; communication skills; decision-making (...) and problem-solving skills; perceptual skills; motor skills related to use-of-force; emotion and behavior regulation; and an ability to treat people in a procedurally just manner. Following our review, we conducted semi-structured interviews with researchers who specialize in police training and adult education, interactions with individuals in crisis, and racialized policing, as well as two police trainers with expertise in de-escalation and use-of-force training. These interviews confirmed the importance of the 10 KSAs and highlighted two additional KSAs that are likely to be critical: understanding the role of policing in a free and democratic society and tactical knowledge and skills. To ensure that police–public interactions are managed effectively, police trainers may want to focus on the development and evaluation of these KSAs—something that is not always done currently. (shrink)

Although theories that examine direct links between behavior and brain remain incomplete, it is known that brain expansion significantly correlates with caloric and oxygen demands. Therefore, one of the principles governing evolutionary cognitive neuroscience is that cognitive abilities that require significant brain function (and/or structural support) must be accompanied by significant fitness benefit to offset the increased metabolic demands. One such capacity is self-awareness (SA), which (1) is found only in the greater apes and (2) remains unclear in terms of (...) both cortical underpinning and possible fitness benefit. In the current experiment, transcranial magnetic stimulation (TMS) was applied to the prefrontal cortex during a spatial perspective-taking task involving self and other viewpoints. It was found that delivery of TMS to the right prefrontal region disrupted self-, but not other-, perspective. These data suggest that self-awareness may have evolved in concert with other right hemisphere cognitive abilities. (shrink)

The present study of the philosophical orientation within the poetics of Rilke and Stevens aims to show that in the context of modern poetry, transcendence, or “crossing beyond,” must be understood in two distinct senses, as vertical and horizontal projections. The usurpation of one by the other or the transfer between them distinguishes the poetry of Rilke and Stevens and makes a comparative reading particularly illuminating. The fact that Rilke and Stevens are two of the most widely (...) invoked poets in the phenomenological tradition will help to establish a modern sense of transcendence distinct from a traditional or Romantic longing for a realm above and beyond earthly existence. This would be an “immanent” transcendence, a crossing of horizons between perception and imagination or imagination and reality, by the disclosures and inventions of which, it is argued here, the more traditional notion of transcendence is usurped in distinct ways. (shrink)

This book's importance is derived from three sources: careful conceptualization of teacher induction from historical, methodological, and international perspectives; systematic reviews of research literature relevant to various aspects of teacher induction including its social, cultural, and political contexts, program components and forms, and the range of its effects; substantial empirical studies on the important issues of teacher induction with different kinds of methodologies that exemplify future directions and approaches to the research in teacher induction.

In lieu of an abstract, here is a brief excerpt of the content:Ethics & the Environment 7.1 (2002) 147-153 [Access article in PDF] Book Review Rattling the Cage: Toward Legal Rights for Animals Rattling the Cage: Toward Legal Rights for Animals Steven M. Wise. Foreward by Jane Goodall. Cambridge, Mass.: Perseus Books, 2000. pp. 384. US $17.50. ISBN 0-7382-0437-4 (Paperback) "Ancient philosophers claimed that all nonhuman animals had been designed and placed on this earth just for human beings. Ancient jurists (...) declared that law had been created just for human beings. Although philosophy and science have long since recanted, the law has not." Steven M. Wise, Rattling the Cage, p. 4. Readers of this journal are well-versed in the myriad ways in which nonhuman animals are harmfully exploited at the hands of human beings—from battery hens and veal calves to mass-produced pigs; from Pennsylvania pigeon shoots to canned hunts on Texas ranches; from rodeos to roadside zoos; from LD-50 toxicity tests on rats and Draize eye tests on rabbits to head trauma and infectious disease experimentation on primates. Despite other sticking points, it is by now uncontroversial among [End Page 147] nonanthropocentric theorists that, in utilitarian terms, the benefits to humans of the above practices fall far short of justifying the harms they cause to their nonhuman victims or, in deontological terms, that they violate the rights of creatures with inherent value. Indeed, these arguments are so well-rehearsed and so widely regarded as compelling that it no longer seems particularly bold to predict that if reason ever prevails over tradition and prejudice, the future will look back on this generation's treatment of our fellow creatures with the same kind of shame and condemnation with which European Americans regard our slaveholding past.More sobering but equally familiar is the observation that decisive arguments for the gross immorality of existing practices will bring about neither their elimination nor significant reform as long as the presumed legitimacy of human exploitation of nonhuman beings remains entrenched in both popular consciousness and economic, political, and legal institutions. In the interests of chipping away at popular apathy, academics should no doubt go on repeating the well-worn arguments against speciesism in classrooms, popular venues, and professional research. But in a world structured far more directly by the interests of a powerful few than by the values of the many, this consciousness-raising strategy properly plays at most a supporting role to the even more vital project of challenging and ultimately restructuring the institutions that sanction and carry out these injustices. In short, what nonhuman animals need from ethically sensitive intellectuals is not just rational argument, but effective legal and political action.One of the main institutional obstacles to progress in this area is undoubtedly the legal relegation of animals to property status—which is why Steve M. Wise's Rattling the Cage: Toward Legal Rights for Animals is such an important book. Wise teaches animal rights law at Harvard, Vermont, and John Marshall Law Schools and has spent more than twenty years fighting for animals in the legal system; his book displays the bittersweet fruit of that experience. The tenor throughout is a mixture of conviction in the justice of his cause—which cannot but sustain a vision of its eventual success—together with the frustration and determined patience borne from decades of butting up against an utterly implacable wall. An eloquent foreword by Jane Goodall, together with Wise's own harrowing first chapter, describe the nightmarish existences imposed on our nearest nonhuman relatives, the chimpanzees and bonobos, for the sake of science, entertainment, and profit—nightmares enabled by a legal system that [End Page 148] treats all nonhumans as mere things. An engaging storyteller with a synthetic conception of the history of ideas, Wise unearths the origins of this conception of animals in the Great Chain of Being, demonstrates its defeat by Darwinian science, and builds piece by piece a case—drawing heavily on research into animal consciousness—for extending legal rights at least to chimpanzees and bonobos.The substantive theses of this case are, first, that the denial of... (shrink)

The purpose of this study is to take preliminary steps to unify psychoacoustic techniques with reaction-time methodologies to address the perceptual mechanisms responsible for the detection of one vs. multiple sounds. We measured auditory redundancy gains for auditory detection of pure tones widely spaced in frequency using the tools of Systems Factorial Technology to evince the system architecture and workload capacity in two different scenarios. We adopted an experimental design in which the presence or absence of a target at each (...) of two frequencies was combined factorially with two stimulus levels. Replicating previous work, results did not allow an assessment of system architecture due to a failure to observe factor influence at the level of distribution ordering for dual-target stimuli for both SOFT and LOUD scenarios. All subjects demonstrated very modest redundancy gains for the dual-target compared to the single-target stimuli, and results were similar for both LOUD and SOFT. We propose that these results can be predicted by a mental architecture that falls into the class of integrated subadditive parallel systems, using a well-supported assumption that reaction time is driven by loudness. We demonstrate that modeled loudness of the experimental sounds is highly correlated with mean reaction time, and we provide a proof-of-concept model based on Steven’s Power law that predicts both a failure of distributional ordering for dual-target stimuli and very modest redundancy gains. (shrink)

Steven Hales and Jennifer Johnson—building off their (2014) work as well as Hales (2015, 2016)—have recently conducted two studies in Philosophical Psychology (2018) that show that there is a relationship between optimism and folk assessments of luck. Hales and Johnson use these results to argue that there is no such thing as luck. Instead, they claim that the concept is highly subjective and a cognitive illusion and that what we are in need of is an error theory. After reviewing (...) Hales and Johnson’s position, I levy four objections against their view. First, they ignore the fact that luck involves a chanciness condition. Second, their standards for what it means to be a useful philosophical theory are too high. Third, their view ignores the fact that there are various accounts of value in the literature and assumes a kind of relativism that few people would be willing to accept. Lastly, their error theory is not supported by the empirical evidence. Because of these problems, Hales and Johnson’s argument is not a serious threat to extant accounts of luck. (shrink)

Robinson argues that by certain threshold criteria, pregnant women qualify for a higher moral status by reason of their pregnancies. While her intention is to make this a status upgrade for women, we worry that it may result in a status downgrade for women as a class, by presupposing and reinforcing women’s value in relation to their reproductive labour. Historically, central to feminist analysis is resistance to reductive accounts of women in relation to their reproductivity. For example, de Beauvoir addressed (...) men’s transcendence and contrasted it with women’s immanence, a status distinction possible because women are mired in expectations that they will marry, produce children and remain in the domestic realm; and for her part, Firestone argued that biological reproduction underlies women’s inferiority to men and that ‘The reproduction of the species by one sex for the benefit of both (should) be replaced by…artificial reproduction’1 2 Her concern was to liberate women from expectations of biological reproduction so their productive value in society is not reduced to their reproductive contributions. A formidable body of analysis in this same vein cautions against collapsing the value of women into their pregnancies, so much so that some commentators even distinguish ‘mothering’ from gestation.3 Robinson’s argument that pregnant women qualify at a higher threshold of personhood emphasises …. (shrink)

Promiscuous realism is the thesis that there are many equally legitimate ways of classifying the world’s entities. Advocates of promiscuous realism are typically taken to hold the further the- sis, often undistinguished, that kind terms usefully deployed in scientific generalisations are no more natural than those deployed for any other purposes. Call this further thesis promiscuous nat- uralism. I here defend a version of promiscuous realism which denies promiscuous naturalism. To do so, I introduce the notion of a promiscuous kind: (...) a kind that is maximally usefully referenced in predictive and explanatory generalisations, none of which are scientific generalisations. I first defend the claim that pain is a promiscuous kind before extending these considerations to everyday mental kinds more generally. I draw on further reflections from both everyday life and contem- porary psychology to make credible the novel suggestion that our everyday theory of our minds is for the explanation and prediction of individuals. Combined with the complex idiosyncrasy of individual minds, this suggested aim of everyday theory gives us reason to think that promiscuity is prevalent among everyday mental kinds. (shrink)

Studies of group selection have been done with both natural and manipulated populations using plants, insects and birds. Group selection occurred in all studies and often the strength of group selection was equal to that of individual selection. Laboratory selection experiments resulted in the opposite response to individual selection than that predicted. Selection with plants for high leaf area resulted in plants with smaller leaf area and selection for high emigration rate in beetles produced lines with lower rates. The selected (...) traits included interactions among individuals. Theoretical studies have shown that genetically based interactions among individuals can interfere with individual selection. Evolution can be partitioned into selection and the response to selection. A response to selection requires genetic variation. Properties of group genetic structure for the natural populations are discussed. The experimental populations had controlled group structure and demonstrate that populations can respond to group selection under some genetic structures. (shrink)

THE TITLE OF THIS PAPER calls for clarification. Not only are there several senses in which something may be said to "be," there are also many nuances to the terms "categorial" and "intuition." Taking Aristotle as a guide, let us focus upon the primary sense of "being," that is, substance considered both as first substance and second substance. We may then take "categorial" as referring to what Aristotle calls the "figures of predication," the ways in which predicates characterize subjects, indicating (...) "what" the subject is, its quality, quantity, relation, its "where," its "when," and so forth. The term "intuition" expresses something too primitive to be defined, but Edmund Husserl's metaphorical contrast between the "emptiness" of thought and speech and the "fullness" of intuition successfully highlights its essential characteristic. A couple of examples should suffice to grasp the import of Husserl's distinction. Consider the difference, for instance, between first entertaining vague plans of visiting a foreign city and then experiencing the fulfillment of actually strolling through its streets, or the difference between first reading a manual of instructions for performing some task and then actually executing the task skillfully. Taking Husserl as a guide, let us therefore characterize intuition broadly as the presentation of something in its fullness, as opposed to thinking or talking about it in an empty way. Finally, combining Husserlian and Aristotelian terminologies, we may describe categorial intuition as the presentation of figures of predication. Rather than presenting some particular thing, say a red chair, categorial intuition presents the chair's being red, the red quality's belonging to the chair. In short, categorial intuition makes present the modes of presentation of things. (shrink)

What makes a life meaningful and how do we know when our lives have meaning? This paper provides an answer to these questions drawing on the experience of grief. Grief, I argue, is a unique kind of personally and epistemically transformative experience. The experience of grief provides a subject with new insight into what-it-is-like to experience a transformative loss. But not only does one learn what-it-is-like to be personally transformed by loss in the way that one is, in the dynamic (...) process of grieving one often gains retrospective access to facts about the meaningfulness and value that even the most seemingly mundane aspects of their day-to-day lives have had all along. These are facts that can go underappreciated and even unrecognized until the source of that meaning is lost. I propose an explanation for why these facts aren’t more easily known through a simple process like introspection or reflection, and instead require an experience as disorienting as loss. I end by discussing what the epistemic account suggests about a theory of life’s meaningfulness. (shrink)

It has recently been argued that Harvey Brown and Oliver Pooley’s ‘dynamical approach’ to special relativity should be understood as what might be called an ontologically and ideologically relationalist approach to Minkowski geometry, according to which Minkowski geometrical structure supervenes upon the symmetries of the best-systems dynamical laws for a material world with primitive topological or differentiable structure. Fleshing out the details of some such primitive structure, and a conception of laws according to which Minkowski geometry could so supervene, has (...) been referred to by some as the ‘constructivist project’. Here, it is explained that Nick Huggett’s work on ‘regularity relationalism’ provides a framework for such an approach, and a relativistic version of Huggett’s regularity relationalism is outlined for that purpose. Finally, by way of examples, it is shown that this approach fails in the simplest cases. Still, reasons are given for which this should not necessarily discourage an advocate of this interpretation of the dynamical approach. _1_ Introduction to the Dynamical Approach _2_ Huggett’s Regularity Relationalism _3_ The Dynamical Approach as a Form of Regularity Relationalism _4_ A Simple Way to Set the Stage _5_ A First Attempt _5.1_ Complex-valued planewave solutions _5.2_ Real-valued planewave solutions _6_ More General Solutions _7_ Summary and Reflections. (shrink)

ABSTRACT I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments. INTRODUCTION In contrast to the classic model of randomized-control trials, often with a large number of (...) subjects enrolled, precision medicine attempts to optimize therapeutic outcomes by focusing on the individual.[i] A recent publication highlights the strengths and weakness of both traditional evidence-based medicine and precision medicine.[ii] Plus, it outlines a tension in the shift from evidence-based medicine’s inductive reasoning style (the collection of data to postulate general theories) to precision medicine’s abductive reasoning style (the generation of an idea from the limited data available).[iii] The paper’s main example is the application of precision medicine for the treatment of cancer.[iv] I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. As the name suggests, brain-computer interfaces are a significant advancement in neurotechnology that directly connects someone’s brain to external or implanted devices.[v] Among the various kinds of brain-computer interfaces, adaptive deep brain stimulation devices require numerous personalized adjustments to their settings during the implantation and computation stages in order to provide adequate relief to patients with treatment-resistant disorders. What makes these devices unique is how adaptive deep brain stimulation integrates a sensory component to initiate the stimulation. While not commonly at the level of sophistication as self-supervising or generative large language models,[vi] they currently allow for a semi-autonomous form of neuromodulation. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments.[vii] ANALYSIS I. The State of Precision Medicine in Oncology and the Epistemological Shift While a thorough overview of precision medicine for the treatment of cancer is beyond the scope of this article, its practice can be roughly summarized as identifying clinically significant characteristics a patient possesses (e.g., genetic traits) to land on a specialized treatment option that, theoretically, should benefit the patient the most.[viii] However, in such a practice of stratification patients fall into smaller and smaller populations and the quality of evidence that can be applied to anyone outside these decreases in turn.[ix] As inductive logic helps to articulate, the greater the number of patients that respond to a particular therapy the higher the probability of its efficacy. By straying from this logical framework, precision medicine opens the treatment of cancer to more uncertainty about the validity of these approaches to the resulting disease subcategories.[x] Thus, while contemporary medical practices explicitly describe some treatments as “personalized”, they ought not be viewed as inherently better founded than other therapies.[xi] A relevant contemporary case of precision medicine out of Norway focuses on the care of a patient with cancer between the ventricles of the heart and esophagus, which had failed to respond to the standard regimen of therapies over four years.[xii] In a last-ditch effort, the patient elected to pay out-of-pocket for an experimental immunotherapy (nivolumab) at a private hospital. He experienced marked improvements and a reduction in the size of the tumor. Understandably, the patient tried to pursue further rounds of nivolumab at a public hospital. However, the hospital initially declined to pay for it given the “lack of evidence from randomised clinical trials for this drug relating to this [patient’s] condition.”[xiii] In rebuttal to this claim, the patient countered that he was actually similar to a subpopulation of patients who responded in “open‐label, single arm, phase 2 studies on another immune therapy drug” (pembrolizumab).[xiv] Given this interpretation of the prior studies and the patient’s response, further rounds of nivolumab were approved. Had the patient not had improvements in the tumor’s size following a round of nivolumab, then pembrolizumab’s prior empirical evidence in isolation would have been insufficient, inductively speaking, to justify his continued use of nivolumab.[xv] The case demonstrates a shift in reasoning from the traditional induction to abduction. The phenomenon of ‘cancer improvement’ is considered causally linked to nivolumab and its underlying physiological mechanisms.[xvi] However, “the weakness of abductions is that there may always be some other better, unknown explanation for an effect. The patient may for example belong to a special subgroup that spontaneously improves, or the change may be a placebo effect. This does not mean, however, that abductive inferences cannot be strong or reasonable, in the sense that they can make a conclusion probable.”[xvii] To demonstrate the limitations of relying on the abductive standard in isolation, commentators have pointed out that side effects in precision medicine are hard to rule out as being related to the initial intervention itself unless trends from a group of patients are taken into consideration.[xviii] As artificial intelligence (AI) assists the development of precision medicine for oncology, this uncertainty ought to be taken into consideration. The implementation of AI has been crucial to the development of precision medicine by providing a way to combine large patient datasets or a single patient with a large number of unique variables with machine learning to recommend matches based on statistics and probability of success upon which practitioners can base medical recommendations.[xix] The AI is usually not establishing a causal relationship[xx] – it is predicting. So, as AI bleeds into medical devices, like brain-computer interfaces, the same cautions about using abductive reasoning alone should be carried over. II. Responsive Neurostimulation, AI, and Personalized Medicine Like precision medicine in cancer treatment, computer-brain interface technology similarly focuses on the individual patient through personalized settings. In order to properly expose the intersection of AI, precision medicine, abductive reasoning, and implantable neurotechnologies, the descriptions of adaptive deep brain stimulation systems need to deepen.[xxi] As a broad summary of adaptive deep brain stimulation, to provide a patient with the therapeutic stimulation, a neural signal, typically referred to as a local field potential,[xxii] must first be detected and then interpreted by the device. The main adaptive deep brain stimulation device with premarket approval, the NeuroPace Responsive Neurostimulation system, is used to treat epilepsy by detecting and storing “programmer-defined phenomena.”[xxiii] Providers can optimize the detection settings of the device to align with the patient’s unique electrographic seizures as well as personalize the reacting stimulation’s parameters.[xxiv] The provider adjusts the technology based on trial and error. One day machine learning algorithms will be able to regularly aid this process in myriad ways, such as by identifying the specific stimulation settings a patient may respond to ahead of time based on their electrophysiological signatures.[xxv] Either way, with AI or programmers, adaptive neurostimulation technologies are individualized and therefore operate in line with precision medicine rather than standard treatments based on large clinical trials. Contemporary neurostimulation devices are not usually sophisticated enough to be prominent in AI discussions where the topics of neural networks, deep learning, generative models, and self-attention dominate the conversation. However, implantable high-density electrocorticography arrays (a much more sensitive version than adaptive deep brain stimulation systems use) have been used in combination with neural networks to help patients with neurologic deficits from a prior stroke “speak” through a virtual avatar.[xxvi] In some experimental situations, algorithms are optimizing stimulation parameters with increasing levels of independence.[xxvii] An example of neurostimulation that is analogous to the use of nivolumab in Norway surrounds a patient in the United States who was experiencing both treatment-resistant OCD and temporal lobe epilepsy.[xxviii]Given the refractory nature of her epilepsy, implantation of an adaptive deep brain stimulation system was indicated. As a form of experimental therapy, her treatment-resistant OCD was also indicated for the off-label use of an adaptive deep brain stimulation set-up. Another deep brain stimulation lead, other than the one implanted for epilepsy, was placed in the patient’s right nucleus accumbens and ventral pallidum region given the correlation these nuclei had with OCD symptoms in prior research. Following this, the patient underwent “1) ambulatory, patient-initiated magnet-swipe storage of data during moments of obsessive thoughts; (2) lab-based, naturalistic provocation of OCD-related distress (naturalistic provocation task); and (3) lab-based, VR [virtual reality] provocation of OCD-related distress (VR provocation task).”[xxix] Such signals were used to identify when to deliver the therapeutic stimulation in order to counter the OCD symptoms. Thankfully, following the procedure and calibration the patient exhibited marked improvements in their OCD symptoms and recently shared her results publicly.[xxx] In both cases, there is a similar level of abductive justification for the efficacy of the delivered therapy. In the case study in which the patient was treated with adaptive deep brain stimulation, they at least had their neural activity tested in various settings to determine the optimum parameters for treatment to avoid them being based on guesswork. Additionally, the adaptive deep brain stimulation lead was already placed before the calibration trials were conducted, meaning that the patient had already taken on the bulk of the procedural risk before the efficacy could be determined. Such an efficacy test could have been replicated in the first patient’s cancer treatment, had it been biopsied and tested against the remaining immunotherapies in vitro. Yet, in the case of cancer with few options, one previous dose of a drug that appeared to work on the patient may justify further doses. However, as the Norwegian case presents, corroboration with known responses to a similar drug (from a clinical trial) could be helpful to validate the treatment strategy. (It should be noted that both patients were resigned to these last resort options regardless of the efficacy of treatment.) There are some elements of inductive logic seen with adaptive deep brain stimulation research in general. For example, abductively the focus could be that patient X’s stimulation parameters are different from patient Y’s and patient Z’s. In contrast, when grouped as subjects who obtained personalized stimulation, patients X, Y, and Z demonstrate an inductive aspect to this approach’s safety and/or efficacy. The OCD case holds plenty of abductive characteristics in line with precision medicine’s approach to treating cancer and as more individuals try the method, there will be additional data. With the gradual integration of AI into brain-computer interfaces in the name of efficacy, this reliance on abduction will continue, if not grow, over time. Moving forward, if a responsive deep brain stimulation treatment is novel and individualized (like the dose of nivolumab) and there is some other suggestion of efficacy (like clinical similarities to other patients in the literature), then it may justify insurance coverage for the investigative intervention, absent other unrelated reasons to deny it. III. Ethical Implications and Next Steps While AI’s use in oncology and neurology is not yet as prominent as its use in other fields (e.g., radiology), it appears to be on the horizon for both.[xxxi] AI can be found in both the functioning of the neurotechnologies as well as the implementation of precision medicine. The increasing use of AI may serve to further individualize both oncologic and neurological therapies. Given these implications and the handful of publications cited in this article, it is important to have a nuanced evaluation of how these treatments, which heavily rely on abductive justification, ought to be managed. The just use an abductive approach may be difficult as AI infused precision medicine is further pursued. At baseline, such technology relies on a level of advanced technology literacy among the general public and could exclude populations who lack access to basic technological infrastructure or know-how from participation.[xxxii] Even among nations with adequate infrastructure, as more patients seek out implantable neurotechnologies, which require robust healthcare resources, the market will favor patient populations that can afford this complex care.[xxxiii] If patients already have the means to pay for an initial dose/use of a precision medicine product out of pocket, should insurance providers be required to cover subsequent treatments?[xxxiv] That is, if a first dose of a cancer drug or a deep brain stimulator over its initial battery life is successful, patients may feel justified in having the costs of further treatments covered. The Norwegian patient’s experience implies there is a precedent for the idea that some public insurance companies ought to cover successful cancer therapies, however, insurance companies may not all see themselves as obligated to cover neurotechnologies that rely on personalized settings or that are based on precision/abductive research more than on clinical trials. CONCLUSION The fact that the cases outlined above rely on abductive style of reasoning implies that there may not be as strong a justification for coverage by insurance, as they are both experimental and individualized, when compared to the more traditional large clinical trials in which groups have the same or a standardized protocol (settings/doses). If a study is examining the efficacy of a treatment with a large cohort of patients or with different experimental groups/phases, insurance companies may conclude that the resulting symptom improvements are more likely to be coming from the devices themselves. A preference for inductive justification may take priority when ruling in favor of funding someone’s continued use of an implantable neurostimulator. There are further nuances to this discussion surrounding the classifications of these interventions as research versus clinical care that warrant future exploration, since such a distinction is more of a scale[xxxv] than binary and could have significant impacts on the “right-to-try” approach to experimental therapies in the United States.[xxxvi] Namely, given the inherent limitations of conducting large cohort trials for deep brain stimulation interventions on patients with neuropsychiatric disorders, surgically innovative frameworks that blend abductive and inductive methodologies, like with sham stimulation phases, have traditionally been used.[xxxvii] Similarly, for adaptive brain-computer interface systems, if there are no large clinical trials and instead only publications that demonstrate that something similar worked for someone else, then, in addition to the evidence that the first treatment/dose worked for the patient in question, the balance of reasoning would be valid and arguably justify insurance coverage. As precision approaches to neurotechnology become more common, frameworks for evaluating efficacy will be crucial both for insurance coverage and for clinical decision making. ACKNOWLEDGEMENT This article was originally written as an assignment for Dr. Francis Shen’s “Bioethics & AI” course at Harvard’s Center for Bioethics. I would like to thank Dr. Shen for his comments as well as my colleagues in the Lázaro-Muñoz Lab for their feedback. - [i] Jonathan Kimmelman and Ian Tannock, “The Paradox of Precision Medicine,” Nature Reviews. Clinical Oncology 15, no. 6 (June 2018): 341–42, https://doi.org/10.1038/s41571-018-0016-0. [ii] Henrik Vogt and Bjørn Hofmann, “How Precision Medicine Changes Medical Epistemology: A Formative Case from Norway,” Journal of Evaluation in Clinical Practice 28, no. 6 (December 2022): 1205–12, https://doi.org/10.1111/jep.13649. [iii] David Barrett and Ahtisham Younas, “Induction, Deduction and Abduction,” Evidence-Based Nursing 27, no. 1 (January 1, 2024): 6–7, https://doi.org/10.1136/ebnurs-2023-103873. [iv] Vogt and Hofmann, “How Precision Medicine Changes Medical Epistemology,” 1208. [v] Wireko Andrew Awuah et al., “Bridging Minds and Machines: The Recent Advances of Brain-Computer Interfaces in Neurological and Neurosurgical Applications,” World Neurosurgery, May 22, 2024, S1878-8750(24)00867-2, https://doi.org/10.1016/j.wneu.2024.05.104. [vi] Mark Riedl, “A Very Gentle Introduction to Large Language Models without the Hype,” Medium (blog), May 25, 2023, https://mark-riedl.medium.com/a-very-gentle-introduction-to-large-language-models-without-the-hype-5 f67941fa59e. [vii] David E. Burdette and Barbara E. Swartz, “Chapter 4 - Responsive Neurostimulation,” in Neurostimulation for Epilepsy, ed. Vikram R. Rao (Academic Press, 2023), 97–132, https://doi.org/10.1016/B978-0-323-91702-5.00002-5. [viii] Kimmelman and Tannock, 2018. [ix] Kimmelman and Tannock, 2018. [x] Simon Lohse, “Mapping Uncertainty in Precision Medicine: A Systematic Scoping Review,” Journal of Evaluation in Clinical Practice 29, no. 3 (April 2023): 554–64, https://doi.org/10.1111/jep.13789. [xi] Kimmelman and Tannock, “The Paradox of Precision Medicine.” [xii] Vogt and Hofmann, 1206. [xiii] Vogt and Hofmann, 1206. [xiv] Vogt and Hofmann, 1206. [xv] Vogt and Hofmann, 1207. [xvi] Vogt and Hofmann, 1207. [xvii] Vogt and Hofmann, 1207. [xviii] Vogt and Hofmann, 1210. [xix] Mehar Sahu et al., “Chapter Three - Artificial Intelligence and Machine Learning in Precision Medicine: A Paradigm Shift in Big Data Analysis,” in Progress in Molecular Biology and Translational Science, ed. David B. Teplow, vol. 190, 1 vols., Precision Medicine (Academic Press, 2022), 57–100, https://doi.org/10.1016/bs.pmbts.2022.03.002. [xx] Stefan Feuerriegel et al., “Causal Machine Learning for Predicting Treatment Outcomes,” Nature Medicine 30, no. 4 (April 2024): 958–68, https://doi.org/10.1038/s41591-024-02902-1. [xxi] Sunderland Baker et al., “Ethical Considerations in Closed Loop Deep Brain Stimulation,” Deep Brain Stimulation 3 (October 1, 2023): 8–15, https://doi.org/10.1016/j.jdbs.2023.11.001. [xxii] David Haslacher et al., “AI for Brain-Computer Interfaces,” 2024, 7, https://doi.org/10.1016/bs.dnb.2024.02.003. [xxiii] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 103–4; “Premarket Approval (PMA),” https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P100026. [xxiv] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 104. [xxv] Burdette and Swartz, 126. [xxvi] Sean L. Metzger et al., “A High-Performance Neuroprosthesis for Speech Decoding and Avatar Control,” Nature 620, no. 7976 (August 2023): 1037–46, https://doi.org/10.1038/s41586-023-06443-4. [xxvii] Hao Fang and Yuxiao Yang, “Predictive Neuromodulation of Cingulo-Frontal Neural Dynamics in Major Depressive Disorder Using a Brain-Computer Interface System: A Simulation Study,” Frontiers in Computational Neuroscience 17 (March 6, 2023), https://doi.org/10.3389/fncom.2023.1119685; Mahsa Malekmohammadi et al., “Kinematic Adaptive Deep Brain Stimulation for Resting Tremor in Parkinson’s Disease,” Movement Disorders 31, no. 3 (2016): 426–28, https://doi.org/10.1002/mds.26482. [xxviii] Young-Hoon Nho et al., “Responsive Deep Brain Stimulation Guided by Ventral Striatal Electrophysiology of Obsession Durably Ameliorates Compulsion,” Neuron 0, no. 0 (October 20, 2023), https://doi.org/10.1016/j.neuron.2023.09.034. [xxix] Nho et al. [xxx] Nho et al.; Erik Robinson, “Brain Implant at OHSU Successfully Controls Both Seizures and OCD,” OHSU News, accessed March 3, 2024, https://news.ohsu.edu/2023/10/25/brain-implant-at-ohsu-successfully-controls-both-seizures-and-ocd. [xxxi] Awuah et al., “Bridging Minds and Machines”; Haslacher et al., “AI for Brain-Computer Interfaces.” [xxxii] Awuah et al., “Bridging Minds and Machines.” [xxxiii] Sara Green, Barbara Prainsack, and Maya Sabatello, “The Roots of (in)Equity in Precision Medicine: Gaps in the Discourse,” Personalized Medicine 21, no. 1 (January 2024): 5–9, https://doi.org/10.2217/pme-2023-0097. [xxxiv] Green, Prainsack, and Sabatello, 7. [xxxv] Robyn Bluhm and Kirstin Borgerson, “An Epistemic Argument for Research-Practice Integration in Medicine,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 43, no. 4 (July 9, 2018): 469–84, https://doi.org/10.1093/jmp/jhy009. [xxxvi] Vijay Mahant, “‘Right-to-Try’ Experimental Drugs: An Overview,” Journal of Translational Medicine 18 (June 23, 2020): 253, https://doi.org/10.1186/s12967-020-02427-4. [xxxvii] Michael S. Okun et al., “Deep Brain Stimulation in the Internal Capsule and Nucleus Accumbens Region: Responses Observed during Active and Sham Programming,” Journal of Neurology, Neurosurgery & Psychiatry 78, no. 3 (March 1, 2007): 310–14, https://doi.org/10.1136/jnnp.2006.095315. (shrink)