Objective: To provide an ethical analysis of whether the Ethiopian and Tanzanian national HIV/AIDS treatment guidelines can be considered legitimate and fair rationing tools.Method: Qualitative study and ethical analysis involving guideline documents and interviews with nine key members involved in the development of the guidelines. The analysis followed an editing organising style. The theoretical framework was a guideline-specific framework based on theories of just resource allocation in healthcare and conditions that ensure fair processes in guideline development. According to this framework, (...) legitimate rationing requires reasons for patient selection to be explicit, public and relevant, and decisions must be open to question and revision.Results: The only explicit rationing criteria that both guidelines recommended were clinical antiretroviral treatment indications. Explicit non-clinical rationing criteria were expressed in a separate Ethiopian implementation guideline. Neither of the guideline development processes fully satisfies minimal requirements of procedural fairness. There is a lack of transparency. The reasons for decisions are rarely given and are not publicly available. This reduces the opportunity for public questioning, debate and revisions. The guidelines were based on expert opinion and consensus. Recommendations from the WHO were copied without much discussion, disagreement or adjustment.Conclusions: The two national HIV treatment guidelines discussed are de facto mechanisms for rationing but were developed using methods that do not fully satisfy the requirements of fair processes. (shrink)

Introduction Hundreds of thousands of premature neonates born in low-income countries are implicitly denied treatment each year. Studies from India show that treatment is rationed even for neonates born at 32 gestational age weeks (GAW), and multiple external factors influence treatment decisions. Is withholding of life-saving treatment for children born between 28 and 32 GAW acceptable from an ethical perspective? Method A seven-step impartial ethical analysis, including outcome analysis of four accepted priority criteria: severity of disease, treatment effect, cost effectiveness (...) and evidence for neonates born at 28 and 32 GAW. Results The ethical analysis sketches out two possibilities: (a) It is not ethically permissible to limit treatment to neonates below 32 GAW when assigning high weight to health maximisation and overall health equality. Neonates below 32 GAW score high on severity of disease and efficiency and cost-effectiveness of treatment if one gives full weight to early years of a newborn life. It is in the child's best interest to be treated. (b) It can be considered ethically permissible if high weight is assigned to reducing inequality of welfare and maximising overall welfare and/or not granting full weight to early years of newborns is considered acceptable. From an equity-motivated health and welfare perspective, we would not accept (b), as it relies on accepting the lack of proper welfare policies for the poor and disabled in India. Conclusion Explicit priority processes in India for financing neonatal care are needed. If premature neonates are perceived as worth less than other patient groups, the reasons should be explored among a broad range of stakeholders. (shrink)

High-spin states in the odd-odd N = Z nucleus Co-54 have been investigated by the fusion-evaporation reaction Si-28(S-32,1 alpha 1p1n)Co-54. Gamma-ray information gathered with the Ge detector array Gammasphere was correlated with evaporated particles detected in the charged particle detector system Microball and a 1 pi neutron detector array. A significantly extended excitation scheme of Co-54 is presented, which includes a candidate for the isospin T = 1, 6(+) state of the 1f(7/2)(-2) multiplet. The results are compared to large-scale shell-model (...) calculations in the fp shell. Effective interactions with and without isospin-breaking terms have been used to probe isospin symmetry and isospin mixing. A quest for deformed high-spin rotational cascades proved negative. This feature is discussed by means of cranking calculations. (shrink)

BackgroundInstrumented gait analysis post-stroke is becoming increasingly more common in research and clinics. Although overall standardized procedures are proposed, an almost infinite number of potential variables for kinematic analysis is generated and there remains a lack of consensus regarding which are the most important for sufficient evaluation. The current aim was to identify a discriminative core set of kinematic variables for gait post-stroke.MethodsWe applied a three-step process of statistical analysis on commonly used kinematic gait variables comprising the whole body, derived (...) from 3D motion data on 31 persons post-stroke and 41 non-disabled controls. The process of identifying relevant core sets involved: exclusion of variables for which there were no significant group differences; systematic investigation of one, or combinations of either two, three, or four significant variables whereby each core set was evaluated using a leave-one-out cross-validation combined with logistic regression to estimate a misclassification rate.ResultsThe best MR for one single variable was shown for the Duration of single-support or Duration of 2nd double-support phase, corresponding to an 89–90% probability of correctly classifying a person as post-stroke/control. Adding Pelvis sagittal ROM to either of the variables Self-selected gait speed or Stride length, alternatively adding Ankle sagittal ROM to the Duration of single-stance phase, increased the probability of correctly classifying individuals to 93–94%. Combining three variables decreased the MR further to 0.04, suggesting a probability of 96% for correct classification. These core sets contained: a spatial or a temporal variable, Pelvis sagittal ROM or Ankle plantarflexion during push-off, and Arm Posture Score or Cadence or a knee/shoulder joint angle variable. Adding a fourth variable did not further improve the MR.ConclusionA core set combining a few crucial kinematic variables may sufficiently evaluate post-stroke gait and should receive more attention in rehabilitation. Our results may contribute toward a consensus on gait evaluation post-stroke, which could substantially facilitate future diagnosis and monitoring of rehabilitation progress. (shrink)

The 14 chapters in _Ethics at the End of Life: New Issues and Arguments_, all published here for the first time, focus on recent thinking in this important area, helping initiate issues and lines of argument that have not been explored previously. At the same time, a reader can use this volume to become oriented to the established questions and positions in end of life ethics, both because new questions are set in their context, and because most of the chapters—written (...) by a team of experts—survey the field as well as add to it. Each chapter includes initial summaries, final conclusions, and a Related Topics section. TABLE OF CONTENTS John K. Davis, "Introduction" Geoffrey Scarre, "Is it possible to be better off dead?" Taylor W. Cyr, "How Does Death Harm the Deceased?" Benjamin Mitchell-Yellin, "The Significance of an Afterlife" Jens Johansson, "The Severity of Death" John K. Davis, "Defining Death" James Stacey Taylor, "Autonomy, Competence, and End of Life" Eric Vogelstein, "Deciding for the Incompetent" Paul T. Menzel, "Change of Mind: An Issue for Advance Directives" Nancy S. Jecker, "Medical Futility and Respect for Patient Autonomy" Paul T. Menzel, "Refusing Lifesaving Medical Treatment and Food and Water by Mouth" Thomas S. Huddle, "Suicide, Physician-Assisted Suicide, the Doing-Allowing Distinction and Double Effect" Michael Cholbi, "Grief and End of Life Surrogate Decision-making" Bruce Jennings, "Solidarity near the End of Life: The Promise of Relational Decision-making in the Care of the Dying" Colin Farrelly, "Justice and the Aging of the Human Species". (shrink)

Objective We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments in order to build ethics capacity and provide a foundation for the development of an ethics education programme. Methods This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. Results Of the (...) 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress, conflict management with patients or families and resource issues. Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams was the most desired method. Conclusions Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists. (shrink)

Les fouilles effectuées au cours de ces dernières dizaines d’années, ont modifié profondément le tableau qu’on se faisait de la préhistoire chinoise. Au début du xxe siècle, les savants les plus connus pouvaient encore mettre en doute l’existence d’une époque néolithique chinoise — mais depuis lors, l’activité de l’archéologie a mis à jour un vaste matériel et paléolithique et néolithique. Le présent article, extrait du premier volume d’une histoire économique et sociale de la Chine, donne une vue d’ensemble du matériel (...) nouvellement acquis et cherche à le mettre en valeur pour une considération sociologique.L’homo pekinensis, l’ancien habitant de la Chine paléolithique du Nord connaissait le feu ; il se servait d’instruments et d’armes en pierre travaillée. Aux deux degrés de son évolution de chasseur primitif et de chasseur évolué, correspondent deux degrés de perfection de ces instruments. Il semble bien que les prisonniers aient été tués (et mangés?) sans distinction d’âge et de sexe. Les chasseurs ne sauraient que faire du travail d’esclave.Vers la fin de l’époque néolithique chinoise se produisit un épanouissement que la rare perfection de la céramique „rouge“ et „noire“ indique assez bien. La filiation somatique de l’homo pekinensis et du Chinois des époques ultérieures est probable ; il semble hors de doute que l’homme de l’époque néolithique soit du même type que celui de la Chine historique. Primitivement, l’agriculture (à la houe) était faite par les femmes, qui en même temps confectionnaient à la main — par la suite au moyen d'une plaque très simple — la céramique,,rouge“ ; les hommes continuaient à s'occuper de la chasse et de la pêche. Dès lors apparaît, encore qu'assez vaguement, une civilisation démocratique et paysanne, caractérisée probablement par des éléments matriarchaux. Vers l'époque de la céramique „noire“ se produit la transition vers l'élevage et à la céramique qui connaît alors le tour de potier — ces deux sortes de travaux incombent aux hommes. L'agriculture se fait plus intense, c'est peut-être ici qu'il convient de supposer les premiers débuts de la construction de terrasses et de l'irrigation. Les esclaves trouvent un emploi, une différenciation sociale se produit, c'est l'origine des villes. La société agraire primitive fait place à un ordre nouveau. Celui-ci s'exprime socialement parlant par une noblesse de clan primitive, politiquement par l'État.Les découvertes les plus récentes de l'archéologie chinoise apportent de nombreuses preuves pour l'évolution telle qu'elle vient d'être esquissée. L'analyse des mythes archaïques et des contes populaires de la Chine confirme, par la suite, au moyen de l'anthropologie ce que l'étude avait jusqu'ici rendu hautement probable par les méthodes de l'archéologie.Die Ausgrabungen der letzten Jahrzehnte haben das Bild der chinesischen Frühgeschichte grundlegend geändert. Während noch zu Anfang des 20. Jahrhunderts führende Gelehrte die Existenz eines chinesischen Neolithikums bezweifelten, hat seither die Tätigkeit der Archäologie sowohl paläolithische wie neolithische Funde in grosser Reichhaltigkeit zutage gefördert. Der vorliegende Aufsatz — Sektion I des ersten Bandes einer Wirtschafts-und Sozialgeschichte Chinas — gibt einen Überblick über das neu gewonnene Material und sucht es sozialwissenschaftlich auszuwerten.Homo pekinensis, der (früh) altsteinzeitliche Bewohner Nordchinas kannte das Feuer ; er benutzte Werkzeuge und Waffen aus behauenem Stein. Zwei Stufen der Bearbeitung seiner Geräte deuten zwei Stufen seiner ökonomischen Entwicklung an, die des „niederen“ und des „höheren“ Jägertums. Gefangene scheinen ohne Unterschied von Alter und Geschlecht getötet (und verzehrt?) worden zu sein. Jäger haben für Sklavenarbeit keine Verwendung.Reich entwickelt ist Chinas (spätes) Neolithikum, dessen „rote“ und „schwarze“ Töpferei von seltener Vollkommenheit ist. Der Zusammenhang des homo pekinensis mit den späteren Chinesen ist somatisch wahrscheinlich, die Zugehörigkeit der Bewohner des chinesischen Neolithikums zu dem geschichtlichen Chinesentum scheint ausser Zweifel. Ursprünglich wurde offenbar der Ackerbau (Hackbau) von Frauen betrieben, die zugleich mit der Hand — und später mit einem einfachen Drehrad — die „rote“ Töpferei herstellten, während die Männer fortfuhren zu jagen und zu fischen. Das Bild einer primitiven demokratischen Dorfkultur mit vermutlich mutterrechtlichen Zügen wird andeutungsweise sichtbar. Es folgt zur Zeit der „schwarzen“ Töpferei der Übergang zur von Männern betriebenen Viehzucht und zu einer mit der Töpferscheibe von Männern durchgeführten Töpferei. Der Ackerbau wird intensiver, die ersten Anfänge von Terrassenbau und Bewässerung liegen vielleicht hier. Sklaven werden verwendbar, soziale Differenzierung tritt ein. Städte entstehen. Die primitive Agrargesellschaft verwandelt sich in eine Ordnung neuer Art, deren sozialer Ausdruck ein primitiver Clan-Adel, deren politischer Ausdruck der Staat ist.Die jüngsten Entdeckungen auf dem Gebiete der chinesischen Archäologie erbringen zahlreiche Beweise für einen derartigen Entwicklungsgang. Die Analyse von Chinas archaischen Mythen und Volkserzählungen bestätigt im Fortgang der Untersuchung mit den Mitteln der Anthropologie, was die hier gebotene Darstellung mit den Methoden der Archäologie bereits in hohem Grad wahrscheinlich gemacht hat. (shrink)

In the last century and in the first decades of the present century the historians of India laid stress on the isolation of the subcontinent by the mountains and seas surrounding her on all sides and cutting her off as a separate universe. The progress of modern research has shown how mistaken this view was. We now see the true facts much more clearly than ever. The mountain barriers, though formidable at many points, are broken by gaps which have always (...) allowed a considerable intercourse across the frontiers on the northwest as well as the northeast and at some points due north as well. By her position in the center of the littoral of the Indian Ocean, India enjoyed ample facilities for communication by sea with the countries lying to her west and east, and we now know that she and her neighbors availed themselves of these facilities from time immemorial. The Indian Ocean was navigated freely from very early, even prehistoric, times, and there was a series of lively maritime exchanges—migratory, commercial, and cultural—among the peoples of Africa, India, and Indonesia, or more generally Southeast Asia. Western Asia and the lands adjoining the Levant also took, from the beginning, a prominent part in this commerce of goods and ideas between India and the world. It is the aim of this paper to trace briefly the ancient contacts between India and the Western countries to the time when the rise and spread of Islam and the Islamic impact on India ushered in a new epoch. (shrink)

At the beginning of the study of physical phenomena, the idea of "force" was widely used to explain the non-stationarity of observed phenomena, such as the movement of bodies. However, as mechanics and physical theories developed, the force notions gained own formal definitions and names, without the use of the term "force". So, the concept of kinetic energy arose instead of "vis viva", and "current" instead of "current strength" ets. Additionally, a number of new physical theories have been formulated without (...) the use of force concept. As a result, different types of forces have gradually been replaced by other more important concepts, such as energy and action, which are closely linked to fundamental physical principles. It is interesting to note that the general trend in the development of civilizations has been a shift from unrestricted power (expressed in the thesis "might makes right") to its subordination and incorporation into a legal framework. This is similar to the evolution of physics, which has seen the notion of force become eliminated or subordinated to more general principles and laws. (shrink)

Background and objectives Conscientious refusal of abortion has been discussed widely by medical ethicists but little information on practitioners' opinions exists. The American College of Obstetricians and Gynecologists (ACOG) issued recommendations about conscientious refusal. We used a vignette experiment to examine obstetrician-gynecologists' (OB/GYN) support for the recommendations. Design A national survey of OB/GYN physicians contained a vignette experiment in which an OB/GYN doctor refused a requested elective abortion. The vignette varied two issues recently addressed by the ACOG ethics committee—whether the (...) doctor referred and whether the doctor disclosed their objection to the abortion. Participants and setting 1800 OB/GYN randomly selected physicians were asked to complete a mail survey containing the vignette. The response rate was 66% (n=1154) after excluding 40 ineligible cases. Measurement Physicians indicated their approval for the vignette doctor's decision. Main results Overall, 43% of OB/GYN physicians responded that the conscientious refusal exercised by the vignette physician was appropriate. 70% rated the vignette doctor as acting appropriately when a referral was made. This dropped to 51% when the doctor disclosed objections to the patient, and to 12% when the doctor disclosed objections and refused to make a referral. Consistent with previous research, males were more likely to support disclosure and refusal to refer. Highly religious physicians supported non-referral but not disclosure. Conclusion OB/GYN physicians are less likely to support conscientious refusal of abortion if physicians disclose their objections to patients. This is at odds with ACOG recommendations and with some models of the doctor–patient relationship. (shrink)

Malgré l’accent porté sur les aspects publics, ritualistes de la pratique ancienne, les images et les objets grecs attestent des rencontres privées et personnelles avec des dieux. Cet article recourt à la documentation archéologique pour explorer les traits personnels, vécus, de la vie religieuse de l’Athènes attique. Bien qu’elles soient parfois décrites comme des « transactions », le développement des relations personnelles avec les dieux et de la manipulation de choses matérielles semble être l’un des éléments les plus saillants de (...) l’expérience religieuse des Grecs. Cette étude examine la matérialité religieuse et l’attitude dévotionnelle telle qu’elle existait en dehors de systèmes rituels organisés et des espaces sacrés. La documentation grecque suggère que la culture matérielle était « de la religion » sous forme physique et une part des méthodes des dévots pour développer des relations remarquablement intimes avec des figures sacrées dans un processus appelé « dévotionalisme ». Les femmes athéniennes utilisaient un objet commun de la vie quotidienne comme une forme de médium religieux: la tainia (ruban). Les femmes l’employaient dans tous les lieux de leur vie, y compris les maisons, les lieux de fêtes et les sanctuaires. La céramique suggère que les Athéniens ont employé de tels média dévotionnels pour interagir avec les défunts dans les cimetières. (shrink)

Self-understanding is to a great extent defined by narrative: who we are as human beings is determined by the stories we, and others, tell about ourselves. Yet many are unable to compose coherent personal narratives, as their experiences do not fall within the scope of an accepted conceptual framework. Survivors of trauma are particularly apt to fall into this “narrative rift,” where there can be no words to describe, and hence can be no assimilation of, their experiences. Using the example (...) of child sexual abuse, and drawing on the work of Bass, Spence, Schafer, and Guignon, I propose an examination of the nature of narrative fragmentation itself. Philosophical counselling may succeed where psychoanalysis might not: for where the latter has theoretical commitments to specific narratives, the former, through its reluctance to force epistemological or metaphysical assumptions on the narrator, may well facilitate a more comprehensive self-understanding. (shrink)