BackgroundAn ethics reflection group is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark.MethodsThis is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the analysis (...) of significance.ResultsA recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG.ConclusionThis study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives. (shrink)

There is growing interest in clinical ethics. However, we still have sparse knowledge about what is actually going on in the everyday practice of clinical ethics consultations. This paper introduces a descriptive evaluation tool to present, discuss and compare how clinical ethics case consultations are actually carried out. The tool does not aim to define ‘best practice’. Rather, it facilitates concrete comparisons and evaluative discussions of the role, function, procedures and ideals inherent in clinical ethics case consultation practices. The tool (...) was developed during meetings of the European Clinical Ethics Network. Based on written reports and participation in the network meetings, the development and the content of the tool and the results of its application in presenting and discussing 10 case consultations are summarized. The tool facilitated understanding of the details of clinical ethics case consultations across individuals and institutions with various experiences and cultures, and comparison between various practices. (shrink)

Background: A fair distribution of healthcare services for older patients is an important challenge, but qualitative research exploring clinicians’ consideration in daily clinical prioritisation in healthcare services for the aged is scarce.Objectives: To explore what kind of criteria, values, and other relevant considerations are important in clinical prioritisations in healthcare services for older patients.Design: A semi-structured interview-guide was used to interview 45 clinicians working with older patients. The interviews were analysed qualitatively using hermeneutical content analysis and template organising style.Participants: 20 (...) physicians and 25 nurses working in public hospitals and nursing homes in different parts of Norway.Results and interpretations: Important dilemmas relate to under-provision of community care and comprehensive approaches, and over-utilisation of certain specialised services. Overt ageism is generally not reported, but the healthcare services for the aged seem to be inadequate due to more subtle processes, for example, dominating considerations and ideals and operating conditions that do not pay sufficient attention to older patients’ needs and considerations of justice. Clinical prioritisations are described as being dominated by adapting traditional biomedical approaches to the operating conditions. Many of the clinicians indicate that there is a potential for improving end of life decisions and for reducing exaggerated use of life-prolonging treatment and hospitalisations.Conclusion: The interviews in this study indicate that considerations of justice and patients’ perspectives should be given more attention to strike a balance between specialised medical approaches and more general and comprehensive approaches in healthcare services for older patients. (shrink)

From a cultural-historical perspective, the impairments of a child with a condition like cerebral palsy have biological origins, but the disability evolves from the mismatch between the child and his/her social conditions for development. One example of this dialectical production of disability can be seen in the challenge of the 21st-century welfare state: How to provide economically feasible health and educational services anchored in evidence-based methods and practices. Standardized social service pathways for children with CP illustrates an attempt to address (...) this challenge and moderate the mismatch by acting in the intersection between impairment and society. The aim of the article is to analyze challenges in the practice of connecting research and practice-based knowledge with societal practices in order to diminish the disability of the child. A multidisciplinary group assembled by the Danish National Board of Social Services engaged in a practice of developing a guideline for a social service pathway. Agendas and minutes from their series of meetings provide insight in how the work evolved through conflictual discussions. Rather than a neutral transformation of knowledge into practice, the practice revealed itself as a value-laden process in which the needs of the child and family were at times decentred and the focus shifted to how social services could be realised in complex, structured social practices. While the group managed to overcome several conflicts and agree of a social service pathway, a socio-economic analysis was unable to argue for the comprehensive social service pathway as an economic sound choice for municipal decision-makers. The conflict between the welfare ideology and economic feasibility remains unresolved and can be expected to limit the extent that impairments can be remedied and the mismatch decreased. Overcoming or diminishing the mismatch might never become economic worthwhile. As the political pendulum oscillates between welfare and economic concerns, the experience of disability will likewise diminish or expand. (shrink)

Background: Although fair distribution of healthcare services for older patients is an important challenge, qualitative research exploring clinicians’ considerations in clinical prioritisation within this field is scarce. Objectives: To explore how clinicians understand their professional role in clinical prioritisations in healthcare services for old patients. Design: A semi-structured interview-guide was employed to interview 45 clinicians working with older patients. The interviews were analysed qualitatively using hermeneutical content analysis. Participants: 20 physicians and 25 nurses working in public hospitals and nursing homes (...) in different parts of Norway. Results and interpretations: The clinicians struggle with not being able to attend to the comprehensive needs of older patients, and being unfaithful to professional ideals and expectations. There is a tendency towards lowering the standards and narrowing the role of the clinician. This is done in order to secure the vital needs of the patient, but is at the expense of good practice and holistic role modelling. Increased specialisation, advances and increase in medical interventions, economical incentives, organisational structures, and biomedical paradigms, may all contribute to a narrowing of the clinicians’ role. Conclusion: Distributing healthcare services in a fair way is generally not described as integral to the clinicians’ role in clinical prioritisations. If considerations of justice are not included in clinicians’ role, it is likely that others will shape major parts of their roles and responsibilities in clinical prioritisations. Fair distribution of healthcare services for older patients is possible only if clinicians accept responsibility in these questions. (shrink)

I dette bogkapitel skrevet sammen med Ingeborg Ilkjær fremlægges tre etiske positioner herunder dydsetik, pligtetik og konsekvensetik. Disse teorier er sammen med eksempler på etiske principper og værdier det grundlag, som sygeplejersker kan benytte sig af i arbejdet med patientinvolvering og etiske dilemma, hvor der skal foretages et valg, der har betydning for patienter, pårørrende og de klinisk involverede. -/- For at kunne træffe valg af denne art er det vigtigt at kunne gøre det på et oplyst grundlag samt at (...) kunne påtage sig et klinisk lederskab. Derfor er det nødvendigt at benytte sig af en etisk refleksionsmodel. Dette arbejde kan være med til at skabe klarhed over en given situation, der rummer vanskelige etiske dilemmaer. -/- Bogkapitlet findes i bogen Sygepleje & Patientinvolvering Bind 3 redigeret af Steen Hundborg og udgivet på FADL’s Forlag I 2019. (shrink)

Dette kapitel fokuserer på ’etik og patientinddragelse’, men søger med afsæt i devisen ‘sapere aude’ også at skabe interesse for filosofi og etik blandt sygeplejestuderende. Kapitlet er en opfordring til sygeplejestuderende om at betjene sig af egen forstand og finde mod til at filosofere over problematikker i forbindelse med patientinddragelse frem for at falde tilbage i umyndighedens bekvemmelighed og vente på at andre træder til. Kapitlet starter med at se nærmere på, hvordan patientinddragelse italesættes i vor tid efterfulgt af en (...) kort eksposition af to af oplysningstidens vigtigste libera- le filosoffer, herunder pligtetikeren Immanuel Kant og nytteetikeren John Stuart Mill, hvis syn på henholdsvis autonomi og frihed influerer debatten om patientinddragelse. Efterfølgende præsenteres og diskuteres to eksempler, hvor patientinddragelse og etik er i rampelyset. Mere specifikt rettes fokus på 1) etik, patientinddragelse og den psykiatriske patient og 2) etik, patientinddragelse og unge mennesker. Eksemplerne er udvalgte med henblik på at belyse, hvad der kan komme på spil i sundhedsfaglige situationer udspændt mellem individuel frihed, herunder også ideen om autonomi; sygehusvæsenet, inklusive personale, som autoritær vi- dens-institution/aktør og det etiske, herunder ideen om ’det gode’ eller efterstræbelsesværdige. Afslutningsvis argumenteres der for, at sundhedsarbejdere med blik for etik og patientinddragelse kan udgøre en positiv kraft for den inddragede patient, men at det kræver, at denne vover at være vis. Afsnit: Resume Patientinddragelse i vor tid Autonomi, frihed og patientinddragelse Etik, patientinddragelse og den psykiatriske patient Etik, patientinddragelse og den unge Afslutning . (shrink)

Aim: This study explores priority dilemmas in dialysis treatment and care offered elderly patients within the Norwegian public healthcare system.Background: Inadequate healthcare due to advanced age is frequently reported in Norway. The Norwegian guidelines for healthcare priorities state that age alone is not a relevant criterion. However, chronological age, if it affects the risk or effect of medical treatment, can be a legitimate criterion.Method: A qualitative approach is used. Data were collected through semistructured interviews and analysed through hermeneutical content analysis. (...) The informants were five physicians and four nurses from dialysis wards.Findings: Pressing priority dilemmas centre around decision-making concerning withholding and withdrawal of dialysis treatment. Advanced age is rarely an absolute or sole priority criterion. It seems, however, that advanced age appears to be a more subtle criterion in relation with, for example, comorbidity, functional status and cognitive impairment. Nurses primarily prioritise specialised dialysis care and not comprehensive nursing care. The complex needs of elderly patients are therefore often not always met.Conclusions: Clinical priorities should be made more transparent in order to secure legitimate and fair resource allocation in dialysis treatment and care. Difficult decisions concerning withholding or withdrawal of dialysis ought to be openly discussed within the healthcare team as well as with patients and significant others. The biomedical focus and limitations on comprehensive care during dialysis should be debated. (shrink)

De senere år har pleie- og omsorgstjenesten i mange norske kommuner startet med ulike former for etikkarbeid, oftest initiert av KS’ prosjekt “Samarbeid om etisk kompetanseheving”. Hensikten med vår studie var å evaluere innsatsen i de kommunene som deltok i prosjektet fra starten av, med vekt på hvilke tiltak som var iverksatt, hvilke virksomheter dette omfattet, og om tiltakene har fortsatt utover prosjektperioden. Studien har et kvalitativt design. Materialet er hovedsakelig basert på telefonintervjuer med kontaktpersoner for etikksatsingen i 34 kommuner. (...) Det transkriberte materialet er analysert ved kvalitativ innholdsanalyse. Med unntak av fem kommuner som aldri kom i gang med etikkarbeidet, hadde de fleste startet etikkrefleksjon innenfor flere tjenester, oftest i sykehjem og hjemmetjenester. Noen kommuner hadde imidlertid ikke klart å videreføre etikkarbeidet utover en prosjektperiode. Det var stor variasjon både i etikkarbeidets forankring i kommunen, omfang, hyppighet og metoder. Et gjennomgående funn er vektlegging av behovet for etikkkompetanse og oppfølging av dem som skal lede etikkarbeidet. Flertallet av kommunene som fortsatt gjennomfører etikkrefleksjon, tar utgangspunkt i egen praksis, men et mindretall anvender strukturerte metoder. Dersom etikkarbeidet i kommunen skal være levedyktig over tid, bør arbeidet forankres på flere nivåer i organisasjonen, og de som skal lede dette arbeidet, bør få styrket sin kompetanse i etikk og etikkrefleksjon.Nøkkelord: etikk, evaluering, kommunehelsetjenestenEnglish summary: Building ethical competence in Norwegian municipalities: What has been done and what has been sustainable?“Cooperation for building ethics competence” is a national project aimed to stimulate moral reflection and build competence in ethics in community health services in Norway. This article is based on an evaluation of the activities implemented by the first 34 participating municipalities, exploring which measures were implemented, which services and employees were involved, and if the measures are sustainable. The study has a qualitative design, and the data mainly consists of telephone interviews with “key” persons in 34 municipalities. With the exception of five municipalities that never really started ethics work, the majority had implemented ethical reflection in several areas, most often in nursing homes and home care services. There was great variation with regard to the implementation. Many had tried a variety of reflection models, and only a minority of the municipalities were using a structured method of ethical reflection. A consistent finding is the need for more competence; many of those who run ethical reflection are reported to need more competence both in ethics and methods for systematic reflection. There were also great variations in how well the ethics projects were anchored within the municipality. To make ethical interventions sustainable, this study indicates the importance of strong anchoring within the municipality, the need for ethical competence, as well as good methods for structuring ethical reflection. (shrink)

To controlforceaccurately under a wide range of behavioral conditions, the central nervous system would either require a detailed, continuously updated representation of the state of each muscle (and the load against which each is acting) or else force feedback with sufficient gain to cope with variations in the properties of the muscles and loads. The evidence for force feedback with adequate gain or for an appropriate central representation is not sufficient to conclude that force is the major controlled variable in (...) normal limb movements.Morton's hypothesis, thatlengthis controlled by a follow-up servo, has a number of difficulties related to the delays, gains, variability, and specificity in feedback pathways comprising potential servo loops. However, experimental evidence is consistent with these pathways providing servo assistance for some movements produced by coactivation of α- and static γ-motoneurons. Dynamic γ-motoneurons may provide an additional input for adaptive control of different types of movements.The idea that feedback is used to compensate for changes in musclestiffnesshas received experimental support under static postural conditions. However, reflexes tend to increase rather than decrease the range of variation in muscle stiffness during some cyclic movements. Theoretical problems associated with the regulation of stiffness are also discussed. The possibilities of separate control systems forvelocityorviscosityare considered, but the evidence is either negative or lacking. I conclude that different physical variables can be controlled depending on the type of limb movement required. The concept of stiffness regulation is also useful under some conditions, but should probably be extended to the regulation of the visco-elastic properties (i.e., the mechanical impedance) of a muscle or joint. (shrink)

One area in which the moral philosopher might say something useful for the thinking of economists is that of welfare economics – not by improving formalizations or criticizing proofs as to conditions necessary or sufficient for an optimum situation, much less by suggesting what particular state of society would be optimal. Rather, he can do this by pointing out some distinctions, by suggesting how some terms used by economists can profitably be defined, and by questioning some assumptions which seem to (...) lie behind the thinking of some economists. The following discussion is aimed along these lines. The main goal of the argument will be to produce helpful definitions of “increase the welfare of an individual” and “increase social welfare.”. (shrink)

E.R. Dodds’ 1959 edition of Plato’s Gorgias is a conventional treatment of this dialogue, aimed at audiences interested in close study of the text. Dodds himself regretted this outcome. He felt he had lost sight of an earlier goal, formulated at a time of political turmoil on the eve of WorldWar II, of using the Gorgias to bring out ‘both the resemblance and the difference between Plato’s situation and that of the intellectual today’. The present paper attempts to reconstruct that (...) goal, as it survives residually in his edition, surfaces in his The Greeks and the Irrational, and appears in some writings from the 1930s, particularly in unpublished lectures. Dodds did frequently juxtapose ancient and modern conceptions of the intellectual, and in a way that cast Plato in a positive light, as someone politically engaged and self-critical, and acutely sensitive, as Dodds himself was, to the political implications of social psychology. (shrink)

In their 2008 paper, Persson and Savulescu suggest that for moral bioenhancement (MBE) to be effective at eliminating the danger of ‘ultimate harm’ the intervention would need to be compulsory. This is because those most in need of MBE would be least likely to undergo the intervention voluntarily. By drawing on concepts and theories from epidemiology, this paper will suggest that MBE may not need to be universal and compulsory to be effective at significantly improving the collective moral standing of (...) a human populace and reducing the threat of ultimate harm. It will identify similarities between the mechanisms that allow biological contagions (such as a virus) and behaviours (such as those concerned with ethical and unethical actions) to develop, spread, and be reinforced within a population. It will then go onto suggest that, just as with the epidemiological principle of herd immunity, if enough people underwent MBE to reach a minimum threshold then the incidence and spread of immoral behaviours could be significantly reduced, even in those who have not received MBE. (shrink)

It is the aim of this paper to examine certain aspects of a point of view which has attracted much attention in physical methodology. This is the standpoint known as operationalism. We wish to discuss its significance in the construction and interpretation of physical theories.The essential meaning of operationalism in physics is that physical concepts should be defined in terms of actual physical operations. On this view there is no meaning to a concept unless it represents an operation which can (...) be performed in the laboratory. Thus the term “pressure of a gas” signifies nothing until an operation is described which constitutes the measurement of pressure. When one thinks of pressure one must think. of some actual apparatus, such as, for example, some glass and rubber tubing and some mercury and certain operations performed using these until finally one gets a pointer reading which one calls the pressure of the gas. The same stand is taken with respect to length, time, velocity, acceleration, temperature, etc. (shrink)

Variations in levels of apolipoprotein E have been tied to the risk and progression of Alzheimer's disease . Our group has previously compared and contrasted the promoters of the mouse and human ApoE gene promoter sequences and found notable similarities and significant differences that suggest the importance of the APOE promoter's role in the human disease. We examine here three specific single-nucleotide polymorphisms within the human APOE promoter region, specifically at -491 , -427 , and at -219 upstream from the (...) +1 transcription start site. The -219 and -491 polymorphic variations have significant association with instance of AD, and -491AA has significant risk even when stratified for the APOEepsilon4 allele. We also show significant effects on reporter gene expression in neuronal cell cultures, and, notably, these effects are modified by species origin of the cells. The -491 and -219 polymorphisms may have an interactive effect in addition to any independent activity. DNA-protein interactions differ between each polymorphic state. We propose SP1 and GATA as candidates for regulatory control of the -491 and -219 polymorphic sites. This work's significance lies in drawing connection among APOE promoter polymorphisms' associations with AD to functional promoter activity differences and specific changes in DNA-protein interactions in cell culture-based assays. Taken together, these results suggest that APOE expression levels are a risk factor for AD irrespective of APOEepsilon4 allele status. (shrink)

K.J. Devlin has extended Jensen's construction of a model ofZFC andCH without Souslin trees to a model without Kurepa trees either. We modify the construction again to obtain a model with these properties, but in addition, without Kurepa trees inccc-generic extensions. We use a partially defined ◊-sequence, given by a fine structure lemma. We also show that the usual collapse ofκ Mahlo toω 2 will give a model without Kurepa trees not only in the model itself, but also inccc-extensions.

In this article, we discuss some of the challenges related to formulating and adopting a realist position regarding non-relativistic quantum mechanics. In a standard approach to ontology, the ontological commitments of scientific theories can be extracted from them. Scientific realism is the standpoint that our best scientific theories are approximately true, and thus, their ontological commitments, roughly speaking, correspond to reality. Quantum mechanics complicates this view by introducing an interpretational requirement that links a particular conception of how reality should be (...) to the theory. This generates comprehensive difficulties: when we separate theory and interpretation, we have a clear conception of theory but not of interpretation and how to extract its ontology. On the other hand, if we somehow identify theory and interpretation, we have a reasonably clear conception of the desired ontology but lose our best characterizations of theory, rendering our methods for extracting ontology ineffective. Our aim is to map out the challenges for future rigorous realist approaches to quantum mechanics. (shrink)

This study examines whether scenic beauty judgments based upon photographs of landscapes are similar to scenic beauty judgments based upon on-site experiences of landscapes. Two concerns are emphasized: a concern about the threat to the ecological validity of photo-based assessments caused by differences between on-site and photo-based contexts and a concern that the individual rater, rather than the group average, is the more appropriate unit of analysis for tests of validity of photo-based assessments. On-site scenic beauty assessments were collected from (...) day hikers. These data were compared to photo-based scenic beauty assessments collected from the same persons three months and nine months after their on-site experience. Approximately 38% of participants had insignificant correlations between their on-site and photo-based scenic beauty ratings. These and other results suggest that the validity of photo-based scenic beauty assessments is in doubt, at least for the situation studied here. Moreover, the results suggest that the difference between persons' on-site and photo-based ratings can be explained, in part, by contextual factors such as the mood, meaning, and novelty that differentiate photo-based from on-site landscape experiences. Group averaged on-site and photo-based assessments, however, were very similar, suggesting caution may be in order for studies interpreting summary measures. (shrink)

Despite All Critique (2014) -- World Politics and Western Reason (1980) -- The Doubled Outsides of the Modern International (2005) -- The Subject of Security (1995) -- The Protection of Nature and the Nature of Protection (2005) -- Social Movements/World Politics (1994) -- Europe is Not Where It is Supposed to Be (2000) -- They Seek it Here, They Seek it There : Looking for Politics in Clayoquot Sound (2003) -- Violence, Modernity, Silence : From Weber to International Relations (1993) (...) -- Hobbes, Origins, Limits (2011) -- War, Terror, Judgement (2002) -- International, Imperial, Exceptional (2005) -- Which Democracy for Which Demos? (2013) -- The Political Theory of Boundaries and the Boundaries of Political Theory : Interview With Raia Prokhovnik (2012). (shrink)

It is shown that unavoidable uncertainties arising from the experimental conditions in which systems are prepared for Einstein-Podolsky-Rosen experiments severely limit the possibilities for prediction. In the example originally proposed by EPR, time measurements are necessary for precise position predictions. If the preparation is designed to make the timing errors negligible, the parameters chosen for the preparation fix minimum uncertainties in the predictions leaving the observer no choice in the matter. In the case of correlated spin measurements, the preparation leaves (...) the observer no control over the effect of the detector on the particles; the uncertainty of the previous condition of any one particle is so large that no (classical) prediction of the response of another detector is possible. Thus, there are as yet no proposed experiments which satisfy the conditions required by EPR—i.e., precise predictions which violate the uncertainty principle. (shrink)