How the romantic displaced the rational in French thought.

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. (shrink)

A prolonged professional interest in the problems of obsessional disorder has led me to a consideration of Professor Hare's arguments for prescriptivism. It is perhaps a tribute to the elegance of Hare's argument and the lucidity with which it is presented that the present paper is concerned with the exceptions he cites.

Myc‐driven tumorigenesis involves a non‐transcriptional role for Myc in over‐activating replicative Cdc45‐MCM‐GINS (CMG) helicases. Excessive stimulation of CMG helicases by Myc mismanages CMG function by diminishing the number of reserve CMGs necessary for fidelity of DNA replication and recovery from replicative stresses. One potential outcome of these events is the creation of DNA damage that alters genomic structure/function, thereby acting as a driver for tumorigenesis and tumor heterogeneity. Intriguingly, another potential outcome of this Myc‐induced CMG helicase over‐activation is the creation (...) of a vulnerability in cancer whereby tumor cells specifically lack enough unused reserve CMG helicases to recover from fork‐stalling drugs commonly used in chemotherapy. This review provides molecular and clinical support for this provocative hypothesis that excessive activation of CMG helicases by Myc may not only drive tumorigenesis, but also confer an exploitable “reserve CMG helicase vulnerability” that supports developing innovative CMG‐focused therapeutic approaches for cancer management. (shrink)

Hirschfeldt and Shore have introduced a notion of stability for infinite posets. We define an arguably more natural notion called weak stability, and we study the existence of infinite computable or low chains or antichains, and of infinite $\Pi _1^0 $ chains and antichains, in infinite computable stable and weakly stable posets. For example, we extend a result of Hirschfeldt and Shore to show that every infinite computable weakly stable poset contains either an infinite low chain or an infinite computable (...) antichain. Our hardest result is that there is an infinite computable weakly stable poset with no infinite $\Pi _1^0 $ chains or antichains. On the other hand, it is easily seen that every infinite computable stable poset contains an infinite computable chain or an infinite $\Pi _1^0 $ antichain. In Reverse Mathematics, we show that SCAC, the principle that every infinite stable poset contains an infinite chain or antichain, is equivalent over RCA₀ to WSCAC, the corresponding principle for weakly stable posets. (shrink)

This is a welcome collection of essays addressing Kant’s treatment of natural laws. Kant’s best-known discussion of natural laws is the Critique of Pure Reason’s second analogy, which argues that all alterations take place according to causal laws. But Kant’s overall treatment of natural laws extends far beyond the second analogy. For instance, the Metaphysical Foundations of Natural Science aims to derive specific laws of motion. The appendix to the Critique of Pure Reason’s transcendental dialectic and the introductions to the (...) Critique of the Power of Judgment examine the notion of a systematic order of particular laws. And the Critique of the Power of Judgment discusses the relationship between mechanical and... (shrink)

A familiar post-Kantian criticism contends that Kant enslaves sensibility under the yoke of practical reason. Friedrich Schiller advanced a version of this criticism to which Kant publicly responded. Recent commentators have emphasized the role that Kant’s reply assigns to the pleasure that accompanies successful moral action. In contrast, I argue that Kant’s reply relies primarily on the sublime feeling that arises when we merely contemplate the moral law. In fact, the pleasures emphasized by other recent commentators depend on this sublime (...) feeling. These facts illuminate Kant’s views regarding the relationship between morality, freedom, and the development of moral feelings. (shrink)

In this paper, we present a survey of the development of the technique of argument diagramming covering not only the fields in which it originated - informal logic, argumentation theory, evidence law and legal reasoning – but also more recent work in applying and developing it in computer science and artificial intelligence. Beginning with a simple example of an everyday argument, we present an analysis of it visualised as an argument diagram constructed using a software tool. In the context of (...) a brief history of the development of diagramming, it is then shown how argument diagrams have been used to analyze and work with argumentation in law, philosophy and artificial intelligence. (shrink)

Before the last century, societies around the globe, including Indigenous Peoples and early settlers to Canada’s west coast, relied on local procurement and preservation of seasonal food to support their food security and food sovereignty. In some instances, Indigenous Peoples and settlers shared and adopted each other’s food provisioning and preservation practices and associated values. Such cross-cultural knowledge exchanges provided wide-ranging food provisioning options for those living in the region. In this paper, we conceptualize such exchanges and varieties of provisioning (...) options as part of Indigenous and local food systems that have been co-created through mutual interdependence, support, and food-related values. Using data from interviews and document analysis, we show that current residents of the Clayoquot Sound Biosphere Region have maintained traditional food procurement and preservation techniques, although with some new methods that have emerged in response to new technologies, innovation, and need. Indigenous and non-Indigenous residents who share food and exchange food provisioning practices simultaneously support their food needs, wellbeing, and cultural maintenance. In contrast to research that examines and conceptualizes local food systems and Indigenous food systems separately, this paper highlights the existence of an interrelated Indigenous and local food system, characterized by historical and contemporary shared food provisioning practices and cross-cultural food knowledge exchanges on Canada’s west coast. The advantage of the joint conceptualization lies in acknowledging how food systems can and do evolve to co-exist over time, and how they create opportunities for people living in remote, sometimes marginalized communities to strengthen food security and food sovereignty through shared food provisioning practices that resonate with their values. (shrink)

General Electric has a rich history of being in the center of public discourse regarding the intersection of corporate strategy and environmental concerns. During Jeffrey Immelt’s tenure as Chief Executive Officer, G.E. has taken a proactive approach to coupling corporate social responsibility with organizational profitability in its Ecomagination initiatives. Critics abound with some investor groups questioning the utility of Immelt’s approach for shareholder returns while other stakeholder groups question G.E.’s motives and methods. This case study reviews G.E.’s past CSR efforts (...) and the more recent Ecomagination program and its efficacy and sustainability. The case was developed from public sources. (shrink)

No consensus yet exists on how to handle incidental fnd-ings in human subjects research. Yet empirical studies document IFs in a wide range of research studies, where IFs are fndings beyond the aims of the study that are of potential health or reproductive importance to the individual research participant. This paper reports recommendations of a two-year project group funded by NIH to study how to manage IFs in genetic and genomic research, as well as imaging research. We conclude that researchers (...) have an obligation to address the possibility of discovering IFs in their protocol and communications with the IRB, and in their consent forms and communications with research participants. Researchers should establish a pathway for handling IFs and communicate that to the IRB and research participants. We recommend a pathway and categorize IFs into those that must be disclosed to research participants, those that may be disclosed, and those that should not be disclosed. (shrink)

Outpatient services are increasingly recognised as an important component of health care provision and may be improved through the application of modern management techniques. We have performed a time and role audit of consultation and waiting times in two medical clinics using different queuing systems: namely, a serial processing clinic where patients wait in a single queue and a quasi-parallel processing clinic where patients are directed to the shortest queue to maintain clinic flow. Data collected were used to construct a (...) computer simulation of patient flows in clinic. Assessment of patient satisfaction in the clinic process was determined using a self-administered questionnaire. Mean waiting time was shorter in the quasi-parallel processing clinic: 26 (SD 17) minutes compared with 36(24) minutes in the serial processing clinic. In the serial processing clinic 61% of patients waited more than 30 minutes compared with 41% in the quasi-parallel processing clinic. In the serial processing clinic 8% of 142 patients surveyed complained of the time spent waiting. The computer simulation we produced was able to determine waiting times with different clinic structures. The simulation showed that reductions in waiting time up to 30% might be achieved by changing our serial processing clinic to a quasi-parallel processing one. Performance of medical outpatient clinics can be improved by examining and changing clinic management. Computer simulation of outpatient clinics offers a means of assessing the impact of such changes on waiting time in clinic and on waiting lists. (shrink)

This paper explains how to use a new software tool for argument diagramming available free on the Internet, showing especially how it can be used in the classroom to enhance critical thinking in philosophy. The user loads a text file containing an argument into a box on the computer interface, and then creates an argument diagram by dragging lines from one node to another. A key feature is the support for argumentation schemes, common patterns of defeasible reasoning historically know as (...) topics . Several examples are presented, as well as the results of an experiment in using the system with students in a university classroom. (shrink)

This essay argues that a restatement of Thomistic natural law reasoning is increasingly necessary in jurisprudential debate about international law. Mindful of Pope John Paul II's call for a renewal of international law, the essay engages with the present-day tension between Morgenthau-type realism and neo-Kantian discourse-oriented cosmopolitanism. The essay addresses whether the former is sufficiently realistic in our global 21st century context, and whether the latter is adequately cosmopolitan. Attention is drawn to Aquinas's understanding of the relation between custom, consent (...) and political authority in order to expose some of the limits of present-day statism, and to suggest that Thomistic natural law reasoning is, potentially at least, better able to cope with the intractable disagreement that characterises 21st century global relations than some forms of neo-Kantian jurisprudence. (shrink)

Wittgenstein's Method: Neglected Aspects By Gordon Baker. Oxford: Blackwell, 2004 pp. 328. £40.00 HB.. Wittgenstein's Copernican Revolution: The Question of Linguistic Idealism By Ilham Dilman. Basingstoke: Palgrave, 2002. pp. 240. £52.50 HB. Wittgenstein: Connections and Controversies By P. M. S. Hacker. Oxford: Oxford University Press,. pp. 400. £45.00 HB; £19.99 PB. Wittgenstein's Philosophical Investigations: An Introduction By David G. Stern. Cambridge: Cambridge University Press, 2004. pp. 224. £40.00 HB; £10.99 PB.

This essay warns that Nigel Biggar’s permissive reading of the classic, theological just war tradition is problematic especially when combined with his highly contextual approach to the United Nations Charter and laws of war. Two points are made: When compared to Augustine’s grappling with the disordered loves of the Roman empire—including ‘foreign iniquity’ as an excuse for military action, the animus dominandi, and wars of a kind that generate more war—In Defence of War lacks a political realism robust enough to (...) defend against leaving the laws of war in the hands of the most powerful nations. When compared to Augustine’s engagement with why and how secular law must constitute the conditions for peaceable and ordered co-existence, In Defence of War fails to incorporate into its just war reasoning a defence of the legal regime necessary for the protection of international peace and security. (shrink)

State militaries have strong interests in developing enhanced warfighters: taking otherwise healthy service personnel (soldiers, marines, pilots, etc.) and pushing their biological, physiological, and cognitive capacities beyond their individual statistical or baseline norm. However, the ethical and regulatory challenges of justifying research into these kinds of interventions to demonstrate the efficacy and safety of enhancements in the military has not been well explored. In this paper, we offer, in the context of the US Common Rule and Institutional Review Board framework, (...) potential justifications for justifying research into enhancing warfighters on the grounds of (1) individual and group risk reduction, (2) protection of third parties such as civilians, and (3) military effectiveness. (shrink)

Health care decision making has changed profoundly during the past several decades. Advances in scientific knowledge, technology, and professional skill enable medical providers to extend and enhance life by increasing the ability to cure disease, manage disability, and palliate suffering. Ironically, the same interventions can prolong painful existence and protract the dying process. Recognizing that medical interventions, especially lifesustaining measures, are not always medically appropriate or even desired by a patient or family, health care professionals endeavor to determine who should (...) make health care decisions and according to what standards. The importance that Western culture places on individual rights and self-determination is reflected in the growing advocacy for patient autonomy and the discrediting of physician paternalism. However, the question of autonomy becomes more complex when patients lack the capacity to decide for themselves.Advance directives represent one response to the dilemma of decision making for incapacitated patients. The original advance directive, the living will, is a written list of instructions reflecting the individual's wishes about care, usually at the end of life. (shrink)

We show, for each computable ordinal α and degree $\alpha > {0^{\left( \alpha \right)}}$, the existence of a torsion-free abelian group with proper α th jump degree α.

Nanomedicine is yielding new and improved treatments and diagnostics for a range of diseases and disorders. Nanomedicine applications incorporate materials and components with nanoscale dimensions where novel physiochemical properties emerge as a result of size-dependent phenomena and high surface-to-mass ratio. Nanotherapeutics and in vivo nanodiagnostics are a subset of nanomedicine products that enter the human body. These include drugs, biological products, implantable medical devices, and combination products that are designed to function in the body in ways unachievable at larger scales. (...) Nanotherapeutics andin vivonanodiagnostics incorporate materials that are engineered at the nanoscale to express novel properties that are medicinally useful. These nanomedicine applications can also contain nanomaterials that are biologically active, producing interactions that depend on biological triggers. Examples include nanoscale formulations of insoluble drugs to improve bioavailability and pharmacokinetics, drugs encapsulated in hollow nanoparticles with the ability to target and cross cellular and tissue membranes and to release their payload at a specific time or location, imaging agents that demonstrate novel optical properties to aid in locating micrometastases, and antimicrobial and drug-eluting components or coatings of implantable medical devices such as stents. (shrink)

Smiles that vary in muscular configuration also vary in how they are perceived. Previous research suggests that “Duchenne smiles,” indicated by the combined actions of the orbicularis oculi and the zygomaticus major muscles, signal enjoyment. This research has compared perceptions of Duchenne smiles with non-Duchenne smiles among individuals voluntarily innervating or inhibiting the orbicularis oculi muscle. Here we used a novel set of highly controlled stimuli: photographs of patients taken before and after receiving botulinum toxin treatment for crow’s feet lines (...) that selectively paralyzed the lateral orbicularis oculi muscle and removed visible lateral eye wrinkles, to test perception of smiles. Smiles in which the orbicularis muscle was active were rated as more felt, spontaneous, intense, and happier. Post treatment patients looked younger, although not more attractive. We discuss the potential implications of these findings within the context of emotion science and clinical research on botulinum toxin. (shrink)

The philosophical or metaphysical architecture of Darwin's theory of evolution by natural selection is analyzed and diflussed. It is argued that natural selection was for Darwin a paradigmatic case of a natural law of change — an exemplar of what Ghiselin (1969) has called selective retention laws. These selective retention laws lie at the basis of Darwin's revolutionary world view. In this essay special attention is paid to the consequences for Darwin's concept of species of his selective retention laws. Although (...) Darwin himself explicity supported a variety of nominalism, implicit in the theory of natural selection is a solution to the dispute between nominalism and realism. It is argued that, although implicit, this view plays a very important role in Darwin's theory of natural selection as the means for the origin of species. It is in the context of these selective retention laws and their philosophical implications that Darwin's method is appraised in the light of recent criticisms, and the conclusion drawn that he successfully treated some philosophical problems by approaching them through natural history. Following this an outline of natural selection theory is presented in which all these philosophical issues are highlighted. (shrink)

Background Since the enactment of the euthanasia law in the Netherlands, there has been a lively public debate on assisted dying that may influence the way patients talk about euthanasia and physician-assisted suicide with their physicians and the way physicians experience the practice of EAS. Aim To show what developments physicians see in practice and how they perceive the influence of the public debate on the practice of EAS. Methods We conducted a secondary analysis of in-depth interviews with 28 Dutch (...) physicians who had experience with a complex case of EAS. Respondents were recruited both by the network of physicians working for SCEN as well as via a national questionnaire, wherein participating physicians could indicate their willingness to be interviewed. Results Three themes came up in analysing the interviews. First, the interviewed physicians experienced a change in what patients would expect from them: from a role as an involved caregiver to being the mere performer of EAS. Second, interviewees said that requests for EAS based on non-medical reasons came up more frequently and wondered if EAS was the right solution for these requests. Last, respondents had the impression that the standards of EAS are shifting and that the boundaries of the EAS regulation were stretched. Conclusions The perceived developments could make physicians less willing to consider a request for EAS. Our results also raise questions about the role of physicians and of EAS in society. (shrink)

Legal reasoning requires identification through search of authoritative legal texts (such as statutes, constitutions, or prior judicial opinions) that apply to a given legal question. In this paper, using a network representation of US Supreme Court opinions that integrates citation connectivity and topical similarity, we model the activity of law search as an organizing principle in the evolution of the corpus of legal texts. The network model and (parametrized) probabilistic search behavior generates a Pagerank-style ranking of the texts that in (...) turn gives rise to a natural geometry of the opinion corpus. This enables us to then measure the ways in which new judicial opinions affect the topography of the network and its future evolution. While we deploy it here on the US Supreme Court opinion corpus, there are obvious extensions to large evolving bodies of legal text (or text corpora in general). The model is a proxy for the way in which new opinions influence the search behavior of litigants and judges and thus affect the law. This type of “legal search effect” is a new legal consequence of research practice that has not been previously identified in jurisprudential thought and has never before been subject to empirical analysis. We quantitatively estimate the extent of this effect and find significant relationships between search-related network structures and propensity of future citation. This finding indicates that “search influence” is a pathway through which judicial opinions can affect future legal development. (shrink)

The purpose of medical humanities is to improve the delivery of effective health care through a better understanding of disease in society, and in the individual. The interfaces between the science of medicine and the arts, philosophy, sociology and law interpret causes and effects of disease. The field of medical ethics is the most prominent offspring of this wider debate, yet the context of disease in the life of the individual and of society is profound and far-reaching. The influences of (...) medicine on the humanities and vice versa are all around, yet only recently have they been recognised in the wider world of health care. How can you encapsulate the essence of medical humanities and teach it to health professionals? Medical Humanities is designed to fill the need for a clear, well illustrated text that both provides the principles for the individual reader, and encourages discussion. The issues are explored in four main sections. Based on a highly successful seminar, and with contributions from leading writers, thinkers, and teachers, this book provides a comprehensive and authoritative reference for what is becoming a professional requirement in medicine. It will be invaluable for clinicians and students alike. (shrink)

Jeremy Bentham was a British philosopher, jurist, and social reformer. He is regarded as the founder of modern utilitarianism.