Background This study assessed patient perceptions of the Physician Payments Sunshine Act and opinions toward physicians who receive gifts and/or payments from pharmaceutical or medical device companies. Methods During their office visit, patients attending different specialty clinics volunteered to complete our survey. The survey asks if the patient knows what the Sunshine Act is, then asks questions on 5-point response scales to assess the patient's opinions toward physicians who receive compensation from companies, their self-rated knowledge of physician compensation, (...) and how they believe this compensation affects the cost of care. Results Over 13 months, 523 responses were collected: 8.6% of patients reported having knowledge of the Sunshine Act, 56.8% rated their knowledge of physician compensations as “poor,” and 67.1% agreed with the statement that patients should be aware of the compensation physicians receive. When asked how their opinion toward their physician would change if they learned the physician received free meals or gifts from companies, 58.9% replied “not at all,” and 36.11% of patients did not believe their cost of care would increase if their physician received compensation from companies. Conclusions Most patients were unfamiliar with the Sunshine Act, and believe their knowledge of physician compensation is poor. Over half of the respondents would not change their opinion of their physician based on knowledge of their physician receiving payments/gifts from companies, and over one-third of respondents did not believe such compensation increased the cost of care. The majority of respondents agreed that patients should be aware of payments/gifts to physicians. (shrink)

The Physician Payments Sunshine Act requires health care product manufacturers to report to the federal government payments more than $10 to physicians. Bringing unprecedented transparency to medicine, PPSA holds great potential for enabling medical stakeholders to manage conflicts of interest and build patient trust—crucial responsibilities of medical professionalism. The authors conducted six focus groups with 42 physicians in Chicago, IL, San Francisco, CA, and Washington, DC, to explore attitudes and experiences around PPSA. Participants valued the concept of transparency but (...) were wary of the law's design and consequences. They downplayed PPSA's potential and felt it undermined public trust. Showing broad unawareness of COI, they dismissed the notion of industry influence and welcomed company “perks.” Misapprehensions may leave physicians unprepared to advance the opportunities PPSA holds for professionalism. The authors offer recommendations for government and medicine to improve physicians' and other stakeholders' understandings and use of the data. (shrink)

In 2008 pharmaceutical companies spent over $12 billion on product promotion and detailing aimed at U.S. health care practitioners. Drug and device manufacturers rely on a workforce of detailers and physician speakers to reach health care practitioners and nudge their prescribing habits. To prevent undue influence and protect the public fisc, a number of states began regulating these marketing practices, requiring companies to disclose all gifts to practitioners, prohibiting the commercialized sale of prescription data, and prohibiting certain gifts altogether. The (...) 2010 enactment of the Physician Payment Sunshine Act marks the first Congressional involvement in the regulation of disclosure related to pharmaceutical marketing. Overall, the Act improves transparency in pharmaceutical marketing to physicians and expands the regulation of disclosure of pharmaceutical marketing activities in important substantive ways. (shrink)

Public disclosure of industry payments to physicians is one way to address financial conflicts of interest in medicine. As part of the Patient Protection and Affordable Care Act, the Physician Payment Sunshine Act requires pharmaceutical, medical device, and biologics manufacturers who have at least one product reimbursed by Medicare or Medicaid to disclose payments to physicians and teaching hospitals on a public website starting in 2014. The physician payment data will contain individual physician names, monetary values, and specific products (...) connected to payments.According to the Final Regulations issued by the Centers for Medicare and Medicaid Services in February 2013, the law will make transparent the extent and nature of relationships between physicians, teaching hospitals, and manufacturers. (shrink)

The pharmaceutical industry, in its marketing efforts, often turns to “key opinion leaders” or “KOLs” to disseminate scientific information. Drawing on the author's fieldwork, this article documents and examines the use of KOLs in pharmaceutical companies’ marketing efforts. Partly due to the use of KOLs, a small number of companies with well-defined and narrow interests have inordinate influence over how medical knowledge is produced, circulated, and consumed. The issue here, as in many other cases of institutional corruption, is that a (...) few actors have accumulated the power to shape the information on which many others base their decisions. Efforts to address this corruption should focus on correcting large imbalances in the current political economy of medical knowledge. A sequestration of pharmaceutical research and development on one hand from pharmaceutical marketing on the other, though difficult to achieve, would address this and many other problems. (shrink)

How corporations surveil and influence consumers using big data tools is a major area of research and public debate. However, few studies explore it in relation to physicians in the USA, even though they have been surveilled and targeted by the pharmaceutical industry since at least the 1950s. Indeed, in 2010, concerns about the pharmaceutical industry's undue influence led to the passing of the Physician Sunshine Act, a unique piece of transparency legislation that requires companies to report their financial (...) ties to physicians and teaching hospitals in a public database. This article argues that while the Sunshine Act has clearly helped expose important commercial influences on both prescribing and the scale of industry involvement with physicians, it has also, paradoxically, fuelled further commercial surveillance and marketing. The article casts new light on innovative pharmaceutical marketing approaches and the key role of data brokers and analytics companies in the identification, targeting, managing, and surveillance of physicians. We place this analysis within the political economies of the pharmaceutical industry, surveillance-based marketing, and transparency, and argue that policies to promote increased transparency must be tightly tied to policies that impede the commodification and use of transparency data for surveillance and marketing purposes. (shrink)

ObjectivesTo compare changes in the number and amount of payments received by orthopedic and non-orthopedic surgeons from industry between 2014 and 2017.MethodsUsing the Centers for Medicare and Medicaid Services (CMS) Open Payment database from 2014 to 2017, we conducted a retrospective cohort study of industry payments to surgeons, including general payments and research payments.ResultsAmong orthopedic surgeons, the total number of general payments decreased from 248,698 in 2014 to 241,966 in 2017, but their total value increased from $97.1 million in 2014 (...) to $110.2 million in 2017. Among non-orthopedic surgeons, the total number decreased from 604,884 in 2014 to 582,490 in 2017, while the total value remained stable at approximately $159 million. Between 2014 and 2017, there was a differential increase in the median number of general payments received by non-orthopedic when compared to orthopedic surgeons (incidence rate ratio, 1.09; 95% CI, 1.08–1.09; p < 0.001), but a differential decline in the median value of general payments (− 8.9%; 95% CI, − 9.5%, − 8.4%; p < 0.001). Findings were consistent when stratified by nature of payment. In contrast, between 2014 and 2017, there was neither a differential change in the median number nor median value of research payments received by non-orthopedics.ConclusionExamination of a natural experiment of prior public disclosure of payments to orthopedic surgeons suggests that the Physician Payment Sunshine Act was associated with an increase in the number, but a decline in the value, of general payments received by non-orthopedic surgeons, but not on research payments received. (shrink)

125. The madman. Have you not heard of that madman who lighted a lantern at the bright sunshine of the morning, ran to the market, and began ceaselessly screaming: "I seek God! I seek God!"?This present essay is a shortened and adapted version of the first chapter of a large book of mine devoted to a comparison between ancient Greece and Christianity, shortly to be published in English by Michigan State University Press. Its theoretical core is the idea of (...) mediation, that is to say, the intangible connective element acting as a medium capable of linking humans to the world and the divine sphere that made the world possible in ancient times2. All this is related to our experience of object meant not only as a... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction: Conflicting Interest in Medicine: Stories by Physicians on How Financing Affects Their WorkJames M. DuBois, Symposium EditorPhysicians frequently enter into special relationships that establish personal financial interests that could conflict with their patients’ best interests. Examples include receiving gifts from drug companies, sharing a patent on a medical device, or accepting funding from industry to conduct a drug study. In recent years, such “conflicts of interests” in medicine (...) have received growing attention from medical associations (Association of American Medical Colleges, 2008, 2010), policy bodies (Institute of Medicine, 2009), industry (Pharmaceutical Research and Manufacturers of America, 2008), journalists (Caputo, 2009; Nguyen, Ornstein, & Weber, 2010), and even Congress, which included in the 2010 Patient Protection Affordable Care Act a Physician Payment Sunshine provision requiring industry to report a wide variety of ties to physicians. All of these efforts appear motivated by a similar assumption: Gifts and financially beneficial relationships can unconsciously motivate physicians to prioritize their own or industry’s interests over patients’ interests when providing care, conducting medical research, or educating physicians (American Association of Medical Colleges, 2008; Dana & Loewenstein, 2003).The call for stories produced for this narrative symposium provided the following request:We are interested in hearing about positive and negative experiences associated with a variety of financial relationships. The stories should give readers a sense of what it is like to be a physician in the midst of complex relationships to industry, physician practices, and third–party payers—relationships that go beyond ordinary reimbursement for care or research expenses.Obtaining stories proved more challenging than anticipated for reasons related to our theme. Precisely because access to physicians is considered valuable, it is highly restricted. Listservs and blogs that serve physicians typically prohibit postings from anyone except physician members, and even they are sometimes not allowed to post messages freely. While at least one listserv circulated our call to members (at the request of a member), others rejected our request, and one blog offered to post our call as a 1–month ad for $20,000. This contrasts radically with the relatively easy access we have had to other groups, including mental health consumers and living organ donors, who have broad grass root communication systems, and bioethicists, who have several listservs and blogs that readily share news about relevant scholarly opportunities.The collection of stories obtained resulted from extensive personal networking and a small amount of arm twisting. The collection was not what we expected to obtain, but is in many ways even more interesting. One story (Hodges) explicitly addresses the impact that pharmaceutical representatives can have on prescribing patterns—the classic, voluntary, conflicted relationship, insofar as sales reps are [End Page 65] welcomed in facilities, often bearing free samples, free lunches, and glossy articles on their products, all in the hopes of influencing prescribing patterns. But most stories do not fit the typical mold found in discussions of conflicts of interest. Among those expressing concerns about the impact of financial factors on medical practice, one focuses on the insufficient management of bias within the Food and Drug Administration (Perlmutter); three focus on the bias that is introduced through our current fee–for–service reimbursement system (Mikulec, Nagaldine, and Zientek)—of these, two illustrate ways that third parties seek to manipulate physician practices to maximize profits; one notes how any kind of clinical trial—whether government or industry sponsored—may affect patient care decisions (Cruz); while two argue that worries over industry sponsorship of research are disproportionate (Bierut and Sofair), and two address widespread concerns about industry sponsorship of educational activities, with one illustrating how bias might be reduced (Seitz & Diao), and another illustrating the potential harms of prohibiting educational sponsorship (Peppin).To be clear, all of these narratives are responsive to our call for stories that “describe positive and negative experiences associated with a variety of financial relationships.” Yet they are not classic conflict of interest stories; rather, they represent the conflicting interests that concern physicians today—conflicts that are often intrinsic to our current healthcare and research systems rather than special relationships courted by physicians.While making no pretense of representativeness or comprehensiveness, these stories provide fertile ground for reflection, as seen in our... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Five More MinutesKristen Carey RockFive more minutes. How many times have you said the phrase, "I need just five more minutes"—perhaps to finish a note, clean up the kitchen, or read the kids a bedtime story? It is a seemingly insignificant amount of time. But what if you knew that these five minutes were the last five minutes you would spend conscious on this earth? The last five minutes (...) you would spend with your parents and your young children before you would receive a sedative and be transported down to the operating room, where you would be removed from life support and then donate your organs? In a hoarse rasp through his tracheostomy, he kept whispering, "Please. Just five more minutes."This is the reality that I walked into one Friday morning in 2021 as I took over the ICU service at my hospital. I am an ICU doctor at a busy academic center in the northeast and was on the frontlines of our COVID response, including the care of patients who required ECMO (extracorporeal membrane oxygenation)—the last resort for treating patients suffering from severe lung disease.I did not have the privilege of meeting this patient until the morning of his death, but I knew he had been in the hospital for close to three months due to acute respiratory distress syndrome (ARDS) due to COVID-19. On the spectrum of COVID symptoms, this problem is the worst of the worst, and it left his lungs in tatters—so much so that he had relied on an ECMO machine to perform the functions of his lungs for many weeks in hopes that he would either recover or become eligible for a lung transplant. During this time, many hundreds of doctors, nurses, nurse practitioners and respiratory therapists had gotten to know him quite well. They met his father, former wife, and his four school-aged children. They learned of his service to our country as a member of the Air Force and his subsequent devotion to his community as a religious leader and beacon in his community. As he recovered to the point where he was able to be awake and interactive with a tracheostomy, allowing him to mouth words, they also got to know him as a kind and gentle man with a fierce will to live and devotion to his family.Yet, after many weeks of ups and downs, progress and setbacks, it became clear that he could not survive without the help of his ECMO machine. Though it is possible for someone to survive for many months on ECMO, like most forms of life support, it is a bridge rather than a destination therapy. More complicated and invasive than other forms of life support, it is resource-intense and fraught with medical complications. And one day, came the heartbreaking news that due to too many blood transfusions during his illness, he would not be able to receive a lung transplant. He and his care team realized this meant there was no path forward. It came as little surprise to those who knew him that when he realized that he could not live independent of machines or outside the walls of an intensive care unit, his final act would be to help others. He would give others the opportunity for the organ transplant that he so cruelly could not receive.And so, the date and time were set. The transplant teams from other hospitals began to arrive. His final morning on earth would be spent with his family, except for a last trip outside to see the sunshine. With masterful coordination, his ICU room was recreated on the roof atop our helipad. As an army of caregivers attended to his tubes, pumps, and machines, he was able to feel the warmth of the spring wind as the Air Force sent an honor guard of fighter jets to pay their final respects. I watched him smile as the planes flew overhead, unsure if he could see or just hear them. Even though someone had the foresight to place a pair of sunglasses on his face, he still grimaced at the sunlight after months of artificial... (shrink)

Emergency declarations are a vital legal authority that can activate funds, personnel, and material and change the legal landscape to aid in the response to a public health threat. Traditionally, declarations have been used against immediate and unforeseen threats such as hurricanes, tornadoes, wildfires, and pandemic influenza. Recently, however, states have used emergency declarations to address public health issues that have existed in communities for months and years and have risk factors such as poverty and substance misuse. Leaders in these (...) states have chosen to use emergency powers that are normally reserved for sudden catastrophes to address these enduring public health issues. This article will explore emergency declarations as a legal mechanism for response; describe recent declarations to address hepatitis A and the opioid overdose epidemic; and seek to answer the question of whether it is appropriate to use emergency powers to address public health issues that are not traditionally the basis for an emergency declaration. (shrink)

How have we come by our worldviews, and what influence did Christianity have on those that are common to Western civilization?

Cross jurisdictional collaboration efforts and emergency vaccine plans that are consistent with Tribal sovereignty are essential to public health emergency preparedness. The widespread adoption of clearly written federal, state, and local vaccine plans that address fundamental assumptions in vaccine distribution to Tribal nations is imperative for future pandemic response.

According to the conceptual act theory, emotions emerge when physical sensations in the self and physical actions in others are meaningfully linked to situations during a process that can be called both cognitive and perceptual (creating emotional experiences, and emotion perceptions, respectively). There are key four hypotheses: (a) an emotion (like anger) is a conceptual category, populated with instances that are tailored to the environment; (b) each instance of emotion is constructed within the brain’s functional architecture of domain-general core systems; (...) (c) the workings of each system must be holistically understood within the momentary state of the brain, the body, and the surrounding context; (d) being emergent states, emotional episodes have functional features that physical states, alone, do not have. Similarities and differences to other theoretical approaches to emotion are discussed. (shrink)

L’articolo esamina la proposta europea di regolamento sull’intelligenza artificiale, AI Act (AIA). In particolare, esamina il modello di analisi e valutazione del rischio dei sistemi di IA. L’articolo identifica tre potenziali problemi di implementazione del regolamento: (1) la predeterminazione dei livelli di rischio, (2) la genericità del giudizio di significatività del rischio e (3) l’indeterminatezza della valutazione sull’impatto dei diritti fondamentali. Il saggio suggeriscealcune soluzioni per affrontare questi tre problemi.

Talking about action comes easily to us. We quickly make distinctions between voluntary and non-voluntary actions; we think we can tell what intentions are; we are confident about evaluating reasons offered in rational justification of action. Berent Enc provides a philosopher's sustained examination of these issues: he portrays action as belonging to the causal order of events in nature, a theory from which new and surprising accounts of intention and voluntary action emerge. Philosophers and cognitive scientists alike will find How (...) We Act a provocative and enlightening read. (shrink)

Ever since Frege, propositions have played a central role in philosophy of language. Propositions are generally conceived as abstract objects that have truth conditions essentially and fulfill both the role of the meaning of sentences and of the objects or content of propositional attitudes. More recently, the abstract conception of propositions has given rise to serious dissatisfaction among a number of philosophers, who have instead proposed a conception of propositional content based on cognitive acts (Hanks, Moltmann, Soames). This approach is (...) not entirely new, though, but has important precedents in early analytic philosophy and phenomenology. The aim of this volume is bring together some of the most important texts from the relevant historical literature and new contributions from contemporary proponents of act-based conceptions of propositional content. (shrink)

According to the axiologist the value concepts are basic and the deontic concepts are derivative. This paper addresses two fundamental problems that arise for the axiologist. Firstly, what ought the axiologist o understand by the value of an act? Second, what are the prospects in principle for an axiological representation of moral theories. Can the deontic concepts of any coherent moral theory be represented by an agent-netural axiology: (1) whatever structure those concepts have and (2) whatever the causal structure of (...) the world happens to be. We show that the answer is "almost always". The only substantive constraint is that autonomous moral agents cannot have the power to simultaneously block the options open to other autonomous moral agents. But this seems to be part and parcel of the notion of an autonomous moral agent. (shrink)

Empirical studies indicate that business compliance with the UK Modern Slavery Act is disappointing, but they struggle to make sense of this phenomenon. This article offers a novel framework to understand how business organizations construct the meaning of compliance with the UK Modern Slavery Act. Our analysis builds on the endogeneity of law theory developed by Edelman. Empirically, our study is based on the analysis of the modern slavery statements of 10 FTSE 100 (Financial Times Stock Exchange 100 Index) companies (...) in the food and tobacco sector, backed by interviews with business, civil society, and public officers. We offer a dynamic model that draws attention to the role of compliance professionals in framing ambiguous rules and devising a variety of organizational responses to modern slavery law. Contrary to extant research that tends to praise organizations for going “beyond compliance”, our study underlines the risks of managerialization of modern slavery law, whereby merely symbolic structures come to be associated with legal compliance, even when they are ineffective at tackling modern slavery. (shrink)

This essay argues that non-linguistic animals qualify not just for externalist notions of rationality (maximizing biological fitness or utility), but also for internal ones. They can act for reasons in several senses: their behaviour is subject to intentional explanations, they can act in the light of reasons - provided that the latter are conceived as objective facts rather than subjective mental states - and they can deliberate. Finally, even if they could not, it would still be misguided to maintain that (...) animals are capable only of (mechanical) behaviour, not of (intentional) action. (shrink)

This paper attempts to explain what a protest is by using the resources of speech-act theory. First, we distinguish the object, redress, and means of a protest. This provided a way to think of atomic acts of protest as having dual communicative aspects, viz., a negative evaluation of the object and a connected prescription of redress. Second, we use Austin’s notion of a felicity condition to further characterize the dual communicative aspects of protest. This allows us to distinguish protest from (...) some other speech acts which also involve a negative evaluation of some object and a connected prescription of redress. Finally, we turn to Kukla and Lance’s idea of a normative functionalist analysis of speech acts to advance the view that protests are a complex speech act constituted by dual input normative statuses and dual output normative statuses. (shrink)

In this paper I survey a range of trolling behaviors and analyze a particular species that stands out. After a brief discussion of some of the inherent challenges in studying internet speech, I describe a few examples of behaviors commonly described as ‘trolling’ in order to identify what they have in common. I argue that most of these behaviors already have well-researched offline counterparts. In contrast, in the second half of the paper I argue that so-called ‘subcultural trolling’ calls out (...) for further analysis: it cannot be fully explained using standard tools like insincerity or bullshit, or even using new tools like dogwhistling. Instead, I propose a new species of speech act force. I conclude by highlighting some implications for broader issues in pragmatics and ethics. (shrink)

As this passage from a recent book on the psychology of decision-making indicates, deciding seems to be part of our daily lives. But what is it to decide to do something? It may be true, as some philosophers have claimed, that to decide to A is to perform a mental action of a certain kind – specifically, an action of forming an intention to A. (Henceforth, the verb ‘form’ in this context is to be understood as an action verb.) Even (...) if this is so, we are faced with pressing questions. Do we form all of our intentions? If not, how does forming an intention differ from other ways of acquiring one? Do we ever, in fact, form intentions, or do we rather merely acquire them in something like the way we acquire beliefs or desires? These are some of the questions that will occupy me here. My aim is to clarify the nature of deciding to act and to make a case for the occurrence of genuine acts of intention formation. (shrink)

A theory is agent neutral if it gives every agent the same set of aims and agent relative otherwise. Most philosophers take act-consequentialism to be agent-neutral, but I argue that at the heart of consequentialism is the idea that all acts are morally permissible in virtue of their propensity to promote value and that, given this, it is possible to have a theory that is both agent-relative and act-consequentialist. Furthermore, I demonstrate that agent-relative act-consequentialism can avoid the counterintuitive implications associated (...) with utilitarianism while maintaining the compelling idea that it is never wrong to bring about the best outcome. (shrink)