Cartwright and Munro argued that extrapolation of findings from randomized controlled trials to other settings can be difficult because information about the underlying causal structure and subgroups is often not available. They advocated the use of ‘capacities’ – that is fixed causal contributions – in predicting effects of interventions. In psychiatry, it is often not possible to determine what the fixed causal contributions are and one can only establish ‘approximate capacities’. However, using ‘approximate capacities’ does imply a different way of (...) evaluating health services, especially combined interventions. In health service research, if different studies, randomized controlled trials or other designs, have given different outcomes, the best way to investigate the effectiveness of a particular way of service organization is not to conduct more randomized controlled trials. It is preferable to study the effects of certain elements of the complex intervention, which have been tested before in other settings, that is investigating ‘approximate capacities’. One should check whether the separate elements do form a part of the complex intervention in practice and whether they have the same effect as in other studies and if not, why not. This enhances knowledge about the underlying causal structure and increases the possibility of extrapolation of the findings. (shrink)

In this paper I look at causality in the context of intervention research, and discuss some problems faced in the evaluation of causal hypotheses via interventions. I draw attention to a simple problem for evaluations that employ randomized controlled trials. The common alternative to randomized trials, the observational study, is shown to face problems of a similar nature. I then argue that these problems become especially acute in cases where the intervention is complex (i.e. that involves intervening (...) in a complex system). Finally, I consider and reject a possible resolution of the problem involving the simulation of complex interventions. The conclusion I draw from this is that we need to radically reframe the way we think about causal inference in complex intervention research. (shrink)

Evaluating clinical ethics support services has been hailed as important research task. At the same time, there is considerable debate about how to evaluate CESS appropriately. The criticism, which has been aired, refers to normative as well as empirical aspects of evaluating CESS. In this paper, we argue that a first necessary step for progress is to better understand the intervention in CESS. Tools of complex intervention research methodology may provide relevant means in this respect. In a (...) first step, we introduce principles of “complex intervention research” and show how CESS fulfil the criteria of “complex interventions”. In a second step, we develop a generic “conceptual framework” for “ethics consultation on request” as standard for many forms of ethics consultation in clinical ethics practice. We apply this conceptual framework to the model of “bioethics mediation” to make explicit the specific structural and procedural elements of this form of ethics consultation on request. In a final step we conduct a comparative analysis of two different types of CESS, which have been subject to evaluation research: “proactive ethics consultation” and “moral case deliberation” and discuss implications for evaluating both types of CESS. To make explicit different premises of implemented CESS interventions by means of conceptual frameworks can inform the search for sound empirical evaluation of CESS. In addition, such work provides a starting point for further reflection about what it means to offer “good” CESS. (shrink)

BackgroundHow should clinical ethics support services such as clinical ethics committees (CECs) be implemented and evaluated? We argue that both the CEC itself and theimplementationof the CEC should be considered as ‘complex interventions’.Main textWe present a research project involving the implementation of CECs in community care in four Norwegian municipalities. We show that when both the CEC and its implementation are considered as complex interventions, important consequences follow – both for implementation and the study thereof. Emphasizing four such (...) sets of consequences, we argue, first, that the complexity of the intervention necessitates small-scale testing before larger-scale implementation and testing is attempted; second, that it is necessary to theorize the intervention in sufficient depth; third, that the identification of casual connections charted in so-called logic models allows the identification of factors that are vital for the intervention to succeed and which must therefore be studied; fourth, that an important part of a feasibility study must be to identify and chart as many as possible of the causally important contextual factors.ConclusionThe conceptualization of the implementation of a CEC as a complex intervention shapes the intervention and the way evaluation research should be performed, in several significant ways. We recommend that researchers consider whether a complex intervention approach is called for when studying CESS implementation and impact. (shrink)

Aim: The aim of this paper is to present the development and evaluation of an art psychotherapy brief treatment method for complex depression for patients referred to mental health services.Background: Art Psychotherapy literature describes a range of processes of relational change through the use of arts focused and relationship focused interventions. Complex depression has a prevalence of 3% of the population in the West and it is recorded that in 2016 only 28% of that population were receiving psychological (...) treatment. This study was developed to test the hypothesis of whether an accessible and acceptable approach to the treatment of complex depression could be developed in relation to existing evidence-based practice within mental health services.Method: The United Kingdom Medical Research Council phased guidance for complex intervention development was used to develop the intervention. The process included producing a literature overview, systematic description of clinical practice, including a logic model and a clinical protocol. The art psychotherapy protocol described an arts-based dynamic interpersonal therapy approach, offered 1:1 over 24 sessions. Further to this the intervention was tested for referrer acceptability. The intervention is in the early stages of evaluation, using changes to the patient's depression and anxiety measured pre- and post-treatment with a follow-up measure at 3 months following completion of treatment.Results: Phase I of the study provided a good basis for developing a logic model and protocol. The authors found that there was good clinical consensus about the use of a structured clinical art psychotherapy method and the literature overview was used to support specific examples of good practice. The verification of clinical coherence was represented by a logic model and clinical protocol for delivering the intervention. The acceptability study demonstrated very high levels of acceptability for referrers reporting that ADIT was acceptable for patients with complex/major depression, that they were likely to refer to ADIT in the future that the use of arts was likely to improve accessibility the use of arts was likely to improve outcomes and that offering ADIT was an effective use of mental health resources.Discussion: Phase I of this intervention development study demonstrated theoretical and practice coherence resulting in a clinical protocol and logic model. Whilst Phase II of this study showed promising results, Phase II would need to be sufficiently scaled up to a full trial to further test the intervention and protocol. (shrink)

This paper proposes a conceptual framework for understanding the implementation process of a complex intervention concerned with professional role change. The proposed framework holds that the intervention must address three interacting systems (socio-cultural, educational and disciplinary) through which a health professional role is evolved. Each system is operationalized by four dimensions (values, methods, actors and targets). As for the implementation, the framework posits that it can be analyzed, by depicting the barriers and facilitators located within the dimensions (...) of the three interacting systems and within the intervention involved in the process through using the “menu of constructs” approach suggested by the Consolidated Framework for Implementation Research (CFIR). The implications of this framework, on theoretical research and practical levels, are reviewed. (shrink)

An amendment to this paper has been published and can be accessed via the original article.

Background: The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience. Discussion: Some researchers suggest that a closer examination of how socio-political structures influence healthcare (...) delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress. Conclusion: We posit moral distress as a form of relational trauma and subsequently point to the need to better understand how nurses as moral agents are influenced by—and influence—the complex socio-political structures they inhabit. In so doing, we identify this reciprocity as a framework for interventions. (shrink)

Object relative clauses are harder to process than subject relative clauses. UnderGrillo’s (2009)Generalized Minimality framework, complexity effects of object relatives are construed as intervention effects, which result from an interaction between locality constraints on movement (Relativized Minimality) and the sentence processing system. Specifically, intervention of the subject DP in the movement dependency is expected to generate a minimality violation whenever processing limitations render the moved object underspecified, resulting in compromised comprehension. In the present study, assuming Generalized Minimality, we (...) compared the processing of object relatives with the processing of subject control in ditransitives, which, like object relatives, instantiates a syntactic dependency across an intervening DP. This comparison is justified by the current debate on whether Control should be analyzed as movement: if control involves movement of the controller DP, as proposed byHornstein (1999), a parallel between the processing of object relatives and subject control in ditransitives may be anticipated on the basis of intervention. In addition, we explored whether general cognitive factors contribute to complexity effects ascribed to movement across a DP. Sixty-nine adult speakers of European Portuguese read sentences and answered comprehension probes in a self-paced reading task with moving-window display, comprising four experimental conditions:Subject Relatives;Object Relatives;Subject Control;Object Control. Furthermore, participants performed four supplementary tasks, serving as measures of resistance to interference, lexical knowledge, working memory capacity and lexical access ability. The results from the reading task showed that whereas object relatives were harder to process than subject relatives, subject control was not harder to process than object control, arguing against recent movement accounts of control. Furthermore, we found that whereas object relative complexity effects assessed by response times to comprehension probes interacted with Reading Span, object relative complexity effects assessed by comprehension accuracy and reading times did not interact with any of the supplementary tasks. We discuss these results in light of Generalized Minimality and the hypothesis of modularity in syntactic processing (Caplan and Waters, 1999). (shrink)

Background: The ethics and value bases in healthcare are widely acknowledged. There is a need to improve and raise awareness of ethics in complex systems and in line with competing needs, different stakeholders and patients’ rights. Evidence-based strategies and interventions for the development of procedures and practice have been used to improve care and services. However, it is not known whether and to what extent ethics can be developed using interventions. Objectives: To examine ethics interventions conducted on healthcare professionals (...) and healthcare students to achieve ethics-related outcomes. Research design: A systematic review. Methods: Five electronic databases were searched: CINAHL, the Cochrane Library, Philosopher’s Index, PubMed and PsycINFO. We searched for published articles written in English without a time limit using the keywords: ethic* OR moral* AND intervention OR program OR pre-post OR quasi-experimental OR rct OR experimental AND nurse OR nursing OR health care. In the four-phased retrieval process, 23 full texts out of 4675 citations were included in the review. Data were analysed using conventional content analysis. Ethical consideration: This systematic review was conducted following good scientific practice in every phase. Findings: It is possible to affect the ethics of healthcare practices through professionals and students. All the interventions were educational in type. Many of the interventions were related to the ethical or moral sensitivity of the professionals, such as moral courage and empowerment. A few of the interventions focused on identifying ethical problems or research ethics. Conclusion: Patient-related outcomes followed by organisational outcomes can be improved by ethics interventions targeting professionals. Such outcomes are promising in developing ethical safety for healthcare patients and professionals. (shrink)

Science and technology studies analyses of emerging forms of treatment often result in the detailed display of complexities and at times lead to explicit critiques of particular healthcare practices. Simultaneously, there seems to be an increasing interest in exploring more experimental engagements by STS researchers in the proactive construction of such practices. In this article, I explore the relevance of experimental interventions in health care practices for both these care practices and for issues of the normativity of STS research. By (...) analyzing my involvement in changes in the practice of hemophilia home treatment, I indicate how this care practice was reconfigured, partly by drawing on STS insights on the issue of compliance. I also claim that experimenting with forms of ‘‘artful contamination’’ allow STS researchers to do normativity in the practices they engage with. Such practices of interventionist STS research may be of value for refiguring debates in which constructivism has been accused of being normatively deficient. This may make interventionist STS research a fruitfully risky business. (shrink)

The intervention stairway emerges from recognising the complexity inherent in public health issues. While the original intervention ladder is a valuable tool, it risks ignoring this complexity, narrowing our focus to individual-level interventions at the expense of systemic considerations. Some have interpreted this critique as claiming the ladder entirely precludes consideration of systemic factors.1 This is not the case. Instead, the claim is that the ladder obscures these factors, making them more challenging to recognise and incorporate into policy. (...) This critique has generated several responses. Smith and Gauthier argue that the ladder will not obscure systemic considerations as it is primarily a tool for policy evaluation, not policy creation.1 Moreover, they suggest that even if used for policy creation, the ladder will likely generate systemic interventions as these are often less intrusive. By contrast, Dawson has objected to the stairways’ focus on intrusiveness, supposedly at the expense of other values, saying, ‘the only justification for a tool such as the intervention ladder is if liberty is, implausibly, given some privileged status over other values’.2 These critiques warrant careful consideration but ultimately misunderstand the purpose of both the original ladder and the proposed stairway. Neither tool is meant to privilege liberty or be used in isolation. Rather, they are tools for weighing considerations of intrusiveness and proportionality designed to be applied within …. (shrink)

Recent advances in genetic research pose many complex problems for moral and political philosophers. On the one hand, these advances promise great things. Genetic enhancement techniques might allow us to prevent or cure a variety of debilitating diseases. But on the other hand, talk about intervening in people's genetic make-up conjures up memories of the sinister episodes of past eugenic movements. Such movements violated the most basic principles of justice. How can society capitalize on the benefits of genetic (...) class='Hi'>intervention and yet avoid the injustices of past eugenic movements? What basic moral principles should guide public policy and individual choice concerning the use of genetic interventions? These important questions are tackled by Allen Buchanan, Dan Brock, Norman Daniels, and Daniel Wikler in From Chance to Choice: Genetics and Justice. This book brings together the thoughts of leading scholars in the field and is likely to set the agenda for serious debate on this topic. (shrink)

I argue that the Causal Markov Condition (CMC) is in principle applicable to the Einstein–Podolsky–Rosen (EPR) correlations. This is in line with my defence in the past of the applicability of the Principle of Common Cause to quantum mechanics. I first review a contrary claim by Dan Hausman and Jim Woodward, who endeavour to preserve the CMC against a possible counterexample by asserting that the conditions for the application of the CMC are not met in the EPR experiment. In their (...) view the CMC is inapplicable to the EPR correlations—i.e. it neither obtains nor fails. The view is grounded upon the non-separability of the quantum state, and the consequent unavailability of interventions. I urge that whether interventions are available in EPR—and why—is a complex and contextual question that does not have a unique or uniform answer. Instead, I argue that different combinations of causal hypotheses under test and interpretations of quantum mechanics yield different answers to the question. (shrink)

In the field of health technology assessment, there are several approaches that can be used for ethical analysis. However, there is a scarcity of literature that critically evaluates and compares the strength and weaknesses of these approaches when they are applied in practice. In this paper, we analyse the applicability of some selected approaches for addressing ethical issues in HTA in the field of complex health interventions. Complex health interventions have been the focus of methodological attention in HTA. (...) However, the potential methodological challenges for ethical analysis are as yet unknown.Six of the most frequently described and applied ethical approaches in HTA were critically assessed against a set of five characteristics of complex health interventions: multiple and changing perspectives, indeterminate phenomena, uncertain causality, unpredictable outcomes, and ethical complexity. The assessments are based on literature and the authors’ experiences of developing, applying and assessing the approaches.The Interactive, participatory HTA approach is by its nature and flexibility, applicable across most complexity characteristics. Wide Reflective Equilibrium is also flexible and its openness to different perspectives makes it better suited for complex health interventions than more rigid conventional approaches, such as Principlism and Casuistry. Approaches developed for HTA purposes are fairly applicable for complex health interventions, which one could expect because they include various ethical perspectives, such as the HTA Core Model® and the Socratic approach.This study shows how the applicability for addressing ethical issues in HTA of complex health interventions differs between the selected ethical approaches. Knowledge about these differences may be helpful when choosing and applying an approach for ethical analyses in HTA. We believe that the study contributes to increasing awareness and interest of the ethical aspects of complex health interventions in general. (shrink)

Infants, children and adolescents with life-limiting and life-threatening disease need long-term care that may change according to disease’s natural history. With the primary goal of quality of life, the psychologist of pediatric palliative care network deals with a large variety of issues. Little consideration has been given to the variety of intervention areas of psychology in PPC that concern the whole life span of the patient and family. The PPC network is composed by a multidisciplinary team of palliative care (...) specialists that intervenes at home, in the hospital and in every place where the patient is living. The network coordinates different public health services to respond to clinical, psychosocial and spiritual needs. In these scenarios, the psychological need is not a single event but a moment inserted in the complexity of the child’s needs. This retrospective monocentric project consists of an analysis of characteristics of psychological interventions in our PPC service. The time frame taken into consideration is 2019–2020, analyzing the clinical records of 186 patients of Pediatric Palliative Care and Pain Service of Veneto Region. The areas that emerged in the analysis show how the intervention of the psychologist in PPC does not concern only end-of-life, but a series of topics that are significant for the family to guarantee psycho-social wellbeing oriented toward the best quality of life. In conclusion, these different topics highlight the complexity of the child and family experience. This variety must be taken into consideration, the psychologist must increase holistic support with a dedicated skills curriculum. (shrink)

With a critical eye, Gabriel Rockhill guides you through complex debates in history, politics and aesthetics, giving you an overview of key issues and central figures, including Foucault, Derrida, Castoriadis, Badiou and Ranciere.Rockhill also engages in a nuanced exploration of recent work that calls into question the stereotype of 'prominent figures' and 'intellectual movements. Far from hiding behind towering figures of the intellectual world, Rockhill stakes out positions in relationship to them and formulates precise arguments in favour of a (...) new understanding of the historical relationship between art and politics. (shrink)

Donald VanDeVeer probes the moral complexities of the question: under what conditions is it permissible to intervene invasively in the lives of competent persons--for example, by deception, force, or coercive threat--for their own good? In a work with broad significance for law, public policy, professional-client relations, and private interactions, he presents a theory of an autonomy-respecting" paternalism. Originally published in 1986. The Princeton Legacy Library uses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished backlist (...) of Princeton University Press. These editions preserve the original texts of these important books while presenting them in durable paperback and hardcover editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905. (shrink)

In the aftermath of the complex humanitarian crises of the 1990s, the concept of the Responsibility to Protect emerged powerfully on the international stage. The report of the International C...

The moral complexity surrounding intervention is influenced by a broad spectrum of both ethical and practical assumptions and considerations.

Community-based interventions (CBIs) show promise as effective and cost-effective obesity prevention initiatives. CBIs are typically complex interventions, including multiple settings, strategies and stakeholders. Cost-effectiveness evidence, however, generally only considers a narrow range of costs and benefits associated with anthropometric outcomes. While it is recognised that the complexity of CBIs may result in broader non-health societal and community benefits, the identification, measurement, and quantification of these outcomes is limited. This study aimed to understand the perspectives of stakeholders on the broader (...) benefits of CBIs and their measurement, as well as perceptions of CBI cost-effectiveness. Purposive sampling was used to recruit participants from three stakeholder groups (lead researchers, funders, and community stakeholders of CBIs). Online semi-structured interviews were conducted, taking a constructivist approach. Coding, theme development and analysis were based on published guidance for thematic analysis. Twenty-six stakeholders participated in the interviews (12 lead researchers; 7 funders; 6 community stakeholders). Six key themes emerged; (1) Impacts of CBIs (health impacts and broader impacts); (2) Broader benefits were important to stakeholders; (3) Measurement of benefits are challenging; (4) CBIs were considered cost-effective; (5) Framing CBIs for community engagement (6) Making equitable impacts and sustaining changes—successes and challenges. Across all stakeholders, broader benefits, particularly the establishment of networks and partnerships within communities, were seen as important outcomes of CBIs. Participants viewed the CBI approach to obesity prevention as cost-effective, however, there were challenges in measuring, quantifying and valuing broader benefits. Development of tools to measure and quantify broader benefits would allow for more comprehensive evaluation of the cost-effectiveness of CBIs for obesity prevention. (shrink)

Background: Providing care for a home-dwelling person with dementia who resists care is an ethical and practical complex and challenging task. Faced with a growing number of persons with dementia, the healthcare professional’s understanding of how to best care for and prevent unnecessary use of coercion with persons with dementia is of key importance. Research aim: The aim of this study was to explore the use of trust-building interventions in home-dwelling persons with dementia resisting care, as described by health (...) professionals in documents of decisions of forced treatment and care. Research design: A qualitative thematic document analysis inspired by critical realism was conducted. Participants and research context: Descriptions of trust-building interventions were extracted from 88 documents of forced treatment and care for home-dwelling persons with dementia, receiving home healthcare, in 2015 and 2016. Ethical considerations: Approved by the Regional Committee for Medical and Health Research Ethics, reference number 2017/788, and controlled by the Norwegian Centre for Research Data, reference number 54897. The study adhered to the guidelines of the Declaration of Helsinki. Findings: We found that “balancing safe care with the person’s integrity” was an overarching theme that permeated the descriptions of trust-building interventions in the study. Three main themes were identified when the data were analyzed: safeguarding care, protecting integrity, and optimizing the environment. Discussion and conclusion: Health professionals balanced on a thin line between care and integrity when met with resistance from person with dementia. However, the trust-building interventions used in the most challenging situations did not differ from the interventions used in general in dementia care. Two knowledge gaps were identified: how to perform appropriate assessments of situations of home-dwelling persons with dementia when met with resistance to care, and whether environmental initiatives may also benefit home-dwelling persons with dementia who are not easily cared for. (shrink)

Humanitarian agencies have confronted one disaster after another over the last twenty-five years. Decades of intense growth in reacting to complex global calamities have seriously affected humanitarian efforts. Contending organizations – NGOs, states – engage in transnational interventions. From regions of natural disaster to sectors marked by political clashes, a new rationale for intervention has appeared which merges humanitarian assistance and military engagement. Humanitarian intervention sanctions the notion that military power is a necessary part of the responsibility (...) to protect. The imperative to safeguard lives in jeopardy results in a form of humanitarian and military government in constant motion from one disaster to the next. Under the mandate of the right to intervene, this tactic confronts state sovereignty, particularly since humanitarian organizations engage in political activities such as establishing respect for human rights. The relation between military and humanitarian intervention in the context of disaster, is founded on a calculus of security, based in the legitimacy of measures meant to safeguard human life. A new form of humanitarian governance is thus emerging from military occupations and natural disasters. This paper will examine the human rights consequences of these states of disaster and the novel form of government associated with them. (shrink)

Given the contemporary complexity of cities, landscape and society, urgent social tasks call for an integral, multidisciplinary approach. Rietveld Landscape’s strategic interventions focus and use the forces of existing developments and processes. This design method creates new opportunities for landscape, architecture, the public domain, ecology, recreation and economic activity.

This study aims to examine how interdisciplinary urban interventions within architectural education can effectively address social justice issues. Motivated by the growing need for inclusive and equitable urban spaces, this research explores the potential of collaborative design and participatory research methods to foster social awareness and community engagement. Focusing on student-led projects in cities such as Houston, San Diego, and Amsterdam, this study addresses social justice challenges across themes like Art Activism, Tactical Urbanism, environmental justice, and gender equity. Using case (...) study analysis, digital mapping, and poster creation as core methodologies, the research demonstrates the value of multi-scalar, interdisciplinary approaches in tackling complex urban problems. The key findings highlight that integrating these approaches into architectural education promotes critical engagement with social justice issues, equipping students with practical skills for future professional challenges. The implications suggest that expanding this framework to diverse urban contexts could enhance its impact, offering a foundation for further studies on interdisciplinary design as a tool for urban equity. (shrink)

In this paper we aim to demonstrate the enormous ethical complexity that is prevalent in child obesity cases. This complexity, we argue, favors a cautious approach. Against those perhaps inclined to blame neglectful parents, we argue that laying the blame for child obesity at the feet of parents is simplistic once the broader context is taken into account. We also show that parents not only enjoy important relational prerogatives worth defending, but that children, too, are beneficiaries of that relationship in (...) ways difficult to match elsewhere. Finally, against the backdrop of growing public concern and pressure to intervene earlier in the life cycle, we examine the perhaps unintended stigmatizing effects that labeling and intervention can have and consider a number of risks and potential harms occasioned by state interventions in these cases. (shrink)

BackgroundSome people with progressive neurological diseases find they need additional support with eating and drinking at mealtimes, and may require artificial nutrition and hydration. Decisions concerning artificial nutrition and hydration at the end of life are ethically complex, particularly if the individual lacks decision-making capacity. Decisions may concern issues of life and death: weighing the potential for increasing morbidity and prolonging suffering, with potentially shortening life. When individuals lack decision-making capacity, the standard processes of obtaining informed consent for medical (...) interventions are disrupted. Increasingly multi-professional groups are being utilised to make difficult ethical decisions within healthcare. This paper reports upon a service evaluation which examined decision-making within a UK hospital Feeding Issues Multi-Professional Team.MethodsA three month observation of a hospital-based multi-professional team concerning feeding issues, and a one year examination of their records. The key research questions are: a) How are decisions made concerning artificial nutrition for individuals at risk of lacking decision-making capacity? b) What are the key decision-making factors that are balanced? c) Who is involved in the decision-making process?ResultsDecision-making was not a singular decision, but rather involved many different steps. Discussions involving relatives and other clinicians, often took place outside of meetings. Topics of discussion varied but the outcome relied upon balancing the information along four interdependent axes: Risks, burdens and benefits; Treatment goals; Normative ethical values; Interested parties.ConclusionsDecision-making was a dynamic ongoing process with many people involved. The multiple points of decision-making, and the number of people involved with the decision-making process, mean the question of ‘who decides’ cannot be fully answered. There is a potential for anonymity of multiple decision-makers to arise. Decisions in real world clinical practice may not fit precisely into a model of decision-making. The findings from this service evaluation illustrate that within multi-professional team decision-making; decisions may contain elements of both substituted and supported decision-making, and may be better represented as existing upon a continuum. (shrink)

Causal models show promise as a foundation for the semantics of counterfactual sentences. However, current approaches face limitations compared to the alternative similarity theory: they only apply to a limited subset of counterfactuals and the connection to counterfactual logic is not straightforward. This article addresses these difficulties using exogenous interventions, where causal interventions change the values of exogenous variables rather than structural equations. This model accommodates judgments about backtracking counterfactuals, extends to logically complex counterfactuals, and validates familiar principles of (...) counterfactual logic. This combines the interventionist intuitions of the causal approach with the logical advantages of the similarity approach. (shrink)

Background Advances in life-prolonging technologies increasingly create dilemmas for physicians who must decide whether to offer various interventions to patients nearing the end of life. Clinical ethicists are often consulted to support physicians in making these complex decisions and can do so most effectively if they understand physicians’ reasons for making recommendations in this context.Methods Semi-structured interviews were conducted with surgeons, nephrologists, intensivists, emergency physicians, and oncologists regarding the considerations they have used to make decisions about offering interventions for (...) patients nearing the end of life. Interview transcripts were thematically analyzed.Results We identified six types of considerations physicians take into account: (1) patient characteristics at baseline; (2) likelihood to cause harm; (3) likelihood to achieve a goal or perceived benefit; (4) patient and family values and preferences; (5) institutional factors, and (6) professional and personal factors.Conclusions While considerations converged into major themes, many participants evaluated and applied these themes differently, opening the door to potential disagreement and variation based on physicians’ personal values. Clinical ethicists can help navigate uncertainty and resolve conflicts by helping physicians recognize, evaluate, and communicate their decisional factors to aid informed decision-making. (shrink)

After the end of the Cold War, many in the West viewed Africa as a testing ground for the solidarist argument that sovereignty was no longer an absolute principle and that the international community could intervene to protect individual from human rights violations. This argument seems particularly challenging in the African context, given the continental leadership’s historic commitment to territorial integrity and non-intervention. However, as the author shows, African leaders from 1945 to 1990 were largely upholding the pluralist international (...) norms of the time. In other words, the case for humanitarian intervention – and the problems posed by the practice – are not region-specific. The early 1990s, during which the United Nations intervened in Somalia, seemed to confirm the solidarist position. However, the failure to intervene in Rwanda in 1994, and the more recent experience of interventions in Sierra Leone, present a more mixed picture. Humanitarian intervention remains a controversial practice because of its coercive means, and its tendency to attribute blame or responsibility in what are often very complex civil conflicts. (shrink)

Recent improvements in virtual reality allow for the representation of authentic environments and multiple users in a shared complex virtual world in real time. These advances have fostered clinical applications including in psychiatry. However, although VR is already used in clinical settings to help people with mental disorders, the related ethical issues require greater attention. Based on a thematic literature search the authors identified five themes that raise ethical concerns related to the clinical use of VR: reality and its (...) representation, autonomy, privacy, self-diagnosis and self-treatment, and expectation bias. Reality and its representation is a theme that lies at the heart of VR, but is also of specific significance in a clinical context when perceptions of reality are concerned, for example, during psychosis. Closely associated is the autonomy of VR users. Although autonomy is a much-considered topic in biomedical ethics, it has not been sufficiently discussed when it comes to applications of VR in psychiatry. In this review, the authors address the different themes and recommend the development of an ethical framework for the clinical use of VR. (shrink)

Feminist analyses of the roles gender has played in art lead to an alternative theory that emphasizes art's complex interactions with culture(s) rather than the autonomy within culture claimed for it by formalism. Focusing on the visual arts, I extrapolate the new theory from feminist research and compare it with formalist precepts. Sharing Arthur Danto's concern that art has been disenfranchised in the twentieth century by its preoccupation with theory, I claim that feminist thought re-enfranchises art by revisioning its (...) relationship to its contexts. (shrink)

abstract In his ‘Suicide Intervention and Non‐Ideal Kantian Theory’ (2002), Michael J. Cholbi argues that nihilism and hopelessness are often motivating factors behind suicide, contrary to Immanuel Kant's prescribed motive of self‐love. In light of this, Cholbi argues that certain paternalistic modes of intervention may not only be effective in preventing suicide, but are ultimately consistent with Kantian morality. This paper addresses certain perceived shortcomings in Cholbi's account of Kantian suicide intervention. Once the psychological complexities of the (...) suicidal person are brought to bear, the suicidal person is found in many cases to be irrational at the time of her death. Because of this, rationalistic intervention strategies may prove ineffective, despite their being consistent with Kantian morality, and despite instances of suicide being non‐ideal circumstances. Cholbi assumes throughout his article that suicidal human beings remain Kantian moral agents. However, because rationality represents a crucial criterion for Kantian moral agency, and because certain human beings who commit suicide are not rational, such human beings are not Kantian moral agents. Because Cholbi's intervention strategies are not applicable to (or effective towards) irrational suicidal people, his account is found incomplete. (shrink)

Provided that traditional jus ad bellum principles are fulfilled, military humanitarian intervention to stop large scale violations of human rights (such as genocide, crimes against humanity or war crimes) is widely regarded as morally permissible. In cases of “supreme humanitarian emergency”, not only are the victims morally permitted to rebel, but other states are also permitted to militarily intervene. Things are different if the human rights violations in question fall short of supreme humanitarian emergency. Because of the importance of (...) respecting political self‐determination, in cases of “ordinary oppression”, we normally think that rebellion might be permissible, but not military humanitarian intervention. Thus, according to the received view, the conditions for the permissibility of intervention coincide with the conditions for the permissibility of revolution in cases of supreme humanitarian emergency, but not in cases of ordinary oppression. In cases of ordinary oppression there is an asymmetry between the conditions for the permissibility of revolution and intervention (call this the Asymmetry View). Should we accept the Asymmetry View? I answer this question by outlining an account of political self‐determination and by illustrating the complex role that this notion should play in discussing the morality of revolution and intervention. (shrink)

The recent Ebola outbreak in West Africa began in the spring of 2014 and has since caused the deaths of over 6,000 people. Since there are no approved treatments or prevention modalities specifically targeted at Ebola Virus Disease , debate has focused on whether unproven interventions should be offered to Ebola patients outside of clinical trials. Those engaged in the debate have responded rapidly to a complex and evolving crisis, however, and this debate has not provided much opportunity for (...) in-depth analysis. Additionally, the existing literature on access to unproven therapies has focused on contexts like HIV/AIDS and oncology, which are very different than the Ebola epidemic. In this paper, we examine the ethical issues surrounding access to unproven therapies in the context of the recent Ebola outbreak to yield new insights about this controversial and unsettled issue. We argue first that, in this context, the interests of patients in obtaining access to unproven therapies are not fully aligned.. (shrink)

Teaching mathematics and improving mathematics competence are pending subjects within our educational system. The PEIM (Programa Evolutivo Instruccional para Matemáticas), a constructivist intervention program for the improvement of mathematical performance, affects the different agents involved in math learning, guaranteeing a significant improvement in students’ performance. The program is based on the following pillars: (a) students become the main agents of their learning by constructing their own knowledge; (b) the teacher must be the guide to facilitate and guarantee such a (...) construction by being a great connoisseur of the fundamental aspects of the development of the child’s mathematical thinking; (c) the mathematical contents must be sequenced in terms of the complexity and significance for the student as well as contextualized at all times; and (d) the classroom must have a constructivist climate highlighting cooperative work among students. The implementation of PEIM along with the empirical evaluation conducted in several centers in Madrid and Zaragoza (Spain) confirm how students improve their mathematical competence. Both first- and second-grade students in elementary education were far more effective in solving problems, highlighting the use of more advanced strategies in their resolution and a lower incidence of conceptual errors. Moreover, it was possible to verify how the students proving greater difficulty, experienced an evolution in learning similarly to those who did not present it. The program provides customized education to allow the teacher to know at all times how he should be more influential on the students’ learning through mathematical profiles. Both teaching practice and teachers were observed, being that of the experimental group more prone to analyzing processes and allowing the construction of knowledge by students, due to their psycho-developmental training. As a result, we found several improvements through the implementation of the program that may serve, for upcoming years, as a basis for the necessary changes in the teaching of mathematics. (shrink)

This paper attempts a critical discussion of the possibilities for mental health nurses to claim a particular right of conscientious objection to their involvement in enforced pharmaceutical interventions. We nest this within a more general critique of perceived shortcomings of psychiatric services, and injustices therein. Our intention is to consider the philosophical and practical complexities of making demands for this conscientious objection before arriving at a speculative appraisal of the potential this may hold for broader aspirations for a transformed or (...) alternative mental health care system, more grounded in consent than coercion. We consider a range of ethical and practical dimensions of how to realize this right to conscientious objection. We also rely upon an abolition democracy lens to move beyond individual ethical frameworks to consider a broader politics for framing these arguments. (shrink)

Genetic interventions, which include transgenic engineering, gene editing, and other forms of genome modification aimed at altering the information “in” the genetic code, are rapidly increasing in power and scale. Biosemiotics offers unique tools for understanding the nature, risks, scope, and prospects of such technologies, though few in the community have turned their attention specifically in this direction. Bruni is an important exception. In this paper, I examine how we frame the concept of “side effects” that result from genetic interventions (...) and how the concept stands up to current perspectives of the role of organism activity in development. I propose that once the role of living systems in constructing and modifying the informational value of their various developmental resources is taken into account, the concept of a “side effect” will need to be significantly revised. Far from merely a disturbance brought about in a senseless albeit complex system, a biosemiotic view would take “side effects” as at least sometimes the organism’s active re-organization in order to accommodate or make use of novelty. This insight is nascent in the work of developmental plasticity and niche construction theory, but it is brought into sharper focus by the explicitly interpretive perspective offered by biosemiotics. Understanding the “side effects” of genetic interventions depends in part on being able to articulate when and where unexpected consequences are a result of semiotic activity at various levels within the system. While a semiotic interpretation of “side effects” puts into question the naive attitude that would see all unintended side effects as indications of disturbance in system functionality, it certainly does not imply that such side effects are of no concern for the viability of the organisms in the system. As we shall see, the fact that such interventions do not respect the translation of information that occurs in multi-level biological systems ensures that disruption is still likely. But it does unprivilege the human agent as the sole generator of meaning and information in the products of biotechnology, with important consequences on how we understand our relationship with other species. (shrink)

The question of when or if a nation should intervene in another country’s affairs is one of the most important concerns in today’s volatile world. Taking John Stuart Mill’s famous 1859 essay “A Few Words on Non-Intervention” as his starting point, international relations scholar Michael W. Doyle addresses the thorny issue of when a state’s sovereignty should be respected and when it should be overridden or disregarded by other states in the name of humanitarian protection, national self-determination, or national (...) security. In this time of complex social and political interplay and increasingly sophisticated and deadly weaponry, Doyle reinvigorates Mill’s principles for a new era while assessing the new United Nations doctrine of responsibility to protect. In the twenty-first century, intervention can take many forms: military and economic, unilateral and multilateral. Doyle’s thought-provoking argument examines essential moral and legal questions underlying significant American foreign policy dilemmas of recent years, including Libya, Iraq, and Afghanistan. (shrink)

Background: Flow states are considered a positive, subjective experience during an optimal balance between skills and task demands. Previously, experimentally induced flow experiences have relied solely on adaptive tasks. Objective: To investigate whether cathodal transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex (DLPFC) area and anodal tDCS over the right parietal cortex area during video game play will promote an increased experience of flow states. Methods: Two studies had participants play Tetris or first-person shooter (FPS) video games (...) while receiving either real tDCS or sham stimulation. Tetris recruited nineteen untrained players who infrequently played video games while the ten FPS participants played FPS frequently. Flow experience was assessed before and after stimulation. Results: Compared to sham stimulation, real stimulation increased flow experience for both untrained Tetris and trained FPS players. No ceiling effects were noticed between trained and untrained groups. Conclusion: Cathodal and anodal tDCS over the left DLPFC and right parietal areas respectively may encourage flow experiences in complex real-life motor tasks that occur during sports, games and everyday life. (shrink)

Although nursing seems to understand itself and its practice as complex, the literature is less clear about what this actually means. While complexity is discussed as an attribute of nursing, it is also suggested that complexity in nursing remains misunderstood and poorly articulated, is devalued, is not considered as a measure of health outcomes and remains invisible. Despite the overarching lack of a definition, some nurse scholars have conceptualized complexity as a complex intervention. For these authors, complexity (...) becomes a complex intervention defined as that which is composed of component parts interacting in a variety of ways that influence the delivery of and outcomes of health‐related interventions for populations. Conceptualizing complexity as a complex intervention forces nursing to embrace and adopt a received interpretation of complexity as expressed through complexity theory and complexity science. While complexity theory may afford us some tools for thinking about complexity, when we deconstruct nursing complexity to explicitly determinate and quantifiable tasks, this artificially narrowed orientation to complexity reveals an oversimplified explanation of the complexities associated with nursing and serves to blind us to its real qualities. Through a consideration of complexity from a Western philosophical tradition, I demonstrate that when nursing adopts the received interpretation of complexity as a complex intervention, this perspective on complexity contains nursing epistemologically and ontologically. I offer an extended conceptualization of complexity framed upon the consideration that nurses assume complexity and do not reduce it; that nurses have the capacity to not be paralysed by complexity and have developed logics to mobilize it in productive ways. Mobilizing complexity through navigating paradox and contradiction shapes an orientation to complexity that embraces an extended epistemology. This extended epistemology is characterized by a ‘yes/and’ mindset that expresses the dynamic and generative relationship between forms of knowledge which reflects complexity that characterizes nursing. (shrink)

There has been little previous research regarding the effectiveness of ethics education interventions for residential care‐givers. The Researching Interventions to Promote Ethics in social care project responded to the question: Which is the most effective ethics education intervention for care‐givers in residential social care? A pragmatic cluster trial explored the impact of three ethics education interventions for: (a) interactive face‐to‐face ethics teaching; (b) reflective ethics discussion groups; and (c) an immersive simulation experience. There was also a control arm (d). (...) 144 trial participants were recruited from 39 residential care homes for older people in southern England. Change scores compared across intervention arms showed a significant reduction in work‐related moral stress in the teaching arm compared with control group (p =.03); there were no significant differences between control and intervention arms in change scores for moral sensitivity, interpersonal reactivity (empathy) or ethical leadership. Qualitative data themes were as follows: ethical care; care challenges; and ethical care inhibitors. Overall findings stimulate reflection on the value of three different ethics education interventions and the most appropriate means to evaluate their impact. Findings suggest the complexity and diverse nature of ethical competence in care. We suggest a way forward for research evaluating ethics education. (shrink)

The conditional intervention principle is a formal principle that relates patterns of interventions and outcomes to causal structure. It is a central assumption of the causal Bayes net formalism. Four experiments suggest that preschoolers can use the conditional intervention principle both to learn complex causal structure from patterns of evidence and to predict patterns of evidence from knowledge of causal structure. Other theories of causal learning do not account for these results.

During the last few decades we have witnessed a proliferation of exercises dealing with the public participation of citizens in various different dimensions of their societies, including issues of science and technology. On the one hand, these mechanisms provide more robust forms of public engagement with matters that were traditionally dealt with by experts; on the other hand, they raise concerns relating to their design, efficiency or potential for the empowerment of citizens. As part of the EC-funded project DEEPEN (Deepening (...) Ethical Engagement and Participation in Emerging Nanotechnologies) a research team in Coimbra, Portugal, was put in charge of identifying the ethical and social “impacts” of emerging nanotechnologies, transforming the traditional focus groups through the incorporation of two methodological innovations: the Pedagogy of the Oppressed and the Theatre of the Oppressed. This article reflects on the outcomes and complexities of the introduction of these two methodologies. Since the participants had little or no information on nanotechnologies, we reflect on the politics of these focus groups by exploring how issues of intervention, subjectivity, representation and agency were interconnected during this exercise of public participation in Science and Technology, analyzing the role of social sciences in developing nanoethics. (shrink)