This study investigates the performance of psychopathic individuals on tasks believed to be sensitive to dorsolateral prefrontal and orbitofrontal cortex (OFC) functioning. Psychopathic and non-psychopathic individuals, as defined by the Hare psychopathy checklist revised (PCL-R) [Hare, The Hare psychopathy checklist revised, Toronto, Ontario: Multi-Health Systems, 1991] completed a gambling task [Cognition 50 (1994) 7] and the intradimensional/extradimensional (ID/ED) shift task [Nature 380 (1996) 69]. On the gambling task, psychopathic participants showed a global tendency to choose disadvantageously. Specifically, they showed an (...) impaired ability to show learning over the course of the task. On the ID/ED task, the performance of psychopathic individuals was not significantly different from incarcerated controls on attentional set-shifting, but significant impairments were found on response reversal. These results are interpreted with reference to an OFC and amygdala dysfunction explanation of psychopathy. (shrink)

Un travail de terrain ethnographique dans un grand tribunal pour enfants de la région parisienne sur la décision d’incarcérer des mineurs, fait apparaître l’utilisation de critères stricts qui réduit considérablement la prise en compte de la personnalité et de l’histoire des jeunes infracteurs placés en détention provisoire. Ainsi débarrassée de l’adolescent, la décision d’incarcération devient facilement l’objet de positionnements identitaires des magistrats. Derrière les motivations officielles se cachent en effet toujours des motifs d’ordre relationnel, des défenses de position (...) et d’identité entre les substituts et les juges pour enfants. Lorsqu’ils décident ou non d’incarcérer un mineur, les magistrats mobilisent donc moins leur sens du bon et du juste envers l’adolescent et son infraction, qu’ils ne s’engagent à partir des constructions identitaires qui leur permettent de se situer à l’intérieur de leur corps. Dès lors, la personne qui compte est moins le jeune infracteur que le magistrat qui décide de son destin. Ce qui va à l’encontre du principe phare de l’Ordonnance de 1945 qui régit la justice des mineurs, et recommande avant tout la prise en compte de la « personnalité » du mineur.Fieldwork in a major juvenile court in the Paris area shows how the use of strict incarceration criteria considerably reduces the possibility for taking into account a young offender’s personality and past. The decision to incarcerate, by getting rid of the youth, soon becomes the grounds on which magistrates and public prosecutors make a stand that expresses their own identity. Behind official motivations are rationales of a relational sort that lead prosecutors and magistrates to defend current positions and identities. When deciding whether or not to incarcerate a minor, judges use their sense of what is right and just toward the adolescent in light of his offense ; but they do so by referring to a sense of identity whereby they position themselves within their occupational corps. As a consequence, the person who counts is not so much the juvenile offender as the magistrate who decides his fate. This does not comply with the key principle of the Ordinance of 1945, which instituted juvenile justice and recommends that, above all, the minor’s personality be taken under consideration. (shrink)

Psychopathy is a disorder characterized by severe and frequent moral violations in multiple domains of life. Numerous studies have shown psychopathy-related limbic brain abnormalities during moral processing; however, these studies only examined negatively valenced moral stimuli. Here, we aimed to replicate prior psychopathy research on negative moral judgments and to extend this work by examining psychopathy-related abnormalities in the processing of controversial moral stimuli and positive moral processing. Incarcerated adult males (N = 245) completed a functional magnetic resonance imaging protocol (...) on a mobile imaging system stationed at the prison. Psychopathy was assessed using the Hare Psychopathy Checklist–Revised (PCL-R). Participants were then shown words describing three types of moral stimuli: wrong (e.g., stealing), not wrong (e.g., charity), and controversial (e.g., euthanasia). Participants rated each stimulus as either wrong or not wrong. PCL-R total scores were correlated with not wrong behavioral responses to wrong moral stimuli, and were inversely related to hemodynamic activity in the anterior cingulate cortex in the contrast of wrong > not wrong. In the controversial > noncontroversial comparison, psychopathy was inversely associated with activity in the temporal parietal junction and dorsolateral prefrontal cortex. These results indicate that psychopathy-related abnormalities are observed during the processing of complex, negative, and positive moral stimuli. (shrink)

Games and Decision Making, Second Edition, is a unique blend of decision theory and game theory. From classical optimization to modern game theory, authors Charalambos D. Aliprantis and Subir K. Chakrabarti show the importance of mathematical knowledge in understanding and analyzing issues in decision making. Through an imaginative selection of topics, Aliprantis and Chakrabarti treat decision and game theory as part of one body of knowledge. They move from problems involving the individual decision-maker to progressively more complex problems such as (...) sequential rationality, auctions, and bargaining. By building each chapter on material presented earlier, the authors offer a self-contained and comprehensive treatment of these topics. Successfully class-tested in an advanced undergraduate course at the Krannert School of Management and in a graduate course in economics at Indiana University, Games and Decision Making, Second Edition, is an essential text for advanced undergraduates and graduate students of decision theory and game theory. The book is accessible to students who have a good basic understanding of elementary calculus and probability theory. (shrink)

We present a theory of decision by sampling (DbS) in which, in contrast with traditional models, there are no underlying psychoeconomic scales. Instead, we assume that an attribute’s subjective value is constructed from a series of binary, ordinal comparisons to a sample of attribute values drawn from memory and is its rank within the sample. We assume that the sample reflects both the immediate distribution of attribute values from the current decision’s context and also the background, real-world distribution of attribute (...) values. DbS accounts for concave utility functions; losses looming larger than gains; hyperbolic temporal discounting; and the overestimation of small probabilities and the underestimation of large probabilities. Ó 2005 Elsevier Inc. All rights reserved. (shrink)

Every one of us will die, and the processes we go through will be our own - unique to our own experiences and life stories. End-of-Life Care and Pragmatic Decision Making provides a pragmatic philosophical framework based on a radically empirical attitude toward life and death. D. Micah Hester takes seriously the complexities of experiences and argues that when making end-of-life decisions, healthcare providers ought to pay close attention to the narratives of patients and the communities they inhabit so that (...) their dying processes embody their life stories. He discusses three types of end-of-life patient populations - adults with decision-making capacity, adults without capacity, and children - to show the implications of pragmatic empiricism and the scope of decision making at the end of life for different types of patients. (shrink)

This book grew out of previously published papers of mine composed over a period of years; they have been reworked (sometimes beyond recognition) so as to form a reasonably coherent whole. Part One treats of informative inference. I argue (Chapter 2) that the traditional principle of induction in its clearest formulation (that laws are confirmed by their positive cases) is clearly false. Other formulations in terms of the 'uniformity of nature' or the 'resemblance of the future to the past' seem (...) to me hopelessly unclear. From a Bayesian point of view, 'learning from experience' goes by conditionalization (Bayes' rule). The traditional stum bling block for Bayesians has been to fmd objective probability inputs to conditionalize upon. Subjective Bayesians allow any probability inputs that do not violate the usual axioms of probability. Many subjectivists grant that this liberality seems prodigal but own themselves unable to think of additional constraints that might plausibly be imposed. To be sure, if we could agree on the correct probabilistic representation of 'ignorance' (or absence of pertinent data), then all probabilities obtained by applying Bayes' rule to an 'informationless' prior would be objective. But familiar contra dictions, like the Bertrand paradox, are thought to vitiate all attempts to objectify 'ignorance'. BuUding on the earlier work of Sir Harold Jeffreys, E. T. Jaynes, and the more recent work ofG. E. P. Box and G. E. Tiao, I have elected to bite this bullet. In Chapter 3, I develop and defend an objectivist Bayesian approach. (shrink)

This book argues that the othering and criminalization of Black people in times of crisis is part of the religious meaning of America that fuels the problem of mass incarceration. The author develops a religious interpretation of the significance of these images to America’s political economy the produces the very problems we punish as a society.

This study examines the use of a modified form of the theory of planned behavior in understanding the decisions of undergraduate students in engineering and humanities to engage in cheating. We surveyed 527 randomly selected students from three academic institutions. Results supported the use of the model in predicting ethical decision-making regarding cheating. In particular, the model demonstrated how certain variables (gender, discipline, high school cheating, education level, international student status, participation in Greek organizations or other clubs) and moral constructs (...) related to intention to cheat, attitudes toward cheating, perceptions of norms with respect to cheating, and ultimately cheating behaviors. Further the relative importance of the theory of planned behavior constructs was consistent regardless of context, whereas the contributions of variables included in the study that were outside the theory varied by context. Of particular note were findings suggesting that the extent of cheating in high school was a strong predictor of cheating in college and that engineering students reported cheating more frequently than students in the humanities, even when controlling for the number of opportunities to do so. (shrink)

Decision-making assisted by algorithms developed by machine learning is increasingly determining our lives. Unfortunately, full opacity about the process is the norm. Would transparency contribute to restoring accountability for such systems as is often maintained? Several objections to full transparency are examined: the loss of privacy when datasets become public, the perverse effects of disclosure of the very algorithms themselves, the potential loss of companies’ competitive edge, and the limited gains in answerability to be expected since sophisticated algorithms usually are (...) inherently opaque. It is concluded that, at least presently, full transparency for oversight bodies alone is the only feasible option; extending it to the public at large is normally not advisable. Moreover, it is argued that algorithmic decisions preferably should become more understandable; to that effect, the models of machine learning to be employed should either be interpreted ex post or be interpretable by design ex ante. (shrink)

Corporate social responsibility, sustainability and acting ethically are all accepted business aims, but their meaning and implementation in a global context is far less clear-cut. Global Business Ethics cuts through the confusion to provide a coherent basis for ethical decision-making within the complications of the international business landscape. Underpinned by theory and including worked-through examples of ethical dilemmas and their solutions, this textbook will guide the reader beyond theory to real-world business decisions. Practical tools such as decision trees and suggested (...) principles to apply in dilemma situations give readers the skills and confidence to tackle the ethical challenges they face. A unique working code of ethics is provided as a model with guidance to readers for adaptation and implementation. Case studies include: Walmart, Hershey's, Citibank, Ford, Nike, Johnson & Johnson, Harley- Davidson, The Body Shop and Procter and Gamble. A chapter on the legal aspects of ethics provides clear guidance on the complex relationship between law and ethics in international business. The final part takes an in-depth look at the practical application of ethics in business life. Covering all the major theories of ethics, including an examination of the role of quantification of ethics, Global Business Ethics demonstrates how their principles can be applied to inform better business decisions. (shrink)

Although case-based training is popular for ethics education, little is known about how specific case content influences training effectiveness. Therefore, the effects of (a) codes of ethical conduct and (b) forecasting content were investigated. Results revealed richer cases, including both codes and forecasting content, led to increased knowledge acquisition, greater sensemaking strategy use, and better decision ethicality. With richer cases, a specific pattern emerged. Specifically, content describing codes alone was more effective when combined with short-term forecasts, whereas content embedding codes (...) within context was more effective when combined with long-term forecasts, leading to greater knowledge acquisition and sensemaking strategy use. (shrink)

D. A. Lloyd Thomas; VIII—Political Decision Procedures1, Proceedings of the Aristotelian Society, Volume 70, Issue 1, 1 June 1970, Pages 141–160, https://doi.or.

Psychologists have a long tradition of studying human behavior, strengths and weaknesses, biases and limitations. Economists have constructed normative frameworks that capture the most important elements of human decision-making and developed powerful tools to determine individual and strategic choices in a variety of situations. Only recently have their strengths been combined and economic models enriched with key ingredients found in psychological studies.This volume covers four of the most important themes in this interdisciplinary field: feelings, inconsistencies, limitations and biases. Each chapter (...) contributes to a more comprehensive and accurate modelling and description of human behavior. Its four parts cover: the origins, formation, and evolution of beliefs; consistency, commitment, and intertemporal separability of dynamic choices; attention, preference formation, and risk evaluation in limited cognition; and affective behaviour, specifically the role of emotions in decision making. (shrink)

Based on the institutional theory, this article attempts to examine two consecutive questions regarding the impact of various factors on corporate decision in environmental information disclosure (EID): (1) whether or not to disclose; and (2) the level of disclosure. The relevance of these factors is empirically tested using data collected from publicly listed manufacturing companies from 2006 to 2008 in China. Some interesting findings appear. We find that firms that are state-owned, those that operate in environmentally sensitive industries, those having (...) more industrial peers engaged in EID, and those with better reputation are more likely to disclose environmental information. When it comes to the content of EID, variables that attempt to capture external institutional pressures exhibit either no or weak explanatory power. Only the variable of organizational image and reputation is demonstrated to have a significant impact on both the act and the content of EID. This study provides a snapshot of the dialogues between constituencies in the organizational field and EID development. (shrink)

Phase 1 healthy volunteer clinical trials—which financially compensate subjects in tests of drug toxicity levels and side effects—appear to place pressure on each joint of the moral framework justifying research. In this article, we review concerns about phase 1 trials as they have been framed in the bioethics literature, including undue inducement and coercion, unjust exploitation, and worries about compromised data validity. We then revisit these concerns in light of the lived experiences of serial participants who are income-dependent on phase (...) 1 trials. We show how participant experiences shift attention from discrete exchanges, behaviors, and events in the research enterprise to the ongoing and dynamic patterns of serial participation in which individual decision-making is embedded in collective social and economic conditions and shaped by institutional policies. We argue in particular for the ethical significance of structurally diminished voluntariness, routine powerlessness in setting the terms of exchange, and incentive structures that may promote pharmaceutical interests but encourage phase 1 healthy volunteers to skirt important rules. (shrink)

Integrating large language models (LLMs) like GPT-4 into medical ethics is a novel concept, and understanding the effectiveness of these models in aiding ethicists with decision-making can have significant implications for the healthcare sector. Thus, the objective of this study was to evaluate the performance of GPT-4 in responding to complex medical ethical vignettes and to gauge its utility and limitations for aiding medical ethicists. Using a mixed-methods, cross-sectional survey approach, a panel of six ethicists assessed LLM-generated responses to eight (...) ethical vignettes.The main outcomes measured were relevance, reasoning, depth, technical and non-technical clarity, as well as acceptability of GPT-4’s responses. The readability of the responses was also assessed. Of the six metrics evaluating the effectiveness of GPT-4’s responses, the overall mean score was 4.1/5. GPT-4 was rated highest in providing technical (4.7/5) and non-technical clarity (4.4/5), whereas the lowest rated metrics were depth (3.8/5) and acceptability (3.8/5). There was poor-to-moderate inter-rater reliability characterised by an intraclass coefficient of 0.54 (95% CI: 0.30 to 0.71). Based on panellist feedback, GPT-4 was able to identify and articulate key ethical issues but struggled to appreciate the nuanced aspects of ethical dilemmas and misapplied certain moral principles.This study reveals limitations in the ability of GPT-4 to appreciate the depth and nuanced acceptability of real-world ethical dilemmas, particularly those that require a thorough understanding of relational complexities and context-specific values. Ongoing evaluation of LLM capabilities within medical ethics remains paramount, and further refinement is needed before it can be used effectively in clinical settings. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

An expert on ethical issues offers straightforward, easy-to-follow advice on how to handle difficult and complex situations at work, in relationships, and in everyday life, presenting a four-step program designed to help readers make the best decisions possible. Original.

The right to refuse medical intervention is well established, but it remains unclear how best to respect and exercise this right in life support. Contemporary ethical guidelines for critical care give ambiguous advice, largely because they focus on the moral equivalence of withdrawing and withholding care without confronting the very real differences regarding who is aware and informed of intervention options and how patient values are communicated and enacted. In withholding care, doctors typically withhold information about interventions judged too futile (...) to offer. They thus retain greater decision-making burden and face weaker obligations to secure consent from patients or proxies. In withdrawing care, there is a clearer imperative for the doctor to include patients in decisions, share information and secure consent, even when continued life support is deemed futile. How decisions to withhold and withdraw life support differ ethically in their implications for positive versus negative interpretations of patient autonomy, imperatives for consent, definitions of futility and the subjective evaluation of benefits and burdens of life support in critical care settings are explored. Professional reflection is required to respond to trends favouring a more positive interpretation of patient autonomy in the context of life support decisions in critical care. Both the bioethics and critical care communities should investigate the possibilities and limits of growing pressure for doctors to disclose their reasoning or seek patient consent when decisions to withhold life support are made. (shrink)

In spite of the wide variety of approaches to ethics training it is still debatable which approach has the highest potential to enhance professionals’ integrity. The current effort assesses a novel curriculum that focuses on metacognitive reasoning strategies researchers use when making sense of day-to-day professional practices that have ethical implications. The evaluated trainings effectiveness was assessed by examining five key sensemaking processes, such as framing, emotion regulation, forecasting, self-reflection, and information integration that experts and novices apply in ethical decision-making. (...) Mental models of trained and untrained graduate students, as well as faculty, working in the field of physical sciences were compared using a think-aloud protocol 6 months following the ethics training. Evaluation and comparison of the mental models of participants provided further validation evidence for sensemaking training. Specifically, it was found that trained students applied metacognitive reasoning strategies learned during training in their ethical decision-making that resulted in complex mental models focused on the objective assessment of the situation. Mental models of faculty and untrained students were externally-driven with a heavy focus on autobiographical processes. The study shows that sensemaking training has a potential to induce shifts in researchers’ mental models by making them more cognitively complex via the use of metacognitive reasoning strategies. Furthermore, field experts may benefit from sensemaking training to improve their ethical decision-making framework in highly complex, novel, and ambiguous situations. (shrink)

Introduction: In The Netherlands, physicians have to be convinced that the patient suffers unbearably and hopelessly before granting a request for euthanasia. The extent to which general practitioners (GPs), consulted physicians and members of the euthanasia review committees judge this criterion similarly was evaluated. Methods: 300 GPs, 150 consultants and 27 members of review committees were sent a questionnaire with patient descriptions. Besides a “standard case” of a patient with physical suffering and limited life expectancy, the descriptions included cases in (...) which the request was mainly rooted in psychosocial or existential suffering, such as fear of future suffering or dependency. For each case, respondents were asked whether they recognised the case from their own practice and whether they considered the suffering to be unbearable. Results: The cases were recognisable for almost all respondents. For the “standard case” nearly all respondents were convinced that the patient suffered unbearably. For the other cases, GPs thought the suffering was unbearable less often (2–49%) than consultants (25–79%) and members of the euthanasia review committees (24–88%). In each group, the suffering of patients with early dementia and patients who were “tired of living” was least often considered to be unbearable. Conclusions: When non-physical aspects of suffering are central in a euthanasia request, there is variance between and within GPs, consultants and members of the euthanasia committees in their judgement of the patient’s suffering. Possible explanations could be differences in their roles in the decision-making process, differences in experience with evaluating a euthanasia request, or differences in views regarding the permissibility of euthanasia. (shrink)

We present a novel variant of decision making based on the mathematical theory of separable Hilbert spaces. This mathematical structure captures the effect of superposition of composite prospects, including many incorporated intentions, which allows us to describe a variety of interesting fallacies and anomalies that have been reported to particularize the decision making of real human beings. The theory characterizes entangled decision making, non-commutativity of subsequent decisions, and intention interference. We demonstrate how the violation of the Savage’s sure-thing principle, known (...) as the disjunction effect, can be explained quantitatively as a result of the interference of intentions, when making decisions under uncertainty. The disjunction effects, observed in experiments, are accurately predicted using a theorem on interference alternation that we derive, which connects aversion-to-uncertainty to the appearance of negative interference terms suppressing the probability of actions. The conjunction fallacy is also explained by the presence of the interference terms. A series of experiments are analyzed and shown to be in excellent agreement with a priori evaluation of interference effects. The conjunction fallacy is also shown to be a sufficient condition for the disjunction effect, and novel experiments testing the combined interplay between the two effects are suggested. (shrink)

Background Informed consent is an integral component of good medical practice. Many researchers have investigated measures to improve the quality of informed consent, but it is not clear which techniques work best and why. To address this problem, we propose developing a core outcome set to evaluate interventions designed to improve the consent process for surgery in adult patients with capacity. Part of this process involves reviewing existing research that has reported what is important to patients and doctors in the (...) informed consent process. Methods This qualitative synthesis comprises four phases: identification of published papers and determining their relevance; appraisal of the quality of the papers; identification and summary of the key findings from each paper while determining the definitiveness of each finding against the primary data; comparison of key themes between papers such that findings are linked across studies. Results Searches of bibliographic databases returned 11,073 titles. Of these, 16 studies met the inclusion criteria. Studies were published between 1996 and 2016 and included a total of 367 patients and 74 health care providers. Thirteen studies collected data using in-depth interviews and constant comparison was the most common means of qualitative analysis. A total of 94 findings were extracted from the primary papers and divided into 17 categories and ultimately 6 synthesised findings related to: patient characteristics, knowledge, communication, the model patient, trust and decision making. Conclusions This qualitative meta-aggregation is the first to examine the issue of informed consent for surgery. It has revealed several outcomes deemed important to capture by patients and clinicians when evaluating the quality of a consent process. Some of these outcomes have not been examined previously in research comparing methods for informed consent. This review is an important step in the development of a COS to evaluate interventions designed to improve the consent process for surgery. Registration The study protocol was registered on the international prospective register for systematic reviews. (shrink)

Background While there are many guidelines on how to make ethical decisions at the end of life, there is little evidence regarding the quality of this sort of ethical guidelines. Objectives First, this study aims to demonstrate the conceptual transferability of the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument for the quality assessment of ethical guidelines. Second, it aims to illustrate the status quo of the quality of guidelines on end-of-life decision-making by using the AGREE instrument in a (...) first practice test. Method The transferability of the AGREE instrument on the quality assessment of ethical guidelines is demonstrated by conceptual analysis. Guidelines on end-of-life decisions in medicine are identified through a systematic search in MEDLINE (from June 1999 to June 2009). The quality of all included guidelines was assessed with a slightly modified AGREE instrument. Results Of 103 guidelines identified, 34 were included as relevant. The majority of the guidelines analysed in this study were assessed as qualitatively insufficient in five out of six AGREE quality domains. A few guidelines demonstrated, however, that a high level of quality in accordance with the AGREE requirements is possible. Conclusion This review concludes that the quality of many ethical guidelines should and can be improved in all quality domains specified by the AGREE instrument. Furthermore, conceptual analysis indicates that a slightly modified AGREE instrument is transferable to the comprehensive evaluation of the quality of ethical guidelines. Nevertheless, future research is needed to improve the assessment of the presentation of the guidelines' normative basis. (shrink)

Objectives: To analyse legislation and medical professional positions concerning the doctor’s role in assisted dying in western Europe, and to discuss their implications for doctors.Method: This paper is based on country-specific reports by experts from European countries where assisted dying is legalised , or openly practiced , or where it is illegal .Results: Laws on assisted dying in The Netherlands and Belgium are restricted to doctors. In principle, assisted suicide is not illegal in either Germany or Switzerland, but a doctor’s (...) participation in Germany would violate the code of professional medical conduct and might contravene of a doctor’s legal duty to save life. The Assisted Dying for the Terminally Ill Bill proposed in the UK in 2005 focused on doctors, whereas the Proposal on Assisted Dying of the Norwegian Penal Code Commission minority in 2002 did not.Professional medical organisations in all these countries except The Netherlands maintain the position that medical assistance in dying conflicts with the basic role of doctors. However, in Belgium and Switzerland, and for a time in the UK, these organisations dropped their opposition to new legislation. Today, they regard the issue as primarily a matter for society and politics. This “neutral” stance differs from the official position of the Royal Dutch Medical Association which has played a key role in developing the Dutch practice of euthanasia as a “medical end-of-life decision” since the 1970s.Conclusion: A society moving towards an open approach to assisted dying should carefully identify tasks to assign exclusively to medical doctors, and distinguish those possibly better performed by other professions. (shrink)

This is the second paper in a two-part series describing subject and family perspectives from the CENTURY-S (CENtral Thalamic Deep Brain Stimulation for the Treatment of Traumatic Brain InjURY-Safety) first-in-human invasive neurological device trial to achieve cognitive restoration in moderate to severe traumatic brain injury (msTBI). To participate, subjects were independently assessed to formally establish decision-making capacity to provide voluntary informed consent. Here, we report on post-operative interviews conducted after a successful trial of thalamic stimulation. All five msTBI subjects met (...) a pre-selected primary endpoint of at least a 10% improvement in completion time on Trail-Making-Test Part B, a marker of executive function. We describe narrative responses of subjects and family members, refracted against that success. Interviews following surgery and the stimulation trial revealed the challenge of adaptation to improvements in cognitive function and emotional regulation as well as altered (and restored) relationships and family dynamics. These improvements exposed barriers to social reintegration made relevant by recoveries once thought inconceivable. The study’s success sparked concerns about post-trial access to implanted devices, financing of device maintenance, battery replacement, and on-going care. Most subjects and families identified the need for supportive counseling to adapt to the new trajectory of their lives. (shrink)

The introduction of non-invasive prenatal testing in healthcare systems around the world offers an opportunity to reconsider funding policies for prenatal screening. In some countries with universal access healthcare systems, pregnant women and their partners are asked to pay for NIPT. In this paper, we discuss two important rationales for charging women for NIPT: to prevent increased uptake of NIPT and to promote informed choice. First, given the aim of prenatal screening, high or low uptake rates are not intrinsically desirable (...) or undesirable. Using funding policies to negatively affect uptake, however, is at odds with the aim of screening. Furthermore, copayment disproportionally affects those of lower socioeconomic status, which conflicts with justice requirements and impedes equal access to prenatal screening. Second, we argue that although payment models may influence pregnant women’s choice behaviours and perceptions of the relevance of NIPT, the copayment requirement does not necessarily lead to better-informed choices. On the contrary, external influences on women’s personal choices for or against prenatal screening should ideally be avoided. To improve informed decision-making, healthcare systems should instead invest in adequate non-directive, value-focused pretest counselling. This paper concludes that requiring copayments for NIPT in universal access healthcare systems fails to promote reproductive autonomy and is unfair. (shrink)

Background: Nursing students on clinical placements as part of their professional training are routinely faced with situations involving ethical conflicts. The initial act of perceiving a situation as causing an ethical dilemma is the result of both the students’ personal values, drawn from their culture and families, and of the professional knowledge and values that they have acquired through training and experience. Objectives: Nursing students’ experiences on clinical placements in primary care settings were investigated in order to identify situations that (...) they perceived as involving ethical conflict and describe the elements they took into consideration during their decision-making processes in these situations. Methods: The research design was qualitative descriptive case study. Around 50 students from three different intakes to a nursing degree answered a questionnaire and discussed it in focus groups. Ethical considerations: The study was designed in accordance with the principles guiding research with human beings and was approved by the Human Research Ethics Committee. Results: Synthesised into two principal axes: (a) ethical conflicts in primary care, linked with the domains of working processes, professional nursing ethics and human and social rights and (b) students’ decision-making processes – realisation, reflection and intervention. Conclusion: The student nurses saw themselves both as actors and spectators in situations involving ethical problems and demanding moral deliberation, demonstrating the ability to base their arguments soundly. They tended to emphasise the possibilities offered by dialogue and that different ethical values must be respected to find fair solutions to ethical problems. (shrink)

Physicians have developed a number of implicit and explicit approaches to complex medical decisions. Decision analysis is an explicit, quantitative method of clinical decision making that involves the separation of the probabilities of events from their relative values, or utilities. Its use can help physicians make difficult choices in a manner that promotes true patient participation. Decision analysis also provides a framework for the incorporation of data from multiple sources and for the assessment of the impact of uncertain data on (...) the final decision. Although this approach is imperfect, it represents a significant advance in clinical decision making. (shrink)

As thousands of healthy research participants are being included in small and large imaging studies, it is essential that dilemmas raised by the detection of incidental findings are adequately handled. Current ethical guidance indicates that pathways for dealing with incidental findings should be in place, but does not specify what such pathways should look like. Building on an interview study of researchers’ practices and perspectives, we identified key considerations for the set-up of pathways for the detection, management and communication of (...) incidental findings in imaging research. We conducted an interview study with a purposive sample of researchers at research facilities across the Netherlands. Based on a qualitative analysis of these interviews and on existing guidelines found in the literature, we developed a prototype ethical framework, which was critically assessed and fine-tuned during a two-day international expert meeting with bioethicists and representatives from large population-based imaging studies from the United Kingdom, Germany, Sweden and Belgium. Practices and policies for the handling of incidental findings vary strongly across the Netherlands, ranging from no review of research scans and limited feedback to research participants, to routine review of scans and the arrangement of clinical follow-up. Respondents felt that researchers do not have a duty to actively look for incidental findings, but they do have a duty to act on findings, when detected. The principle of reciprocity featured prominently in our interviews and expert meeting. We present an ethical framework that may guide researchers and research ethics committees in the design and/or evaluation of appropriate pathways for the handling of incidental findings in imaging studies. The framework consists of seven steps: anticipation of findings, information provision and informed consent, scan acquisition, review of scans, consultation on detected abnormalities, communication of the finding, and further clinical management and follow-up of the research participant. Each of these steps represents a key decision to be made by researchers, which should be justified not only with reference to costs and/or logistical considerations, but also with reference to researchers’ moral obligations and the principle of reciprocity. (shrink)

Ethical decision making measures are widely applied as the principal dependent variable used in studies of research integrity. However, evidence bearing on the internal and external validity of these measures is not available. In this study, ethical decision making measures were administered to 102 graduate students in the biological, health, and social sciences, along with measures examining exposure to ethical breaches and the severity of punishments recommended. The ethical decision making measure was found to be related to exposure to ethical (...) events and the severity of punishments awarded. The implications of these findings for the application of ethical decision making measures are discussed. (shrink)