Background Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians’ decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients’ ability to comprehend (...) complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored. Methods Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents’ perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test. Results Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient’s AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to “pass away in peace.” Few (17%) would forgo an AD following a family’s request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD. Conclusions Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient’s initial wishes and preferences expressed by the AD. (shrink)

Background Regarding controversial medical services, many have argued that if physicians cannot in good conscience provide a legal medical intervention for which a patient is a candidate, they should refer the requesting patient to an accommodating provider. This study examines what US physicians think a doctor is obligated to do when the doctor thinks it would be immoral to provide a referral. Method The authors conducted a cross-sectional survey of a random sample of 2000 US physicians from all specialties. The (...) primary criterion variable was agreement that physicians have a professional obligation to refer patients for all legal medical services for which the patients are candidates, even if the physician believes that such a referral is immoral. Results Of 1895 eligible physicians, 1032 (55%) responded. 57% of physicians agreed that doctors must refer patients regardless of whether or not the doctor believes the referral itself is immoral. Holding this opinion was independently associated with being more theologically pluralistic, describing oneself as sociopolitically liberal, and indicating that respect for patient autonomy is the most important bioethical principle in one's practice (multivariable ORs, 1.6–2.4). Conclusions Physicians are divided about a professional obligation to refer when the physician believes that referral itself is immoral. These data suggest there is no uncontroversial way to resolve conflicts posed when patients request interventions that their physicians cannot in good conscience provide. (shrink)

Starting with The Calculus of Consent James M. Buchanan published many books and articles emphasizing the importance of constitutional institutions and the promise of constitutional reforms. In this chapter I review some of these publications. The review begins with The Calculus, and then goes on to The Limits of Liberty, The Power to Tax, The Reason of Rules, Politics by Principle, Not Reason, and essays about the importance of constitutions in the European Union. The chapter closes with discussions of the (...) prospects of and impediments to constitutional reform in the United States and the European Union. (shrink)

In his critical study of Speusippus Leonardo Tarán (T.) expounds an interpretation of a considerable part of the controversial books M and N of Aristotle's Metaphysics. In this essay I want to consider three aspects of the interpretation, the account of Plato's ‘ideal numbers’ (section I), the account of Speusippus’ mathematical ontology (section II), and the account of the principles of that ontology (section III). T. builds his interpretation squarely on the work of Harold Cherniss (C.), to whom I will (...) also refer. I concentrate on T. because he has brought the ideas in which I am interested together and given them a concise formulation; he is also meticulous in indicating the secondary sources with which he agrees or disagrees, so that anyone interested in pursuing particular points can do so easily by consulting his book. (shrink)

In his own writings, Rawls purposively used only a loose characterization of the basic structure, but two prominent misinterpretations highlight the current need for a more detailed account. First, G.A. Cohen argues that the Rawlsian focus on the basic structure is arbitrary due to the Rawlsian appeal to profound effects. Second, some theorists conflate the justification of coercion with the assessment of a basic structure by defining the basic structure as the coercive structure. Both misinterpretations can be corrected by carefully (...) specifying what social institutions are and explaining which social institutions come together to form the basic structure of society. (shrink)

Features include a comprehensive review of existing material, combined with new perspectives to equip students for the challenges in the work environment; chapter overviews and student learning objectives offer a solid and useful framework in which to organise study; diagrams and charts present overviews and contexts for the subject to act as useful revision aids; effective pedagogy including a review of the arguments considered, a menu of seminar topics, and questions in every chapter, serving as an ideal basis for seminar (...) study; and additional open-ended simulations to allow students to work through unfolding scenarios. (shrink)

The dominant conventionalist view explains the wrong of breaking a promise as failing to do our fair share in supporting the practice of promise-keeping. Yet, this account fails to explain any unique moral standing that a promisee has to demand that the promisor keep the promise. In this paper, I provide a conventionalist response to this problem. In any cooperative practice, participants stand as both beneficiary and contributor. As a beneficiary, they are morally required to follow the rules of the (...) practice. As a contributor, they have claims on other participants to follow the rules. According to the rules of promise-keeping, a promisee has a unique claim on the promisor, and the personal wrong of breaking a promise should be understood as the violation of this unique and practice-dependent claim. (shrink)

Undercover filming is a method commonly used by animal activist groups to expose animal cruelty and it is important to consider the effects of publically releasing video footage of cruel practices on the viewers’ mental health. Previously, we reported that members of the Australian public were emotionally distressed soon after viewing media broadcasts of cruelty to Australian cattle exported for slaughter in Indonesia in 2011. To explore if there were any long term impacts from exposure to media on this issue, (...) a self-selecting group of 15 people who were exposed to a documentary exposé of the cruelty were re-interviewed 12 months later. Nearly all recalled their strong initial reaction to the footage. Approximately one half of the respondents who initially had had a strong emotional reaction to the footage reported negative reactions that were still strong even after this period of time. They reported potential triggers for these feelings. Of the rest, some managed to internalise their feelings. Approximately one half of respondents were unaware of continued live export exposés, suggesting less prominent media coverage. Despite the aversion and repulsion reported after viewing the initial coverage, most respondents said they would choose to watch another broadcast of animal cruelty and nearly all supported undercover investigations as a means of revealing cruelty to animals. We conclude that many people viewing footage of cruelty to animals will have long term memory of this, but that they would prefer to be informed about the issues and not be protected from them. (shrink)

Most liberals agree that governments should protect certain basic liberties, such as freedom of speech, freedom of religion and freedom of the person. Liberals disagree, however, about whether free market rights should also be protected. By “free market rights,” we mean those rights typically associated with laissez-faire economic systems such as freedom of contract, a right to market returns, and claims to privately own the means of production.We do not use the phrase “economic liberties,” as Tomasi does, because it does (...) not distinguish between the “economic rights” defended by classical liberal and those defended by socialists. Those on the right often see such freedoms as core liberal commitments, while those on the left argue that an economic system should be organized to protect the interests of the less advantaged members of society. If free market rights should be protected, then most existing societies are unjust. These societies fail the liberal standard in the same ways as th .. (shrink)

Theories of truth and vagueness are closely connected; in this article, I draw another connection between these areas of research. Gupta and Belnap’s Revision Theory of Truth is converted into an approach to vagueness. I show how revision sequences from a general theory of definitions can be used to understand the nature of vague predicates. The revision sequences show how the meaning of vague predicates are interconnected with each other. The approach is contrasted with the similar supervaluationist approach.

As the frequency of internet-based research has increased, it is important for researchers to consider how the conditions in which data are collected may influence the risks to participants. In particular, because internet-based data collection often occurs outside a clinical or research setting, there may be unintentional disclosures of a participant's involvement in a research study of which the researcher is unaware. The current analysis examined the responses of men who have sex with men participating in an internet-based HIV behavioural (...) risk study when queried about the possible disclosure of their participation in the study. Fewer than 2% of participants indicated that their participation in the research study was disclosed, and all but one indicated no negative outcomes associated with the disclosure. As the field of online research continues to expand, it is important to consider risks that are unique to internet-based research, and to monitor these risks to ensure that the confidentiality of research subjects is maintained. (shrink)

In E.N. I. c. 5 Aristotle is considering divers views as to what constitutes Eudaimonia. He told us in c. 4, 2–3 that there are many conflicting opinions on the subject. The Many identify Happiness with some palpable good, such as pleasure, wealth, honour, but the Wise identify it with something beyond the Many, while [Plato] denied it to be any specific good at all. Of all these views we should consider such as have many adherents or are considered to (...) be reasonable. Accordingly, the Universal Good is considered in c. 6 after consideration in c. 5 of five particular goods—pleasure in the form of bodily pleasure, honour, wealth, virtue [and, implied in the theoretic Life, wisdom]. These five goods are brought into relation with four Lives—viz. pleasure with the apolaustic; honour and virtue with the political; [wisdom] with the theoretic; wealth with the business or money-making Life; and the first three Lives are called προέχοντες. There is nothing in this introduction of the Lives to astonish us; for, as Aristotle himself tells us, τò ληθς ν τοȋς πρακτικοȋς κ τν ργων κα τοû βίου κρίνεται . But there is much difference of opinion as to the argument he draws from the Lives. According to the view now submitted for consideration, the argument is that when a specific good, which some suppose to be Eudaimonia, is also the end of a ‘pre-eminent’ Life, then there is some prima facie probability in the view that that specific good is Eudaimonia. (shrink)

Recent evaluation of the practice of euthanasia and related medical decisions at the end of life in the Netherlands has shown a slight decrease in the frequency of physician-assisted death since the enactment of the Euthanasia Law in 2002. This paper focuses on the absence of euthanasia cases concerning patients with dementia and a written advance euthanasia directive, despite the fact that the only real innovation of the Euthanasia Law consisted precisely in allowing physicians to act upon such directives. The (...) author discusses two principal reasons for this absence. One relates to the uncertainty about whether patients with advanced dementia truly experience the suffering they formerly feared. There is reason to assume that they don’t, as a consequence of psychological adaptation and progressive unawareness (anosognosia). The second, more fundamental reason touches upon the ethical relevance of shared understanding and reciprocity. The author argues that, next to autonomy and mercifulness, “reciprocity” is a condition sine qua non for euthanasia. The absence thereof in advanced dementia renders euthanasia morally inconceivable, even if there are signs of suffering and notwithstanding the presence of an advance euthanasia directive. This does not mean, however, that advance euthanasia directives of patients with dementia are worthless. They might very well have a role in the earlier stages of certain subtypes of the disease. To illustrate this point the author presents a case in which the advance directive helped to create a window of opportunity for reciprocity and shared decision-making. (shrink)

In The Tyranny of the Ideal, Gerald Gaus gives an extended argument on behalf of the “Open Society.” Instead of claiming that it is uniquely best from some privileged moral perspective, he argues for the Open Society by showing why it is acceptable to many perspectives. In this way, Gaus argues for a liberal market-based society in a way that treats deep diversity as a fundamental feature of social life. However, the argument falters at four important points. When taken together, (...) these four problems significantly limit the significance of Gaus’s conclusions. (shrink)

Fractal time fluctuations of the spectral “1/f” form are universal in natural self-organizing systems. Neurobiology is uniquely infused with fractal fluctuations in the form of statistically self-similar clusters or bursts on all levels of description from molecular events such as protein chain fluctuations, ion channel currents and synaptic processes to the behaviors of neural ensembles or the collective behavior of Internet users. It is the thesis of this essay that the brain self-organizes via a vertical collation of these spontaneous events (...) in order to perceive the world and generate adaptive behaviors. REM sleep, which coalesces from self-similar clusters of burst-within-burst behavior during ontogeny, is essential to cognitive-emotional function, and has recurrent fractal organization. Empirical fMRI observations further support the association of fractal fluctuations in the temporal lobes, brainstem and cerebellum during the expression of emotional memory, spontaneous fluctuations of thought and meditative practice. Cognitive-emotional integration arises as amygdaloid-brainstem-cerebellar systems harmonize the vertical “1/f” symphony of coupled isochronous cortical oscillations in the pursuit of mindfulness. (shrink)

Understanding risk factors for relationship dissolution and poor relationship adjustment among couples has been an active area of research in relationship science. One risk factor, non-marital cohabitation, has shown to predict higher rates of relationship dissolution and relationship instability in some samples, but the associations among German parents with children over time are less clear. In this study, we examined the links between non-marital cohabitation and 10-year outcomes in 220 German families with preschool-aged children at the initial assessment followed into (...) adolescence. Families were assessed 7 times over the 10 years and retention at the 10-year follow-up was over 92%. After accounting for multiple testing, only mother’s report of better initial interparental communication predicted whether parents were likely to stay together over the course of the 10 years. Adolescents of parents who cohabited were at higher risk for externalizing symptoms 10 years later compared to children of married parents. In addition, although there were no differences between cohabiting couples and married couples at the initial assessment in relationship adjustment, cohabiting mothers who stayed with their partner over the 10 years showed significantly greater declines in relationship adjustment over the 10 years compared to married mothers. Findings indicate the need for further research that explores family structure and dynamics over time to inform refinement of prevention programs targeting relationships and children’s mental health. (shrink)

Among the scanty remains of poetry attributed to Eumelus of Corinth two lines 2 stand out as different from the rest, first because they are concerned not with the legendary past but with an actual, present occasion, and secondly because they are composed not for Corinthians but for Messenians. Our evidence comes from Pausanias and may be set out at the start.

The optimal design of cables under selfweight and concentrated loads is considered and the maximum feasible span for a given permissible stress is evaluated. All solutions are obtained in a closed analytical form.

When a man attempts to combat the principle of utility, it is with reasons drawn, without his being aware of it, from that very principle itself. His arguments, if they prove anything, prove not that the principle is wrong, but that, according to the applications he supposes to be made of it, it is misapplied.