In the face of mounting criticism against advance directives, we describe how a novel, computer-based decision aid addresses some of these important concerns. This decision aid, Making Your Wishes Known: Planning Your Medical Future , translates an individual's values and goals into a meaningful advance directive that explicitly reflects their healthcare wishes and outlines a plan for how they wish to be treated. It does this by (1) educating users about advance care planning; (2) helping individuals identify, clarify, and prioritize (...) factors that influence their decision-making about future medical conditions; (3) explaining common end-of-life medical conditions and life-sustaining treatment; (4) helping users articulate a coherent set of wishes with regard to advance care planning—in the form of an advance directive readily interpretable by physicians; and (5) helping individuals both choose a spokesperson, and prepare to engage family, friends, and health care providers in discussions about advance care planning. (shrink)

PurposeAdvance directives have been criticized for failing to help physicians make decisions consistent with patients’ wishes. This pilot study sought to determine if an interactive, computer-based decision aid that generates an advance directive can help physicians accurately translate patients’ wishes into treatment decisions.MethodsWe recruited 19 patient-participants who had each previously created an advance directive using a computer-based decision aid, and 14 physicians who had no prior knowledge of the patient-participants. For each advance directive, three physicians were randomly assigned to review (...) the advance directive and make five to six treatment decisions for each of six (potentially) end-of-life clinical scenarios.From the three individual physicians’ responses, a “consensus physician response” was generated for each treatment decision (total decisions = 32). This consensus response was shared with the patient whose advance directive had been reviewed, and she/he was then asked to indicate how well the physician translated his/her wishes into clinical decisions.ResultsPatient-participants agreed with the consensus physician responses 84 percent (508/608) of the time, including 82 percent agreement on whether to provide mechanical ventilation, and 75 percent on decisions about cardiopulmonary resuscitation (CPR).Across the six vignettes, patient-participants’ rating of how well physicians translated their advance directive into medical decisions was 8.4 (range = 6.5-10, where 1 = extremely poorly, and 10 = extremely well). Physicians’ overall rating of their confidence at accurately translating patients’ wishes into clinical decisions was 7.8 (range = 6.1-9.3, 1 = not at all confident, 10 = extremely confident).ConclusionFor simulated cases, a computer-based decision aid for advance care planning can help physicians more confidently make end-of-life decisions that patients will endorse. (shrink)

Mr. Galanas, an eighty‐six‐year‐old man, intentionally shot himself in the chest and abdomen. Surprisingly, the bullet damaged only his distal pancreas and part of his colon, requiring a diverting colostomy to prevent leakage of bowel fluids into his abdomen. After being admitted, he lies intubated in the intensive care unit awaiting surgery to repair his colon. He is responsive but does not demonstrate clear decision‐making capacity. He grudgingly accepts pain medications but refuses antibiotics and antidepressants. He has a living will (...) that gives his wife durable power of attorney and also explicitly states a desire to refuse all medical interventions if he is permanently unconscious or in an end‐stage condition. Mrs. Galanas reports frequent conversations in which her husband said he would not want to be sustained on life support. She also says that he often mentioned he would not want an ostomy bag—a likely, albeit temporary, outcome of the proposed surgery. His physicians are nervous about withholding medical interventions when Mr. Galanas's injury is the result of a suicide attempt and his prognosis is good. Should the care team surgically repair his injured colon, regardless of the patient's capacity, his advance directive, and his wife's statement that he would not want surgery or other life‐sustaining treatment? (shrink)

The adage “an ounce of prevention is worth a pound of cure” is widely used in healthcare settings and can be applied to the work of institutional clinical ethics committees. The model of clinical ethics consultation, however, is inherently reactive: a crisis or question emerges, and ethics experts are called to help. In an effort to employ a proactive component to the model of clinical ethics consultation (as well as to standardize our educational interventions), we developed ethics pocket cards. The (...) purpose of this article is to: (1) describe the rationale for using ethics pocket cards, (2) provide examples of our cards, and (3) begin a dialogue about the potential uses of ethics pocket cards. In doing so, we hope to explore how such portable, economical devices can advance the goals of ethics consultation as well as the educational aims of ethics committees. (shrink)

Background: Discussions about medical errors facilitate professional learning for physicians and may provide emotional support after an error, but little is known about physicians’ attitudes and practices regarding error discussions with colleagues.Methods: Survey of faculty and resident physicians in generalist specialties in Midwest, Mid-Atlantic and Northeast regions of the US to investigate attitudes and practices regarding error discussions, likelihood of discussing hypothetical errors, experience role-modelling error discussions and demographic variables.Results: Responses were received from 338 participants . In all, 73% of (...) respondents indicated they usually discuss their mistakes with colleagues, 70% believed discussing mistakes strengthens professional relationships and 89% knew at least one colleague who would be a supportive listener. Motivations for error discussions included wanting to learn whether a colleague would have made the same decision , wanting colleagues to learn from the mistake and wanting to receive support . Given hypothetical scenarios, most respondents indicated they would likely discuss an error resulting in no harm , minor harm or major harm . Fifty-seven percent of physicians had tried to serve as a role model by discussing an error and role-modelling was more likely among those who had previously observed an error discussion .Conclusions: Most generalist physicians in teaching hospitals report that they usually discuss their errors with colleagues, and more than half have tried to role-model discussions. However, a significant number of these physicians report that they do not usually discuss their errors and some do not know colleagues who would be supportive listeners. (shrink)

We report the identification of a recurrent, 520-kb 16p12.1 microdeletion associated with childhood developmental delay. The microdeletion was detected in 20 of 11,873 cases compared with 2 of 8,540 controls and replicated in a second series of 22 of 9,254 cases compared with 6 of 6,299 controls. Most deletions were inherited, with carrier parents likely to manifest neuropsychiatric phenotypes compared to non-carrier parents. Probands were more likely to carry an additional large copy-number variant when compared to matched controls. The clinical (...) features of individuals with two mutations were distinct from and/or more severe than those of individuals carrying only the co-occurring mutation. Our data support a two-hit model in which the 16p12.1 microdeletion both predisposes to neuropsychiatric phenotypes as a single event and exacerbates neurodevelopmental phenotypes in association with other large deletions or duplications. Analysis of other microdeletions with variable expressivity indicates that this two-hit model might be more generally applicable to neuropsychiatric disease. © 2010 Nature America, Inc. All rights reserved. (shrink)

This book, written by a close friend, recounts episodes in the life and career of Eugene M. Shoemaker , an ever‐youthful geologist with a passionate interest in applying geological principles to the moon and planets. In the early 1960s Shoemaker persuaded the U.S. Geological Survey to found an Astrogeology Branch, of which he served as the first director, to search for impact scars on the earth and to map the moon and other planetary bodies. He also played a leadership role (...) in persuading NASA to include scientific investigations in its plans for the Apollo missions. In the 1970s, when images from spacecraft revealed the presence of impact craters on all the rocky planets and satellites, he declared that the impact of solid bodies was the most fundamental process to have taken place on the terrestrial planets. Acting on this insight, he helped to transform geology from an earth‐centered to a planetary science. Eugene Shoemaker was, indeed, a man who made an impact.Details of Shoemaker's career and his many accomplishments have been documented elsewhere, including the numerous citations for honors bestowed upon him and, sadly, his recent obituaries. In this book David Levy, an amateur astronomer and a collaborator with Gene Shoemaker and his wife, Carolyn, gives us personal reminiscences that are available nowhere else. Levy writes in a relaxed, anecdotal style that adds new information and a great sense of fun to this story.Levy tells us, for example, that as a young member of the U.S. Geological Survey, Gene broke with a stern tradition by bringing his wife and children to live with him in his field camps, arguing that their presence made him more rather than less efficient in conducting his work. It was perfectly natural, then, for Gene and Carolyn, decades later, to work together in the Australian outback, where they discovered ten previously unknown impact scars and confirmed several more suspected ones.From 1948 onward Gene harbored a fervent desire to go to the moon, a wish Levy ascribes to his view of a spectacular moonrise over the Colorado Plateau. Back then, such ideas were pure science fiction; but years later, when a real possibility arose, Gene was overcome by a mystifying loss of energy. When his doctor found nothing wrong, Gene and Carolyn took a river trip, hoping to restore his strength and spirits. But his condition worsened until he found a doctor who recognized, on sight, that Gene was a victim of Addison's disease, a formerly fatal illness that could be controlled by cortisone. On taking his second dose, Gene felt his energy returning, but he—like his contemporary President John Kennedy—was obliged to take cortisone every day for the rest of his life. This dashed Gene's hopes of going to the moon himself, but he redoubled his efforts to provide geological training to the fighter‐pilot astronauts who did go there.Beginning in the 1970s, Gene and Carolyn performed systematic searches of the night skies for comets and Near Earth Objects—bodies in orbits that might cause collisions with the earth. Levy joined in many of their searches, and the three of them shared the ultimate triumph of discovering their ninth comet together—Shoemaker‐Levy 9—and watching more than twenty luminous fragments of it plunge one by one into the atmosphere of Jupiter. Several of the pieces sent up dark plumes that lasted more than a year and would have been large enough to envelope the entire earth. No doubt remained that impacts could cause global damage to earth's lithosphere and biosphere were such impactors to strike our own planet. Levy tells us that as the last few pieces disappeared Carolyn lamented the loss of “her string of pearls”; as a consolation, Gene surprised her with the gift of a string of pearls.This book is not, nor was it intended to be, a serious biography based on extensive interviews and archival research. Regrettably, its excellence as a personal account is somewhat marred by the lack of attention from a good fact checker and editor, who would have fixed the slips that appear here and there. For example, on page 41 Levy describes Meteor Crater as being 1.2 kilometers across, and on page 43 as being 1.3 kilometers across—a small but needless discrepancy . On page 144 we read that when Gene brought a carload of students to the Grand Canyon, “a steady snow was falling as they made their way into the canyon. Gene showed a lot of enthusiasm—after all it was his crater!” Clearly, several sentences are missing from between these two sentences. Such lapses are minor, but they are sufficiently common to make the book unreliable as a source of facts. Nevertheless, it is a delightful book that can be strongly recommended to general readers and also to specialists, both for their enjoyment and for the personal details it will add to their knowledge of Eugene Shoemaker's contributions to science. (shrink)

On April 26, 1995, the United States Supreme Court limited the reach of the preemption provision of ERISA in New York State Conference of Blue Cross & Blue Shield Plans v. Tavelers Insurance Co. ). In Travelers, the Supreme Court upheld the validity of a New York statute requiring hospitals to collect surcharges from patients covered by commercial insurers and requiring health maintenance organizations to pay a surcharge to the state's general fund that varies depending on the number of Medicaid-eligible (...) HMO members enrolled. Neither patients insured by Blue Cross/Blue Shield plans nor the plans themselves are similarly charged under the statute. Several commercial insurers and HMOs claimed the surcharges should be preempted under ERISA because they are levied on patients whose insurance or HMO membership premiums are purchased by an ERISA plan.The ERISA preemption clause means that federal regulation, or lack thereof, supersedes state regulation that is related to employee pension and benefit plans. This preemption clause prevents states from changing health care and benefit law for a significant portion of state residents. (shrink)

Christopher Caudwell’s The Crisis in Physics is a stylish and readable analysis of the lines of connection between scientific theories and economic realities. Caudwell provides a trenchant critique of mechanism and positivism. In the words of J.B.S. Haldane, The Crisis in Physics offers a “quarry of ideas” for future philosophers: a wealth of insights and arguments that demands continuing critical reflection.

"Every word, like a sacred object, has its place. No _précis_ is possible. This extraordinary book must be read."—Edmund Carpenter, _New York Times Book Review _ "No outline is possible; I can only say that reading this book is a most exciting intellectual exercise in which dialectic, wit, and imagination combine to stimulate and provoke at every page."—Edmund Leach, _Man _ "Lévi-Strauss's books are tough: very scholarly, very dense, very rapid in argument. But once you have mastered him, human history (...) can never be the same, nor indeed can one's view of contemporary society. And his latest book, _The Savage Mind_, is his most comprehensive and certainly his most profound. Everyone interested in the history of ideas _must_ read it; everyone interested in human institutions _should _read it."—J. H. Plumb, _Saturday Review_ "A constantly stimulating, informative and suggestive intellectual challenge."—Geoffrey Gorer, _The Observer_, London. (shrink)

By reappraising the biological theory of vitalism, Canguilhem attempted to give pride of place to the idea that acquiring knowledge about living beings is an activity of living beings. He is indeed credited with the view that knowledge in particular and rationality in general are “tied to a conception of life” whereby “life predominantly manifests itself in organic individuals that act and react within specific environments which, in turn, are defined by the needs and desires of these individuals” (Schmidgen H. (...) Hist Philos Life Sci, 36(2): 4, 2014. doi:10.1007/s40656-014-0030-1). These needs and desires, we are told, constitute “un système de référence irréductible et par là absolu” (Canguilhem G. Le vivant et son milieu. In: La connaissance de la vie (Deuxième édition revue et augmenté). Librairie philosophique J. Vrin, 129–154, 1992c). Canguilhem’s legacy is exactly this: rationality is rooted in life, and not the other way around. And yet, in “Le concept et la vie” (from 1966) and “De la science et de la contre-science” (from 1971), Canguilhem seems to tell another story about the complex intertwinement of life and rationality. Not only are we condemned to enter the realm of rationality (i.e., to take part in logical activities such as forming concepts and judgments about the world and about our own condition) because we have needs and desires as living beings, but we also have needs and desires as living beings that depend on the fact we are always already caught-up in the dynamics of rationality, i.e., always already logically active. At this point, Canguilhem’s thinking comes closer than ever to a Kantian, transcendental point of view on rationality. Paradoxically, the inscription of human rationality in organic life brings with it the idea of a subject, divided between two inverse but correlated realms in which it cannot but participate: the singular realm of sensibility and the general realm of logic. (shrink)

Published with the aid of a grant from the National Endowment for the Humanities. Contains the only complete English-language text of The Concept of Truth in Formalized Languages. Tarski made extensive corrections and revisions of the original translations for this edition, along with new historical remarks. It includes a new preface and a new analytical index for use by philosophers and linguists as well as by historians of mathematics and philosophy.

A naturalistic theory of intentionality is proposed that differs from previous evolutionary and tracking theories. Full-blown intentionality is constructed through a series of evolvable refinements. A first, minimal version of intentionality originates from a conjectured internal process that estimates an organism’s own fitness and that continually modifies the organism. This process produces the directedness of intentionality. The internal estimator can be parsed into intentional components that point to components of the process that produces fitness. It is argued that such intentional (...) components can point to mistaken or non-existing entities. Different Fregian senses of the same reference correspond to different components that have different roles in the estimator. Intentional components that point to intentional components in other organisms produce directedness towards semi-abstract entities. Finally, adding a general, population-wide means of communication enables intentional components that point to fully abstract entities. Intentionality thus naturalized has all of its expected properties: being directed; potentially making errors; possibly pointing to non-existent, abstract, or rigid entities; capable of pointing many-to-one and one-to-many; distinguishing sense and reference; having perspective and grain; and having determinate content. Several examples, such as ‘swampman’ and ‘brain-in-a-vat’, illustrate how the theory can be applied. (shrink)

In the end of the 1960s France witnessed the response of the younger generation of philosophers to the leftist ideologies of 1968, as well as to the "intellectual models" of that time: Sartre, Lévi-Strauss, Lacan etc. It was from this response that the so called "new philosophy" raised. Among them also B.-H. Lévy, who later, as a mature philosopher , in spite of having suppressed his model J.-P. Sartre returned to him in his remarkable biography. The question than is: Which (...) Sartre - then there were more than one Sartre: Sartre as the author of Nausea is not identical with Sartre as a follower of Stalinism - and how could he substantiate the whole century, which was a century of seething of ideas, events mostly tragic, challenges, defeats, which all are constitutive of our modernity? (shrink)