The rule of rescue describes the powerful human proclivity to rescue identified endangered lives, regardless of cost or risk. Deciding whether or not to perform a decompressive craniectomy as a life-saving or ‘rescue’ procedure for a young person with a severe traumatic brain injury provides a good example of the ethical tensions that occur in these situations. Unfortunately, there comes a point when the primary brain injury is so severe that if the patient survives they are likely to remain severely (...) disabled and fully dependent. The health resource implications of this outcome are significant. By using a web-based outcome prediction model this study compares the long-term outcome and designation of two groups of patients. One group had a very severe injury as adjudged by the model and the other group a less severe injury. At 18 month follow-up there were significant differences in outcome and healthcare requirements. This raises important ethical issues when considering life-saving but non-restorative surgical intervention. The discussion about realistic outcome cannot be dichotomised into simply life or death so that the outcome for the patient must enter the equation. As in other ‘rescue situations’, the utility of the procedure cannot be rationalised on a mere cost–benefit analysis. A compromise has to be reached to determine at what point either the likely outcome would be unacceptable to the person on whom the procedure is being performed or the social utility gained from the rule of rescue intervention fails to justify the utilitarian value and justice of equitable resource allocation. (shrink)

Decompressive craniectomy is a technically straightforward procedure whereby a large section of the cranium is temporarily removed in cases where the intracranial pressure is dangerously high. While its use has been described for a number of conditions, it is increasingly used in the context of severe head injury. As the use of the procedure increases, a significant number of patients may survive a severe head injury who otherwise would have died. Unfortunately some of these patients will be left severely disabled; (...) a condition likened to the RUB, an acronym for the Risk of Unacceptable Badness. Until recently it has been difficult to predict this outcome, however an accurate prediction model has been developed and this has been applied to a large cohort of patients in Western Australia. It is possible to compare the predicted outcome with the observed outcome at 18 months within this cohort. By using predicted and observed outcome data this paper considers the ethical implications in three cases of differing severity of head injury in view of the fact that it is possible to calculate the RUB for each case. (shrink)

In all fields of clinical medicine, there is an increasing awareness that outcome must be assessed in terms of quality of life and cost effectiveness, rather than merely length of survival. This is especially the case when considering decompressive craniectomy for severe traumatic brain injury. The procedure itself is technically straightforward and involves temporarily removing a large section of the skull vault in order to provide extra space into which the injured brain can expand. A number of studies have demonstrated (...) many patients going on to make a good long-term functional recovery, however, this is not always the case and a significant number survive but are left with severe neurocognitive impairment. Unfortunately, many of these patients are young adults who were previously fit and well and are, therefore, likely to spend many years in a condition that they may feel to be unacceptable, and this raises a number of ethical issues regarding consent and resource allocation. In an attempt to address these issues, we have used the analytical framework proposed by Jonsen, that requires systematic consideration of medical indications, patient preferences, quality of life and contextual features. (shrink)

Objectives: To study the attitudes of both medical and non-medical students towards the do-not-resuscitate decision in a university in Hong Kong, and the factors affecting their attitudes.Methods: A questionnaire-based survey conducted in the campus of a university in Hong Kong. Preferences and priorities of participants on cardiopulmonary resuscitation in various situations and case scenarios, experience of death and dying, prior knowledge of DNR and basic demographic data were evaluated.Results: A total of 766 students participated in the study. There were statistically (...) significant differences in their DNR decisions in various situations between medical and non-medical students, clinical and preclinical students, and between students who had previously experienced death and dying and those who had not. A prior knowledge of DNR significantly affected DNR decision, although 66.4% of non-medical students and 18.7% of medical students had never heard of DNR. 74% of participants from both medical and non-medical fields considered the patient’s own wish as the most important factor that the healthcare team should consider when making DNR decisions. Family wishes might not be decisive on the choice of DNR.Conclusions: Students in medical and non-medical fields held different views on DNR. A majority of participants considered the patient’s own wish as most important in DNR decisions. Family wishes were considered less important than the patient’s own wishes. (shrink)

We present a method for rejecting competing models from noisy time-course data that does not rely on parameter inference. First we characterize ordinary differential equation models in only measurable variables using differential-algebra elimination. This procedure gives input-output equations, which serve as invariants for time series data. We develop a model comparison test using linear algebra and statistics to reject incorrect models from their invariants. This algorithm exploits the dynamic properties that are encoded in the structure of the model equations without (...) recourse to parameter values, and, in this sense, the approach is parameter-free. We demonstrate this method by discriminating between different models from mathematical biology. (shrink)

We study connections between strong reducibilities and properties of computably enumerable sets such as simplicity. We say that a class of computably enumerable sets bounded iff there is an m-incomplete computably enumerable set A such that every set in is m-reducible to A. For example, we show that the class of effectively simple sets is bounded; but the class of maximal sets is not. Furthermore, the class of computably enumerable sets Turing reducible to a computably enumerable set B is bounded (...) iff B is low2. For r = bwtt,tt,wtt and T, there is a bounded class intersecting every computably enumerable r-degree; for r = c, d and p, no such class exists. (shrink)

In order to introduce the text description of this class will show seven keywords, they represent In order to understand the general process for the seven. Need to mention is that the author published in Chinese script - title "Gadamer's philosophy of the seven key" - and this content is not the same. In fact, only one in that the use of key words in this speech mentioned the four key words will be used the next article. 1 Linguistics as (...) high as the United States in the "real management and methods," a book in the last third of the contents of the specified language is "the universal medium of interpretation of experience." It is in this medium, things are understood, understanding and interpretation to occur. It is the fundamental and the first thing on a switch, it makes things possible, without it, understanding must not occur. It is in this medium, the real management there, although in terms of the real incidence of management and is not limited to this medium. Sprachlichkeit is up to the universal language of the United States to name the first of of a proper noun. history of as language, history is a popular media, and history is also rising to become "a hermeneutical principle." To understand history, which must be traced back to Heidegger, "and there is time," the first six parts, entitled "Timing and historical nature." This title has been out of correct revelation, history is the study of this structure there is some a result of this there is the same as in the past and the present one there, it was possible there through his plans and will itself which extend to the future. Dilthey on Heidegger benefit of this term and its historical significance, but that裡Dilthey, the basic processes of life, and in Heidegger, the basic process is still alive there in the past and future Among the visual field. It is a learning process rather than the life there is a process, there is a process rather than the life philosophy of life regardless of the process. Dilthey and Gadamer and Heidegger places of historical analysis for the premise. 3 by the historical role of awareness up to the United States, this keyword has not appeared in from Schleiermacher, Dilthey, or Heidegger that裡. But Heidegger once spoke to the author, the concept represented by the word directly from Dilthey and future. Indeed, the word and the "fusion of" two persons都benefit from Hegel and Dilthey, Heidegger than In order to impact. At the same time, for the resumption of encounter with the text of the history of this effort directly, the recall In order to Heidegger and Qike fruit. Up to the United States shows that it is essential that "the existence of the structure." That is to say, it is usually associated with the text coming from a tradition, crushed In order to present before the sight. 4 hermeneutics into the cycle and see in understanding the structure and the first cycle between hermeneutics, there is a close link. Hermeneutics and the cycle regardless of such a concept, not only from a part of the overall future understanding, understanding from the part of the overall future. This is a logical contradiction, but it depicts In order to understand the kind of work does not have the way to recovery. This is to see What are the relationship? Up with the United States use this word in the former understanding of the meaning of a person he can understand any part of the text and context before, must have a pre-understanding. When Schleiermacher hermeneutics for the cycle to take a more formalistic point of view, he also participate in an objective and subjective look for. In order to reject the United States is up for the subjective, and he describes, in understanding the text, our understanding of a person but a different meaning, and this sense of ownership in a situation with a theme of the event . Heidegger the hermeneutic circle and put the world on their own understanding of the context in which the world is time and the existence of the world, in order to In order to reinvent the meaning of hermeneutic circle. It exists in the time being and is expected to forward to the future, it is a person exists in the world of all possibilities of a personal meaning. Gadamer Heidegger and then one more step beyond, he is defined as the cycle of hermeneutics and the interpretation of the traditional sports were a correlation between the movement. Heidegger's masterpiece裡tradition and not important, but those for the traditional and the interpretation of the relationship between text, up to the U.S. In order to play an important role in the analysis. Up to the United States, brought into the discussion In order to "complete expectation" that the key concept, it is subject to the historical role of awareness of the operation of the core. In this part of the contents of the directory for the present review is to show to some of the major associated. 5 authority and tradition up to the United States on the authority of the traditional view is that from his understanding and the hermeneutic circle before the concept developed in the future. Enlightenment for the suspect an effort made ​​to switch the authority of the United States to see coming up is one-sided, because the authority is naturally found in the leading field in a PhD, the referee, professors and experts. Recognize these people for a topic you know even in the natural and appropriate. So regardless of up to his brother's wife is not a legitimate authority and legitimate authority, and authority as a concept to see the future is appropriate. Similarly, our traditional understanding among the living, and we should explore a more deeper with our traditional relationship. Traditional German text is Űberlieferung, incurs passed along . Once again, as a fair decision without dialogue and is not legal to see, up to the United States against this anti-traditional views of the Enlightenment. 6 Depending on the domain of integration sight philosophy of integration is another sign up to the United States is not to find elsewhere. Basically, the text of the encounter with a sight In order to involve the integration of text and interpreter of the visual field of sight. And a man's own awareness is a fusion of traditional with the product. "That is convenient to get a sight of their own, but also requires a fusion of traditional with." In order for each dialogue also involves a fusion of sight. It is a wildcard description of the terminology. 7 Dialogue dialogue leading up to the U.S. interpretation of the theme of philosophy, relying on a life of his ideal, he as such a show of openness. Schleiermacher as high as the United States in general, is a talented rapper. However, the need for a fruitful dialogue open to others point of view, and the need to recognize that he or she may be right. In a true dialogue, both sides都want to talk more close to the truth regardless of management topics, which are more important than winning. Finally, the dialogue is a basic hermeneutical tool, a means to understand, so we coming close to the theme of the issue, but ready to change our point of view. An introductory section explains that the lecture will present seven key terms, representing seven aspects of the universal process of understanding. It is noted that a published lecture in Chinese by this author under the title "Seven Key Terms in the Philosophy of Hans-Georg Gadamer "is not the same as this, and indeed only one of the terms in that lecture is used in this one, although four of them are used in tomorrow's lecture. An introductory section explains that the lecture will present seven key terms, representing seven aspects of the universal process of understanding. It is noted that a published lecture in Chinese by this author under the title "Seven Key Terms in the Philosophy of Hans-Georg Gadamer" is not the same as this, and indeed only one of the terms in that lecture is used in this one, although four of them are used in tomorrow's lecture. 1. Sprachlichkeit-Linguisticality As Gadamer notes in the final third of Truth and Method, language is the "universal medium of hermeneutical experience." It is the medium in which things are understood, the medium in which understanding and interpretation take place. It is fundamental and prior to everything. It makes things possible, and without it understanding cannot take place at all. It is the medium in which truth happens, although there is more than this to the happening of truth. Sprachlichkeit is the term Gadamer uses to name the "universal priority" of language. 2. Geschichtlichkeit-Historicity Like language, history is a universal medium, and historicity is raised to the status of "a hermeneutical principle. "To understand historicity, one has to go back to the six sections of Heidegger's Being and Time that carry the heading" Temporality and Historicity. "Already this title correctly suggests that historicity is a consequence of the ontological structure of Dasein as a being that lives with a past and a present, and also extends itself into the future through projecting possible being. Heidegger is indebted to Dilthey for the term and sense of historicity, but in Dilthey the basic process is life, whereas in Heidegger, the basic process is being-in-the-world in horizons of past and future. It is an ontological process rather than a life process, a process of being rather than the vitalism of life in life-philosophy. Gadamer presupposes Dilthey's and Heidegger's analysis of Geschichtlichkeit . 3. das wirkungsgeschichtliche Bewusstsein-the Historically Effected Consciousness This is a key term in Gadamer that does not appear in Schleiermacher, Dilthey, or Heidegger. Heidegger once remarked to the author that the idea that this term represents is straight out of Dilthey. Certainly it and the "fusion of horizons" are more indebted to Hegel and Dilthey than to Heidegger. At the same time, the effort to restore the historical immediacy of encounter with a text recalls Heidegger and Kierkegaard. Gadamer argues that the essence of it is " the structure of experience. "That is to say, it shatters the present horizon, usually with a text from tradition. 4. Hermeneutische Zirkel and Vorurteil-Prejudice and the Hermeneutical Circle There is an intimate connection between the fore-structure of understanding and the hermeneutical circle. The hermeneutical circle refers to the idea that one understands the part from the whole, but also the whole from the parts. This is a logical contradiction, but it describes the back and forth way that understanding works. What has this to do with prejudices ? Gadamer uses this word as synonymous with pre-understanding, and one has to have a prior understanding before one can understand any part of a text or situation. While Schleiermacher took a more formalistic view of the hermeneutical circle, he also looked at the objective and subjective sides. Gadamer rejects the subjective side and explains that in understanding a text we are not understanding a person but a meaning that resides in a situation and a subject-matter. Heidegger revolutionized the meaning of the hermeneutical circle by placing it in the context of an understanding of self and world that is temporal and existential. It exists in time and anticipates a future, and it is the personal sense of one's possibilities for being in the world. Gadamer took a step beyond Heidegger by defining the hermeneutical circle as the interplay between the movement of tradition and that of the interpreter. Tradition plays little role in Heidegger's masterwork, but it and the interpreter's relation to the text loom large in Gadamer's analysis. The discussion brings in the key concept in Gadamer of the "anticipation of completion" which is central to the working of historically effected consciousness. A review of the table of contents for the section is presented to show some of the major relationships. 5. Autorität und Tradition-Authority and Tradition Gadamer's views with regard to authority and tradition grow out of his concepts of preunderstanding and the hermeneutical circle. The effort by the Enlightenment to discredit all authority seemed one-sided to Gadamer because authority is naturally accorded to doctors, judges, professors, and other experts in a field. To acknowledge that they know more about a subject than you do is natural and appropriate. So Gadamer speaks of legitimate authority and illegitimate authority, but authority as a concept seems appropriate. Likewise, tradition inhabits our understanding, and we should seek an ever deeper relationship to our tradition. The German word for tradition is Űberlieferung, that which is handed down. Again, Gadamer takes up arms against the Enlightenment prejudice against tradition as illegitimate without dialogue or a fair trial. 6. Horizontverschmelzung-Fusion of Horizons The "fusion of horizons "is another trademark of Gadamerian philosophy. It is not found elsewhere. Basically, the encounter with the text involves a fusion of horizons, that of the text and that of the interpreter. Also one's own consciousness is a product of a fusion of horizons with the tradition. "Even to acquire one's own horizon requires a fusion of horizons with the tradition." Every conversation, too, involves a fusion of horizons. It is an all-purpose term. 7. Conversation Conversation is a leitmotif of Gadamer's hermeneutical philosophy, an ideal he lived by, an openness he exemplified. Schleiermacher was a gifted conversationalist, as was Gadamer. But a fruitful conversation requires openness to the viewpoint of the other person, and the acknowledgement that he or she could be right. In a true conversation both partners want to come closer to the truth about a matter, and that is more important than winning. Ultimately, conversation is a basic hermeneutical tool, a means of reaching understanding, so we approach a subject with questions, but ready to change our point of view. (shrink)

The aim of this paper was to explore the issue of consent when considering the use of a life saving but not necessarily restorative surgical intervention for severe traumatic brain injury. A previous study has investigated the issue amongst 500 healthcare workers by using a two-part structured interview to assess opinion regarding decompressive craniectomy for three patients with varying injury severity. A visual analogue scale was used to assess the strengths of their opinions both before and after being shown objective (...) outcome data. Opinions were assessed in a number of scenarios, one of which was that the participants themselves were the injured party. The implication, which was clearly stated, was whether they would provide consent for the procedure to be performed. The study demonstrated that participants were relatively risk aversive in regards to survival with severe disability especially when the injury was severe and there was high probability of that outcome occurring. This finding was not however universal and a minority of participants would provide consent even when the possibility of survival with severe disability was very high. The obvious difficulty comes when considering consent in patients who are unable to express their wishes. In order to address this issue we propose a model of consent based on a balance of the various factors that seem to be of material relevance. These include the severity of the injury, the willingness or otherwise to accept survival with severe disability and the willingness to “risk” the possibility of an unacceptable outcome in order to achieve an acceptable outcome. (shrink)