Specialists and primary care physicians play an integral role in treating the twin epidemics of pain and addiction. But inadequate access to specialists causes much of the treatment burden to fall on primary physicians. This article chronicles the differences between treatment contexts for both pain and addiction — in the specialty and primary care contexts — and derives a series of reforms that would empower primary care physicians and better leverage specialists.

This article examines five different Medical-Legal Partnerships associated with Yale Law School in New Haven, Connecticut to illustrate how MLP addresses the social determinants of poor health. These MLPs address varied and distinct health and legal needs of unique patient populations, including: 1) children; 2) immigrants; 3) formerly incarcerated individuals; 4) patients with cancer in palliative care; and 5) veterans. The article charts a research agenda to create the evidence base for quality and evaluation metrics, capacity building, sustainability, and best (...) practices; it also focuses specifically on a research agenda that identifies the value of the lawyers in MLP. Such a focus on the “L” has been lacking and is overdue. (shrink)

This paper sheds light on the role of digital platform labour in the development of today’s artificial intelligence, predicated on data-intensive machine learning algorithms. Focus is on the specific ways in which outsourcing of data tasks to myriad ‘micro-workers’, recruited and managed through specialized platforms, powers virtual assistants, self-driving vehicles and connected objects. Using qualitative data from multiple sources, we show that micro-work performs a variety of functions, between three poles that we label, respectively, ‘artificial intelligence preparation’, ‘artificial intelligence verification’ (...) and ‘artificial intelligence impersonation’. Because of the wide scope of application of micro-work, it is a structural component of contemporary artificial intelligence production processes – not an ephemeral form of support that may vanish once the technology reaches maturity stage. Through the lens of micro-work, we prefigure the policy implications of a future in which data technologies do not replace human workforce but imply its marginalization and precariousness. (shrink)

One of the most striking findings of the study by Foglia and colleagues (2009) was that clinicians and managers were most concerned with limited resources while ethics committee chairpersons focuse...

Excessive prescribing of pain medications after surgery has contributed to the epidemic of opioid misuse and diversion in the United States. Pain specialists may be particularly well situated to address these issues. We describe an attempt to reverse the trend at an orthopedic surgical hospital by implementing a peri-operative assessment and treatment service which minimizes preoperative opioid use, when necessary implements addiction treatment, and encourages early tapering from opioids.

The aim of J.-L. Marion’s article is to revisit the important debate on the place of Augustine in the history of metaphysics. Often, quibbles arise upon considering the use of substance (substantia) by Augustine, not only as approximative of essentia and as synonymous with ousia, but in deciding whether in so doing Augustine effectuates a ‘metaphysical turn’. While he elsewhere argues that Augustine is a pre-metaphysical thinker, in this article Marion focuses on showing the diverse range of usages (...) of the term substance in the Augustinian corpus. Marion observes: first, whenever substance seems a fixed definition, the term allows for equivocity; second, God is substance in an indeterminate sense or by negation; third, human beings are substances fundamentally to capture the mutability of human existence. As such, Marion concludes, the Augustinian use of substance is insufficient to inelude Augustine in the history of metaphysics. (shrink)

Although rationing by clinical judgment is controversial, its acceptability partly depends on how it is practiced. In this paper, rationing by clinical judgment is defined in three different circumstances that represent increasingly wider circles of resource pools in which the rationing decision takes place: triage during acute shortage, comparison to other potential patients in a context of limited but not immediately strained resources, and determination of whether expected benefit of an intervention is deemed sufficient to warrant its cost by reference (...) to published population based thresholds. Notions of procedural justice are applied along with an analytical framework of six minimal requisites in order to facilitate fair bedside rationing: (1) a closed system that offers reciprocity, (2) attention to general concerns of justice, (3) respect for individual variations, (4) application of a consistent process, (5) explicitness, and (6) review of decisions. The process could be monitored for its applicability and appropriateness. (shrink)

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step (...) on the pathway to an eventual certification process for clinical ethics consultants. (shrink)

The required professional and ethical pronouncements of accountants mean that auditors need to be competent and exercise due care and skill in the performance of their audits. In this study, we examine what happens when auditors take on more clients than they should, thus raising doubts about their ability to maintain competence and audit quality. Using 2803 observations of Malaysian companies from 2010 to 2013, we find that auditors with multiple clients are associated with lower earnings quality, proxied by total (...) accruals and discretionary accruals. Our results demonstrate that associating client firms’ reported discretionary accruals with individual auditors, rather than their firms or offices, is important in determining audit quality. Moreover, we demonstrate that the disclosure of auditors’ signatures on their reports is useful for assessing auditor quality at the individual level, thus contributing to the debate on the usefulness of having auditor identities on reports. (shrink)

The purpose of this paper is to describe the nature of dental practice and to identify some recent innovations which have effect on cost containment in dentistry. The first of these innovations is dental insurance or prepaid dental services. Dental insurance has only recently emerged as a significant economic factor. The chronic and prevalent nature of dental disease mandates that the management of these programs incorporate insurance devices which limit demand and utilization. These devices amount to cost containment measures. The (...) second factor to be discussed is advertising. Advertising has been foisted on the dental profession by recent rulings of the Federal Trade Commission in an effort to promote competition. The Reagan administration, despite a market oriented approach to health care, had attempted to blunt some of the FTC actions. Advertising, nevertheless, has the potential to stimulate competition and restrain price escalation. The third factor includes a discussion of alternative delivery systems. These commercially oriented dental enterprises have the potential to compete with established practices as well as increase the demand for services. (shrink)

The spacing effect is among the most widely replicated empirical phenomena in the learning sciences, and its relevance to education and training is readily apparent. Yet successful applications of spacing effect research to education and training is rare. Computational modeling can provide the crucial link between a century of accumulated experimental data on the spacing effect and the emerging interest in using that research to enable adaptive instruction. In this paper, we review relevant literature and identify 10 criteria for rigorously (...) evaluating computational models of the spacing effect. Five relate to evaluating the theoretic adequacy of a model, and five relate to evaluating its application potential. We use these criteria to evaluate a novel computational model of the spacing effect called the Predictive Performance Equation. Predictive Performance Equation combines elements of earlier models of learning and memory including the General Performance Equation, Adaptive Control of Thought—Rational, and the New Theory of Disuse, giving rise to a novel computational account of the spacing effect that performs favorably across the complete sets of theoretic and applied criteria. We implemented two other previously published computational models of the spacing effect and compare them to PPE using the theoretic and applied criteria as guides. (shrink)

The increasing complexity of human subjects research and its oversight has prompted researchers, as well as institutional review boards, to have a forum in which to discuss challenging or novel ethical issues not fully addressed by regulations. Research ethics consultation services provide such a forum. In this article, we rely on the experiences of a national Research Ethics Consultation Collaborative that collected more than 350 research ethics consultations in a repository and published 18 challenging cases with accompanying ethical commentaries to (...) highlight four contexts in which REC can be a valuable resource. REC assists: 1) investigators before and after the regulatory review; 2) investigators, IRBs, and other research administrators facing challenging and novel ethical issues; 3) IRBs and investigators with the increasing challenges of informed consent and risk/benefit analysis; and 4) in providing flexible and collaborative assistance to overcome study hurdles, mediate conflicts within a team, or directly engage with research participants. Institutions that have established, or plan to establish, REC services should work to raise the visibility of their service and engage in open communication with existing clinical ethics consult services as well as the IRB. While the IRB system remains the foundation for the ethical review of research, REC can be a valuable service for investigators, regulators, and research participants aligned with the goal of supporting ethical research. (shrink)

Along with Husserl's Ideas and Heidegger's Being and Time, Being Given is one of the classic works of phenomenology in the twentieth century. Through readings of Kant, Husserl, Heidegger, Derrida, and twentieth-century French phenomenology (e.g., Merleau-Ponty, Levinas, and Henry), it ventures a bold and decisive reappraisal of phenomenology and its possibilities. Its author's most original work to date, the book pushes phenomenology to its limits in an attempt to redefine and recover the phenomenological ideal, which the author argues has never (...) been realized in any of the historical phenomenologies. Against Husserl's reduction to consciousness and Heidegger's reduction to Dasein, the author proposes a third reduction to givenness, wherein phenomena appear unconditionally and show themselves from themselves at their own initiative. Being Given is the clearest, most systematic response to questions that have occupied its author for the better part of two decades. The book articulates a powerful set of concepts that should provoke new research in philosophy, religion, and art, as well as at the intersection of these disciplines. Some of the significant issues it treats include the phenomenological definition of the phenomenon, the redefinition of the gift in terms not of economy but of givenness, the nature of saturated phenomena, and the question “Who comes after the subject?” Throughout his consideration of these issues, the author carefully notes their significance for the increasingly popular fields of religious studies and philosophy of religion. Being Given is therefore indispensable reading for anyone interested in the question of the relation between the phenomenological and the theological in Marion and emergent French phenomenology. (shrink)

To function well in an unpredictable environment using unreliable components, a system must have a high degree of robustness. Robustness is fundamental to biological systems and is an objective in the design of engineered systems such as airplane engines and buildings. Cognitive systems, like biological and engineered systems, exist within variable environments. This raises the question, how do cognitive systems achieve similarly high degrees of robustness? The aim of this study was to identify a set of mechanisms that enhance robustness (...) in cognitive systems. We identify three mechanisms that enhance robustness in biological and engineered systems: system control, redundancy, and adaptability. After surveying the psychological literature for evidence of these mechanisms, we provide simulations illustrating how each contributes to robust cognition in a different psychological domain: psychomotor vigilance, semantic memory, and strategy selection. These simulations highlight features of a mathematical approach for quantifying robustness, and they provide concrete examples of mechanisms for robust cognition. (shrink)

The problems of racism and racially motivated violence in predominantly African American communities in the United States are complex, multifactorial, and historically rooted. While these problems are also deeply morally troubling, bioethicists have not contributed substantially to addressing them. Concern for justice has been one of the core commitments of bioethics. For this and other reasons, bioethicists should contribute to addressing these problems. We consider how bioethicists can offer meaningful contributions to the public discourse, research, teaching, training, policy development, and (...) academic scholarship in response to the alarming and persistent patterns of racism and implicit biases associated with it. To make any useful contribution, bioethicists will require preparation and should expect to play a significant role through collaborative action with others. (shrink)

Theory of mind competence and knowledge of emotions were studied longitudinally in a sample of preschoolers aged 3 (n=263) and 4 (n=244) years. Children were assessed using standard measures of theory of mind and emotion knowledge. Three competing hypotheses were tested regarding the developmental associations between children's theory of mind abilities and their knowledge of emotions. First, that an understanding of emotion develops early and informs children's understanding of others’ thinking. Alternatively, having a basic theory of mind may help children (...) learn about emotions. Third, that the two domains are separate aspects of children's social cognitive skills such that each area develops independently. Results of hierarchical regressions supported the first hypothesis that early emotion understanding predicts later theory-of-mind performance, and not the reverse. (shrink)

Following on from _A Life of One’s Own_ and _An Experiment in Leisure_, _Eternity’s Sunrise_ explores Marion Milner’s way of keeping a diary. Recording small private moments, she builds up a store of ‘bead memories.’ A carved duck, a sprig of asphodel, moments captured in her travels in Greece, Kashmir and Israel, circus clowns, a painting _-_ each makes up a 'bead' that has a warmth or glow which comes in response to asking the simple question: What is the (...) most important thing that happened yesterday? From these beads – sacred, horrific, profane, funny – grows a sense of an ‘answering activity’, the result of turning one’s attention inwards to experience real joy. What Marion Milner conveys so vividly and inspirationally is her lifelong intention to live as completely as possible in the moment. With a new introduction by Hugh Haughton, _Eternity’s Sunrise_ will be essential reading for all those interested in reflecting on the nature of their own happiness – whether readers from a literary, an artistic, a historical, an educational or a psychoanalytic/psychotherapeutic background. (shrink)

In this paper we provide an interpretation of Aristotle's rule for the universal quantifier in Topics Θ 157a34–37 and 160b1–6 in terms of Paul Lorenzen's dialogical logic. This is meant as a contribution to the rehabilitation of the role of dialectic within the Organon. After a review of earlier views of Aristotle on quantification, we argue that this rule is related to the dictum de omni in Prior Analytics A 24b28–29. This would be an indication of the dictum’s origin in (...) the context of dialectical games. One consequence of our approach is a novel explanation of the doctrine of the existential import of the quantifiers in dialectical terms. After a brief survey of Lorenzen's dialogical logic, we offer a set of rules for dialectical games based on previous work by Castelnérac and Marion, to which we add here the rule for the universal quantifier, as interpreted in terms of its counterpart in dialogical logic. We then give textual evidence of the use of that rule in Plato's dialogues, thus showing that Aris... (shrink)

The devastating impact of the national opioid epidemic has given rise to hundreds of lawsuits. This article details the extremely broad range of legal claims, compares the opioid cases to other public health litigation efforts, including tobacco, and describes the special mechanism — a multidistrict litigation — through which more than 700 opioid-related cases have been consolidated thus far, with settlement almost certain to follow.

As pressures increase to contain growing healthcare expenditures, there is currently a prominent rise in the shift of healthcare costs to patients in the form of deductibles, co-pays, and co-insurance. Rising co-payments are part of a larger picture of increasing overall out-of-pocket healthcare expenditures. From 1990 to 2000, per capita out-of-pocket payments for healthcare reached $707 in the United States, and doubled in several European countries with universal health insurance, reaching $396 in Denmark, $290 in Germany, and $466 in Italy (...) in 2000. (shrink)

Clinical ethics support services are developing in Europe. They will be most useful if they are designed to match the ethical concerns of clinicians. We conducted a cross-sectional mailed survey on random samples of general physicians in Norway, Switzerland, Italy, and the UK, to assess their access to different types of ethics support services, and to describe what makes them more likely to have used available ethics support. Respondents reported access to formal ethics support services such as clinical ethics committees (...) (23%), consultation in individual cases (17.6%), and individual ethicists (8.8%), but also to other kinds of less formal ethics support (23.6%). Access to formal ethics support services was associated with work in urban hospitals. Informal ethics resources were more evenly distributed. Although most respondents (81%) reported that they would find help useful in facing ethical difficulties, they reported having used the available services infrequently (14%). Physicians with greater confidence in their knowledge of ethics (P = 0.001), or who had had ethics courses in medical school (P = 0.006), were more likely to have used available services. Access to help in facing ethical difficulties among general physicians in the surveyed countries is provided by a mix of official ethics support services and other resources. Developing ethics support services may benefit from integration of informal services. Development of ethics education in medical school curricula could lead to improved physicians sensititity to ethical difficulties and greater use of ethics support services. Such support services may also need to be more proactive in making their help available. (shrink)

The question of responsibility plays a critical role not only in our attempts to resolve social and political problems, but in our very conceptions of what those problems are. Who, for example, is to blame for apartheid in South Africa? Is the South African government responsible? What about multinational corporations that do business there? Will uncovering the "true facts of the matter" lead us to the right answer? In an argument both compelling and provocative, Marion Smiley demonstrates how attributions (...) of blame—far from being based on an objective process of factual discovery—are instead judgments that we ourselves make on the basis of our own political and social points of view. She argues that our conception of responsibility is a singularly modern one that locates the source of blameworthiness in an individual's free will. After exploring the flaws inherent in this conception, she shows how our judgments of blame evolve out of our configuration of social roles, our conception of communal boundaries, and the distribution of power upon which both are based. The great strength of Smiley's study lies in the way in which it brings together both rigorous philosophical analysis and an appreciation of the dynamics of social and political practice. By developing a pragmatic conception of moral responsibility, this work illustrates both how moral philosophy can enhance our understanding of social and political practices and why reflection on these practices is necessary to the reconstruction of our moral concepts. (shrink)

Examines the relationship between the question of God and the destiny of metaphysics. Concept of the end of metaphysics; Ambiguous relation between phenomenology and metaphysics; Return of special metaphysics in phenomenology; Phenomenological figure of God. Examines the relationship between the question of God and the destiny of metaphysics. Concept of the end of metaphysics; Ambiguous relation between phenomenology and metaphysics; Return of special metaphysics in phenomenology; Phenomenological figure of God.

As a contribution to a wider discussion on moral discernment in theological anthropology, this paper seeks to answer the question “What is the impact of mental illness on an individual’s ability to make moral decisions?” Written from a clinical psychiatric perspective, it considers recent contributions from psychology, neuropsychology and imaging technology. It notes that the popular conception that mental illness necessarily robs an individual of moral responsibility is largely unfounded. Most people who suffer from mental health problems do not lose (...) the capacity to make moral decisions, and mental illness on its own rarely explains anti-social or criminal behaviour. Moreover, the assumptions of some scientists, that recent developments in neuropsychology and brain imaging suggest biological determinism, must be treated with caution. (shrink)

Natural kinds is a widely used and pivotal concept in philosophy – the idea being that the classifications and taxonomies employed by science correspond to the real kinds in nature. Natural kinds are often opposed to the idea of kinds in the human and social sciences, which are typically seen as social constructions, characterised by changing norms and resisting scientific reduction. Yet human beings are also a subject of scientific study.Does this mean humans fall into corresponding kinds of their own? (...) In The Epistemology and Morality of Human Kinds Marion Godman defends the idea of human kinds. She first examines the scientific use and nature of human kinds, considering the arguments of key philosophers whose work bears upon human kinds, such as Ian Hacking, John Searle, Richard Boyd and Ruth Millikan. Using the examples of gender, ethnic minorities and Buddhism she then argues that human kinds are a result of ongoing historical reproduction, chiefly due to pre-existing cultural models and social learning. Her novel argument shifts the focus away from the reductionism characteristic of research about human kinds. Instead, she argues that they are “multiply projectable” and deserving of scientific study not in spite of, but because of their role in explaining our identity, injustice and the emergence of group rights. (shrink)

In his challenging article, Steneck (1997) criticized the creation of the Institutional Animal Care and Use Committee (IACUC) system established by the 1985 amendments to the Animal Welfare Act. He saw the IACUC review and approval of biomedical and behavioral research with animals as an unnecessary "reassignment" of duties from existing animal care programs to IACUC committees. He argued that the committees are unable to do the work expected of them for basically three reasons: (a) the membership lacks the expertise (...) in matters relevant to animal research and care, (b) there exists an inherent and disabling conflict of interest, and (c) the committee's operational base of authority is alien to academic culture and violates essential aspects of academic freedom. In addition, he found that the system is burdensome, requiring enormous expenditures of time and money that inappropriately diverts resources away from the business of scientific discovery. We dispute several aspects of Steneck's historical account and the coherence of his proposals. We believe his proposals, if followed, would be a step back into a failed past. (shrink)

Events in the US in 2020 have laid bare the reality that racism and its effects continue to take a heavy toll on the lives of Black Americans. The three articles in this issue of AJOB each provide...

Résumé — La question de l’éducation, telle qu’elle se pose dès les premiers écrits de Simone Weil, où elle est pensée comme un apprentissage de la nécessité par l’action, puis dans ses réflexions politiques sur l’éducation syndicale d’une part et celle d’un peuple tout entier de l’autre, pour enfin se retrouver dans la pensée mystique des dernières années, offre un angle intéressant pour aborder l’œuvre de la philosophe. Jamais thématisée comme telle par Simone Weil, la notion d’éducation est pourtant transversale (...) et permet de comprendre à la fois l’unité profonde et les apparentes contradictions de sa pensée. Dans cet article, nous dégageons un certain nombre de caractéristiques importantes de la notion d’éducation qui se retrouvent aux plans individuel, politique et finalement mystique. On verra peu à peu émerger l’importance de la notion de symbole qui nous permettra de proposer, à partir de la " philosophie de l’éducation " de Simone Weil, un " mode d’emploi " pour la lecture de son œuvre même.— The issue of education provides us with an interesting perspective to approach Simone Weil’s works : though she never takes education as such as an object of study, it is a ubiquitous notion which enables us to understand both the deep unity and the apparent contradictions of her thought. In her first works, education is thought of as concrete learning of the necessity by one’s own actions on the world. In her political reflections, Simone Weil is concerned with both the education of workers by the syndicate and the education of a whole country. Finally, the issue of education is central, as I will show, to her late mystical thought. In this paper, I emphasize some important features of " the notion of " education as it appears in the individual, political and mystical works of Simone Weil. The notion of symbol will turn out to be of central importance, and I will finally show that it provides us with some " reading instructions " of the very writings of Simone Weil from the perspective of her philosophy of education. (shrink)

BackgroundRandomized controlled trials (RCTs) are often complex and expensive to perform. Less than one third achieve planned recruitment targets, follow-up can be labor-intensive, and many have limited real-world generalizability. Designs for RCTs conducted using cohorts and routinely collected health data, including registries, electronic health records, and administrative databases, have been proposed to address these challenges and are being rapidly adopted. These designs, however, are relatively recent innovations, and published RCT reports often do not describe important aspects of their methodology in (...) a standardized way. Our objective is to extend the Consolidated Standards of Reporting Trials (CONSORT) statement with a consensus-driven reporting guideline for RCTs using cohorts and routinely collected health data.MethodsThe development of this CONSORT extension will consist of five phases. Phase 1 (completed) consisted of the project launch, including fundraising, the establishment of a research team, and development of a conceptual framework. In phase 2, a systematic review will be performed to identify publications (1) that describe methods or reporting considerations for RCTs conducted using cohorts and routinely collected health data or (2) that are protocols or report results from such RCTs. An initial “long list” of possible modifications to CONSORT checklist items and possible new items for the reporting guideline will be generated based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statements. Additional possible modifications and new items will be identified based on the results of the systematic review. Phase 3 will consist of a three-round Delphi exercise with methods and content experts to evaluate the “long list” and generate a “short list” of key items. In phase 4, these items will serve as the basis for an in-person consensus meeting to finalize a core set of items to be included in the reporting guideline and checklist. Phase 5 will involve drafting the checklist and elaboration-explanation documents, and dissemination and implementation of the guideline.DiscussionDevelopment of this CONSORT extension will contribute to more transparent reporting of RCTs conducted using cohorts and routinely collected health data. (shrink)