My purpose is to examine two of the foundations of medical ethics: the principle of autonomy and the concept of the human. I also investigate the extent to which health technology makes autonomy and humanness possible. I begin by underlining Illich's point that the same health technology designed to promote health and autonomy also is pathogenic. I proceed to analyse the Kantian concept of autonomy, a concept which is closely associated with health and which continues to determine current ethical thinking. (...) In so doing, I uncover an unexpected ontological function of health technology, a function described in Heidegger's work on technology. Based on this discovery, I suggest that calls for Kantian autonomy may often be self-defeating or even sometimes harmful. I conclude by calling for continued ethical vigilance, but also for a questioning of the hitherto virtually unquestionable concepts of ethics and humanness which may themselves play a role in our era's greatest problems. (shrink)

We describe the structure, operation, and experience of the Massachusetts General Hospital ethics committee, formally called the Edwin H. Cassem Optimum Care Committee, from January 2007 through December 2013. Founded in 1974 as one of the nation’s first hospital ethics committees, this committee has primarily focused on the optimum use of life-sustaining treatments. We outline specific sociodemographic and clinical characteristics of consult patients during this period, demographic differences between the adult inpatient population and patients for whom the ethics committee was (...) consulted, and salient features of the consults themselves. We include three case studies that illustrate important consult themes during this period. Our findings expand knowledge about the structure and workings of hospital ethics committees and illustrate how one ethics committee has developed and utilized policies on end-of-life care. More generally, we model a sociological approach to the study of clinical ethics consultation that could be utilized to contextualize institutional practices over time. (shrink)

Background: The bioethics literature contains speculation but little data about sociodemographic differences between patients for whom ethics committees (EC) are consulted for conflict about life-sustaining treatment (LST) and the broader hospital population that these committees serve. To provide an empirical context for this discussion, we examined differences in five sociodemographic factors between patients for whom an EC was consulted for conflict over LST and the general inpatient population, hypothesizing that nonwhite patients were most likely to be disproportionately represented. Methods: This (...) was a retrospective cohort study comparing self-reported race/ethnicity, household income, insurance status, primary language, and religious affiliation between patients involved in EC consultations for conflict over LST and the general adult inpatient population at a large academic hospital from January 1, 2007, through December 31, 2013. Results: There were 169 EC consultations involving conflict over LST and 243,197 adult inpatient admissions over the study period. On bivariate analysis, patients for whom the EC was consulted for conflict over LST were more likely to be nonwhite, low-income, and to speak a primary language other than English. They were not more likely to be underinsured or to report a religious affiliation. On multivariate analysis, patients for whom the EC was consulted for conflict over LST were more likely to be nonwhite (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.7–3.7; p <.001). They were also more likely to be low income (OR, 1.8; 95% CI, 1.1–3.0; p =.02). They were not more likely to speak a primary language other than English (OR, 1.4; 95% CI, 0.9–2.1; p =.17). None of the assessed variables were associated with conflict over LST requiring additional meetings beyond the first EC consultation. Conclusions: Nonwhite and low-income status patients are disproportionately represented in EC committee consultation for conflict over LST compared to the general inpatient population. (shrink)

A growing body of research has demonstrated significant heterogeneity of hospital ethics committee (HEC) size, membership and training requirements, length of appointment, institutional support, clinical and policy roles, and predictors of self identified success. Because these studies have focused on HECs at a single point in time, however, little is known about how the composition of HECs changes over time and what impact these changes have on committee utilization. The current study presents 20 years of data on the evolution of (...) the Massachusetts General Hospital HEC. Between 1993 and 2012, the average number of committee members per year was 38 ± 3 and the average length of membership was 4.8 ± 0.4 years. During that time, the committee performed 934 consults, averaging 47 ± 3 per year. Attendance rates fell from 61.5 to 23.8 % over the study period and were inversely correlated with the total number of members. Between 1993 and 2012, the committee saw substantial growth in the diversity of the professional backgrounds of its members. Multivariate analysis, however, suggests that substantial changes in committee composition did not impact its utilization and that other factors are more likely to explain fluctuations in consultation volume. (shrink)

Physical determinism is a metaphysical thesis about the natural world whose consequences for freedom and moral responsibility have been widely discussed. In this paper, I articulate a different form of determinism, motivational determinism, which claims that all intentional action is causally determined by the prior motivational state of the agent. Motivational determinism was defended in a simple form by Hume, but has been neglected in recent philosophical literature. I show that there are important reasons that support the plausibility of MD. (...) I then compare MD with libertarian and physical deterministic theories of agency and note that MD has various attractive features. I show that MD is much more threatening to moral responsibility than physical determinism. I conclude that MD is an interesting theory of human agency that deserves wide attention. (shrink)

Background Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be (...) successfully introduced and implemented, where legislations allow it. Methods Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders’ well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria. Results Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders. Conclusion The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD. (shrink)

(2007). Strategies For Successful Science Teaching. Sharon Brendzel. Lanham, MD: University Press of America, 2005. pp. 152. $26.00 (paper). Educational Studies: Vol. 41, No. 3, pp. 264-268.

BackgroundIn Parkinson's disease, the side of motor symptoms onset may influence disease progression, with a faster motor symptom progression in patients with left side lateralization. Moreover, worse neuropsychological outcomes after subthalamic nucleus deep brain stimulation have been described in patients with predominantly left-sided motor symptoms. The objective of this study was to evaluate if the body side of motor symptoms onset may predict motor outcome of bilateral STN-DBS.MethodsThis retrospective study included all consecutive PD patients treated with bilateral STN-DBS at Grenoble (...) University Hospital from 1993 to 2015. Demographic, clinical and neuroimaging data were collected before and 1 year after surgery. The predictive factors of motor outcome at one-year follow-up, measured by the percentage change in the MDS-UPDRS-III score, were evaluated through univariate and multivariate linear regression analysis.ResultsA total of 233 patients were included with one-year follow-up after surgery [143 males ; 121 right body onset; 112 left body onset; mean age at surgery, 55.31 ± 8.44 years; mean disease duration, 11.61 ± 3.87]. Multivariate linear regression analysis showed that the left side of motor symptoms onset did not predict motor outcome.ConclusionsIn this retrospective study, the body side of motor symptoms onset did not significantly influence the one-year motor outcome in a large cohort of PD patients treated with bilateral STN-DBS. (shrink)

Background: Notwithstanding near-universal agreement on the theoretical importance of truthfulness, empirical research has documented gaps between ethical norms and physician behaviors. Although prior research has explored situations in which physicians may not be truthful with patients, it has focused on contexts within specialty practice. In this article, we report on a qualitative study of truthfulness in primary care. Methods: We conducted a qualitative study during December 2014–March 2015 involving both focus groups and in-depth, semistructured interviews with 32 primary care physicians (...) from the Boston, MA, and Baltimore, MD, metro areas in three specialties: internal medicine, family practice, and pediatrics. Interviews and focus groups were led using a semistructured guide, which explored situations in which primary care physicians find it difficult to be honest with patients; factors shaping truthfulness; and rationales for truthful and untruthful communication. Results: While physicians described outright lying to patients as rare, other deviations from truthfulness were not uncommon, including slanting and deliberately withholding information. Physicians described a range of factors as influencing truthfulness, from patient-level characteristics such as educational background to societal considerations including avoiding unnecessary tests and procedures. Physicians described truthfulness as an ethical requirement, deviations from which required further justification. Perceived justifications included promoting patient well-being and avoiding harm. Conclusions: Our results suggest a potential need to augment opportunities for training in “everyday ethics” challenges, such as the appropriateness of deception in response to patient requests for inappropriate tests or pain medications. Furthermore, they indicate that, in various circumstances encountered in primary care, physicians perceive other moral duties as potentially in conflict with the duty of truthfulness. Further ethical analysis should focus on identifying when deviations from complete truthfulness do and do not serve patients' interests, to guide physicians in striking a reasonable balance among principles of medical ethics that may conflict with one another. (shrink)

This article critically examines Saul Kripke's (1972) argument for the separability of necessary truths from truths known a priori, focusing on his criticism of the standard meter case presented by Wittgenstein (1968). It attempts to show that Kripke's argument is unworkable on any of several readings. Wittgenstein's own broadly conventionalist account of necessary truth is then considered in the light of the standard meter example.

In November 2018 the American Society for Bioethics and Humanities (ASBH) administered the first Healthcare Ethics Consultant Certification examination to 138 candidates, 136 of whom (98.5 percent) passed and were “certified” as “healthcare ethics consultants.” I believe this certification process is both premature and inadequate.Certification for ethics consultants is premature because, as Kornfeld and Prager state repeatedly in their article in this issue of The Journal of Clinical Ethics, “The Clinician as Clinical Ethics Consultant: An Empirical Method of Study,” there (...) is a lack of “empirical data on the nature of the problems that prompt ethics consultation requests and on the functions required to address them.” These authors proceed to provide a model for the kind of empirical data collection that is needed.Even more relevant, the ASBH model that certifies clinical ethics consultants is inadequate. First, it is inappropriate for a nonclinical organization such as the ASBH to claim the right to certify a clinical process, ethics consultation, involving patients and health professionals. Second, the current certification process requires only a written examination in contrast to the two-step quality attestation process proposed in 2013 by Eric Kodish, MD, and 11 other senior members of the ASBH, including its then president.Third and most importantly, the eligibility criteria for being certified to work on hospital units and to make clinical recommendations for patients and families are minimal and insufficient. The only stated requirements are a bachelor’s degree and 400 hours of healthcare ethics consulting experience. By contrast, practicing physicians and nurses train for many years to gain clinical experience that enables them to apply clinical ethical standards in the care and management of all inpatients and outpatients, not just the small percent for whom an ethics consultation is requested. (shrink)

Adam Smith is rediscovered every few generations by philosophers surprised by his subtlety, originality, and relevance. Smith’s status as mythical father of economic science and his role as canonical defender of free trade is secure within economics, but few philosophers have been more often misrepresented and underestimated. Because he is well known as an advocate of commercial society, many scholars, public intellectuals, commentators, and journalists are happy to implicate him automatically in its successes and failures, or to enlist him in (...) one side or another of the various ideological battles surrounding the utility and dangers of market economics. This book is an accessible and engaging introduction to Smith’s most important contributions to philosophy. Beginning with an introductory chapter on Smith’s life, writings and readings, Eric Schliesser locates Smith in his immediate social and philosophical context. Later chapters analyse key concepts in his core moral, political and metaphysical theories, before turning to Smith's contribution to areas of ongoing philosophical interest, especially philosophy of science, and the metaphysics of mind and self. Schliesser concludes by summarising Smith's complicated legacy in the eighteenth, nineteenth, and twentieth centuries, and explores how Smith is being 're-discovered' in contemporary moral philosophy. (shrink)

People are biased toward beliefs that are welcomed by their in-group. Some beliefs produced by these biases—such as climate change denial and religious belief—can be fruitfully modeled by signaling theory. The idea is that the beliefs function so as to be detected by others and manipulate their behavior, primarily for the benefits that accrue from favorable tribal self-presentation. Signaling theory can explain the etiology, distinctive form, proper function, and alterability of these beliefs.

There is much to admire in this book. It is written in a pleasingly straightforward style, and offers insight on a wide range of important issues.

Recently, Doolittle and Inkpen formulated a thought provoking theory, asserting that evolution by natural selection was responsible for the sideways evolution of two radically different kinds of selective units (also called Domains). The former entities, termed singers, correspond to the usual objects studied by evolutionary biologists (gene, genomes, individuals, species, etc.), whereas the later, termed songs, correspond to re‐produced biological and ecosystemic functions, processes, information, and memes. Singers perform songs through selected patterns of interactions, meaning that a wealth of critical (...) phenomena might receive novel evolutionary explanations. However, this theory did not provide an empirical approach to study evolution in such a broadened context. Here, we show that analyzing songs and singers, using patterns of interaction networks as a common ontology for both, offers a novel, actionable, inclusive and mathematical way to analyze not only the re‐production but also the evolution and fitness of biological and ecosystemic interconnected processes. (shrink)

What is a temporal part? Most accounts explain it in terms of timeless parthood: a thing's having a part without temporal qualification. Some find this hard to understand, and thus find the view that persisting things have temporal parts--fourdimensionalism--unintelligible. T. Sider offers to help by defining temporal parthood in terms of a thing's having a part at a time. I argue that no such account can capture the notion of a temporal part that figures in orthodox four-dimensionalism: temporal parts must (...) be timeless parts. This enables us to state four-dimensionalism more clearly. (shrink)

This paper explains Sophie de Grouchy’s philosophical debts to Adam Smith. I have three main reasons for this: first, it should explain why eighteenth-century philosophical feminists found Smith, who has—to put it mildly—not been a focus of much recent feminist admiration, a congenial starting point for their own thinking; second, it illuminates De Grouchy’s considerable philosophical originality, especially her important, overlooked contributions to political theory; third, it is designed to remove some unfortunate misconceptions that have found their way into Karin (...) Brown’s ‘Introduction’ to the recent and much-to-be-welcomed translation of Sophie de Grouchy’s Lettres Sur La Sympathie. While Brown claims that there are major ‘differences’ in their programs of ‘social reform’, I argue there are important commonalities between Smith and De Grouchy. In particular, I highlight how they share a common understanding of how human sensibilities are shaped by social institutions and I show that De Grouchy’s path-breaking analysis of negative and positive liberty is grounded in her extension of Smith’s political theory and moral psychology. (shrink)

Recent attempts to define being moved have difficulties agreeing on its eliciting conditions. The status quaestionis is often summarized as a question of whether the emotion is evoked by exemplifications of a wide range of positive core values or a more restricted set of values associated with attachment. This conclusion is premature. Study participants associate being moved with interactions with their loved ones not merely for what they exemplify but also for their affective bond to them. Being moved is elicited (...) when we apprehend the value of entities to which we are connected through basic as well as extended forms of affiliative attachment. These comprise people, certain objects, and even abstract entities, including the unshakable life-guiding ideas we call “core values.”. (shrink)

The prosaic content of these sayings is that events change from future to present and from present to past. Your next birthday is in the future, but with the passage of time it draws nearer and nearer until it is present. 24 hours later it will be in the past, and then lapse forever deeper into history. And things get older: even if they don’t wear out or lose their hair or change in any other way, their chronological age is (...) always increasing. These changes are universal and inescapable: no event could ever fail to be first future, then present, then past, and no persisting thing can avoid growing older. We call this process time’s passage. (shrink)

Differing views on reduction are briefly reviewed and a suggestion is made for a working definition of 'approximate reduction'. Ab initio studies in quantum chemistry are then considered, including the issues of convergence and error bounds. This includes an examination of the classic studies on CH2 and the recent work on the Si2C molecule. I conclude that chemistry has not even been approximately reduced.

E. J. Lowe and others argue that there can be 'uncountable' things admitting of no numerical description. This implies that there can be something without there being at least one such thing, and that things can be identical without being one or nonidentical without being two. The clearest putative example of uncountable things is portions of homogeneous stuff or 'gunk'. The paper argues that there is a number of portions of gunk if there is any gunk at all, and that (...) the possibility of uncountable things is inadequately supported. (shrink)

I defend a how-possibly argument for Kantian (or Kant*-ian) transcendental idealism, drawing on concepts from David Chalmers, Nick Bostrom, and the cyberpunk subgenre of science fiction. If we are artificial intelligences living in a virtual reality instantiated on a giant computer, then the fundamental structure of reality might be very different than we suppose. Indeed, since computation does not require spatial properties, spatiality might not be a feature of things as they are in themselves but instead only the way that (...) things necessarily appear to us. It might seem unlikely that we are living in a virtual reality instantiated on a non-spatial computer. However, understanding this possibility can help us appreciate the merits of transcendental idealism in general, as well as transcendental idealism’s underappreciated skeptical consequences. (shrink)

Un examen de la division quasi officielle du monde philosophique en deux blocs : phénoménologique et analytique. Bilan de ses prolongements en France ces vingt dernières années.

In a survey on research misconduct, roughly 20% of the respondents admitted that they have submitted federal grant proposals that include scholars as research participants even though those scholars were not expected to contribute to the research effort. This manuscript argues that adding such false investigators is illegal, violating multiple federal statutes including the False Statements Act, the False Claims Act, and False, Fictitious, or Fraudulent Claims. Moreover, it is not only the offending academics and the false investigators that face (...) civil and criminal penalties because administrators may also be liable if they sign off on proposals and are in a position to know that false investigators might be included. Policy recommendations that should reduce the use of false investigators include changing institutional cultures, better training and oversight of the responsible conduct of research, and, most importantly, making all grant reviews double blind. (shrink)

Research on the perception of silence has led to insights regarding its positive effects on individuals. We conducted a series of studies during which individuals were exposed to several minutes of silence in different contexts. Participants were introduced to different social and environmental settings, either in a seminar room at a university or in a city garden, alone or in a group. Instructions across studies varied, as participants were exposed to real waiting situations, were asked to just think and to (...) explicitly experience the time interval without further instructions or following a session of Depth Relaxation Music Therapy (DRMT)/ Hypnomusictherapy (HMT). Silence was judged to significantly increase relaxation, improve mood states, and alter the perception of time and the orientation towards the present moment. We controlled for influences of trait variables, such as impulsivity, mindfulness, daydreaming, and time perspective. Findings empirically demonstrate that exposure to silence can be effective in therapeutic and educational contexts to promote relaxation and well-being. (shrink)

“Everyday ethics” is a term that has been used in the clinical and ethics literature for decades to designate normatively important and pervasive issues in healthcare. In spite of its importance, the term has not been reviewed and analyzed carefully. We undertook a literature review to understand how the term has been employed and defined, finding that it is often contrasted to “dramatic ethics.” We identified the core attributes most commonly associated with everyday ethics. We then propose an integrative model (...) of everyday ethics that builds on the contribution of different ethical theories. This model proposes that the function of everyday ethics is to serve as an integrative concept that (1) helps to detect current blind spots in bioethics (that is, shifts the focus from dramatic ethics) and (2) mobilizes moral agents to address these shortcomings of ethical insight. This novel integrative model has theoretical, methodological, practical, and pedagogical implications, which we explore. Because of the pivotal role that moral experience plays in this integrative model, the model could help to bridge empirical ethics research with more conceptual and normative work. (shrink)

Violations of the Bell inequalities in EPR-Bohm type experiments have set the literature on the metaphysics of microscopic systems to flirting with some sort of metaphysical holism regarding spatially separated, entangled systems. The rationale for this behavior comes in two parts. The first part relies on the proof, due to Jon Jarrett [2] that the experimentally observed violations of the Bell inequalities entail violations of the conjunction of two probabilistic constraints. Jarrett called these two constraints locality and completeness. We prefer (...) the terminology of locality and factorizability.[3] The first part of the rationale for metaphysical holism urges that only Jarrett’s locality allows for “peaceful coexistence” between any model of EPR-Bohm type experiments and special relativity. Factorizability, it is suggested, must be jettisoned. (shrink)

Common understandings of neuroethics, i.e., of its distinctive nature, are premised on two distinct sets of claims: (1) neuroscience can change views about the nature of ethics itself and neuroethics is dedicated to reaping such an understanding of ethics; (2) neuroscience poses challenges distinct from other areas of medicine and science and neuroethics tackles those issues. Critiques have rightfully challenged both claims, stressing how the first may lead to problematic forms of reductionism while the second relies on debatable assumptions about (...) the nature of bioethics specialization and development. Informed by philosophical pragmatism and our experience in neuroethics, we argue that these claims are ill-founded and should give way to pragmatist reconstructions. Namely, neuroscience, much like other areas of empirical research on morality, can provide useful information about the nature of morally problematic situations but it does not need to promise radical and sweeping changes to ethics based on neuroscientism. Furthermore, the rationale for the development of neuroethics as a specialized field need not to be premised on the distinctive nature of the issues it tackles or of neurotechnologies. Rather, it can espouse an understanding of neuroethics as both a scholarly and a practical endeavor dedicated to resolving a series of problematic situations raised by neurological and psychiatric conditions. (shrink)

Recent work in the cognitive sciences has argued that beliefs sometimes acquire signaling functions in virtue of their ability to reveal information that manipulates “mindreaders.” This paper sketches some of the evolutionary and design considerations that could take agents from solipsistic goal pursuit to beliefs that serve as social signals. Such beliefs will be governed by norms besides just the traditional norms of epistemology. As agents become better at detecting the agency of others, either through evolutionary history or individual learning, (...) the candidate pool for signaling expands. This logic holds for natural and artificial agents that find themselves in recurring social situations that reward the sharing of one’s thoughts. (shrink)

I argue that it is rational and appropriate for atheists to give thanks to deep impersonal agents for the benefits they give to us. These agents include our evolving biosphere, the sun, and our finely-tuned universe. Atheists can give thanks to evolution by sacrificially burning works of art. They can give thanks to the sun by performing rituals in solar calendars. They can give thanks to our finely-tuned universe, and to existence itself, by doing science and philosophy. But these linguistic (...) types of thanks-giving are forms of non-theistic contemplative prayer. Since these behaviors resemble ancient pagan behaviors, it is fair to call them pagan. Atheistic paganism may be part of an emerging ecosystem of naturalistic religions. (shrink)

Some ethical imperatives pertaining to climate change are mostly uncontroversial. Humanity has caused the problem and must do something to mitigate it and this job must to a large extent be carried by the current generations, as time is short. There is also wide agreement, at least among climate justice scholars, that the reason for why this is so is a combination of causal responsibility and ability to pay, and that the affluent therefore must lead the transition away of fossil (...) fuels. However, when it comes to implementing a just transition to a low-car- bon and sustainable future, most policies are ethically and politically contentious. (shrink)

ABSTRACTMany philosophers say that the nature of personal identity has to do with narratives: the stories we tell about ourselves. While different narrativists address different questions of personal identity, some propose narrativist accounts of personal identity over time. The paper argues that such accounts have troubling consequences about the beginning and end of our lives, lead to inconsistencies, and involve backwards causation. The problems can be solved, but only by modifying the accounts in ways that deprive them of their appeal.

Uncertainty and affect are fundamental and interrelated aspects of the human condition. Uncertainty is often associated with negative affect, but in some circumstances it is associated with positive affect. In this paper, we review different explanations for the varying relationship between uncertainty and affect. We identify “mental simulation” as a key process that links uncertainty to affective states. We suggest that people have a propensity to simulate negative outcomes, which results in a propensity towards negative affective responses to uncertainty. We (...) also propose the existence of several important moderators of this process, including context and individual differences such as uncertainty tolerance, as well as emotion regulation strategies. Finally, we highlight important knowledge gaps and promising areas for future research, both empirical and conceptual, to further elucidate the relationship between uncertainty and affect. (shrink)

Chalmers' anti-materialist arguments are an interesting twist on a well-known argument form, and his naturalistic dualism is exciting to contemplate. Nevertheless, we think we can save materialism from the Chalmerian attack. This is what we do in the present paper.

This book analyzes crucial episodes in the history of American higher education in order to discover the best way to rescue the humanities. It urges apologists to stop focusing on the humanistic disciplines as inculcators of poorly defined skills and envisions a globalized approach to education based on humanistic masterworks.

This article addresses the place of situationist ideas in the current drive to make meaningful social and political change to avoid the catastrophic consequences of climate change. After a brief review of some key situationist concepts, the article shows how situationist thinkers post-1968 saw the prospect of environmental degradation as one of the key consequences of the social apathy induced by the spectacle and the grim prospects for the prevailing liberal assemblage of power to address the problem. The article concludes (...) by briefly discussing the place of a situationist-inspired environmentalism in the larger debates about radical solutions to climate change. (shrink)