In lieu of an abstract, here is a brief excerpt of the content:Who or What is the Preembryo?S.J. Richard A. McCormick (bio)IntroductionAlthough widely used by scientists, the term "preembryo" has raised some suspicions. Histopathologist Michael Jarmulowicz (1990), for example, asserts that the term was adopted by the American Fertility Society (AFS) and the Voluntary Licensing Authority (VLA) in Britain "as an exercise of linguistic engineering to make human embryo research more palatable to the general public."I cannot speak for the VLA, (...) but I can clarify that this was not the motive of the AFS. As a member of the AFS ethics committee that discussed and adopted this terminology, I know that our discussion was not tied to embryo research or moral issues. The term "preembryo" was adopted because the earliest stages of mammalian development primarily involve establishment of the nonembryonic trophoblast, rather than the formation of the embryo. As Clifford Grobstein (1988, p. 61), a distinguished basic scientist who also sat on the AFS committee notes:The scientific rationale for the term preembryo... is its greater accuracy in characterizing the initial phase of mammalian and human development.... The status implications of such a change in terminology were not at issue in the discussion.This is not to say that the moral status of the preembryo is not a concern worthy of independent consideration. It is an important question with significant practical implications, especially in the context of in vitro fertilization. At stake are issues such as: (1) what may be done to preembryos before transfer; (2) whether all preembryos must be transferred; and (3) what may be done to preembryos that are not transferred (Ethics Committee of the American Fertility Society (AFS) 1986, p. 29S). Furthermore, emergency treatment of rape cases may also depend on such a determination. [End Page 1]Cryopreservation, which entails freezing unused preembryos for possible later use, is one example of a procedure that raises issues associated with the moral status of the preembryo. Cryopreservation decreases the number of stimulated egg recovery cycles a woman must undergo and increases flexibility in transfer protocols. But thawing of the preembryos is not a completely benign process; significant numbers of the preembryos die in the process and injury cannot be excluded.In addition, down the road a year or so lies preimplantation genetic diagnosis, now being tested in several centers of reproductive research. This would involve the removal of one or more cells from a preembryo developing in vitro. The DNA from these cells would be studied and then only genetically normal preembryos would be transferred. With the growth in knowledge about single gene defects and the rapid advance of amplification technology, which allows gene visualization, it is not difficult to imagine scientists embarking on a variety of micromanipulations of the preembryo for the sake of gaining knowledge.Not all research with gametes involves preembryos, but clearly some experiments and procedures await resolution of the moral status of the preembryo. I contend in this paper that the moral status—and specifically the controversial issue of personhood—is related to attainment of developmental individuality (being the source of one individual). This contrasts with the view that holds that personhood occurs earlier, at the point of genetic uniqueness. I believe that an embryo that has developed to the point where it can be one individual and one individual only, differs in moral status from a preembryo that has not, even if in many cases we may choose to treat them similarly.The Scientific UnderpinningsTwo things must be kept in mind—and in a sense, in tension—in turning to science for help in assessing the status of the preembryo. First, science is not competent to decide the question of personhood or ensoulment. As the Catholic document, Declaration on Procured Abortion, which I will return to later, notes: "It is a philosophical problem" (Congregation for the Doctrine of the Faith (CDF) 1974, p. 10, endnote 19). On the other hand, another Catholic document, Donum vitae(CDF 1987), notes that the conclusions of science provide a "valuable indication" for reason's deliberations about personhood. We might say that if science cannot decide the question of personhood, neither can it be decided without science.For my review of embryological science... (shrink)

In this paper the authors argue that research ethics committees should not be paternalistic by rejecting research that poses risk to people competent to decide for themselves. However it is important they help to ensure valid consent is sought from potential recruits and protect vulnerable people who cannot look after their own best interests. The authors first describe the tragic deaths of Jesse Gelsinger and Ellen Roche. They then discuss the following claims to support their case: competent individuals are (...) epistemologically and ethically in the best position to say which risks are reasonable for them, so RECs should be no more restrictive than the “normal” constraints on people taking risks with themselves; RECs do not judge individual competence ; individual liberty is mostly limited by what serves the public interest, and RECs do not determine public interest; RECs may have a paternalistic role in preventing exploitation of competent people vulnerable to the use of incentives, and in protecting the interests of incompetent people; however, the moral and political authority of RECs has not been established in this respect. (shrink)

Increasingly, medical students are required to face up to ethical issues in their training and practice. At the same time, there is growing interest in philosophy courses in the ethical issues raised by medical practice. This textbook, designed primarily for students of medicine, develops the issues to a philosophical level complex enough to be satisfying to students of philosophy as well as MA students on applied ethics courses. The author advocates an approach to medical ethics which breaks out of the (...) straitjacket of the narrow choice between utilitarian or deontological theory, and contains a valuable discussion of practical wisdom. It maintains a balance between case studies and philosophical arguments - which are developed in a historical context, and will be of interest at all levels of the medical profession. (shrink)

There are good reasons for envisioning a global discourse about God, premised necessarily agreed upon perfections considered to be by definition proper to God, and for thinking through the implications of our understanding of God for morality. Philosophically, it makes sense to hold that claims about omnipotence, omniscience, and other superlative perfections are indeed maximal, and define “God” wherever the terminology of divine persons is taken up. Religiously too, it makes sense to assert that a deity possessed of perfections is (...) not just the deity of one’s own tribe or religion, but also the deity of the whole world, whether acknowledged as such or not. This essay delves into the larger set of rich complexities by three moves. First, I look into a single extended historical case of the extension of the discourse about God beyond the Christian West, the discourse on God proffered by Western Jesuit missionaries in India from the sixteenth to twentieth centuries. Second, I place next to that Jesuit learning the instance of a famed Hindu theologian’s discourse on God, God’s perfections, and their moral implications. Third, I briefly step back and assess the dangers and fruitful prospects inherent in thinking about God and morality in an interreligious context. (shrink)

In this paper, we argue that our moral concern for future well-being should reduce over time due to important practical considerations about how humans interact with spacetime. After surveying several of these considerations (around equality, special duties, existential contingency, and overlapping moral concern) we develop a set of core principles that can both explain their moral significance and highlight why this is inherently bound up with our relationship with spacetime. These relate to the equitable distribution of (1) moral concern in (...) a universe that we can only causally affect in one temporal direction; (2) access to the benefits from using spacetime as a resource; and (3) the burdens of care given (1) and (2). We conclude by considering the practical implications of our argument and find that, while it is often assumed that a preference for present over future well-being weakens the case for existential risk mitigation, this likely is not the case. (shrink)

This article focuses mainly on (1) the policy of Delft University of Technology since 1992 as regards the university-wide introduction of a compulsory course on ethics and engineering, and (2) the ideal structure of such a course, including the educational goals of the course.

One group of commentators takes book 10 as determinative and thus tortures the text in book 1 to say the same thing. This position is described as intellectualist or exclusivist and produces certain puzzles in reading Aristotle’s ethical theory. These puzzles are not benign since the privileged position given wisdom in book 10 seems at odds with the discussion of virtue in book 1 and its development in the Nicomachean Ethics as a whole. Indeed, Aristotle appears inconsistent or even contradictory, (...) recommending in these two brief chapters of book 10 a life devoted to contemplation that only grudgingly allows for the necessity of the practical life discussed in such detail in the rest of his ethical works. If this is the case, under what conditions are we expected to forgo contemplation to engage in the various activities of the moral virtues? Since no conditions are spelled out in the text, the range of speculation is confused and ways around the apparent inconsistencies complex. (shrink)

This article considers how legislators should respond to evidence that identifies a common and widely accepted parental practice as a potential source of harm to children, using domestic exposure to environmental tobacco smoke as a test case. It is claimed that children are parties to the Harm Principle, and that the State has an obligation to protect children from exposure to harm. Parental prerogative is limited by the need to avoid harming children. That said, there is considerable uncertainty about (...) what is harmful to children. Several sources of uncertainty, both empirical and conceptual, are explored, in order to demonstrate the complexity of the task legislators face. Seven considerations that are relevant to decisions about legislation of harmful parental practices are outlined, and these considerations are then employed to assess the case in favour of legislating to prohibit the exposure of children to environmental tobacco smoke in domestic settings. (shrink)

This article argues that within the context of settler colonialism, the goal of transitional justice must be decolonisation. Settler colonialism operates according to a logic of elimination that aims to affect the disappearance of Indigenous populations in order to build new societies on expropriated land. This eliminatory logic renders the death of Indigenous peoples “ungrievable”. Therefore, this article proposes a decolonising transitional justice premised on a politics of grief that re-conceptualises Indigenous death as grievable, posing a challenge to the logic (...) of elimination and advancing a “decolonisation of the mind”, and resists a purely affective concept of grief in order to mobilise grief as a political resource to demand transformative structural justice. This article consider deaths at Canada’s Indian Residential Schools as a case study of ungrievability under settler colonialism and the Project of Heart as an illustration of a decolonising form of informal transitional justice. (shrink)

Most of these eight essays on contemporary figures were given as lectures or speeches between 1990 and 1996. A piece on Ernst Cassirer’s humanistic legacy gives the collection its title, but the other subjects treated are far-ranging: Karl Jaspers on the clash of religious cultures, Georg Henrik von Wright’s noncognitive ethics, Gershom Scholem’s magisterial biography of the kabbalist Sabbatai Sevi, Karl-Otto Apel’s hermeneutics, Johann Baptist Metz on the Jewish element in Christianity, Michael Theunissen on the relation of negative theology to (...) social theory, and a review of the work of script writer and film director Alexander Kluge. Habermas unifies this panoply by his fascination with the transformation of the modern West’s key symbols through their confrontation with other cultures. Prime among these symbols are language and religious doctrines, especially Christian and Jewish. When he examines this general theme in particular cases, Habermas first presents an exposé of a thinker, then raises critical questions, and finally points out insights of enduring significance. One decided advantage of his method is its attention to clarity and organization. Probably because these essays were originally delivered orally, they never leave the reader in doubt as to what topics they will handle and when each is being taken up. (shrink)

The controversy surrounding the use of hydroxychloroquine, an antimalarial drug, for COVID-19 has raised numerous ethical and policy problems. Since the suggestion that HCQ has potential for COVID-19, there have been varying responses from clinicians and healthcare institutions, ranging from adoption of protocols using HCQ for routine care to the conduct of randomised controlled trials to an effective system-wide prohibition on its use for COVID-19. In this article, we argue that the concept of ‘disease public profile’ has become a prominent, (...) if not the sole, determinant in decision-making across various healthcare responses to the pandemic. In the case of COVID-19, the disease’s public profile is based on clinical and non-clinical factors that include contagiousness, clinical presentation and media coverage. In particular, we briefly examine the dangers of a heightened public profile in magnifying the inequality of diseases and undermining three key ethical concepts, namely evidence-based practice, sustainable allocation and meaningful consent. (shrink)

Background: In Switzerland, non-medical right-to-die organisations such as Exit Deutsche Schweiz and Dignitas offer suicide assistance to members suffering from incurable diseases. Objectives: First, to determine whether differences exist between the members who received assistance in suicide from Exit Deutsche Schweiz and Dignitas. Second, to investigate whether the practices of Exit Deutsche Schweiz have changed since the 1990s. Methods: This study analysed all cases of assisted suicide facilitated by Exit Deutsche Schweiz (E) and Dignitas (D) between 2001 and 2004 and (...) investigated by the University of Zurich’s Institute of Legal Medicine (E: n = 147; D: n = 274, total: 421). Furthermore, data from the Exit Deutsche Schweiz study which investigated all cases of assisted suicide during the period 1990–2000 (n = 149) were compared with the data of the present study. Results: More women than men were assisted in both organisations (D: 64%; E: 65%). Dignitas provided more assistance to non-residents (D: 91%; E: 3%; p = 0.000), younger persons (mean age in years (SD): D: 64.5 (14.1); E: 76.6 (13.3); p = 0.001), and people suffering from fatal diseases such as multiple sclerosis and amyotrophic lateral sclerosis (D: 79%; E: 67%; p = 0.013). Lethal medications were more often taken orally in cases assisted by Dignitas (D: 91%; E: 76%; p = 0.000). The number of women and the proportion of older people suffering from non-fatal diseases among suicides assisted by Exit Deutsche Schweiz has increased since the 1990s (women: 52% to 65%, p = 0.031; mean age in years (SD): 69.3 (17.0) to 76.9 (13.3), p = 0.000), non-fatal diseases: 22% to 34%, p = 0.026). Conclusions: Weariness of life rather than a fatal or hopeless medical condition may be a more common reason for older members of Exit Deutsche Schweiz to commit suicide. The strong over-representation of women in both Exit Deutsche Schweiz and Dignitas suicides is an important phenomenon so far largely overlooked and in need of further study. (shrink)

Rights have two properties which prima facie appear to be inconsistent. The first is that they are conditional in the sense that one some occasions it is always justifiable for someone to act in a way which appears to be inconsistent with someone else's rights, such as when the defence of necessity applies. The second is that rights are indefeasible in the sense that they are not subject to being defeated our outweighed by utilitarian or policy considerations. If we view (...) rules and the rights which they establish as being subject to a ceteris paribus clause, the form of which generates out the exceptions, the conditionality of rights becomes reconcilable with their nondefeasibility. Such a view of rules and rights would entail that the goals of the law and their orderings be considered as a part of the law. When so viewed, propositions about goals and their orderings become legitimate premises for legal reasoning, furnishing solutions to hard cases in the law of torts, without resort to balancing of interests or judicial discretion. (shrink)

Our study presents an overview of the issues that were brought forward by participants of a moral case deliberation (MCD) project in two elderly care organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting of care providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within two care institutions (residential homes and nursing homes). Care (...) providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: ‘resident’s behavior’, ‘divergent perspectives on good care’ and ‘organizational context’. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identify moral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Once care providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical ‘blind spots’. (shrink)

This article focuses mainly on (1) the policy of Delft University of Technology since 1992 as regards the university-wide introduction of a compulsory course on ethics and engineering, and (2) the ideal structure of such a course, including the educational goals of the course.

Horace addresses Torquatus again in Carm. 4.7. There the poet distinguishes three cardinal qualities: Torquatus's genus, his facundia, and hispietas. Since Horace distinguishes them they were no doubt qualities on which Torquatus prided himself, but they are, in any case, the key by which Torquatus slips into Horace's lyric. I suggest that we can use the same key to open up the Epistle, and that by taking up these qualities we have ready access to the wit of the poem, (...) carefully predicated upon its addressee. (shrink)

Our study presents an overview of the issues that were brought forward by participants of a moral case deliberation (MCD) project in two elderly care organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting of care providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within two care institutions (residential homes and nursing homes). Care (...) providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: ‘resident’s behavior’, ‘divergent perspectives on good care’ and ‘organizational context’. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identify moral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Once care providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical ‘blind spots’. (shrink)

Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes. In both of these nursing homes the MCD groups had a heterogeneous composition and were (...) organized apart from existing institutional communication structures. As part of a naturalistic evaluation, systematic observations, interviews and focus groups were completed. The findings indicate that the heterogeneous composition and MCD meetings separate from existing structures have benefits. However, the participants also reported negative experiences. This gives rise to the question whether a mixed MCD group which meets separately is an effective way to embed MCD as an instrument for reflection on moral issues in daily practice. We conclude that there is no single answer to that question. In the end, the two implementation strategies (i.e. within existing communication structures and a mixed MCD group) can be complementary to each other. (shrink)

Within many animal taxa there is a trend for the species of larger body size to eat food of lower caloric value. For example, most large extant lizards are herbivorous. Reasonable arguments based on energetic considerations are often invoked to explain this trend, yet, while these factors set limits to feasible body size, they do not in themselves mathematically produce optimum body sizes. A simple optimization model is developed here which considers food search, capture, and eating rates and the metabolic (...) cost of these activities for animals of different sizes. The optimization criterion is defined as the net caloric gain a consumer accrues per day. This model does produce an optimum intermediate body size which increases with food quality - not the reverse. This discrepancy is accounted for, however, because the model also predicts that body size should be even more sensitive to increases in food abundance. In nature, many poor quality foods are also relatively abundant foods, hence the consumers eating them may maximize their daily energetic profit by evolving a relatively large body size. Optimum consumer body size also decreases with increases in consumer metabolic rate and prey speed. (shrink)

The Declaration of Helsinki and the Council of the International Organization of Medical Sciences provide guidance on standards of care and prevention in clinical trials. In the current and increasingly challenging research environment, the ethical status of a trial design depends not only on protection of participants, but also on social value, feasibility, and scientific validity. Using the example of a study assessing efficacy of a vaccine to prevent human papilloma virus in HIV-1 infected adolescent girls in low resource countries (...) without access to the vaccine, we compare several trial designs which rank lower on some criteria and higher on others, giving rise to difficult trade-offs. This case demonstrates the need for developing more nuanced guidance documents to help researchers balance these often conflicting criteria. (shrink)

Organizational sensemaking is crucial for resource planning and crisis management since facing complex strategic problems that exceed their capacity and ability, such as crises, forces organizations to engage in inter-organizational collaboration, which leads to obtaining individual and diverse perspectives to comprehend the issues and find solutions. This online qualitative survey study examines how Norwegian Sea Rescue Society employees perceived the concept of an organizational crisis and how they sensed their co-workers react to it. The scope was the ongoing COVID-19 pandemic, (...) a global event affecting all countries and organizations and responding similarly globally. Data were collected during the Fall of 2020. The instrument of choice was the Internal Crisis Management and Crisis Communication survey. The results showed that the overall sample strongly believed in their organization’s overall resilience level. However, a somewhat vague understanding of roles and responsibilities in a crisis where detected, together with some signs of informal communication, rumor spreading, misunderstanding, frustration, and insecurity. This study contributes to the academic field of organizational research, hence crisis management and sensemaking, and could be valuable to managers and decision-makers across sectors. Increased knowledge about how employees react to a crisis may help optimize internal crisis management planning and utilize robust mitigation and response strategies. (shrink)

In a recent article, C. H. Kahn addresses an ‘old scholarly myth’, namely the idea that Book I of the Republic began life as an earlier, independent dialogue and was subsequently adapted to serve as a prelude to the much longer work that we know. The case for this hypothesis rests both on stylometric considerations and on the many ‘Socratic’ features that Book I, unlike the rest of the Republic, shares with Plato's earlier works. Having disposed of the positive (...) arguments in favour of the ‘myth’, Kahn turns to the contrary—and in his view overwhelming—evidence that Book I was composed from the start as an integral part of the longer Republic. He catalogues 12 passages in Book I, accounting for roughly half its length, whose full significance will, he argues, only emerge if they are seen as instances of prolepsis, deliberate anticipations of what is to come in later books. (shrink)

We will show that there is a strong form of emergence in cell biology. Beginning with C.D. Broad's classic discussion of emergence, we distinguish two conditions sufficient for emergence. Emergence in biology must be compatible with the thought that all explanations of systemic properties are mechanistic explanations and with their sufficiency. Explanations of systemic properties are always in terms of the properties of the parts within the system. Nonetheless, systemic properties can still be emergent. If the properties of the components (...) within the system cannot be predicted, even in principle, from the behavior of the system's parts within simpler wholes then there also will be systemic properties which cannot be predicted, even in principle, on basis of the behavior of these parts. We show in an explicit case study drawn from molecular cell physiology that biochemical networks display this kind of emergence, even though they deploy only mechanistic explanations. This illustrates emergence and its place in nature. (shrink)

Patient narratives from two investigational deep brain stimulation trials for traumatic brain injury and obsessive‐compulsive disorder reveal that injury and illness rob individuals of personal identity and that neuromodulation can restore it. The early success of these interventions makes a compelling case for continued post‐trial access to these technologies. Given the centrality of personal identity to respect for persons, a failure to provide continued access can be understood to represent a metaphorical identity theft. Such a loss recapitulates the pain (...) of an individual's initial injury or illness and becomes especially tragic because it could be prevented by robust policy. A failure to fulfill this normative obligation constitutes a breach of disability law, which would view post‐trial access as a means to achieve social reintegration through this neurotechnological accommodation. (shrink)

We present the case of a 36-year-old woman who has experienced three lost pregnancies; during the most recent loss, a full term pregnancy, she almost died from complications of placental abruption. She is now completing the 34th week of gestation and is experiencing symptoms similar to those under which she lost the previous pregnancy. Despite a lack of specific medical indications, the patient and her husband firmly but politely request that the attending obstetrician/perinatologist perform an immediate cesarean section in (...) order to alleviate the couple’s anxiety about possibly never having a family. Discussing the case are an experienced perinatologist, a neonatologist, a regional perinatal center coordinator, and a clinical ethicist. (shrink)

Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes. In both of these nursing homes the MCD groups had a heterogeneous composition and were (...) organized apart from existing institutional communication structures. As part of a naturalistic evaluation, systematic observations, interviews and focus groups were completed. The findings indicate that the heterogeneous composition and MCD meetings separate from existing structures have benefits. However, the participants also reported negative experiences. This gives rise to the question whether a mixed MCD group which meets separately is an effective way to embed MCD as an instrument for reflection on moral issues in daily practice. We conclude that there is no single answer to that question. In the end, the two implementation strategies (i.e. within existing communication structures and a mixed MCD group) can be complementary to each other. (shrink)

A 1999–2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to “best informants” in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. (...) The median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC. (shrink)

Objectives: To investigate the quality of consent gained for the use in research of tissue that is surplus after surgery. To compare the use of two consent forms: a simple locally introduced form and a more complex centrally instigated form. To discuss the attitudes of patients towards the use of their surplus tissue in research.Design: Data were collected through interviews and analysed with a combination of quantitative and qualitative analytical techniques.Participants and setting: Patients of the breast care unit at a (...) teaching hospital were interviewed at home or in a quiet room at the hospital.Results: 57 people were interviewed out of 81 approached, between October 2003 and March 2004. Most participants had a poor level of knowledge about the consent they had given, but reported being happy about having given it. The patients who had signed the locally introduced form had considerably more knowledge than those who had signed the centrally instigated form . Participants considered being well informed to be less important than believing that their opinions were valued and respected.Conclusions: The findings suggest that traditional models of informed consent are not universally applicable and, in this case, seem to overstate what people wish to know. The simple consent form achieved a better quality of informed consent and provided a better model of practice than the complex form, and it seemed that a focused approach to consent seeking is more effective and acceptable than more complex approaches. (shrink)