Emmanuel Levinas argues that justice is meaningful only to the extent that other persons are encountered in their individuality, as my neighbors, and not merely abstract citizens of a political community. That is, the political demand for justice arises from my ethical relationship with the other whose face I cannot look past. But despite his revolutionary ideas about the origins of justice, Levinas ultimately appeals to a very traditional view of justice in which persons are considered equal and comparable. and (...) responsibilities and rights are distributed evenly among them. In response to Levinas, I argue that insofar as justice is constructed by and for the ethicalrelationship, it must also be deconstructed by that relationship. If one takes seriously Levinas’s claim that asymmetrical ethical responsibility is the origin of justice, then one must also reject Levinas’s suggestion that justice involves viewing persons and responsibilities as comparable and symmetrical. (shrink)

Biological evolution provides a creative fount of complex and subtle adaptations, often surprising the scientists who discover them. However, because evolution is an algorithmic process that transcends the substrate in which it occurs, evolution’s creativity is not limited to nature. Indeed, many researchers in the field of digital evolution have observed their evolving algorithms and organisms subverting their intentions, exposing unrecognized bugs in their code, producing unexpected adaptations, or exhibiting outcomes uncannily convergent with ones in nature. Such stories routinely reveal (...) creativity by evolution in these digital worlds, but they rarely fit into the standard scientific narrative. Instead they are often treated as mere obstacles to be overcome, rather than results that warrant study in their own right. The stories themselves are traded among researchers through oral tradition, but that mode of information transmission is inefficient and prone to error and outright loss. Moreover, the fact that these stories tend to be shared only among practitioners means that many natural scientists do not realize how interesting and lifelike digital organisms are and how natural their evolution can be. To our knowledge, no collection of such anecdotes has been published before. This paper is the crowd-sourced product of researchers in the fields of artificial life and evolutionary computation who have provided first-hand accounts of such cases. It thus serves as a written, fact-checked collection of scientifically important and even entertaining stories. In doing so we also present here substantial evidence that the existence and importance of evolutionary surprises extends beyond the natural world, and may indeed be a universal property of all complex evolving systems. (shrink)

Methods Young healthy heterosexual couples underwent sleep-lab-based polysomnography of two sleeping arrangements: individual sleep and co-sleep. Individual and dyadic sleep parameters (i.e., synchronization of sleep stages) were collected. The latter were assessed using cross-recurrence quantification analysis. Additionally, subjective sleep quality, relationship characteristics, and chronotype were monitored. Data were analyzed comparing co-sleep vs. individual sleep. Interaction effects of the sleeping arrangement with gender, chronotype, or relationship characteristics were moreover tested. Results As compared to sleeping individually, co-sleeping was associated with about 10% (...) more REM sleep, less fragmented REM sleep (p = 0.008), longer undisturbed REM fragments (p = 0.0006), and more limb movements (p = 0.007). None of the other sleep stages was significantly altered. Social support interacted with sleeping arrangement in a way that individuals with suboptimal social support showed the biggest impact of the sleeping arrangement on REM sleep. Sleep architectures were more synchronized between partners during co-sleep (p = 0.005) even if wake phases were excluded (p = 0.022). Moreover, sleep architectures are significantly coupled across a lag of ± 5min. Depth of relationship represented an additional significant main effect regarding synchronization, reflecting a positive association between the two. Neither REM sleep nor synchronization was influenced by gender, chronotype, or other relationship characteristics. Conclusion Depending on the sleeping arrangement, couple's sleep architecture and synchronization show alterations that are modified by relationship characteristics. We discuss that these alterations could be part of a self-enhancing feedback loop of REM sleep and sociality and a mechanism through which sociality prevents mental illness. (shrink)

El objetivo principal de este trabajo es dar a conocer en lengua castellana un texto del profesor Thomas Buchheim acerca de la «última prueba» de la existencia de Dios a partir del futurum exactum de su maestro, Robert Spaemann. Para ello se analiza en primer lugar el argumento del futurum exactum del «haber-sido». Seguidamente se exponen las objeciones contra el argumento presentado de esta forma. A continuación, la presentación del argumento a partir del futurum exactum de la verdad. Finalmente se (...) plantean los rasgos personales de la capacidad de verdad que dan pie a considerar la necesidad de una conciencia personal para poder hablar de verdad en sentido propio. (shrink)

Platonic discourses concerning the soul are incredibly rich and multitiered. Plato's own diverse and disparate arguments and images offer competing accounts of how we are to understand the nature of the soul. Consequently, it should come as no surprise that the accounts of Platonists who engage Plato’s dialogues are often riddled with questions. This volume takes up the theories of well-known philosophers and theologians, including Plato, Plotinus, Proclus, the emperor Julian, and Origen, as well as lesser-known but equally important figures (...) in a collection of essays on topics such as transmigration of the soul, the nature of the Platonist enlightenment experience, soul and gender, pagan ritual practices, Christian and pagan differences about the soul, mental health and illness, and many other topics. Contributors include Crystal Addey, Sara Ahbel-Rappe, Dirk Baltzly, Robert Berchman, Jay Bregman, Luc Brisson, Kevin Corrigan, John Dillon, John F. Finamore, Lloyd P. Gerson, Dorian Gieseler Greenbaum, Elizabeth Hill, Sarah Klitenic Wear, Danielle A. Layne, Ilaria L. E. Ramelli, Gregory Shaw, Svetla Slaveva-Griffine, Suzanne Stern-Gillet, Harold Tarrant, Van Tu, and John D. Turner. (shrink)

Researchers have argued that bilingual speakers experience less emotion in their second language. However, some studies have failed to find differences in emotionality between first and second lang...

We hypothesize that juvenile baboons are less efficient foragers than adult baboons owing to their small size, lower level of knowledge and skill, and/or lesser ability to maintain access to resources. We predict that as resources are more difficult to extract, juvenile baboons will demonstrate lower efficiency than adults will because of their lower levels of experience. In addition, we hypothesize that juvenile baboons will be more likely to allocate foraging time to easier-to-extract resources owing to their greater efficiency in (...) acquiring those resources.We use feeding efficiency and time allocation data collected on a wild, free-ranging, non-provisioned population of chacma baboons (Papio hamadryas ursinus) in the Moremi Wildlife Reserve, Okavango Delta, Botswana to test these hypotheses. The major findings of this study are:1. Juvenile baboons are significantly less efficient foragers than adult baboons primarily for difficult-to-extract resources.We propose that this age-dependent variation in efficiency is due to differences in memory and other cognitive functions related to locating food resources, as is indicated by the greater amount of time juvenile baboons spend searching for food. There is no evidence that smaller body size or competitive disruption influences the differences in return rates found between adult and juvenile baboons in this study.2. An individual baboon’s feeding efficiency for a given resource can be used to predict the duration of its foraging bouts for that resource.These results contribute both to our understanding of the ontogeny of behavioral development in nonhuman primates, especially regarding foraging ability, and to current debate within the field of human behavioral ecology regarding the evolution of the juvenile period in primates and humans. (shrink)

Why do some parents refuse to vaccinate their children? Why do some people keep guns at home, despite scientific evidence of risk to their family members? And why do people use antibiotics for illnesses they cannot possibly alleviate? When it comes to health, many people insist that science is wrong, that the evidence is incomplete, and that unidentified hazards lurk everywhere. In Denying to the Grave, Gorman and Gorman, a father-daughter team, explore the psychology of health science denial. Using several (...) examples of such denial as test cases, they propose six key principles that may lead individuals to reject "accepted" health-related wisdom: the charismatic leader; fear of complexity; confirmation bias and the internet; fear of corporate and government conspiracies; causality and filling the ignorance gap; and the nature of risk prediction. The authors argue that the health sciences are especially vulnerable to our innate resistance to integrate new concepts with pre-existing beliefs. This psychological difficulty of incorporating new information is on the cutting edge of neuroscience research, as scientists continue to identify brain responses to new information that reveal deep-seated, innate discomfort with changing our minds. Denying to the Grave explores risk theory and how people make decisions about what is best for them and their loved ones, in an effort to better understand how people think when faced with significant health decisions. This book points the way to a new and important understanding of how science should be conveyed to the public in order to save lives with existing knowledge and technology. (shrink)

The effective provision of psychotherapy services to individuals with intellectual disability requires consideration of ethical issues related to clinical competence, access to services, obligations to multiple parties, guardianship, and appropriate assessment practices. This article provides an overview of major ethical considerations with guidance for clarifying and resolving common ethical concerns. Psychologists are encouraged to expand access to psychotherapy services for this population while maintaining awareness of potential modifications, training needs, and boundaries of professional competence. The authors provide recommendations and resources (...) for effective and ethical treatment of psychotherapy clients with intellectual disabilities. (shrink)

Despite the enormous progress made in the advancement of health technologies over the last century, infectious diseases continue to cause significant morbidity and mortality in developing countries. Neglected diseases are a subset of infectious diseases that lack treatments that are effective, simple to use, or affordable. Neglected diseases primarily affect populations in poor countries that do not constitute a lucrative market sector, thus failing to provide incentives for the pharmaceutical industry to conduct R&D for these diseases. Of the treatments that (...) do exist for neglected diseases, most are completely out-dated, with poor side-effect profiles, cumbersome logistics of administration, and inadequate efficacy. Historically, the impetus for a majority of neglected disease research was driven by early 20th-century colonialism, and in the post-colonial era, these diseases have been virtually ignored. Of the 1556 New Chemical Entities brought to market during the 30-year period from 1975 to 2004, only 20 — less than 0.02% — were for neglected diseases. (shrink)

There is an increased controversy surrounding Westerners' use of ayahuasca. One issue of importance is psychological resiliency of users and lack of screening by ayahuasca tourism groups in the Amazon. Given the powerful effects of ayahuasca coupled with lack of cultural support, Western users are at increased risk for psychological distress. Many Westerners who experience psychological distress following ayahuasca ceremonies report concurrently profound spiritual experiences. Because of this, it may be helpful to consider these episodes "spiritual emergencies," or crises resulting (...) from intense and transformative spiritual experiences. Although the author warns readers to avoid romantic comparisons of Western ayahuasca users to shamans, ethnographic data on indigenous shamanic initiates along with theory on liminality may be of some use to understand difficult experiences that accompany ayahuasca use. Given that psychotherapy is culturally sanctioned, therapists trained in treating spiritual crises can help Western ayahuasca users make meaning of their distress. Three case studies are offered as examples of individuals working through various sorts of crises following ayahuasca ceremonies. (shrink)

About one third of patients with epilepsy have seizures refractory to the medical treatment. Electrical stimulation mapping is the gold standard for the identification of “eloquent” areas prior to resection of epileptogenic tissue. However, it is time-consuming and may cause undesired side effects. Broadband gamma activity recorded with extraoperative electrocorticography during cognitive tasks may be an alternative to ESM but until now has not proven of definitive clinical value. Considering their role in cognition, the alpha and beta bands could further (...) improve the identification of eloquent cortex. We compared gamma, alpha and beta activity, and their combinations for the identification of eloquent cortical areas defined by ESM. Ten patients with intractable focal epilepsy participated in a delayed-match-to-sample task, where syllable sounds were compared to visually presented letters. We used a generalized linear model approach to find the optimal weighting of each band for predicting ESM-defined categories and estimated the diagnostic ability by calculating the area under the receiver operating characteristic curve. Gamma activity increased more in eloquent than in non-eloquent areas, whereas alpha and beta power decreased more in eloquent areas. Diagnostic ability of each band was close to 0.7 for all bands but depended on multiple factors including the time period of the cognitive task, the location of the electrodes and the patient’s degree of attention to the stimulus. We show that diagnostic ability can be increased by 3–5% by combining gamma and alpha and by 7.5–11% when gamma and beta were combined. We then show how ECoG power modulation from cognitive testing can be used to map the probability of eloquence in individual patients and how this probability map can be used in clinical settings to optimize ESM planning. We conclude that the combination of gamma and beta power modulation during cognitive testing can contribute to the identification of eloquent areas prior to ESM in patients with refractory focal epilepsy. (shrink)

"Here is a unique and penetrating postmodernist invitation to reread Pascal's Pensées. With a full control on two centuries of Pascalian hermeneutics, Sara Melzer leads her readers into a passionate quest far beyond the worn-out search for a paleontological reconstruction of the Pensées's hypothetical final form. She rightly and deeply understands Pascal's writing--écriture--as the complex story of the "Fall of Truth into language." Such a perspective gives to Pascal's fragments a rejuvenated life, a newness, a dramatic and powerful voice (...) for our own culture. In brief, a welcome breeze of fresh air in the Pascalian world!" --Edouard Morot-Sir, The University of North Carolina at Chapel Hill "By approaching Pascal's Pensées from the point of view of contemporary critical theory, Melzer sheds new light on this well-known work. Her argument is clear, lucid, and cogent. She has a firm grasp of the major issues at stake in debates among literary critics. I think this is an important work that will be of interest not only to Pascal specialists but also to people who work in the general area of literary theory.... One of the genuine strengths of the book is the author's ability to discern the theological implications of issues that preoccupy literary theorists. This is particularly important at a time when students of theology and religion are becoming more and more interested in literary theory. They will find this analysis of Pascal very suggestive." --Mark Taylor, Williams College. (shrink)

In this target article by Morain and Largent (2023), the authors focus on an investigator’s duty to patient-subjects specifically regarding incidental or collateral findings within the context of e...

Receiving a diagnosis of cancer can be devastating. Cancer continues to be one of the most feared diagnoses, and experiencing pain is a major fear for people diagnosed with cancer. Cancer pain is complex in aetiology and can be acute or chronic and can be caused by various compression, ischaemic, neuropathic or inflammatory processes. Many people with cancer will experience excruciating pain, which is often underreported and undertreated. The reasons for this are complex and include various factors including fears and (...) beliefs held by patients. Cognitive factors are important modulators of pain and the appraisals, meanings and beliefs that people have in relation to illness, cancer, and pain, have implications in regard to help-seeking behaviours and the coping strategies people adopt. Cancer pain can impact a range of psycho-social factors across its course. Cancer pain relates to higher rates of psychological distress, anxiety and low mood, and the perception of pain intensity is, in turn, influenced by psychological factors. Cancer pain can negatively affect psychological health, and psycho-social factors can affect the pain experience. It has been suggested that people with a life-limiting illness experience ‘total pain’, and this can encompass psychological, social, practical, spiritual domains. Research demonstrates that cancer is predominantly an illness affecting older people, yet there is a higher risk of under-treated pain in this age group and there is a paucity of research into the subjective experiences of older people managing their cancer pain. Many older people are required to self-manage cancer pain at home as outpatients, due to drivers to keep people out of inpatient care, such as the high healthcare costs of inpatient treatment, and patients wanting to manage their illness, and die, at home. Our own research into this area found that the self-management of cancer pain involves a sequential and temporal process, which centres on perceptions of control. We describe how the older people in our study experienced a perceived loss of control, followed by a sense of gaining control over pain through various experience of certain internal and external factors. The assessment and treatment of physical pain should be done in combination with assessment and treatment of psycho-social and spiritual pain, and interventions for cancer pain need to focus on increasing positive affect and reducing helplessness. No person should suffer with poorly controlled pain and we argue for the need for further research in this area to ensure adequate treatment for all.Clinical Implications: Assessment and treatment of physical pain in people with cancer needs to be conducted in combination with assessment and treatment of psycho-social issues and spiritual pain. Psychological and behavioural approaches have strong evidence supporting their efficacy for reducing cancer pain. Interventions should target helplessness and focus on increasing positive affect through positive psychological states including fighting spirit and resilience. Person-centred interventions that focus on helping people with the search for meaning may help those with cancer pain derive positive benefits. (shrink)

Public discourse on race-specific medicine typically erects a wall between the scientific use of race as a biological category and the ideological battle over race as a social identity. Scientists often address the potential for these therapeutics to reinforce a damaging understanding of “race” with precautions for using them rather than questioning their very development. For example, Esteban Gonzalez Burchard, an associate professor of medicine and biopharmaceutical sciences at the University of California, San Francisco, states, “We do see racial differences (...) between populations and shouldn’t just close our eyes. Unfortunately, race is a politically charged topic, and there will be evildoers. But the fear should not outweigh the benefit of looking.” Although it is recognized that ideology influences thesocialmeaning of race, it is usually assumed that there is a separate, prior scientific understanding of race that is not contaminated by politics. (shrink)

The crisis of western civilization is a crisis of public philosophy. This is the charge of Public Philosophy and Political Science, a stunning new collection of essays edited by E. Robert Statham Jr. Vividly cataloging the decay of the moral and intellectual foundations of civic liberty, the book portrays a generation of Americans alienated from institutions built on public philosophy. The work exposes the failure of America's political scientists to acknowledge and understand this alarming crisis in the American body politic. (...) The distinguished contributors examine the evolution of public philosophy; the inextricable relationship between politics and philosophy; and the interplay between public philosophy, the constitution, natural law, and government. They reveal the dire threat to deliberative democracy and the fundamental order of constitutional society posed by public philosophy's waning power to refine, cultivate, and civilize. The work is an indictment of a society which has discarded a way of life rooted in natural law, democracy and the traditions of civility; and is a denunciation of an educated elite that has divorced itself from the standards upon which public philosophy rests. It is essential reading for philosophers and political and social scientists seeking to resurrect the standards of American public life. (shrink)

A common reductionist assumption is that macro-scale behaviors can be described "bottom-up" if only sufficient details about lower-scale processes are available. The view that an "ideal" or "fundamental" physics would be sufficient to explain all macro-scale phenomena has been met with criticism from philosophers of biology. Specifically, scholars have pointed to the impossibility of deducing biological explanations from physical ones, and to the irreducible nature of distinctively biological processes such as gene regulation and evolution. This paper takes a step back (...) in asking whether bottom-up modeling is feasible even when modeling simple physical systems across scales. By comparing examples of multi-scale modeling in physics and biology, we argue that the “tyranny of scales” problem presents a challenge to reductive explanations in both physics and biology. The problem refers to the scale-dependency of physical and biological behaviors that forces researchers to combine different models relying on different scale-specific mathematical strategies and boundary conditions. Analyzing the ways in which different models are combined in multi-scale modeling also has implications for the relation between physics and biology. Contrary to the assumption that physical science approaches provide reductive explanations in biology, we exemplify how inputs from physics often reveal the importance of macro-scale models and explanations. We illustrate this through an examination of the role of biomechanics modeling in developmental biology. In such contexts, the relation between models at different scales and from different disciplines is neither reductive nor completely autonomous, but interdependent. (shrink)

Categorical loudness scaling (CLS) measures provide useful information about an individual’s loudness perception across the dynamic range of hearing. A probability model of CLS categories has previously been described as a multi-category psychometric function (MCPF). In the study, a representative “catalog” of potential listener MCPFs was used in conjunction with maximum-likelihood estimation to derive CLS functions for participants with normal hearing and with hearing loss. The approach of estimating MCPFs for each listener has the potential to improve the accuracy of (...) the CLS measurements, particularly when a relatively low number of data points are available. The present study extends the MCPF approach by using Bayesian inference to select stimulus parameters that are predicted to yield maximum expected information (MEI) during data collection. The accuracy and reliability of the MCPF-MEI approach were compared to the standardized CLS measurement procedure (ISO16832:2006). A non-adaptive, fixed-level, paradigm served as a “gold-standard” for this comparison. The test time required to obtain measurements in the standard procedure is a major barrier to its clinical uptake. Test time was reduced from approximately 15 minutes to approximately 3 minutes with the MEI-adaptive procedure. Results indicated that the test-retest reliability and accuracy of the MCPF-MEI adaptive procedures were similar to the standardized CLS procedure. Computer simulations suggest that the reliability and accuracy of the MEI procedure were limited by intrinsic uncertainty of the listeners represented in the MCPF catalog. In other words, the MCPF provided insufficient predictive power to significantly improve adaptive-tracking efficiency under practical conditions. Concurrent optimization of both the MCPF catalog and the MEI-adaptive procedure have the potential to produce better results. Regardless of the adaptive-tracking method used in the CLS procedure, the MCPF catalog remains clinically useful for enabling maximum-likelihood determination of loudness categories. (shrink)

Recent research in ethics education shows a potentially problematic variation in content, curricular materials, and instruction. While ethics instruction is now widespread, studies have identified significant variation in both the goals and methods of ethics education, leaving researchers to conclude that many approaches may be inappropriately paired with goals that are unachievable. This paper speaks to these concerns by demonstrating the importance of aligning classroom-based assessments to clear ethical learning objectives in order to help students and instructors track their progress (...) toward meeting those objectives. Two studies at two different universities demonstrate the usefulness of classroom-based, formative assessments for improving the quality of students’ case responses in computational modeling and research ethics. (shrink)

Withholding or withdrawing life-saving ventilators can become necessary when resources are insufficient. In the USA, such rationing has unique social justice dimensions. Structural elements of dominant allocation frameworks simultaneously advantage white communities, and disadvantage Black communities—who already experience a disproportionate burden of COVID-19-related job losses, hospitalisations and mortality. Using the example of New Jersey’s Crisis Standard of Care policy, we describe how dominant rationing guidance compounds for many Black patients prior unfair structural disadvantage, chiefly due to the way creatinine and (...) life expectancy are typically considered.We outline six possible policy options towards a more just approach: improving diversity in decision processes, adjusting creatinine scores, replacing creatinine, dropping creatinine, finding alternative measures, adding equity weights and rejecting the dominant model altogether. We also contrast these options with making no changes, which is not a neutral default, but in separate need of justification, despite a prominent claim that it is simply based on ‘objective medical knowledge’. In the regrettable absence of fair federal guidance, hospital and state-level policymakers should reflect on which of these, or further options, seem feasible and justifiable.Irrespective of which approach is taken, all guidance should be supplemented with a monitoring and reporting requirement on possible disparate impacts. The hope that we will be able to continue to avoid rationing ventilators must not stand in the way of revising guidance in a way that better promotes health equity and racial justice, both to be prepared, and given the significant expressive value of ventilator guidance. (shrink)

Top-down causation is often taken to be a metaphysically suspicious type of causation that is found in a few complex systems, such as in human mind-body relations. However, as Ellis and others have shown, top-down causation is ubiquitous in physics as well as in biology. Top-down causation occurs whenever specific dynamic behaviors are realized or selected among a broader set of possible lower-level states. Thus understood, the occurrence of dynamic and structural patterns in physical and biological systems presents a problem (...) for reductionist positions. We illustrate with examples of universality and functional equivalence classes how higher-level behaviors can be multiple realized by distinct lower-level systems or states. Multiple realizability in both contexts entails what Ellis calls “causal slack” between levels, or what others understand as relative explanatory autonomy. To clarify these notions further, we examine procedures for upscaling in multi-scale modeling. We argue that simple averaging strategies for upscaling only work for simplistic homogenous systems, because of the scale-dependency of characteristic behaviors in multi-scale systems. We suggest that this interpretation has implications for what Ellis calls mechanical top-down causation, as it presents a stronger challenge to reductionism than typically assumed. (shrink)

The COVID‐19 pandemic exposes underlying inequalities in our socio‐economic and health systems, such as gender‐based violence (GBV). In emergencies, particularly ones that involve quarantine, GBV often increases. Policymakers must utilize community expertise, technology and existing global guidelines to disrupt these trends in the early stages of the COVID‐19 epidemic. Gender norms and roles relegating women to the realm of care work puts them on the frontlines in an epidemic, while often excluding them from developing the response. It is critical to (...) value women’s roles in society and include their voices in the decision‐making process to avoid unintended consequences and ensure a comprehensive response that caters to the needs of the most vulnerable groups. (shrink)

Strategic games require reasoning about other people’s and one’s own beliefs or intentions. Although they have clear commonalities with psychological tests of theory of mind, they are not clearly related to theory of mind tests for children between 9 and 10 years of age “Flobbe et al. J Logic Language Inform 17(4):417–442 (2008)”. We studied children’s (5–12 years of age) individual differences in how they played a strategic game by analyzing the strategies that they applied in a zero, first, and (...) second-order reasoning task. For the zero-order task, we found two subgroups with different accuracy levels. For the first-order task, subgroups of children applied different suboptimal strategies or an optimal strategy. For the second-order task only suboptimal strategies were present. Strategy use for all tasks was related to age. The 5- and 6-year old children were additionally tested on theory of mind understanding and executive functioning. Strategy-use in these children was related to working memory, but not to theory of mind after correction for age, verbal ability and general IQ. (shrink)

Inclusion of children in medical decision making, to the extent of their ability and interest in doing so, should be the default position, ensuring that children are routinely given a voice. However, optimizing the involvement of children in their health care decisions remains challenging for clinicians. Missing from the literature is a stepwise approach to assessing when and how a child should be included in medical decision making. We propose a systematic approach for doing so, and we apply this approach (...) in a discussion of two challenging clinical cases. The approach is informed by a literature review, and is anchored by case studies of teenagers' refusal of clinical care, regulatory requirements for research assent, and the accepted approach to involving cognitively impaired adults in medical decisions. (shrink)