Unnecessary health care is a tremendous problem that negatively impacts individuals and also increases health care costs across the system. While much scholarly attention has been paid to the role of patients and providers, payors' role in contributing to the problem is underexplored. The article recommends that payors should nudge providers away from unnecessary care by requiring electronic alerts intended to deter unnecessary care.

Many health care systems include programs that allow patients in exceptional circumstances to access medical interventions of as yet unproven benefit. In this article we consider the ethical justifications for—and demands on—these special access programs (SAPs). SAPs have a compassionate basis: They give patients with limited options the opportunity to try interventions that are not yet approved by standard regulatory processes. But while they signal that health care systems can and will respond to individual suffering, SAPs have several disadvantages, including (...) the potential to undermine regulatory and knowledge-generation structures that constitute significant public goods. The “balance” between these considerations depends in part on how broadly SAPs are used, but also on whether SAPs can be made to contribute to the generation of knowledge about the effects of health interventions. We argue that patients should usually be required to contribute outcome data while using SAPs. (shrink)

In this paper, we examine recent critiques of the debate about defining disease, which claim that its use of conceptual analysis embeds the problematic assumption that the concept is classically structured. These critiques suggest, instead, developing plural stipulative definitions. Although we substantially agree with these critiques, we resist their implication that no general definition of “disease” is possible. We offer an alternative, inductive argument that disease cannot be classically defined and that the best explanation for this is that the concept (...) is structured as a cluster. We further argue that we do not need to reject the possibility of defining the general concept “disease” to legitimate developing stipulative definitions of disease that are relative to particular purposes. A cluster definition of disease is compatible with contextually motivated definitions, which may be considered précisifications of the more general cluster concept. (shrink)

This article reports the findings of a qualitative study that explored the organizational influences on moral distress for health professionals working in pediatric intensive care units across Canada. Participants were recruited to the study from PICUs across Canada. The PICU is a high-tech, fast-paced, high-pressure environment where caregivers frequently face conflict and ethical tension in the care of critically ill children. A number of themes including relationships with management, organizational structure and processes, workload and resources, and team dynamics were identified. (...) This study provides a rare and important multi-disciplinary perspective on this topic and the findings have implications for administrators and leaders who seek to improve the moral climate of healthcare delivery. (shrink)

Recently, concerns have been raised about the phenomenon of ‘overdiagnosis’, the diagnosis of a condition that is not causing harm, and will not come to cause harm. Along with practical, ethical, and scientific questions, overdiagnosis raises questions about our concept of disease. In this paper, we analyse overdiagnosis as an epistemic problem and show how it challenges many existing accounts of disease. In particular, it raises ques- tions about conceptual links drawn between disease and dysfunction, harm, and risk. We argue (...) that ‘disease’ should be considered a vague concept with a non-classical structure. On this view, overdiagnosed cases are ‘borderline’ cases of disease, falling in the zone between cases that are clearly disease, and cases that are clearly not disease. We then develop a pre ́cising definition of disease designed to provide practical help in preventing and limiting overdiagnosis. We argue that for this purpose, we can define disease as dysfunction that has a significant risk of causing severe harm to the patient. (shrink)

An increasing number of patients receive diagnoses of disease without having any symptoms. These include diseases detected through screening programs, as incidental findings from unrelated investigations, or via routine checks of various biological variables like blood pressure or cholesterol. In this article, we draw on narrative identity theory to examine how the process of making sense of being diagnosed with asymptomatic disease can trigger certain overlooked forms of harm for patients. We show that the experience of asymptomatic disease can involve (...) ‘mismatches’ between one’s beliefs about one’s health status on the one hand, and bodily sensations or past experience on the other. Patients’ attempts to integrate these diagnoses into their self-narratives often involve either forming inaccurate beliefs about bodily sensations and/or past experience, or coming to believe that feelings and experience do not necessarily track or predict health status, leading to an ongoing sense of vulnerability to ill health. These resulting alterations in self-understanding can sometimes be considered harmful, in view of their implications for ascriptions of responsibility and ongoing anxiety. (shrink)

Although health and disease occupy opposite ends of a spectrum, distinguishing between them can be difficult. This is the “line-drawing” problem. The papers in this special issue engage with this challenge of delineating the boundaries of disease. The authors explore different views as to where the boundary between disease and nondisease lies, and related questions, such as how we can identify, or decide, what counts as a disease and what does not; the nature of the boundary between the two categories; (...) and what sorts of considerations could justify the location of that boundary. In exploring these questions, the papers draw on detailed clinical examples, provide theoretical critiques of existing approaches to disease definition, and offer new ways to conceptualize key features in debates about disease, including harm and biological dysfunction. (shrink)

Nursing faces an uncertain future as technological developments, structural changes within health systems and rapidly evolving health needs create new and challenging possibilities. This article draws on the results of a qualitative study undertaken with a range of Queensland nurse leaders to explore their perceptions of these changes. The study re‐surfaced, and allows for a re‐examination of, four issues that have long created tension within nursing and which continue to have a negative impact on the profession as a whole. These (...) are as follows: professionalisation; preparation of graduates; myths and narratives of nursing; and leadership. We provide a metaphor that imagines all of these tensions operating in dynamic interplay. The image is that of a Newton's Cradle – a model for energy and momentum. The metaphor allows one to see the wide context of changes affecting nursing and the significance of the interconnections. If tensions within nursing maintain their own integrity through containment, understanding and development, they remain in alignment, and energy is conserved rather than wasted or misdirected. It suggests that with increased awareness and attention paid to internal challenges, and by taking a broad‐based approach to systemic improvements, nursing could become more effective, progressive and proactive in shaping its own future. (shrink)

Positive claims about narrative approaches to healthcare suggest they could have many benefits, including supporting person-centred healthcare (PCH). Narrative approaches have also been criticised, however, on both theoretical and practical grounds. In this paper we draw on epistemological work on narrative and knowledge to develop a conception of narrative that responds to these concerns. We make a case for understanding narratives as accounts of events in which the way each event is described as influenced by the ways other events in (...) the narrative are described. This view of narratives recognises that they can contribute knowledge of different kinds of connections between events: not just causal, and not just of patient’s perspectives. Additionally, narratives can add further epistemic value by suggesting potentially useful lines of inquiry. We take narrative approaches to healthcare to include clinicians considering both patients’ informational offerings and their own professional understandings as narratives. On this understanding, our account is able to overcome the major theoretical and practical criticisms that have been levelled against the use of narrative approaches in healthcare, and can help to explain why and how narrative approaches are consistent with PCH. (shrink)

Surgery is an important part of contemporary health care, but currently much of surgery lacks a strong evidence base. Uptake of evidence-based medicine (EBM) methods within surgical research and among practitioners has been slow compared with other areas of medicine. Although this is often viewed as arising from practical and cultural barriers, it also reflects a lack of epistemic fit between EBM research methods and surgical practice. In this paper we discuss some epistemic challenges in surgery relating to this lack (...) of fit, and investigate how resources from feminist epistemology can help to characterize them. We point to ways in which these epistemic challenges may be addressed by gathering and disseminating evidence about what works in surgery using methods that are contextual, pluralistic, and sensitive to hierarchies. (shrink)

Evidence in medicine can come from more or less trustworthy sources and be produced by more or less reliable methods, and its interpretation can be disputed. As such, it can be unclear when disagreements in medicine result from different, but reasonable, interpretations of the available evidence and when they result from unreasonable refusals to consider legitimate evidence. In this article, we seek to show how assessments of the relevance and implications of evidence are typically affected by factors beyond that evidence (...) itself, such as our beliefs about the credibility of the speaker or source of the evidence. In evaluating evidence, there is thus a need for reflective awareness about why we accept or dismiss particular claims. (shrink)

A Citizen Public Debt Audit is an emancipatory praxis that can mobilize citizens to make legible public debt that has been accrued in their name. Ideally, it should hold creditors accountable for debt that is determined to be odious. This study examines the public debt crisis in Puerto Rico to illustrate the historically unjust circumstances under which public debt was accumulated on the island in the context of US federal taxation and economic policies. It explains how citizens are mobilizing via (...) a CPDA to make these circumstances legible and argues that citizens should not be obliged to service debt that was accrued contrary to their own welfare, especially if conditions of repayment threaten their current and future well-being. (shrink)

Lloyd (2009) contends that climate models are confirmed by various instances of fit between their output and observational data. The present paper argues that what these instances of fit might confirm are not climate models themselves, but rather hypotheses about the adequacy of climate models for particular purposes. This required shift in thinking—from confirming climate models to confirming their adequacy-for-purpose—may sound trivial, but it is shown to complicate the evaluation of climate models considerably, both in principle and in practice.

After a short introduction, this article contains the text of a previously unpublished interview with Raymond Aron in which he discusses what he takes to be the significance and continuing importance, if any, of the French Revolution. In the course of the interview Aron discusses different interpretations of the Revolution. The interview took place in February 1983.

To study Earth’s climate, scientists now use a variety of computer simulation models. These models disagree in some of their assumptions about the climate system, yet they are used together as complementary resources for investigating future climatic change. This paper examines and defends this use of incompatible models. I argue that climate model pluralism results both from uncertainty concerning how to best represent the climate system and from difficulties faced in evaluating the relative merits of complex models. I describe how (...) incompatible climate models are used together in ‘multi-model ensembles’ and explain why this practice is reasonable, given scientists’ inability to identify a ‘best’ model for predicting future climate. Finally, I characterize climate model pluralism as involving both an ontic competitive pluralism and a pragmatic integrative pluralism. (shrink)

On the 24th June 2015, Feminist Legal Studies and the London School of Economics Law Department hosted an afternoon event with Professor Wendy Brown, Class of 1936 First Professor of Political Science, University of California. Professor Brown kindly agreed to discuss her scholarship on feminist theory, and its relationship to both the law and neoliberalism. The event included an interview by Dr Katie Cruz and a Q&A session, which are presented here in an edited version of the transcript. Sumi (...) Madhock, Professor of Gender Studies, LSE chaired the interview and discussion and introduced Professor Brown’s work. Katie Cruz asked Wendy Brown to reflect upon topics that span her scholarship and activism, including the state of critical, feminist, and Left approaches to rights, neoliberalism, despair and utopianism, and the future of feminist theory and practice in the context of neoliberalism and current debates about intersectionality. Participants in the discussion asked questions on a wide range of issues, including the limits of feminist engagement with law as a tool for social change, the dominance of neoliberalism, imperialist feminism, Islamophobia, secularism, and our attachment to the figure of homo politicus. (shrink)

In 1946, after an eight-year debate with the New Critics, Charles Morris doggedly maintained that "an education which gave due place to semiotic would destroy at its foundations the cleavage and opposition of science and the humanities."1 This insistence on the unity of disciplines—the hallmark of the logical empiricist movement and its brainchild, The International Encyclopedia of Unified Science —effectively silenced semiotics as a force in American literary studies. For the New Critics' point of departure—and one of the few tenets (...) that they held in common—was the belief that art creates a mode of knowledge different in kind from that of practical or scientific discourse and that a criticism modeled on the latter would miss the essence of its subject matter. The quarrel, which continued unresolved during the polemics of the war years, now fuels the controversy between structuralism and post-structuralism. It lies at the very heart of the question of the relevance of semiotics to the humanities. · 1. Charles Morris, Signs, Language, and Behavior, in Writings on the General Theory of Signs , p. 327. Wendy Steiner, assistant professor of English at the University of Pennsylvania, is the author of Exact Resemblance to Exact Resemblance: The Literary Portraiture of Gertrude Stein. She has written a book on the relations between modern painting and literature and edited the proceedings of the 1978 Ann Arbor Conference on the Semiotics of Art. (shrink)

Whether in characterizing Catharine MacKinnon's theory of gender as itself pornographic or in identifying liberalism as unable to make good on its promises, Wendy Brown pursues a central question: how does a sense of woundedness become the basis for a sense of identity? Brown argues that efforts to outlaw hate speech and pornography powerfully legitimize the state: such apparently well-intentioned attempts harm victims further by portraying them as so helpless as to be in continuing need of governmental protection. "Whether (...) one is dealing with the state, the Mafia, parents, pimps, police, or husbands," writes Brown, "the heavy price of institutionalized protection is always a measure of dependence and agreement to abide by the protector's rules." True democracy, she insists, requires sharing power, not regulation by it; freedom, not protection.Refusing any facile identification with one political position or another, Brown applies her argument to a panoply of topics, from the basis of litigiousness in political life to the appearance on the academic Left of themes of revenge and a thwarted will to power. These and other provocations in contemporary political thought and political life provide an occasion for rethinking the value of several of the last two centuries' most compelling theoretical critiques of modern political life, including the positions of Nietzsche, Marx, Weber, and Foucault. (shrink)

Data from further human experiments touch four open questions in the target article. (1) Extinction of reward acquisition postulated by Depue & Collins's model could not be confirmed if correlating craving for, liking of, and satisfaction from smoking. (2) Intraindividual correspondence between responsivity to dopamine agonists and antagonists could likewise not be confirmed. (3) Nicotine craving and drug-induced hormone responses were not substantially correlated. (4) Low serotonin can be the cause and not just the moderator of dopaminergic sensitivity, and personality (...) correlates of low dopamine/low MAO (aggressive impulsive traits) can hardly be related to the positive emotion associated with dopaminergic activity. (shrink)

Wendy Brown's work commands widespread attention and respect, and there has been considerable interest as to how it would develop after "States of Injury." This book will not disappoint.

An esteemed scholar of Hinduism presents a groundbreaking interpretation of ancient Indian texts and their historic influence on subversive resistance. Ancient Hindu texts speak of the three aims of human life: dharma, artha, and kama. Translated, these might be called religion, politics, and pleasure, and each is held to be an essential requirement of a full life. Balance among the three is a goal not always met, however, and dharma has historically taken precedence over the other two qualities in Hindu (...) life. Here, historian of religions Wendy Doniger offers a spirited and close reading of ancient Indian writings, unpacking a long but unrecognized history of opposition against dharma. Doniger argues that scientific disciplines (shastras) have offered lively and continuous criticism of dharma, or religion, over many centuries. She chronicles the tradition of veiled subversion, uncovers connections to key moments of resistance and voices of dissent throughout Indian history, and offers insights into the Indian theocracy's subversion of science by religion today. (shrink)

_Eros for the Other_ takes up the problem of how truth claims and ethical norms can survive the increasingly radical recognition of the historical, cultural, pluralistic, and often ideological character of human experience. Sharing with postmodernism a suspicion of totalizing forms of knowledge and practice, Wendy Farley parts with postmodernism in defending the possibility of truth and ethics. Arguing that reality occurs in the concrete existence of actual beings, she develops an interpretation of the nature of knowledge as an (...) eros for the other—as an openness to the distinctive beauties and fragilities of other creatures. Employing Plato, Levinas, Hannah Arendt, Iris Murdoch, Anne Carson, and representatives of Continental philosophy and feminist theory, _Eros for the Other _constructs an original argument for the interdependence of truth, ethics, and pluralism. Through dialogues with Western thought and its critics an original vision emerges of the way reason discerns reality, experiences beauty, and lives compassionately in the midst of the plurality of concrete, historical existence. (shrink)

A participatory democracy necessarily minimizes legal restraints on its citizens, substituting, for the common good, moral obligations to contribute with their activities. This article argues that a democratic society is endangered unless both media and citizens accept reciprocal moral obligations related to the distribution and use of information. Journalists are expected to facilitate distribution of information and engage citizens usefully in the knowledge process, fueling the participatory engine that drives a democracy. Citizens, in return, have a reciprocal obligation to expose (...) themselves to useful information, respond publicly, tolerate (and even encourage) diversity, and protect media autonomy. (shrink)

This volume offers an empirical and diachronic investigation of the foundations and nature of metaphor in English. Metaphor is one of the hot topics in present-day linguistics, with a huge range of research focusing on the systematic connections between different concepts such as heat and anger, sight and understanding, or bodies and landscape. Until recently, the lack of a comprehensive data source made it difficult to obtain an overview of this phenomenon in any language, but this changed with the completion (...) in 2009 of The Historical Thesaurus of English, the only historical thesaurus ever produced for any language. Chapters in this volume use this unique resource as a basis for case studies of semantic domains including Animals, Colour, Death, Fear, Food, Reading, and Theft, providing a significant step forward in the data-driven understanding of metaphor. (shrink)

Low-income women and, disproportionately low-income women of color seeking reproductive and pregnancy care are increasingly subject to what this article terms carceral care – care compromised by its’ proximity to punishment systems. This article identifies the legal and health care practice mechanisms leading to carceral care and proposes solutions designed to stop criminalization at the bedside.

This article summarizes the April 5–6, 2002 conference on Conflict of Interest and Its Significance in Science and Medicine. Several themes are identified and addressed, including the globalization of science, the widespread presence of conflicts, the increased interest and involvement in conflict of interest by a number of organizations, the difference between academic research and research conducted by industry, and the tension between science and medicine. At the heart of the matter lies objectivity in research and the need for transparency (...) to ensure objectivity. Several future activities were discussed, including the need to share specific examples of how conflict has been managed, and the need for behavioral research to provide a sound empirical understanding of the best ways to provide informed consent for research subjects. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Duality and Non-Duality in Christian Practice:Reflections on the Benefits of Buddhist-Christian Dialogue for Constructive TheologyWendy FarleyThe question before us is the desirability of Buddhist-Christian dialogue in the work of (what Christians call) constructive theology. As a feminist theologian whose work is ever more deeply shaped by such a dialogue, my immediate answer is an unequivocal yes.1 This dialogue fits a general pattern over two thousand years in which theologians (...) have drawn from the wisdom of other traditions or cultures to better understand the mysteries of human experience. Without neo-Platonism and Aristotle there could hardly have been anything we recognize as Christian theology. Without pre-Christian Irish religion, there would be no Saint Brigit or Celtic Christianity. Without phenomenology, process, and Marxist philosophy the greatest works of twentieth-century Christian thought would not exist. Christianity, like all religions, is a moving river changed by time and culture and nearly as interiorly diverse as its members. The dialogue with Buddhism might be seen as a contemporary example of Christianity's openness to exchange with other ways of thinking that broadens and deepens its best insights. It is perhaps analogous to Origen's reliance on neo-Platonism or Thomas Aquinas's inspiration by the rediscovery of Aristotle.2The porous boundaries between Christianity and its culture open it to wisdom beyond itself but they also open it to cruelty and ignorance. Nothing protects religions from participating in the human condition and thus the prejudices and power structures that mutilate human society. Consumer culture and oppressions by class, ethnicity, and gender are seamlessly incorporated into Christian identity. The tacit synthesis of a culture's values with those of a religion neutralizes possible critique and can elevate a society's oppressions to a sacred duty. For this reason, too, dialogue with Buddhism is important to call Christianity back to its ethical moorings in the ideal of universal love and compassion.Religions are porous to the world around them, but they tend to conceal this from themselves and often imagine themselves to be not only untainted but also uniquely [End Page 135] qualified to mediate salvation. Religions provide human beings with language and practice through which dimensions of reality that cannot simply be read off of nature or experience are (in some sense) encountered. This is their great gift. The difficulty of religions is that tradition can become an end in itself. Because a tradition really does offer meaning and tools for transformation it is easy to slip into the existential posture of so idealizing a tradition that it seems in some direct and exclusive way to correlate to ultimate truth. The curvature of the ego onto itself, so attached to its own pain and pleasure that everything else seems a mere shadow, moves from the microcosm of the self to the macrocosm of religious tradition. The particular religion—or that element within it with which I identify—becomes identical with sacred reality. In the hostility to other religions characteristic of many Christians we see the illusion of egocentrism in its religious form. Paul Tillich described this tendency to absolutize itself as the demonic distortion of religion.3 Religious dialogue is a potent medicine against this overattachment to one's own tradition.These different senses in which a religion integrates into itself the wisdom and illusions of its time and place create enormous diversity within a religious tradition. Root concepts within Christianity concerning soteriology, divinity, and suffering do not have any agreed upon meaning. That is, there is no "Christian" view of salvation. Gregory of Nyssa's ideal of theosis, Luther's emphasis on salvation by grace through faith, an evangelical's experience of being born again, a liberal Protestant's commitment to social justice are so diverse that they seem to represent almost different religions.In light of the malleability and interior diversity of traditions, dialogue may not be between two self-sufficient religions but between participants who inhabit their tradition in a variety of ways.4 With this in mind, I would like to experiment with practice as a basis for some kinds of dialogue. Practice is concretely located in a religious tradition and yet reflects... (shrink)

Psilocybin-assisted psychotherapy, i.e., psilocybin treatment with psychological support, has demonstrated the efficacy of psilocybin to reduce depressive symptoms. However, in clinical trials, the structure of psilocybin-assisted psychotherapy is primarily based on preparation, navigation, and integration. For psychotherapeutic guidance, the application of this structure is favored over the usage of theoretical models. The applied psychotherapeutic models may be of critical importance if the effects are augmented due to the psychologically insightful experiences during the navigation and integration sessions. One of the important (...) next steps is to provide therapists with guidance on how to provide psilocybin-assisted psychotherapy. We present an integrated protocol for psilocybin-assisted psychotherapy for depression based on the theoretical model and psychotherapeutic framework of Compassion Focused Therapy. We hypothesize that CFT can provide the theoretical model and compassion practices that will reinforce the experiences during the navigation and follow-up therapy sessions. In this paper, we describe the rationale for selecting CFT, the compatibility of CFT and psilocybin-therapy, an overview of the psilocybin-assisted CFT protocol, the study protocol, and limitations to this approach. (shrink)