This article questions the commonly held view that professional ethics is grounded in general ethical principles, in particular, respect for client (or patient) autonomy and beneficence in the treatment of clients (or patients). Although these are admirable as general ethical principles, we argue that there is considerable logical difficulty in applying them to the professional-client relationship. The transition from general principles to professional ethics cannot be made because the intended conclusion applies differently to each of the parties involved, whereas (...) the premise is a general principle that applies equally to both parties. It is widely accepted that professionals are required to recognize that clients or patients possess rights to autonomy that are more than the general rights to personal autonomy accepted in ordinary social life, and that professionals are expected to display beneficence toward their clients that is more than the beneficence expected of anyone in ordinary social life. The comparative component of professional ethics is an intrinsic feature of the professional situation, and thus it cannot be bypassed in working out a proper professional ethics. Thus, we contend, the proper professional treatment of clients or patients has not been explained by appeal to general ethical principles. (shrink)

Background: Mental health professionals working in correctional contexts engage a double role to care and control. This dual loyalty conflict has repeatedly been criticized to impede the development of a high-quality alliance. As therapeutic alliance is a robust predictor of outcome measures of psychotherapy, it is essential to investigate the effects of this ethical dilemma. Methods: This qualitative interview study investigates patients’ perceptions of their therapists’ dual role conflict in court-mandated treatment settings. We interviewed 41 older incarcerated persons using a (...) semi-structured interview guide, the interviews were subsequently analyzed following thematic analysis. Results: We first present the patients’ perceptions of their treating psychotherapist’s dual loyalty conflict, which was linked to their overall treatment experience. In a second step, we outline the study participants’ reasons for this judgment, which were most commonly linked to feelings of trust or betrayal. More specifically, they named certain therapist characteristics and activities that enabled them to develop a trustful therapeutic alliance, which we grouped into four topics: respecting the patient’s pace and perceived coercion; patient health needs to be first priority; clarity in roles and responsibilities; and the art of communication – between transparency and unchecked information sharing. Discussion: Developing a high quality alliance in mandatory offender treatment is central due to its relationship with recovery and desistance. Our findings show that some therapists’ characteristics and activities attenuate the negative impact of their double role on the development and maintenance of the alliance. To increase the effectiveness of court-mandated treatments, we need to support clinicians in dealing with their dual role to allow the formation of a high quality therapeutic alliance. Our qualitative interview study contributed to this much-needed empirical research on therapist’ characteristics promoting a trustful relationship in correctional settings. (shrink)

Biomedical diagnostic science is a great deal less successful than we've been willing to acknowledge in bioethics, and this fact has far-reaching ethical implications. In this article I consider the surprising prevalence of medically unexplained symptoms, and the term's ambiguous meaning. Then I frame central questions that remain answered in this context with respect to informed consent, autonomy, and truth-telling. Finally, I show that while considerable attention in this area is given to making sure not to provide biological care to (...) patients without a need, comparatively little is given to the competing, ethically central task of making sure never to obstruct access to biological care for those with diagnostically confusing biological conditions. I suggest this problem arises from confusion about the philosophical value of vagueness when it comes to the line between biological and psychosocial needs. (shrink)

Physicians frequently ask whether they should give patients what they want, usually when there are considerations pointing against doing so, such as medicine’s values and physicians’ obligations. It has been argued that the source of medicine’s values and physicians’ obligations lies in what has been dubbed “the internal morality of medicine”: medicine is a practice with an end and norms that are definitive of this practice and that determine what physicians ought to do qua physicians. In this paper, I defend (...) the claim that medicine requires a morality that is internal to its practice, while rejecting the prevalent characterization of this morality and offering an alternative one. My approach to the internal morality of medicine is constructivist in nature: the norms of medicine are constructed by medical professionals, other professionals, and patients, given medicine’s end of “benefitting patients in need of prima facie medical treatment and care.” I make the case that patients should be involved in the construction of medicine’s morality not only because they have knowledge that is relevant to the internal morality of medicine—namely, their own values and preferences—but also because medicine is an inherently relational enterprise: in medicine the relationship between physician and patient is a constitutive component of the craft itself. The framework I propose provides an authoritative morality for medicine, while allowing for the incorporation, into that very morality, of qualified deference to patient values. (shrink)

In medical settings, machines are in close proximity with human beings: with patients who are in vulnerable states of health, who have disabilities of various kinds, with the very young or very old, and with medical professionals. Machines in these contexts are undertaking important medical tasks that require emotional sensitivity, knowledge of medical codes, human dignity, and privacy. -/- As machine technology advances, ethical concerns become more urgent: should medical machines be programmed to follow a code of medical ethics? What (...) theory or theories should constrain medical machine conduct? What design features are required? Should machines share responsibility with humans for the ethical consequences of medical actions? How ought clinical relationships involving machines to be modeled? Is a capacity for empathy and emotion detection necessary? What about consciousness? -/- The essays in this collection by researchers from both humanities and science describe various theoretical and experimental approaches to adding medical ethics to a machine, what design features are necessary in order to achieve this, philosophical and practical questions concerning justice, rights, decision-making and responsibility, and accurately modeling essential physician-machine-patient relationships. -/- This collection is the first book to address these 21st-century concerns. (shrink)

Loneliness in medicine is a serious problem not just for patients, for whom illness is intrinsically isolating, but also for physicians in the contemporary condition of medicine. We explore this problem by investigating the ideal physician-patient relationship, whose analogy with friendship has held enduring normative appeal. Drawing from Talbot Brewer and Nir Ben-Moshe, we argue that this appeal lies in a dynamic form of companionship incompatible with static models of friendship-like physician-patient relationships: a mutual refinement of embodied virtue that (...) draws both persons together. The ideal physician-patient relationship has a dialectical character that fosters each member's improvement of phenomenologically recognizing and embodying moral virtues. A key component of this dynamic is a commitment to the common goal of the patient's health, realized through joint interactivities and conversations over time. The physician's presence to the patient's suffering—understood best as an alienating phenomenological condition for the patient—orients and discloses possibilities for virtuous caregiving by structuring the meanings of the goals, conversations, and joint narrative constitutive of their relationship. Presence to suffering, paradoxically, is perhaps an important prerequisite for this dynamic partnership. These activities dialectically build an interpretive horizon of understanding through which moral goods and character refinement—in and for the other—may become revealed for both persons in their shared being-in-the-world. This analysis of suffering, mood, and revealing of (possible) moral goods has implications for addressing the modern problem of loneliness for patients and physicians, who are increasingly inhibited from building flourishing relationships with each other. (shrink)

The historical relationship between health care professionals and people with disabilities is fraught, a fact all the more troubling in light of the distinctive roles clinicians play in both establishing and responding to that which is considered normal or abnormal by society at large. Those who wish to improve their clinical practice might struggle, however, to keep up with developments across numerous disability communities as well as the ever-growing body of disability studies scholarship. To assist with this goal, I (...) offer an overview of recent disability theory, outline a set of responsibilities clinicians have to disability communities, and provide recommendations for clinicians who hope to justly treat patients with disabilities and improve their care and health outcomes. (shrink)

Migraine is a complex neurological disorder characterized by recurrent moderate to severe headaches, accompanied by additional symptoms such as nausea, sensitivity to light and sound, and visual disturbances. Accurate and timely diagnosis of migraines is crucial for effective management and treatment. However, the diverse range of symptoms and overlapping characteristics with other headache disorders pose challenges in the diagnostic process. In this research, we propose the development of an expert system for migraine diagnosis using artificial intelligence and the CLIPS (C (...) Language Integrated Production System) framework. The expert system utilizes a rule-based inference engine to analyze patient-reported symptoms and provide reliable diagnoses or probability scores indicating the likelihood of migraine. The knowledge base of the expert system is designed based on expert knowledge obtained from medical professionals specializing in migraines. The collected knowledge is translated into a structured format suitable for the CLIPS inference engine, incorporating rules and facts to represent the diagnostic criteria and associated symptoms. The system prompts users to provide relevant information about their symptoms, medical history, and potential triggers. It applies the defined rules and facts to evaluate the likelihood of migraine and generate accurate diagnoses or probability scores. Preliminary evaluation results demonstrate the potential of the expert system as a valuable tool for diagnosing migraines. A dataset of anonymized patient records with confirmed migraine cases was used to test the system. The diagnoses generated by the expert system were compared against the known diagnoses, and a high level of accuracy was observed, with 90% of cases correctly diagnosed as migraines. These results highlight the effectiveness and reliability of the system in assisting medical professionals in the diagnosis of migraines. The proposed expert system offers several advantages for migraine diagnosis. It leverages the collective knowledge and expertise of experienced migraine specialists, providing a standardized and consistent approach to diagnosis. The system can handle large amounts of patient data and effectively analyse complex relationships between symptoms, risk factors, and diagnostic criteria. Furthermore, it offers real-time feedback and recommendations, supporting medical professionals in their clinical decision-making process. Future work involves refining the expert system based on feedback from medical experts, expanding the knowledge base to encompass a wider range of symptoms and risk factors, and conducting further evaluations to enhance its accuracy and applicability in clinical settings. The development of an expert system for migraine diagnosis has the potential to improve the diagnostic process, leading to more effective management and treatment strategies for individuals suffering from migraines. (shrink)

In Deep Medicine, Eric Topol argues that the development of artificial intelligence (AI) for healthcare will lead to a dramatic shift in the culture and practice of medicine. Topol claims that, rather than replacing physicians, AI could function alongside of them in order to allow them to devote more of their time to face-to-face patient care. Unfortunately, these high hopes for AI-enhanced medicine fail to appreciate a number of factors that, we believe, suggest a radically different picture for the future (...) of healthcare. Far from facilitating a return to “the golden age of doctoring”, the role of economic and institutional considerations in determining how medical AI will be used mean that it is likely to further erode therapeutic relationships and threaten professional and patient satisfaction. (shrink)

Routine testing is a practice whereby medical professionals ask all patients whether they would like an HIV test, regardless of whether there is anything unique to a given patient that suggests the presence of HIV. In three respects I aim to offer a fresh perspective on the debate about whether a developing country with a high rate of HIV infection morally ought to adopt routine testing. First, I present a neat framework that organises the moral issues at stake, bringing out (...) the basic principles involved and exhibiting their logical relationships. Second, appealing to the Kantian principle of respect for the dignity of persons, I offer a thorough justification for routine testing when it serves as a gateway to anti-retroviral treatment (ART). Third, I present a respect-based defence of the controversial and novel thesis that routine testing is morally justified even if ART is unaffordable or otherwise unavailable. (shrink)

Respect for autonomy and beneficence are frequently regarded as the two essential principles of medical ethics, and the potential for these two principles to come into conflict is often emphasised as a fundamental problem. On the one hand, we have the value of beneficence, the driving force of medicine, which demands that medical professionals act to protect or promote the wellbeing of patients or research subjects. On the other, we have a principle of respect for autonomy, which demands that we (...) respect the self-regarding decisions of individuals. As well as routinely coming into opposition with the demands of beneficence in medicine, the principle of respect for autonomy in medical ethics is often seen as providing protection against beneficial coercion (i.e. paternalism) in medicine. However, these two values are not as straightforwardly opposed as they may appear on the surface. In fact, the way that we understand autonomy can lead us to implicitly sanction a great deal of paternalistic action, or can smuggle in paternalistic elements under the guise of respect for autonomy. -/- This paper is dedicated to outlining three ways in which the principle of respect for autonomy, depending on how we understand the concept of autonomy, can sanction or smuggle in paternalistic elements. As the specific relationship between respect for autonomy and beneficence will depend on how we conceive of autonomy, I begin by outlining two dominant conceptions of autonomy, both of which have great influence in medical ethics. I then turn to the three ways in which how we understand or employ autonomy can increase or support paternalism: firstly, when we equate respect for autonomy with respect for persons; secondly, when our judgements about what qualifies as an autonomous action contain intersubjective elements; and thirdly, when we expect autonomy to play an instrumental role, that is, when we expect people, when they are acting autonomously, to act in a way that promotes or protects their own wellbeing. I then provide a proposal for how we might work to avoid this. I will suggest that it may be impossible to fully separate paternalistic elements out from judgements about autonomy. Instead, we are better off looking at why we are motivated to use judgements about autonomy as a means of restricting the actions of patients or research subjects. I will argue that this is a result of discomfort about speaking directly about our beneficent motivations in medical ethics. Perhaps we can reduce the incentive to smuggle in these beneficent motivations under the guise of autonomy by talking directly about beneficent motivations in medicine. This will also force us to recognise paternalistic motivations in medicine when they appear, and to justify paternalism where it occurs. (shrink)

In recent decades, phenomenology has been utilized not only as a conceptual framework from which to understand medical encounters in healthcare settings, but also to guide medical professionals in providing care. In the realm of physical therapy, phenomenology has been touted as a philosophically-based avenue to aid in helping to understand what it means to be a patient. The works of Edmund Husserl and Martin Heidegger have been utilized as paths to approach phenomenologically-informed care in physical therapy. However, to our (...) knowledge, no significant connection has been made in regard to the work of Hans-Georg Gadamer’s phenomenology and hermeneutics in the realm of physical therapy. The authors aim to close that gap by showing the ways in which Gadamer’s philosophy can help physical therapists provide phenomenologically-informed patient care. They begin by outlining some of the touchpoints between phenomenology and healthcare and then introduce Gadamer as a figure who deserves attention in the question of how to apply phenomenology to healthcare settings. Upon analyzing Gadamer’s account of what it means to experience an altered body, they outline Gadamer’s understanding of tact, practical knowledge, and good sense in order to show how to understand at a conceptual level what it means to empathize with patients on the path to building therapeutic alliance, that is, a cooperative working relationship. They then look closely at Gadamer’s hermeneutics and particularly his comments on how to cultivate a fusion of horizons in order to attempt to help guide physical therapists in theoretically understanding how to empathize with their patients. Ultimately, they argue that physical therapists who practice phenomenologically-informed care, which they call “hermeneutical healing,” are positioned well to form strong working relationships with their patients. (shrink)

Ongoing research in the fields of genetics and biotechnology hold the promise of improved diagnosis and treatment of genetic diseases, and potentially the development of individually tailored pharmaceuticals and gene therapies. Difficulty, however, arises in determining how these services are to be evaluated and integrated equitably into public health care systems such as Canada's. The current context is one of increasing fiscal restraint on the part of governments, limited financial resources being dedicated to health care, and rising costs for new (...) health care services and technologies. This has led to increasing public debate in the last few years about how to reform public health care, and whether we should prohibit, permit or perhaps even encourage private purchase of health care services. ;In Canada, some of these concerns have crystallized around the issue of gene patents and commercial genetic testing, in particular as illustrated by the case of Myriad Genetics' patented BRACAnalysis test for hereditary breast and ovarian cancer. While most Canadians who currently access genetic services do so through the public health care system, for those with the means, private purchase is becoming an option. This situation raises serious concerns---about justice in access to health care; about continued access to safe and reliable genetic testing supported by unbiased patient information; and about the broader effects of commercialization for ongoing research and the Canadian public health care system. Commercial genetic testing presents a challenge to health care professionals, policy analysts, and academics concerned with the social, ethical and policy implications of new genetic technologies. Using the Myriad case as an exemplar, tools from moral philosophy, the social sciences, and health policy and law will be brought to bear on the larger issues of how as a society we should regulate commercial research and product development, and more coherently decide which services to cover under public health insurance and which to leave to private purchase. Generally, the thesis is concerned with the question of "how best to bring capital, morality, and knowledge into a productive and ethical relationship". (shrink)

ABSTRACT When patients refuse to receive medical treatment, the consequences of honouring their decisions can be tragic. This is no less true of patients who autonomously decide to refuse treatment. I distinguish three possible implications of these autonomous decisions. According to the Permissibility Claim, such a decision implies that it is permissible for the patient who has made the autonomous decision to forego medical treatment. According to the Anti‐Paternalism Claim, it follows that health‐care professionals are not morally permitted to treat (...) that patient. According to the Binding Claim it follows that these decisions are binding on health‐care professionals. My focus is the last claim. After arguing that it is importantly different from each of the first two claims, I give two arguments to show that it is false. One argument against the Binding Claim draws a comparison with cases in which patients autonomously choose perilous positive treatments. The other argument appeals to considered judgments about cases in which disincentives are used to deter patients from refusing sound treatments. (shrink)

One of the most unpredictable things the pandemic brought to our societies was the closure of hospitals and other health services to visitors. Preventing the spread of infection was the main reason for these decisions in the early days of the pandemic when there was no clarity about the means of transmission and the origin of the virus. However, in view of the persistence of the restrictions to date and the numerous negative consequences they have had on the professional and (...) personal quality of life of doctors, nurses, patients and carers, the aim of this article is to analyse in depth the reasons why these decisions have been and, above all, are still being applied, also considering the hypothesis that the choices made so far in the training of health professionals should be questioned. The persistence of restrictions, the constant reduction of human and economic resources in the face of an increase in the demand for care have exacerbated the distance between health professionals and users, to the point of escalating into actual acts of violence and aggression. According to the Critical Pedagogy approach, educators can play a central role in activating formative and collaborative strategies, such as maieutic groups, to rebuild an alliance between those who today find themselves on opposite sides: health professionals on the one hand, and patients and families on the other. (shrink)

In this essay, by example of the physician-patient relationship and drawing on the work of D.W. Winnicott, I explore what may be possible together in relationships, and in the pursuit of health and flourishing, at understanding what we need, and getting ourselves and the other “right”—what we are afraid of and how we get each other wrong, and the distance or gap between “what has been” and “what might be.” In pursuit of these questions, I consider what both physicians (...) and patients might endeavor to do together to address this distance: to recognize and respond to each other, and to identify and address common needs and felt distances. And, how, along the way, we may be able to better identify and understand fundamental challenges to all relationships. Finally, I ask the reader to imagine a physician-patient encounter (and all relationships) as vulnerable possibilities. And I suggest a method for a way forward. While we may not always get what we want in a relationship, perhaps our earnest effort at knowing together will open a potential space for us to get what we need. This is where I imagine that the physician-patient relationship begins: where all relationships begin. (shrink)

Background: Patient participation in clinical ethics support services has been marked as an important issue. There seems to be a wide variety of practices globally, but extensive theoretical or empirical studies on the matter are missing. Scarce publications indicate that, in Europe, patient participation in CESS varies from region to region, and per type of support. Practices vary from being non-existent, to patients being a full conversation partner. This contrasts with North America, where PP seems more or less standard. While (...) PP seems to be on the rise in Europe, there is no data to confirm this. This study sought a deep understanding of both habits and the attitudes towards PP in the Netherlands, including respondents’ practical and normative perspectives on the matter. Methods and Results: We developed a national survey on PP for Dutch CESS staff. Our survey comprised a total of 25 open and close-ended questions, focused on four topics related to PP goals of CESS, status quo of PP, ideas and ideals concerning PP, and obstacles for PP. Discussion: The four most important findings were that: Patient participation in Dutch CESS is far from standard. Views on patient participation are very much intertwined with the goals of ethics support. Hesitations, fears and perceived obstacles for PP were not on principle and Most respondents see PP as a positive opportunity, yet requiring additional training, practical guidance and experience. Conclusions: Various normative reasons require PP. However, PP seems far from standard and somewhat rare in Dutch CESS settings. Our respondents did not raise many principled objections to PP. Instead, reasons for the lack of PP are intertwined with viewpoints on the goals of CESS, which seemingly focus on supporting health care professionals. Training and practical guidance was thought to be helpful for gaining experience for both CESS staff and HCPs. (shrink)

Purpose. The purpose of this study is to investigate how professionals learn from varying experiences with errors in health-care digitalization and develop and use negative knowledge and digital ignorance in efforts to improve digitalized health care. Design/methodology/approach. A two-year qualitative field study was conducted in the context of a public health-care organization working with digital patient communication. The data consisted of participant observation, semistructured interviews and document data. Inductive coding and a theoretically informed generation of themes were applied. Findings. The (...) findings show that both health-care and digital communication professionals learn through experiences with digital “rule-” and “knowledge-based” errors in patient communication and develop negative knowledge and awareness of digital ignorance. In their joint efforts, they use negative knowledge to “bend the rules” and to explore digital ignorance in efforts to improve patient communication. Originality/value. This study provides insight into the importance of collaboration between professionals with varying experience of errors in digitalizing patient communication. Such collaboration is required to acknowledge own shortcomings and create complementary negative knowledge to improve digital patient communication. This is particularly important when working with innovative digitalization in health care. (shrink)

A lively topic of debate in decision theory over recent years concerns our understanding of the different risk attitudes exhibited by decision makers. There is ample evidence that risk-averse and risk-seeking behaviours are widespread, and a growing consensus that such behaviour is rationally permissible. In the context of clinical medicine, this matter is complicated by the fact that healthcare professionals must often make choices for the benefit of their patients, but the norms of rational choice are conventionally grounded in a (...) decision maker’s own desires, beliefs and actions. The presence of both doctor and patient raises the question of whose risk attitude matters for the choice at hand and what to do when these diverge. Must doctors make risky choices when treating risk-seeking patients? Ought they to be risk averse in general when choosing on behalf of others? In this paper, I will argue that healthcare professionals ought to adopt a deferential approach, whereby it is the risk attitude of the patient that matters in medical decision making. I will show how familiar arguments for widely held anti-paternalistic views about medicine can be straightforwardly extended to include not only patients’ evaluations of possible health states, but also their attitudes to risk. However, I will also show that this deferential view needs further refinement: patients’ higher-order attitudes towards their risk attitudes must be considered in order to avoid some counterexamples and to accommodate different views about what sort of attitudes risk attitudes actually are. (shrink)

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and Merleau-Ponty (...) in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

While there is a prolific debate surrounding the issue of conscientious objection of individuals towards performing certain clinical acts, this debate ignores the fact that there are other reasons why clinicians might wish to object providing specific services. This paper briefly discusses the idea that healthcare workers might object to providing specific services because they are against their professional judgement, they want to maintain a specific reputation, or they have pragmatic reasons. Reputation here is not simply understood as being in (...) good standing with a professional body. Rather, reputation is treated in the sense that a craftsman might wish to be known for providing a specific type, quality, and style of service. Professionalism is understood as acting according to the philosophical and scientific principles that are the basis of healthcare (such as acting for the benefit of the patient’s health and following well- evidenced treatment pathways). (shrink)

Background: This study was conducted to measure depression literacy (D-Lit) and mental health literacy (MHL) and to investigate their relationship with psychological status and quality of life among Iranian patients with type 2 diabetes mellitus (T2DM). -/- Methods: This cross-sectional study was conducted in 2021 among 400 patients with T2DM in Iran. Samples were selected using proportional stratified sampling. Data collection tools comprised a demographic questionnaire, measures of MHL and D-Lit, the diabetes quality of life (DQOL) scale, and the (...) DASS-21. After confirming the normality of the data using the Kolmogorov-Smirnov test, parametric statistical tests (such as one-way ANOVA, independent samples t-test, and Chi-Square) were used to investigate the relationship between the variables using SPSS v22 software. The results of continuous quantitative data are reported in the form of means and standard deviations, and qualitative data are reported in the form of absolute and relative frequencies. -/- Results: In this study, 10.25% of the participants (n = 41) had severe depression, while 36.75% (n = 147) experienced severe anxiety. The mean (standard deviation) of MHL was 80.92 (9.16) from 130 points. Of the participants, only 1.7% (n = 7) did not answer any questions correctly on the D-lit scale, and only 5.8% (n = 23) were able to answer 15 questions or more correctly on the D-lit. MHL had a significant negative correlation with depression (r = −0.236), anxiety (r = −0.243), and stress (r = −0.155) (P < 0.001). There was a positive and significant correlation between MHL and D-Lit (r = 0.186) (P < 0.001). D-Lit had a significant negative correlation with depression (r = −0.192), anxiety (r = −0.238), and stress (r = −0.156) (P < 0.001). There was a positive and significant correlation between the ability to recognize disorders (r = 0.163), knowledge of self-treatment (r = 0.154), and DQOL (P < 0.001). Depression (r = −0.251), anxiety (r = −0.257), and stress (r = −0.203) had a significant negative correlation with DQOL (P < 0.001). -/- Conclusion: MHL and D-Lit levels were found to be inadequate in patients with T2DM. These low levels of MHL and D-Lit among patients with T2DM were associated with higher levels of anxiety, depression, and stress, as well as a lower quality of life. Therefore, designing and implementing preventive programs to improve the mental health of patients with T2DM can help prevent mental disorders and ultimately improve their quality of life. (shrink)

Advanced AI systems are rapidly making their way into medical research and practice, and, arguably, it is only a matter of time before they will surpass human practitioners in terms of accuracy, reliability, and knowledge. If this is true, practitioners will have a prima facie epistemic and professional obligation to align their medical verdicts with those of advanced AI systems. However, in light of their complexity, these AI systems will often function as black boxes: the details of their contents, calculations, (...) and procedures cannot be meaningfully understood by human practitioners. When AI systems reach this level of complexity, we can also speak of black-box medicine. In this paper, we want to argue that black-box medicine conflicts with core ideals of patient-centered medicine. In particular, we claim, black-box medicine is not conducive for supporting informed decision-making based on shared information, shared deliberation, and shared mind between practitioner and patient. (shrink)

According to many of its proponents, shared decision making ("SDM") is the right way to interpret the clinician-patient relationship because it respects patient autonomy in decision-making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational autonomy, this paper argues (...) that standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy. (shrink)

There are two main questions that any account of corporate lawyers’ moral obligations needs to answer: (1) Do corporate lawyers have moral obligations to third parties? and (2) In cases of conflict between obligations to the corporation and obligations to third parties, which should prevail? This Article offers answers to these questions in the context of lawyers working in medical corporations. I argue that lawyers do have moral obligations to third parties, and that in cases where patients’ rights are being (...) violated by a medical company, patients’ rights should prevail. Consequently, attorney–client confidentiality rules should be relaxed to allow for attorney disclosures in egregious cases of potential harm to third parties. (shrink)

New technologies such as smart sensors improve rehabilitation processes and thereby increase older adults’ capabilities to participate in social life, leading to direct physical and mental health benefits. Wearable smart sensors for home use have the additional advantage of monitoring day-to-day activities and thereby identifying rehabilitation progress and needs. However, identifying and selecting rehabilitation priorities is ethically challenging because physicians, therapists, and caregivers may impose their own personal values leading to paternalism. Therefore, we develop a discussion template consisting of a (...) series of adaptable questions for the patient–physician encounter based on the capability approach. The goal is to improve geriatric rehabilitation and thereby increase participation in social life and well-being. To achieve this goal, we first analyzed what is considered important for participation on basis of the capability approach, human rights, and ethics of care. Second, we conducted an ethical analysis of each of the four identified dimensions of participation: political, economic, socio-cultural, and care. To improve compliance with rehabilitation measures, health professionals must align rehabilitation measures in an open dialogue with the patient’s aspiration for participation in each dimension. A discussion template based on the capability approach allows for a proactive approach in patient information and stimulates a critical assessment of treatment alternatives while reducing the risk of imposing personal values. (shrink)

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

Healthcare professionals decide wisely about personalized medicine, treatment plans, and resource allocation by utilizing big data analytics and machine learning. To guarantee that algorithmic recommendations are impartial and fair, however, ethical issues relating to prejudice and data privacy must be taken into account. Big data analytics and machine learning have a great potential to disrupt healthcare, and as these technologies continue to evolve, new opportunities to reform healthcare and enhance patient outcomes may arise. In order to investigate the patient’s outcomes (...) with empirical evidence, this research was conducted using an online survey to incorporate healthcare professionals, patient’s reviews, and clinical staff. The data were analyzed using SmartPLS 4.0 to predict the structural model. The findings revealed a direct impact as positive influence of using machine learning on healthcare performance and patient outcomes through big data analytics. Moreover, it is evident that this can lead to personalized treatment plans, early interventions, and improved patient outcomes. Additionally, big data analytics can help healthcare providers optimize resource allocation, improve operational efficiency, and reduce costs. The impact of big data analytics on patient outcome and healthcare performance is expected to continue to grow, making it an important area for investment and research. (shrink)

Crises in therapist-patient relationship can also become a challenge in clinical supervision. However, success and failure in establishing and maintaining constructive relationships in therapy and supervision is not only subject to a lucky fit of personal characteristics (therapist A gets along well/badly with client B; supervisee A gets along well/badly with supervisor C). Rather, we can identify determining field conditions in the overall therapeutic and supervisory situation for this outcome. We do not only focus on the persons involved, but (...) also on their environment, the task to be accomplished together, further framework conditions and the power relations resulting from their mutual influence-in the supervised case of therapy as well as in supervision itself. We want to examine the structure and dynamics of these relationships from a genuine Gestalt psychological perspective. What contributes to a cooperative atmosphere? When do goals get out of sight? What can make the atmosphere hostile? How do such developments become accessible in supervision? (shrink)

My question in the chapter is this: could (and should) the role of the physician be construed as that of a friend to the patient? I begin by briefly discussing the “friendship model” of the physician-patient relationship—according to which physicians and patients could, and perhaps should, be friends—as well as its history and limitations. Given these limitations, I focus on the more one-sided idea that the physician could, and perhaps should, be a friend to the patient (a “physician-qua-friend model” (...) of the physician-patient relationship). I show that given recent developments in our understanding of the physician-patient relationship, this idea is far from asinine. I then make the case that the most plausible conception of the physician-qua-friend model incorporates the following components: (a) a common goal, that is, one that physician and patient share; (b) certain forms of equality between physician and patient; (c) an ideal of a caring physician. Finally, I show how the model can be instantiated in a certain type of physician-patient interaction, namely, in physician-assisted dying. (shrink)

Physicians, so it will be argued have by virtue of their profession a weightier obligation than patients to disclose their HIV infection, and also have a duty to refrain from performing exposure-prone invasive procedures. This argument supports both the AMA and CDC guidelines on HIV infected health care workers (HCWS), while undermining the recommendations against disclosure suggested by the National Commission on AIDS (NCA). The argument is divided into three parts. First, a distinction is made between entrenched and fuzzy roles. (...) Second, the physician-patient relationship is described as essentially fiduciary rather than businesslike or merely contractual. Third, the conflict between patients' and physicians' right to know is portrayed as one between patients' and physicians' right to life. Last, given the the probability of infection from seropositive patients to seronegative physicians, and, conversely, is roughly the same, it is recommended as a fair social policy that whenever an invasive procedure occurs, both physicians and patients have a duty to disclose any serious infection that may jeopardize their lives. (shrink)

This paper investigates the scope and limits of parents' and physicians' obligations to anencephalic newborns. Special attention is paid to the permissibility of harvesting anencephalic organs for transplant. My starting point is to identify the general justification for treating patients in order to benefit third parties. This analysis reveals that the presence of a close relationship between patients and beneficiaries is often crucial to justifying treating in these cases. In particular, the proper interpretation of the Kantian injunction against treating (...) persons as means only takes on a different light in the context of special relationships. The implications of this analysis for our responsibilities to anencephalic infants is clarified. (shrink)

It is often assumed that the chief responsibility medical professionals bear is patient care and advocacy. The meeting of other duties, such as ensuring a more just distribution of medical resources and promoting the public good, is not considered a legitimate basis for curtailing or slackening beneficial patient services. It is argued that this assumption is often made without sufficient attention to foundational principles of professional ethics; that once core principles are laid bare this assumption is revealed as largely unwarranted; (...) and, finally, that these observations at the level of moral theory should be reflected, in various ways, in medical practice. Specifically, this essay clarifies a tension that exists between different kinds of moral principles and explores the possibility of dissipating that tension by shoring up foundational principles. The paper begins by setting out three alternative models of how best to balance patient advocacy responsibilities with broader social responsibilities. It then turns to critically assess these models and argue that one has several advantages over the others. (shrink)

Abstract: The study aimed to determine the strategic flexibility and its relationship to the level of quality of services provided, from the viewpoint of the internal beneficiary in non-governmental hospitals in Gaza Strip. The study relied on the descriptive and analytical approach, and the questionnaire was designed as a tool to collect data and consisted of (39) items, and the researchers used the comprehensive survey method, and the number of the study population was (536) individuals, where (434) questionnaires were (...) retrieved, and the recovery rate was (80.97%). The study revealed many results, the most important of which were: the existence of a moderate degree of approval by the study sample individuals on strategic flexibility, as it was evident through the area of strategic flexibility as a whole having a relative weight (60.44%). The study is on the quality of services, as it became clear through the field of service quality obtaining a relative weight (79.90%). The results of the study revealed a statistically significant relationship between strategic flexibility and the quality of services in non-governmental hospitals in Gaza Strip, with a correlation coefficient of 0.490. The study reached many recommendations, the most important of which were: the need to work on appointing young people and those with potentials, because jobs are vacant in the hospitals under study, and the need to seek the help of an administrative staff with scientific and practical qualifications, and to work on updating information systems, archiving and networks through which data and information are transferred between departments And the creation of mechanisms by which stored information can be used to enhance the decision-making process, and an effective system to receive patients' complaints in a manner that ensures rapid response and treatment, to achieve continuous communication between patients and the hospital management, and to notify patients of dealing with the complaints they submit, and work to provide all Medical and health specialties in the hospitals under study, by making use of the medical delegations that visit Gaza Strip, involving them in the treatment processes, bringing in doctors and specialists from abroad, updating the standards related to measuring the services provided to patients on an ongoing basis, based on the suggestions and complaints of patients, and developing facilities in hospitals As well as updating the medical devices and equipment used in hospitals periodically. (shrink)

Objective Manic and depressive phases of bipolar disorder (BD) show opposite psychomotor symptoms. Neuronally, these may depend on altered relationships between sensorimotor network (SMN) and subcortical structures. The study aimed to investigate the functional relationships of SMN with substantia nigra (SN) and raphe nuclei (RN) via subcortical-cortical loops, and their alteration in bipolar mania and depression, as characterized by psychomotor excitation and inhibition. -/- Method In this resting-state functional magnetic resonance imaging (fMRI) study on healthy (n = 67) and BD (...) patients (n = 100), (1) functional connectivity (FC) between thalamus and SMN was calculated and correlated with FC from SN or RN to basal ganglia (BG)/thalamus in healthy; (2) using an a-priori-driven approach, thalamus-SMN FC, SN-BG/thalamus FC, and RN-BG/thalamus FC were compared between healthy and BD, focusing on manic (n = 34) and inhibited depressed (n = 21) patients. -/- Results (1) In healthy, the thalamus-SMN FC showed a quadratic correlation with SN-BG/thalamus FC and a linear negative correlation with RN-BG/thalamus FC. Accordingly, the SN-related FC appears to enable the thalamus-SMN coupling, while the RN-related FC affects it favoring anti-correlation. (2) In BD, mania showed an increase in thalamus-SMN FC toward positive values (ie, thalamus-SMN abnormal coupling) paralleled by reduction of RN-BG/thalamus FC. By contrast, inhibited depression showed a decrease in thalamus-SMN FC toward around-zero values (ie, thalamus-SMN disconnection) paralleled by reduction of SN-BG/thalamus FC (and RN-BG/thalamus FC). The results were replicated in independent HC and BD datasets. -/- Conclusions These findings suggest an abnormal relationship of SMN with neurotransmitters-related areas via subcortical-cortical loops in mania and inhibited depression, finally resulting in psychomotor alterations. (shrink)

We often consider medical practitioners to be epistemic authorities: “Doctor knows best,” as the saying goes. The place of expert judgment in evidence-based medicine hierarchies, and the crucial role of patient preferences and values in medical decision-making, however, pose problems for making sense of such authority. I argue that there is an account of such medical epistemic authority that does justice to the complexities of the doctor–patient relationship, while maintaining that medical practitioners hold an epistemically privileged position. Such a (...) view can better inform medical practice by clearly illuminating the distinct roles of patients and doctors in decision-making processes. (shrink)

Torture is unethical and usually counterproductive. It is prohibited by international and national laws. Yet it persists: according to Amnesty International, torture is widespread in more than a third of countries. Physicians and other medical professionals are frequently asked to assist with torture. -/- Medical complicity in torture, like other forms of involvement, is prohibited both by international law and by codes of professional ethics. However, when the victims of torture are also patients in need of treatment, doctors can find (...) themselves torn. To accede to the requests of the torturers may entail assisting or condoning terrible acts. But to refuse care to someone in medical need may seem like abandoning a patient and thereby fail to exhibit the beneficence expected of physicians. -/- In this paper, we argue that this dilemma is real and that sometimes the right thing for a doctor to do, overall, is to be complicit in torture. Though complicity in a wrongful act is itself prima facie wrongful, this judgment may be outweighed by other factors. We propose three criteria for analyzing how those factors apply to particular cases of medical complicity in torture. (shrink)

Discussions of patient-centred care and patient autonomy in bioethics have tended to focus on the decision-making context and the process of obtaining informed consent, leaving open the question of how patients ought to be counselled in the daily maintenance of their health and management of chronic disease. Patient activation is an increasingly prominent counselling approach and measurement tool that aims to improve patients’ confidence and skills in managing their own health conditions. The strategy, which has received little conceptual or ethical (...) analysis, raises important questions about how clinicians ought to foster confidence and a sense of control in their patients without exposing them to blame, stigma and other harms. In this paper, we describe patient activation, discuss its relationship to personal responsibility, autonomy and health disparities, and make recommendations regarding its use and measurement. (shrink)

Aim: This research determined the relationship between university teachers’ professional identity and their work performance. -/- Methodology: The design that was used in this study is a Descriptive Comparative- Correlational research design using the quantitative approach. Participants in this study were taken from the 967 university teachers at Guangdong Business and Technology University from the 14 colleges. They were chosen randomly. The researcher used the Qualtrics calculator at a 5% margin of error to arrive at 275 respondents. Data analyses (...) include frequency count and percentage, weighted mean, and descriptive equivalent. A five-point scale was used in this study as a guide to answer the questionnaire. -/- Results: Based on the result, the highest manifestation of teachers’ professional identity was found to be on their professional behavior tendency which was ranked first among the four indicators. It was followed by professional values and professional belonging, while role values tend to be the least manifested professional identity based on the self -assessment of the teachers. The over-all mean value of 3.52 reveals that professional identity was highly manifested among the teachers of Guangdong Business and Technology University. Teacher respondents have manifested an outstanding work performance particularly on work attitude as this was given the highest rating by the teachers themselves. Second in rank was the interpersonal promotion, followed by completion of teaching activities which also shows an outstanding work performance. On the other hand, teachers’ work performance on student achievement was given the lowest assessment by the teachers showing a very satisfactory performance. Generally, the result reveals that teachers exhibited an outstanding work performance as perceived by themselves. Based on the result, there were no significant differences in the assessment of teacher respondents when they are grouped according to gender. This is taken to mean that male and female teachers have relatively the same assessment as regards their work performance in terms of work attitude, interpersonal promotion, completion of teaching activities, and student achievement. Generally, the result reveals that there was a significant relationship between the teachers’ professional identity and their work performance. The result reveals that professional identity of teachers has positive impact on their work performance. -/- Conclusion: Respondents are dominated by female teachers who are mostly in their middle age. A good number of teachers who have earned master’s and doctoral degrees are also evident. They perceived themselves to have a high level of professional identity specifically on professional behavior tendency, professional values, and professional belonging. Teachers have relatively the same assessments on their professional identity regardless of their gender, age, educational attainment, and monthly income. They exhibit an outstanding work performance particularly on work attitude, interpersonal promotion, and completion of teaching activities. However, they feel that they had less contribution to student achievement. Teachers have relatively the same assessments on their work performance regardless of their gender, age, educational attainment, and monthly income. Professional identity of teachers can somehow influence their work performance in general. Specifically, professional values and professional belonging give positive effect to work attitude of teachers, and to their completion of teaching activities. (shrink)

Patient and public involvement is widely thought to be important in the improvement of health care delivery and in health equity. Purpose: The article examines the role of experiential knowledge in service co-production in order to develop opiate substitution treatment services (OST) for high-risk opioid users. Method: Drawing on social representations theory and the concept of social identity, we explore how experts’ by experience and registered nurses’ understandings of OST contain discourses about the social representations, identity, and citizenship of the (...) participants and the effects these may have on developing or hindering inclusive and bottom-up forms of patient and public involvement. Results: The meeting sessions that potentially offer room for creativity and problem-solving fail to provide any new propositions for fixing the system. The health care professionals primarily identify themselves as regulators who protect the correctness of their actions and show little interest in considering experiential knowledge on opioid addiction. Conclusion: The participation of patients has been one of the prominent reforms implemented in health care. The goal of client-centered thinking is often emphasised; however, the implementation is not simple due to the strongly institutionalised knowledge and related working patterns and practices in health care. (shrink)

In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity as an alternative justification. However, (...) this approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatric diagnosis. (shrink)

Objective: The aim of this study is to evaluate relationship between ostiomeatal complex variations (OMC) and maxillary sinus pathologies in children and adolescents using cone-beam computed tomography (CBCT). -/- Methods: CBCT images of 72 patients (44 males and 28 females) aged 7-18 years were evaluated retrospectively. Presence of nasal septal deviation (NSD), nasal septal pneumatization (NSP), concha bullosa (CB), accessory maxillary ostium (AMO), agger nasi cell (ANC), Haller cell (HC), Onodi cell (OC), ethmoid sinusitis and maxillary sinus pathologies were (...) investigated. Maxillary sinus pathologies were classified. Correlations of OMC variations with each other, maxillary sinus pathologies and ethmoid sinusitis were investigated. Chi-square test was used to analyze relationships among variables and distribution of parameters. -/- Results: NSD was determined in 70.8%, NSP in 40.3%, ethmoid sinusitis in 75%, maxillary sinus pathology in 34.8% of images. OMC variations rates were detected as CB 31.3%, AMO 16%, ANC 16%, HC 24.3% and OC 18.8%. The most common maxillary sinus pathology was localized mucosal thickening, with a rate of 15.3% on right and 22.2% on left. Statistically significant differences were determined between almost all OMC variations with each other, and between anatomical variations in OMC with maxillary sinus pathologies except for NSP and AMO (p < 0.05). The presence of ethmoid sinusitis was more common in males (p =0.026). -/- Conclusion: Anatomical variations in OMC had no significant effect on maxillary sinus pathology except for NSP and AMO. Besides, most of anatomical variations in OMC were statistically significantly correlated with each other. CBCT visualization of these variations is important for sinonasal surgery and is an effective method in children and adolescents with low radiation dose and high image quality compared to computed tomography. (shrink)

Euthanasia and assisted suicide have proved to be very contentious topics in medical ethics. Some ethicists are particularly concerned that allowing physicians to carry out these procedures will undermine their professional obligations and threaten the very goals of medicine. However, I maintain that the fundamental goals of medicine not only do not preclude the practice of euthanasia and assisted suicide by physicians, but can in fact be seen to support these practices in some instances. I look at two influential views (...) of the goals of medicine, one based on the broad guiding principles of autonomy, beneficence and nonmaleficence, and the other focusing on several more concrete aims, concluding that both approaches can be seen to support euthanasia and assisted suicide. I then turn to the popular concern that allowing physicians to carry out euthanasia and assisted suicide will lead to widespread abuse. I argue that the possibility for abuse can be minimised if we make the patient's autonomous consent an essential requirement of the practice. (shrink)

Subjective rights enjoy limited import in Kelsenian theory for whereas the concept of duty underlies every legal norm, that of rights is merely possible and only emerges when the imposition of the sanction attached to the breach of the duty is made dependent upon a subject's will to bring legal action. The presence of secondary norms establishing certain duties of medical professionals on informed consent displays the existence of correlative reflex rights of patients. Yet, together with secondary norms, Western legal (...) systems typically institute norms of competence enabling patients to take legal action when those duties correlative to their reflex right to informed consent have been infringed. Thus, informed consent constitutes a set of subjective legal positions of patients and medical professionals. Despite its excessive formalism and questionable neutrality, the Kelsenian approach permits to define and clearly distinguish patients' genuine rights from mere aspirations devoid of legal basis. (shrink)

The study aimed to identify the delegation of authority for the performance of the medical staff and its relationship to improving the quality of health care in Al-Shifa Medical Complex in the southern Palestinian governorates. Administrators, and technicians) with a total of 2150 employees, and the questionnaire was distributed to a stratified random sample of 330 employees, and 302 questionnaires were retrieved, with a rate of 91.5%. One of the most important results of the study was the existence of (...) a statistically significant relationship between delegation of authority and the quality of health care. One of the most important recommendations of the study was to strengthen the direction of senior management towards excellence in patient service, because the patient represents a fundamental focus in health services. (shrink)

We are sometimes unsure of the moral status of our relationships with other entities. Recent case studies in this uncertainty include our relationships with artificial agents (robots, assistant AI, etc.), animals, and patients with “locked-in” syndrome. Do these entities have basic moral standing? Could they count as true friends or lovers? What should we do when we do not know the answer to these questions? An influential line of reasoning suggests that, in such cases of moral uncertainty, we need meta-moral (...) decision rules that allow us to either minimize the risks of moral wrongdoing or improve the choice-worthiness of our actions. One particular argument adopted in this literature is the “risk asymmetry argument,” which claims that the risks associated with accepting or rejecting some moral facts may be sufficiently asymmetrical as to warrant favoring a particular practical resolution of this uncertainty. Focusing on the case study of artificial beings, this article argues that this is best understood as an ethical-epistemic challenge. The article argues that taking potential risk asymmetries seriously can help resolve disputes about the status of human–AI relationships, at least in practical terms (philosophical debates will, no doubt, continue); however, the resolution depends on a proper, empirically grounded assessment of the risks involved. Being skeptical about basic moral status, but more open to the possibility of meaningful relationships with such entities, may be the most sensible approach to take. (shrink)

Integrating the concept of place meanings into protected area management has been difficult. Across a diverse body of social science literature, challenges in the conceptualization and application of place meanings continue to exist. However, focusing on relationships in the context of participatory planning and management allows protected area managers to bring place meanings into professional judgment and practice. This paper builds on work that has outlined objectives and recommendations for bringing place meanings, relationships, and lived experiences to the forefront of (...) land-use planning and management. It proposes the next steps in accounting for people’s relationships with protected areas and their relationships with protected area managers. Our goals are to 1) conceptualize this relationship framework; 2) present a structure for application of the framework; and 3) demonstrate the application in a specific protected area context, using an example from Alaska. We identify three key target areas of information and knowledge that managers will need to sustain quality relationship outcomes at protected areas. These targets are recording stories or narratives, monitoring public trust in management, and identifying and prioritizing threats to relationships. The structure needed to apply this relationship-focused approach requires documenting and following individual relationships with protected areas in multiple ways. The goal of this application is not to predict relationships, but instead to gain a deeper understanding of how and why relationships develop and change over time. By documenting narratives of individuals, managers can understand how relationships evolve over time and the role they play in individual’s lives. By understanding public trust, the shared values and goals of individuals and managers can be observed. By identifying and prioritizing threats, managers can pursue efforts that steward relationships while allowing for the protection of experiences and meanings. The collection and interpretation of these three information targets can then be integrated and implemented within planning and management strategies to achieve outcomes that are beneficial for resource protection, visitor experiences, and stakeholder engagement. By investing in this approach, agencies will gain greater understanding and usable knowledge towards the achievement of quality relationships. It represents an investment in both place relationships and public relations. By integrating such an approach into planning and management, protected area managers can represent the greatest diversity of individual place meanings and connections. relationships, place meanings, trust, narratives, planning, protected areas. (shrink)

The main objective of the research was to assess the relationship between instructional practices of teachers on students’ academic performancein English. To achieve this aim, the researcher selectedAssistant Language Teachers (ALTs)and public secondary students in Okinawa Prefectureas respondents of the study during the school year 2020-2021. The primary data gathering tools used in the study was a standardized questionnaire Instructional Practices Survey adopted from Valentine (2000) on determining teachers’ instructional practices and a documentary analysisto determine the point average of (...) the respondents’ level of academic performancein English. The collected data were analyzed and treated statisticallywith theuse of Statistical Packages for Social Sciences (SPSS). Results revealed that there is a positive strong correlation between instructional practices andthe students’ academic performance in English as evidenced by .853 correlation coefficient. Findings indicate that a high level of instructional practices among teachers contribute to the increase of academic performance of students in English. The study recommended that school principals may conduct frequent teachers’ assessment, training needs assessment to maintain this status -focusing on the needs of teachers in terms of their professional growth and development, and continuous monitoring of students endeavors. (shrink)

Current developments in reproductive technology forecast that in the foreseeable future artificially generated gametes might be presented as a possible fertility treatment for infertile couples and for homosexual couples desiring to have children genetically originating from both partners. It is important to evaluate the ethical issues connected to this technology before its emergence. This article first reviews the meaning that gametes (sperm and eggs) might have to those who procreate, as well as their ontology. From this, suggestions are made as (...) to what qualities artificially generated gametes need to be truly called gametes. Finally, different proposed routes for artificial gamete generation are examined on the basis of these qualities, with their prospective problems and advantages highlighted. Autotransplanted gametes (or their progenitors) generated solely from patient-derived tissue are deemed to be the most ethically suitable route for the development of this technology. (shrink)