In this paper, I argue for a fundamentally different kind of moral luck, Patient Moral Luck (PML). Unlike traditional moral luck, PML concerns the amount of moral consideration that different moral patients — that is, creatures (including human beings) with moral status — will be owed, independent of factors in their control. PML, I argue, entails that morality itself appears to sanction and even obligate actions which, along predictable patterns, involve repeatedly failing to equally consider certain moral patients - (...) and repeatedly the same people - over sustained periods of time, through no fault of their own. And often these people will be members of groups who are already worse off through no fault of their own, thus exacerbating unjust inequalities. I defend the existence and normative puzzle of PML by introducing the notion of “moral force” - roughly, the amount of considerative weight a given moral patient is owed by some deliberating agent or group of agents. I then argue that this will vary widely between different moral patients through no fault or credit of their own. This, I claim, is inconsistent with the intuition that supports Equal Consideration principles in moral theory. I conclude by considering how we can minimize or mitigate PML without a radically revisionary normative theory. (shrink)

Objective: Patients' satisfaction is one of the most important goals in complete denture therapy, and there are many factors influencing this parameter. This study aimed to determine patient satisfaction with conventional removable complete denture made by clinical year students at the Faculty of Dentistry, Al Azhar University - Gaza. Methods: A sample of 85 patient who had conventional removable complete denture made by clinical year students at the Faculty of Dentistry Al Azhar University - Gaza filled a questionnaire (...) two months after denture insertion. The questionnaire involving four sections including personal information, history, denture evaluation in aspects of mastication, speech, aesthetics and retention, and patient comfort. Results: Of the 85 patient studied, 81% were males, and the mean age was 60.3 years SD+-9.64. The majority (n= 67, 79 %) lost their teeth because of bad oral hygiene. The overall satisfaction level was (92.1%), and patients were more satisfied with their upper denture. A significant association was found between the patient satisfaction and prior denture use experience (p=0.013). No significant correlation was established between the patient satisfaction and their gender (p=0.188), age group (p=0.640) and employment status (p=0.667).Conclusion: The patients have shown a high level of overall satisfaction. A significant association was found between the overall satisfaction level of patients and prior denture use experience. No statistically significant association was observed between the overall satisfaction level of patients and with each of age group, employment status and gender. (shrink)

Epileptogenesis involves an increase in excitatory synaptic strength in the brain in a manner similar to synaptic potentiation. In the present study we investigated the mechanisms of short-term synaptic potentiation in patients with focal epilepsy by using 5 Hz repetitive transcranial magnetic stimulation (rTMS), a non invasive neurophysiological technique able to investigate the mechanisms of synaptic plasticity in humans. Ten patients with focal idiopathic cortical epilepsy were studied. 5 Hz-rTMS (10 stimuli-trains, 120% of motor threshold, RMT) was delivered over the (...) first dorsal interosseus (FDI) motor area of both (affected and unaffected) hemispheres. Changes in the motor evoked potential (MEP) size in the FDI muscle during the trains and the RMT were measured and compared between the hemispheres. 5 Hz-rTMS was also delivered in a group of healthy subjects over both hemispheres. 5 Hz-rTMS in patients elicited a reduced MEP facilitation compared to normal subjects. The reduced MEP amplitude was more evident in the affected hemisphere than in the unaffected hemisphere. RMT in the affected hemisphere was higher than in the unaffected hemisphere and in healthy subjects. Our findings showing a decreased response to 5 Hz-rTMS over the affected hemisphere, differently from the expected results suggest a reduced cortical excitability in epileptic patients. We hypothesize an altered balance between excitatory and inhibitory circuits in epileptic patients under chronic therapy. (shrink)

Disclosure in clinical practice is aimed at promoting patient autonomy, usually culminating in patient choice (e.g., to consent to an operation or not, or between different medications). In medical ethics, there is an implicit background assumption that knowing more about (X) automatically translates to greater, or more genuine, autonomy with respect to one's choices involving (X). I challenge this assumption by arguing that in rare cases, withholding information can promote a patient's autonomy (understood as the capacity for (...) rational choice in alignment with one's values and goals). (shrink)

Ethics should guide the design of electronic health records (EHR), and recognized principles of bioethics can play an important role. This approach was adopted recently by a team of informaticists designing and testing a system where patients exert granular control over who views their personal health information. While this method of building ethics in from the start of the design process has significant benefits, questions remain about how useful the application of bioethics principles can be in this process, especially when (...) principles conflict. For instance, while the ethical principle of respect for autonomy supports a robust system of granular control, the principles of beneficence and non-maleficence counsel restraint due to the danger of patients being harmed by restrictions on provider access to data. Conflict between principles has long been recognized by ethicists and has even motivated attacks on approaches that state and apply principles. In this paper we show how using ethical principles can help in the design of EHRs by first, explaining how ethical principles can and should be used generally, and then by, discuss how attention to details in specific cases can show that the tension between principles is not as bad as it initially appeared. We conclude by suggesting further ways in which the application of these (and other) principles can add value to the ongoing discussion of patient involvement in their health care. This is a new approach to linking principles to informatics design that we expect will stimulate further interest. (shrink)

The notion that the family is the unit of care for family doctors has been enigmatic and controversial. Yet systems theory and the biopsychosocial model that results when it is imported into medicine make the family system an indispensable and important component of family medicine. The challenge, therefore, is to provide a coherent, plausible account of the role of the family in family practice. Through an extended case presentation and commentary, we elaborate two views of the family in family medicine (...) — treating the patient in the family and treating the family in the patient — and defend both as appropriate foci for care by family doctors. The practical problem that arises when the family is introduced into health care is deciding when to concentrate on the family system. The moral problems that arise concern how extensively doctors may become involved in the personal lives of their patients and families. The patient-centered clinical method provides a strategy for handling both problems. Thus, making the family a focus of care in family medicine can be justified on theoretical, practical, and moral grounds. (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)

People suffering from Obsessive-Compulsive Disorder (OCD) do things they do not want to do, and/or they think things they do not want to think. In about 10 percent of OCD patients, none of the available treatment options is effective. A small group of these patients is currently being treated with deep brain stimulation (DBS). Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes give a continuous electrical pulse to the brain area in which they are implanted. (...) It turns out that patients may experience profound changes as a result of DBS treatment. It is not just the symptoms that change; patients rather seem to experience a different way of being in the world. These global effects are insufficiently captured by traditional psychiatric scales, which mainly consist of behavioural measures of the severity of the symptoms. In this article we aim to capture the changes in the patients’ phenomenology and make sense of the broad range of changes they report. For that we introduce an enactive, affordance-based model that fleshes out the dynamic interactions between person and world in four aspects. The first aspect is the patients’ experience of the world. We propose to specify the patients’ world in terms of a field of affordances, with the three dimensions of broadness of scope (‘width’ of the field), temporal horizon (‘depth’), and relevance of the perceived affordances (‘height’). The second aspect is the person-side of the interaction, that is, the patients’ self-experience, notably their moods and feelings. Thirdly, we point to the different characteristics of the way in which patients relate to the world. And lastly, the existential stance refers to the stance that patients take towards the changes they experience: the second-order evaluative relation to their interactions and themselves. With our model we intend to specify the notion of being in the world in order to do justice to the phenomenological effects of DBS treatment. (shrink)

Individual health assessments (IHAs) for asymptomatic individuals provide a challenge to traditional distinctions between patient care and non-medical practice. They may involve undue radiation exposure, lead to false positives, and involve high out-of-pocket costs for recipients. A recent paper (Journal of the American College of Radiology 13(12): 1447–1457.e1, 2016) has criticised the use of IHAs and argued that recipients should be classified as ‘presenters’, not ‘patients’, to distinguish it from regular medical care. I critique this classificatory move, on two (...) grounds: one, it is conceptually suspect. Two, it obviates the medical ethics framework for IHAs, potentially exposing recipients of IHAs to lower standards of oversight and protection. Responsible regulation of IHAs will be easier to ethically justify if those seeking IHAs are considered patients and not merely presenters. (shrink)

—One of the promising applications of wireless sensor networks (WSNs) is monitoring of the human body for health concerns. For this purpose, a large number of small sensors are implanted in the human body. These sensors altogether provide a network of wireless sensors (WBANs) and monitor the vital signs and signals of the human body; these sensors will then send this information to the doctor. The most important application of the WBAN is the implementation of the monitoring network for (...) class='Hi'>patient safety in the hospital environment. In this case, supporting patients’ mobility is one of the basic needs, which has been underestimated in recent studies. The problem that involves providing the required energy for the units used in this type of network is challenging; for this reason, sent/ received units with very low power consumption and with a very small radius are used in order to save energy. The resulting small sending range, leads to the lack of support for patients' mobility. In this paper, the AD HOC mode is suggested for use to establish a network and a multi-path routing algorithm, for the purpose of importing patients’ mobility in hospital setting. The results of the simulation show that in addition to supporting patients' mobility, the use of the proposed idea instead of previously presented protocols, reduces delays in data transmission and energy consumption; and it also increases the delivery rate depending on the destination and the lifetime of the network, while on the other hand, it increases routing overhead. (shrink)

The underreporting of suspected adverse drug reactions hinders pharmacovigilance. Solutions to underreporting are oftentimes directed at clinicians and health care professionals. However, given the recent rise of public inclusion in medical science, solutions may soon begin more actively involving patients. I aim to offer an evaluative framework for future possible proposals that would engage patients with the aim of mitigating underreporting. The framework may also have value in evaluating current reporting practices. The offered framework is composed of three criteria that (...) are bioethical, social-epistemic, and pragmatic: (i) patients should not be exposed to undue harms, e.g., nocebo effects; (ii) data should be collected, analyzed, and communicated prioritizing pharmacovigilance’s aims, i.e., free from industry bias; and (iii) proposals should account for existing and foreseeable pragmatic constraints like clinician ‘buy in’ and existing reporting infrastructure. Proposals to engage patients in pharmacovigilance that fulfil or address these criteria are preferable to those that do not. (shrink)

The IPAP Schizophrenia Algorithm was originally designed in the form of a flow chart to help physicians optimise the treatment of schizophrenic patients. We examined the current version from the perspective of recent work on terminologies and ontologies thereby drawing on the resources of Basic Formal Ontology, and this with the objective to make the algorithm appropriate for Semantic Web applications. We found that Basic Formal Ontology is a rich enough theory to represent all the entities involved and that applying (...) the theory to the IPAP schizophrenia algorithm results in a representation that can be used by software agents to perform monitoring and control in a referent tracking environment. (shrink)

Effective knowledge and practice regarding diabetic foot care among diabetic patients are crucial in reducing the risk of complications of foot ulcers and amputations. This cross-sectional study evaluates the levels of knowledge and practice of diabetic foot standards of care among Libyan diabetic patients. Thus, a total of 481 Libyan patients participated in 2024. Data were collected through a validated self-designed questionnaire that assessed foot care knowledge and practice. Scores were assigned for each yes response, and a median score was (...) calculated to categorize participants as having good or poor knowledge and practice. The association between socio-demographic and diabetes-related factors with knowledge and practice was analyzed using the Chi-square test. The findings revealed that 74.1% of the participants had poor knowledge about the standards of diabetic foot care and 72.0% demonstrated poor practice related to diabetic foot care. A significant association was found between variables such as age, gender, and diabetes duration with knowledge and practice (p<0.05). 36.2%, reported having received formal education on diabetic foot care. This study recommends enhancing educational efforts and increasing physician involvement in foot care strategies. The majority of Libyan diabetic patients demonstrate a lack of knowledge and poor practice regarding diabetic foot care, which increases their risk of foot ulcers and amputations. This situation highlights the urgent need for an enhanced educational campaign focused on foot hygiene and care, as well as increased involvement of healthcare providers to deliver clear practical guidance preventing and an early examination to avoid complications in clinical practice. (shrink)

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: -/- The main aim of this review will be to assess the effects of changing practitioner empathy or patient expectations for all conditions. The main objective is to conduct a systematic review of randomised trials where the intervention involves manipulating either (a) practitioner empathy or (b) patient expectations, or (c) both.

Treatment adherence is a critical component of epilepsy management. Antiepileptic drug side effects affect adherence and may result in the discontinuation of medication. This study aimed to investigate the association between antiepileptic drug side effects and medication adherence among Libyan patients with epilepsy while identifying predictors of adherence. A cross-sectional study was conducted at Tripoli University Hospital involving 200 adult epilepsy patients. Adherence was assessed via a self-report tool dichotomized as adherent/ non-adherent if patients stopped medication due to side effects. (...) Side effects were evaluated using the Side Effects of Antiepileptic Drugs questionnaire. Logistic regression analyzed predictors of adherence, including antiepileptic drug use, therapy regimen, and side-effect profiles, with p<0.05 declared association. The overall adherence rate was 87.0%. Higher adherence was observed in older age groups, 95.8% in patients aged 51-60, 89.4% in married patients, and 91.0% in university-educated patients. Patients on monotherapy and those seizure-free in the preceding month demonstrated better adherence (88.4% and 93.0%, respectively). Valproate users had notably low adherence (52.6%) while carbamazepine and phenytoin users showed higher adherence (89.7% and 91.7%, respectively). Cognitive complaints significantly reduced adherence (76.1% vs. 79.6%), as did aggressive behavior (58.3% adherence). Logistic regression identified two independent predictors: patients on old-generation antiepileptic drugs had 2.7 times higher adherence (AOR=2.702, 95% CI: 1.168-6.249; p=0.02) while cognitive side effects reduced adherence by 86.4% (AOR=0.136, 95% CI: 0.031-0.596; p=0.008). Cognitive side effects predict non-adherence, necessitating routine monitoring. Paradoxically, older antiepileptic drugs correlated with better adherence. Integrating patient-reported metrics and addressing cognitive impacts could optimize epilepsy care, highlighting gaps in side-effect management and advocating personalized strategies in clinical settings. (shrink)

n hospitals, preliminary health assessments are typically performed by doctors, involving direct physical contact with patients. This practice not only exposes healthcare workers to potential infectious diseases but also consumes valuable time that could be better spent on critical cases. Routine checks, which could be automated, often contribute to longer patient wait times and reduced overall efficiency in hospital operations. The COVID-19 pandemic has further emphasized the importance of minimizing human-to-human contact, with the World Health Organization (WHO) advocating for (...) social distancing and contactless interaction to prevent the spread of the virus. This situation highlights a pressing need for innovative solutions that maintain highquality care while reducing direct physical contact. This project addresses the challenge by developing an Autonomous Smart Medical Assistant Robot capable of performing contactless preliminary health testing. Designed to automate routine assessments, the robot significantly reduces doctors’ workload, improves hospital workflow, and enhances patient management. It has been precisely designed and simulated using Autodesk Fusion 360, ensuring mechanical accuracy, while its control system is programmed using the Arduino IDE, allowing seamless integration of health-monitoring sensors and autonomous functionality. Beyond health assessments, the robot also provides emotional support to patients and can be used for the transport of medical supplies between healthcare providers and patients. This multifunctional capability not only enhances safety by limiting unnecessary exposure but also introduces operational efficiency and emotional care into medical settings. The implementation of this robot represents a step toward smarter, safer, and more compassionate healthcare environments. (shrink)

Objective: Vascular disorders severely impair the psycho-social status of individuals. Various laser and light systems, which have advantages and disadvantages, including the pro-yellow laser are used for the therapy of these disorders. Aim: The goal of the present study was to investigate the effectiveness and feasibility of the 577 nm pro-yellow laser for a broad range of indications including erythematelangiectatic rosacea, facial erythema, post-acne erythema, facial telangiectasis, hemangioma, genital angiokeratoma, and port wine stain nevus. Methods: A total of 98 patients (...) (25 male, 73 female) older than 15 years who were treated with the pro-yellow laser for vascular disorders at the cosmetology unit between 2017 and 2019 were retrospectively included in the study. Results: The mean rate of recovery was 100% in genital angiokeratoma, 94.4% in spider angioma, 83.3% in facial telangiectasis, 74.8% in erythematotelangiectatic rosacea, 72% in facial erythema + facial telangiectasis, and 68.3% in facial erythema. Over 60% of improvement was observed in most patients with vascular disorders. There was no significant link between the Fitzpatrick skin type and treatment success. Treatment success was significantly low in cases with nasal involvement. Conclusion: The current study concluded that pro-yellow laser is an efficient and safe laser modality that may yield satisfactory outcomes regardless of the different skin types. (shrink)

In this issue, Ahmadi1 reports on the practice of hymenoplasty—a surgical intervention meant to restore a presumed physical marker of virginity prior to a woman's marriage. As Mehri and Sills2 have stated, these women ‘want to ensure that blood is spilled on their wedding night sheets.’ Although Ahmadi's research was carried out in Iran specifically, this surgery is becoming increasingly popular in a number of Western countries as well, especially among Muslim populations.3 What are the ethics of hymen restoration?Consider the (...) role of the physician. Two of the doctors interviewed by Ahmadi reported being in ‘a perpetual state of guilt because of the surgery's inherent aim at deceiving the groom’ and noted their ‘personal conflict’ at being involved in this deception. Yet: "None of the doctors believed that the surgery was unethical, arguing that the girl could be ‘abused’ and ‘can even die’ if she is discovered not … ". (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)

During the recent Ebola epidemic, some commentators and stakeholders argued that it would be unethical to carry out a study that withheld a potential treatment from affected individuals with such a serious, untreatable disease. As a result, the initial trials of experimental treatments did not have control arms, despite important scientific reasons for their inclusion. In this paper, we consider whether the duty to rescue entails that it would be unethical to withhold an experimental treatment from patient-participants with serious (...) diseases for which there are no effective treatments, even when doing so is scientifically necessary to test the effectiveness of the treatment. We argue that the duty to rescue will rarely apply. The context of medical research also throws new light on the content of the duty to rescue, since the interests of future patients—who stand to benefit from the fruits of medical research—are relevant to whether the duty applies. (shrink)

Currently, documentation on the effects of psychedelics on psychosis appears scarce. In the present case, a higher-dose LSD experience during acute paranoid psychosis before the initiation of antipsychotics induced feelings of love, which resolved the majority of the symptoms of the paranoid psychosis in one session, leading the person to reconnect with his family and seek treatment in a psychiatric hospital. The session did not resolve schizoaffective disorder, however. More than a decade later, while using the antipsychotic aripiprazole, concurrent self-administration (...) of ketamine induced psychedelic effects that appeared to allow for practicing 'grounding' of psychotic thoughts. Immediately afterwards, daily self-administration of psycholytic doses of LSD for four weeks caused a mood-enhancing effect that enabled the patient to successfully discontinue aripiprazole without the return of psychotic symptoms. No psychotic or other noticeable symptoms could be observed during two interviews conducted in the two months following the discontinuation of the antipsychotic. -/- The mechanisms of action remain unexplored, and their possible generalizability to other cases remains unclear, but the observations may serve as a basis for further research. It may, for example, be that chronic use of LSD induces a tolerance to its psychedelic effects but not to its anti-inflammatory or other possibly unknown effects, which may be related to the observed mood-enhancing effect. A preclinical study from 1971 appeared consistent with the claimed effect. -/- In the present case, paranoia, i.e., the hypersensitivity to potential threats, was partly due to childhood trauma, partly intentionally induced by military training, and partly accentuated by war experiences. It could not be 'turned off'. Fear related to the uncertainty of survival formed the core of psychosis; without the fear, psychosis would likely not have existed. Paranoid psychosis presented itself as a biased estimation of probabilities of possible adverse outcomes, as a mismatch between the past and the present. (shrink)

Patients suffering from depersonalization complain of feeling detached from their body, their mental states, and actions or even from themselves. In this chapter, I argue that depersonalization consists in the lack of a phenomenal feature that marks my experiences as mine, which is usually called “mineness,” and that the study of depersonalization constitutes a neglected yet incomparable probe to assess empirically the scope, role, and even the nature of mineness. Here is how I will proceed. After describing depersonalization (§2) and (...) arguing that it involves a lack of mineness (§3) I will confront a series of objections (§4). I will then spell out what depersonalization can teach us about the scope of mineness (§5), about its role and psychological function (§6) and even about its nature (§7). (shrink)

A patient is diagnosed with the persistent vegetative state (PVS) when they show no evidence of the awareness of the self or the environment for an extended period of time. The chance of recovery of any mental function or the ability to interact in a meaningful way is low. Though rare, the condition, considering its nature as a state outwith the realm of the conscious, coupled with the trauma experienced by the patient's kin as well as health care (...) staff confronted with painful decisions regarding the patient's care, has attracted a considerable amount of discussion within the bioethics community. At present, there is a wealth of literature that discusses the relevant neurology, that elucidates the plethora of ethical challenges in understanding and dealing with the condition, and that analyses the real-world cases which have prominently featured in the mainstream media as a result of emotionally charged, divergent views concerning the provision of care to the patient. However, there is scarcely anything in the published scholarly literature that proposes concrete and practically actionable solutions to the now widely recognized moral conundrums. The present article describes a step in that direction. I start from the very foundations, laying out a sentientist approach which serves as the basis for the consequent moral decision-making, and then proceed to systematically identify and deconstruct the different cases of discord, using the aforementioned foundations as the basis for their resolution. A major intellectual contribution concerns the fluidity of the duty of care which I argue is demanded by the sentientist focus. The said duty is shown initially to have for its object the patient, which depending on the circumstances, can change to the patient's kin, or the health care staff themselves. In conclusion, the proposed framework represents the first comprehensive proposal regarding the decision-making processes involved in the deliberation on the provision of life sustaining treatment to a patient in a PVS. (shrink)

I defend the feasibility of a medical conscience in the following sense: a medical professional can object to the prevailing medical norms because they are incorrect as medical norms. In other words, I provide an account of conscientious objection that makes use of the idea that the conscience can issue true normative claims, but the claims in question are claims about medical norms rather than about general moral norms. I further argue that in order for this line of reasoning to (...) succeed, there needs to be an internal morality of medicine that determines what medical professionals ought to do qua medical professionals. I utilize a constructivist approach to the internal morality of medicine and argue that medical professionals can conscientiously object to providing treatment X, if providing treatment X is not in accordance with norms that would have been constructed, in light of the end of medicine, by the appropriate agents under the appropriate conditions. (shrink)

This article, based on a case study, examines issues of confidentiality and family impact in a diagnosis of Huntington's disease. Genetic-based illness transcends individualistic models of patient autonomy because it also involves other family members, requiring a new approach to patient confidentiality.

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)

Diagnosing flatulence involves a thorough assessment of an individual's symptoms, medical history, and, if necessary, the use of diagnostic tests. Healthcare providers gather information about the patient's medical background and conduct a physical examination to identify any signs of gastrointestinal issues. Dietary habits are evaluated, and potential triggers are identified through an elimination diet. Diagnostic tests such as breath tests, stool analysis, or imaging studies may be performed to further investigate the underlying causes of excessive flatulence. Accurate diagnosis is (...) crucial for effective management and treatment of flatulence, enabling individuals to gain control over their symptoms and address any underlying conditions. (shrink)

Background The health care sector is experiencing a drastic transition all over the world. This has an impact not only on the way hospitals, clinics, special-care homes etc. are organized, but also on patients, personnel and other stakeholders involved. The consequences of changes for both physicians and patients are investigated using a comprehensive health care reform in Ukraine as an example. -/- Methods The analysis is based on empirical data collected from general physicians in 2 Ukrainian cities. Based on the (...) Job Demands-Resources Model, we developed a set of hypotheses and tested them using the structural equation modelling technique. A total of 178 general physicians (81% of the approached population) participated in the study. -/- Results Our investigation reveals a clear relationship between the organizational job demands (additional tasks, structural changes, new processes) and their psychological effects (e. g., burnout). The latter have a negative impact on cooperation of physicians in hospitals leading to lower patient satisfaction. -/- Discussion and Conclusions Change in health care is inevitable. The example of Ukraine shows that openness of hospitals towards change reduces the probability of physicians’ burnout and, eventually, increases patient satisfaction. We strongly suggest applying the process management approach in order to increase openness to change, especially in turbulent times. (shrink)

Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion (...) between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required. (shrink)

Introduction. The medical sphere is constantly evolving, requiring improved approaches to its organisation and functioning. Advances in medical technology, observable changes in patient needs and growing competition challenge medical institutions to improve their strategies and approaches. Marketing technologies are becoming one of the key tools for achieving strategic goals. Purpose. This article is aimed at studying the peculiarities of the use of marketing technologies in the medical field. The main purpose of the study is to analyse the impact of (...) marketing tools on the development and success of medical institutions. Method (methodology). The methodological approach involves the use of an analytical approach to studying current trends in marketing and their impact on the healthcare sector. The study uses methods of data analysis and comparative analysis of marketing practices in medical institutions. Results. The study found that the use of targeted marketing strategies allows healthcare facilities to attract more patients, increase customer satisfaction and ensure an excellent reputation. The results of the study show a positive impact of the use of marketing tools on changing the perception of medical services by patients. Conclusions. The scope of application of the results is the practical activities of medical institutions seeking to improve their strategy of promotion and interaction with customers. The findings of the study can be used by marketers and managers of healthcare organisations to develop and implement effective marketing strategies. In summary, this article reveals the importance of using marketing technologies in the healthcare sector and provides practical recommendations for their successful implementation. The study emphasises that marketing in the healthcare industry is necessary to increase competitiveness and ensure quality medical care. (shrink)

Electronic Health Records (EHRs) are organized around two kinds of statements: those reporting observations made, and those reporting acts performed. In neither case does the record involve any direct reference to what such statements are actually about. They record not: what is happening on the side of the patient, but rather: what is said about what is happening. While the need for a unique patient identifier is generally recognized, we argue that we should now move to an EHR (...) regime in which all clinically salient particulars – from the concrete disorder on the side of the patient and the body parts in which it occurs to the concrete treatments given – should be uniquely identified. This will allow us to achieve interoperability among different systems of records at the level where it really matters: in regard to what is happening in the real world. It will also allow us to keep track of particular disorders and of the effects of particular treatments in a precise and unambiguous way. We discuss the ontological and epistemological aspects of our claim and describe a scenario for implementation within EHR systems. (shrink)

Even though the evidence‐based medicine movement (EBM) labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism would respond to intervention. (...) I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population‐level recommendations to individual patients. Thus, even though the evidence‐based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of evidencebased medicine who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms. (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)

The Substituted Judgment Standard for surrogate decision-making dictates that a surrogate, when making medical decisions on behalf of an incapacitated patient, ought to make the decision that the patient would have made if the patient had decisional capacity. Despite its intuitive appeal, however, SJS has been the target of a variety of criticisms. Most objections to SJS appeal to epistemic difficulties involved in determining what a patient would have decided in a given case. In this article, (...) I offer an alternative standard for surrogate decision-making that avoids these difficulties. I then offer an account of its theoretical underpinnings which shows that it preserves the central moral justification for SJS, namely, respect for patient autonomy. (shrink)

Two main approaches can be discerned in the literature on agentive self-awareness: a top-down approach, according to which agentive self-awareness is fundamentally holistic in nature and involves the operations of a central-systems narrator, and a bottom-up approach that sees agentive self-awareness as produced by lowlevel processes grounded in the very machinery responsible for motor production and control. Neither approach is entirely satisfactory if taken in isolation; however, the question of whether their combination would yield a full account of agentive self-awareness (...) remains very much open. In this paper, I contrast two disorders affecting the control of voluntary action: the anarchic hand syndrome and utilization behavior. Although in both conditions patients fail to inhibit actions that are elicited by objects in the environment but inappropriate with respect to the wider context, these actions are experienced in radically different ways by the two groups of patients. I discuss how top-down and bottom-up processes involved in the generation of agentive self-awareness would have to be related in order to account for these differences. (shrink)

The structural scarcity of healthcare resources raises im- portant bioethical issues regarding their allocation, such as who should make such decisions. This paper evaluates whether or not physicians should be responsible for deciding how to allocate healthcare resources in the micro-allocation context. Addressing this issue is essential for determining the moral or legal responsibility of physicians when allocating scarce healthcare resources in both ordinary and emer- gency conditions. The paper is structured as follows: First, I discuss the perspective of the (...) physician as a double agent, balancing their duty to their patient with that towards other patients and society. This perspective aims to justify bedside rationing by physicians. After discussing some critical issues with this conception, I propose a critique based of the prin- ciple of justice. I then define the necessary requirements for a fair and legitimate allocation choice in healthcare and argue that the specificity of such a choice makes it morally problematic to attribute a direct decision-making role to the treating physician when rationing healthcare resources in the micro-allocation context. This leads to a rejection of the conception of the physician as a double agent and bedside rationing, although I observe that this does not preclude the physician from some involvement in the process of defining allocation criteria and methods. (shrink)

Innovative practice involves medical interventions that deviate from standard practice in significant ways. For many patients, innovative practice offers the best chance of successful treatment. Because little is known about most innovative treatments, clinicians who engage in innovative practice might consider including extra procedures, such as scans or blood draws, to gather information about the innovation. Such information-gathering interventions can yield valuable information for modifying the innovation to benefit future patients and for designing scientific studies of the innovation. However, existing (...) guidelines do not say when or whether it is appropriate to add potentially risky information-gathering interventions for these purposes. As a result, clinicians may assume that information-gathering interventions are ethically inappropriate and should not be used in innovative practice. This assumption can lead to seriously negative consequences, such as increasing the likelihood that harmful or ineffective innovations will be adopted and creating new barriers to the development of genuinely beneficial treatments. We argue that health care institutions need to promote the responsible use of information-gathering interventions as an adjunct to innovative practice, and that these interventions are not clinical research and should not be subject to research oversight. (shrink)

The practice of medicine frequently involves the unconsented restriction of liberty. The reasons for unilateral liberty restrictions are typically that being confined, strapped down, or sedated are necessary to prevent the person from harming themselves or others. In this paper, we target the ethics of chemical restraints, which are medications that are used to intentionally restrict the mental states associated with the unwanted behaviors, and are typically not specifically indicated for the condition for which the patient is being treated. (...) Specifically, we aim to identify the conditions under which chemical restraints are ethically permissible. It is wrong to assume that what is morally true of physical restraints is also true of chemical restraints. Our aim is thus to identify the conditions under which chemical restraints are permissible while distinguishing these conditions from those of the application of physical restraints. (shrink)

This paper adds another argument to the rising tide of panic about robots and AI. The argument is intended to have broad civilization-level significance, but to involve less fanciful speculation about the likely future intelligence of machines than is common among many AI-doomsayers. The argument claims that the rise of the robots will create a crisis of moral patiency. That is to say, it will reduce the ability and willingness of humans to act in the world as responsible moral agents, (...) and thereby reduce them to moral patients. Since that ability and willingness is central to the value system in modern liberal democratic states, the crisis of moral patiency has a broad civilization-level significance: it threatens something that is foundational to and presupposed in much contemporary moral and political discourse. I defend this argument in three parts. I start with a brief analysis of an analogous argument made in pop culture. Though those arguments turn out to be hyperbolic and satirical, they do prove instructive as they illustrates a way in which the rise of robots could impact upon civilization, even when the robots themselves are neither malicious nor powerful enough to bring about our doom. I then introduce the argument from the crisis of moral patiency, defend its main premises and address objections. (shrink)

Artificial agents (AAs), particularly but not only those in Cyberspace, extend the class of entities that can be involved in moral situations. For they can be conceived of as moral patients (as entities that can be acted upon for good or evil) and also as moral agents (as entities that can perform actions, again for good or evil). In this paper, we clarify the concept of agent and go on to separate the concerns of morality and responsibility of agents (most (...) interestingly for us, of AAs). We conclude that there is substantial and important scope, particularly in Computer Ethics, for the concept of moral agent not necessarily exhibiting free will, mental states or responsibility. This complements the more traditional approach, common at least since Montaigne and Descartes, which considers whether or not (artificial) agents have mental states, feelings, emotions and so on. By focussing directly on mind-less morality we are able to avoid that question and also many of the concerns of Artificial Intelligence. A vital component in our approach is the Method of Abstraction for analysing the level of abstraction (LoA) at which an agent is considered to act. The LoA is determined by the way in which one chooses to describe, analyse and discuss a system and its context. The Method of Abstraction is explained in terms of an interface or set of features or observables at a given LoA. Agenthood, and in particular moral agenthood, depends on a LoA. Our guidelines for agenthood are: interactivity (response to stimulus by change of state), autonomy (ability to change state without stimulus) and adaptability (ability to change the transition rules by which state is changed) at a given LoA. Morality may be thought of as a threshold defined on the observables in the interface determining the LoA under consideration. An agent is morally good if its actions all respect that threshold; and it is morally evil if some action violates it. That view is particularly informative when the agent constitutes a software or digital system, and the observables are numerical. Finally we review the consequences for Computer Ethics of our approach. In conclusion, this approach facilitates the discussion of the morality of agents not only in Cyberspace but also in the biosphere, where animals can be considered moral agents without their having to display free will, emotions or mental states, and in social contexts, where systems like organizations can play the role of moral agents. The primary cost of this facility is the extension of the class of agents and moral agents to embrace AAs. (shrink)

The few people familiar with the pseudo-Platonic dialogue Axiochus generally have a low opinion of it. It's easy to see why: the dialogue is a mish-mash of Platonic, Epicurean and Cynic arguments against the fear of death, seemingly tossed together with no regard whatsoever for their consistency. As Furley notes, the Axiochus appears to be horribly confused. Whereas in the Apology Socrates argues that death is either annihilation or a relocation of the soul, and is a blessing either way, "the (...) Socrates of the Axiochus wants to have it both ways": death is both annihilation and a release of the soul from the body into a better realm. This may be used to construct a valid argument for the conclusion that death is not evil, but at the expense of having a contradiction as one of its premises. But D. S. Hutchinson has recently proposed that these inconsistencies shouldn't surprise us if we view the Axiochus as "an unconventional version of a very conventional genre--the consolation letter." In this paper I expand on Hutchinson's brief suggestion and argue that the Axiochus can be rehabilitated by paying attention to its genre. Although the Axiochus does display many similarities to the consolation letter, the shift from letter to dialogue does--pace Hutchinson--significantly affect what's going on. Within the dialogue, Socrates behaves toward Axiochus in a way similar to the way the author of a consolation letter behaves towards the letter's reader: he is willing to use inconsistent arguments, borrowed from any source, in order to soothe the patient. However, in depicting this type of consolatory relationship between Socrates and Axiochus, the dialogue itself is not aiming at consoling its readers. Instead, it should be seen as displaying for the reader's consideration a certain type of consolatory argumentative practice. -/- Socrates notes that Axiochus is "very much in need of consolation" (365a), and he uses any means necessary to accomplish this task. Socrates exhibits many ways in which he is willing to sacrifice argumentative hygiene for the sake of therapeutic effectiveness. These include: -/- * Use of arguments with inconsistent premises, presented in propria persona. * Appeals to emotion * Tailoring arguments to the audience. * Presenting invalid arguments so as to induce unjustified but comforting beliefs. * Evasion. In these respects, I think that Socrates' argumentative practice is best compared to PH III 280-1, where Sextus Empiricus says that the skeptic will deliberately use logically weak arguments as long as they work. Dorothy Tarrant claims that what links the Socrates of the Axiochus to Socrates as he appears elsewhere in the Platonic corpus is his evident care for the welfare of his interlocutor's psyche. But this concern takes a quite different form in the Axiochus than it usually does. As with Sextus, psychic therapy in the Axiochus involves relief from pain. The primary difference between them is that Socrates, unlike Sextus, is not aiming at producing epochê in his patient. (shrink)

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion (...) has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice. (shrink)

Abstract: Colon cancer is a prevalent and life-threatening disease, necessitating accurate and timely diagnosis for effective treatment and improved patient outcomes. This research paper presents the development of a knowledge-based system for diagnosing colon cancer using the CLIPS language. Knowledge-based systems offer the potential to assist healthcare professionals in making informed diagnoses by leveraging expert knowledge and reasoning mechanisms. The methodology involves acquiring and structuring medical knowledge specific to colon cancer, followed by the implementation of a knowledge- based system (...) using CLIPS. The system's design integrates relevant medical databases and employs advanced reasoning mechanisms to facilitate accurate diagnosis. Evaluation results demonstrate the system's effectiveness, with high accuracy and sensitivity rates compared to existing methods. The findings highlight the potential of knowledge-based systems in improving clinical practice and patient care. The research contributes to the growing field of medical informatics by demonstrating the feasibility and effectiveness of CLIPS-based knowledge systems for colon cancer diagnosis. Future research can focus on enhancing system performance and expanding its scope to encompass other types of cancer diagnoses. (shrink)

Cancer care has transitioned from clinical-based to home-based care to support longterm care in a more familiar and comfortable environment. This care transition has put family caregivers (FCGs) in a strategic position as care providers. Cancer care at home involves psychological and emotional treatment at some point, making FCGs deal with the stress of cancer patients frequently. Due to their limited care competencies, they need supportive care from healthcare professionals in cancer stress management. This study aims to examine how types (...) of demanded healthcare information affect the FCG’s role in reducing the stress of female cancer patients. The mindsponge theory was used in conceptual development and interpretation. Bayesian Mindsponge Framework (BMF) analytics were used for statistical analysis on a dataset of 48 spouses (husbands) and 12 other family members in five congested communities of Surabaya, Indonesia. Results showed that among the six types of healthcare information, FCGs with higher demand for cancer-specific information were more likely to need support in reducing the stress of female cancer patients. Meanwhile, FCGs with a higher demand for information about support services were less likely to need support to reduce cancer patients’ stress. Other types of healthcare information have ambiguous effects on the need for support in reducing cancer-induced stress. This study reveals that the demanded cancer-specific information, e.g., cancer prognosis or likely outcome, must be prioritized to assist FCG’s role in managing cancer stress. (shrink)

Jennifer Hawkins (2024) offers two cases that challenge traditional accounts of decision-making capacity, according to which respect for a medical decision turns on an individual’s cognitive capacities at the time the decision is made (Hawkins 2024; Appelbaum and Grisso 1988). In each of her described cases (involving anorexia nervosa and grief, respectively), a patient makes a decision that—although instrumentally rational at the time—does not reflect the patient’s longer-term values due to being in a particular psychological state. Importantly, this (...) state does not impair the patient’s cognition, but rather predisposes them to make a decision that conflicts with their own broader values, beliefs, or desires. (shrink)

Suppose some person 'A' sets out to accomplish a difficult, long-term goal such as writing a passable Ph.D. thesis. What should you believe about whether A will succeed? The default answer is that you should believe whatever the total accessible evidence concerning A's abilities, circumstances, capacity for self-discipline, and so forth supports. But could it be that what you should believe depends in part on the relationship you have with A? We argue that it does, in the case where A (...) is yourself. The capacity for "grit" involves a kind of epistemic resilience in the face of evidence suggesting that one might fail, and this makes it rational to respond to the relevant evidence differently when you are the agent in question. We then explore whether similar arguments extend to the case of "believing in" our significant others -- our friends, lovers, family members, colleagues, patients, and students. (shrink)

Ong, Caroline Whilst the reason and purpose of suffering may never be fully understood, there are ways of enduring, transcending and growing resilience to how it affects us. Our experience of suffering lies in the web of perceptions that involve our physical, spiritual and cosmological beliefs. Referencing Pain Seeking Understanding: Suffering, Medicine and Faith, edited by Margaret E. Mohrmann and Mark J. Hanson, this article gives a brief exploration of some propositions as to why an all-powerful, good God would allow (...) suffering to exist. From these various perspectives and using examples cited in the book, the article proposes that the healing art of medicine, honed through years of experience, knowledge and wisdom, can help individual patients endure and transcend suffering, and be whole once again. (shrink)

How does doubt come about? What are the mechanisms responsible for our inclinations to reassess propositions and collect further evidence to support or reject them? In this paper, I approach this question by focusing on what might be considered a distorting mirror of unreasonable doubt, namely the pathological doubt of patients with obsessive–compulsive disorder (OCD). Individuals with OCD exhibit a form of persistent doubting, indecisiveness, and over-cautiousness at pathological levels (Rasmussen and Eisen in Psychiatr Clin 15(4):743–758, 1992; Reed in Obsessional (...) experience and compulsive behaviour: a cognitive-structural approach, Academic Press, Cambridge, 1985; Tolin et al. in Cogn Ther Res 27(6):657–669, 2003). I argue that the failure in OCD is of an affective nature, involving both excessive epistemic anxiety and hyperactive feelings of uncertainty. I further argue that our adaptive disposition to inquire about the right matters—that is, about propositions which are both epistemically risky and imply harmful possibilities—might depend on these affective mechanisms. (shrink)

Preface/Introduction: The question under discussion is metaphysical and truly elemental. It emerges in two aspects — how did we come to be conscious of our own existence, and, as a deeper corollary, do existence and awareness necessitate each other? I am bold enough to explore these questions and I invite you to come along; I make no claim to have discovered absolute answers. However, I do believe I have created here a compelling interpretation. You’ll have to judge for yourself. -/- (...) What follows is the presentation of three essays I have worked on over the past several years seeing publication for the first time. “Hollows of Experience” was written first as an invited chapter for a collection on the ontology of consciousness. However, when cuts became necessary, my chapter got the knife. Its length has prohibited it from publication in any print journal. “Myth and Mind” was written next as a journal article, but as my involvement with it grew so did its length, so it has also idled on my websty awaiting its call. “From Panexperientialism to Conscious Experience” was written most recently, but it is the only one to have been available to the public elsewhere than my own website. Under the name, “The Continuum of Experience”, it was Target Article #95 on the recently closed Karl Jaspers Forum (for discussion purposes only). -/- I have put them in a different sequence here, for reasons of logical sense. Up first, “Panexperientialism” deals with an idea difficult for many to accept, namely that conscious experience is a particular mode of symbolically reflected experience that is largely unique to our species. However, I aver that experienced sensation in itself (as found, for example, in autonomic sensory response systems) goes “all the way down” into nature, and thus the title, panexperientialism. -/- Understanding this idea is helpful to dealing with the focus on language in Part I of “Hollows”, next, since here speech and general symbolic interaction in general are found to be the catalysts for the creation of our consciously experienced world (our “lived reality”). In Part II, however, I explore how experienced sensations must be coeval with existence, and, with even greater temerity, how all this sensational existence might have arisen within some literally inconceivable background of awareness-in-itself that yet has a dynamism that occasionally breaks into existence as experiential events and entities. (The latter may sound wacky, but physicists and cosmologists are themselves attempting to come to terms with that which seethes with vast potential energy in what they refer to as the quantum vacuum.) -/- “Myth and Mind” was put third since it deals with a major lacuna in “Hollows” — that presumed prehistoric period when members of our species made the painful crossing of the symbolic threshold into the beginnings of cultural consciousness. Speech plays a central role here, too, but I look more at narrative structures from the dawn of self-awareness when ritual and myth became vital to human survival. Why would fantastic stories and bizarre rituals be necessary? I speculate that growing foresight led to the unavoidable realization of certain mortality, from which, in turn, emerged the secondary realization that we were now alive. In contrast to our yet-to-come death, we have life here and now, and by ritually identifying with a symbolically expanded mythic, i.e., sacred, reality, we may continue to live on after bodily death, just as our ancestors and loved ones must also do. Language and mythmaking are necessary to avoid mortal despair and they remain at the core of human consciousness. -/- As Ernst Cassirer (1944) has noted, language and myth are “twin creatures”, both metaphoric webs over a reality we can never wholly comprehend. We live in the symbolic and construct our works of imagination and wars of conquest to make life meaningful, to feel immortal, and to sense that we ourselves participate in a reality greater than ourselves. No doubt we do, but this does not mean our culturally constructed self-identities survive the death of our bodies, and it does not imply that our symbolic concepts can ever indicate the ultimate truth. We simply must symbolize an extended reality that was sacred to our ancestors: “Is it not our way, as illusory as it may be, to force continuance on our world and our life in the face of their inevitable ending? Are we not compelled to extend those imaginary horizons as far as we can despite the terror and the sometime joy their extension incites? Is their closure not a form of death?” (Crapanzano, p. 210) -/- Of course, this leaves me in the uncomfortable position of being forced to admit that this venture of mine must inevitably be another attempt at meaningful mythmaking. But what else could it be? This is certainly not a scientific proof though it is indeed an academically rigorous exploration. (Just try to count the citations!) I hope the reader will judge my thesis on the basis of its coherence, the sense of meaning it evokes, my intellectual responsibility, and, finally, the engagement it inspires. If you have read my expositions and found yourself immersed in the timeless questions I here call forth, I would call these writings successful (even if you violently disagree with my answers). -/- I am very grateful to Huping Hu for granting me this special issue of JCER in which to present my ideas in some detail. He has patiently dealt with my exuberant approach and allowed the many changes I kept coming up with right until the final publication date. I also wish to thank the many potential commentators who politely replied to my invitation, and, even more, I thank those who made time to write actual commentaries. -/- References -/- Cassirer, E. (1944). An Essay on Man: An Introduction to a Philosophy of Human Culture. New Haven/London: Yale UP. -/- Crapanzano, V. (2004). Imaginative Horizons: An Essay in Literary-Philosophical Anthropology. Chicago: U of Chicago Press. -/- Gregory M. Nixon University of Northern British Columbia Prince George, British Columbia, Canada Email: [email protected] Websty: http://members.shaw.ca/doknyx. (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)