Rationale and objectives: Medical humanities are becoming increasingly recognized as positively impacting medical education and medical practice. However, the extent of medical humanities teaching in medical schools is largely unknown. We reviewed medical school curricula in Canada, the UK and the US. We also explored the relationship between medical school ranking and the inclusion of medical humanities in the curricula. -/- Methods: We searched the curriculum websites of all accredited medical schools (...) in Canada, the UK and the US to check which medical humanities topics were taught, and whether they were mandatory or optional. We then noted rankings both by Times Higher Education and U.S. News and World Report and calculated the average rank. We formally explored whether there was an association between average medical school ranking and medical humanities offerings using Spearman's correlation and inverse variance weighting meta-analysis. -/- Results: We identified 18 accredited medical school programmes in Canada, 41 in the UK, and 154 in the US. Of these, nine (56%) in Canada, 34 (73%) in the UK and 124 (80%) in the US offered at least one medical humanity that was not ethics. The most common medical humanities were medical humanities (unspecified), history, and literature (Canada); sociology and social medicine, medical humanities (unspecified), and art (UK); and medical humanities (unspecified), literature and history (US). Higher ranked medical schools appeared less likely to offer medical humanities. -/- Conclusions: The extent and content of medical humanities offerings at accredited medical schools in Canada, the UK and the US varies, and there appears to be an inverse relationship between medical school quality and medical humanities offerings. Our analysis was limited by the data provided on the Universities' websites. Given the potential for medical humanities to improve medical education and medical practice, opportunities to reduce this variation should be exploited. (shrink)

After an intensive 4-year process, the World Medical Association (WMA) has revised its International Code of Medical Ethics (ICoME). In their report outlining this process, Parsa-Parsi et al not only describe how the WMA sought to ‘cultivat[e] international agreement’ on a ‘global medical ethos’, but also outline the philosophical framework of the ICoME: how the WMA, as the ‘global representation of the medical profession’, created and revised the ICoME through the process of international professional (...) self-regulation.1 However, there is a significant tension to be found in this framework—one which contrasts the international scope of the ICoME with the supposed source of its legitimacy. Here, we seek to characterise this tension and the doubt which it casts on the legitimacy of the ICoME. (shrink)

Since 1964, through 7 revisions, the World Medical Association’s Declaration of Helsinki has stood as an important statement regarding the ethical principles guiding medical research with human participants. It is consulted by ethics review committees, funders, researchers, and research participants. It has been incorporated into national legislation and is routinely invoked to ascertain the ethical appropriateness of clinical trials. There is much to praise about the revision process and the latest revision, which coincides with the declaration’s (...) 50th anniversary. Nevertheless, the proposed declaration contains persistent flaws... (shrink)

There has been a growing concern over establishing norms that ensure the ethically acceptable and scientifically sound conduct of clinical trials. Among the leading norms internationally are the World Medical Association's Declaration of Helsinki, guidelines by the Council for International Organizations of Medical Sciences, the International Conference on Harmonization's standards for industry, and the CONSORT group's reporting norms, in addition to the influential U.S. Federal Common Rule, Food and Drug Administration's body of regulations, and information sheets (...) by the Department of Health and Human Services. There are also many norms published at more local levels by official agencies and professional groups.Any account of international standards should cover both scientific and ethical norms at once – the two are conceptually intertwined. Recent sources recognize that “[s]cientifically unsound research on human subjects is unethical in that it exposes research subjects to risks without possible benefit.”. (shrink)

The Hippocratic Oath is a code of ethics defining correct behaviour by physicians they are required to commit themselves to before being accepted into the profession. It was the first code of ethics for any profession. While originating in Ancient Greece, it subsequently evolved, but the current code still embodies many of the core injunctions of the original code. The most widely accepted current form is the 2006 The Declaration of Geneva by the World Medical Association to (...) be taken before being admitted as a member of the medical profession. The most important of its injunctions are: ‘The health of my patient will be my first consideration’ and ‘I will maintain the utmost respect for human life’. The first is a rewording of the injunction from Epidemics, Book I, of the Hippocratic school: ‘Practice two things in your dealings with disease: either help or do not harm the patient.’ This was later simplified to the most basic precept of the Hippocratic Oath: ‘First, do no harm.’ It is one of the principal precepts of bioethics that all students in healthcare that, given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good. The development of neurotechnology could be subsumed with little modification under the Geneva formulation of the Hippocratic Oath, extending this precept to a commitment not to damage people’s psychological health. (shrink)

I. EXECUTIVE SUMMARY The MRCT Center Post-trial Responsibilities: Continued Access to an Investigational Medicine Framework outlines a case-based, principled, stakeholder approach to evaluate and guide ethical responsibilities to provide continued access to an investigational medicine at the conclusion of a patient’s participation in a clinical trial. The Post-trial Responsibilities (PTR) Framework includes this Guidance Document as well as the accompanying Toolkit. A 41-member international multi-stakeholder Workgroup convened by the Multi-Regional Clinical Trials Center of Brigham and Women’s Hospital and Harvard University (...) (MRCT Center) developed this Guidance and Toolkit. Project Motivation A number of international organizations have discussed the responsibilities stakeholders have to provide continued access to investigational medicines. The World Medical Association, for example, addressed post-trial access to medicines in Paragraph 34 of the Declaration of Helsinki (WMA, 2013): “In advance of a clinical trial, sponsors, researchers and host country governments should make provisions for post-trial access for all participants who still need an intervention identified as beneficial in the trial. This information must also be disclosed to participants during the informed consent process.” This paragraph and other international guidance documents converge on several consensus points: • Post-trial access (hereafter referred to as “continued access” in this Framework [for terminology clarification – see definitions]) is the responsibility of sponsors, researchers, and host country governments; • The plan for continued access should be determined before the trial begins, and before any individual gives their informed consent; • The protocol should delineate continued access plans; and • The plan should be transparent to potential participants and explained during the informed consent process. -/- However, there is no guidance on how to fulfill these responsibilities (i.e., linking specific responsibilities with specific stakeholders, conditions, and duration). To fill this gap, the MRCT Center convened a working group in September of 2014 to develop a framework to guide stakeholders with identified responsibilities. This resultant Framework sets forth applicable principles, approaches, recommendations and ethical rationales for PTR regarding continued access to investigational medicines for research participants. (shrink)

Background: Transgender health care is a subject of much debate among clinicians, political commentators, and policy-makers. While the World Professional Association of Transgender Health (WPATH) Standards of Care (SOC) establish clinical standards, these standards contain implied ethics but lack explicit focused discussion of ethical considerations in providing care. An ethics chapter in the SOC would enhance clinical guidelines. Aims: We aim to provide a valuable guide for healthcare professionals, and anyone interested in the ethical aspects of clinical support (...) for gender diverse and transgender people of all ages. Recognizing that the WPATH is a global association, we address broad challenges. We offer a reflection on general ethical principles, providing conceptual tools for healthcare providers, patients, and families to navigate the specific challenges they might encounter in transgender health care, in line with WPATH’s worldwide mission and scope. Method: This article employs a descriptive analysis, and our framework of reference is the four principles of biomedical ethics: respect for autonomy, beneficence, nonmaleficence, and justice. Results: The article presents a discussion on the four ethical principles as applied to transgender health care. We address issues such as respect for patient autonomy in decision-making, the role of beneficence and nonmaleficence in clinical interventions, and the importance of justice in equitable treatment and access to care. Some of the ethical concerns we address in this article pertain to the current sociopolitical climate, where there has been increasing legal interference, internationally, for transgender and nonbinary people, particularly youth, seeking medical care. Discussion: We highlight the interplay between ethical principles and clinical practice, underscoring the need for ethical guidance in addressing the diverse challenges faced by healthcare providers and patients in transgender health care. We advocate for continuous refinement of ethical thinking to ensure that transgender health care is not only medically effective but also ethically sound. (shrink)

Review of British Medical Association handbook on human rights and doctors.

The practice of assigning authorship for a scientific publication tends to raise two normative questions: 1) ‘who should be credited as an author?’; 2) ‘who should not be credited as an author but should still be acknowledged?’. With the publication of the revised version of The European Code of Conduct for Research Integrity (ECCRI), standard answers to these questions have been called into question. This article examines the ways in which the ECCRI approaches these two questions and compares these approaches (...) to standard definitions of ‘authorship’ and ‘acknowledgment’ in guidelines issued by the International Committee of Medical Journal Editors (ICMJE) and the World Association of Medical Editors (WAME). In light of two scenarios and the problems posed by these kinds of ‘real-world’ examples, we recommend specific revisions to the content of the ECCRI in order not only to provide a more detailed account of the tasks deserving of acknowledgment, but to improve the Code’s current definition of authorship. (shrink)

As parents of a young woman who very much resembles Ashley, we recognize the way her parents speak of their daughter’s preciousness, and of the love and joy she brings into their life. We know too well the hardships associated with rearing a child with severe physical and intellectual disabilities, especially in our own society, unyielding as it is to the medical needs even “normals” have. We would not have our daughter Sesha undergo similar interventions. We do not believe (...) she is a perpetual child, even if her intellectual capacities do not exceed those of a child, for she has lived for thirty-seven years in this world and with that has acquired knowledge, sensitivities, and sensibilities that no child of “comparable” capacities could have. (shrink)

Dear Colleagues, -/- In this editorial, we would like to share with you important developments in the European Journal of Therapeutics (Eur J Ther). -/- First of all, as the editorial team, we would like you to know that we hold frequent meetings to benefit our esteemed colleagues and continue to work with great devotion in line with our goal of taking the journal further. We have previously shared with you that we have applied to many indexes. It is with (...) great pleasure that we would like to inform you that in the last few months, more of our index applications have been approved. -/- Index Copernicus, as a result of this application, the ICV 2022 value of our journal was determined to be 100 (approved 2023-10-31) [1] BASE (Bielefeld Academic Search Engine) (approved 2023-11-30) [2] Sherpa Romeo (approved 2023-09-27) [3] MIAR (approved 2023-10-16) [4] -/- All indexes in our journal are currently included on the journal web page [5]. -/- As the editorial team, we would like to inform you that we have determined a policy on this issue for our journal [6], taking into account the recommendations of important international ethics committees such as the Committee on Publication Ethics (COPE) [7] and the World Association of Medical Editors (WAME) [8], which have recently become a trendy topic of discussion about AI chatbots and academic studies prepared with the support of such tools. -/- As you know, when our journal was founded in 1990 [9], it was published in two yearly issues. It is an essential responsibility for us to carry our journal, which continued its publication life with three issues a year in 2009 [10] and four issues a year in 2014 [11]. With your valuable support, we would like to announce that we will increase our journal to 6 issues a year as of 2024 (February, April, June, August, October and December) with the rapidly growing progress of our journal. -/- Unfortunately, we cannot share the names of the referees who made significant contributions to our journal in 2023 due to the changes in the article submission interface during the year and the inaccessibility of some data in the previous interface. However, we would like to emphasize again that we are grateful to all of them for their valuable contributions. Moreover, to expand our journal's referee list, we would like to remind you that competent academics who volunteer in this regard can fill out the “Become a Reviewer for the European Journal of Therapeutics” form [12]. -/- Finally, we would like to point out that we have strengthened our editorial team with an academician competent in dentistry, Fatih Sari, DDS, PhD. -/- Fatih Sari, DDS, PhD, is a new Editorial Board Member of the Eur J Ther. Dr. Sari is an Associate Professor in the Department of Prosthodontics at the Gaziantep University Faculty of Dentistry. He is a Vice Dean of the Faculty of Dentistry and Head of Clinical Departments. Dr. Sari is a prosthodontist and a member of the Turkish Dental Association. He has experience in implant-supported fixed prostheses, Cad/Cam applications and dental materials. -/- We look forward to being able to offer you a large number of high-quality and valuable articles over the coming year. In addition, we would like to thank the readers, authors and reviewers of the Eur J Ther for their continuous support. -/- Sincerely yours,. (shrink)

Recent developments in neuroscience create new opportunities for understanding the human brain. The power to do good, however, is also the power to harm, so scientific advances inevitably foster as many dystopian fears as utopian hopes. For instance, neuroscience lends itself to the fear that people will be forced to reveal thoughts and feelings which they would not have chosen to reveal, and of which they may be unaware. It also lends itself to the worry that people will be encouraged (...) to submit to medication or surgery which, even if otherwise beneficial, alters their brain in ways that undermine their identity and agency. As Kenneth Foster notes, neural implants can have surprising and unintended adverse effects, even when they help to mitigate the loss of bodily control associated with Parkinson’s disease, or help to provide hearing for children who would otherwise be profoundly deaf. While the risk of adverse outcomes are scarcely specific to neuroscience, he thinks that ‘These issues are perhaps more acute’ with the latter than with other medical interventions, ‘because they are intimately and fundamentally related to a person’s communication with the outside world’. [ 2006 196] -/- Neuroscience, like genomic science, then, is likely to create new ways of harming people. Many of these will involve violations of privacy. However, these are unlikely fundamentally to challenge the reasons to value privacy, or our ability to protect it in the foreseeable future. Rather, I would suggest, the major threat to privacy comes from the difficulty of determining its nature and value and when, if ever, efforts to protect it are justified. So I will start by examining some threats to privacy, and their implications for neuroscience, before turning to philosophical problems in understanding the nature and value of privacy, and the practical consequences of those philosophical difficulties. (shrink)

People construe reality by using words as basic units of meaningful categorization. The present theory-driven study applied the method of a free association task to explore how people express the concepts of the world and the self in words. The respondents were asked to recall any five words relating with the word world. Afterwards they were asked to recall any five words relating with the word self. The method of free association provided the respondents with absolute (...) freedom to choose any words they wanted. Such free recall task is suggested as being a relatively direct approach to the respondents’ self- and world-related conceptual categories, without enormous rational processing. The results provide us, first, with associative ranges for constructs of the world and the self, where some associative dimensions are defined by semantic polarities in the meanings of peripheral categories (e.g., Nature vs. Culture). Second, our analysis showed that some groups of verbal categories that were associated with the words world and self are central, while others are peripheral with respect to the central position. Third, the analysis of category networks revealed that some categories play the role of a transmitter, mediating the pathway between other categories in the network. (shrink)

Our experiences with the external world are possible mainly through vision, hearing, taste, touch, and smell providing us a sense of reality. How the brain is able to seamlessly integrate stimuli from our external and internal world into our sense of reality has yet to be adequately explained in the literature. We have previously proposed a three-dimensional unified model of consciousness that partly explains the dynamic mechanism. Here we further expand our model and include illustrations to provide a (...) better conception of the ill-defined space within the self, providing insight into a unified mind-body concept. In this article, we propose that our senses “super-impose” on an existing dynamic space within us after a slight, imperceptible delay. The existing space includes the entire intrapersonal space and can also be called the “the body’s internal 3D default space”. We provide examples from meditation experiences to help explain how the sense of ‘self’ can be experienced through meditation practice associated with underlying physiological processes that take place through cardio-respiratory synchronization and coherence that is developed among areas of the brain. Meditation practice can help keep the body in a parasympathetic dominant state during meditation, allowing an experience of inner ‘self’. Understanding this physical and functional space could help unlock the mysteries of the function of memory and cognition, allowing clinicians to better recognize and treat disorders of the mind by recommending proven techniques to reduce stress as an adjunct to medication treatment. (shrink)

Thought experiments that concoct bizarre possible world modalities are standard fare in debates on personal identity. Appealing to intuitions raised by such evocations is often taken to settle differences between conflicting theoretical views that, albeit, have practical implications for ethical controversies of personal identity in health care. Employing thought experiments that way is inadequate, I argue, since personhood is intrinsically linked to constraining facts about the actual world. I defend a moderate modal skepticism according to which intuiting across (...) conceptually incongruent worlds constitutes ‘invalid intuitioninferences’—i.e., carrying over intuitions gathered from facts about possible worlds that are at odds with facts about the actual world, for the purpose of making claims about real-life persons and their identity, leads to conceptual incongruences. Such a methodological fallout precludes accurate, informative judgments about personal identity in the actual world, calling into question the adequacy of thought experimental considerations for potential real world applications in medical ethics. (shrink)

Aim: Low professional help-seeking intention (PHSI) hinders effective treatment of mental illness. PHSI among Chinese students is still understudied and under-recognized. This study aimed to evaluate the status of PHSI and its associated risk factors among Chinese medical students. -/- Methods: A cross-sectional survey was conducted in Hainan province, South China, between January 1, 2021, and May 31, 2021. A total of 2182 medical students were recruited and surveyed via an anonymous structured questionnaire. Logistic regression analyses were performed (...) to identify the factors associated with PHSI. -/- Results: Among the 2182 medical students (mean age 21.0 years (SD = 3.70), 61.5% females), those with and without PHSI were 72.0% and 28.0%, and 16.4% with moderate to severe depression. Male students, those with a high level of depression stigma, serious family dysfunction, and heavy dependence on mobile phones were significantly less likely to seek professional mental health help, with odds ratios (ORs) of 1.5, 2.0, 2.1, and 1.7, respectively. -/- Conclusion: A significant proportion of Chinese medical students demonstrate low PHSI, influenced by factors such as gender, depression stigma, family dysfunction, and mobile phone dependence. Future interventions aimed at increasing medical students’ PHSI should prioritize reducing depression stigma, mitigating reliance on mobile phone use, and enhancing family function to address these key barriers to seeking professional mental health support. (shrink)

Several attempts have been made to apply the choice-sensitive theory of distributive justice, luck egalitarianism, in the context of health and healthcare. This article presents a framework for this discussion by highlighting different normative decisions to be made in such an application, some of the objections to which luck egalitarians must provide answers and some of the practical implications associated with applying such an approach in the real world. It is argued that luck egalitarians should address distributions of health (...) rather than healthcare, endorse an integrationist theory that combines health concerns with general distributive concerns and be pluralist in their approach. It further suggests that choice-sensitive policies need not be the result of applying luck egalitarianism in this context. (shrink)

In contemporary healthcare, medical image categorization is essential for illness prediction, diagnosis, and therapy planning. The emergence of digital imaging technology has led to a significant increase in research into the use of machine learning (ML) techniques for the categorization of images in medical data. We provide a thorough summary of recent developments in this area in this review, using knowledge from the most recent research and cutting-edge methods.We begin by discussing the unique challenges and opportunities associated with (...) medical image classification, including the complexity of anatomical structures, variability in imaging modalities, and the need for interpretability and reliability in clinical settings. Subsequently, we survey a wide range of ML algorithms and techniques employed for medical image classification, including traditional methods such as support vector machines and k-nearest neighbors, as well as deep learning approaches like convolutional neural networks (CNNs) and recurrent neural networks (RNNs). Furthermore, we examine key considerations in dataset preparation, feature extraction, and model evaluation specific to medical image classification tasks. We highlight the importance of large, annotated datasets, transfer learning, and data augmentation techniques in enhancing model performance and generalization. (shrink)

William Smith’s recent article criticises the so-called orthodox approaches to the normative analysis of healthcare resource allocation, associated to the requirement that decision-makers should abide by strictly procedural principles of legitimacy defining a deliberative democratic process. Much of the appeal of Smith’s argument goes down to his awareness of real-world processes and, in particular, to the large gap he identifies between well-led democratic deliberation and the messiness of the process through which the intuitively legitimate Affordable Care Act (ACA) was (...) created. This reply aims to demonstrate that the ACA provides no counterexample to orthodox views, seizing this opportunity to explore the specific space that the procedural principles populating orthodox accounts are meant to regulate. Neither general questions of healthcare justice concerning, for example, universal access nor, relatedly, the activity of elected politicians falls within the natural scope of application of such principles, revealing a much more complex picture of the interactions between justice and legitimacy as well as substantive and procedural considerations than acknowledged by Smith. In the end, orthodox accounts of healthcare resource allocation turn out to provide a precious fund of theoretical resources for the normative study of administrators, which might be useful well beyond bioethics and health policy. (shrink)

It is unknown to what extent medical researchers generalize study findings beyond their samples when their sample size, sample diversity, or knowledge of conditions that support external validity do not warrant it. It is also unknown to what extent medical researchers describe their results with precise quantifications or unquantified generalizations, i.e., generics, that can obscure variations between individuals. We therefore systematically reviewed all prospective studies (n = 533) published in the top four highest ranking medical journals, Lancet, (...) New England Journal of Medicine (NEJM), Journal of the American Medical Association (JAMA), and the British Medical Journal (BMJ), from January 2022 to May 2023. We additionally reviewed all NEJM Journal Watch clinical research summaries (n = 143) published during the same time. Of all research articles reporting prospective studies, 52.5% included generalizations beyond specific national study populations, with the numbers of articles with generics varying significantly between journals (JAMA = 12%; Lancet = 77%) (p < 0.001, V = 0.48). There was no evidence that articles containing broader generalizations or generics were correlated with larger or more nationally diverse samples. Moreover, only 10.2% of articles with generalizations beyond specific national populations reported external validity strengthening factors that could potentially support such extrapolations. There was no evidence that original research articles and NEJM Journal Watch summaries intended for practitioners differed in their use of broad generalizations, including generics. Finally, from the journal with the highest citation impact, articles containing broader conclusions were correlated with more citations. Since there was no evidence that studies with generalizations beyond specific national study populations or with generics were associated with larger, more nationally diverse samples, or with reports of population similarity that may permit extensions of conclusions, our findings suggest that the generalizations in many articles were insufficiently supported. Caution against overly broad generalizations in medical research is warranted. (shrink)

Miracle Max, it seems, is the only remaining miracle worker in all of Florin. Among other things, this means that he (unlike anyone else) can resurrect the recently dead, at least in certain circumstances. Max’s peculiar talents come with significant perks (for example, he can basically set his own prices!), but they also raise a number of ethical dilemmas that range from the merely amusing to the truly perplexing: -/- How much about Max’s “methods” does he need to reveal to (...) his patients? Is it really OK for Max to lie about Valerie’s being a witch, even though she really isn’t? Just how much of the “truth” does Max have to tell his patients? -/- Let’s suppose that Humperdinck had offered Max his old job back. Would it have been OK for Max to accept this offer? What about if Humperdinck wanted him to do experiments at “the Zoo”? -/- Is Max obligated to offer his services to everyone who needs them, such as the (mostly) dead Westley and friends? Or is he free to pick and choose? -/- In this chapter, I’ll consider how these questions might be addressed using concepts of medical ethics. As it turns out, Max’s dilemmas are not too different from the sorts of dilemmas that many medical professionals encounter in their daily lives, and exploring how Max could (or should) respond to them can help us figure out what we can do here in the “real” world. (shrink)

Medical assistance in dying, which includes voluntary euthanasia and assisted suicide, is legally permissible in a number of jurisdictions, including the Netherlands, Belgium, Switzerland and Canada. Although medical assistance in dying is most commonly provided for suffering associated with terminal somatic illness, some jurisdictions have also offered it for severe and irremediable psychiatric illness. Meanwhile, recent work in the philosophy of psychiatry has led to a renewed understanding of psychiatric illness that emphasises the role of the relation between (...) the person and the external environment in the constitution of mental disorder. In this paper, I argue that this externalist approach to mental disorder highlights an ethical challenge to the practice of medical assistance in dying for psychiatric illness. At the level of the clinical assessment, externalism draws attention to potential social and environmental interventions that might have otherwise been overlooked by the standard approach to mental disorder, which may confound the judgement that there is no further reasonable alternative that could alleviate the person’s suffering. At the level of the wider society, externalism underscores how social prejudices and structural barriers that contribute to psychiatric illness constrain the affordances available to people and result in them seeking medical assistance in dying when they otherwise might not have had under better social conditions. (shrink)

Most people are completely oblivious to the danger that their medical data undergoes as soon as it goes out into the burgeoning world of big data. Medical data is financially valuable, and your sensitive data may be shared or sold by doctors, hospitals, clinical laboratories, and pharmacies—without your knowledge or consent. Medical data can also be found in your browsing history, the smartphone applications you use, data from wearables, your shopping list, and more. At best, data (...) about your health might end up in the hands of researchers on whose good will we depend to avoid abuses of power.2 Most likely, it will end up with data brokers who might sell it to a future employer, or an insurance company, or the government. At worst, your medical data may end up in the hands of criminals eager to commit extortion or identity theft. In addition to data harms related to exposure and discrimination, the collection of sensitive data by powerful corporations risks the creation of data monopolies that can dominate and condition access to health care. -/- This chapter aims to explore the challenge that big data brings to medical privacy. Section I offers a brief overview of the role of privacy in medical settings. I define privacy as having one’s personal information and one’s personal sensorial space (what I call autotopos) unaccessed. Section II discusses how the challenge of big data differs from other risks to medical privacy. Section III is about what can be done to minimise those risks. I argue that the most effective way of protecting people from suffering unfair medical consequences is by having a public universal healthcare system in which coverage is not influenced by personal data (e.g., genetic predisposition, exercise habits, eating habits, etc.). (shrink)

Background: Critically ill patients often require complex clinical care by highly trained staff within a specialized intensive care unit (ICU) with advanced equipment. There are currently limited data on the costs of critical care in low-and middle-income countries (LMICs). This study aims to investigate the direct-medical costs of key infectious disease (tetanus, sepsis, and dengue) patients admitted to ICU in a hospital in Ho Chi Minh City (HCMC), Vietnam, and explores how the costs and cost drivers can vary between (...) the different diseases. -/- Methods: We calculated the direct medical costs for patients requiring critical care for tetanus, dengue and sepsis. Costing data (stratified into different cost categories) were extracted from the bills of patients hospitalized to the adult ICU with a dengue, sepsis and tetanus diagnosis that were enrolled in three studies conducted at the Hospital for Tropical Diseases in HCMC from January 2017 to December 2019. The costs were considered from the health sector perspective. The total sample size in this study was 342 patients. -/- Results: ICU care was associated with significant direct medical costs. For patients that did not require mechanical ventilation, the median total ICU cost per patient varied between US$64.40 and US$675 for the different diseases. The costs were higher for patients that required mechanical ventilation, with the median total ICU cost per patient for the different diseases varying between US$2,590 and US$4,250. The main cost drivers varied according to disease and associated severity. -/- Conclusion: This study demonstrates the notable cost of ICU care in Vietnam and in similar LMIC settings. Future studies are needed to further evaluate the costs and economic burden incurred by ICU patients. The data also highlight the importance of evaluating novel critical care interventions that could reduce the costs of ICU care. (shrink)

Abstract: Background: Vitamin D insufficiency/deficiency prevalent in all age groups across the world is common in obesity and may play an important role in the risk factors of metabolic syndrome (MS). Objectives: This cross-sectional study is to evaluate the relationship between levels of adiponectin and circulating 25(OH)D, and its effect on metabolic biomarker among overweight/obese female students. Methods: Three hundred female students; with mean age 20.9 ± 3.2 years were attending the Aljouf University, Sakaka, Saudi Arabia. They were randomly (...) selected from university during the studying year 2015 – 2016. Anthropometric and biochemical indices were determined. Results: The study showed 19% of the female’s student were either overweight or obese (15% and 4%, respectively). The frequency of MS diagnosis among the students was 17%, with 13% and 4% had either three or four risk factors, respectively. Overweight/obese subjects had significantly worse anthropometric and biochemical characteristics, including waist/hip ratio, blood pressure (BP), fasting blood glucose (BG), insulin, insulin resistance (HOMA-IR), triglyceride levels (TG), low-density lipoprotein cholesterol levels (LDL-C), leptin, adiponectin, leptin/adiponectin ratio and high-density lipoprotein cholesterol levels (HDL-C) compared to normal weight. Of the subjects diagnosed with MS, 59% had mild and 8.6% had severe 25(OH)D deficiency. There was negative association between 25(OH)D and both FBG and HOMA-IR among young women obese/overweight. Conclusion: In our study, it suggested that low level of adiponectin was strongly correlated with low 25(OH)D levels. Also, the prevalence of MS tends to increase with high occurrence rate of low circulating 25(OH)D levels that is, known cause poor glycemic control and prediction of cardiovascular outcomes. (shrink)

Definition of the problem The umbrella term “explicability” refers to the reduction of opacity of artificial intelligence (AI) systems. These efforts are challenging for medical AI applications because higher accuracy often comes at the cost of increased opacity. This entails ethical tensions because physicians and patients desire to trace how results are produced without compromising the performance of AI systems. The centrality of explicability within the informed consent process for medical AI systems compels an ethical reflection on the (...) trade-offs. Which levels of explicability are needed to obtain informed consent when utilizing medical AI? Arguments We proceed in five steps: First, we map the terms commonly associated with explicability as described in the ethics and computer science literature, i.e., disclosure, intelligibility, interpretability, and explainability. Second, we conduct a conceptual analysis of the ethical requirements for explicability when it comes to informed consent. Third, we distinguish hurdles for explicability in terms of epistemic and explanatory opacity. Fourth, this then allows to conclude the level of explicability physicians must reach and what patients can expect. In a final step, we show how the identified levels of explicability can technically be met from the perspective of computer science. Throughout our work, we take diagnostic AI systems in radiology as an example. Conclusion We determined four levels of explicability that need to be distinguished for ethically defensible informed consent processes and showed how developers of medical AI can technically meet these requirements. (shrink)

World Crisis and Underdevelopment examines the impact of poverty and other global crises in generating forms of structural coercion that cause agential and societal underdevelopment. It draws from discourse ethics and recognition theory in criticizing injustices and pathologies associated with underdevelopment. Its scope is comprehensive, encompassing discussions about development science, philosophical anthropology, global migration, global capitalism and economic markets, human rights, international legal institutions, democratic politics and legitimation, world religions and secularization, and moral philosophy in its many varieties.

Current challenges in medical practice, research, and administration demand physicians who are familiar with bioethics, health law, and health economics. Curriculum directors at American Association of Medical Colleges-affiliated medical schools were sent confidential surveys requesting the number of required hours of the above subjects and the years in which they were taught, as well as instructor names. The number of relevant publications since 1990 for each named instructor was assessed by a PubMed search.In sum, teaching in (...) all three subjects combined comprises less than two percent of the total hours in the American medical curriculum, and most instructors have not recently published articles in the fields they teach. This suggests that medical schools should reevaluate their curricula and instructors in bioethics, health law, and health economics. (shrink)

Forms of Artificial Intelligence (AI) are already being deployed into clinical settings and research into its future healthcare uses is accelerating. Despite this trajectory, more research is needed regarding the impacts on patients of increasing AI decision making. In particular, the impersonal nature of AI means that its deployment in highly sensitive contexts-of-use, such as in healthcare, raises issues associated with patients’ perceptions of (un) dignified treatment. We explore this issue through an experimental vignette study comparing individuals’ perceptions of being (...) treated in a dignified and respectful way in various healthcare decision contexts. Participants were subject to a 2 (human or AI decision maker) x 2 (positive or negative decision outcome) x 2 (diagnostic or resource allocation healthcare scenario) factorial design. We found evidence of a “human bias” (i.e., a preference for human over AI decision makers) and an “outcome bias” (i.e., a preference for positive over negative outcomes). However, we found that for perceptions of respectful and dignified interpersonal treatment, it matters more who makes the decisions in diagnostic cases and it matters more what the outcomes are for resource allocation cases. We also found that humans were consistently viewed as appropriate decision makers and AI was viewed as dehumanizing, and that participants perceived they were treated better when subject to diagnostic as opposed to resource allocation decisions. Thematic coding of open-ended text responses supported these results. We also outline the theoretical and practical implications of these findings. (shrink)

Integrating medical imaging with computing technologies, such as Artificial Intelligence (AI) and its subsets: Machine learning (ML) and Deep Learning (DL) has advanced into an essential facet of present-day medicine, signaling a pivotal role in diagnostic decision-making and treatment plans (Huang et al., 2023). The significance of medical imaging is escalated by its sustained growth within the realm of modern healthcare (Varoquaux and Cheplygina, 2022). Nevertheless, the ever-increasing volume of medical images compared to the availability of imaging (...) experts. Biomedical experts and radiologists have resulted in a widening disparity, causing an excess and overwhelming workload on these healthcare professionals (Chen et al., 2021). Several studies indicate that the present-day biomedical radiologist is now saddled with the daunting task of interpreting an image almost every 10 seconds to keep pace with the burgeoning clinical demands (McDonald et al., 2015; Hosny et al., 2018; Lantsman et al., 2022). This cognitive drain has invariably led to inevitable consequences such as delays in diagnosis and an amplified risk of diagnostic errors – thus, the biomedical imaging aspect is in dire need of methods that would aid accurate diagnostics and analytics for improved decision making. In this review, the importance of AI-related technologies such as ML and/or DL methods are reviewed in relation to the processing of medical or biomedical images along with their potentials, challenges, and possible suggestions for future studies in the health landscape. The focus will be on machine learning methods associated with the medical field of image classification. (shrink)

Suppose that you are at a live jazz show. The drummer begins a solo. You see the cymbal jolt and you hear the clang. But in addition seeing the cymbal jolt and hearing the clang, you are also aware that the jolt and the clang are part of the same event. Casey O’Callaghan (forthcoming) calls this awareness “intermodal feature binding awareness.” Psychologists have long assumed that multimodal perceptions such as this one are the result of a subpersonal feature binding mechanism (...) (see Vatakis and Spence, 2007, Kubovy and Schutz, 2010, Pourtois et al., 2000, and Navarra et al., 2012). I present new evidence against this. I argue that there is no automatic feature binding mechanism that couples features like the jolt and the clang together. Instead, when you experience the jolt and the clang as part of the same event, this is the result of an associative learning process. The cymbal’s jolt and the clang are best understood as a single learned perceptual unit, rather than as automatically bound. I outline the specific learning process in perception called “unitization,” whereby we come to “chunk” the world into multimodal units. Unitization has never before been applied to multimodal cases. Yet I argue that this learning process can do the same work that intermodal binding would do, and that this issue has important philosophical implications. Specifically, whether we take multimodal cases to involve a binding mechanism or an associative process will have impact on philosophical issues from Molyneux’s question to the question of how active or passive we consider perception to be. (shrink)

Over the past 25 years, several new “medicines” have come screeching onto health care’s various platforms, including narrative medicine, personalized medicine, precision medicine and person-centred medicine. Philosopher Miriam Solomon calls the first three of these movements different “ways of knowing” or “methods,” and argues that they are each a response to shortcomings of methods that came before them. They should also be understood as reactions to the current dominant model of medicine. In this article, I will describe our dominant model, (...) which I call “the new medical model.” I will argue that several towering problems in modern medicine can be traced to its philosophical foundations, which calls for philosophical analysis. (shrink)

Most regulations and guidelines require that potential research participants be told a great deal of information during the consent process. Many of these documents, and most of the scholars who consider the consent process, assume that all this information must be disclosed because it must all be understood. However, a wide range of studies surveying apparently competent participants in clinical trials around the world show that many do not understand key aspects of what they have been told. The standard (...) view of the conditions for valid consent therefore implies that these people have failed to give valid consent to research participation. In this paper we argue that the standard view is false. The primary function of the requirement that researchers disclose information about a study is the avoidance of illegitimate control over someone’s consent decision, which is a form of fraud.We derive the content and manner of appropriate disclosure by analysing the ways in which the manipulation of information can invalidate consent. Our analysis shows that the informational requirements for valid consent are conceptually distinct and thus unlikely to have identical contents. This implies that consent can be valid when not everything that ought to be disclosed by the person asking for consent is understood by the person who proffers it. (shrink)

The world never stands still. There is always a Brownian movement of economic subjects and objects on the face of it. But, if we have been visualizing this movement over a relatively long period of time, then we can distinguish the acceleration and increase in the volume of movements along individual commodity routes, the growth and formation of new subjects of international economic relations. From time to time, "accelerators" of this movement appear, either in the form of new types (...) of energy to service production, or technologies to simplify the exchange and distribution of benefits. The market, controlled by the "invisible hand", is gradually taking over the whole world, and some new goods appear to meet the needs. We use technologies and devices described in unreal fantasy plots of classical literature already today in real life. The speed of change is exciting on the one hand and is frightening on the other hand. In the modern world, it would seem, everything is mobile. The quality and cost of transportation has no longer been a physical obstacle to any exchange and travel. The forms of modern financial transactions for service international economic relations, their speed and coverage are impressive. Enterprises, in terms of capitalization, exceed the national incomes of states and do not have spatial territorial boundaries, being the main players in international economic relations along with states, their associations and international organizations. Digitalization is no longer a challenge for society, but our present. It seems sometimes that the world allegedly wants to slow down the further development of mankind and creates obstacles in the form of wars, epidemics and crises. Such obstacles become challenges for the development of economic entities of all levels. Change always creates unexpected opportunities for someone and insurmountable restrictions for other one. Change always leads to a redistribution of forces. Changes are needed to overthink the nature and direction of movement. Changes are the certain reorganization of the world economic system. The world is always on the verge of changes. What will they be this time? (shrink)

A prominent view in contemporary political theory, the ‘associative view’, says that duties of justice are triggered by particular cooperative relations between morally significant agents, and that ‘therefore’ principles of justice apply only among fellow citizens. This view has been challenged by advocates of global justice, who point to the existence of a world-wide cooperative network to which principles of justice apply. Call this the challenge from geographical extension. In this paper, I pose a structurally similar challenge to the (...) associative view: the challenge from species extension. This says that the existing network of cooperation extends beyond the human species, to encompass some non-human animals, particularly domesticated dogs. In light of this, if one believes that (i) certain non-human animals are morally significant (i.e. objects of moral concern), and that (ii) justice applies to fellow cooperators, one should also hold that domesticated dogs are owed justice in much the same way our human fellow citizens are. I conclude by considering the implications of this argument for the associative view, and animal-rights theory. (shrink)

COVID-19 affected to the people all around the world. As its first and second wave has been passed and we are facing currently to third wave, but all around the world no one can overcome to this viral infectious disease. Likewise it is affecting to people like a viral disease physically but along with its effect, its huge effect on mental health worldwide. The significant academic research has shown that there is a correlation of mental issues and covid-19 (...) pandemic. Among all people it has seen that mostly students are affected. Recent studies have suggest that psychiatric problems, includes nervousness, depressive symptom, disappointment in students due to exposure of covid-19. However the mental health strategies of lockdown are unknown. In addition, illness perceptions and relevant consequences facing the pandemic have played role due to restrictions. Survey type studies are conducted for the investigation of anxiety and depression during pandemic lockdown. All people like adults, men, women, students are invited for survey through social media. (shrink)

Bradford Hill (1965) highlighted nine aspects of the complex evidential situation a medical researcher faces when determining whether a causal relation exists between a disease and various conditions associated with it. These aspects are widely cited in the literature on epidemiological inference as justifying an inference to a causal claim, but the epistemological basis of the Hill aspects is not understood. We offer an explanatory coherentist interpretation, explicated by Thagard's ECHO model of explanatory coherence. The ECHO model captures the (...) complexity of epidemiological inference and provides a tractable model for inferring disease causation. We apply this model to three cases: the inference of a causal connection between the Zika virus and birth defects, the classic inference that smoking causes cancer, and John Snow’s inference about the cause of cholera. (shrink)

The epidemiologist Bradford Hill famously argued that in epidemiology, specificity of association (roughly, the fact that an environmental or behavioral risk factor is associated with just one or at most a few medical outcomes) is strong evidence of causation. Prominent epidemiologists have dismissed Hill’s claim on the ground that it relies on a dubious `one-cause one effect’ model of disease causation. The paper examines this methodological controversy, and argues that specificity considerations do have a useful role to play (...) in causal inference in epidemiology. More precisely, I argue that specificity considerations help solve a pervasive inferential problem in contemporary epidemiology: the problem of determining whether an exposure-outcome correlation might be due to confounding by a social factor. This examination of specificity has interesting consequences for our understanding of the methodology of epidemiology. It highlights how the methodology of epidemiology relies on local tools designed to address specific inference problems peculiar to the discipline, and shows that observational causal inference in epidemiology can proceed with little prior knowledge of the causal structure of the phenomenon investigated. I also argue that specificity of association cannot (despite claims to the contrary) be entirely explained in terms of Woodward’s well-known concept of “one-to-one” causal specificity. This is because specificity as understood by epidemiologists depends on whether an exposure (or outcome) is associated with a `heterogeneous’ set of variables. This dimension of heterogeneity is not captured in Woodward’s notion, but is crucial for understanding the evidential import of specificity of association. (shrink)

COVID-19 affected to the people all around the world. As its first and second wave has been passed and we are facing currently to third wave, but all around the world no one can overcome to this viral infectious disease. Likewise it is affecting to people like a viral disease physically but along with its effect, its huge effect on mental health worldwide. The significant academic research has shown that there is a correlation of mental issues and covid-19 (...) pandemic. Among all people it has seen that mostly students are affected. Recent studies have suggest that psychiatric problems, includes nervousness, depressive symptom, disappointment in students due to exposure of covid-19. However the mental health strategies of lockdown are unknown. In addition, illness perceptions and relevant consequences facing the pandemic have played role due to restrictions. Survey type studies are conducted for the investigation of anxiety and depression during pandemic lockdown. All people like adults, men, women, students are invited for survey through social media. (shrink)

The Unified Medical Language System and the Gene Ontology are among the most widely used terminology resources in the biomedical domain. However, when we evaluate them in the light of simple principles for wellconstructed ontologies we find a number of characteristic inadequacies. Employing the theory of granular partitions, a new approach to the understanding of ontologies and of the relationships ontologies bear to instances in reality, we provide an application of this theory in relation to an example drawn from (...) the context of the pathophysiology of hypertension. This exercise is designed to demonstrate how, by taking ontological principles into account we can create more realistic biomedical ontologies which will also bring advantages in terms of efficiency and robustness of associated software applications. (shrink)

The paper investigates the role played by pre-scientific experience in the philosophy of Josiah Royce and Edmund Husserl. Such a notion, generally associated with Husserl’s conception of the life-world (Lebenswelt) in the Crisis of European Sciences and Transcendental Phenomenology (1936), finds an equivalent and historical antecedent in Royce’s distinction between a world of description and a world of appreciation. The final goal is to show how, despite their different philosophical frameworks, Royce and Husserl agree on the idea (...) that, through the rejection of the world given through mere perception (Lebenswelt/world of appreciation), European sciences have somehow failed their task of universality. As it will be shown, this idea is also due to methodological affinities among the two thinkers. The experience of interconnectedness among individual minds, while precluded in the mere scientific explanation of the world, it becomes possible through the enactment of the Lebenswelt or, as in Royce’s case, through a return to the experience of the world of appreciation. (shrink)

Medical terminology collects and organizes the many different kinds of terms employed in the biomedical domain both by practitioners and also in the course of biomedical research. In addition to serving as labels for biomedical classes, these names reflect the organizational principles of biomedical vocabularies and ontologies. Some names represent invariant features (classes, universals) of biomedical reality (i.e., they are a matter for ontology). Other names, however, convey also how this reality is perceived, measured, and understood by health professionals (...) (i.e., they belong to the domain of epistemology). We analyze terms from several biomedical vocabularies in order to throw light on the interactions between ontological and epistemological components of these terminologies. We identify four cases: 1) terms containing classification criteria, 2) terms reflecting detectability, modality, uncertainty, and vagueness, 3) terms created in order to obtain a complete partition of a given domain, and 4) terms reflecting mere fiat boundaries. We show that epistemology-loaded terms are pervasive in biomedical vocabularies, that the “classes” they name often do not comply with sound classification principles, and that they are therefore likely to cause problems in the evolution and alignment of terminologies and associated ontologies. (shrink)

This paper sketches a new and somewhat heterodox metaphysical theory of consciousness: the “many-worlds theory”. It drops the assumption that all conscious subjects’ experiences are features of one and the same world and instead associates different subjects with different “first-personally centred worlds”. We can think of these as distinct “first-personal realizers” of a shared “third-personal world”, where the latter is supervenient, in a sense to be explained. This is combined with a form of modal realism, according to which (...) different subjects’ first-personally centred worlds are all real, though only one of them is present for each subject. The theory offers a novel way of capturing the irreducibly subjective nature of conscious experience without lapsing into solipsism. The paper also looks at some scientific theories of consciousness, such as integrated information theory, through the proposed lens and reconsiders the hard problem of consciousness. (shrink)

As a result of the world-wide COVID-19 epidemic, an internal tension in the goals of medicine has come to the forefront of public debate. Medical professionals are continuously faced with a tug of...

Dans le diagnostic du cancer, la précocité du diagnostic est généralement un élément valorisé. Selon la croyance commune, un cancer détecté tôt aura plus de chance d’être traitable. Or, cette conception des avantages du diagnostic précoce mène dans certains cas au phénomène de surdiagnostic, soit le fait de diagnostiquer un cancer à des individus qui n’en ont pas encore un et qui sont potentiellement en voie de le développer. Dans cet article, nous défendrons d’abord que le phénomène de surdiagnostic est (...) lié en majeure partie à notre connaissance grandissante du cancer, et au fait que ces nouvelles connaissances causent des biais dans les processus de dépistage, conduits en vue de trouver un cancer. Afin de remédier à cette problématique, nous tenterons de montrer que le fait de simplement modifier notre approche du cancer et le vocabulaire médical associé permettrait de réduire les cas de surdiagnostics. (shrink)

As a way to make medical decisions, Evidence-Based Medicine (EBM) has failed. EBM's failure arises from not being founded on real-world decision-making. EBM aspires to a scientific standard for the best way to treat a disease and determine its cause, but it fails to recognise that the scientific method is inapplicable to medical and other real-world decision-making. EBM also wrongly assumes that evidence can be marshaled and applied according to an hierarchy that is determined in an (...) argument by authority to the method by which it has been obtained. If EBM had valid theoretical, practical or empirical foundations, there would be no hierarchy of evidence. In all real-world decision-making, evidence stands or falls on its inherent reliability. This has to be and can only be assessed on a case-by-case basis applying understanding and wisdom against the background of all available facts—the "factual matrix." EBM's failure is structural and was inevitable from its inception. EBM confuses the inherent reliability and probative value of evidence with the means by which it is obtained. -/- EBM is therefore an ad hoc construct and is not a valid basis for medical decision-making. This is further demonstrated by its exclusion of relevant scientific and probative real-world decision-making evidence and processes. It draws upon a narrow evidence base that is itself inherently unreliable. It fails to take adequate account of the nature of causation, the full range of evidence relevant to its determination, and differing approaches to determining cause and effect in real-world decision-making. EBM also makes a muddled attempt to emulate the scientific method and it does not acknowledge the role of experience, understanding and wisdom in making medical decisions. (shrink)

In this paper I sketch a liberal studies course designed to explore our fundamental problem of thought and life: How can our human world exist and best flourish embedded as it is in the physical universe? The fundamental character of this problem provides one with the opportunity to explore a wide range of issues. What does physics tell us about the universe and ourselves? How do we account for everything physics leaves out? How can living brains be conscious? If (...) everything occurs in accordance with physical law, what becomes of free will? How does Darwin's theory of evolution contribute to the solution to the fundamental problem? What is the history of thought about this problem? What is of most value associated with human life? What kind of civilized world should we seek to help create? Why is the fundamental problem not a part of standard education in schools and universities? What are the most serious global problems confronting humanity? Can humanity learn to make progress towards as good a world as possible? These are some of the questions that can be tackled as an integral part of exploring the fundamental problem. But the course does not merely wander at random from one issue to another. Taking the fundamental problem as central provides the course with a coherent structure. The course would be conducted as a seminar, and it would respond to queries and suggestions from students. (shrink)

Background and Aim: Global trends and national policies have made internationalization and paying attention to the international markets of higher education inevitable on the one hand and becoming a legal requirement of Iranian medical sciences universities on the other hand. Therefore, the main goal of this article was to show, by examining the experience of international marketing of higher education in Tehran University of Medical Sciences, what are the futures of international marketing of higher education in medical (...) sciences? Materials and methods: in this documented data and the views, knowledge and lived experiences of the beneficiaries of the University of Medical Sciences were the basis of the study, and in the following, the methods of documentary studies, trend analysis, brainstorming, expert panel, theme analysis and scenario planning were used. Results: The most important achievement of this article is that among the challenges facing the international marketing of higher education in the University of Medical Sciences, two driving forces have the highest importance and uncertainty in shaping the future of this issue, including: sustainable security and cultural development. Conclusion: The normalization of political and economic relations with the world along with appropriate cultural development inside and outside the university and acceptance of cultural, racial, religious, intellectual, ethnic and gender differences strengthens the marketing process of higher education. In such a situation, the risk of investing in providing international higher education will be reduced. Therefore, the most expensive and the most important uncertainty facing the country's universities in international marketing is the attitude and approach of science and technology governance to the relations and structure governing the international system. (shrink)

A resurgence of national and international interest in citizenship education, citizenship and social cohesion has been coupled with an apparent emergence of a language of crisis (Sears & Hyslop‐Margison, 2006). Given this background, how can or should one consider a subjective sense of membership in a single political community? What this article hopes to show is that confining the subject of citizenship or patriotism to a national framework is inadequate in as much as there are grounds to argue for a (...) more expansive and, at the same time, integrated outlook. Patriotism, like Citizenship, is still open to interpretation and potentially in danger of falling short of a richer conception. Education, therefore, needs to incorporate inclusive practices and encourage an integrative mindset in order to accommodate: increasingly complex identities, associations, experiences and continuing changes in the political landscape. In this article, the author argues for the importance of learning ways in which to value and respect diversity while working towards a principle of unity in diversity. Cultivating a subjective sense of membership in a single world polity is vital in matters pertaining to sustainability and justice. In response to considering possible ways of sharing a subjective sense of membership in a single community and some implications for Citizenship, Patriotism and Citizenship Education, this article looks to three areas: ways in which to understand the notion of citizenship and patriotism, cultural crises and the notion of a cosmopolitan nation and, finally, the personal dimension to education for world citizenship. (shrink)