Reflecting on group theory within clinical supervision offers useful vantage points from which to engage nursing and the helping professions in the task of supervisory practice. This paper presents reflective experiences of group clinical supervision training and practice through a critique of Hawkins and Shohet’s process centred model. The underlying premise of transference hypothesis is that experiences and memories from the past inform present behaviours. Little has been written about the hypothesis in relation to clinical (...) supervision in nursing and the helping professions. However, the hypothesis was criticised by John M. Shlien in the 1980s and remains pertinent today due to expansion into social and healthcare practice. Reflective autobiographical diary entries focus on the model’s two latter stages which propose the use of Sigmund Freud’s transference hypothesis. The work of Freud, Foulkes, Heidegger and Hawkins and Shohet are synthesised and conclude with a phenomenological suggestion that immediacy and openness are necessary ontological conditions for group clinical supervision. Valuing empathic attunement to better understand group clinical supervision may be more important than theoretical distractions for non-therapeutic clinical supervision practice. (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)

School administrators are mandated to take the instructional leadership roles. On this premise, a study assessed the extent of instructional leadership practices of public elementary school administrators in El Salvador City Division, Philippines. Also, it explored their actual practices, challenges encountered, and the ways they overcome the challenges in practicing instructional leadership. It employed a mixed-method research design. It administered the adopted assessment tool on instructional leadership to 15 school administrators and 12 of them were involved in the individual interviews. (...) This was conducted between the last quarter of 2019 and the first quarter of 2020. Descriptive statistics were used to describe the extent of instructional leadership practices. Also, it analyzed the actual practices, the challenges encountered, and the ways of overcoming these challenges using thematic narrative analysis. Results revealed that public school administrators have always practiced the four domains or strands of instructional leadership to a very high extent. Providing the technical assistance, conducting clinical supervision, and innovating teaching and learning emerged as themes of their actual practices. These administrators had encountered challenges in dealing with teachers’ attitudes, conflicting schedules and activities, and teachers’ resistance to changes. They overcome the challenges by trying to meet the competency standards, adapting and modifying the existing programs, contextualizing teaching and learning, and inculcating the value and benefits of class observation. Looking at the findings from the lens of deliberate practice theory, it was concluded that school administrators have indicated they have acquired knowledge and a high level of understanding of their instructional leadership roles. But despite of this, they still met challenges and have tried their best to manage them. This study presented some doable and practical recommendations to the Department of Education (DepEd) and concerned offices which may benefit both the internal and external stakeholders of the schools. (shrink)

Recent clinical trials show that psychedelics such as LSD and psilocybin can be given safely in controlled conditions, and can cause lasting psychological benefits with one or two administrations. Supervised psychedelic sessions can reduce symptoms of anxiety, depression, and addiction, and improve well-being in healthy volunteers, for months or even years. But these benefits seem to be mediated by "mystical" experiences of cosmic consciousness, which prompts a philosophical concern: do psychedelics cause psychological benefits by inducing false or implausible beliefs (...) about the metaphysical nature of reality? This book is the first scholarly monograph in English devoted to the philosophical analysis of psychedelic drugs. Its central focus is the apparent conflict between the growing use of psychedelics in psychiatry and the philosophical worldview of naturalism. Within the book, Letheby integrates empirical evidence and philosophical considerations in the service of a simple conclusion: this "Comforting Delusion Objection" to psychedelic therapy fails. While exotic metaphysical ideas do sometimes come up, they are not, on closer inspection, the central driver of change in psychedelic therapy. Psychedelics lead to lasting benefits by altering the sense of self, and changing how people relate to their own minds and lives-not by changing their beliefs about the ultimate nature of reality. The upshot is that a traditional conception of psychedelics as agents of insight and spirituality can be reconciled with naturalism (the philosophical position that the natural world is all there is). Controlled psychedelic use can lead to genuine forms of knowledge gain and spiritual growth-even if no Cosmic Consciousness or transcendent divine Reality exists. Philosophy of Psychedelics is an indispensable guide to the literature for researchers already engaged in the field of psychedelic psychiatry, and for researchers-especially philosophers-who want to become acquainted with this increasingly topical field. (shrink)

The study investigated principals’ supervisory techniques for combating corruption and the attainment of quality school governance. Two null hypotheses were formulated. The ex-post facto research design was adopted for the study. Census technique was used to draw the entire population of 81 principals from all the public secondary schools in Aba Education Zone of Abia State. Data collection was carried out with the use of a research instrument titled: “Principals’ Supervisory Techniques for Combating Corruption and Attainment of Quality School Governance (...) Questionnaire (PSTCCAQSGQ)”. The instrument was validated by two experts of Test and Measurement in the Department of Educational Foundations, University of Calabar. The reliability value obtained was .88 using Cronbach Alpha technique. One-way analysis of variance was used in testing the null hypotheses at .05 level of significance. Findings revealed that there is a significant influence of principals’ clinical and demonstration techniques of supervision for combating corruption on quality school governance. Based on the findings, it was concluded that school governance should be enhanced with supervisory techniques by principals for the attainment of anti-corruption culture in Aba education zone of Abia State, Nigeria. (shrink)

Abstract The values of the healthcare sector are fairly ubiquitous across the globe, focusing on caring and respect, patient health, excellence in care delivery, and multi-stakeholder collaboration. Many individual pharmacists embrace these core values. But their ability to honor these values is significantly determined by the nature of the system they work in. -/- The paper starts with a model of the prevailing pharmacist workforce model in Scotland, in which core roles are predominantly separated into hierarchically disaggregated jobs focused on (...) one professional ‘pillar’: Clinician /Practice Provider; Educator; Leader/Manager; and Researcher. This is the ‘Atomistic’ Model. This skills-segregation yields a workforce of individuals working in isolation rather than collaborating together, and lacking a shared information flow, purpose and identity. Key strategic flaws include suboptimal responsiveness to population and subpopulation needs, inconsistency and inequity of care, an erosion of professional agency, and lower job satisfaction. It is conjectured that this results from a lack of congruence between values, professional ethos, and organizational structure. ‘Atomism’ culminates in a syndrome of widespread professional-level cognitive dissonance. -/- The paper contrasts this with a new emerging workforce vision, The Collaborative Care Model. This new model defines a systems-first-approach, built on the principle that all jobs must include all four professional ‘pillars’. Vertical skills integration, involving education and task sharing, will support sustainability and succession planning. Horizontal skills integration (across practice, leadership and research) is included to improve responsiveness to population need and individual professional agency. The working conditions, supportive ethos, and career structure needed to make the model work are described. Moral theory and workforce theory are used to justify why the model may be more effective for population health, delivering greater job satisfaction for individuals and ultimately helping systematically realize and honor healthcare values. Finally, the paper sketches the first steps needed to implement the model at the national level, starting with the operationalization of new multi-pillar professional curricula across the career spectrum. Potential pitfalls and challenges are also discussed. -/- Co-Authors: 1. Paul Forsyth (PF) Lead Pharmacist Clinical Cardiology, Pharmacy, NHS Greater Glasgow & Clyde. Contribution: Conceptualization; Model Curation; Model Theory; Model Visualization; Writing - original draft (lead author), Writing - review & editing (lead author) 2. Andrew Radley (AR), Consultant in Public Health Pharmacy, NHS Tayside. Contribution: Conceptualization; Model curation; Model Theory; Writing - review & editing 3. Gordon Rushworth (GR), MPharm MSc FFRPS FRPharmS (Consultant). Programme Director, Highland Pharmacy Education & Research Centre, NHS Highland, Inverness. Contribution: Model curation; Writing - review & editing 4. Fiona Marra (FM) National Lead Clinician Scottish Infection and Immunology Network (SPAIIN) / Advanced Pharmacist HCV / HIV, NHS Greater Glasgow & Clyde. Contribution: Model curation; Writing - review & editing 5. Susan Roberts (SR) Associate Postgraduate Pharmacy Dean, NHS Education for Scotland. Contribution: Model curation; Writing - review & editing 6. Roisin O’Hare (RO) Lead Teacher Practitioner Pharmacist, Northern Ireland University Network, Southern Health and Social Care Trust. Contribution: Model curation; Writing - review & editing 7. Catherine Duggan (CD) Chief Executive Officer, International Pharmaceutical Federation (FIP). Contribution: Model curation; Writing - review & editing 8. Barry Maguire (BM) Senior Lecturer, School of Philosophy, Psychology and Life Sciences, The University of Edinburgh. Contribution: Conceptualization; Model Curation; Model Theory; Model Visualization; Supervision; Writing - original draft (senior academic supervisor), Writing - review & editing (senior academic supervisor) -/- . (shrink)

Two general ethical problems in psychiatry are thrown into sharp relief by long term care. This article discusses each in turn, in the context of two anonymised case studies from actual clinical practice. First, previous mental health legislation soothed doubts about patients' refusal of consent by incorporating time limits on involuntary treatment. When these are absent, as in the provisions for long term care which have recently come into force, the justification for compulsory treatment and supervision becomes more (...) obviously problematic. Second, Anglo-American law does not normally allow the preventive detention of someone who may be dangerous but has not actually committed any crime. The justification for detaining a possibly dangerous user of mental health services without his or her consent can only be based on risk assessment, but this raises issues of moral luck. Is the psychiatrist who decides not to take out a supervision order for a possibly dangerous patient with an initial psychotic diagnosis morally at fault if that person harms someone in the community, or himself? Or is the psychiatrist merely unlucky? (shrink)

At the age of 70 years, Professor Chris Nwamuo is still breaking new grounds in the Theatre, Media and Communication disciplines, not only in the University of Calabar, but also in Cross River University of Technology (CRUTECH) in Cross River State Nigeria, Abia State University in Abia State, Nigeria and many other state, national and international higher institutions of learning. He is tireless in research, clinical in project supervision, stern in the resolution of academic knots and committed to (...) teaching students both at the graduate and undergraduate levels. One would imagine that despite the ever busy schedule of this prolific scholar, including his attendance to family affairs, he still has the time to write out his findings, thoughts and perspectives in the very field that he has worked for more than three decades. One of his most recent works is his book “The Dynamics of International Communication” published in 2016. Communication is the human nutrient that grows a healthy relationship among people and nations of the world. When absent or not properly handled, communication effects result to rumor, grapevines, conflict or in internationally severe cases, war. ‘Communication’ as a term is surrounded by mysteries of comprehension but Nwamuo has attempted an unraveling throughout his years of academic surgeon in the field. Ike (2005:40) define communication as the process by which people share information, ideas and feelings using spoken and written words, body language, personal mannerism and style, the physical environment or anything that adds meaning to a message. Iyorza (2015:11) views communication as the transmission of information, idea or beliefs from the encoder to the decoder with the aim of achieving a common ground of understanding, promoting a course or reacting to given stimuli in the communication encounter. Both definitions share a common characteristic: information or ideas sharing or transmission. (shrink)

The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) COVID-19 dataset is one of the largest international databases of prospectively collected clinical data on people hospitalized with COVID-19. This dataset was compiled during the COVID-19 pandemic by a network of hospitals that collect data using the ISARIC-World Health Organization Clinical Characterization Protocol and data tools. The database includes data from more than 705,000 patients, collected in more than 60 countries and 1,500 centres worldwide. Patient data are available (...) from acute hospital admissions with COVID-19 and outpatient follow-ups. The data include signs and symptoms, pre-existing comorbidities, vital signs, chronic and acute treatments, complications, dates of hospitalization and discharge, mortality, viral strains, vaccination status, and other data. Here, we present the dataset characteristics, explain its architecture and how to gain access, and provide tools to facilitate its use. (shrink)

The paper analyses issues related to supervision and support of early career researchers in Estonian academia. We use nine focus groups interviews conducted in 2015 with representatives of social sciences in order to identify early career researchers’ needs with respect to support, frustrations they may experience, and resources they may have for addressing them. Our crucial contribution is the identification of wider support networks of peers and colleagues that may compensate, partially or even fully, for failures of official (...) class='Hi'>supervision. On the basis of our analysis we argue that support for early career researchers should take into account the resources they already possess but also recognise the importance of wider academic culture, including funding and employment patterns, and the roles of supervisors and senior researchers in ensuring successful functioning of support networks. Through analysing the conditions for the development of early career researchers – producers of knowledge – our paper contributes to social epistemology understood as analysis of specific forms of social organisation of knowledge production. (shrink)

The aim of the research is to identify the relationship between the performance criteria and the achievement of the objectives of supervision which is represented in the performance of the job at the Islamic University in Gaza Strip. To achieve the objectives of the research, the researchers used the descriptive analytical approach to collect information. The questionnaire consisted of (22) paragraphs distributed to three categories of employees of the Islamic University (senior management, faculty members, their assistants and members of (...) the administrative board). A random sample of 314 employees was selected, 276 responses were retrieved with a return rate of 88.1%. The SPSS program was used to enter, process, and analyze the data. The results of the study showed a positive relationship between the performance criteria and the achievement of the control objectives represented by the job performance in the Islamic University from the point of view of the members (senior management, faculty and their assistants and the administrative board). The researchers also recommended a number of recommendations, including the provision of an appropriate level of control system components today through the continuous updating and development of performance standards and the need to provide the necessary physical and financial resources to continue the development and achievement within the university. Expand the development of technology in the various activities of the university through the construction of a complete and integrated system to support the control systems in the university to suit its size. The researchers also recommended the follow-up, review of the performance standards and work to modify them in line with the mission of the university and the goals that the university seeks to reach. (shrink)

The article describes a comparative analysis of research on the approaches and peculiarities of the implementation of supervision and intervision in the professional activity of teachers abroad and in Ukraine. The concept of supervision and intervision in the work of teachers in the secondary school is revealed. The use of supervision and interference in the professional activity of teachers makes it possible to effectively prevent their emotional and professional burnout. It is noted that in Ukraine, for the (...) first time, a program of psychosocial support, which includes regular supervision for teachers and school psychologists, was developed and implemented by specialists of the National University of Kyiv-Mohyla Academy with the support of UNICEF in the eastern regions of the country where the military conflict has been taking place. However, among the teachers around the country, this practice is not used because there is no system for the preparation of supervisors; most teachers are not familiar with this concept at all. Intervision in schools abroad is quite developed, it is carried out systematically, it is aimed at creating a special and safe space for professional support, exchange of experience, and information, and it prevents emotional and professional degradation. In Ukrainian schools, the intervision between colleagues is partial. Therefore, this form of work needs support and development from the school administration. Examples of the plan of work during intervision among the teachers on the basis of foreign experience are given and recommendations on conducting intervision in pedagogical collectives are offered. (shrink)

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the National Institute of Mental Health’s Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, and the general psychopathology factor, as well as a revival of interest in phenomenological psychopathology. The question naturally emerges as to what the relationship between these new approaches is – are they mutually exclusive, competing approaches, or can they be integrated in some way (...) and used to enrich each other? In this opinion piece, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology, such as selfhood, embodiment, affectivity, etc., can be overlaid on clinical stages in order to enrich and deepen the phenotypes captured in clinical staging (‘high resolution’ clinical phenotypes). This approach may be useful both ideographically and nomothetically, in that it could complement diagnosis, enrich clinical formulation, and inform treatment of individual patients, as well as help guide aetiological, prediction, and treatment research. The overlaying of phenomenological domains on clinical stages may require that these domains are reformulated in dimensional rather than categorial terms. This integrative project requires assessment tools, some of which are already available, that are sensitive and thorough enough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging may be enriched by introducing greater depth to phenotypes; phenomenological psychopathology may be enriched by introducing stages of severity and disorder progression to phenomenological analysis. (shrink)

Outcomes research in healthcare has been a topic much addressed in recent years. Efforts in this direction have been supplemented by work in the areas of guidelines for clinical practice and computer-interpretable workflow and careflow models.In what follows we present the outlines of a framework for understanding the relations between organizations, guidelines, individual patients and patient-related functions. The derived framework provides a means to extract the knowledge contained in the guideline text at different granularities, in ways that can help (...) us to assign tasks within the healthcare organization and to assess clinical performance in realizing the guideline. It does this in a way that preserves the flexibility of the organization in the adoption of the guidelines. (shrink)

The desideratum of semantic interoperability has been intensively discussed in medical informatics circles in recent years. Originally, experts assumed that this issue could be sufficiently addressed by insisting simply on the application of shared clinical terminologies or clinical information models. However, the use of the term ‘ontology’ has been steadily increasing more recently. We discuss criteria for distinguishing clinical ontologies from clinical terminologies and information models. Then, we briefly present the role clinical ontologies play in (...) two multicentric research projects. Finally, we discuss the interactions between these different kinds of knowledge representation artifacts and the stakeholders involved in developing interoperational real-world clinical applications. We provide ontology engineering examples from two EU-funded projects. (shrink)

The purpose of this paper was to examine institutional variables and the supervision of security in secondary schools in Cross River State. The study specifically sought to determine whether there was a significant influence of school population, school type and school location, on the supervision of security in public secondary schools in Cross River State. Three null hypotheses were formulated accordingly to guide the study. 360 students and 120 teachers resulting in a total of 480 respondents, constituted the (...) sample for the study. The instrument used for data collection was a questionnaire while Independent t-test was used to analyze data and test the hypotheses at .05 level of significance using Microsoft Excel version 2013. The results of the findings revealed that school population, school type and school location, all have an influence in the supervision of security in public secondary schools of Cross River State. It was also revealed that lowly populated, mixed-gender, and urban public secondary schools were more efficient in the supervision of security than their counterparts such as highly populated, single-gender and rural secondary schools. Based on the findings of this study, conclusions were drawn and recommendations were made. (shrink)

Clinical guidelines are special types of plans realized by collective agents. We provide an ontological theory of such plans that is designed to support the construction of a framework in which guideline-based information systems can be employed in the management of workflow in health care organizations. The framework we propose allows us to represent in formal terms how clinical guidelines are realized through the actions of are realized through the actions of individuals organized into teams. We provide various (...) levels of implementation representing different levels of conformity on the part of health care organizations. Implementations built in conformity with our framework are marked by two dimensions of flexibility that are designed to make them more likely to be accepted by health care professionals than standard guideline-based management systems. They do justice to the fact 1) that responsibilities within a health care organization are widely shared, and 2) that health care professionals may on different occasions be non-compliant with guidelines for a variety of well justified reasons. The advantage of the framework lies in its built-in flexibility, its sensitivity to clinical context, and its ability to use inference tools based on a robust ontology. One disadvantage lies in its complicated implementation. (shrink)

We analyze a series of interviews with Estonian humanities researchers to explore topics related to the beginning of academic careers and the relationships with supervisors and mentors. We show how researchers strive to have meaningful relationships and produce what they consider quality research in the conditions of a system that is very strongly oriented towards internationalization and project-based funding, where their efforts are compromised by a lack of policies helping them establish a stable position in academia. Leaving researchers to face (...) these obstacles alone places a great burden on them and may lead to a loss of talent in academia. Identifying and addressing these issues is thus important for both the well-being of early career researchers and the future of academia. (shrink)

In this paper, I discuss an argument for the existence of God known as “The Argument from the Survival of the Jews.” This argument has the form of an Inference to the Best Explanation (IBE). It proceeds from the phenomenon of Jewish survival to the existence of God as the best explanation for this phenomenon. I will argue that, even if we grant that Jewish survival is a remarkable occurrence that demands an explanation, and even if we gloss over the (...) difficulties in defining the terms “Jewish” and “survive,” the argument ultimately fails as an argument for the existence of God. It fails because it postulates divine supervision in order to explain Jewish endurance, but it doesn’t provide any clues as to what might be the underlying mechanism at work. (shrink)

We argue that charging people to participate in research is likely to undermine the fundamental ethical bases of clinical research, especially the principles of social value, scientific validity, and fair subject selection.

Diabetic ketoacidosis is a serious, medical emergency that can be fatal but treatable, we aimed to evaluate the clinical profile of patients admitted with diabetic ketoacidosis. This case series study enrolled 213 non-pregnant adult and adolescent patients admitted with diabetic ketoacidosis at Tripoli Diabetes Hospital from January to September 2023. Demographic data, clinical characteristics, laboratory findings, precipitating factors, and patient outcomes were extracted from medical records and analyzed. Type 1 diabetes mellitus was present in 187 (87.8%) of patients, (...) the age range 11-84 years, (30.26±13.28), with 130 patients ≤30 years old (61.0%), females accounting for 110 of the patients (51.6%), 109 had a diabetes duration of less than 10 years (51.2%). The most common precipitating factor was insulin omission 92 (43.2%) in patients with known diabetes mellitus, whereas, diabetic ketoacidosis as the first presentation of diabetes mellitus in 24 patients (11.7%), systolic blood pressure ranged 50-160 mmHg (112.82±16.19), diastolic blood pressure varied 30-100 mmHg (70.24±11.32). Plasma glucose at presentation ranged 183-1494 mg/dl (462.92±169.85), with Eu-glycemic diabetic ketoacidosis 100-249 mg/dl were in nine patients (4.2%), whereas most of cases (135 patients, 63.4%) present with plasma glucose 250-500 mg/dl, while hyperosmolar status (≥701 mg/dl) were present in 13 patients (6.1%). Venous pH varied from 6.7-7.42 (7.13±0.14), 132 (62.0%) patients presented with pH <7.24, while severe acidosis was pH < 7 in 32 of patients (14.6%), serum bicarbonate with 10.93±4.95, severe (<5 mmol) in 91 patients (42.7%) and moderate (5-10 mmol) were in 79 patients (37.08%). The mean length of hospital stay was 3.33 days, with an average of 2.11 days spent in the high-dependent unit. Serum potassium varied from 2.4-6.7 meq/L with 3.66± 0.63, most common complications of diabetic ketoacidosis treatment were hypokalemia observed in 82 (35.7%) of cases, and hypoglycemia was detected in 41 patients (19.2%). 170 patients were discharged in good condition (79.8%), and 17.8% of patients were transferred to another hospital to receive further management for co-morbid diseases with diabetes after controlling their hyperglycemic crises. The majority of patients presented with the critical status of diabetic ketoacidosis. The findings emphasize the importance of patient education about prevention measures prompt presentation to the hospital, and clinicians' awareness for early and aggressive treatment of hyperglycemic crises. (shrink)

I argue that generic generalizations expressed in language (i.e., “generics”) are apt for good clinical reasoning. I begin by introducing what generics are in language and describe two problems in the use and interpretation of generics: Generics can license inaccurate judgements about the frequency of events or properties within a group (i.e., a problem with the “truth-aptness” of generics) and can facilitate problematic beliefs about social kinds (e.g., prejudice or essentializing). I provide an account of clinical reasoning and (...) describe some features of what I call “good” clinical reasoning. I offer examples of generics in clinical contexts and examine how the two problems with generics (i.e., of truth-aptness and social generics) can be harmful to patients and impair clinical reasoning. However, I ultimately argue that generics are important for good clinical reasoning because they track “conspicuous” features of disease processes (e.g., severe possible outcomes). Further, I argue that prejudicial generics are often irrational to believe, and social generics that are rational to believe need not lead to problematic implicatures about social kinds and can, in principle, instead facilitate meaningfully articulating societal injustices. I then argue that statistical statements, which are tempting alternatives to generics in clinical reasoning, are no better than generics for good clinical reasoning, even with respect to the two problems identified in the use of generics. (shrink)

The principle of clinical equipoise has been variously characterized by ethicists and clinicians as fundamentally flawed, a myth, and even a moral balm. Yet, the principle continues to be treated as the de facto gold standard for conducting randomized control trials in an ethical manner. Why do we hold on to clinical equipoise, despite its shortcomings being widely known and well-advertised? This paper reviews the most important arguments criticizing clinical equipoise as well as what the most prominent (...) proposed alternatives are. In the process, it evaluates the justification for continuing to use clinical equipoise as the gold standard for randomized control trials. (shrink)

I argue that generic generalizations expressed in language (i.e. ‘generics’) are apt for clinical reasoning. I introduce generics and describe two problems in the use and interpretation of generics: Generics may license inaccurate judgements about the frequency of events or properties within a group (i.e. a problem with the ‘truth-aptness’ of generics) and may facilitate problematic beliefs about social kinds (e.g. prejudice or essentializing). I provide an account of clinical reasoning and describe some features of what I call (...) ‘good’ clinical reasoning. I offer examples of generics in clinical contexts and examine how the two problems with generics (i.e. of truth-aptness and social generics) can harm patients and impair clinical reasoning. However, I ultimately argue that generics are important for good clinical reasoning because they track ‘conspicuous’ features of disease processes (e.g. severe possible outcomes). Further, I argue that prejudicial generics are often irrational to believe. Social generics that are rational to believe need not lead to problematic implicatures about social kinds and can instead facilitate meaningfully articulating societal injustices. I then argue that statistical statements, which are tempting alternatives to generics in clinical reasoning, are no better than generics for good clinical reasoning. (shrink)

The Belmont Report was written by a US Commission charged by the US Congress to advise on research supported by the US government. Its focus was understandably domestic. In the 40 years since its publication, clinical research has become increasingly international. Many clinical trials have sites in multiple countries, and many of the host countries are relatively impoverished. Such research raises some distinctive ethical issues. This paper outlines some of the key ethical challenges that have been raised by (...) clinical research conducted in low- and middle-income countries (LMICs) and sponsored by high-income country (HIC) institutions. It then considers whether the Belmont Report has the resources to address these problems and argues that it does not. The article closes by noting some parallels between this international research and domestic US research, which suggest that the US might benefit from the discussions abroad. (shrink)

Clinical Ethics Consultations are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs’ perceived availability, use of CECs, and perceived usefulness of such support. (...) Physicians in our study generally encounter hard ethics cases, even—surprisingly—those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful—even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system. (shrink)

The paper reports results of the very first survey-based study on the prevalence, frequency and nature of ethical or other non-medical difficulties faced by Polish physicians in their everyday clinical practice. The study involved 521 physicians of various medical specialties, practicing mainly in inpatient healthcare. The study showed that the majority of Polish physicians encounter ethical and other non-medical difficulties in making clinical decisions. However, they confront such difficulties less frequently than their foreign peers. Moreover, Polish doctors indicate (...) different circumstances as a source of the experienced problems. The difficulties most often reported relate to (i) patients (or their proxies) requests for medically non-indicated interventions; (ii) problems with communication with patients (or their proxies) due to the patients’ negative attitude, unwillingness to cooperate, or aggression; and (iii) various difficulties with obtaining informed consent. Polish physicians report difficulties associated with disagreements among care givers or scarcity of resources less frequently than doctors from other countries. The study’s findings provide support for the thesis that a significant portion of Polish physicians still follow a traditional, paternalistic, and hierarchical model of healthcare practice. Instead of promoting patient’s empowerment, engagement, and rights, they often consider these ideas as a threat to physicians’ professional authority and autonomy. The study leads to the conclusion that due to insufficient training in medical ethics, communication skills, and medical law, many Polish physicians lack the knowledge and competence necessary to adequately respond to challenges posed by modern healthcare practice. (shrink)

Machine learning algorithms may radically improve our ability to diagnose and treat disease. For moral, legal, and scientific reasons, it is essential that doctors and patients be able to understand and explain the predictions of these models. Scalable, customisable, and ethical solutions can be achieved by working together with relevant stakeholders, including patients, data scientists, and policy makers.

The theory of granular partitions (TGP) is a new approach to the understanding of ontologies and other classificatory systems. The paper explores the use of this new theory in the treatment of task-based clinical guidelines as a means for better understanding the relations between different clinical tasks, both within the framework of a single guideline and between related guidelines. We used as our starting point a DAML+OIL-based ontology for the WHO guideline for hypertension management, comparing this with related (...) guidelines and attempting to show that TGP provides a flexible and highly expressive basis for the manipulation of ontologies of a sort which might be useful in providing more adequate Computer Interpretable Guideline Models (CIGMs) in the future. (shrink)

This article addresses two areas of continuing controversy about consent in clinical research: the question of when consent to low risk research is necessary, and the question of when consent to research is valid. The article identifies a number of considerations relevant to determining whether consent is necessary, chief of which is whether the study would involve subjects in ways that would (otherwise) infringe their rights. When consent is necessary, there is a further question of under what conditions consent (...) is valid or successful in waiving a right. The most influential account of validity conditions is non-moralized, in the sense that the conditions make no essential reference to whether the researcher soliciting consent has obtained it in a way that wrongs the subject. The article examines the implications of this account, and compares it with recent accounts that moralize some of the validity conditions. -/- . (shrink)

CLE aims and clients’ needs conflict where students’ interests are put beyond clients’ needs. Students have interests in gaining employment, impressing instructors and supervisors, and experiencing the active application of law. Where the clients’ service-needs are subordinated to students’ interests, the relationship between the two—the ‘tension’—is tilted in a manner in which the clients are disserved through the fulfilment of students’ interests. This may be exacerbated by faulty institutional cultures where clinical faculty are treated differently, or as less accomplished (...) or ‘worthwhile’ than their ‘traditional’ counterparts. This also emphasizes that it is the clinical law faculty who may exacerbate or assuage the tension, as it is for clinical faculty to assure that clients’ needs are met on ethical grounds,20 and to equate the practice of law with excellence before students. (shrink)

Ontological realism aims at the development of high quality ontologies that faithfully represent what is general in reality and to use these ontologies to render heterogeneous data collections comparable. To achieve this second goal for clinical research datasets presupposes not merely (1) that the requisite ontologies already exist, but also (2) that the datasets in question are faithful to reality in the dual sense that (a) they denote only particulars and relationships between particulars that do in fact exist and (...) (b) they do this in terms of the types and type-level relationships described in these ontologies. While much attention has been devoted to (1), work on (2), which is the topic of this paper, is comparatively rare. Using Referent Tracking as basis, we describe a technical data wrangling strategy which consists in creating for each dataset a template that, when applied to each particular record in the dataset, leads to the generation of a collection of Referent Tracking Tuples (RTT) built out of unique identifiers for the entities described by means of the data items in the record. The proposed strategy is based on (i) the distinction between data and what data are about, and (ii) the explicit descriptions of portions of reality which RTTs provide and which range not only over the particulars described by data items in a dataset, but also over these data items themselves. This last feature allows us to describe particulars that are only implicitly referred to by the dataset; to provide information about correspondences between data items in a dataset; and to assert which data items are unjustifiably or redundantly present in or absent from the dataset. The approach has been tested on a dataset collected from patients seeking treatment for orofacial pain at two German universities and made available for the NIDCR-funded OPMQoL project. (shrink)

Janet Malek (91–102, 2019) argues that a “clinical ethics consultant’s religious worldview has no place in developing ethical recommendations or communicating about them with patients, surrogates, and clinicians.” She offers five types of arguments in support of this thesis: arguments from consensus, clarity, availability, consistency, and autonomy. This essay shows that there are serious problems for each of Malek’s arguments. None of them is sufficient to motivate her thesis. Thus, if it is true that the religious worldview of (...) class='Hi'>clinical ethics consultants should play no role whatsoever in their work as consultants, this claim will need to be defended on some other ground. (shrink)

Background: The internationalization of clinical studies requires a shared understanding of the fundamental ethical values guiding clinical studies. It is important that these values are not only embraced at the legal level but also adopted by clinicians themselves during clinical studies. Objective: Our goal is to provide an insight on how clinicians in Germany and Poland perceive and identify the different ethical issues regarding informed consent in clinical studies. Methods: To gain an understanding of how clinicians (...) view clinical studies in the countries they work in, we carried out semi-structured problem-centered interviews per telephone in Poland (n = 6) and Germany (n = 6). Our interviewees concentrated on three main topics: an appraisal of the normative framework, challenges in the information process and the protection of all participants in clinical studies. Results: Clinicians generally supported the normative framework, even though they considered it quite complex. In the two study countries, a widely noted dilemma in the information process was whether to overburden participants with extensive information or risking leaving out important facts. Clinicians were ready to exclude larger population groups from participating in clinical studies when the information process could not be carried out with standard procedures or when their inclusion was ethically sensitive. Conclusion: Clinicians need to gain a better understanding of the consequences of excluding larger population groups form participating in clinical studies. They should seek assistance in improving the information process for the inclusion of underrepresented groups in clinical studies. (shrink)

Introduction: Clinical practice guidelines (CPGs) are an important source of justification for clinical decisions in modern evidence-based practice. Yet, we have given little attention to how they argue their evidence. In particular, how do CPGs argue for treatment with long-term medications that are increasingly prescribed to older patients? Approach and rationale: I selected six disease-specific guidelines recommending treatment with five of the medication classes most commonly prescribed for seniors in Ontario, Canada. I considered the stated aims of these (...) CPGs and the techniques employed towards those aims. Finally, I reconstructed and logically analysed the arguments supporting recommendations for pharmacotherapy. Analysis: The primary function of CPGs is rhetorical, or persuasive, and their means of persuasion include both a display of their credibility and their argumentation. Arguments supporting pharmacotherapy recommendations for the target population follow a common inductive pattern: statistical generalization from randomized controlled trial (RCT) and meta-analysis evidence. Two of the CPGs also argue their treatment recommendations for older patients in this style, while three fail to justify pharmacotherapy specifically for the older population. Discussion: The arguments analysed lack the auxiliary assumptions that would warrant making a generalization about the clinical effectiveness of medications for the older population. Guidelines reason using simple induction, while ignoring important inferential gaps. Future guidelines should aspire to be well-reasoned rather than simply evidence-based; argue from a plurality of evidence; be wary of hasty inductions; appropriately limit the scope of their recommendations; and avoid making law-like, prescriptive generalizations. (shrink)

Abstract: In this article, we explore what are ethical forms of holding service users responsible in mental health care contexts. Hanna Pickard has provided an account of how service users should be held responsible for morally wrong or seriously harmful conduct within contexts of mental health care, called the clinical stance. From a clinical stance one holds a person responsible for harm, but refrains from emotionally blaming the person and only considers the person responsible for this conduct in (...) a detached sense. Her account is based on what are considered best practices in the treatment of people with borderline personality disorder and addiction. We ask if this account generalizes across different diagnostic criteria and different clinical contexts. To begin to answer this question, we compare the clinical stance to an account of what are considered best practices in the treatment of service users at a specialized clinic for people with autism spectrum disorder in the Netherlands. We refer to this alternative account as the nurturing stance and highlight relevant similarities and differences between the clinical stance and the nurturing stance. We conclude with suggestions for further research and theorizing. (shrink)

Regarding the appropriateness of deception in clinical practice, two (apparently conflicting) claims are often emphasised. First, that ‘clinicians should not deceive their patients.’ Second, that deception is sometimes ‘in a patient’s best interest.’ Recently, Hardman has worked towards resolving this conflict by exploring ways in which deceptive and non-deceptive practices extend beyond consideration of patients’ beliefs. In short, some practices only seem deceptive because of the (common) assumption that non-deceptive care is solely aimed at fostering true beliefs. Non-deceptive care, (...) however, relates to patients’ non-doxastic attitudes in important ways as well. As such, Hardman suggests that by focusing on belief alone, we sometimes misidentify non-deceptive care as ‘deceptive’. Further, once we consider patients’ beliefs and non-doxastic attitudes, identifying cases of deception becomes more difficult than it may seem. In this essay, I argue that Hardman’s reasoning contains at least three serious flaws. First, his account of deception is underdeveloped, as it does not state whether deception must be intentional. The problem is that if intention is not required, absurd results follow. Alternatively, if intention is required, then identifying cases of deception will be much easier (in principle) than Hardman suggests. Second, Hardman mischaracterises the ‘inverse’ of deceptive care. Doing so leads to the mistaken conclusion that common conceptions of non-deceptive care are unjustifiably narrow. Third, Hardman fails to adequately separate questions about deception from questions about normativity. By addressing these issues, however, we can preserve some of Hardman’s most important insights, although in a much simpler, more principled way. (shrink)

Brummett and Salter propose a useful and timely taxonomy of clinical ethics expertise (2019). As the field becomes further “professionalized” this taxonomy is important, and the core of it is right. It needs some refinement around the edges, however. In their conclusion, Brummett and Salter rightly point out that there is a significant difference between the ethicist whose recommendations are procedure- and process-heavy, consensus-driven, and dialogical and the authoritarian ethicist whose recommendations flow from “private moral views” (Brummett and Salter, (...) 2019). This admission doesn’t go far enough. Brummett and Salter’s taxonomy fails to capture the notion that offering recommendations whose normative force is moral is different in kind from recommendations whose normative force is non-moral, such as those recommendations that are free of moral content or justified by convention. The difference is in kind, not scale. I argue further that clinical ethics expertise, if possible, consists at least in offering recommendations whose normative force is moral. These two claims imply that the taxonomy fails to cut clinical ethics expertise at the joints: the ethicist who offers justified non-moral normative recommendations is a different kind of ethicist from the one who offers justified moral normative recommendations, yet both are categorized as clinical ethics experts. I finish by offering a refinement of the taxonomy that more precisely categorizes clinical ethicists. (shrink)

The article presents the advantages and limitations of adaptive clinical trials for assessing the effectiveness of medical interventions and specifies the conditions that contributed to their development and implementation in clinical practice. I advance two arguments by discussing different cases of adaptive trials. The normative argument is that responsible adaptation should be taken seriously as a new way of doing clinical research insofar as a valid justification, sufficient understanding, and adequate operational conditions are provided. The second argument (...) is historical. The development of adaptive trials can be related to lessons learned from research in cases of urgency and to the decades-long efforts to end the productivity crisis of pharmaceutical research, which led to the emergence of translational, personalized, and, recently, precision medicine movements. (shrink)

The desideratum of semantic interoperability has been intensively discussed in medical informatics circles in recent years. Originally, experts assumed that this issue could be sufficiently addressed by insisting simply on the application of shared clinical terminologies or clinical information models. However, the use of the term ‘ontology’ has been steadily increasing more recently. We discuss criteria for distinguishing clinical ontologies from clinical terminologies and information models. Then, we briefly present the role clinical ontologies play in (...) two multicentric research projects. Finally, we discuss the interactions between these different kinds of knowledge representation artifacts and the stakeholders involved in developing interoperational real-world clinical applications. We provide ontology engineering examples from two EU-funded projects. (shrink)

Our goal in this paper is to articulate a precise concept of at least a certain kind of disease-mongering, showing how pharmaceutical marketing can commercially exploit certain diseases when their best definition is given through the success of a treatment in a clinical trial. We distinguish two types of disease-mongering according to the way they exploit the definition of the trial population for marketing purposes. We argue that behind these two forms of disease-mongering there are two well-known problems in (...) the statistical methodology of clinical trials (the reference class problem and the distinction between statistical and clinical significance). Overcoming them is far from simple. (shrink)

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

Machine intelligence already helps medical staff with a number of tasks. Ethical decision-making, however, has not been handed over to computers. In this proof-of-concept study, we show how an algorithm based on Beauchamp and Childress’ prima-facie principles could be employed to advise on a range of moral dilemma situations that occur in medical institutions. We explain why we chose fuzzy cognitive maps to set up the advisory system and how we utilized machine learning to train it. We report on the (...) difficult task of operationalizing the principles of beneficence, non-maleficence and patient autonomy, and describe how we selected suitable input parameters that we extracted from a training dataset of clinical cases. The first performance results are promising, but an algorithmic approach to ethics also comes with several weaknesses and limitations. Should one really entrust the sensitive domain of clinical ethics to machine intelligence? (shrink)

When discussing the safety of research subjects, including their exploitation and vulnerability as well as failures in clinical research, recent commentators have focused mostly on countries with low or middle-income economies. High-income countries are seen as relatively safe and well-regulated. This article presents irregularities in clinical trials in an EU member state, Poland, which were revealed by the Supreme Audit Office of Poland (the NIK). Despite adopting many European Union regulations, including European Commission directives concerning Good Clinical (...) Practice, these irregularities occurred. Causes as well as potential solutions to make clinical trials more ethical and safer are discussed. (shrink)

The prospect of vaccinating children and young people (CYP) against COVID raises questions that apply more widely to vaccination in children. When can CYP consent, on their own, for vaccination? What should happen if children and their parents disagree about the desirability of a vaccine? When, if ever, should vaccination proceed despite a child’s dissent or apparent refusal? A range of ethical dilemmas may arise. (Box 1) In this article, we will address general ethical issues relating to consent for vaccination, (...) highlighting their relevance to COVID. We will not address the wider ethical questions of whether or when children should be vaccinated against COVID. (shrink)

Many extant theories of placebo focus on their causal structure wherein placebo effects are those that originate from select features of the therapy (e.g., client expectations or “incidental” features like size and shape). Although such accounts can distinguish placebos from standard medical treatments, they cannot distinguish placebos from everyday occurrences, for example, when positive feedback improves our performance on a task. Providing a social-epistemological account of a treatment context can rule out such occurrences, and furthermore reveal a new way to (...) distinguish clinical placebos from standard medical treatments. (shrink)

An important part of the Unified Medical Language System (UMLS) is its Semantic Network, consisting of 134 Semantic Types connected to each other by edges formed by one or more of 54 distinct Relation Types. This Network is however for many purposes overcomplex, and various groups have thus made attempts at simplification. Here we take this work further by simplifying the relations which involve the three Semantic Types – Diagnostic Procedure, Laboratory Procedure and Therapeutic or Preventive Procedure. We define operators (...) which can be used to generate terms instantiating types from this selected set when applied to terms designating certain other Semantic Types, including almost all the terms specifying clinical tasks. Usage of such operators thus provides a useful and economical way of specifying clinical tasks. The operators allow us to define a mapping between those types within the UMLS which do not represent clinical tasks and those which do. This mapping then provides a basis for an ontology of clinical tasks that can be used in the formulation of computer-interpretable clinical guideline models. (shrink)

The UN Convention against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person” by someone acting in an official capacity for purposes such as obtaining a confession or punishing or intimidating that person.1 It is unethical for healthcare professionals to participate in torture, including any use of medical knowledge or skill to facilitate torture or allow it to continue, or to be present during torture.2-7 Yet medical participation (...) in torture has taken place throughout the world and was a prominent feature of the US interrogation practice in military and Central Intelligence Agency (CIA) detention facilities in the years after the attacks of 11 September 2001.8-11 Little attention has been paid, however, to how a regime of torture affects the ability of health professionals to meet their obligations regarding routine clinical care for detainees. -/- The 2016 release of previously classified portions of guideline from the CIA regarding medical practice in its secret detention facilities sheds light on that question. These show that the CIA instructed healthcare professions to subordinate their fundamental ethical obligations regarding professional standards of care to further the objectives of the torturers. (shrink)

Albert Jonsen and Stephen Toulmin have argued that the best way to resolve complex “moral” issues in clinical settings is to focus on the details of specific cases. This approach to medical decision-making, labeled ‘casuistry’, has met with much criticism in recent years. In response to this criticism, Carson Strong has attempted to salvage much of Jonsen’s and Toulmin’s version of casuistry. He concludes that much of their analysis, including Jonsen’s further elaboration about the casuistic methodology, is on the (...) mark. In this essay, the details of Jonsen’s and Toulmin’s version of casuistry and the major criticisms against their approach to clinical decision-making are explicated. Furthermore, it is argued that Strong’s salvage efforts fail to deflect these criticisms. The upshot of this analysis, which includes a few additional criticisms, is that Jonsen’s and Toulmin’s version of casuistry is not an appropriate framework from which to resolve complex “moral” issues in clinical settings. (shrink)

Did the impartiality of clinical trials play any role in their acceptance as regulatory standards for the safety and efficacy of drugs? According to the standard account of early British trials in the 1930s and 1940s, their impartiality was just rhetorical: the public demanded fair tests and statistical devices such as randomization created an appearance of neutrality. In fact, the design of the experiment was difficult to understand and the British authorities took advantage of it to promote their own (...) particular interests. I claim that this account is based on a poorly defined concept of experimental fairness . I present an alternative approach in which a test would be impartial if it incorporates warrants of non-manipulability. With this concept, I reconstruct the history of British trials showing that they were indeed fair and this fairness played a role in their acceptance as regulatory yardsticks. (shrink)