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

Although there is a growing recognition that older adults and those with extensive comorbid conditions undergo cancer screening too frequently, there is little information about patients’ perceptions regarding cessation of cancer screening. Information on older adults’ views of screening cessation would be helpful both for clinicians and for those designing interventions to reduce overscreening.

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)

Suicide is a major public health issue in many industrialized countries. It is one of the top ten causes of death and older age is a significant risk factor for suicide. For example, in Japan older adults (age ≥ 65) shared about 18.5% of total population but account for 24% of all suicide, in Taiwan, older adults representing 12.4% of the total population and account for 28.9% of suicide death. Dementia is a broad term for a progressive (...) deterioration in memory ability and dementia patients ran higher risk for suicide. (shrink)

This report describes a questionnaire-based study on 309 adult patients attending the Dental Outpatients Department of Bangladesh Medical College and Hospital, Dhaka during December 2000 to March 2001. The aim of the study was to determine the oral health knowledge of the patients in relation to their age, gender, economic and educational status. Almost two third (63.1%) of the subjects correctly said that pan chewing was bad for teeth. Three fourth (78.3%) of the subjects gave correct answer on (...) question of how to prevent teeth decay. When question was asked about cause of teeth decay, bleeding gum and action of fluoride on teeth, only 38.2%, 41.4% and 32.3% could give correct answer respectively. With a few exceptions, knowledge of oral health was comparatively poor among the older generation, females, less educated and less privileged group. (shrink)

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

Globally, breast cancer is the most common cancer in women worldwide, it represents about 25.0% of all cancer cases. In developing countries, breast cancer is mainly discovered at a late stage, which has a negative impact on the prognosis. To determine the extent of, and the factors contributing to, delay in breast cancer presentation, and to evaluate the mammography screening practice in breast cancer Libyan women. A descriptive cross-sectional study was carried out on five hundred and one breast cancer (...) class='Hi'>patients who attended the Oncology Outpatient Clinic of the Medical Department at Tripoli University Hospital and Tripoli Central Hospital during a period between February and August 2019, after the application of inclusion and exclusion criteria enrolled in the study. The mean age of the patients was 47.35±01.0 years, 55.1% of them were diagnosed in late stage (III and IV), and 30.9% of the patients were presented late (≥3 months). The time interval between the initial breast symptom and first presentation to a clinic ranged between 2nd day and up to three years, with a median time of 1.5 months, and the main factor of the delayed presentation to a clinic was a lack of knowledge about symptoms (33.5%). The study revealed a significant association between delayed presentation and older age (P<0.001), low educational level (P<0.001), low family income (P<0.001), unemployed women (P< 0.002), postmenopausal women (P<0.001), patients with negative family history (P<0.05). This study concluded that delayed presentation is found in less than a third of the study population, and lack of knowledge about breast cancer signs and symptoms is a common factor. Age, educational status, family income, unemployed women, menopausal status, and family history of breast cancer were all significant factors for delayed presentation. Improving women's awareness about breast cancer is needed and applying the policy of regular screening mammograms is a useful tool for early diagnosis and early treatment in Libya. (shrink)

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

Background: Arthritis is very common but is not well understood. Actually, “arthritis” is not a single disease; it is an informal way of referring to joint pain or joint disease. There are more than 100 different types of arthritis and related conditions. People of all ages, sexes and races can and do have arthritis, and it is the leading cause of disability in America. More than 50 million adults and 300,000 children have some type of arthritis. It is most common (...) among women and occurs more frequently as people get older. Common arthritis joint symptoms include swelling, pain, stiffness and decreased range of motion. Symptoms may come and go. They can be mild, moderate or severe. They may stay about the same for years, but may progress or get worse over time. Severe arthritis can result in chronic pain, inability to do daily activities and make it difficult to walk or climb stairs. Arthritis can cause permanent joint changes. These changes may be visible, such as knobby finger joints, but often the damage can only be seen on X-ray. Some types of arthritis also affect the heart, eyes, lungs, kidneys and skin as well as the joints. Objectives: The main goal of this expert system is to get the appropriate diagnosis of disease and the correct treatment and give the appropriate method of treatment through several tips that concern the disease and how to treat it and we will see it through the application on the expert system. Methods: in this paper the design of the proposed Expert System which was produced to help Orthopedist in diagnosing Arthritis disease through its symptoms such as: pain on pressure in a joint , Inflammation indicated by joint swelling, Stiffness especially in the morning , Loss of flexibility of joint, Limited, joint movement, Deformity of the joints , Weight loss and fatigue , Non-specific fever and Crepitus. The proposed expert system presents an overview about Arthritis disease is given, the cause of diseases is outlined and the treatment of disease whenever possible is given out. SL5 Object Expert System language was used for designing and implementing the proposed expert system. Results: The proposed Arthritis disease diagnosis expert system was evaluated by Orthopedics students and they were satisfied with its performance. Conclusions: The Proposed expert system is very useful for Orthopedist, patients with arthritis and newly graduated Orthopedics students. (shrink)

There are many eye diseases but the most two common retinal diseases are Age-Related Macular Degeneration (AMD), which the sharp, central vision and a leading cause of vision loss among people age 50 and older, there are two types of AMD are wet AMD and DRUSEN. Diabetic Macular Edema (DME), which is a complication of diabetes caused by fluid accumulation in the macula that can affect the fovea. If it is left untreated it may cause vision loss. Therefore, early (...) detection of diseases is a critical importance. Our main goal is to help doctors detect these diseases quickly before reaching a late stage of the disease. In ophthalmology, optical coherence tomography (OCT) is critical for evaluating retinal conditions. OCT is an imaging technique used to capture high-resolution cross-sections of the retinas of patient. In this thesis, we review ways and techniques to use deep learning classification of the optical coherence tomography images of diseases from which a Retinal is suffering. The models used to improve patient care are (VGG-16, MobileNet, ResNet-50, Inception V3, and Xception) to reduce costs and allow fast and reliable analysis in large studies. The obtained results are encouraging, since the best model ResNet-50 reaching 96.21% of testing accuracy, which is very useful for doctors, to diagnose retinal diseases. (shrink)

Delusions are unhinged hinge certainties. Delusions are defined as strongly anchored beliefs that do not change in the face of adverse evidence. The same goes for Wittgensteinian certainties. My paper refines the so-called framework views of delusion, presenting an argument that epistemically speaking, considering them to be certainties best accounts for delusions’ doxastic profile. Until now there has been little argument in favour of this position and the original proposals made too extreme predictions about the belief systems of delusional (...) class='Hi'>patients. I show that my account fares better with the diverse objections that have been raised against older framework views of delusion (Campbell 2001, Gipps and Rhodes 2008). Finally, I examine what makes a harmless hinge into a pathological delusion. (shrink)

In this chapter, we explore how themes of existential philosophy have been used to develop a formal orientation of psychotherapy, and we discuss the main principles of existential psychotherapy and their application in practice. We also draw upon case examples to specifically illustrate how the approach of existential psychotherapy is utilized in clinical practice. In the case examples, each patient's identify has been disguised to maintain confidentiality. The new science of meaning, represented by the chapters in this volume, not only (...) offers therapists a deep conceptual framework within which to practice older, more established techniques but should also suggest new approaches. By recognizing the centrality of meaning as sense making and acknowledging the distinction between the what and the why of sense making, therapists should be armed with a variety of epistemic and teleological tools with which to fashion therapy strategies that are unique for each individual. (shrink)

Objective Our study sought to (1) describe the practices and preferences of Colombian adolescents in accessing sexual and reproductive health services: accompanied versus alone; (2) compare actual practices with stated preferences; and (3) determine age and gender differences regarding the practice and these stated preferences. -/- Methods 812 participants aged 11–24 years old answered a survey in two Profamilia clinics in the cities of Medellin and Cali in Colombia. A cross-sectional analysis was performed to compare participants’ answers based on the (...) variables of gender and age. -/- Results A quarter of participants visited the clinic alone (25.4%). Females were more likely to go alone in comparison to males (26.3% vs 14.1%; p = 0.031), and older participants went alone more often than younger participants (p < 0.001). Most participants – 72.7% (95 %CI: 69.3–75.9) – expressed a preference in being accompanied to the clinic, and more than 90% had their preferences met. The preferences of older participants were, however, less likely to be met than those of younger participants (p < 0.001), notably, because they predominantly wanted to be accompanied. -/- Conclusion Contemporary public health and bioethics literature advocates in favor of developing health services that better meet the preferences of adolescents. The present research highlights an apparent blind spot related to the role that others (e.g., parents, friends, partners) can or should play in accompanying adolescent patients when they access sexual and reproductive health services. Respecting adolescents’ preferences, and hence their autonomy, is not simply a matter of ensuring freedom from constraints (e.g., their right and ability to go alone). Rather, it should also consider the liberty to choose whether to be accompanied when accessing SHRS and by whom. (shrink)

The U.S. FDA has issued emergency use authorizations for monoclonal antibodies for non-hospitalized patients with mild or moderate COVID-19 disease and for individuals exposed to COVID-19 as post-exposure prophylaxis. One EUA for an oral antiviral drug, molnupiravir, has also been recommended by FDA’s Antimicrobial Drugs Advisory Committee, and others appear likely in the near future. Due to increased demand because of the Delta variant, the federal government resumed control over the supply and asked states to ration doses. As future (...) variants with increased infectivity and/or severity emerge, further rationing may be required. We identify relevant ethical principles and priority groups for access to therapies based on an integrated approach to population health and medical factors. Using priority categories to allocate scarce therapies effectively operationalizes important ethical values. This strategy is preferable to the current approach of categorical rules based on vaccination, immunocompromise status, or older age, or the ad hoc consideration of clinical risk factors. (shrink)

Some philosophers and segments of the public think age is relevant to healthcare priority-setting. One argument for this is based in equity: “Old” patients have had either more of a relevant good than “young” patients or enough of that good and so have weaker claims to treatment. This article first notes that some discussions of age-based priority that focus in this way on old and young patients exhibit an ambiguity between two claims: that patients classified as (...) old should have a low priority, and that patients classified as young should have high priority. The author next argues, drawing on a problem raised by Christine Overall, that equity cannot justify giving “old” patients low priority, since there is wide variety in the total lifetime experiences of older people, partly influenced by gender, race, class, and disability injustice. Finally, the author suggests that there might be a limited role for age-based prioritization in the context of infant and childhood death, since those who die in childhood are always and uncontroversially among the worst-off. (shrink)

Background: Smart sensors have been developed as diagnostic tools for rehabilitation to cover an increasing number of geriatric patients. They promise to enable an objective assessment of complex movement patterns. -/- Objective: This research aimed to identify and analyze the conflicting ethical values associated with smart sensors in geriatric rehabilitation and provide ethical guidance on the best use of smart sensors to all stakeholders, including technology developers, health professionals, patients, and health authorities. -/- Methods: On the basis of (...) a systematic literature search of the scientific databases PubMed and ScienceDirect, we conducted a qualitative document analysis to identify evidence-based practical implications of ethical relevance. We included 33 articles in the analysis. The practical implications were extracted inductively. Finally, we carried out an ethical analysis based on the 4 principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice. The results are reported in categories based on these 4 principles. -/- Results: We identified 8 conflicting aims for using smart sensors. Gains in autonomy come at the cost of patient privacy. Smart sensors at home increase the independence of patients but may reduce social interactions. Independent measurements performed by patients may result in lower diagnostic accuracy. Although smart sensors could provide cost-effective and high-quality diagnostics for most patients, minorities could end up with suboptimal treatment owing to their underrepresentation in training data and studies. This could lead to algorithmic biases that would not be recognized by medical professionals when treating patients. -/- Conclusions: The application of smart sensors has the potential to improve the rehabilitation of geriatric patients in several ways. It is important that patients do not have to choose between autonomy and privacy and are well informed about the insights that can be gained from the data. Smart sensors should support and not replace interactions with medical professionals. Patients and medical professionals should be educated about the correct application and the limitations of smart sensors. Smart sensors should include an adequate representation of minorities in their training data and should be covered by health insurance to guarantee fair access. (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)

It is common to distinguish moral rules, reasons, or values that are agent-relative from those that are agent-neutral. One can also distinguish moral rules, reasons, or values that are moment-relative from those that are moment-neutral. In this article, I introduce a third distinction that stands alongside these two distinctions—the distinction between moral rules, reasons, or values that are patient-relative and those that are patient-neutral. I then show how patient-relativity plays an important role in several moral theories, gives us a better (...) understanding of agent-relativity and moment-relativity, and provides a novel objection to Derek Parfit’s “appeal to full relativity” argument. (shrink)

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

This paper offers an ethical framework for the development of robots as home companions that are intended to address the isolation and reduced physical functioning of frail older people with capacity, especially those living alone in a noninstitutional setting. Our ethical framework gives autonomy priority in a list of purposes served by assistive technology in general, and carebots in particular. It first introduces the notion of “presence” and draws a distinction between humanoid multi-function robots and non-humanoid robots to suggest (...) that the former provide a more sophisticated presence than the latter. It then looks at the difference between lower-tech assistive technological support for older people and its benefits, and contrasts these with what robots can offer. This provides some context for the ethical assessment of robotic assistive technology. We then consider what might need to be added to presence to produce care from a companion robot that deals with older people’s reduced functioning and isolation. Finally, we outline and explain our ethical framework. We discuss how it combines sometimes conflicting values that the design of a carebot might incorporate, if informed by an analysis of the different roles that can be served by a companion robot. (shrink)

Patient centred diagnosis is best practised through shared decision making; an iterative dialogue between doctor and patient, whichrespects a patient’s needs, values, preferences, and circumstances. -/- Shared decision making for diagnostic situations differs fundamentally from that for treatment decisions. This has important implications when considering its practical application. -/- The nature of dialogue should be tailored to the specific diagnostic decision; scenarios with higher stakes or uncertainty usually require more detailed conversations.

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

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

Recently, Jardas _et al_ have convincingly defended the patient preference predictor (PPP) against a range of autonomy-based objections. In this response, I propose a new autonomy-based objection to the PPP that is not explicitly discussed by Jardas _et al_. I call it the ‘objection from higher-order preferences’. Even if this objection is not sufficient reason to reject the PPP, the objection constitutes a pro tanto reason that is at least as powerful as the ones discussed by Jardas _et al._.

Health services internationally struggle to ensure health care is “person-centered” (or similar). In part, this is because there are many interpretations of “person-centered care” (and near synonyms), some of which seem unrealistic for some patients or situations and obscure the intrinsic value of patients’ experiences of health care delivery. The general concern behind calls for person-centered care is an ethical one: Patients should be “treated as persons.” We made novel use of insights from the capabilities approach to (...) characterize person-centered care as care that recognizes and cultivates the capabilities associated with the concept of persons. This characterization unifies key features from previous characterisations and can render person-centered care applicable to diverse patients and situations. By tying person-centered care to intrinsically valuable capability outcomes, it incorporates a requirement for responsiveness to individuals and explains why person-centered care is required independently of any contribution it may make to health gain. (shrink)

Patient preference predictors aim to solve the moral problem of making treatment decisions on behalf of incapacitated patients. This commentary on a case of an unrepresented patient at the end of life considers 3 related problems of such predictors: the problem of restricting the scope of inputs to the models (the “scope” problem), the problem of weighing inputs against one another (the “weight” problem), and the problem of multiple reasonable solutions to the scope and weight problems (the “multiple reasonable (...) models” problem). Each of these problems poses challenges to reliably implementing patient preference predictors in important, high-stakes health care decision making. This commentary also suggests a way forward. (shrink)

Abstract:Respect for persons protects patients regarding their own healthcare decisions. Patient informed choice for altruism (PICA) is a proposed means for a fully autonomous patient with decisionmaking capacity to limit his or her own treatment for altruistic reasons. An altruistic decision could bond the patient with others at the end of life. We contend that PICA can also be an advance directive option. The proxy, family, and physicians must be reminded that a patient’s altruistic treatment refusal should be respected.

Patient-funded trials are gaining traction as a means of accelerating clinical translation. However, such trials sidestep mechanisms that promote rigor, relevance, efficiency, and fairness. We recommend that funding bodies or research institutions establish mechanisms for merit review of patient-funded trials, and we offer some basic criteria for evaluating PFT protocols.

Except in extraordinary circumstances, patients' clinical care should reflect their preferences. Incapacitated patients cannot report their preferences. This is a problem. Extant solutions to the problem are inadequate: surrogates are unreliable, and advance directives are uncommon. In response, some authors have suggested developing algorithmic "patient preference predictors" (PPPs) to inform care for incapacitated patients. In a recent paper, Earp et al. propose a new twist on PPPs. Earp et al. suggest we personalize PPPs using modern machine learning (...) (ML) techniques. In this paper, I argue that, contrary to Earp et al.'s claim, personalized patient preference predictors are neither technically feasible nor ethically desirable. (shrink)

The issue of voting rights for older children has been high on the political and philosophical agenda for quite some time now, and not without reason. Aside from principled moral and philosophical reasons why it is an important matter, many economic, environmental, and political issues are currently being decided—sometimes through indecision—that greatly impact the future of today’s children. Past and current generations of adults have, arguably, mortgaged their children’s future, and this makes the question whether (some) children should be (...) granted the right to vote all the more pressing. Should (some) children be given the right to vote? Moreover, does the answer to this question depend on civic education, on whether children have been deliberately prepared for the exercise of that right? These are the questions that will occupy us in this article. Our answer to the first will be that older children—children roughly between 14 and 16 years of age1—ought to be given the right to vote. (shrink)

Precision medicine functions by grouping patients along genetic, molecular, and related ‘-omics’ factors. This stratification relies on large, growing databases of patient-volunteered information. Both private companies and government bodies incentivize patients to volunteer this genetic information appealing to the creation of collaborative patient partnerships and the concept of empowerment. This paper aims to address two related questions: (1) what is the actual nature of patient participation in precision medicine research? And (2) is this participation in precision medicine research (...) really that empowering for the average patient? I contend that firstly, the nature of this participation is best conceived of as merely contributory. Contributory participation, as it will be shown, falls short of collaboration. The partnership created by participation in precision medicine research is not one of sharing values, equal say in decisions, or shared benefit. Secondly, I contend that there are important caveats to claims that patient participation in precision medicine is empowering. Empowerment is hindered by the type of participation, the practical use or actionability of genetic data, genetic literacy, the cost of precision drugs for patients that qualify for them, and bioethical considerations of informed consent. (shrink)

A number of bioethicists have been critical of the power of the family to “veto” a patient’s decision to posthumously donate her organs within opt-in systems of organ procurement. One major objection directed at the family veto is that when families veto the decision of their deceased family member, they do something wrong by violating or failing to respect the autonomy of that deceased family member. The goal of this paper is to make progress on answering this objection. I do (...) this in two stages. First, I argue that the most plausible interpretation of what happens when a person registers as an organ donor in an opt-in system is that she gives her consent to the state to posthumously remove her organs for transplantation purposes. Call this the Authorization Account. Second, given the Authorization Account, I argue by analogy that when families veto an individual’s decision to donate and the individual’s organs are not in the end removed, neither the doctors nor the family violate the individual’s autonomy in any morally objectionable sense. Call this the Nonremoval Thesis. I argue that since the Nonremoval Thesis is true, we do not violate or fail to respect the autonomy of registered donors when we fail to remove their organs because their family has objected. (shrink)

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

Objective: There are benefits and risks of giving patients more granular control of their personal health information in electronic health record (EHR) systems. When designing EHR systems and policies, informaticists and system developers must balance these benefits and risks. Ethical considerations should be an explicit part of this balancing. Our objective was to develop a structured ethics framework to accomplish this. -/- Methods: We reviewed existing literature on the ethical and policy issues, developed an ethics framework called a “Points (...) to Consider” (P2C) document, and convened a national expert panel to review and critique the P2C. -/- Results: We developed the P2C to aid informaticists designing an advanced query tool for an electronic health record (EHR) system in Indianapolis. The P2C consists of six questions (“Points”) that frame important ethical issues, apply accepted principles of bioethics and Fair Information Practices, comment on how questions might be answered, and address implications for patient care. -/- Discussion: The P2C is intended to clarify whatis at stake when designers try to accommodate potentially competing ethical commitments and logistical realities. The P2C was developed to guide informaticists who were designing a query tool in an existing EHR that would permit patient granular control. While consideration of ethical issues is coming to the forefront of medical informatics design and development practices, more reflection is needed to facilitate optimal collaboration between designers and ethicists. This report contributes to that discussion. (shrink)

Patients with serious illnesses or injuries may decide to quit their medical treatment if they think paying the fees will put their families into destitution. Without treatment, it is likely that fatal outcomes will soon follow. We call this phenomenon “near-suicide”. This study attempted to explore this phenomenon by examining how the seriousness of the patient’s illness or injury and the subjective evaluation of the patient’s and family’s financial situation after paying treatment fees affect the final decision on the (...) treatment process. Bayesian Mindsponge Framework (BMF) analytics were employed to analyze a dataset of 1042 Vietnamese patients. We found that the more serious the illnesses or injuries of patients were, the more likely they were to choose to quit treatment if they perceived that paying the treatment fees heavily affected their families’ financial status. Particularly, only one in four patients with the most serious health issues who thought that continuing the treatment would push themselves and their families into destitution would decide to continue the treatment. Considering the information-filtering mechanism using subjective cost–benefit judgments, these patients likely chose the financial well-being and future of their family members over their individual suffering and inevitable death. Our study also demonstrates that mindsponge-based reasoning and BMF analytics can be effective in designing and processing health data for studying extreme psychosocial phenomena. Moreover, we suggest that policymakers implement and adjust their policies (e.g., health insurance) following scientific evidence to mitigate patients’ likelihood of making “near-suicide” decisions and improve social equality in the healthcare system. (shrink)

The slogan “Do Your Own Research” (DYOR) is often invoked by people who are distrustful, even downright sceptical, of recognized expert authorities. While this slogan may serve various rhetorical purposes, it also expresses an ethic of inquiry that valorises independent thinking and rejects uncritical deference to recognized experts. This paper is a qualified defence of this ethic of inquiry in one of the central contexts in which it might seem attractive. I use several case studies of patient activist groups to (...) argue that these groups often engage in valuable independent research that advances biomedical knowledge. In doing so they demonstrate the value of “lay expertise” and the epistemic as well as political necessity of not simply deferring to recognized experts. I also give some reasons why patient activist groups often produce valuable biomedical knowledge: they are examples of what I call “research collectives”. Research collectives are research communities that differ from the traditional research communities we find in universities and research institutes in that their members typically lack formal relevant scientific credentials and training. But they are similar in that they have internal structures—training procedures, norms of discussion, venues for holding discussions—that facilitate the production of knowledge. I finish by suggesting that future research into the differences and similarities between research collectives and traditional research communities is required. (shrink)

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

In contemporary bioethics, the autonomy of the patient has assumed considerable importance. Progressing from a more limited notion of informed consent, shared decision making calls upon patients to voice the desires and preferences of their authentic self, engaging in choice among alternatives as a way to exercise deeply held values. One influential opinion in Jewish bioethics holds that Jewish law, in contradistinction to secular bioethics, limits the patient's exercise of autonomy only in those instances in which treatment choices are (...) sensitive to preferences. Here, we analyze a discussion in the Mishna, a foundational text of rabbinic Judaism, regarding patient autonomy in the setting of religiously mandated fasting, and commentaries in the Babylonian and Palestinian Talmuds, finding both a more expansive notion of such autonomy and a potential metaphysical grounding for it in the importance of patient self-knowledge. (shrink)

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

At least since Anaximander’s apeiron, there have been philosophical questions about what, if anything, preceded the gods. But, as far as I know, the precise question that I address in this essay was first explicitly asked by Ronald W. Hepburn, in his essay ‘Restoring the Sacred: Sacred as a Concept of Aesthetics’. In his essay, Hepburn is interested in the actual and potential relationships between religious and aesthetic uses of the concept of the sacred. Which leads him to the question: (...) Does the concept have a valid meaning – an aesthetic meaning, say – that is logically independent of (and therefore might have preceded) the religious one, which seems most strongly associated with the metaphysical belief that God or the gods exist? In other words, is the sacred older than the gods? While he does not provide a definitive answer, Hepburn adumbrates his view on whether this claim is correct. In this essay, I set out my own answer within the guidelines that Hepburn’s sketch has laid out. (shrink)

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

Paul Ricoeur argues that narration is lived life. Therefore, human experience has a narrative dimension, ie, it has a narrative structure and every effort you want to make for the human need to consider the narrative. For this reason, the text theory is converted to Ricoeur in a general model for the study of human action, since this is conceived as an open work to anyone who can read it. Given this general framework for discussion, we have deepened the notion (...) of the patient as “text”, and described their richness for reflection of bioethics and medical act, rescuing the value of listening, prudence, responsibility and rediscovering a place for the principle of autonomy and casuistry. -/- Paul Ricoeur sostiene que la narración es vida vivida. Por lo tanto, la experiencia humana posee una dimensión narrativa, es decir, tiene una estructura narrativa y todo esfuerzo que quiera dar cuenta de lo humano tendrá que contar con lo narrativo. Por esta razón, la teoría del texto se convierte para Ricoeur en un modelo general para el estudio de la acción humana, pues esta es concebida como una obra abierta a cualquiera que pueda leer. Teniendo en cuenta este marco general de reflexión, hemos profundizado en la noción del paciente como “texto”, y describimos su riqueza para la reflexión de la bioética y el actuar médico, rescatando el valor de la escucha, la prudencia, la responsabilidad y redescubriendo un lugar para el principio de autonomía y la casuística. (shrink)

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

Social inequalities abound worldwide. However, those social inequalities that encompass the lack of access to resources, including primary healthcare, are more prevalent at older ages in low- and middle-income countries, which is the focus of this chapter. This challenge has become critical due to the increasing population of older age. The design and implementation of key policy measures, including primary healthcare in low- and middle-income countries, is essential in reducing such social disparities. Access to primary healthcare is perhaps (...) the principal determinant of social equality and/or equity for older people, which in turn supports achieving Sustainable Development Goals and comprehensive healthcare access. (shrink)

In this paper, we defend three claims about what it will take for an AI system to be a basic moral patient to whom we can owe duties of non-maleficence not to harm her and duties of beneficence to benefit her: (1) Moral patients are mental patients; (2) Mental patients are true intentional systems; and (3) True intentional systems are systematically flexible. We suggest that we should be particularly alert to the possibility of such systematically flexible true (...) intentional systems developing in the areas of exploratory robots and artificial personal assistants. Finally, we argue that in light of our failure to respect the well-being of existing biological moral patients and worries about our limited resources, there are compelling moral reasons to treat artificial moral patiency as something to be avoided at least for now. (shrink)

In order to determine whether current (or future) machines have a welfare that we as agents ought to take into account in our moral deliberations, we must determine which capacities give rise to interests and whether current machines have those capacities. After developing an account of moral patiency, I argue that current machines should be treated as mere machines. That is, current machines should be treated as if they lack those capacities that would give rise to psychological interests. Therefore, they (...) are moral patients only if they have non-psychological interests. I then provide an account of what I call teleo interests that constitute the most plausible type of non-psychological interest that a being might have. I then argue that even if current machines have teleo interests, they are such that agents need not concern themselves with these interests. Therefore, for all intents and purposes, current machines are not moral patients. (shrink)

This paper explores the relationship between dignity and robot care for older people. It highlights the disquiet that is often expressed about failures to maintain the dignity of vulnerable older people, but points out some of the contradictory uses of the word ‘dignity’. Certain authors have resolved these contradictions by identifying different senses of dignity; contrasting the inviolable dignity inherent in human life to other forms of dignity which can be present to varying degrees. The Capability Approach (CA) (...) is introduced as a different but tangible account of what it means to live a life worthy of human dignity. It is used here as a framework for the assessment of the possible effects of eldercare robots on human dignity. The CA enables the identification of circumstances in which robots could enhance dignity by expanding the set of capabilities that are accessible to frail older people. At the same time, it is also possible within its framework to identify ways in which robots could have a negative impact, by impeding the access of older people to essential capabilities. It is concluded that the CA has some advantages over other accounts of dignity, but that further work and empirical study is needed in order to adapt it to the particular circumstances and concerns of those in the latter part of their lives. (shrink)

Objective We reviewed human–robot interaction (HRI) participatory design (PD) research with older adults. The goal was to identify methods used, determine their value for design of robots with older adults, and provide guidance for best practices. Background Assistive robots may promote aging-in-place and quality of life for older adults. However, the robots must be designed to meet older adults’ specific needs and preferences. PD and other user-centered methods may be used to engage older adults in (...) the robot development process to accommodate their needs and preferences and to assure usability of emergent assistive robots. Method This targeted review of HRI PD studies with older adults draws on a detailed review of 26 articles. Our assessment focused on the HRI methods and their utility for use with older adults who have a range of needs and capabilities. Results Our review highlighted the importance of using mixed methods and including multiple stakeholders throughout the design process. These approaches can encourage mutual learning (to improve design by developers and to increase acceptance by users). We identified key phases used in HRI PD workshops (e.g., initial interview phase, series of focus groups phase, and presentation phase). These approaches can provide inspiration for future efforts. Conclusion HRI PD strategies can support designers in developing assistive robots that meet older adults’ needs, capabilities, and preferences to promote acceptance. More HRI research is needed to understand potential implications for aging-in-place. PD methods provide a promising approach. (shrink)

Transactive memory theory describes the processes by which benefits for memory can occur when remembering is shared in dyads or groups. In contrast, cognitive psychology experiments demonstrate that social influences on memory disrupt and inhibit individual recall. However, most research in cognitive psychology has focused on groups of strangers recalling relatively meaningless stimuli. In the current study, we examined social influences on memory in groups with a shared history, who were recalling a range of stimuli, from word lists to personal, (...) shared memories. We focused in detail on the products and processes of remembering during in-depth interviews with 12 older married couples. These interviews consisted of three recall tasks: (1) word list recall; (2) personal list recall, where stimuli were relevant to the couples’ shared past; and (3) an open-ended autobiographical interview. We conducted these tasks individually and then collaboratively two weeks later. Across each of the tasks, although some couples demonstrated collaborative inhibition, others demonstrated collaborative facilitation. We identified a number of factors that predicted collaborative success, in particular, group-level strategy use. Our results show that collaboration may help or hinder memory, and certain interactions are more likely to produce collaborative benefits. (shrink)

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