Legal briefing: The unbefriended: making healthcare decisions for patients without surrogates (Part 2)

This issue's "Legal Briefing" column continues coverage of recent legal developments involving medical decision making for unbefriended patients. These patients have neither decision-making capacity nor a reasonably available surrogate to make healthcare decisions on their behalf. This topic has been the subject of recent articles in JCE. It has been the subject of major policy reports. Indeed, caring for the unbefriended has even been described as the "single greatest category of problems" encountered in bioethics consultation. Moreover, the scope of the problem continues to expand, especially with rapid growth in the elderly population and with an increased prevalence of dementia. Unfortunately, most U.S.jurisdictions have failed to adopt effective healthcare decision-making systems or procedures for the unbefriended. "Existing mechanisms to address the issue of decision making for the unbefriended are scant and not uniform." Most providers are "muddling through on an ad hoc basis." Still, over the past several months, a number of state legislatures have finally addressed the issue. These developments and a survey of the current landscape are grouped into the following 14 categories. The first two categories define the problem of medical decision making for the unbefriended.The remaining 12 describe different solutions to the problem. The first six categories were covered in Part 1 of this article; the last eight categories are covered in this issue (Part 2). 1. Who are the unbefriended? 2. Risks and problems of the unbefriended. 3. Prevention: advance care planning, diligent searching, and careful capacity assessment. 4. Decision-making mechanisms and standards. 5. Emergency exception to informed consent. 6. Expanded default surrogate lists: close friends. 7. Private guardians. 8. Volunteer guardians. 9. Public guardians. 10. Temporary and emergency guardians. 11. Attending physicians. 12. Other clinicians, individuals, and entities. 13. Institutional committees. 14. External committees.     

The priority heuristic: making choices without trade-offs

Bernoulli's framework of expected utility serves as a model for various psychological processes, including motivation, moral sense, attitudes, and decision making. To account for evidence at variance with expected utility, the authors generalize the framework of fast and frugal heuristics from inferences to preferences. The priority heuristic predicts (a) the Allais paradox, (b) risk aversion for gains if probabilities are high, (c) risk seeking for gains if probabilities are low (e.g., lottery tickets), (d) risk aversion for losses if probabilities are low (e.g., buying insurance), (e) risk seeking for losses if probabilities are high, (f) the certainty effect, (g) the possibility effect, and (h) intransitivities. The authors test how accurately the heuristic predicts people's choices, compared with previously proposed heuristics and 3 modifications of expected utility theory: security-potential/aspiration theory, transfer-of-attention-exchange model, and cumulative prospect theory.     

Cache decision making: the effects of competition on cache decisions in Merriam's kangaroo rat (Dipodomys merriami)

Caching food is an economic, decision-making process that requires animals to take many factors into account, including the risk of pilferage. However, little is known about how food-storing animals determine the risk of pilferage. In this study, the authors examined the effect of a dominant competitor species on the caching and behavior of Merriam's kangaroo rat (Dipodomys merriami). The authors found that, as with conspecific competitors, kangaroo rats did not alter caching in response to the mere presence of a heterospecific competitor, but moved caches to an unpreferred area when the competitor's presence was paired with pilferage. These data suggest that Merriam's kangaroo rat assesses pilfer risk from actual pilferage by a competitor and adaptively alters cache strategy to minimize future risk.     

Genograms in counselling practice: A review (Part 1)

Genograms are an important clinical tool for many counsellor, therapists and other health care professionals and can be used for assessment, gathering information on family relationships and exploring themes in counselling practice. This article reviews the recent literature on genograms and examines the efficacy and use of this tool from a number of perspectives including the use of genograms in health care, psychological counselling and in genetic counselling. The predictive value, and future development of the use of the genogram in counselling are also discussed.     

关于道德与政治哲学视野中的法律哲学的对话(上)

Joseph Raz has been dedicated to using the philosophies of mind and of action to explain the nature of normativity. By the same token, his research on jurisprudence and the nature of law has been rooted in his use of the context of the philosophy of practical reason to explain the normativity of law, namely,the relation between law and morality. Our understanding of the Razian philosophy of law thus cannot be divorced from his research on moral and political philosophies. Our dialogue with Joseph Raz will h...     

Participatory action research: The distress of (not) making a difference

Participatory action research (PAR) is alluring for researchers investigating traumatic and sensitive topics. While it is distressing for interviewees to recount these stories – and for researchers to hear them – PAR promises to make the pain worthwhile. Something good will come of it. In this paper, I reflect on a PAR project conducted with Tanzanian child domestic workers. Research vignettes are used to highlight moments of emotional complexity unique to PAR projects. First, the emotional burdens of PAR are distributed across a research team. Researchers need to think carefully about the appropriate ‘level’ of participation to pursue. Second, there is no guarantee that the impacts of PAR projects will be unambiguously positive. The risk of doing more harm than good can weigh heavily on the minds of the research team. Third, when PAR projects are conceived with the intent of producing long-lasting structural changes that benefit marginalised people, ‘failure’ can become a source of great distress. Those attempting PAR need to be prepared for the emotional pitfalls of research endeavours that seek to tangibly intervene in traumatised people's lives.     

(EN)Gendered Sikhism: The iconolatry of manliness in the making of Sikh identity

Among the most insidious regimes of control inaugurated by the British in India was the identification of a fundamental affinity between themselves and manly ‘races’ such as the Sikhs. I will suggest that this apparent commensurability of colonial and native traditions depended upon the Sikhs readily accepting a masculine signature which restricted the ambiguous organization of the Khalsa Sikh body to the muscular piety prescribed by colonial discourse. Thus, far from inscribing ontological parity between the British and the Sikhs, this advocacy of ‘racial’ kinship actually communicated a censorious judgement about Sikh identity. The significance of interventions by Sikh reformers, such as Bhai Kahan Singh Nabha (1861–1938) and Bhai Vir Singh (1872–1958), will be highlighted as key influences in the disciplining of a native semiotics of the body. This reformist ideology encouraged the representation of Sikh corporeality as not-effeminate, signalling not only the insinuation of a colonial iconolatry of manliness at the heart of Sikh tradition, but also the disingenuousness of received opinion concerning the progressive nature of Sikh sexual politics.     

Towards a relational framework for pathological gambling (Part I): Five circuits

Relationship patterns before and after pathological gambling were investigated qualitatively using eight in‐depth clinical case studies in which one partner met Diagnostic and Statistical Manual of Mental Disorders‐IV pathological gambling criteria. Five circuits of couple interactions are described: (i) fault‐lines; (ii) pressure points; (iii) escalation; (iv) relapse and (v) congruence. The exploration of these circuits is developed in two complementary articles. This first article delineates the first four circuits as recursive self‐perpetuating cycles of couple distress in systemic interaction with pathological gambling development and relapse. The second article delineates how a couple can be helped to extricate themselves from these recursive circuits through ‘congruence’. Implications of this relational formulation of pathological gambling for conceptualization, assessment and treatment are discussed.