When Parents Refuse: Resolving Entrenched Disagreements Between Parents and Clinicians in Situations of Uncertainty and Complexity

When shared decision making breaks down and parents and medical providers have developed entrenched and conflicting views, ethical frameworks are needed to find a way forward. This article reviews the evolution of thought about the best interest standard and then discusses the advantages of the harm principle (HP) and the zone of parental discretion (ZPD). Applying these frameworks to parental refusals in situations of complexity and uncertainty presents challenges that necessitate concrete substeps to analyze the big picture and identify key questions. I outline and defend a new decision-making tool that includes three parts: identifying the nature of the disagreement, checklists for key elements of the HP and ZPD, and a “think list” of specific questions designed to enhance use of the HP and ZPD in clinical decision making. These tools together will assist those embroiled in complex disagreements to disentangle the issues to find a path to resolution.     

Ethics Consultation in Pediatrics: Long-Term Experience From a Pediatric Oncology Center

There is little information about the content of ethics consultations (EC) in pediatrics. We sought to describe the reasons for consultation and ethical principles addressed during EC in pediatrics through retrospective review and directed content analysis of EC records (2000–2011) at St. Jude Children's Research Hospital. Patient-based EC were highly complex and often involved evaluation of parental decision making, particularly consideration of the risks and benefits of a proposed medical intervention, and the physician's fiduciary responsibility to the patient. Nonpatient consultations provided guidance in the development of institutional policies that would broadly affect patients and families. This is one of the few existing reviews of the content of pediatric EC and indicates that the distribution of ethical issues and reasons for moral distress are different than with adults. Pediatric EC often facilitates complex decision making among multiple stakeholders, and further prospective research is needed on the role of ethics consultation in pediatrics.     

The Harm Principle Cannot Replace the Best Interest Standard: Problems With Using the Harm Principle for Medical Decision Making for Children

For many years the prevailing paradigm for medical decision making for children has been the best interest standard. Recently, some authors have proposed that Mill’s “harm principle” should be used to mediate or to replace the best interest standard. This article critically examines the harm principle movement and identifies serious defects within the project of using Mill’s harm principle for medical decision making for children. While the harm principle proponents successfully highlight some difficulties in present-day use of the best interest standard, the use of the harm principle suffers substantial normative and conceptual problems. A medical decision-making framework for children is suggested, grounded in the four principles. It draws on the best interest standard, incorporates concepts of harm, and provides two questions that can act as guide and limit in medical decision making for children.     

Is There Social Consensus Regarding Researcher Conflicts of Interest?

Consensus around what constitutes researcher conflicts of interest (COIs) and awareness of their influence on our research are two critical steps in ensuring the integrity of our science. In this research, data were collected from individual scholars via 2 surveys 5 years apart and from journals and associations to examine the level of social consensus and moral awareness among scholars, journals, and associations regarding researcher COIs. Although we observed increases in level of social consensus and moral awareness between 2012 and 2017, results still revealed limited agreement about what relationships constitute a COI and limited awareness about the presence of and the ethical issues surrounding COIs. Although all journals and associations we examined supported COI disclosure, most did not provide researchers with detailed COI-related information, guidance, or disclosure tools. Limited social consensus and moral awareness regarding COIs is problematic because it inhibits the recognition, disclosure, and management of COIs and limits ethical decision making. We need to continue and enhance discussions about COIs and aim to create consensus and awareness where we do not have it with the goal of reducing potential scientific misconduct related to COIs.     

Individual postdecision processes in group settings

In two experiments Differentiation and Consolidation Theory (Diff Con) (Svenson, 1992) was used to investigate individual postdecision making processes in three-member groups. It was predicted that in groups in which the subjects preferred different alternatives (conflict groups), subjects would consolidate their own preferred alternative, and not the group's final decision. A second hypothesis was that no consolidation would be indicated in groups in which all members preferred the same alternative (non-conflict groups). The results showed that in conflict groups, the members who gave up their preferred alternative (minority members) consolidated their own preference, thereby significantly regretting the group decision. In contrast, members who got their own will through in the majority decision (majority members) showed no consolidation of the group decision. The corresponding pattern of results was replicated in a second experiment, using a different decision situation. The results indicated that perceptions of social support, agreement in a group and decreasing responsibility for a group's decision, could all partly substitute consolidation by attractiveness restructuring.     

The transience of constructed preferences

A large body of research suggests that preferences are constructed rather than merely accessed in the course of making decisions. The current research examines the stability of constructed preferences over time. Preferences for various factors relevant to a job choice were measured prior to presentation of the job‐choice task, at the point of decision, and again following a delay. It was found that relative to baseline pre‐decision levels, preferences shifted to provide stronger support for the emerging decision. Preference changes proved to be transient, receding to baseline after 1 week (Experiment 1), and even within 15 minutes (Experiment 2). These findings, which can be interpreted in terms of decision‐making by constraint satisfaction, suggest that preferences are constructed to serve the decision at hand, without constraining the decision maker in future decisions. Copyright © 2007 John Wiley & Sons, Ltd.     

Escalation in organizational decision making a case of recruiting an incompetent employee

This paper analyses a case of hiring a manager who subsequently proves to be incompetent. Analysis reveals the importance of structural factors in escalation, especially politics. When these are considered, persistence emerges as both escalatory and rational. Likewise, behaviours manifest of information bias are actually logical managerial strategies and may mask political calculation. New potential escalation variables are identified including power, visibility, and organization culture. Withdrawal reflects an intricate balancing of factors including risk and opportunity. The theoretical implications of the findings are discussed.     

医师多点执业制度实施的现状调查及相关建议——以成都市为例

我国于2009年新医改方案提出实施“医师多点执业”制度, 但有关数据显示, 该制度在推进过程中效果并不理想, 为了探究医师多点执业制度的实施现状及其影响因素, 通过问卷调查和访谈对成都市医疗机构人员进行调研。最后在分析调研结果的基础上提出相关建议:采取措施取得医院管理者支持、平衡各方利益冲突、借鉴“团队多地点执业”模式降低医疗风险、加强政策的宣传、建立完善的基层服务体系等, 期望对成都市乃至我国该方案的实施推进提供参考依据。     

In re Edna MF: Case Law Confusion in Surrogate Decision Making

I review the recent case of Edna Folz, a 73 year-old woman who was suffering through the end stages of very advanced Alzheimer's dementia when her case was adjudicated by the Wisconsin Supreme Court. I consider this case as an example of how courts are increasingly misinterpreting the ethical and legal decision-making standards known as substituted judgment and best interests and thereby threatening individuals' treatment decision-making rights as developed by other courts over the past two decades and creating serious roadblocks to health-care providers' ability to render appropriate patient care. The Wisconsin Supreme Court held that Edna's legal guardian could not authorize withdrawal of Edna's treatment, ruling that as a matter of law, if an incompetent person is not in a persistent vegetative state, it is not in his or her best interests for life-sustaining treatment to be withdrawn unless (s)he has executed an advance directive or other statement clearly indicating his or her desires.     

Trait anger and anger expression style in children's risky decisions

In this study, 104 children completed a task, measuring risk decision-making, and the State-Trait Anger Expression Inventory for Children and Adolescents. Subjects were also asked to evaluate the degree of danger, benefit, fun and fear perceived for each risky choice. Analyses indicated that (a) risk decision-making was predicted by both trait anger and outward expression of anger; (b) appraisal of danger fully mediated the relationship between trait anger and risk; (c) perceptions of benefit, scare and fun partially mediated the relationship between trait anger and risk; and (d) appraisal of danger partially mediated the relationship between outward expression of anger and risk decision-making. The results provide evidence for a relationship between dispositional anger and risk decision-making during childhood, suggesting a possible explanation of the mechanisms below. In particular, risk decision-making can be viewed as the output of cognitive and emotive processes, linked to dispositional anger that leads children to be amused, optimistic and fearless in potentially risky situations. These findings substantiate the importance of incorporating cognitive and emotive factors in theories that seek to explain the relationship between personality traits and risk decision-making across a broad age range.     

Rational Choice and Moral Decision Making in Research

University psychology and sociology researchers rated the likelihood they would engage in misconduct as described in 9 research scenarios, while also making moral judgments and rating the likelihood of discovery and sanctions. Multiple regression revealed significant effects across various scenarios for moral judgment as well as shame and embarrassment on reducing misconduct. The effects on misconduct of the perceived probability of sanctions were conditioned on moral judgments in some scenarios. The results have implications for how universities address the prevention, detection, and sanctioning of research misconduct.     

医疗风险决策的自我他人差异及其影响因素

从心理学的层面梳理医疗风险决策自我他人差异的表现及影响因素,狭义的医疗风险是患者在医疗服务的过程中因为医疗过失导致的损害等不安全事件,而广义的医疗风险包含了患者受到的伤害和整个医疗卫生体系受到的损失。在实际的医疗决策中,医生、家属和患者三方通常会做出不同的决策并且伴随着其立场的合理性,决策时也会受到决策框架和医疗决策模式等多方面的影响,可以采用解释水平理论、社会价值理论和双系统理论对不同决策主体之间的决策差异进行解释。未来可以从真实的医疗情境、个人特质、文化差异等方面进行深入研究。

     

愿望采择发展水平对幼儿情感决策的影响

选取148名4岁儿童, 运用实验法考察了幼儿的愿望采择发展水平对其情感决策的影响。结果表明: (1) 幼儿的愿望采择水平对其情感决策具有显著影响。情境中他人愿望信息充足时, 幼儿会采择他人愿望并以此为线索为他人决策, 但对线索的利用程度受其愿望采择水平的制约。(2) 在无关于他人愿望信息提示的条件下, 4岁儿童为他人与为自己的情感决策不存在显著差异。(3) 4岁儿童能够采择他人的单一愿望, 但其冲突愿望采择能力还不成熟。     

自然语言处理预测抑郁症的技术陷阱与道德风险

抑郁症患者倾向于在网络社交平台上发布带有抑郁信号的推文。基于这些文字信息，借助自然语言处理进行分析，提取归纳用户的语言特征，可以预测潜在用户的抑郁症状况。由于隐私信息的敏感、相关技术的不成熟等原因，出现了诸如信息获取与隐私侵犯、算法偏见与信息误判、信息权利与信息利益、责任界定与权限模糊等现实问题，成为进一步发展的掣肘。进行算法技术升级、完善法律法规、加强行业伦理约束等是避免道德风险的重要措施。     

Moral priorities under risk

Many moral theories are committed to the idea that some kinds of moral considerations should be respected, whatever the cost to ‘lesser’ types of considerations. A person’s life, for instance, should not be sacrificed for the trivial pleasures of others, no matter how many would benefit. However, according to the decision-theoretic critique of lexical priority theories, accepting lexical priorities inevitably leads us to make unacceptable decisions in risky situations. It seems that to operate in a risky world, we must reject lexical priorities altogether. This paper argues that lexical priority theories can, in fact, offer satisfactory guidance in risky situations. It does so by equipping lexical priority theories with overlooked resources from decision theory.     

Explaining the Sense of Family Coherence Among Husbands and Wives: The Israeli Case

ABSTRACT

This study examined variables belonging to the family environment that explain the sense of family coherence among husbands (n = 133) and wives (n = 133) in Israel. Specifically, the explanatory variables tested were spousal power relations (as expressed in equality in the division of household labor and decision making), and perceived family conflict. In general, the sense of family coherence among spouses was found to be high. Perceived family conflict contributed to explaining the sense of family coherence for both husbands and wives. Equality in the division of household labor and in decision making had a greater impact on husbands than wives. Family coherence correlated negatively with age for husbands and positively with income for wives. The explanatory variables had a greater impact on the sense of family coherence among husbands than among wives.     

The role of desires in sequential impulsive choices

The present research provides evidence for a sequential mitigation effect, which is the phenomenon that participation in a prior impulsive choice task significantly reduces the decision maker’s likelihood of choosing impulsively in a subsequent task. The results of five experiments: (a) provide evidence for the Sequential Mitigation Effect using different study materials and contexts (Experiments 1–3), (b) show that prior impulsive (as opposed to non-impulsive) choice is required for the effect to occur (Experiment 4), and (c) find that the decision maker’s chronic sensitivity to positive and negative outcomes moderates the effect (Experiment 5). The results support the notion that desire for impulsive options functions as a limited motivational resource, and being consumed in the first task, is experienced to a lesser extent in the second task. The sequential mitigation effect may be characterized as a motivational contextual influence on decision making, complementing existing research showing that cognitive context effects influence sequential choices.     

Losses Induce Consistency in Risk Taking Even Without Loss Aversion

It is posited that because of the attentional effect of losses, individuals would show more behavioral consistency in risk‐taking tasks with losses, even in the absence of loss aversion. In two studies, the consistency of risky choices across different experience‐based tasks was evaluated for gain, loss, and mixed (gain loss) tasks. In both studies, losses facilitated the consistency across tasks: the correlation between risk‐taking choices in different tasks increased when the tasks involved frequent losses. Study 2 also showed a positive effect of losses on temporal consistency. Losses increased the correlation between risk‐taking levels across two sessions that were 45 days apart. Also in Study 2, losses induced consistency between experiential risk‐taking choices and self‐reported ratings of risky behavior. In both studies, the positive effect of losses on consistency was observed even when the average participant did not exhibit loss aversion. Taken together, the results indicate that losses increase the consistency of risk‐taking behavior and suggest that this is due to the effect of losses on attention. Copyright © 2011 John Wiley & Sons, Ltd.     

浅议生物医学研究中不同主体的利益冲突

作为医学伦理学研究的重要内容,生物医学研究中的利益冲突问题日益受到公众、研究机构和管理部门的关注。探讨生物医学活动中研究者、研究机构、学术期刊三种不同主体利益冲突的表现、危害及其特点,以期有针对性地促进人们对该领域利益冲突问题的认识。