Consensus, clinical decision making, and unsettled cases

The model of clinical ethics consultation (CEC) defended in the ASBH Core Competencies report has gained significant traction among scholars and healthcare providers. On this model, the aim of CEC is to facilitate deliberative reflection and thereby resolve conflicts and clarify value uncertainty by invoking and pursuing a process of consensus building. It is central to the model that the facilitated consensus falls within a range of allowable options, defined by societal values: prevailing legal requirements, widely endorsed organizational policies, and professional standards of practice and codes of conduct. Moreover, the model stipulates that ethics consultants must refrain from giving substantive recommendations regarding how parties to a moral disagreement in the clinic should evaluate their options. We argue that this model of CEC is incomplete, because it wrongly assumes that what counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible. We illustrate this problem with a recent case on which one of us consulted-a neonate born with trisomy 18 (T18). We try to show that law, policy, and standards of practice reveal no clear answer to the question posed by the case: namely, whether forgoing gastrostomy tube feedings for a baby with T18 is allowable. We suggest there may be other kinds of cases in which it may simply be unsettled whether a given choice falls within the set of allowable options within which consensus is to be facilitated. What should an ethicist do when confronting such unsettled cases? We agree with the facilitation model that an ethicist should remain neutral among the allowable options, when it is clear what the allowable options are. But, in unsettled cases, the role of a consultant should be expanded to include a process of moral inquiry into what the allowable options should be. We end by raising the issue of whether this means an ethicist should share his or her own conclusions or views about the allowability of a given clinical option.     

Job Seeking Among Retirees Seeking Bridge Employment

Using a sample of recent retirees, the study described here sought to test the general propositions of the Wanberg, Watt, and Rumsey (1996) model by (a) including specific variables that are likely to be relevant to older adults seeking work after retirement (bridge employment) and (b) integrating more recent variable groups (e.g., situational constraints) suggested by recent research (e.g., Wanberg, Kanfer, & Rotundo (1999) and Kanfer, Wanberg, & Kantrowitz (2001) . Generally, the results support the efficacy of the Wanberg et al. model to predict job seeking among this group. Biographical variables such as older worker job search constraints, self-evaluations (e.g., job seeking self-efficacy), and motive/social variables (e.g., social support) were related to job seeking. Some of these, however, were not in the expected direction. Similarities and differences between "regular" job seeking and bridge employment job seeking are discussed.     

Active inference, sensory attenuation and illusions

Active inference provides a simple and neurobiologically plausible account of how action and perception are coupled in producing (Bayes) optimal behaviour. This can be seen most easily as minimising prediction error: we can either change our predictions to explain sensory input through perception. Alternatively, we can actively change sensory input to fulfil our predictions. In active inference, this action is mediated by classical reflex arcs that minimise proprioceptive prediction error created by descending proprioceptive predictions. However, this creates a conflict between action and perception; in that, self-generated movements require predictions to override the sensory evidence that one is not actually moving. However, ignoring sensory evidence means that externally generated sensations will not be perceived. Conversely, attending to (proprioceptive and somatosensory) sensations enables the detection of externally generated events but precludes generation of actions. This conflict can be resolved by attenuating the precision of sensory evidence during movement or, equivalently, attending away from the consequences of self-made acts. We propose that this Bayes optimal withdrawal of precise sensory evidence during movement is the cause of psychophysical sensory attenuation. Furthermore, it explains the force-matching illusion and reproduces empirical results almost exactly. Finally, if attenuation is removed, the force-matching illusion disappears and false (delusional) inferences about agency emerge. This is important, given the negative correlation between sensory attenuation and delusional beliefs in normal subjects—and the reduction in the magnitude of the illusion in schizophrenia. Active inference therefore links the neuromodulatory optimisation of precision to sensory attenuation and illusory phenomena during the attribution of agency in normal subjects. It also provides a functional account of deficits in syndromes characterised by false inference and impaired movement—like schizophrenia and Parkinsonism—syndromes that implicate abnormal modulatory neurotransmission.     

Personality and Dissonance Among Mormon Missionaries

The distinguishing characteristics of dissonant missionaries were identified by examining the responses of 58 current and former Mormon missionaries to a questionnaire about missionary service, a Minnesota Multiphasic Personality Inventory (MMPI) Denial scale, and Millon Clinical Multiaxial Inventory (MCMI) Compulsive and Submissive/Aggressive special scales. The participants, 12 women and 46 men, were mailed the materials after being identified by their friends or acquaintances as current or former missionaries. Women had less satisfying missionary experiences than men and were more likely to report a loss of self-esteem due to missionary service, but were not more dissonant missionaries than men. Missionaries with lower scores on the Denial, Compulsive, and Submissive/Aggressive scales were more likely to question mission policies than subjects with higher scores. Thus, it appears that Denial, Compulsive, and Submissive/Aggressive scale scores can identify potentially dissonant missionaries.     

Motivational systems of social behavior in male rats and monkeys: Are they homologous?

A comparison is presented between the behaviors of male rats and male stumptail macaques that occur when two unfamiliar males are paired for 10 min. Results which have been presented in detail in separate papers elsewhere are compared and discussed here in terms of the hypothetical organization of motivational systems. The following motivational mechanisms appear to be homologous in the rat and monkey: offense, defense, submission, male sex, self grooming, and allogrooming. Two motivational mechanisms are analogous but not homologous: patrol/marking in the rat and display in the monkey. There is a shift in sensory modality of motivating stimuli from olfaction in the rat to complex visual and auditory stimuli in the monkey. There is also a shift in the modalities of motor patterns from predominant use of the mouth by the rat to use of the hands by the monkey. Both shifts affect most or all motivational systems of social behavior. It is hypothesized that the outer parts of motivational systems, their sensory and motor interfaces with the environment, change more rapidly and incrementally during the course of mammalian evolution than does the inner part, the integrational portion that consists of the motivational mechanisms.     

Identifying runners as football teammates from 400 msec. video clips

Ability to recognize a runner as a teammate from only a brief visual exposure is suggested from research on gait recognition with point-light displays and has particular importance for ball-passing in sports. 15 touch football players of mean age 20 yr. (SD=0.7), on two teams of 7 wk. standing, observed 31 400-msec, video clips of running individuals whose familiarity varied from high to low. These were their teammates, players from the other team, or nonfootball players. After viewing each clip, participants rated their certainty that each running player was a teammate. Despite the brevity of the visual display, overall performance at discriminating teammates from other runners was significantly better than chance, and accuracy did not differ between colour or black-and-white formats. Recognition of teammates was better if familiar nonteammates were removed from the set of analyzed clips and worse if unfamiliar nonplayers were removed.     

Life satisfaction and health related quality of life among low-income medical patients: The mediating influence of self-esteem

This study investigated the relationship between life satisfaction, self-esteem, and perceived health for an ethnically diverse, low SES sample of primary care patients. Results indicated that several specific domains of health-related quality of life (HRQL), including health perception, social functioning, mental health, and energy/fatigue, significantly predicted life satisfaction in this sample of 60 patients. Self-esteem mediated this relationship, partially with health perception and fully with the remaining three domains. The results of this study underscore the importance of healthcare interventions that consider the bidirectional relationship between physical and emotional well-being.     

Different components of working memory have different relationships with different mathematical skills

A comprehensive working memory battery and tests of mathematical skills were administered to 90 children-41 in Year 1 (5-6 years of age) and 49 in Year 3 (7-8 years of age). Working memory could explain statistically significant variance in number writing, magnitude judgment, and single-digit arithmetic, but the different components of working memory had different relationships with the different skills. Visual-spatial sketchpad (VSSP) functioning predicted unique variance in magnitude judgments and number writing. Central executive functioning explained unique variance in the addition accuracy of Year 1 children. The unique variance explained in Year 3 multiplication explained by phonological loop functioning just missed conventional levels of significance (p=.06). The results are consistent with the VSSP having a role in the development of number writing and magnitude judgments but a lesser role in early arithmetic.     

Obsessive beliefs predict cognitive behavior therapy outcome for obsessive compulsive disorder

Cognitive accounts of obsessive compulsive disorder (OCD) assert that core beliefs are crucial to the development, maintenance, and treatment of the disorder. There are a number of obsessive beliefs that are considered fundamental to OCD, including personal responsibility, threat estimation, perfectionism, need for certainty, importance of thoughts, and thought control. The present study investigated if pretreatment severity of obsessive beliefs, as well as the change in obsessive beliefs following treatment, predicted intensive, residential cognitive behavioral therapy (CBT) treatment outcome. A series of hierarchical regression analyses were carried out to investigate the relations between obsessive beliefs and treatment outcome. Results indicated that inflated pretreatment responsibility/threat estimation beliefs were significantly related to less overall obsessive compulsive (OC) symptom reduction at discharge, explaining 2% of the overall variance. Changes in obsessive beliefs broadly, and importance/control of thoughts specifically, were positively related to overall OC symptom reduction at discharge, respectively explaining 18% and 3.6% variance. Results are modestly consistent with a number of theoretical models, which argue that inflated responsibility, threat estimation, and thought control are important to the maintenance and treatment of OCD.     

Intrinsic religiosity and social anxiety of intercollegiate athletes

For 105 intercollegiate athletes intrinsic religiosity and social anxiety as measured by self-repot questionnaires were not associated.