Toward an expanded vision of clinical ethics education: from the individual to the institution

This paper advances a new paradigm in clinical ethics education that not only emphasizes development of individual clinicians' skills, but also focuses on the institutional context within which health care professionals work. This approach has been applied to the goal of improving the care provided to critically and terminally ill adults. The model has been adopted by about thirty hospitals and nursing homes; additional institutions will soon join the program, entitled Decisions Near the End of Life. Here, we describe the history and rationale for this approach, its goals, pedagogical assumptions, and design.     

The architect as person: a Rorschach image

Analysis of the Rorschachs of 40 eminent male architects collected in 1959 revealed a highly consistent personality profile. The picture that emerges is of a person who appears to be ambitious, highly sensitive, intellectually and emotionally energetic, and reasonably well adjusted socially. His thinking is well oriented in reality. He prefers large scale conceptualizing to mundane 'concerns. There is evidence of conflict, tension, and a concern with emotional control. Feminine and exhibitionistic interests are exceptionally high and sources of inspiration appear to reside in unresolved sexual conflicts. The attitude toward the world is positive. The eminent male American architect at the turn of the Sixties believed in his own ability to create a truly superior environment. His conscious concerns were with creation rather than with self-confrontation.     

Perceptual similarity of mirror images in infancy

Perception of mirror images by three-to four-month infants was studied in five experiments using habituation paradigms. In the first experiment, babies discriminated right profiles of two different faces but not the left and right profile of the same face. In the second, babies discriminated a 45° oblique from a vertical line, but not the oblique from its mirror image. In the third, babies discriminated oblique lines that differed by 50° and were not mirror images. In the final experiments. 90° rotations of a ?-shape were discriminated but not 180° rotations that formed lateral or vertical mirror images. These results demonstrated that although babies were able to discriminate differences in orientation (even among obliques) they tended to view mirror images, especially lateral mirror images, as equivalent stimuli. We propose that the perceptual equivalence of mirror images reflects an adaptive mode of visual processing; mirror images in nature are almost always aspects of the same object, and they usually need not be discriminated. The relations of the perceptual similarity of mirror images to the ontogeny of the object concept and to the development of reading are discussed.     

Covariation, discounting, and augmentation: Towards a clarification of attributional principles

Two experiments were conducted to examine the interrelation of the attributional principles of covariation, discounting, and augmentation. In Experiment 1 the presence (vs. absence) of covariation information was manipulated orthogonally to the number of plausible causes for an effect (one vs. two). In Experiment 2 the number of plausible causes for an effect (one vs. two) was manipulated orthogonally to the presence (vs. absence) of an inhibitory factor. The major findings of this research were interpreted to mean that the covariation principle may be applied concomitantly with the discounting principle and that the latter principle pertains to a different aspect of the attributional process than does the augmentation principle. Implications of these findings for the further development of attribution theory were considered.     

Differential runway performance using goal box placement and running trials as discriminative stimuli

Two experiments compared the effects of reinforced, partially reinforced and nonreinforced intertrial goal box placements (ITR, ITP, and ITN respectively) on runway performance. In Experiment I differential responding (animals running slower on nonreinforced (N) trials than on reinforced (R) trials) was observed during acquisition for subjects receiving ITP preceding N trials or subjects receiving ITP before R trials, and also for subjects receiving ITR preceding N trials. No differential responding was observed in subjects receiving ITP prior to both N and R trials or ITN prior to N trials. In extinction, the subjects which had responded differentially during acquisition demonstrated reduced resistance to extinction in comparison to the subjects which had not. In Experiment II, a 2 × 2 factorial design was utilized with placement schedule (ITN and ITP) and type of trial predicted by placement (N and R) serving as the factors. Differential responding was observed in all four groups. The apparent contradiction between the results and the discrimination hypothesis proposed by Capaldi and Olivier (1967) to explain the attenuation of ITR and ITN effects on resistance to extinction is discussed.     

Factors affecting withdrawal from an escalating conflict: Quitting before it's too late

In an experimental study of “entrapping” conflicts —situations in which a decisionmaker may continue to expend resources in part to justify previous expenditures—subjects were given an initial stake of $4.00 and had the opportunity to win an additional $2.00 jackpot. Two independent variables (Process of Resource Allocation and Prior Limit-Setting) were combined in a 2 × 3 design. Once the subjects had started to invest, half of them had to make an “active” decision to continue. Unless they actively decided to continue, their investments automatically ceased and they were no longer eligible for the jackpot (Selfterminating condition). The other half only had to make a “passive” decision to continue. Unless they actively decided to dis continue, their investments for the jackpot automatically increased (Self-sustaining condition). In addition, before investments began, some subjects were asked to inform the experimenter of the nonbinding limit they had set on the amount they planned to invest (Public condition), some were asked to set a limit which they kept to themselves (Private condition), while a third group was not asked to set a limit (Control condition). Subjects invested significantly more money in the Self-sustaining condition. Also, investments were somewhat greater in the Control than the Public condition. Although the mean investments in the Public and Private conditions did not differ, those in the Public condition deviated significantly less from their earlier set limits, suggesting greater commitment to these limits. Theoretical and practical implications are discussed.     

Suicide ideation: its relation to depression, suicide and suicide attempt

A random sample of 3,935 adults from a general population were interviewed and asked to report how often they had thoughts of suicide as well as their opinion on the frequency of suicide ideation in others. Depression was found to be related to the respondent's reports of his/her own suicidal thoughts and to reports of frequent suicide ideation in others. A total of 5.4 percent of the respondents reported some degree of suicide ideation in the previous month and 9.1 percent reported that others think about suicide once a month or more. When the demographic characteristics of those who report suicide ideation in themselves or others were compared to those of suicide attempters and committers, some consistencies were found, suggesting that such questions may be useful in identifying those "at risk." Nevertheless, sufficient discrepancies were found which suggest that there may be a number of factors which increase or decrease the likelihood that someone with thoughts of suicide will attempt or commit suicide. Follow-up studies are necessary to uncover such factors and the degrees to which they influence the occurrence of suicide.     

Family and psychosocial predictors of obsessive compulsive disorder in a community sample of young adolescents

A two-stage epidemiologic study conducted between 1986 and 1988 in the southeastern United States investigated family and psychosocial predictors of obsessive compulsive disorder (OCD) and subclinical OCD in young adolescents. In the first stage, a life-event schedule and a family adaptability and cohesion scale were administered to a community sample of 3,283 adolescents. In stage two, the Schedule for Affective Disorders and Schizophrenia in School Age Children and the Children's Global Assessment Scale were administered to 488 mother-child pairs. In multivariable models family cohesion was the only significant correlate of OCD (odds ratio=0.95, 95% confidence interval 0.91–0.98). Gender, race, age, socioeconomic status, guardian status, adaptability, undesirable life events and desirable life events were not found to be significant predictors of OCD in models adjusting for cohesion. Note of the above variables were significantly associated with subclinical OCD. However, separate analyses of the 41 individual life events indicated seven specific events were significantly associated with OCD or subclinical OCD. These findings are at odds with the theory that overinvolvement of family members is a risk factor for OCD, though an association with overly rigid family structure cannot be eliminated based on these data. Further exploration of family characteristics is warranted.