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.     

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.     

Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, “How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?” We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle.     

The Processing Wheel: An Arts-based Intervention for Clinical Supervision

The primary goal of supervision is to promote professional growth among counselors-in-training. Art making is an under-explored method of promoting exploration and self-awareness, and thus professional growth, within the process of supervision. While outlining the literature on creativity in counselor education and implementing art into supervision, the author also includes details about her experience of infusing art into supervision. Additionally, a case example of a new specific art-based intervention, dubbed the “Processing Wheel,” is described. Finally, implications, limitations, and future directions for counselor educators are discussed.     

Naturalistic Decision-Making Task Processes in Multiprofessional Assessment of Disability

Evaluation of preschool children with complex disabilities is regarded as a group decision-making process. This process was studied in two tertiary-level multiprofessional groups in London, UK: one based in a neurodisability center and one organized by a school psychological service. The assessment discussions about two preschool children at each site were audio recorded. Each assessment was carried out over half a day by all the professionals simultaneously with the family. Postassessment interviews were held with each professional and family. Verbal protocol analysis captured the structure of each assessment through six TASK decision-making processes applied at three levels of reasoning and decision making. Sequential application of processes was found to be influenced by the occurrence of a series of three cycles of decision making within each assessment and the decomposition of the assessment task into distinct subproblems.     

Forcing the issue: Little psychological influence in a magician’s paradigm

Forcing is usually described as the effect in which stage magicians covertly influence decisions made by spectators. The phenomenon has been subject to a number of recent articles and is typically placed within the context of social influence, priming, decision making, awareness, free will, and the science of magic. In the present paper I will argue that forcing researchers, when framing and describing the phenomenon, have exaggerated what magicians typically achieve with the technique. Specifically, the magician is said to influence and manipulate the spectator’s decision when in fact the vast majority of forces do not include any such influence. The consequence of this misrepresentation is that psychologists will be led to believe that the forcing phenomenon has more to contribute to priming and the psychology of influence than it actually does.     

Does morality predict aggressive driving? A conceptual analysis and exploratory empirical investigation

Risky and aggressive driving is an important cause of traffic casualties and as such a major health and cost problem to society. Given the consequences for others, risky and aggressive driving has a clear moral component. Surprisingly, however, there has been little research on the relation between morality and risky and aggressive driving behavior. In this study we aim at addressing this gap. First, we present a conceptual analysis of the relationship between moral values and aggressive driving behavior. For this purpose, we extend Schwartz’s integrated model of ethical decision making and apply it to the context of aggressive driving. This conceptual analysis shows that moral decision-making processes consist of several stages, like moral awareness, moral judgment and moral intent, each of which are influenced by individual and situational factors and all of which need to materialize before someone’s generally endorsed moral value affects concrete behavior. This suggests that the moral value-aggressive driving relationship is rather indeterminate. This conceptual picture is confirmed by our empirical investigation, which tests to what extent respondents’ moral values, measured through the Moral Foundation Questionnaire, are predictive of respondents’ aggressive driving behavior, as measured through an aggressive driving behavior scale. Our results show few and rather weak empirical relationships between moral values and committed aggressive driving behaviors, as was expected in light of our conceptual analysis. We derive several policy implications from these results.     

医学化与医学界限的反思

自20世纪下半叶以来,医学在科技、资本、政治等社会力量影响下,日益从传统的疾病、健康领域扩展到日常生活领域,导致了原属于生活方式和正常生命历程事件的酗酒、性取向、分娩等问题的医学化,这体现了医学跨越固有界限的趋势。从历史看,医学在古代并没有把上述社会生活问题纳入其视域,而随着社会的现代转型,医学的传统界限常常被打破,医学对社会生活问题的干预范围越来越广泛。但是,某些医学实践对科学界限和伦理界限的跨越却缺乏足够的科学性和正当性,其重要根源在于经济系统和权力系统对这一日常生活世界的侵蚀。

     

The anatomy of antagonistic coregulation: Emergent coordination,path dependency,and the interplay of biomechanic parameters in Aikido

Using a video-supported cognitive ethnographic and phenomenological approach, we address the interactively generated dynamic of bouts in Aikido. This “soft” martial art enables a defender to blend with and then redirect an attacker’s aggressive energy so as to break his balance, while preserving an ethos of non-violence, mutuality, and respect. Our analysis explores the skills used to minutely adapt to the opponent, the causal-temporal structure of Aikido, notably the cumulative effect build-up and main decision points in a bout, as well as the perceptual cues from inter-body geometry, timing, and force dynamics that inform decisions. We then contrast different interaction scenarios by focusing on micro-events that shape defensive preferences. For a successful defense, technical modulations or even the preferred technique itself can be selected as the interaction unfolds (“decision-making-in-action”). For a closer look, we analyze the interplay of multiple parameters: flexibility of intention (i.e. early deciding vs. keeping options openlonger), technique (i.e. type of lever or throw), initial body symmetry, step combinations, spacing and timing relative to the attacker, degree of force, as well as possible skill differentials. We describe complex interdependencies between these parameters, which can be balanced in various ways as agents respond to the interaction dynamic.     

新医科背景下医学院系治理边界嬗变研究

医学院系是医学教育的关键实体组织和实践主体,各项教育改革任务的推进都离不开院系的底部支撑。以新医科统领的医学教育变革对医学院系治理提出具有针对性的内在要求,医学院系治理边界呈现出整体性、系统性、开放性等价值旨向。面对当前治理实践中客观存在的组织边界路径依赖,医学院系应守正创新、主动赋能,通过多元参与、问题导向的垂直治理,多维激活、包容自反的水平治理,开放议程、价值共享的外部治理,融合创新、精准安全的数字治理,进一步优化组织建构,促进现代化治理能力提升,以组织良治的行动路向助力新医科建设。