Ethics in health care and medical technologies

In this paper a case is used to demonstrate how ethical analysis enables health care professionals, patients and family members to make treatment decisions which ensure that medical technologies are used in the overall best interests of the patient. The claim is made and defended that ethical analysis can secure four beneficial outcomes when medical technologies are employed: (1) not allowing any medical technologies to be employed until the appropriate decision makers are identified and consulted; (2) insisting that medical technologies be employed not merely to promote the medical interests of the patient but rather on the basis of their ability to contribute to the overall well-being of the patient; (3) challenging caregivers to reflect on the dynamic interplay between their conscious and unconscious values and consequent determinations of what is in the patient's best interests; and (4) providing a justification for selected interventions which makes possible rational dialogue between caregivers espousing different viewpoints about treatment options.     

Physicians,entrepreneurism and the problem of conflict of interest

This paper examines the ethical issues of conflict of interest raised by the burgeoning development of physician involvement in for-profit entrepreneurial activities outside their practice. After documenting the nature and extent of these activities, and their potential for conflicts of interest, the paper assesses the major arguments for and against physicians' referral of patients to facilities they own or in which they invest. The paper concludes that an outright ban on such activity seems ethically warranted.     

Medical hermeneutics: Where is the “text” we are interpreting?

The present paper is a commentary on an article by Drew Leder [1]. Leder identifies a series of texts in the clinical encounter, emphasizes the central role of interpretation in making sense of each of these texts, and articulates ordering principles to guide the interpretive work.The metaphor of clinical work as textual explication, however, creates the expectation that there is a text somewhere to be found. Such an expectation invites doctors and patients to search for the text and runs the risk of conceptualizing patients as more static than they are. If one is to use the textual metaphor, one must appreciate the radical extent to which the clinical encounter is a mutually produced and shifting entity. The qualities of mutuality and indeterminacy are not those one usually associates with texts. One might ultimately be better served by a different metaphor based more directly on uncertainty.     

Praxis makes perfect: Illness as a bridge between biological concepts of disease and social conceptions of health

Analyses of biological concepts of disease and social conceptions of health indicate that they are structurally interdependent. This in turn suggests the need for a bridge theory of illness. The main features of such a theory are an emphasis on the logical properties of value terms, close attention to the features of the experience of illness, and an analysis of this experience as action failure, drawing directly on the internal structure of action. The practical applications of this theory are outlined for a number of problems in each of the three main practical areas, clinical work, teaching and research. In each case the resources of the theory suggest new models and generate new results. The full practical significance of the theory, however, is shown to consist in the way in which it ties together biological and social theories into an integrated picture of the conceptual structure of medicine as a whole. It is argued, finally, that practical efficiency of this kind is a test of theory not only in the philosophy of medicine but also in general philosophy.     

Testing a stochastic foraging model in an operant simulation: Agreement with qualitative but not quantitative predictions

An operant simulation of foraging through baited and empty patches was studied with 4 pigeons. On a three-key panel, side keys were designated as patches, and successive opportunities to complete 16 fixed-ratio 10 schedules on side keys were defined as encounters with feeders. In a random half of the patches in any session, some of the fixed-ratio 10 schedules yielded reinforcement (baited feeders) and the other schedules yielded nonreinforcement (empty feeders). In the other half of the patches, all feeders were empty. Pigeons could travel between patches at any time by completing a fixed-ratio schedule on the center key. An optimal foraging model was tested in Experiments 1 and 2 by varying center-key travel time and number of baited feeders in baited patches. The ordinal predictions that number of feeders visited in empty patches would increase with travel time and decrease as number of baited feeders increased were supported, but pigeons visited far more feeders in empty patches than the optimal number predicted by the model to maximize energy/time. In Experiment 3, evidence was found to suggest that the number of empty feeders encountered before the first baited feeder in baited patches is an important factor controlling leaving empty patches.     

The many null distributions of person fit indices

This paper deals with the situation of an investigator who has collected the scores ofn persons to a set ofk dichotomous items, and wants to investigate whether the answers of all respondents are compatible with the one parameter logistic test model of Rasch. Contrary to the standard analysis of the Rasch model, where all persons are kept in the analysis and badly fittingitems may be removed, this paper studies the alternative model in which a small minority ofpersons has an answer strategy not described by the Rasch model. Such persons are called anomalous or aberrant. From the response vectors consisting ofk symbols each equal to 0 or 1, it is desired to classify each respondent as either anomalous or as conforming to the model. As this model is probabilistic, such a classification will possibly involve false positives and false negatives. Both for the Rasch model and for other item response models, the literature contains several proposals for a person fit index, which expresses for each individual the plausibility that his/her behavior follows the model. The present paper argues that such indices can only provide a satisfactory solution to the classification problem if their statistical distribution is known under the null hypothesis that all persons answer according to the model. This distribution, however, turns out to be rather different for different values of the person's latent trait value. This value will be called ability parameter, although our results are equally valid for Rasch scales measuring other attributes.As the true ability parameter is unknown, one can only use its estimate in order to obtain an estimated person fit value and an estimated null hypothesis distribution. The paper describes three specifications for the latter: assuming that the true ability equals its estimate, integrating across the ability distribution assumed for the population, and conditioning on the total score, which is in the Rasch model the sufficient statistic for the ability parameter.Classification rules for aberrance will be worked out for each of the three specifications. Depending on test length, item parameters and desired accuracy, they are based on the exact distribution, its Monte Carlo estimate and a new and promising approximation based on the moments of the person fit statistic. Results for the likelihood person fit statistic are given in detail, the methods could also be applied to other fit statistics. A comparison of the three specifications results in the recommendation to condition on the total score, as this avoids some problems of interpretation that affect the other two specifications.The authors express their gratitude to the reviewers and to many colleagues for comments on an earlier version.     

Modeling item responses when different subjects employ different solution strategies

A model is presented for item responses when different subjects employ different strategies, but only responses, not choice of strategy, can be observed. Using substantive theory to differentiate the likelihoods of response vectors under a fixed set of strategies, we model response probabilities in terms of item parameters for each strategy, proportions of subjects employing each strategy, and distributions of subject proficiency within strategies. The probabilities that an individual subject employed the various strategies can then be obtained, along with a conditional estimate of proficiency under each. A conceptual example discusses response strategies for spatial rotation tasks, and a numerican example resolves a population of subjects into subpopulations of valid responders and random guessers.The first author's work was supported by Contract No. N00014-85-K-0683, project designation NR 150-539, from the Cognitive Science Program, Cognitive and Neural Sciences Division, Office of Naval Research. We are grateful to Murray Aitkin, Isaac Bejar, Neil Dorans, Frederiksen, and Marklyn Wingersky for their comments and suggestions, and to Alison Gooding, Maxine Kingston, Donna Lembeck, Joling Liang, and Kentaro Yamamoto for their assistance with Example 2.     

Medical education: The training of ethical physicians

This paper suggests that medical education be revised to assist in diffusing potential ethical dilemmas that arise during health care provision. A revised medical education would emphasize the role of the humanities in the training of physicians, especially in light of recent critiques of the canonical scientific model in general, and more specifically in the use of that model for medical training and practice.I wish to thank Dr. Mary Ann Cutter and Melissa M. Amaro for their critical suggestions.     

The Future of Neuropsychology in Medical Specialties

Although neuropsychology continues to grow as a valued service in most medical specialties, because of its multiple uses with diverse populations, it is necessary to evaluate the specialty critically in order to ensure continued future success. This article reviews areas in which neuropsychology is most firmly established, potential growth areas, and likely obstacles to success in the future. Suggestions are provided for ways in which neuropsychology can be improved/adapted in clinical, business, research, and training areas. On sabattical at Bebek University, Instanbul, Turkey