Causal Responsibility and Rationing in Medicine

The article addresses the issue of rationing health care services, a topic currently being hotly debated in many countries. The author argues that the aspect of causal responsibility ought to play a decisive role in the allocation of limited medical resources. Starting out from Ronald Dworkin's distinction between option luck and brute luck, the appropriate and meaningful uses of the term causal responsibility are clarified first. A discussion of the conditions which might justify giving lower priority to patients whose illnesses are the result of unhealthy behavior, like e.g. alcohol abuse, follows. Causal responsibility is then viewed in the context of private health insurance and the club model of organ donation. It is argued that individuals themselves are basically responsible for their decisions regarding insurance coverage and membership in organ donors' clubs. Causal responsibility is shown to be a more suitable criterion for rationing scarce medical resources than other criteria which might alternatively be considered, such as patients' age.     

Treatment of covert food stealing in an individual with Prader-Willi syndrome

Covert food stealing is common among individuals with Prader-Willi syndrome. We found that verbal reprimands, delivered contingent upon eating prohibited foods, were sufficient to decrease the food stealing of a girl with Prader-Willi syndrome. Warning stimuli were then used to help her discriminate between permitted and prohibited foods during sessions in which food stealing was not directly observed. This procedure resulted in decreases in food stealing from containers labeled with the warning stimuli.     

Progressive-ratio schedules: effects of later schedule requirements on earlier performances

Four rats were studied with variants of a progressive-ratio schedule with a step size of 6 in which different terminal components followed completion of the 20th ratio: (a) a reversal of the progression, (b) a fixed-ratio 6 schedule, or (c) extinction. Responding in the progressive-ratio components of these schedules was compared to performances under conventional progressive-ratio baselines. Under baseline conditions, postreinforcement pauses increased exponentially as a function of increasing ratio size, whereas running rates showed modest declines. The procedure of linking the progressive-ratio schedule to the reversed progression or to the fixed-ratio component resulted in decreased pausing. Linking the progressive-ratio schedule to the extinction component had the opposite effect, that of producing weakened progressive-ratio performances as evidenced by increased pausing. Subjects whose responses were reinforced on half of the ratios also showed exponential increases; however, pauses were substantially shorter following ratios on which the reinforcer was omitted. The results suggested that progressive-ratio pausing reflects the influence of remote as well as local contingencies.     

An evaluation of a brief multiple-stimulus preference assessment with adolescents with emotional-behavioral disorders in an educational setting

Brief multiple-stimulus-without-replacement (MSWO) preference assessments were conducted with 3 adolescent boys with emotional-behavioral disorders in the context of their public school educational program. The reinforcing effects of stimuli identified as high, medium, and low preference were then evaluated using an alternating treatments design in which, following an initial baseline, stimuli were delivered contingent on on-task behavior. High-preference stimuli produced the highest percentages of on-task behavior for all 3 participants.     

Admissibility of Cut in <Emphasis Type="Italic">LC</Emphasis> with Fixed Point Combinator

The fixed point combinator (Y) is an important non-proper combinator, which is defhable from a combinatorially complete base. This combinator guarantees that recursive equations have a solution. Structurally free logics (LC) turn combinators into formulas and replace structural rules by combinatory ones. This paper introduces the fixed point and the dual fixed point combinator into structurally free logics. The admissibility of (multiple) cut in the resulting calculus is not provable by a simple adaptation of the similar proof for LC with proper combinators. The novelty of our proof—beyond proving the cut for a newly extended calculus–is that we add a fourth induction to the by-and-large Gentzen-style proof. Presented by Robert Goldblatt     

Chronic Fatigue Syndrome: The Need for Subtypes

Chronic fatigue syndrome (CFS) is an important condition confronting patients, clinicians, and researchers. This article provides information concerning the need for appropriate diagnosis of CFS subtypes. We first review findings suggesting that CFS is best conceptualized as a separate diagnostic entity rather than as part of a unitary model of functional somatic distress. Next, research involving the case definitions of CFS is reviewed. Findings suggest that whether a broad or more conservative case definition is employed, and whether clinic or community samples are recruited, these decisions will have a major influence in the types of patients selected. Review of further findings suggests that subtyping individuals with CFS on sociodemographic, functional disability, viral, immune, neuroendocrine, neurology, autonomic, and genetic biomarkers can provide clarification for researchers and clinicians who encounter CFS characteristically confusing heterogeneous symptom profiles. Treatment studies that incorporate subtypes might be particularly helpful in better understanding the pathophysiology of CFS. This review suggests that there is a need for greater diagnostic clarity, and this might be accomplished by subgroups that integrate multiple variables including those in cognitive, emotional, and biological domains.     

Genetic Counseling for Fragile X Syndrome: Updated Recommendations of the National Society of Genetic Counselors

These recommendations describe the minimum standard criteria for genetic counseling and testing of individuals and families with fragile X syndrome, as well as carriers and potential carriers of a fragile X mutation. The original guidelines (published in 2000) have been revised, replacing a stratified pre- and full mutation model of fragile X syndrome with one based on a continuum of gene effects across the full spectrum of FMR1 CGG trinucleotide repeat expansion. This document reviews the molecular genetics of fragile X syndrome, clinical phenotype (including the spectrum of premature ovarian failure and fragile X-associated tremor-ataxia syndrome), indications for genetic testing and interpretation of results, risks of transmission, family planning options, psychosocial issues, and references for professional and patient resources. These recommendations are the opinions of a multicenter working group of genetic counselors with expertise in fragile X syndrome genetic counseling, and they are based on clinical experience, review of pertinent English language articles, and reports of expert committees. These recommendations should not be construed as dictating an exclusive course of management, nor does use of such recommendations guarantee a particular outcome. The professional judgment of a health care provider, familiar with the facts and circumstances of a specific case, will always supersede these recommendations.     

Relations Between Coping and Positive and Negative Outcomes in Carers of Persons with Multiple Sclerosis (MS)

This study examined relations between stress and coping predictors and negative and positive outcomes in MS caregiving. A total of 222 carers and their care-recipients completed questionnaires at Time 1 and three months later, Time 2 (n = 155). Predictors included care-recipient characteristics (age, time since diagnosis, course and life satisfaction), and Times 1 and 2 carer problems, stress appraisal and coping. Dependent variables were Time 2 negative (anxiety, depression) and positive outcomes (life satisfaction, positive affect, benefits). Regressions indicated that, overall, the hypothesised direct effects of stress appraisal and coping strategies on positive and negative outcomes were supported. The hypothesised stress-buffering effects of positive reframing coping were also supported. All but one of the coping strategies were related to both positive and negative outcomes; specifically, practical assistance coping emerged as a unique predictor of distress. Of the model predictors, care-recipient life satisfaction emerged as the strongest and most consistent predictor of both positive and negative outcomes except benefit finding. Findings support the role of care-recipient characteristics and the carers appraisal and coping processes in shaping both positive and negative outcomes. The guiding framework and findings have the potential to inform interventions designed to promote well-being in carers.     

Measurement Structure of the Turkish Translation of the Child Behavior Checklist Using Confirmatory Factor Analytic Approaches to Validation of Syndromal Constructs

The new correlated 8-factor measurement structure of the Child Behavior Checklist for ages 6-18 (CBCL/6-18; T. M. Achenbach & L. A. Rescorla, 2001) derived from an American sample was used as a benchmark to evaluate its generalizability to Turkish general population (N = 5,195) and clinical (N = 963) samples. Item-level confirmatory factor analysis (CFA) was used to evaluate the adequacy of the correlated 8-factor model across 3 sample conditions (general population, clinical, and combined sample whose Total Problems scores were above the Turkish national median). The results supported the generalizability of the overall measurement structure of the CBCL to the Turkish population.