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Age-rationing of health care is beginning to be widely debated. Two recent proposals are examined. It is argued that age-rationing proposals must be viewed in the light of current rationing practices, and that all such proposals must be placed in the context of a more just overall health care system.
It is often claimed that nursing is both a science and an art. Science, it is argued, involves a rational process in which empirical findings are used to determine what is the case. Art, on the other hand, is associated with creative and intuitive activities. The author steps back from this position and examines the question of whether the art of nursing is properly conceived as involving a rational aspect. The study upon which this paper is based involved the analysis of a discourse contained in the work of 43 nurse scholars, published between 1860 and 1992. A philosophical approach is used to examine two contrary positions regarding the place of the rational aspect in relation to the art of nursing. The analysis attempts to expand the discourse by delineating questions and concerns that, as yet, have not been fully considered.
Nanotechnology as an emerging field is strongly related to visionary prospects which are disposed to reappear as dystopian concerns. As long as nanotechnology does not provide reliable criteria for assessing these worries as rational or as irrational they remain a challenge for ethical reflection. Given this underdetermination, many nanovisions and their corresponding concerns should therefore be considered as "arational." For that reason, a "constructivist" stance is endorsed which does not seek to take part in discussions as to how ethicists should cope with controversial worries, but tries to observe how concerns are managed by different social actors. This perspective allows us to remodel some concerns such as "grey goo" not solely as a societal reaction, but also as challenging and irritating factors. As such they potentially initiate two different processes simultaneously: a differentiation in terms of demarcating science from non-science on the one hand, and a rationalization of concerns on the other. Analyzing these processes empirically allows to reconstruct how "arational" concerns are socially made rational or, on the contrary, irrational.
Consumption of an otherwise balanced ration containing 1% of corn invaded by Fusarium tricinctum isolate 2061-C resulted in the death of 13% of turkey poults within 35 days, in decreased feed efficiency and weight gain, and moderate development of bilateral necrotic lesions at angles of the mouth, especially in those that succumbed. Consumption of a ration with 2% of corn invaded by F. tricinctum resulted in death of 60 to 83% of the birds, in greatly reduced growth and feed efficiency in the survivors, and in development of severe mouth lesions. Consumption of rations containing 5, 10, and 20% of corn invaded by the fungus resulted in death of all birds in 5 to 15 days.
This paper criticises the current approach of the courts to the problem of patients who refuse life-saving medical treatment. Recent judicial decisions have indicated that, so long as the patient satisfies the minimal test for capacity outlined in Gillick, the courts will not be concerned with the substantive grounds for the refusal. In particular, a 'rationality requirement' will not be imposed. This paper argues that, whilst this approach may accord with our desire to uphold the autonomy of a patient who refuses treatment on religious grounds, it fails to address the problem of the deluded decision-maker whose refusal is based on wrongheaded reasons (and where talk of autonomy is a disservice). The difficulty can be overcome, however, by recognising that the two patients in fact inhabit at distinct realms-the non-rational and the irrational. The test for capacity, at least in the context of life-saving treatment, should revert accordingly to the older concept of 'sound mind', to disallow refusals of an irrational (as opposed to a non-rational) nature.
Although suicide has traditionally carried a negative sanction in Western societies, this is now being challenged, and while there remains substantial public concern surrounding youth and elder suicide, there is a paradoxical push to relax the prohibition under certain circumstances. Central to the arguments behind this are the principles of respect for autonomy and the importance of rationality. It is argued here that the concepts of rationality and autonomy, while valuable, are not strong enough to substantiate a categorical "right to suicide" and that the concepts of "understandability" and "respect" are more useful and able to provide the foundation for responding to a person expressing a wish to die. Roman suicide, sometimes held as an example of "rational suicide", illustrates the effects of culture, tradition and values on the attitudes to, and the practice of, suicide.
This chapter reviews selected findings in research on reasoning, judgment, and choice and considers the systematic ways in which people violate basic requirements of the corresponding normative analyses. Recent objections to the empirical findings are then considered; these objections question the findings' relevance to assumptions about rationality. These objections address the adequacy of the tasks used in the aforementioned research and the appropriateness of the critical interpretation of participants' responses, as well as the justifiability of some of the theoretical assumptions made by experimenters. The objections are each found not to seriously impinge on the general conclusion that people often violate tenets of rationality in inadvisable ways. In the process, relevant psychological constructs, ranging from cognitive ability and need for cognition, to dual process theories and the role of incentives, are discussed. It is proposed that the rationality critique is compelling and rightfully gaining influence in the social sciences in general.
To investigate the adequacy of food rations to supply energy needs in cold-temperature environments, caloric expenditure and intake and body composition changes were measured in a group of infantrymen during a 10-day field exercise in the Canadian Arctic. Energy expenditure was measured by the doubly labeled water method (n = 10), and caloric intake was measured by complete food intake records (n = 20). Body composition was determined by isotope dilution (n = 10) and bioelectrical impedence analysis (n = 20) on days 0 and 10. Baseline isotopic enrichment shifts due to geographical relocation were also monitored (n = 5). Mean body weight decreased 0.63 +/- 0.83 (SD) kg over the study period (P < 0.005), although fat-free and fat mass compartment changes were not significant. Baseline isotopic changes were -4.65 +/- 2.54 and -0.48 +/- 0.07 /1000/day for deuterium and 18O, respectively. Mean baseline corrected energy expenditure level was 4,317 +/- 927 kcal/day. Self-reported caloric intakes obtained from food records were 2,633 +/- 499 kcal/day (61.0% of expenditure). Rations packs contained 4,350 kcal/day. Results suggest that 1) food intake was significantly underreported and 2) the energy needs of most subjects were being met by rations and available supplements.
In recent years a more tolerant attitude has emerged concerning suicide as an acceptable alternative to some life situations. This trend is attributable in large part to the growth of the "Rationale Suicide" movement. Proponents of rational suicide have consistently offered the terminally ill cancer patient in intractable pain as the paradigmatic case on which their position rests. Once having established the principle, however, they would extend the right-to-suicide to any individual who felt his life was not worth living, for any reason. They would also wish to institute a law to protect the individual's right to end his life. While the basic argument for rational suicide may seem reasonable, serious limitations in the position are demonstrated when it is examined in light of existing clinical and research findings. Unanticipated adverse individual and societal consequences that can result from extending and legally safeguarding the right-to-suicide were reviewed. Evidence was also presented that individuals who contemplate what they regard as a rational suicide may have much in common psychodynamically with the much more numerous suicides that occur each year and which are clearly desperate and tragic acts.
The author argues that rational mental health care delivery is possible through an appropriate managed care system of independent providers. The right model for delivery of care incorporates principles that include rational assignment of clinical functions, epidemiologic accountability, fiscal as well as clinical responsibility, open and direct patient access, incentives for preventive psychiatry, partnership between management and clinical providers, choice of services, outcome assessment, and interface between public and private providers. The author maintains that a link between what is good about private practice and what is good in rational managed care represents the best mental health care delivery system currently available.
This article considers the relation between rationality and intelligence. The article is divided into three main parts: In the first, I consider the concept of rationality and conclude that rational thinking is a part of intelligence, but not a major part. In the second, I consider Stanovich's concept of dysrationalia, and propose that an alternative concept, practical intelligence (or the lack thereof), may better accomplish the goals that Stanovich wishes to achieve with his concept. Finally, I draw some conclusions.
BACKGROUND: Cost containment typically involves rationalizing healthcare service delivery through centralization of services to achieve economies of scale. Hospitals are frequently the chosen site of cost containment and rationalization especially in rural areas. Socio-demographic and geographic characteristics make hospital service allocation more difficult in rural and remote regions. This research presents a methodology to model rational catchments or service areas around rural hospitals--based on travel time. RESULTS: This research employs a vector-based GIS network analysis to model catchments that better represent access to hospital-based healthcare services in British Columbia's rural and remote areas. The tool permits modelling of alternate scenarios in which access to different baskets of services (e.g. rural maternity care or ICU) are assessed. In addition, estimates of the percentage of population that is served--or not served--within specified travel times are calculated. CONCLUSION: The modelling tool described is useful for defining true geographical catchments around rural hospitals as well as modelling the percentage of the population served within certain time guidelines (e.g. one hour) for specific health services. It is potentially valuable to policy makers and health services allocation specialists.
BACKGROUND: During the past few decades, research has reported gender bias in various areas of clinical and academic medicine. To prevent such bias, a gender perspective in medicine has been requested, but difficulties and resistance have been reported from implementation attempts. Our study aimed at analysing this resistance in relation to what is considered good medical research. METHOD: We used a theoretical model, based on scientific competition, to understand the structures of scientific medicine and how they might influence the resistance to a gender perspective in medicine. The model was originally introduced to discuss how pluralism improves rationality in the social sciences. RESULTS: The model provided a way to conceptualise different fields of research in medicine: basic research, applied research, medical philosophy, and 'empowering' research. It clarified how various research approaches within medicine relate to each other, and how they differ and compete. It also indicated why there might be conflicts between them: basic and applied research performed within the biomedical framework have higher status than gender research and other research approaches that are performed within divergent research paradigms. CONCLUSION: This hierarchy within medical research contributes to the resistance to a gender perspective, causing gender bias and making medical scientific rationality suboptimal. We recommend that the theoretical model can be applied in a wider medical context when different and hierarchically arranged research traditions are in conflict. In this way, the model might contribute to shape a medical community where scientific pluralism is acknowledged to enlarge, not to disturb, the scientific rationality of medicine.
BACKGROUND: Dysmorphophobia may improve after a variety or combination of treatments, but which elements of a treatment are useful is usually not certain. METHOD: In a single out-patient case study rational role-play ('paradoxical discourse') was added to exposure plus cognitive restructuring (CR) for a dysmorphic delusion study comprised of 20-minute sessions one week apart. RESULTS: Previous exposure plus attempted CR had improved anxiety, phobias, work and social leisure, but not dysmorphic belief. Added brief rational role-play was followed by resolution of the dysmorphic belief. All measures remained much improved at 18-month follow-up. CONCLUSIONS: Rational role-play deserves a controlled trial in dysmorphophobia and other problems and exploration of its mechanism of action.
Although the use of corticosteroid (CS) eye drops of the use of eye washing by artificial tears was effective for the prevention of ocular toxicity such as keratitis and photophobia in the high-dose cytosine arabinoside (Ara-C) therapy, the toxicity was not prevented perfectly. We studied the effects of the rational use of CS eye drops, and the combined use of CS eye drops and eye washing by physiological saline in order to prevent the ocular toxicity. Before the study, the instillation of 0.1% sodium bethamethazone phosphate (BM) eye drops was carried out at 4-6 times per day during the high-dose Ara-C therapy, and continued for several days after the high-dose Ara-C therapy. However, the rational use of "eyelid closure" and "naso-lacrimal occlusion" after the instillation was not performed Consequently, the ocular toxicity was observed in 3 (19%) of 16 cases of the patients. When the instillation of BM eye drops at 4 times per day was carried out rationally according to the consultation of pharmacist during the high-dose Ara-C therapy and for additional 10 days after the therapy, no ocular toxicity was observed in all cases (0 of 6 cases). Furthermore, the combined use of eye washing by physiological saline and instillation of BM eye drops was effective for the decrease of the risk of ocular toxicity, because no ocular toxicity was observed in the high-dose Ara-C therapy (0 of 34 cases). Our procedure in this study would be effective for the prevention of ocular toxicity in the high-dose Ara-C therapy.
Rational drug selection for formulary purposes is important. Besides rational selection criteria, other factors play a role in drug decision making, such as emotional, personal financial and even unconscious criteria. It is agreed that these factors should be excluded as much as possible in the decision making process. A model for drug decision making for formulary purposes is described, the System of Objectified Judgement Analysis (SOJA). In the SOJA method, selection criteria for a given group of drugs are prospectively defined and the extent to which each drug fulfils the requirements for each criterion is determined. Each criterion is given a relative weight, i.e. the more important a given selection criterion is considered, the higher the relative weight. Both the relative scores for each drug per selection criterion and the relative weight of each criterion are determined by a panel of experts in this field. The following selection criteria are applied in all SOJA scores: clinical efficacy, incidence and severity of adverse effects, dosage frequency, drug interactions, acquisition cost, documentation, pharmacokinetics and pharmaceutical aspects. Besides these criteria, group specific criteria are also used, such as development of resistance when a SOJA score was made for antimicrobial agents. The relative weight that is assigned to each criterion will always be a subject of discussion. Therefore, interactive software programs for use on a personal computer have been developed, in which the user of the system may enter their own personal relative weight to each selection criterion and make their own personal SOJA score. The main advantage of the SOJA method is that all nonrational selection criteria are excluded and that drug decision making is based solely on rational criteria. The use of the interactive SOJA discs makes the decision process fully transparent as it becomes clear on which criteria and weighting decisions are based. We have seen that the use of this method for drug decision making greatly aids the discussion in the formulary committee, as discussion becomes much more concrete. The SOJA method is time dependent. Documentation on most products is still increasing and the score for this criterion will therefore change continuously. New products are introduced and prices are also subject to change. To overcome the time-dependence of the SOJA method, regular updates of interactive software programs are being made, in which changes in acquisition cost, documentation or a different weighting of criteria are included, as well as newly introduced products. The possibility of changing the official acquisition cost into the actual purchasing costs for the hospital in question provides a tailor-made interactive program.
There have been extraordinary advances in anticancer therapy over the last few decades, particularly for patients with relatively uncommon malignancies, largely because of the advent of nonspecific cytotoxic chemotherapeutics. Although these agents have also brought improved outcomes for patients with many of the more common solid cancers, it is clear that the point of 'diminishing return' has been reached. The recent development of a plethora of rationally designed target-based anticancer agents has opened up new opportunities and extraordinary therapeutic challenges. Since these agents appear primarily to target malignant cells, they can be expected to be less toxic at clinically effective doses than the cytotoxic agents. Among the various types of rationally designed target-based agents are those that target strategic facets of cell growth signal transduction, angiogenesis, metastasis and cell cycle regulation. While the primary therapeutic benefit of these agents is expected to be decreased tumour growth, evidence suggests that objective tumour responses may also be achieved. However, because of their potentially cytostatic properties, the clinical efficacy of such biologically based agents may not be readily demonstrable with traditional phase I and II study methodologies. Additionally, their dose-toxicity relationships are likely to be less steep than those of the nonspecific cytotoxic agents, thereby rendering such concepts as the maximum tolerated dose less meaningful than alternatives such as the optimal biological dose or the biologically effective dose. Those end-points generally considered, both from a regulatory and clinical viewpoint, to be of secondary importance in trials of cytotoxic agents, such as time to disease progression, disease-related symptoms and quality of life, may evolve into primary end-points. Present findings from preclinical studies suggest that the development, evaluation and general clinical use of rationally designed target-based anticancer agents will require a radical departure from the traditional paradigms if the full potential of these new therapies is to be exploited.
Hammerhead ribozymes that are subject to allosteric control by small molecule and oligonucleotide effectors have been reported recently. Rational design has been an effective strategy for the creation of these ribozymes, which incorporate structurally interdependent hammerhead motifs and effector-binding sequences. In this paper we report the rational design of the first protein-responsive allosteric ribozymes that are regulated by the HIV-1 Tat. The TAR-Tat interaction of HIV-1 has the interesting feature that both Tat and arginine are able to bind to and bring about comparable conformational changes in the TAR loop. Here we describe the construction of two classes of TAR-modified hammerhead ribozymes and their response to Tat protein and to its derivatives. Instances of both allosteric activation and inhibition were found. Interestingly, the activation response was stimulated by both Tat and argininamide while the inhibitory response was stimulated by Tat and by its derivative peptide, ADP1, but not by argininamide. Overall, the extent of allosteric response in our ribozymes was modest relative to those reported for ribozymes with small molecule effectors. Future work utilizing combinatorial approaches along with elements of rational design should reveal the means by which highly efficient, protein-mediated allostery of ribozymes may be achieved.