Shall organized medicine be unified, or separate?

MEMBERS OF THE CALIFORNIA MEDICAL ASSOCIATION ARE TO BE CALLED UPON IN SEPTEMBER TO BALLOT ON A QUESTION OF GREAT IMPORTANCE TO THE FUTURE OF ORGANIZED MEDICINE: Shall membership in organized medicine-county medical society, California Medical Association, American Medical Association-be unified, or shall such membership be separate?In the July issue we published statements pro and con which the Informed Membership Poll Committee had prepared from statements of position on both sides of the question that the committee had solicited from county societies and individuals.Here, for the fuller information of our readers on this momentous question, we are presenting material representative of the arguments that the Committee digested in the statements printed in the July issue.     

Shall Organized Medicine be Unified, or Separate?

At present, physicians in California who choose to join organized medicine do so through their county medical societies, and membership in the California Medical Association and the American Medical Association is then automatic. At the March meeting of the CMA House of Delegates, question was raised whether membership in CMA, and the AMA, or both should remain automatic.The House requested an ad hoc committee to cause a "poll and its attendant statements to be developed by May 21 for copy distribution to component medical societies and printing in the CMA membership news media-with mailing of the official questionnaires to the society members on September 1, 1971." Members will be asked to express their opinions by ballot in September.The Speaker of the House appointed an ad hoc committee of the House to conduct this informed opinion poll of the membership. The committee has met to set ground rules, prepare accurate pro and con statements and write the poll questions-in accord with the directions of the House action.The Informed Membership Opinion Poll Committee, with the advice of Decision Making Information, Inc., an independent consultant, prepared statements regarding unified and separate membership in CMA and AMA from comments which were solicited from every county medical society. A statement by legal counsel for the California Medical Association on the structural relationship of AMA, CMA and component societies, and the statements on unified or separate membership prepared by the committee appear on the following two pages.     

When rational men fall sick: An inquiry into some assumptions made by medical anthropologists

Medical anthropologists spend most of their time eliciting and interpreting people's statements about sickness and health. For this task, they make certain assumptions about the importance of language and reason. In this paper I argue that their assumptions are tailored to fit an hypothetical Rational Man rather than real people. The concept of explanatory models of sickness is used to illustrate this point.My critique begins by drawing attention to two non-cognitive determinants of people's statements: their degree of emotional arousal and their capacities for discoursing on medical subjects. These determinants are briefly discussed and then set aside, to make room for the paper's argument proper. This starts with the observation that medical anthropologists tend to overlook the fact that they have established a cognitive no man's land stretching between their informants' statements and the cognitive structures which are supposed to generate these statements.I survey this void, using a five-fold model of medical knowledge. People use one kind of knowledge to organize their medical experiences and perceptions. In Rational Man writing, this form of knowledge is considered equivalent to cognitive structures (e.g., causal models, classificatory schemes), but I argue that it also includes knowledge of prototypical sickness events and knowledge that is embedded in actions, social relations, and material equipment. The theoretical implications of the five-fold model are outlined.This is followed by an analysis of the reasoning processes in which people use medical knowledge to produce the statements whose meaning we wish to learn. I demonstrate the importance of being able to distinguish operational and monothetic forms of reasoning from pre-operational and polythetic ones. Rational Man writers are described as ignoring the latter pair. The concept of prototypes is reintroduced to illustrate these points.     

On the Other "Phylogenetic Systematics"

De Queiroz and Gauthier, in a serial paper, argue that biological taxonomy is in a sad state, because taxonomists harbor "widely held belief" systems that are archaic and insufficient for modern classification, and that the bulk of practicing taxonomists are essentialists. Their paper argues for the scrapping of the current system of nomenclature, but fails to provide specific rules for the new "Phylogenetic Systematics"—instead we have been presented with a vague and sketchy manifesto based upon the assertion that "clades are individuals" and therefore must be pointed at with proper names, rather than diagnosed by synapomorphies. They claim greater stability for "node pointing," yet even their own examples show that the opposite is true, and their node pointing system is only more stable in a purely metaphysical sense detached from characters, evidence, usage of names, and composition of groups. We will show that the node pointing system is actually far LESS stable than the existing Linnaean System when stability is measured by the rational method of determining the net change in taxa (species) included in a particular group under different classifications.     

Health,illness, and immigration. East Indians in the United States.

East Indian immigrants to the United States represent the diversity in religion, language, and culture that exists in India, so it is difficult to make unequivocal statements about their health beliefs and behaviors. Despite the diversity, an understanding of Ayurvedic humoral concepts of health and illness provides a key to some pervasive and persistent ideas and practices. India has a pluralistic medical system in which Western medicine, which is increasingly popular for some ailments, is one option among many. Even those who are familiar with the "Western" medical system in India may find American medicine alien.     

Voluntary euthanasia: a utilitarian perspective

Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life--if they are able to swallow and digest them. But despite President Bush's oft-repeated statements that his philosophy is to 'trust individuals to make the right decisions' and his opposition to 'distant bureaucracies', his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician-assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia.     

Conscientious objection,professional duty and compromise: A response to Savulescu and Schuklenk

In a recent article in this journal, Savulescu and Schuklenk defend and extend their earlier arguments against a right to medical conscientious objection in response to criticisms raised by Cowley. I argue that while it would be preferable to be less accommodating of medical conscientious than many countries currently are, Savulescu and Schuklenk's argument that conscientious objection is ‘simply unprofessional’ is mistaken. The professional duties of doctors should be defined in relation to the interests of patients and society, and for reasons set out in this article, these may support limited accommodation of conscientious objection on condition that it does not impede access to services. Moreover, the fact that conscientious objection appears to involve unjustifiable compromise from the objector's point of view is not a reason for society not to offer that compromise. Arguing for robust enforcement of the no‐impediment condition, rather than opposing conscientious objection in principle, may be a more effective way of addressing the harms resulting from an over‐permissive conscientious objection policy.     

A Theoretical Foundation for Life-Cycle Assessment

The presence of value judgments in life-cycle impact assessment (LCIA) has been a constant source of controversy. According to a common interpretation, the international standard on LCIA requires that the assessment methods used in published comparisons be "value free." Epistemologists argue that even natural science rests on "constitutive" and "contextual" value judgments. The example of the equivalency potential for climate change, the global warming potential (GWP), demonstrates that any impact assessment method inevitably contains not only constitutive and contextual values, but also preference values. Hence, neither life-cycle assessment (LCA) as a whole nor any of its steps can be "value free." As a result, we suggest a more comprehensive definition of objectivity in LCA that allows arguments about values and their relationship to facts. We distinguish three types of truth claims: factual claims, which are based on natural science; normative claims, which refer to preference values; and relational claims, which address the proper relation between factual knowledge and values. Every assessment method, even the GWP, requires each type of claim. Rational arguments can be made about each type of claim. Factual truth claims can be assessed using the scientific method. Normative claims can be based on ethical arguments. The values of individuals or groups can be elicited using various social science methods. Relational claims must follow the rules of logic. Relational claims are most important for the development of impact assessment methods. Because LCAs are conducted to satisfy the need of decision makers to consider environmental impacts, relational claims about impact assessment methods should refer to this goal. This article introduces conditions that affect environmental decision making and discusses how LCA—values and all—can be defended as a rational response to the challenge of moving uncertain scientific information into the policy arena.     

Species and kinds: a critique of Rieppel's "one of a kind" account of species

A major issue in philosophical debates on the species problem concerns the opposition between two seemingly incompatible views of the metaphysics of species: the view that species are individuals and the view that species are natural kinds. In two recent papers in this journal, Olivier Rieppel suggested that this opposition is much less deep than it seems at first sight. Rieppel used a recently developed philosophical account of natural kindhood, namely Richard Boyd's "homeostatic property cluster" theory, to argue that every species taxon can be conceived of as an individual that constitutes the single member of its own specific natural kind. In this paper I criticize Rieppel's approach and argue that it does not deliver what it is supposed to, namely an account of species as kinds about which generalized statements can be made.     

Healthy Bodies,Toxic Medicines: College Students and the Rhetorics of Flu Vaccination

This article examines flu vaccination beliefs and practices produced during a survey of undergraduate students in Spring 2012 (IRB#10-732). This research uses the methods of rhetorical analysis — or the study of persuasive features and arguments used in language — to examine statements respondents made regarding flu and flu vaccine. In these responses, students generated unique categories of arguments about the perceived dangers of flu vaccination, including the assertion that vaccines cause disease (including illnesses and conditions other than flu), that vaccines are toxic medicines, and that vaccines carry unknown, population-wide risks that are inadequately acknowledged. This study provides insight into vaccination beliefs and rationales among a population at risk of flu (college students) and suggests that further study of this population may yield important keys to addressing flu vaccine concerns as expressed by college students. Rhetorical analysis also offers a useful set of methods to understanding vaccination beliefs and practices, adding to existing methods of study and analysis of vaccination practices and beliefs in medicine and public health.     

Conditions favoring queen execution in young social insect colonies

Summary. Previous attempts to explain worker aggression against extra queens in young social insect colonies have used kin selection arguments. These have been inconsistent with experimental evidence demonstrating aggression against extra queens without strong evidence of kin discrimination. Using a game theoretical model, I suggest a series of decision rules that are consistent with the current experimental evidence from study of young colonies of the fire ant Solenopsis invicta. These decision rules are: 1) When workers cannot directly determine which queen is their mother, they should behave in favor of a queen that maximizes the product of the chance that a queen is the workers mother multiplied by the chance that it will survive to colony maturity. In some cases, the survival potential of the different queens may be the only character that influences the workers decision. 2) Workers should delay aggression against extra queens until the workers can gain their greatest advantage through such aggression. 3) Queens may adopt strategies that allow them to dominate rivals, either by gaining an advantage in fights among the queens or by increasing their attractiveness to workers.Received 2 June 2004; revised 5 July 2004; accepted 14 July 2004.     

The dilemma of the selfish herd: the search for a realistic movement rule

The selfish herd hypothesis predicts that aggregations form because individuals move toward one another to minimize their own predation risk. The "dilemma of the selfish herd" is that movement rules that are easy for individuals to follow, fail to produce true aggregations, while rules that produce aggregations require individual behavior so complex that one may doubt most animals can follow them. If natural selection at the individual level is responsible for herding behavior, a solution to the dilemma must exist. Using computer simulations, we examined four different movement rules. Relative predation risk was different for all four movement rules (p<0.05). We defined three criteria for measuring the quality of a movement rule. A good movement rule should (a) be statistically likely to benefit an individual that follows it, (b) be something we can imagine most animals are capable of following, and (c) result in a centrally compact flock. The local crowded horizon rule, which allowed individuals to take the positions of many flock-mates into account, but decreased the influence of flock-mates with distance, best satisfied these criteria. The local crowded horizon rule was very sensitive to the animal's perceptive ability. Therefore, the animal's ability to detect its neighbors is an important factor in the dynamics of group formation.     

"Taming tradition": medicalized female genital practices in western Kenya

This article considers the question of female genital practices at the hands of health workers in western Kenya. Recent articles in Medical Anthropology Quarterly have critically engaged with the biomedical arguments condemning such practices. This article studies the case of medicalized circumcision in which biomedical concerns over health risks have become incorporated in their vernacular practice. Although some suggest that medicalization may provide a harm-reduction strategy to the abandonment of the practice, research in one region challenges this suggestion. It argues that changing and conflicting ideologies of gender and sexuality have led young women to seek their own meaning through medicalized practice. Moreover, attributing this practice to financial motivations of health workers overlooks the way in which these "moral agents" must be situated within their social and cultural universe. Together, these insights challenge the view that medicine can remain neutral in the mediation of tradition.     

Dynamic regulation of mean arterial pressure: special role of renal resistances

In this paper the general properties of homeostatic variables are discussed, and it is shown that mean state regulation must be defined over some stated epoch and that the variance associated with such regulation can permit maximum/minimum variations of 2:1. Dynamic regulation is then contrasted with (automatic) control, and mean systemic arterial pressure (MSAP) in mammals is shown to be under dynamic regulation in the long run, although it may be under control in the short run. The discussion is next developed around the branching rules for mammalian arterial trees. The heart and lymphatic system are introduced as separate, zero-back-pressure, sump pumps that "ground" central venous pressure and interstitial pressure, respectively. Hydraulic flow arguments, combined with arterial tree branching rules, are used to demonstrate the short-circuit character of the renal circulation, and the peculiar distribution of pressure drops within it. From that peculiar distribution it is proposed that there is a nonanatomic, functional resistance located approximately at the region of efferent arterioles, which adds 15 mm Hg of hydrostatic pressure, upstream, to the central arteries. The chief aim of the paper is to raise certain questions about inconsistencies in data about renal circulation, to suggest a resolution, and to show how MSAP is set at (approximately) 100 mm Hg.     

"Sweeping up after the parade": professional, ethical, and patient care implications of "turfing"

"Turfing" denotes a patient transfer or triage from one physician to another when the care of that patient feels more troublesome than it is worth. A widespread phenomenon in medical training programs, turfing appears to allocate patient care to meet physicians' rather than patients' needs. Although turfing reportedly causes inter-physician discord and inter-specialty stereotyping, its deeper consequences are poorly understood. Turfing is an interpersonal conflict masquerading as a medical issue. After examining turfing alongside other patient-related slang, I analyze the distinction between "the turf," a person, and "to turf," a practice. Several explanatory models from medical practice are explored in order to illuminate turfing's implications for medical professionalism, ethics, and patient care. I suggest that a physician's medical specialty or practice type--that is, professional culture--may link to that physician's degree of altruism. If so, then what it means fundamentally to be a physician might vary across medical specialties. Such a link calls for a new notion of cultural competence, one that physicians may apply not to patients but to each other.     

W.H.R. Rivers Graduate Prize Essay (1996). "Imperfect angels" : narrative "emplotment" in the medical management of children with craniofacial anomalies

This article uses the paradigm of "therapeutic emplotment" to investigate the medical management of children with facial disfigurements at a craniofacial anomalies center in Northern California. Data are observations of, and semistructured interviews with, plastic surgeons, nurses, geneticists, orthodontists, and other medical professionals who composed the craniofacial anomalies team. Team members perceived that children feel socially stigmatized by their disfigurements. These medical professionals adjusted their own behavior according to these perceptions. They "emplotted" their actions, using the theme that disfigured children are attractive and worthy of attention and affection. Medical professionals attempted to depersonalize and neutralize the symbolically loaded disfigurements through the use of clinical language in an attempt to "separate" the child from his or her facial anomaly. The range of styles and approaches to interaction was diverse and varied in effectiveness, suggesting that some medical professionals were more skilled at emplotment than others.     

The "Polyphyletic" Origin of the Genus Ablepharus (Reptilia, Scincidae): a Case of Parallel Evolution

It is generally admitted that the some 38 species referred to Ablepharus Lichtenstein, 1823 (Sauria, Scincidae) belong to the same evolutionary level. S mith (1935), followed by P arker (1936), D e W itte (1936), M itchell and S torr (in. litt.) pointed out the "polyphyletic" origin of the "ablepharine" skinks, and G reer (1967) presented arguments on the basis of the skull morphology. The study of nearly all the skinks assigned to the genus Ablepharus is in agreement with the above statements. A tentative new generic arrangement is presented, based on the assumption of several parallel evolutionary series, starting from closely related although different lines, showing convergent morphological features under the action of a similar way of life (burrowing and cryptic). The "ablepharine" skinks assemblage includes different evolutionary levels, which have to be referred to distinct genera. Only bivittatus, pannonicus, deserti and kitaibelii are assigned to Ablepharus Lichtenstein; boutonii belongs to Cryptoblepharus Wiegmann. The African "ablepharine" skinks, together with several other species having a transparent window in the lower lid, are included in Panaspis Cope. The Australian species commonly ascribed to the genus Ablepharus , should be considered as belonging to following generic taxa:
1. Morethia Gray, 1844, including the species lineo-ocellata, butleri, taeniopleura ;
2. Pseudemoia Fuhn, 1967, monotypic ( spenceri );
3. Cryptoblepharus Wiegmann, 1834, monotypic ( boutonii ), but the species is polytypic.
4. Notoscincus n. g., with the species ornatus and wotjulum ;
5. Menetia Gray, 1844, monotypic ( greyi );
6. Species incertae sedis, burnetti (polytypic);
7. Proablepharus n. g., including tenuis (polytypic);
8. Species incertae sedis, with the species davisi and kinghorni ;
9. Lerista Bell, 1833, including elegans, distinguenda, lineata, muelleri, timida and all the species assigned to Rhodona and Nodorha (G reer , 1967).     

"Brother" and "Uncle": An Analysis of Rules, Structural Contradictions, and Meaning in Vietnamese Kinship

This paper analyzes the meanings of Vietnamese kinship terms on the basis of the rules that regulate their referential and nonreferential uses. These rules are not completely consistent with one another. They constitute contradictory models of and for sociocultural reality at a certain level. The structural contradictions among these models render "fuzzy" even the definitions of the prototypical uses of Vietnamese kin terms. The coexistence of alternative models makes the use of a linguistic form both a goal-directed action and the representation of an order.     

Computational complexity of a problem in molecular structure prediction.

The computational task of protein structure prediction is believed to require exponential time, but previous arguments as to its intractability have taken into account only the size of a protein's conformational space. Such arguments do not rule out the possible existence of an algorithm, more selective than exhaustive search, that is efficient and exact. (An efficient algorithm is one that is guaranteed, for all possible inputs, to run in time bounded by a function polynomial in the problem size. An intractable problem is one for which no efficient algorithm exists.) Questions regarding the possible intractability of problems are often best answered using the theory of NP-completeness. In this treatment we show the NP-hardness of two typical mathematical statements of empirical potential energy function minimization of macromolecules. Unless all NP-complete problems can be solved efficiently, these results imply that a function minimization algorithm can be efficient for protein structure prediction only if it exploits protein-specific properties that prohibit the simple geometric constructions that we use in our proofs. Analysis of further mathematical statements of molecular structure prediction could constitute a systematic methodology for identifying sources of complexity in protein folding, and for guiding development of predictive algorithms.