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Bioethics/Introduction

no in order to approach some of the ethical dilemmas in contemporary clinical medicine. Major ethical systems - Kantian, utilitarian, virtue-centered, and care-oriented - all impact on contemporary bioethical discourse.

Some of the questions addressed by bioethics include: When should life-sustaining treatments like breathing machines or feeding tubes be started, continued or stopped? What should family members and health to participate in their own health care decisions?

Some specific fields of bioethics are summarized below:

Medical Ethics and the Law
This field concerns the relationship between clinical bioethics and the law that has evolved as clinical care has become increasingly complex with new medical technologies. It emphasizes legal theories and principles concerning ethical issues in the context of clinical care. Topics include advance directives, proxy decision-making, issues of consent and confidentiality, withholding and withdrawing care, the definition of death, mental competence and related matters.

Ethics of Research and Experimentation
This field concerns the principles of clinical and experimental research ethics and the regulation of research practices, particularly from the perspectives of the Nuremberg code and the Helsinki declaration. Topics include: scientific and research integrity; research with adult and pediatric human subjects; informed consent; vulnerable study populations; privacy and confidentiality of research and clinical records; conflicts of interest; research on animals; and research in third world nations.

Ethical Issues in Death and Dying
This field concerns the ethical issues associated with care of the terminally ill and with death issues more generally. Topics include: death; the definition and diagnosis of brain death; chronic vegetative states; loss of personhood; right-to-life/right-to-die; euthanasia; infanticide; physician-assisted suicide; palliative care; pain management; quality of life and related issues.

Ethical Issues in Health Care Allocation and Government Policy
This field concerns issues related to access to health care resources and on ways of understanding the issues of fairness and justice on an institutional system such as health care. Various models of paying for health care services and the ethical issues inherent in such systems, particularly in settings of limited resources are an important theme. Topics include: use of surrogates, transplantation policy, problems of financing, the allocation of resources, and experimentation.

Ethical Issues of Human Reproduction
This field concerns the various philosophical, legal and ethical issues dealing with human reproduction and considers differing philosophic and ethical positions relating to human reproduction. Topics include genetic engineering, reproductive technologies such as artificial insemination and in vitro fertilization, cloning, sanctity of life, the notion of family, etc.

Religion and Bioethics
This field concerns the various philosophical and ethical considerations of different religious faiths in the particular context of bioethics. Issues include: similarities and differences between religious faith and reasoned justification, the role of faith in morality and ethics, and the relationship of certain established faith traditions (e.g., Christianity, Judiasm, Islam) to particular issues in clinical and experimental medicine.

Ethical Relationships and the Health Care Team
This concerns the role of and relationships between various members of the health care team, focusing on their roles and responsibilities and how they influence decision making and communication regarding ethical issues. Issues concern the appropriate ways to resolve interpersonal difficulties such as challenging or disobeying a superior, reporting or stopping inappropriate behavior, and expressing moral or ethical judgments.

Bioethics Committees and Consulting
This field concerns the workings of hospital and university bioethics committees, institutional review boards, and bioethics consultants, focusing on understanding of nature, purpose and structure of these committees and of the role of bioethicists in such committees. National and international guidelines dealing with experimentation with human subjects, especially the Nuremberg code, are considered.

Ethical Issues in Genetics
This field concerns the bioethical issues present in the rapidly developing area of genetic technology, including the nature and methods of DNA analysis, the concept of genetic disease, genetic testing / screening for various diseases, genetic engineering of plants, animals and humans, and cloning. Social policy issues related to genetically modified foods are also important concerns.

 * Autonomy, Informed Consent and the Death of Therapeutic Privilege: Lessons Learned from the Jehovah’s Witnesses
 * Principlism
 * Bioethics and Moral Theory
 * Utilitarianism

PRINCIPLISM
One particulary popular approach to the analysis of bioethical problems is sometimes known as the “Georgetown School” of bioethics, named after Georgetown University where much of the early work on bioethics originated. This approach to bioethics emphasizes the principles of autonomy (respecting the decisions of autonomous persons), justice (fairness in the distribution of benefits and risks), nonmalfeasance (the duty to avoid causing harm); and beneficence (the duty to provide benefits and to balance benefits against risks). This approach is sometimes also known as "principlism".

“There are a set of principles or ideals which people use as a common ground for bioethics. They include the autonomy of individuals to make choices, while respecting the choices of others, justice. In all things we do, the ideal is to avoiding doing harm, and trying to do good” (Macer, 1999). Each of the following principles plays a key role in the composition of bioethics: respect, beneficence, justice, and do no harm. Individuals have autonomy (the right to make ones own decisions about their own actions freely and without concern) and we should respect people for the simple reason that they are counterparts to our health community. Beneficence is defined as having benefits that are proportionate to risks. For example, in researching treatments for a certain health problem, potential side effects should be weighed against the potential benefits and the weight distribution should be somewhat of an equal balance. Justice is seen as the even distribution of risks/benefits throughout the general public. In biomedical research, groups should potentially benefit and/or potentially be exposed to risk at the same rate of other groups unless there is some factor that justifies unequal distribution. And lastly, there is the principle of do no harm. This principle is quite clear in that certain ideas should not be presented nor should experiments/treatments be performed if we know that they will ultimately produce harm.

BIOETHICS AND MORAL THEORY
Central to bioethics is moral theory. Moral theory can be approached from many viewpoints [1]. The deontological approach to morality (from the Greek word deon, or duty) is based on specific obligations or duties. These can be positive (such as to care for our family) or negative (such as not to steal). This approach is also sometimes called nonconsequentialist since these principles are held to be obligatory regardless of any good or bad consequences of that might result. For example, it is wrong to kill even if it results in great benefit.

Philosophers have subdivided deontological theories into a number of categories, of which the concept of the “categorical imperative” developed by the 18th-century German philosopher Immanuel Kant is the best known. He said that we must “treat people as an end, and never as a means to an end”, by which he meant that we should always treat people with humanity and dignity, and never use individuals as “mere instruments” as a means to our own happiness. Another version of the categorical imperative is: "Always act in such a way that the maxim of your action can be willed as a universal law." Other deontological approaches include “duty theory” (defining duties to God, duties to oneself, and duties to others), “rights theory” (concerned with rights that all people have, and which the rest of us must respect), and a more recent theory developed by W.D. Ross, which emphasizes prima facie duties.

The consequentialist approach to moral theory determines moral responsibility by weighing the consequences of one’s actions. According to the consequentialist view, correct moral actions are determined by a cost-benefit analysis concerning the consequences of an action.

Several subtypes of consequentialism have been proposed: (1) the view that an action is morally correct if its consequences are more positive or favorable than negative to the person performing the action (ethical egoism), (2) the view that an action is morally correct if the consequences of that action are more positive than negative to everyone except the person doing the action (ethical altruism), and (3) the view that an action is morally correct if the action’s consequences are more positive than negative to everyone (utilitarianism).

Any good moral theory should have a set of traits that defines them as being good. These characteristics are needed to avoid a number of philosophical flaws that might otherwise occur. These include: bias, cultural imperialism / cultural ideology, prejudice, racism, sexism and other defects in logic and thinking. I would hold that the following are desirable traits of any good moral theory. (1) It should be consistent – i.e., yielding similar results in similar settings. (2) It should be universal - i.e., if the theory applies to one individual, then it should apply to all individuals. (3) It should be intuitive – i.e., the theory fits our moral intuition.

Other individuals might add other characteristics to this list, such a need for the theory to be understandable by nonphilosophers (certainly a requirement for any practical theory), or the need for the theory not to be based on any religious teachings (although I feel that this is already covered by my requirement (2) above). Others might add the requirements of being time-invariant (that the principles hold true over time) and trans-cultural (that the principles apply to all cultures), but I view these also as being covered by requirement (2). Still others might state that any moral theory must respect all forms of human life, no matter how degraded., while animal rights advocates might emphasize that a moral theory must necessitate respect for all sentient life forms, not just humans. Finally, Princeton’s Professor Peter Singer would likely take issue with my third requirement that a moral theory be intuitive – his moral positions are often taken to be unintuitive and repugnant when first explained, especially in the matters of euthanasia and infanticide, although he makes his case forcefully and lucidly in his many writings.

Professor Paul Taylor, well-known for his writings in the domain of environmental ethics, argues that six characteristics are necessary for a philosophical principle to be a moral rule: (1) generality, (2) universality, (3) priority, (4) disinterestedness, (5) publicity, and (6) substantive impartiality. While his focus is on environmental ethics as opposed to bioethics, it can be seen that his views are substantially similar to mine once the meaning of the terms he uses are fully understood [2].

Beauchamp and Childress offer a number of useful notions on morality in the first chapter of their classic bioethics text [3], but their focus is not on developing a list of specific characteristics as, for example, Taylor has done. Still, their second chapter discusses this matter at some length, introducing requirements of clarity, coherence, completeness, simplicity, explanatory power, justificatory power and practicability. Finally, with respect to people's personal beliefs in the development of a good ethical theory, as discussed in requirement (3) above, a good moral theory should be intuitive with respect to existing beliefs, but only when the personal beliefs meet the other requirements of consistency, time-invariance etc. as discussed above.

UTILITARIANISM
Why does the moral theory of Utilitarianism seem to falter when it is applied to questions of social or individual justice?

Utilitarianism is a school of philosophical thought frequently identified with the writings of Jeremy Bentham and John Stuart Mill. In more recent years it has undergone a number of refinements, such as “Preference Utilitarianism”, advocated by Professor Peter Singer. Classical Utilitarianism advocates the principle of providing “the greatest happiness to the greatest number” as the basis for assessing the morality of various actions, while “Preference Utilitarianism” advocates the principle of meeting the preferences  of the greatest number of people. Thus good variously consists in providing maximal happiness (or satisfying people's preferences, in the case of Preference Utilitarianism) and the rightness of an action depends directly or indirectly on its yielding such outcomes. However, while Utilitarianism has had a strong influence of the intellectual landscape of philosophical discourse and, in particular, in ethical theory, Utilitarianism is often seen to falter when it is applied to questions of social or individual justice. In particular, Utilitarianism sometimes violates common-sense notions of justice. Because Utilitarianism seeks to maximize the total amount of a particular “utility” (like happiness or preferences) over an entire society or social group, it seeks whichever arrangement achieves maximum utility. But such an arrangement might be achieved by distributing benefits and burdens in a way that violates common notions of justice. For instance, the use of slaves might greatly help maximize the net happiness in a society, but common-sense notions of justice almost always take slavery to be wrong (with apologies to both Aristotle and Thomas Jefferson, who were both great intellectuals yet were slave owners).

Another serious criticism of Utilitarianism is that under the goal of maximizing happiness or some other utility, the wishes and desires of sadists and perverts are lumped in with the wishes and desires of everyone else when an overall determination of utility is made. By espousing a system in which the satisfaction of all desires are to be maximized, Utilitarianism can end up violating our intuitive precepts of natural justice. John Rawls takes the position that we must reject Utilitarianism and instead develop a deeper understanding of what is right and wrong as a basis for making ethical decisions. What is needed, Rawls argues, is moral theory with justice at its core. That being said, other philosophers have proposed extensions to the classical utilitarian model to deal with some of the limitations identified above. One example is “Negative Utilitarianism”, a moral philosophy aimed at producing the least amount of suffering throughout the world.

EQUITY ISSUES IN HEALTH CARE
In offering medical services there are often two kinds of health care systems to consider. First, in many countries there is a public system (funded primarily by taxes) that is usually accessible yet often limited in its resources. Then there is often also a private health care system, funded primarily via payments by private insurance or by occasional private individuals paying cash. Some countries have a predominantly public health care system (for instance, the Canadian system is almost entirely public, except for cosmetic procedures and the like), while some countries like the USA have a predominantly private health care system. The British system has both a public National Health Service as well as a thriving private system that has arisen in the face of the many shortcomings present in the National Health Service.

While resource limitations are a problem with all health systems, the problem is usually far worse in the public systems funded through taxation. As a result, many individuals involved in health policy research are seeking to determine which clinical services are most valuable and appropriate and which ones are of more limited value. Their motivation is to make the best use of public funds by only offering those procedures known to be most effective, and not offering procedures that are of very limited or no benefit.

The fact is that some common medical practices have no rational clinical basis in the sense that they provide no benefit relative to the potential risks. Perhaps the best known example is that of newborn circumcision, which is still carried out in 27% of Canadian newborn boys [1]. Other practices such as “female circumcision” can be frankly mutilating and even downright harmful, yet may be considered acceptable or even desirable in some cultures [2]. In a public health care system with limited resources, it makes sense either not to offer such procedures (in the case of male circumcision) or to explicitly forbid them when they are obviously harmful (as in the case of female circumcision). This is not to suggest that all clinically unnecessary procedures should always be unavailable – only that they should not be offered by the public health care system funded by tax money.

The Oregon Health Plan (OHP) [3] has been widely heralded as a landmark innovation in public health care policy that rations public medical resources by a system of prioritizing funding for health care. This is done through a process of systematically ranking publicly offered medical services, an approach that has drawn substantial international interest as a rational model of medical resource allocation.

In 1989, Oregon enacted legislation to provide basic health care to all residents on Medicaid, their public health care system. This required that services be prioritized to determine what would or would not be covered – effectively establishing a rationing plan. To do this, the Oregon legislature created a Health Services Commission charged with producing a list of health care services ranked in priority “according to comparative benefits of each service to the entire population being served.” They heard testimony of numerous panels of physicians from every specialty and assessed how well each treatment that might be offered affected quality of life. From this they established a “cost-effectiveness value” for each “condition-treatment pair”. The final product was a priority list of 709 condition-treatment pairs in ranked order. Based on the available state funds, a line was drawn on the list - any treatment above the line was covered; any treatment below the line was not. This turned out to be at the 587th condition-treatment pair.

While the Oregon system is not without its critics [4], the plan strikes me as a particularly fair and rational approach based on a process of public consultation coupled with clinical efficacy research. I would advocate this model as a good starting point for meeting the various needs and demands of a diverse population. This is not to suggest that the plan would necessarily apply to all residents – only those getting publicly-funded health care would be participate, and wealthier individuals with private insurance would participate in a different (more generous) plan.

Finally, there are a number of practices that are harmful to patients to the extent that they should be forbidden even when well-meaning individuals sometimes seek them. These include the previously mentioned practice of female circumcision, a number of dangerous quack remedies [5], and possibly the practice of euthanasia. Deciding which ineffective or potentially harmful practices should be tolerated (as we do with male circumcision), and which ones should be forbidden (as with female circumcision) is not always an  easy task, but application of the principle of nonmalfience is certainly one approach that has special merit. Still, the principle of nonmalfience may sometimes be in direct conflict with the principle of patient autonomy in the cases of patients seeking ineffective or dangerous treatments. In my book, the principle of nonmalfience takes absolute priority. After all, was it not Hypocrites who said “First do no harm.”

Appendix
The International Society for Equity in Health (www.iseqh.org) seeks to “promote equity in health and health services internationally through education, research, publication, communication and charitable support.” It is concerned with exactly the sort of questions that have been raised here: How does one ensure fairness in access to health care resources? What procedures should not be made publicly available in a socialized health care system? How do we deal with cultural and economic factors that impact on the demand for health care services? They begin by offering two working definitions:

Equity in Health: The absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically.

Inequity in health: Systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically.

Also, the journal for the society, the International Journal for Equity in Health (http://www.equityhealthj.com), features a small number of articles that are helpful to address these issues. These and other sources identify a number of questions that need answering:
 * How is fairness in a health care system to be assessed?
 * Should health equity be measured at the individual or the group level?
 * To what extent are health status inequalities sensitive to the type of health measure used?

The interested reader is referred to these resources for more information.

DISTRIBUTIVE JUSTICE
''"In a situation of unmet need, with patients dying daily for the want of a donor liver, what is fair to all patients is to have approximately the same opportunity of receiving a donor liver." Jeffrey Crippin MD, Baylor University''

Beauchamp and Childress (4th Edition, page 228) discuss various standards of fairness in the context of distributive justice. These are:
 * 1) To each person an equal share
 * 2) To each person according to need
 * 3) To each person according to effort
 * 4) To each person according to contribution
 * 5) To each person according to merit
 * 6) To each person according to free-market exchanges

These standards of fairness may be explored in the context of three commonly described models of distributive justice:
 * Egalitarian model - where individuals have equal access to goods and services
 * Utilitarian model - where goods and services are provided to those who are likely to benefit the most
 * Libertarian model - where individuals rights and resources govern access to goods and services

Which model one agrees with most will depend to some extent on whether one views health care as a right (implying a right to universal access to health care), views health care as a need  (where people with the greatest need have highest priority and  people with similar needs treated similarly ), or  views health care as a market commodity.

Let us now consider the words of Dr. Crippin: "In a situation of unmet need, with patients dying daily for the want of a donor liver, what is fair to all patients is to have approximately the same opportunity of receiving a donor liver." While a single sentence of this kind is usually inadequate to express a complex philosophical position, Dr. Crippin’s statement appears to be an expression of an Egalitarian model. In this model of social justice, one gives equal consideration to all interests while treating everyone as equals. As a result, individuals in need have equal access to goods and services. Note also that when Beauchamp and Childress write “To each person an equal share” they are invoking an Egalitarian model of medical services.

Notice that Crippin does not explicitly emphasize the degree of need in his statement. He does not say: "In a situation of unmet need, with patients dying daily for the want of a donor liver, what is fair to all patients is to have those individuals in greatest need to be given priority over those patients with a lesser need." Such an approach would reflect a Utilitarian model, in which medical resources are provided on the basis of maximal medical benefit. In the Libertarian model medical services are merely a market commodity subject to free-market conditions, and a fair distribution of medical resources occurs as long as they are distributed without force or fraud in a free-market economy. When Beauchamp and Childress write “To each person according to free-market exchanges” they are invoking a Libertarian model of medical services.

One common view is that any ethically appropriate model for organ allocation must take into account issues related to benefit and need., and that those patients who both have a strong need for a transplant and will strongly benefit from a transplant should get priority over patients with either less of a need or who would be expected to obtain less of a benefit. This is a Utilitarian viewpoint based primarily on clinical factors. And, in fact, this is more or less how things are done in the real clinical world. For instance, according to the American Medical Association [1] criteria for organ allocation include:

 * 1) The likelihood of benefit to the patient;
 * 2) The impact of treatment in improving the quality of the patient’s life;
 * 3) The duration of benefits;
 * 4) The urgency of the patient’s condition; and
 * 5) In some cases, the amount of resources required for successful treatment

This particular set of criteria for organ allocation appears to me to be a particularly well thought out set of Utilitarian principles that is superior to the simpler Egalitarian model advocated by Crippin in that if takes into factors like benefit, quality of life and urgency that are not explicitly addressed by the Egalitarian model. I would cast my vote for this approach.

Reference

[1] http://www.ama-assn.org/ama/pub/article/2036-2387.html

MEDICAL FUTILITY THEORY
Starting Point: The Case of Helga Wanglie

Helga Wanglie broke her hip in December 1989 after a fall in her home. She was 86. She was treated in hospital and moved to a nursing home, but a month later she was readmitted for respiratory complications and needed to be placed on a ventilator. Attempts to wean her were unsuccessful. As a result, she was transferred to a long-term care facility that specialized in ventilated patients. While there, she suffered a cardiac arrest with anoxia that resulted in severe, irreversible brain damage. She remained in a persistent vegetative state. Meanwhile, she also remained in a state of permanent ventilator dependency.

Because of her dismal prognosis, the medical staff suggested that her family consider termination of treatment. However, the family decided against any withdrawal of care, as she was apparently heard to have said "If anything happens to me, I want everything done". The matter went to court. In its decision, the court rejected the hospital's position and turned over full guardianship to Helga's 87 year-old husband. Helga Wanglie died of multisystem organ failure on July 4, 1991. Medical bills totaled approximately $750,000 [1-3].

If one were searching for a case to use for starting a classroom discussion on futile care theory, this case would be an excellent starting point. Few clinicians would disagree that Helga Wanglie’s case was completely hopeless, and almost all would also agree that there would be no clinical value in continuing extraordinary measures such as mechanical ventilation. Yet Helga Wanglie’s husband fought for continued treatment of his wife despite these facts. His conflict with the medical profession highlights many of the issues involved in futile care ethics.

Medical Futility Theory
The concept of futility has had historic importance in medicine. According to Drane and Coulehan [4], for Hippocratic physicians, attempting a futile treatment was a display of ignorance. They also note that contemporary ethical standards published by the Council on Ethical and Judicial Affairs of the American Medical Association (AMA) show continuity with this tradition: "Physicians should not provide or seek compensation for services that are known to be unnecessary or worthless." Drane and Coulehan recognize, however, that patients and their families may not agree:

‘Traditionally, applying the principle that physicians do not provide treatments when the interventions at their disposal do not produce medical benefits has been relatively straightforward. However, with the growing importance of patient autonomy and informed consent in treatment decisions, ethicists must now balance this principle with the principle of patient self-determination.‘

‘A patient's right to choose or refuse treatment is limited by the physician's right (and duty) to practice medicine responsibly. Bizarre or destructive choices made by a patient are not sacrosanct simply because the patient made them. In some cases, physicians may choose not to act on patient decisions that appear to be unreasonably destructive.’

‘Physicians also have a right to refuse to provide futile treatments (i.e., interventions that might be physiologically effective in some sense but cannot benefit a patient). Patients themselves have a right to provide input into what would constitute a "benefit" for them, but physicians should be able to decide when a particular treatment is futile based on their knowledge of the treatment's effects and its likely impact on a patient's quality of life.’

Ethical principles dealing with medical futility can be developed based on the traditional bioethical principle of beneficence, as well based on traditional physician values identified above. Under the principle of beneficence, which directs physicians to apply their skill and knowledge only for the good of their patient, physicians should not provide treatment known not to produce clinical benefits. Some authors go further. For example, McGee et al. [5] state: “Withholding futile treatments supports the ethical principles of both nonmaleficence (do no harm) and beneficence (relieve suffering).” Finally, the Catholic Health Association of the United States has issued a statement of principles on the issue that emphasizes similar principles.

Modern arguments against futile care generally center on two issues. First, futile care has no possibility of achieving a good outcome and serves only to prolong death. No physical or spiritual benefit comes from such care. Futile care also prolongs the grieving process and frequently raises false hope. Also, futile care can be very difficult on caregivers, who may see themselves as forced to act against the best interests of their patient [6,7].

Secondly, in a setting of limited resources, futile care involves the expenditure of resources that could be used by other patients with a good likelihood of achieving a positive outcome. This second argument would appear to be strong in those nations with socialized health care systems.

Families Seeking Futile Care
The above not withstanding, families occasionally seek to ensure that their loved ones get heroic or extraordinary care even in the absence of any likelihood of clinical benefit. However, in most of these cases the family eventually comes to realize that there is no possibility of a good outcome from such efforts, and end up agreeing with the clinical team. But not always.

One famous case is that of Baby K, an anencephalic infant. The infant’s mother wanted the hospital to continue with advanced supportive care (primarily ventilatory support) against the wishes of the clinical team, and sought legal support for her position. Ms. H. knew of her baby's condition from the second trimester of her pregnancy, but, motivated by a strong religious conviction that "all life is precious" and that God alone should decide how long the baby would live, she remained adamant that Baby K. be kept alive as long as possible.

The hospital’s position was that such care would be futile. At the trial [Matter of Baby K. 16 F.3d 590 (4th Cir. 1994), n. 9 at 598.], expert testimony was given to demonstrate that provision of ventilator support for anencephalic infants goes beyond the accepted standard of care. The legal team for Baby K's mother adhered to a religious sanctity-of-life principle as the basis for their case. In the end, in a particularly controversial decision, the U. S. District Court ruled that the hospital caring for Baby K must put her on a mechanical ventilator whenever she had trouble breathing. In particular, the court interpreted the Emergency Medical Treatment and Active Labor Act (EMTALA) to require continued ventilation for the infant. The wording of this act requires that patients who present with a medical emergency must get "such treatment as may be required to stabilize the medical condition" before the patient is transferred to another facility. The court took the position that "it is beyond the limits of our judicial function to address the moral or ethical propriety of providing emergency stabilizing medical treatment to anencephalic infants. We are bound to interpret federal statutes in accordance with their plain language..." As a result of the decision, Baby K was kept alive much longer than most anencephalic babies, living to age 2 ½.

The cases of Baby K and Helga Wanglie vividly demonstrate how family and clinical caregivers may sometimes see matters very differently. Such differences usually reflect very different philosophical vistas, and cannot always simply be dismissed as being based on ignorance on the part of the family. For instance, some people take the “santity of life” argument to its extreme, arguing that all efforts to sustain life should be made wherever clinically possible, no matter how degraded that life may be. While much has been written to refute this position (see, for instance, the writings of Peter Singer [8]), such (usually always secular) counterarguments generally have little or no impact on individuals invoking such arguments based on personal religious beliefs.

Some other individuals may argue that clinical care should be a market commodity that one should be able to purchase just like cruise vacations or luxury automobiles, as long as the purchaser of the clinical services has the necessary funds and as long as other patients are not being denied access to clinical resources as a result. In this model, Helga Wanglie should be able to get ICU care until funding vanished.

In my view, this market-oriented viewpoint is either naïve or wrong in several respects. First, in almost all such cases the funding comes from insurance carriers, who must avoid “wasting” funds to ensure that adequate funds are available for other clients. Secondly, competition for ICU resources can be intense, and providing ICU care to patients who will not benefit from them only makes access more difficult for patients for which ICU care would prove to be clinically beneficial. Finally, to view clinical care is a mere market commodity or service is to detach it from its underlying dignity and humanity.

The Case Against Medical Futility Theory
Are there, then, any potential problems with futile care theory? Could it be that the issues are not be as cut and dried as the clinical community would have it?

In this respect, it is helpful to consider matters from the perspective of those who disagree with the traditional clinical view regarding futile care. For Helga Wanglie and her husband, all human life - even a degraded and permanently unconscious human life – is still taken to be valuable, regardless of any considerations of quality of life. Similarly, the mother of Baby K no doubt saw her infant’s life as infinitely valuable, even if incapable of a conscious existence.

One criticism of futile care theory is that the caregivers sometimes see things only from the perspective of their training, and thus seek to be the only decision-makers in these matters. However, as noted by Weijer and Elliott [9], for clinicians to be the sole decision-makers in these situations amounts to saying to families, "Your values don't count."

Weijer and Elliott [9] go on to note that different viewpoints concerning the goals of treatment may form the basis for disagreements between families and clinicians:

“… judgments of futility make sense only in relation to a specified goal: an intervention may be futile if the aim is to cure an underlying disease but effective if the aim is to keep the patient alive. Yet in the most controversial cases in which futility is invoked the disagreement between doctors and families is not about the probability that an intervention will work but about the goals that it will serve.”

“… the concept of medical futility is a tarbaby. It cannot do what it is asked to do, and trying to force the issue won't produce a solution; it will produce a mess. When patients or families demand treatment that is unlikely to produce a good outcome doctors ought to disclose carefully the treatment options, the likely outcomes, and the probabilities of attaining those outcomes. Clearly, both the doctor's judgment and that of the patient (or family) are essential to the decision making process. … This can be achieved only by an open and frank dialogue. Invoking futility ensures, if anything, that this will not occur.” Another problem confronting futile care theory is that invoking the principle of futility is sometimes direct conflict with the principle of patient autonomy. As the case of Helga Wanglie illustrates, when families make end-of-life decisions in conflict with caregivers, and the case ends up in courts, the courts are often strongly influenced by concerns for patient's right to autonomy. As Weijer and Elliott note [9]: “Futility is not the ethical trump card that some would like it to be.”

Another problem with futile care theory is that even defining the notion of clinical futility can be challenging. McGee et al [5] emphasize that various definitions are used in the literature:

“The term medical futility has been used to describe life-or-death situations in which proposed treatments will fail to prolong quality life, achieve the patient's key goals for medical care, achieve a critical physiologic effect on the body, or result in a therapeutic benefit for the patient. Another definition of futility states that "if a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile." In an attempt to give a quantitative definition of futility, some have suggested that treatments with less than a 1% chance of benefiting patients should be considered futile.” The Ethics Committee of The Society of Critical Care Medicine has attempted to clarify the concept of futility with a policy statement. They emphasize, among other things, that care that is extremely unlikely to be beneficial is not necessarily futile in nature [10]. They write:

“Treatments should be defined as futile only when they will not accomplish their intended goal. Treatments that are extremely unlikely to be beneficial, are extremely costly, or are of uncertain benefit may be considered inappropriate and hence inadvisable, but should not be labeled futile. Futile treatments constitute a small fraction of medical care. Thus, employing the concept of futile care in decision-making will not primarily contribute to a reduction in resource use. Nonetheless, communities have a legitimate interest in allocating medical resources by limiting inadvisable treatments. Communities should seek to do so using a rationale that is explicit, equitable, and democratic; that does not disadvantage the disabled, poor, or uninsured; and that recognizes the diversity of individual values and goals. Policies to limit inadvisable treatment should have the following characteristics: a) be disclosed in the public record; b) reflect moral values acceptable to the community; c) not be based exclusively on prognostic scoring systems; d) articulate appellate mechanisms; and e) be recognized by the courts. Healthcare organizations that control payment have a profound influence on treatment decisions and should formally address criteria for determining when treatments are inadvisable and should share accountability for those decisions.“

Finally, futility theory may be challenged on a statistical basis. While scenarios like providing ICU care to the brain dead patient or the anencephalic patient when organ harvesting is not possible or practical are easily identifiable as being completely futile, many other situations usually taken to be futile are far less clear. For instance, should surgeons attempt a heroic clinical rescue in a 99 year old unconscious patient with a ruptured abdominal aortic aneurysm, even though survival with a good outcome would be so very unlikely as to warrant publication of the case as a clinical case report? Various bleak clinical scenarios will vary in their degree of futility. For instance, when elderly patients sustain large third degree burns, mortality is almost guaranteed. This is similarly true for elderly patients sustaining massive trauma. But in many of these cases it can still be very difficult to accurately predict outcome [11, 12].

As Weijer and Elliott note:

“… problems will arise with any criterion that allows doctors to rely solely on their own experience. Their recollections are biased towards cases with a poor outcome. Moreover, doctors' judgments about individual cases are not accurate enough to allow them to claim reliably that a given person has (for instance) less than a 1% chance of responding to treatment. While the agreement of several colleagues about a prognosis may improve the judgment's reliability, support from the literature may be lacking. Even if empirical data exist on a particular intervention, the vast majority of "negative" clinical trials have a sample size that is too small to provide strong enough evidence to rule out a small treatment effect.”

References, Sources and Notes

 * 1) In re the conservatorship of Helga M. Wanglie, No. PX-91-283, District Probate Division, 4th Judicial district of the County of Hennepin, State of Minnesota.
 * 2) http://web.archive.org/19990824232320/www.geocities.com/HotSprings/Oasis/2919/cases.html
 * 3) http://www.missouri.edu/~philwb/wanglie.html
 * 4) James F. Drane, PhD, & John L. Coulehan, MD . The Concept of Futility. Patients Do Not Have a Right to Demand Medically Useless Treatment. Health Progress 1993. http://www.chausa.org/PUBS/PUBSART.ASP?ISSUE=HP9312&ARTICLE=B
 * 5) McGee DC. Weinacker AB. Raffin TA. The patient's response to medical futility. Archives of Internal Medicine. 160(11):1565-6, 2000 Jun 12.
 * 6) Ronald M. Perkin, MD. Stress and Distress in Pediatric Nurses: The Hidden Tragedy of Baby K.  http://www.llu.edu/llu/bioethics/update12_2.htm
 * 7) For a somewhat different view from that of Perkins (above) consider the perspective of Dagi. Dagi argues against making the emotional needs of the caregiver an overriding consideration in clinical ethics, arguing that the claim of health care workers to be a professional “places legitimate constraints on the extent to which they may be permitted to have their needs and wants influence the ethical dialectic.” T. F. Dagi, "Compassion, Consensus, and Conflict: Should Caregivers' Needs Influence the Ethical Dialectic?" The Journal of Clinical Ethics 3 (1992): 214-18.
 * 8) Peter A. Singer. Rethinking Life and Death: The Collapse of Our Traditional Values. St. Martin's Griffin (New York) 1994
 * 9) Weijer C. Elliott C. Pulling the plug on futility. BMJ. 310(6981):683-4, 1995 Mar 18.
 * 10) The Ethics Committee of the Society of Critical Care Medicine. Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possible inadvisable treatments. Crit Care Med. 1997;25:887-891.
 * 11) Dawson NV, Arkes HR. Systematic errors in medical decision making: judgement limitations. J Gen Intern Med 1987; 2:183-7.
 * 12) Poses RM, Bekes C, Copare FJ, Scott WE. The answer to "What are my chances, doctor?" depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients. Crit Care Med 1989; 17:827-33.

VIRTUE IN HEALTH CARE
''"Virtue is harder to be got than a knowledge of the world; and, if lost in a young man, is seldom recovered." John Locke'' ''Wisdom is knowing what to do next; virtue is doing it. David Star Jordan''

According to the Internet Encyclopedia of Philosophy [1] “virtue theory is the view that the foundation of morality is the development of good character traits, or virtues”. According to this model, a person is good or virtuous to the extent that he or she has virtues and lacks vices. Another way of looking at the matter is to state that there are certain ideals, such as the pursuit of excellence or dedication to the common good, which we should strive for and which permit the full development of our humanity. Virtues may be viewed as attitudes or character traits that enable us to develop this potential.

The virtues of everyday life include generosity, fidelity, self-control, honesty, truthfulness, integrity, bravery, courage, justice, patience, prudence, fortitude, tolerance, and countless others. In fact, some virtue theorists have identified over 100 virtuous character traits.

However, different social groups may emphasize different “virtue sets”. For instance, the Boy Scout virtues are “ trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean and reverend” [2]. By contrast, some other social groups (Satanists and Hell’s Angels members come to mind) would not consider all of these character traits to be virtuous [3]. Indeed one man’s virtue may be another man’s vice, as in the often-used term “generous to a fault”.

Minogue details five virtues [4] that are associated with medicine. He holds these to be:
 * 1) Compassion
 * 2) Courage
 * 3) Tolerance
 * 4) Honesty
 * 5) Faithfulness (or Fidelity, or Loyalty)

Missing in this list is a trait that most patients want above all in a physician or nurse – competence. The importance of professional competence as a virtue has been emphasized elsewhere. For instance, the College of Human Medicine at Michigan State University has developed a set of “desirable professional attributes” that are used as examples of “professional virtue” for guiding medical students [5]. These attributes fall into six categories:
 * 1) Competence
 * 2) Honesty
 * 3) Compassion
 * 4) Respect for Others
 * 5) Professional Responsibility
 * 6) Social Responsibility

While there is considerable overlap in these lists (for instance, both lists include compassion and honestly as desirable traits, and  Minogue’s “tolerance” trait is similar to the “respect for others” trait in the College of Human Medicine list), the differences are nonetheless striking. Also, some individuals do not regard “courage” as an especially important trait in clinical practice, except in the context that exercising honesty and responsibility in hostile settings can sometimes require considerable courage. Some individuals would argue that both these lists should be combined to make a list of virtues for physicians. The combined list one might then propose would be:
 * 1) Competence
 * 2) Honesty
 * 3) Compassion
 * 4) Respect for Others
 * 5) Professional Responsibility
 * 6) Social Responsibility
 * 7) Courage
 * 8) Loyalty

Yet it is also appropriate to consider even more virtues that might apply, such as resourcefulness, patience, integrity, wisdom and prudence. To the extent that these traits overlap with the list above it is not necessary to explicitly list them. Still, they are important clinical virtues.

One interesting issue is whether the traits of the virtuous physician and the traits of the virtuous nurse are similar. Many individuals would argue that they are indeed similar, that there are no more differences between the traits of the virtuous physician and the traits of the virtuous nurse then there are between the virtuous traits of the various medical specialties. There are, of course, differences between what nurses and physician do, just as there are differences between the various medical specialties do. But perhaps these differences are so great that different sets of virtues are necessarily implied. Both groups have the same goals in mind for their patient, and both groups share a similar clinical worldview. The fact that one group frequently implements orders from the other is not, in my view, an overriding issue. Nor perpahs should one regard it as particularly relevant that nurses are often said to come from a tradition of caring, while physicians are often said to come from a tradition of science and reason. The reality is that both traditions are major influences on both nurses and physicians in today’s clinical world.

BIOETHICS AND TOBACCO
Tobacco is a legal product and smoking it is a legal practice, at least in most locales. Yet it is understood by all to be unhealthy and a cause of/contributing factor to several diseases leading to disability and death. One interesting question is whether the life-long smoker's right to national health insurance (such as the US Medicare system) to cover the treatment of lung cancer should be forfeited because of this self-destructive behavior.

According to the World Health Organization one out of every two long-term smokers will ultimately be killed by tobacco [1]. They note that “in developed countries, half will be killed in old age, after age seventy, but the other half will be killed in middle age, before age seventy, and those who die from smoking before age seventy will lose more than 20 years of life expectancy”. In the USA, a 1998 study by Leonard Miller, professor of social welfare at the University of California Berkeley and Dorothy Rice, professor emeritus of health economics at the UCSF School of Nursing found that “smoking-related Medicaid costs amount to $12.9 billion per year, or $322 billion in 25 years without inflation”, a figure that they noted “does not include the financial impact of cigarette smoking on Medicare or private insurance companies” [2].

About 75% of Americans do not smoke, yet everyone pays for the cost of treating tobacco-related illnesses via higher insurance premiums and taxes. Many people argue that it is not fair that non-smokers have to pay many billions of dollars in health insurance premiums and taxes for the medical treatment of smokers. Given the well-established link between long-term tobacco use and lung cancer, this has led some individuals to suggest that life-long smokers should be denied Medicare or Medicaid health insurance coverage for the treatment of lung cancer.

However, such a policy may be both impractical and unethical.

First, while there is no doubt that health care costs are higher for smokers, the extra health care costs to Medicare and Medicaid associated with smoking can be recovered simply by increasing the price of cigarettes. This would be a particularly effective alternative to denying Medicare services to smokers, since there is strong data to suggest that raising the cost of cigarettes is one of the most effective ways of reducing consumption.

Secondly, tobacco smoking is hardly the only form of self-destructive behavior. Other self-destructive practices that one might focus one include the following:
 * excessive alcohol consumption
 * not wearing seatbelts while driving
 * participation in unsafe sexual practices
 * excessive food consumption leading to morbid obesity
 * use of dangerous recreational drugs such as cocaine or heroin
 * participation in dangerous sports without sufficient attention to safety issues

In the interests of fairness, if one were to deny Medicare services to smokers, it would also be necessary to deny Medicare services to individuals who sustain clinical insults as a result of other self-destructive behavior. It should be apparent that this would be a logistical nightmare.

Third, if life-long smokers on Medicare health insurance should be denied coverage for the treatment of lung cancer, they should also be denied coverage for other diseases strongly linked to smoking: coronary heart disease, cerebrovascular disease, peripheral vascular disease, emphysema, chronic obstructive pulmonary disease, bladder cancer, and even age-related macular degeneration (AMD), a leading cause of blindness.

Fourth, the US government has not made a concerted effort to reduce tobacco use. Industry commentators often point out that there is an incestuous relationship between the tobacco industry and US government. While the idea of regulating tobacco use and creating a "smoke-free" society remains a popular dream in Washington, the reality is that the federal government and the 50 states eagerly consume a steady flow of sin taxes generated by the sale and consumption of tobacco products. Furthermore, and most amazingly, Washington continues to subsidize the growth of tobacco. Some critics suggest that the US federal government should clean up its own house first before implementing draconian Medicare policies of the nature suggested.

Fifth, there are many causes of lung cancer besides tobacco smoking, and some forms of lung cancer (e.g. small cell cancer) are not related to smoking at all. Radon exposure, exposure to asbestos, and even dietary factors may account for many cases of lung cancer. In fact, the only form of lung cancer that is unequivocally linked to smoking is squamous cell carcinoma.

Finally, medicine has a humane tradition of being nonjudgmental and caring for all regardless of social worth or social standing. Public policy should reflect this. Some critics suggest that setting into place a policy whereby a life-long smoker's access to Medicare for the treatment of lung cancer should be forfeited is inhumane in the extreme. Such action says to the patient that he or she is unworthy of our clinical attention, and is in clear violation of the principle of beneficence.

title: Bioethics/Introduction


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The image shown on this template, Image:Crystal_Clear_app_staroffice.png is based on a copyrighted logo, and thus a copyright violation. It will be soon deleted, so please change the image. User:Bryan 21:20, 14 January 2007 (UTC)

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Wikiversity:Virtual learning environment

Virtual Learning Environment
The object of this page is to create a multimedia learning project by ourselves.

Ideas
A proposal for this as an educational project has started here.


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User:Photographer~enwikiversity

Hi! I'm a student of Sciences and Technologies from Portugal.

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Wikiversity:Reports

This page is for creating reports or reviews about Wikiversity - about the whole project, or about specific pages, materials, groups, processes within Wikiversity. If you'd like to add your report on anything related to Wikiversity, please add it as a subpage (such as Reports/31 December 2007, or Reports/A review of Wikiversity's music-related content ). This page is not to be confused with Wikiversity Reports, which is a learning project to create podcasts about Wikiversity. (If this page's name is too confusing, it can be moved - suggestions are welcome on the talk page.)

Reports

 * /15 January 2007 - a report by Cormaggio on how Wikiversity stands after five months of existence.

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Wikiversity:Reports/15 January 2007

This is a personal (and brief) analysis of (the English) Wikiversity’s progress, after approximately five months of its existence, as well as being an attempted snapshot of where we are at the moment. Please feel free to add comments on this page (preferably indented and signed), or the talk page, or write your own response or analysis elsewhere. If there are specific Wikiversity pages that you feel would benefit or clarify this page, please also feel free to add them here. Also, the "further questions" is an open-ended section to develop questions that we might want to address in the future. Cormaggio talk 00:37, 15 January 2007 (UTC)

Context
Wikiversity was set up (in its beta phase, on August 15th, 2006) to be a repository of educational material, as well as a space for learning (with a question mark over whether and how research would be integrated) - see Wikiversity project proposal. The types of educational materials, or the means for creating them, were not pre-specified - except for the fact that Wikiversity is a wiki, and therefore editable by anyone, as well as specifying that Wikiversity would not seek to undermine the integrity of other projects like Wikibooks and Wikipedia.

Analysis
In an attempt to give a broad overview, based on Wikiversity’s scope, I set the following questions:

 * Is there material of quality on Wikiversity?
 * How do we know whether material is of any quality?
 * Is there a community of teachers on Wikiversity?
 * Is there a community of learners on Wikiversity?
 * Is there a community of researchers on Wikiversity?

On the latter three questions, my own personal perception is that, while there are individual learners, teachers, and researchers on Wikiversity, there is not (at the moment) a fully functioning community of any of these groups (though I may be wrong, and would love to be pointed to a good example).

At the moment, there are evidently good intentions and high aspirations, some good material, and much potential for developing material. Most of the materials (and many of the "school", "topic" etc organiser pages) are "stub-like" (meaning, "sketchy", "not well developed"). However, there are some well-developed pages, available through specific portals as well as Featured. There is a (thus far) fledgling page devoted to assessing Wikiversity’s quality at Quality.

‘’Related pages: Featured; Assessment; Quality; Portal:Learning Materials; Portal:Learning Projects;

However, despite the above, I (Cormaggio) do not see any of this as cause for dismay; on the contrary, I see it as a huge opportunity to develop. Wikiversity is still very young and raw and very much a "work-in-progress". The fact that Wikiversity hasn't yet consolidated in any particular direction still gives it an (IMO) exciting quality in that it can still be defined, shaped, and driven by new ideas and newly-arrived participants. (Question: Is it possible to lose or undermine this quality of openness? If so, how can we act to ensure that it isn’t lost or undermined?)

A model for learning
Wikiversity operates under a free-form model for developing materials, communities and activities - it is up to contributors to deem for themselves what is appropriate for facilitating learning, and it is often largely up to learners to figure out how to go about structuring their learning. There is little guidance for educators on how to go about creating good educational material/activities, and no guidance for students on how they could use Wikiversity as a space for their own learning. Some existing guidance is being developed on pages like: Adding content, Learning goals, Welcome, newcomers, Introduction, Wikiversity teachers, School and university projects, Portal:Education, School:Education, Learning, Learning projects. However, there isn’t yet much guidance as to how we can actually learn or teach in this environment. A notable project is Learning to learn a wiki way, which has attracted some attention, and generated discussion – and there is some content distributed between the pages above, and their talk pages (see also Wiki as a tool for learning and Wiki. There is still confusion ( or, at least uncertainty) about the board’s recommendation (in November 2005) to “exclude online courses” from Wikiversity’s scope. Overall, much work needs to be done here in clarifying what learning means in Wikiversity, and how it can be provided for.

Reflective blogs
There are some reflective blogs within Wikiversity, and some Wikiversity members are keeping their own blogs externally. (Question: How can these blogs be better connected to eachother?) There has been some discussion of what blogs are for, and whether they should be restricted in any way or form, though this has not yet been translated into any formal context, such as guidance or policy. See: Category:Blogs.

Multilingual coordination
Multilingual coordination has been talking place on the beta wiki (http://beta.wikiversity.org/) - so far, there are four language Wikiversities: English, French, German, and Spanish. I cannot comment on the effectiveness of the multilingual coordination so far - my only experience has been on the project of writing guidelines for research, which has, in my opinion, been useful (though has it been conclusive?). There have been ‘’’reports’’’ done about individual Wikiversities - including those on English at Wikiversity Reports (which have been quite creative, and technologically advanced), and at the beta wiki http://beta.wikiversity.org/wiki/Wikiversity:Reports/En. (Questions: What have we learnt, if anything, from these reports? Can multilingual coordination be done better in terms of efficacy/inclusivity.. etc? In making technologically advanced reports, are we excluding the technologically-not-so-advanced participants?)

Organisational Structure, Accredidation
The organisational structure of Wikiversity has been worked on since the beginnings of the project, though not always so consistently. I (Cormaggio) was made a bureaucrat on the first day of Wikiversity's existence, and I gave ‘sysop/admin’ (subsequently renamed "custodian") rights to a number of people, including most of the forming subcommittee, as well as (most) interested parties in the first few days. A process for creating custodians, based on mentorship and learning through experience, was developed on Custodianship, and has, in my view, been working quite well. (Point: To avoid this being based on my own perception, shouldn’t we have some sort of evaluation of this amongst the community?) On bureaucrats, discussion has moved between the Colloquium and Wikiversity talk:Bureaucratship about what bureaucrats are, what they should do, how many we should have, and how they are appointed – however, at the time of writing (14th January, 2007), Bureaucratship has not been developed at all.

Related pages: Bureaucratship, Custodianship, Organizing Wikiversity,

Some of the above organisational-based discussion have been around accreditation, whether this is a desirable option to pursue for Wikiversity, and how it could be managed. (See Wikihigh and Accreditation.) Further discussion has been around namespaces, how many we need, and how they are to be used. This has generated some confusion and frustration. (See Naming conventions, Namespaces, Namespaces/Proposals for new namespaces.)

There has been some discussion of potentially “biased” (or otherwise problematic) content on Wikiversity – notably on Science teaching materials for creationism. We have developed a perspective of “neutrality” which differs from that on Wikipedia (see w:WP:NPOV), on Disclosures. However, I do not feel we have been put to the test by any communities/groups/individuals with any explicit interests/ideologies. (Question; what will/can be done if materials from, say, a Nazi-ist perspective are added to Wikiversity?)

Research
Research guidelines have been developed collaboratively, and across language projects (at http://beta.wikiversity.org/wiki/Wikiversity:Scope_of_research/En), but a complete and coherent picture of what should be permitted across all languages, or what should be done towards managing research has yet to emerge. On the English Wikiversity, for example, there are discussions of Peer review and a Review board. Research (see Research) is still the major outstanding issue to be resolved in becoming a fully-fledged sister project of the Wikimedia Foundation (as opposed to being in ‘beta’ phase).

Newcomers
Many newcomers have expressed confusion about what Wikiversity is, and what they can do with/in it – both on-wiki, or in private correspondence with me (and, presumably, others). Introductory material about Wikiversity is spread over a number of pages, including Main Page, Welcome, newcomers, Introduction, Guided tour, What is Wikiversity?, and About. There has been some work done to develop and clarify this material.

Identity
Defining the project’s identity has been an ongoing and open process since the beginning, with a logo vote on Meta (see Wikiversity/logo) and a contest to find and select a motto and slogan for the project (see Motto contest). There has been an attempt to document/write a history of Wikiversity (ie why/how it came to be) on History of Wikiversity, User:JWSchmidt/history, as well as on Wikipedia (Wikiversity). We still need, I think, to write the history of Wikiversity so far – as well as, of course, to continue to write it by developing Wikiversity! We also need to further refine the relationships and modus operandi between Wikiversity and other projects – particularly Wikibooks, as there is still a certain lack of clarity about the distinction between Wikiversity and Wikibooks - on both projects, it seems.

Further questions
I feel that, in addition to addressing the questions and points so far, as well as developing all of the mentioned pages, we should think about the larger issues that we face as a project. This would include the following questions:

 * What would it take to develop a community of learners, teachers, and/or researchers - both larger communities, and specific ones, around specific subjects?
 * What could/can be done - at the moment - to develop such communities?
 * What needs to be done to sustain these communities in the future?
 * How are we to determine if materials on Wikiversity are of any quality?
 * How can active learning be best facilitated on Wikiversity? (or any wiki?)
 * How can we make it easier for newly-arrived people to get involved - both as learners and educators?
 * ... (please add to this list)

Final comment (for now)
This is, as I said, a personal and brief analysis of Wikiversity – based on what I have seen, rather than being a comprehensive, and systematic survey of the entire site. Any of the above topics could and should be the topic of further, deeper inquiry/reflection, and this can be done by anyone reading this. In general, I think, we may have to think of ways for all of us to begin to reflect on, or analyse our own work, the work of others, and the context of this work (ie. involving some sort of look at the state of Wikiversity, or our own particular ‘patches’ of it). How we do this, or even how we could invite commentary/analysis from other people (eg. learners/educators) is something that hasn’t yet been very well-developed, but it is certainly something that I think (and it seems that some others agree) could be very useful and productive – both in developing Wikiversity, and our own understanding of ourselves within it.

Cormaggio talk 00:37, 15 January 2007 (UTC)

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Introduction to Cardiovascular Fitness

All class discussion should be kept to the talk page. But feel free to add your name to the roster.

Roster
Zero-X
 * Ex Machina

Aerobic Exercise
Aerobic exercise is exercise of any kind that primarily uses the one of the bodies three energy systems known as the "aerobic" energy system(thus the name aerobic exercise). The aerobic energy system is called such because it uses oxygen as it's main source of energy production(aero meaning "air"). Aerobic exercise for the benefits outlined below is usually prescibed using the FITT system. FITT stands for:

 * Frequency: 3-4 times a week

 * Intensity: 60-80% MHR(see below)for increased cardio-vascular fitness. 50-70% MHR for general health and weight loss (note: The lower end of these ranges should be used by those not accustomed to regular aerobic exercise and as fitness increases the higher ranges are used).

 * Time:20-60 minutes

 * Type: "aerobic" exercise

For those that have not heard the term MHR before I will explain it. MHR stands for Maximum(or maximal) Heart Rate. This is the highest BPM(Beats Per Minute) you can achieve through exercise. If you are not sure what your MHR is you can find out easily by simply doing this- 220-(age) where age is your(or whoever will be exercising) age in years. Example: If you are 27 years old then you would do 220-27=193 so your MHR would be 193 BPM. To calculate your THR(Target Heart Rate)simply divide your MHR by the percentage according to the FITT system that suits your requirements on a calculator.

Benefits

 * Increased cardio-vascular endurance (so you don't get "out of breath" as easily)

 * Can, along with a healthy, balanced diet, aid weight loss

 * Generally tends to increase overall energy levels

 * In some cases can increase mood(as in making a person feel "happier")however it is not known wether this is because of increased self-esteem due to factors such as weight loss and increased energy levels or simply due to the release of endorphines during exercise(but it's probably a little of both)

Examples

 * Jogging

 * Swimming

 * Circuit training

 * Many ball sports such as soccer, rugby and basketball

 * Cycling

 * Rowing (boat or machine)

Anaerobic Exercise
Anaerobic exercise is a form of exercise in which the body does not use oxygen as its main energy system. Anaerobic exercise is usually characterized by short bursts of energy, where as a continued effort (such as jogging) would be aerobic.

Benefits

 * Anaerobic exercise improves muscular strength and speed.

 * Anaerobic exercise can result in an increased metabolism, ultimately allowing one's body to burn more calories.

 * Anaerobic exercise increases lean body mass. Especially when it is combined with aerobic training, it can result in a lower body fat percentage.  As a result, one will be more lean, healthier, and stronger.

Examples
Resistance training, praticularly with weights, is a primary method of anaerobic exercise. One should be advised to talk to an instructor familiar with weight training when starting a program, as it is essential to know what kind of training program is appropriate for you. While one's exact needs will vary based on their goals, typically one should not be training with a weight that they can perform over 15-20 repetitions of if they want significant results, and often one should be able to perform many fewer. It is also essential to know and practice proper form for the exercise you are performing.

Session One: Opening Your Journal
The use of a paper journal is strongly recommended for this project. This isn't like high school phys ed. Now, the information is very important to remember. So write it down. The activity of copying something down by hand will encourage your brain to process the information for longer.

Once you have copied down all the information above, you may move on to session two.

Session Two: Choosing an Exercise
Now it is time to choose an exercise. You may choose one of the examples above, or choose something else, as long as it falls under the definition of aerobic exercise.

Now, alot yourself 10 minutes a day of exercise. Each time you exercise, record it in your fitness journal. You are encouraged to post weekly updates on the talk page.

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Category:Wikiversity reports

A category for reports/reviews related to Wikiversity

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Talk:DNA integrated circuits

There is only the djvu file so far, but I'm hoping that Inkscape will help me to create a more image-rich page.

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User:JWSchmidt/Blog/15 January 2007

15 January 2007 Here are some comments on Reports/15 January 2007:

Openness
Cormaggio mentioned that Wikiversity has a quality of openness. I understand this to reflect a comparison between Wikipedia and Wikiversity. Wikipedia has a narrow mission (produce encyclopedia articles) while I view Wikiversity as a more open experiment aimed at trying to explore the full potential of wiki technology as a tool to support human learning. The human capacity to form large and complex social groups and for individuals to learn from participation in social groups defines us as a species. Cormaggio asked how can we act to ensure that the openness of Wikiversity isn’t lost or undermined. Wikiversity needs to remember the broad mission of the Wikimedia Foundation, working to make possible that every human being can freely share in the sum of all knowledge. From a biological perspective, we need to remember that humans are diverse. The human brain is a device that amplifies human behavioral diversity. To respect this diversity Wikiversity can "run small experiments, tests, see what works, what doesn't, and be prepared to be flexible and change, and not be too locked into stone about how things should work" (Jimmy Wales said this in a different context, but I think it applies to Wikiversity source).

What are blogs at Wikiversity for?
Wikipedia was designed to be all about the "content" ot "product" while minimizing the role of the contributors. Wikiversity was given a broader mandate: "..... the idea here is to also host learning communities, so people who are actually trying to learn, actually have a place to come and interact and help each other figure out how to learn things. We're also going to be hosting and fostering research into how these kinds of things can be used more effectively" (source).

Each Wikiversity participant can use blogs to describe their learning goals. Doing so can help individuals find other Wikiversity participants with similar interests. Personal blogs can be used to document the intellectual challenges being faced by Wikiversity participants. I like the idea of "writing across the curriculum". Learners should always be writing and blogs are a natural way for learners to order their own thoughts. Group blogs for collaborative projects should also play a role at Wikiversity. Due to the limited communications channels linking wiki participants, we will all benefit from opening as many communications channels as possible.

connected blogs. I previously placed a request for the developers to start to introduce MediaWiki tools that will make it possible to control individual page sections when transcluding page content from a source page to a target page. Until we have such tools, we can use cut-and-paste and use transclusion of pages with individual blog entries.

Wikiversity Reports
The path to Wikiversity Reports was by way of Wikiversity the Movie and Wikiversity shorts. There were two goals. I wanted to learn about video podcasting and I think it would be useful for Wikiversity to make use of multimedia techniques to facilitate learning. Cormaggio asked, "In making technologically advanced reports, are we excluding the technologically-not-so-advanced participants?." Even if someone has no interest in making or using multimedia they can still participate at Wikiversity Reports and Wikiversity the Movie. There is work in support of making video presentations that can be done just by editing wiki pages. If someone wanted to, the content of a video presentation could be "translated" into other formats such as text descriptions of the content.

Problematic content
Cormaggio asked, "what will/can be done if materials from, say, a Nazi-ist perspective are added to Wikiversity?" The Wikimedia Foundation traditionally hides behind the safety of the "Neutral Point of View" and "No Original Research" policies. If Wikiversity is to create a space for scholarly activty that exists beyond the confines of NPOV and NOR then we need some new protections. I think that we can make use of a policy for Scholarly ethics to help the Wikiversity community distinguish between desirable and undesirable content.

Community development
Cormaggio raised several questions about how best to develop the Wikiversity community. I think this basically means attracting more good editors. There are specific things we can do to support both new wiki editors and experienced editors. I previously put some ideas at Supporting Wikiversity participants.

I think it is worth keeping in mind that most wikis depend on self-motivated volunteer editors who edit because they enjoy doing so. For example, some of the Wikia websites such as the Star Wars wikia are powered by a large fan base for Star Wars. Most students in conventional schools do not associate learning with fun and they are trained that academic learning is something they are forced to do by others.

Those learners who are self-motivated generally do not want to "waste" their time on inefficient learning. Such well-motivated learners seek out the most efficient learning experiences. While the Wikiversity community is forming we are in a situation where it is highly unlikely for several people with the same interests to show up at the same time and develop a constructive collaboration. Editors are likely to stay a short time, confirm that they cannot establish constructive social interactions with like-minded learners and then move on.

Under such conditions, it can be important to attract visionary participants who recognize that even a successful wiki such as Wikipedia started out small and took several years to begin to develop robust collaborative "wikiprojects" for particular academic topics. A first step towards attracting the rare participants who can help get Wikiversity started is to make sure that Wikiversity is widely "advertised". We also need good "help" pages and tutorials to help people learn to be constructive wiki editors.

We also need to build links to Wikipedia so that academically-oriented editors at Wikiversity feel free to help edit at Wikiversity.

title: User:JWSchmidt/Blog/15 January 2007


text: Category:JWSchmidt Blog

title: Category:JWSchmidt Blog


text:
User talk:Bronwynh

Your account will be renamed
Hello,

The developer team at Wikimedia is making some changes to how accounts work, as part of our on-going efforts to provide new and better tools for our users like cross-wiki notifications. These changes will mean you have the same account name everywhere. This will let us give you new features that will help you edit and discuss better, and allow more flexible user permissions for tools. One of the side-effects of this is that user accounts will now have to be unique across all 900 Wikimedia wikis. See the announcement for more information.

Unfortunately, your account clashes with another account also called Bronwynh. To make sure that both of you can use all Wikimedia projects in future, we have reserved the name Bronwynh~enwikiversity that only you will have. If you like it, you don't have to do anything. If you do not like it, you can pick out a different name.

Your account will still work as before, and you will be credited for all your edits made so far, but you will have to use the new account name when you log in.

Sorry for the inconvenience.

Yours, Keegan Peterzell Community Liaison, Wikimedia Foundation 23:31, 17 March 2015 (UTC)

title: User talk:Bronwynh


text: Spanish/Spanish One/Assignments

title: Spanish/Spanish One/Assignments


text:
User:Still life~enwikiversity

Please tell us about yourself. (Erase this and type here.) Robert Elliott

title: User:Still life~enwikiversity


text:
User:Sapphire~enwikiversity

I'm a general newbie to the world of programming. Still, in high school... And.. .Ohmigosh. I'm a girl. Yup.

title: User:Sapphire~enwikiversity


text: Spanish/Spanish One/Vocabulary

title: Spanish/Spanish One/Vocabulary


text:
File talk:Lorenz attractor.svg

Explanation
I was just passing through, and this picture caught my eye. People like me passing through would enjoy some links, or furth explanation in the image description. Cool picture, I think I'll go search around now and find out some more about it:P

Citing
I would like to reuse this picture, but I am not sure how to give the author credit in this situation. How can this be done?

title: File talk:Lorenz attractor.svg


text:
Wikiversity talk:Reports/15 January 2007

I wrote replies to some of Cormaggio's questions at my Wikiversity blog. --JWSchmidt 05:41, 15 January 2007 (UTC)
 * Can you cut and paste it?--Rayc 21:45, 18 January 2007 (UTC)
 * Actually transcusion might better, but whatever...--Rayc 01:18, 19 January 2007 (UTC)

Openness
Cormaggio mentioned that Wikiversity has a quality of openness. I understand this to reflect a comparison between Wikipedia and Wikiversity. Wikipedia has a narrow mission (produce encyclopedia articles) while I view Wikiversity as a more open experiment aimed at trying to explore the full potential of wiki technology as a tool to support human learning. The human capacity to form large and complex social groups and for individuals to learn from participation in social groups defines us as a species. Cormaggio asked how can we act to ensure that the openness of Wikiversity isn’t lost or undermined. Wikiversity needs to remember the broad mission of the Wikimedia Foundation, working to make possible that every human being can freely share in the sum of all knowledge. From a biological perspective, we need to remember that humans are diverse. The human brain is a device that amplifies human behavioral diversity. To respect this diversity Wikiversity can "run small experiments, tests, see what works, what doesn't, and be prepared to be flexible and change, and not be too locked into stone about how things should work" (Jimmy Wales said this in a different context, but I think it applies to Wikiversity source).

What are blogs at Wikiversity for?
Wikipedia was designed to be all about the "content" ot "product" while minimizing the role of the contributors. Wikiversity was given a broader mandate: "..... the idea here is to also host learning communities, so people who are actually trying to learn, actually have a place to come and interact and help each other figure out how to learn things. We're also going to be hosting and fostering research into how these kinds of things can be used more effectively" (source).

Each Wikiversity participant can use blogs to describe their learning goals. Doing so can help individuals find other Wikiversity participants with similar interests. Personal blogs can be used to document the intellectual challenges being faced by Wikiversity participants. I like the idea of "writing across the curriculum". Learners should always be writing and blogs are a natural way for learners to order their own thoughts. Group blogs for collaborative projects should also play a role at Wikiversity. Due to the limited communications channels linking wiki participants, we will all benefit from opening as many communications channels as possible.

connected blogs. I previously placed a request for the developers to start to introduce MediaWiki tools that will make it possible to control individual page sections when transcluding page content from a source page to a target page. Until we have such tools, we can use cut-and-paste and use transclusion of pages with individual blog entries.

Wikiversity Reports
The path to Wikiversity Reports was by way of Wikiversity the Movie and Wikiversity shorts. There were two goals. I wanted to learn about video podcasting and I think it would be useful for Wikiversity to make use of multimedia techniques to facilitate learning. Cormaggio asked, "In making technologically advanced reports, are we excluding the technologically-not-so-advanced participants?." Even if someone has no interest in making or using multimedia they can still participate at Wikiversity Reports and Wikiversity the Movie. There is work in support of making video presentations that can be done just by editing wiki pages. If someone wanted to, the content of a video presentation could be "translated" into other formats such as text descriptions of the content.

Problematic content
Cormaggio asked, "what will/can be done if materials from, say, a Nazi-ist perspective are added to Wikiversity?" The Wikimedia Foundation traditionally hides behind the safety of the "Neutral Point of View" and "No Original Research" policies. If Wikiversity is to create a space for scholarly activty that exists beyond the confines of NPOV and NOR then we need some new protections. I think that we can make use of a policy for Scholarly ethics to help the Wikiversity community distinguish between desirable and undesirable content.

Community development
Cormaggio raised several questions about how best to develop the Wikiversity community. I think this basically means attracting more good editors. There are specific things we can do to support both new wiki editors and experienced editors. I previously put some ideas at Supporting Wikiversity participants.

I think it is worth keeping in mind that most wikis depend on self-motivated volunteer editors who edit because they enjoy doing so. For example, some of the Wikia websites such as the Star Wars wikia are powered by a large fan base for Star Wars. Most students in conventional schools do not associate learning with fun and they are trained that academic learning is something they are forced to do by others.

Those learners who are self-motivated generally do not want to "waste" their time on inefficient learning. Such well-motivated learners seek out the most efficient learning experiences. While the Wikiversity community is forming we are in a situation where it is highly unlikely for several people with the same interests to show up at the same time and develop a constructive collaboration. Editors are likely to stay a short time, confirm that they cannot establish constructive social interactions with like-minded learners and then move on.

Under such conditions, it can be important to attract visionary participants who recognize that even a successful wiki such as Wikipedia started out small and took several years to begin to develop robust collaborative "wikiprojects" for particular academic topics. A first step towards attracting the rare participants who can help get Wikiversity started is to make sure that Wikiversity is widely "advertised". We also need good "help" pages and tutorials to help people learn to be constructive wiki editors.

We also need to build links to Wikipedia so that academically-oriented editors at Wikiversity feel free to help edit at Wikiversity. --JWSchmidt 22:51, 18 January 2007 (UTC)


text:
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return(txt+'Finish the quiz '); }

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function pluginRun { //Cargar todos los plugins for (i=0;i<'+'/script>'); } window.onload = pluginRun;

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title: Template:HB-Quiz


text:
Template:Bcp

 Wikipedia | Commons | Wikibooks | Quiz page | Log page

title: Template:Bcp


text:
Template:Film School - Drama Departments - Script Writing TOC

 * }


text:
User talk:Gnangarra

Bloom clock update
Hi Gnangarra. I moved the two things you had added to the 2006 page to the 2007a page, since it makes more sense to use Solstice rather than calendar year for the clock (since we're after natural rhythms). There's also a new template to use... you'll see it on the current clock page.

BTW: parasitic trees??? You guys have some interesting things going on down under :). --SB_Johnny | talk 12:42, 15 January 2007 (UTC)

title: User talk:Gnangarra


text:
Wikiversity:Forking proposal

This is a proposal for setting up the technical details of making Creative Commons-compliant forks here on Wikiversity. If we are able to set it up, we can integrate this into WV:FORK (this would also make the forking policy a lot easier to enable), and make "family trees" of related wikiversity projects that will share their deep histories.

What it's for
Say we had a learning project on particle physics, and wanted to use various pages for two other learning projects (say History Of Particle Physics and Applied Particle Physics). Rather than starting these new projects from scratch (or just copying and pasting pages from the original project), this system would allow us to make complete copies of any relevant pages (with the edit histories), for use in the other project(s).

How it would work

 * First, the pages would need to be exported to a designated Wikibooks namespace (probably by a Wikibooks Adminiatrator). So Particle Physics/Photons would now be at b:Schoolfork:Particle Physics/Photons
 * Next, the page would be moved on Wikibooks to b:Schoolfork:History of Particle Physics/Photons
 * Finally, the page would then be re-imported to History of Particle Physics/Photons
 * On the Wikibooks side, the content would then be deleted (the namespace should be kept empty for easy maintenence).

Wikibooks too...
Wikibooks also needs a way of making these kinds of forks, so we'd have a similar namespace here ("Bookfork:" might be a good name). This will be a cross-project endeavor, which is unusual but may have added benefits over time.

See Wikibooks:Forking proposal for details on the Wikibooks side.

What we'd need
We will need 3 things from bugzilla:

 * 1) Wikibooks will need Special:Import enabled from Wikiversity.
 * 2) Wikiversity will need to add the namespace "Bookfork:" (having a designated namespace makes for easier maintenence)
 * 3) Wikibooks will need to add the namespace "Schoolfork:"

title: Wikiversity:Forking proposal


text:
The GNOME Desktop - First Impressions

In this lesson, we will explore the GNOME Desktop, discuss our first impressions and gain some practical skills for navigating our desktop, accomplishing common tasks and basic customisation/personalisation.

Read the chapter: Main Desktop of the Using GNOME wikibook.

When GNOME starts, the first thing to do is log in.

Now, we can explore the desktop.

Much like the Windows "Start" button, the Applications button in the top left of the menu bar is used to launch applications. They are organized by usage, such as "Network" or "Office" applications. You can install more applications through your distribution's package manager.

title: The GNOME Desktop - First Impressions


text: User talk:Cabaka

title: User talk:Cabaka


text:
Talk:Katakana

=Questions= =Talk Page copied from Talk:Hiragana & Katakana= Balloonguy 23:42, 16 November 2006 (UTC) -- The table layout looks nice, but it doesn't show the stroke order. I suggest commons:Chinese stroke order:Asian alphabets, which has images with the stroke order of all the hiragana and almost all of the katakana.

 * Xlbnushk 03:58, 17 November 2006 (UTC) -- Wow, that's...a lot. That's in the very distant future. I can't even figure out how to get the tables to work right yet.

Balloonguy 22:54, 17 November 2006 (UTC) -- I modified the table to show different ways on how to show stroke order. One way is to link to the image and the other way is to show it right on the table. We could also organize the table by having separate tables for every consonant group.

 * Xlbnushk 23:53, 17 November 2006 (UTC) -- Hey, good job! Now that you show me, I like the stroke order style. That's definitely a go. And the image approach resolves the display issues that the table was having with Japanese characters.

Balloonguy 21:51, 18 November 2006 (UTC) -- Were you planning on including all the kana on this page? The page would get very long if you did. Also by looking at the bottom of the page and Topic:Japanese, it seems that we are going to have a learning project for reading and writing, speaking and for culture, which is fine, but how are we going to interconnect these concepts? Also, how are we going to apply The Wikiversity model for online learning?

 * Xlbnushk 06:32, 19 November 2006 (UTC) -- We could create assignments for people to practice writing...and then have them scan their practice sheets, if possible? I could put together some PDF's where you would be given the romanization or the kana and would have to figure out its counterpart. Frankly, though, I don't see too much of that happening here in particular. When we get to, say, basic grammar, we could have people put sentences together. That would be much easier to coordinate; people write sentences, submit the documents.
 * It is very possible to scan hand sketches, drawings, or text and then upload the image in gif or jpg to Wikiversity. Use the upload file submenu under toolbox on left.  It is necessary to find the html to copy to rotate the image to proper orientation in the page.  Some of the complicated portals have an image rotated.  Mirwin 12:41, 7 February 2007 (UTC)

 * Balloonguy 20:19, 19 November 2006 (UTC) -- I've thought about it and yes you are right, when people start learning kana, we can't really make a group thing come out of it. When we get more advanced we could ask them to come up with a collaborative story or something where each person adds on to the previous person's story.

 * Limetom 04:44, 23 December 2006 (UTC) -- Of course after forgetting to log in, I added in all the hiragana that were finished. It seems that the dakuten, hadakuten, and yoōn hiragana aren't finished yet.

 * Balloonguy 19:13, 23 December 2006 (UTC) -- Good job!

66.97.202.54 12:23, 29 December 2006 (UTC) -- THIS IS MY FIRST TIME IN WIKIVERSITY! I love this page, AWESOME welldone! Im afraid that japanese lessons are scarce here. But I now know every character! Beautiful illustration! --+I propose a pronounciation guide, a la "Living Language Japanese Coursebook [The Basics]"+-=

Limetom 12:49, 7 January 2007 (UTC) -- Katakana are now up. As with hiragana, the dakuten, hadakuten, and yoōn kana are not yet done. I don't know who did/is doing them, but I'd be glad to finish if I could figure out how they did it (and assuming I can do what they did in Photoshop in GIMP...)

title: Talk:Katakana