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Decades ago, in his foundational essay on the early days of the AIDS crisis, medical historian Charles Rosenberg wrote, “epidemics start at a moment in time, proceed on a stage limited in space and duration, following a plot line of increasing revelatory tension, move to a crisis of individual and collective character, then drift toward closure.” In the course of epidemics, societies grappled with sudden and unexpected mortality and also returned to fundamental questions about core social values. “Epidemics,” Rosenberg wrote, “have always provided occasion for retrospective moral judgment” (Rosenberg 1989, pp. 2, 9). Following Rosenberg’s observations, this essay places COVID-19 in the context of epidemic history to examine common issues faced during health crises—moral, political, social, and individual. Each disease crisis unfolds in its own time and place. Yet, despite specific contexts, we can see patterns and recurring concerns in the history of pandemics: (1) pandemics and disease crises in the past, along with public health responses to them, have had implications for civil liberties and government authority; (2) disease crises have acted as a sort of stress test on society, revealing, amplifying or widening existing social fissures and health disparities; (3) pandemics have forced people to cope with uncertain knowledge about the origin and nature of disease, the best sources of therapies, and what the future will hold after the crisis. While historians are not prognosticators, understanding past experience offers new perspectives for the present. The essay concludes by identifying aspects of history relevant to the road ahead.

Although previous studies have identified behavioral health risks associated with combat exposure, it is unclear which types of combat events are associated with these risks, particularly regarding contrasts among the risks associated with life-threatening experiences, killing combatants, and exposure to unjust war events, such as killing a noncombatant or being unable to help civilian women and children. In the present study, we examined surveys from 402 soldiers following deployment (i.e., baseline) and again 13 months later (i.e., Year 1). Regression analyses were conducted across a range of behavioral health (e.g., posttraumatic stress disorder, depression, suicide ideation, anxiety, somatic, insomnia, aggression) and benefit-finding measures, each controlling for two combat event categories while assessing the predictive utility of a third. The results suggested that life-threatening events were associated with poor behavioral health at baseline, relative risk (RR) = 10.00, but not at Year 1, RR = 2.67. At both baseline and Year 1, killing enemy combatants was not associated with behavioral health, RRs = 1.67-3.33, but was positively associated with benefit-finding, RRs = 26.67-40.00. Exposure to unjust war events was associated with a transdiagnostic pattern of behavioral health symptoms at baseline, RR = 40.00, and Year 1, RR = 23.33. Overall, the results suggest unjust war event exposure is particularly injurious, above and beyond exposure to other combat-related events. Future research can build on these findings to develop clearer descriptions of the combat events that might place service members at risk for moral injury and inform the development of assessment and treatment options.

The Walter Reed Army Institute of Research (WRAIR) supports more than 350,000 people on lifesaving HIV treatment in Kenya, Nigeria, Tanzania, and Uganda through funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Here, we review and synthesize the range of impacts WRAIR’s implementation science portfolio has had on PEPFAR service delivery for military and civilian populations since 2003. We also explore how investments in implementation science create institutional synergies within the U.S. Department of Defense, contributing to broad global health engagements and improving health outcomes for populations served. Finally, we discuss WRAIR’s contributions to PEPFAR priorities through use of data to drive and improve programming in real time in the era of HIV epidemic control and public health messaging that includes prevention, the 95-95-95 goals, and comorbidities.

Causes of birth defects are unclear, and the association with electromagnetic fields is inconclusive. We assessed the relationship between residential proximity to extremely low frequency electromagnetic fields from power grids and risk of birth defects. We analyzed a population-based sample of 2,164,246 infants born in Quebec, Canada between 1989 and 2016. We geocoded the maternal residential postal code at delivery and computed the distance to the nearest high voltage electrical transmission line or transformer station. We used log-binomial regression to estimate risk ratios (RR) and 95% confidence intervals (CI) for the association of residential proximity to transmission lines and transformer stations with birth defects, adjusting for maternal and infant characteristics. The prevalence of birth defects within 200 m of a transmission line (579.4 per 10,000 per live births) was only slightly higher compared with distances further away (568.7 per 10,000). A similar trend was seen for transformer stations. Compared with 200 m, a distance of 50 m was not associated with the risk of birth defects for transmission lines (RR 1.00, 95% CI 1.00-1.01) and transformer stations (RR 1.01, 95% CI 1.00-1.03). There was no consistent association when we examined birth defects in different organ systems. We found no compelling evidence that residential proximity to extremely low frequency electromagnetic fields from electrical power grids increases the risk of birth defects. Women residing near electrical grids can be reassured that an effect on the risk of birth defects is unlikely.

The nature of moral judgment is not only of longstanding philosophical interest, but also it is a matter of immediate practical concern. Currently, when the information, the advice, even the science and the sequela of the pandemic COVID-19 are all consistently and rapidly changing, it creates inconsistency in our decision making. Nevertheless, we lack of a detailed scientific understanding of how people make moral decisions. The letter is an effort aimed at understanding moral decision-making during the present pandemic of COVID-19.

It has been widely accepted that moral violations that involve impurity (such as spitting in public) induce the emotion of disgust, but there has been a debate about whether moral violations that do not involve impurity (such as swearing in public) also induce the same emotion. The answer to this question may have implication for understanding where morality comes from and how people make moral judgments. This study aimed to compared the neural mechanisms underlying two kinds of moral violation by using an affective priming task to test the effect of sentences depicting moral violation behaviors with and without physical impurity on subsequent detection of disgusted faces in a visual search task. After reading each sentence, participants completed the face search task. Behavioral and electrophysiological (event-related potential, or ERP) indices of affective priming (P2, N400, LPP) and attention allocation (N2pc) were analyzed. Results of behavioral data and ERP data showed that moral violations both with and without impurity promoted the detection of disgusted faces (RT, N2pc); moral violations without impurity impeded the detection of neutral faces (N400). No priming effect was found on P2 and LPP. The results suggest both types of moral violation influenced the processing of disgusted faces and neutral faces, but the neural activity with temporal characteristics was different.

Journal of Personality and Social Psychology, Vol 115 (2018), pp. 31-53., When observing an ostracism episode, observers may wish to know whether ostracism is justified or not. If ostracism appears unjustified, observers will likely blame the sources and sympathize with the target; if it appears justified, observers will likely blame and devalue the target. Here we introduce the “social dissimilarity rule,” which holds that observers base their moral judgments on dissimilarities between the members of the observed group. In five studies, participants either recalled observed ostracism episodes or observed group interactions in which one group member was ostracized (e.g., in a chat or a group-working task). Results show that if similar persons exclude a dissimilar target (target is an “odd-one-out”), observers attribute ostracism to malicious motives of the ostracizers, such as ingroup favoritism, and devalue the ostracizers. However, if ostracism cannot be explained by social dissimilarity between the sources and the target, observers assume that the target is being punished for a norm deviation (punitive motive) and devalue the target. Use of the social dissimilarity rule was neither moderated by cognitive load (Study 3) nor by the perceived essentiality of the group distinction (Study 4). But if participants knew that the target previously deviated from a norm, knowledge about the situation had a stronger effect on moral judgments (Study 5) than social dissimilarity. These findings further our understanding of how observers make moral judgments about ostracism, which is important given that an observer’s moral judgment can strongly impact bystander behavior and thus target recovery and well-being.

This mixed-methods study examined the impact of educational space on undergraduate belonging and learning by analyzing the post-event evaluations of 259 healthcare living-learning program (LLP) students who attended co-curricular programming designed to enhance belonging, career exploration, and interprofessional awareness. Students were broken into two groups based on program location. Post-event evaluations were analyzed using a Mann Whitney U-test and thematic analysis. Themes of career exploration and interprofessional awareness/identity formation emerged in the open-ended responses of both groups. Belonging was enhanced/muted by program location. Seemingly superficial, this variable actually reflects the institution's performance of educational space. The study includes a short discussion regarding the goal of constructing more inclusive educational spaces that support student belonging and success for all students.

Ligament laxity is a known complication of erosive immune-mediated polyarthritis (IMPA) in dogs. The purpose of this study was to describe the occurrence and clinical features of carpal or tarsal ligament laxity in cases of nonerosive IMPA in dogs for the first time. Five client-owned dogs with a diagnosis of nonerosive IMPA and carpal or tarsal ligament laxity in which the influence of corticosteroids was excluded were identified. Medical records were reviewed, and data including signalment, investigative findings, and treatment regimen (e.g., surgical management) was extracted. Primary care practices were contacted to obtain follow-up, and the data was descriptively analyzed. The affected joints were either carpi and tarsi (n = 3) or carpi only (n = 2). In three cases, surgical arthrodesis was performed. Three dogs were euthanized (1 mo, 12 mo, and 5 yr) as a result of the severity of clinical signs and poor control. In the four dogs surviving >6 mo, multiple episodes of relapse were recorded, and multimodal immunosuppression was needed. The prognosis for the dogs described was poor, with none achieving control of the disease without ongoing immunosuppressive therapy. Damage to soft-tissue periarticular structures may be related to prolonged clinical disease or a more severe presentation. Jaccoud’s arthropathy in humans with systemic lupus erythematosus may represent a homologous presentation.

The paper discusses Freud's view of the law as the implementation of collective violence on the individual violator. I focus on the implications of the link between the superego (as the source of moral judgment) and the aggressive drive and suggest that we need to be ever vigilant regarding the danger of employing the law as a disguised means of taking pleasure in collective violence. The paper also discusses Freud's conception of personal responsibility, according to which we are responsible for all our behavior, including unconsciously motivated behavior (such as slips and dreams). However, the kind of responsibility Freud has in mind is not the moral responsibility of blameworthiness or praiseworthiness, but rather responsibility in the sense that, whether or not acknowledged, all our behavior reflects our personal desires and motives.

Aim: To examine the stage changes and survival differences among triple-negative breast cancer (TNBC) patients based on the prognostic staging system. Methods: We used the SEER database to identify eligible patients with TNBC diagnosed between 2010 and 2014. Kaplan–Meier curves were drawn for comparison. The primary end point was breast cancer-specific survival. Results: The median follow-up time was 26 months for 19,608 patients. The stages of all TNBC patients increased or remained unchanged during rearrangement from anatomic staging to prognostic staging. Stage IIA, IIIA and IIIC comprised the majority of patients. Several patients did not have prognostic staging. Stage IIIC incorporated six substages that contributed to high heterogeneity. Overall, the Kaplan–Meier curves still showed the favorable differentiation among stages and substages, with the exception of stage IIB and substage IIIA (T2N0, grade 2–3) patients. Conclusion: The prognostic information for breast cancer patients provided by the novel prognostic staging system may be less accurate for TNBC patients in our independent analysis. Moreover, stage IIB and substage IIIA (T2N0, grade 2–3) should possibly undergo further evaluation.

Hospice care is medical care provided to terminally ill patients with a life expectancy of 6 months or less. Hospice services include symptom control, pain management, palliative care, and other supportive services such as providing for home equipment or oxygen; however, it does not provide for life-prolonging therapies such as chemotherapy. Although oncologic benchmarks suggest patients should be enrolled in hospice 3 months prior to death, studies show that most hospice referrals are being made too late. These shorter stays in hospice result in increased cost of care especially at the end of life with most patients dying on aggressive treatments in the hospital. Thus, identifying barriers to hospice placement is critical in improving the referral process and enhancing the quality of end-of-life care. This retrospective study collected data on 418 oncologic patients who passed in 2015 and categorized patients based on hospice status at the time of death. Our study found that the demographics between hospice and nonhospice patients were not significantly different. Hospice patients spent a median of 10 days in hospice and 71% (n = 161) of patients were in hospice 30 days or less. Additionally, 56% of patients were in hospice 10 days or less. Increased education for patients and health-care providers along with better utilization of palliative care services and incorporating a nurse navigator to help with transitioning patients to hospice would improve earlier referral to hospice care and enhance patients’ quality of life.

To evaluate peri- and post-operative outcomes after robotic partial nephrectomy (RPN) in patients with a solitary kidney. A multi-institutional database of 1868 patients was used to identify 35 patients with a solitary kidney who underwent RPN at six different centers from 2007 to 2016. Peri-operative outcomes were summarized with descriptive statistics. We assessed the change in eGFR over time with a linear mixed-effects model. Median operative time, ischemia time, and estimated blood loss were 172 min, 16 min, and 113 mL, respectively. There were no positive surgical margins. The median length of stay was 1 day (range 1–7), and over half (54.3%) of patients were discharged one post-operative day 1. Seven post-operative complications occurred in six patients (17.1%); of which four were Clavien I, two were Clavien II, and one was Clavien III. The linear decline in eGFR up to 24 month post-RPN was marginal and not significant (s = − 0.14; 95% CI = − 0.51, 0.23; p = 0.453), with predicted mean eGFR decreasing from 59.2 to 55.8 mL/min/1.73 m2 at 24 months. These results suggest that, in patients with a solitary kidney, RPN is a safe and feasible treatment option. In patients with a solitary kidney, RPN did not significantly compromise renal function for up to 2 years after surgery.

The association between tea consumption and type 2 diabetes risk remains inconsistent in Asian populations. This case-control study investigated the association between habitual tea consumption and the risk of type 2 diabetes among Vietnamese adults.A hospital-based case-control study was conducted during 2013-2015 in Vietnam. A total of 599 newly diagnosed diabetic cases (aged 40-65 years) and 599 hospital-based controls, frequency matched by age and sex, were recruited. Information about frequency, quantity, and duration of tea drinking, together with demographics, habitual diet and lifestyle characteristics, was obtained from direct interviews using a validated and reliable questionnaire. Unconditional logistic regression analyses were performed to assess the association between different metrics of tea consumption and the type 2 diabetes risk.Control subjects reported higher tea consumption levels than the cases in terms of duration, frequency, and quantity of tea drunk. After accounting for confounding factors, increasing tea consumption was found to be associated with a reduced risk of type 2 diabetes; the adjusted odds ratio (95% confidence interval) was 0.66 (0.49, 0.89) for participants drinking2 cups/day, relative to those drinking1 cup/day. Significant inverse dose-response relationships were also observed for average number of cups consumed daily and years of tea drinking (p0.01).Habitual tea consumption is associated with a reduced risk of type 2 diabetes among Vietnamese adults.

Complex moral decision making is associated with the ventromedial prefrontal cortex (vmPFC) in humans, and damage to this region significantly increases the frequency of utilitarian judgments. Since the vmPFC has strong anatomical and functional links with the hippocampus, here we asked how patients with selective bilateral hippocampal damage would derive moral decisions on a classic moral dilemmas paradigm. We found that the patients approved of the utilitarian options significantly less often than control participants, favoring instead deontological responses-rejecting actions that harm even one person. Thus, patients with hippocampal damage have a strikingly opposite approach to moral decision making than vmPFC-lesioned patients. Skin-conductance data collected during the task showed increased emotional arousal in the hippocampal-damaged patients and they stated that their moral decisions were based on emotional instinct. By contrast, control participants made moral decisions based on the integration of an adverse emotional response to harming others, visualization of the consequences of one's action, and the rational re-evaluation of future benefits. This integration may be disturbed in patients with either hippocampal or vmPFC damage. Hippocampal lesions decreased the ability to visualize a scenario and its future consequences, which seemed to render the adverse emotional response overwhelmingly dominant. In patients with vmPFC damage, visualization might also be reduced alongside an inability to detect the adverse emotional response, leaving only the utilitarian option open. Overall, these results provide insights into the processes involved in moral decision making and highlight the complementary roles played by two closely connected brain regions. SIGNIFICANCE STATEMENT: The ventromedial prefrontal cortex (vmPFC) is closely associated with the ability to make complex moral judgements. When this area is damaged, patients become more utilitarian (the ends justify the means) and have decreased emotional arousal during moral decision making. The vmPFC is closely connected with another brain region-the hippocampus. In this study we found that patients with selective bilateral hippocampal damage show a strikingly opposite response pattern to those with vmPFC damage when making moral judgements. They rejected harmful actions of any kind (thus their responses were deontological) and showed increased emotional arousal. These results provide new insights into the processes involved in moral decision making and highlight the complementary roles played by two closely connected brain regions.

In this essay, we defend the design of the Salk polio vaccine trial and try to put some limits on the role schemata should play in designing clinical research studies. Our presentation is structured as a response to de Freitas and Pietrobon (de Freitas, R. S. and R. Pietrobon. 2007. Whoever could get rid of the context of discovery/context of justification dichotomy? A proposal based on recent developments in clinical research. Journal of Medicine and Philosophy 32:25-42.) who identified the CONSORT statement as a schema that would have, had it existed at the time, ruled out the design of the Salk polio vaccine trial of 1954 in favor of a completely randomized controlled clinical trial (RCT). We argue that large-scale public health interventions often require evidence beyond simple efficacy, the limit of what an RCT can provide, and that the design actually adopted for the Salk trial represented a reasonable-albeit imperfect-compromise. This is of more than historical interest in that many contemporary studies are of the scale and scope to require a more pragmatic, rather than explanatory, approach to study design (Kowalski, C. J. 2010. Pragmatic problems with clinical equipoise. Perspectives in Biology and Medicine 53:161-73.).

A recently published book by the head of Nelson Mandela’s medical team made personal disclosures about his treatment of the late president in his final years up until his death. The author claimed that he had written the book at the request of family members. This was contested by some family members and the executors of Mandela’s estate, and the book was subsequently withdrawn by the publishers. The Mandela book case raises ethical and legal questions about who should consent to publication of medical information about public figures after their death. The ethical rules of conduct of the Health Professions Council of South Africa (HPCSA) state that confidential information about a deceased person should only be divulged ‘with the written consent of his or her next of kin or the executor of his or her estate’. ‘Next of kin’ is not defined, however, and problems arise when family members and the executors are divided about giving such written consent. It is recommended that in such cases the specific order of priority for consent by relatives in the National Health Act be followed. However, conduct that is unethical under the rules of the HPCSA may not necessarily be actionable under the law. For instance, the law does not protect the confidentiality of deceased persons, and generally when people die their constitutional and common-law personality rights – including their right to privacy and confidentiality – die with them. This means that the next of kin or executors of the estates of deceased persons may not bring actions for damages on behalf of such persons for breaches of confidentiality arising after their deaths. The next of kin may, however, sue in their personal capacity if they can show that the disclosures were an unlawful invasion of their own privacy. Conversely, if the privacy of interests of the next of kin are not harmed where there has been publication without their consent, they will not be able to sue for damages.

Background: Moral competence (MC) in physicians is fundamental, given the increasing complexity of medicine. The “Moral Competence Test” (MCT © Lind) evaluates this feature and its indicator is the C Index (CI). Aim: To explore moral competence and its associated factors among physicians working in Chile. Material and Methods: The MCT was answered by 236 physicians from two medical centers who voluntarily participated in the study. Besides the test, participants completed an encrypted form giving information about gender, years in practice and post-graduate studies. Results: The average CI value of the participants was 20,9. Post-graduate studies had a significant positive influence on CI. There was a significant decrease in CI, between 16 and 20 years of professional exercise. Gender and the area of post-graduate studies did not have a significant influence. Conclusions: The studied physicians showed a wide range of CI which was positively affected by the postgraduate studies performed. The years of professional practice had a negative influence. Expanding training opportunities during professional practice could have a positive effect on CM as measured by CI.

Background: Moral competence (MC) in physicians is fundamental, given the increasing complexity of medicine. The “Moral Competence Test” (MCT © Lind) evaluates this feature and its indicator is the C Index (CI). Aim: To explore moral competence and its associated factors among physicians working in Chile. Material and Methods: The MCT was answered by 236 physicians from two medical centers who voluntarily participated in the study. Besides the test, participants completed an encrypted form giving information about gender, years in practice and post-graduate studies. Results: The average CI value of the participants was 20,9. Post-graduate studies had a significant positive influence on CI. There was a significant decrease in CI, between 16 and 20 years of professional exercise. Gender and the area of post-graduate studies did not have a significant influence. Conclusions: The studied physicians showed a wide range of CI which was positively affected by the postgraduate studies performed. The years of professional practice had a negative influence. Expanding training opportunities during professional practice could have a positive effect on CM as measured by CI.

The current study investigated children’s intention-based sociomoral judgments and distribution behavior from a third-party stance. An actor puppet showed either positive or negative intention toward a target puppet, which had previously performed a prosocial or antisocial action toward others (i.e., children witnessed various types of indirect reciprocity). Children (3- and 5-year-olds) were asked to make sociomoral judgments and to distribute resources to the actor puppet. Results showed that 5-year-olds were more likely than 3-year-olds to be influenced by intention when they made their judgment and distributed resources. The target’s previous actions affected only 5-year-olds’ intent-based social preference. These results suggest that children’s judgments about intent-based indirect reciprocity develop from ages 3 to 5 years.

Moral competence (MC) in physicians is fundamental, given the increasing complexity of medicine. The "Moral Competence Test" (MCT © Lind) evaluates this feature and its indicator is the C Index (CI).To explore moral competence and its associated factors among physicians working in Chile.The MCT was answered by 236 physicians from two medical centers who voluntarily participated in the study. Besides the test, participants completed an encrypted form giving information about gender, years in practice and post-graduate studies.The average CI value of the participants was 20,9. Post-graduate studies had a significant positive influence on CI. There was a significant decrease in CI, between 16 and 20 years of professional exercise. Gender and the area of post-graduate studies did not have a significant influence.The studied physicians showed a wide range of CI which was positively affected by the postgraduate studies performed. The years of professional practice had a negative influence. Expanding training opportunities during professional practice could have a positive effect on CM as measured by CI.

This article addresses the question of why the emotions children and adolescents anticipate in the context of hypothetical scenarios have been repeatedly found to predict actual (im)moral behavior. It argues that a common motivational account of this relationship is insufficient. Instead, three links are proposed that connect cognitive representations of emotional experiences related to future (im)moral actions with decision making and action. Accordingly, it is argued that moral emotion attributions can represent a dominant desire (link 1), outcome expectancies (link 2), or an emotional response to anticipated (in)consistencies of the self (link 3). These three links exemplify different forms of moral agency that emerge in the course of children's and adolescents' development.

Victoria (Australia) is considering retrospective legislation on the abolition of gamete donor anonymity. Retrospective legis- lation evokes many negative emotions mainly because it is considered unfair. It also makes it impossible for citizens to organize their life with reasonable certainty of the consequences. Introduction of this law for donor anonymity is defended by the right of the child to know its genetic origins. Against this law, people appeal to the right to privacy and confidentiality of the donor. This paper analyses the arguments for and against a retrospective law on donor anonymity by looking at the conditions that should be respected when two principles (the donor's right to privacy and the child's right to genetic information) have to be balanced. It is concluded that the justification for introducing retrospective law is lacking: the conditions are not fulfilled. Moreover, retroactive laws in the context of gamete donation may jeopardize the whole practice by destroying the trust of candidate donors and recipients in the government.

Seminal articles published in the late 1990s instigated not only an intense interest in health care quality but also a new era of research into quality end-of-life care, particularly in intensive care units (ICUs). ICUs can improve health care quality at the end of life by better using palliative care services and palliative care-related principles. This article details how the interest in health care quality has spurred a similar interest in end-of-life and palliative care in ICUs, defines palliative care and describes how it improves health care quality, and highlights barriers to the incorporation of palliative care in ICUs.

Results from functional magnetic resonance imaging and lesion studies indicate that the prefrontal cortex (PFC) is essential for successful navigation through a complex social world inundated with intricate norms and moral values. This review examines regions of the PFC that are critical for implicit and explicit social cognitive and moral judgment processing. Considerable overlap between regions active when individuals engage in social cognition or assess moral appropriateness of behaviors is evident, underscoring the similarity between social cognitive and moral judgment processes in general. Findings are interpreted within the framework of structured event complex theory, providing a broad organizing perspective for how activity in PFC neural networks facilitates social cognition and moral judgment. We emphasize the dynamic flexibility in neural circuits involved in both implicit and explicit processing and discuss the likelihood that neural regions thought to uniquely underlie both processes heavily interact in response to different contextual primes.

In five studies, we explored whether power increases moral hypocrisy (i.e., imposing strict moral standards on other people but practicing less strict moral behavior oneself). In Experiment 1, compared with the powerless, the powerful condemned other people’s cheating more, but also cheated more themselves. In Experiments 2 through 4, the powerful were more strict in judging other people’s moral transgressions than in judging their own transgressions. A final study found that the effect of power on moral hypocrisy depends on the legitimacy of the power: When power was illegitimate, the moral-hypocrisy effect was reversed, with the illegitimately powerful becoming stricter in judging their own behavior than in judging other people’s behavior. This pattern, which might be dubbed hypercrisy, was also found among low-power participants in Experiments 3 and 4. We discuss how patterns of hypocrisy and hypercrisy among the powerful and powerless can help perpetuate social inequality.

After a trust violation, some people are quick to forgive, whereas others never trust again. In this report, we identify a key characteristic that moderates trust recovery: implicit beliefs of moral character. Individuals who believe that moral character can change over time ( incremental beliefs) are more likely to trust their counterpart following an apology and trustworthy behavior than are individuals who believe that moral character cannot change ( entity beliefs). We demonstrate that a simple but powerful message can induce either entity or incremental beliefs about moral character.

OBJECTIVE: To describe first change or discontinuation in combination antiretroviral treatment (cART) among previously treatment naive HIV-infected adults in a resource-constrained setting. METHODS: The United States Agency for International Development-Academic Model Providing Access to Healthcare Partnership has enrolled >90000 HIV-infected patients at 18 clinics throughout western Kenya. Patients in this analysis were aged > or =18 years previously antiretroviral treatment naive and initiated to cART between January 2006 and November 2007 with at least 1 follow-up visit. A treatment change or discontinuation was defined as change of regimen including single drug substitutions or a complete halting of cART. RESULTS: There were 14162 patients eligible for analysis and 10313 person-years of follow-up of whom 1376 changed or stopped their cART. Among these 859 (62%) changed their regimen (including 514 patients who had a single drug substitution) and 517 (38%) completely discontinued cART. The overall incidence rate (IR) of cART changes or stops per 100 person-years was 13.3 [95% confidence interval (CI): 12.7-14.1]. The incidence was much higher in the first year of post-cART initiation (IR: 25.0 95% CI: 23.6-26.3) compared with the second year (IR: 2.4 95% CI: 2.0-2.8). The most commonly cited reason was toxicity (46%). In multivariate regression individuals were more likely to discontinue cART if they were World Health Organization stage III/IV [adjusted hazard ratio (AHR): 1.37 95% CI: 1.11-1.69] or were receiving a zidovudine-containing regimen (AHR: 4.44 95% CI: 3.35-5.88). Individuals were more likely to change their regimen if they were aged > or =38 years (AHR: 1.44 95% CI: 1.23-1.69) had to travel more than 1 hour to clinic (AHR: 1.34 95% CI: 1.15-1.57) had a CD4 at cART initiation < or =111 cells/mm3 (AHR: 1.51 95% CI: 1.29-1.77) or had been receiving a zidovudine-containing regimen (AHR: 3.73 95% CI: 2.81-4.95). Those attending urban clinics and those receiving stavudine-containing regimens were less likely to experience either a discontinuation or a change of their cART. CONCLUSIONS: These data suggest a moderate incidence of cART changes and discontinuations among this large population of adults in western Kenya. Mostly occurring within 12 months of cART initiation and primarily due to toxicity older individuals those with more advanced disease and those using zidovudine are at higher risk of experiencing a change or a discontinuation in their cART.

Logically, an unethical behavior performed yesterday should also be unethical if performed tomorrow. However, the present studies suggest that the timing of a transgression has a systematic effect on people's beliefs about its moral acceptability. Because people's emotional reactions tend to be more extreme for future events than for past events, and because such emotional reactions often guide moral intuitions, judgments of moral behavior may be more extreme in prospect than in retrospect. In 7 studies, participants judged future bad deeds more negatively, and future good deeds more positively, than equivalent behavior in the equidistant past. In addition, participants thought that future unfair actions deserved more punishment than past unfair actions, and were more willing to sacrifice their own financial gain to be treated fairly in the future compared with in the past. These patterns were explained in part by the stronger emotions that were evoked by thoughts of future events than by thoughts of past events. Taken together, the results suggest that permission for actions with ethical connotations may be harder to get than forgiveness for those same actions, and demonstrate a systematic way in which moral judgments of the same action are inconsistent across time.

In some cases people judge it morally acceptable to sacrifice one person's life in order to save several other lives, while in other similar cases they make the opposite judgment. Researchers have identified two general factors that may explain this phenomenon at the stimulus level: (1) the agent's intention (i.e. whether the harmful event is intended as a means or merely foreseen as a side-effect) and (2) whether the agent harms the victim in a manner that is relatively "direct" or "personal". Here we integrate these two classes of findings. Two experiments examine a novel personalness/directness factor that we call personal force, present when the force that directly impacts the victim is generated by the agent's muscles (e.g., in pushing). Experiments 1a and b demonstrate the influence of personal force on moral judgment, distinguishing it from physical contact and spatial proximity. Experiments 2a and b demonstrate an interaction between personal force and intention, whereby the effect of personal force depends entirely on intention. These studies also introduce a method for controlling for people's real-world expectations in decisions involving potentially unrealistic hypothetical dilemmas.

Moral text processing was used as an ecologically valid method for assessing implicit and explicit moral understanding and development. The authors tested undergraduates, seminarians, and graduate students in political science and philosophy for recall of moral narratives and moral expository texts. Multivariate analyses of covariance using educational experience as an independent variable, age and moral judgment score as covariates, and recall of embedded moral arguments as a dependent variable revealed a relation between education and level of moral arguments recalled. Lower stage moral reasoning was best recalled by undergraduates, whereas higher stage reasoning was best recalled by graduate students, with seminarians intermediate for both types of text. Moral judgment score was related to recall of the highest level moral arguments even when age and educational experience were controlled. Moral judgment development appeared to be particularly helpful in recall of expository compared with narrative texts.

Moral sensitivity is the first component of the 4-component moral action process (J. R. Rest, 1986). The author reviews moral sensitivity operationalization and measurement across multiple samples and domains. She reviews 3 definitions of the construct (i.e., recognition and affective response, recognition, and recognition and ascription of importance) and measurement instruments based on these definitions and assesses these instruments according to their methodological rigor. The author also briefly discusses the measurement of constructs related to moral sensitivity in children (i.e., empathy, role-taking, and prosocial moral reasoning). Last, the author presents the conclusions that can be drawn from current measurement methodology and her recommendations for future measurement development.

Suicide represents one of the leading causes of trauma in industrialized countries. However, when compared with unintentional injury and assault, the outcome of self-inflicted injury has not been well described.All patients admitted to a French academic trauma center from January 2002 to December 2004 and listed in a trauma data bank were included in a prospective analysis. Variables including mortality, circumstances (unintentional vs. assault vs. self-inflicted), and mechanism of injury were recorded.About 1,004 continuous trauma patients were analyzed: 151 (15%) with self-inflicted injuries, 761 (76%) with unintentional injuries, and 91 (9%) with injuries from assault. When compared with patients suffering from unintentional injuries and assault, self-inflicted injury patients presented more frequently after a fall from height (94 of 151 vs. 133 of 759 and 0 of 91, p0.05) and with a severe head injury (47 of 151 vs. 172 of 752 and 10 of 91, p0.05). They also had a more severe injury (Injury Severity Score, 28 +/- 21 vs. 22 +/- 16 and 12 +/- 10; p0.05), a lower probability of survival (Trauma Related Injury Severity Score, 0.71 +/- 0.37 vs. 0.83 +/- 0.28 and 0.92 +/- 0.19; p0.05), and survival rate (70% vs. 85% and 93%, p0.05). In multivariate analysis, Trauma Related Injury Severity Score (odds ratio, 0.54; 95% confidence interval, 0.45-0.59; p0.001), age (odds ratio, 1.17; confidence interval, 1.02-1.34; p0.05), and mechanism of trauma (p = 0.01) were independently correlated with the final mortality rate.Self-inflicted injury patients presented with a higher mortality rate that was related to increased injury severity. The circumstances surrounding the trauma were not independently associated with an increased odds ratio of death after major trauma.

Common morality theory must confront apparent counterexamples from the history of morality, such as the widespread acceptance of slavery in prior eras, that suggest core norms have changed over time. A recent defense of common morality theory addresses this problem by drawing a distinction between the content of the norms of the common morality and the range of individuals to whom these norms apply. This distinction is successful in reconciling common morality theory with practices such as slavery, but only at the cost of underscoring the limits of common morality theory, in particular its inability to resolve disputes about the moral status of entities. Given that many controversies in bioethics center on the disputed status of various entities, such as embryos and nonhuman animals, this is an important limitation. Nonetheless, common morality theory still can be a useful resource in diminishing moral conflict on issues that do not involve disputes over moral status.

An important consideration in judging the blameworthiness (or praiseworthiness) of an action is whether the agent had sufficient control over it. In three experiments, we investigated judgments of moral blame and praise elicited when individuals were presented with vignettes describing actions that were performed either carefully and deliberately or impulsively and uncontrollably. Experiment 1 uncovered an asymmetry between judgments of positive versus negative actions—negative impulsive actions elicited a discounting of moral blame, but positive impulsive actions did not elicit a discounting of moral praise. Experiments 2 and 3 showed that this asymmetry arises because individuals judge agents on the basis of their metadesires (the degree to which the agents embrace or reject the impulses leading to their actions). Individuals assume that an agent would embrace an uncontrollable positive impulse, and reject an uncontrollable negative impulse.

Phenomena of moral conflict and disagreement have led writers in ethics to two antithetical conclusions: Either valid moral distinctions hold universally or they hold relative to a particular and contingent moral framework, and so cannot be applied with universal validly. Responding to three articles in this issue of the Journal that criticize his previously published views on the common morality, the author maintains that one can consistently deny universality to some justified moral norms and claim universality for others. Universality is located on the common morality and nonuniversality in other parts of the moral life, called "particular moralities." The existence of universal moral standards is defended in terms of: (1) a theory of the objectives of morality, (2) an account of the norms that achieve those objectives, and (3) an account of normative justification (both pragmatic and coherentist).

Psychiatry is not only a technical discipline concerned with matching appropriate means to pre-specified ends; it is also a discipline of moral engagement and discernment in which clinicians and patients explore the ends that patients will pursue. Moral engagement is intrinsic to psychiatric practice, particularly when psychiatrists engage issues such as combat trauma in which patients' moral self-evaluations are relevant to the perpetuation of psychological distress. Relative to technical models of practice, however, the space of moral engagement and discernment conveys risk for psychiatrists as it is less "scientific," more prone to exploitation and abuse, and the occasion for social-political critiques of psychiatry. Three prevalent forms of psychiatric dualism, each manifest in the care of combat veterans, seem to allow psychiatrists to avoid this contested moral space: dualism of the self and the self's body, dualism of the self and the self's quantifiable experience and behavior, and dualism of the self and the self's "values." Each of these dualisms is alluring but ultimately unable to protect psychiatrists from the space of moral engagement. Psychiatrists must rather cultivate practices for inhabiting that space in a morally transparent, self-questioning, and responsible way.

Humans show a rare tendency to punish norm-violators who have not harmed them directly-a behavior known as third-party punishment. Research has found that third-party punishment is subject to intergroup bias, whereby people punish members of the out-group more severely than the in-group. Although the prevalence of this behavior is well-documented, the psychological processes underlying it remain largely unexplored. Some work suggests that it stems from people's inherent predisposition to form alliances with in-group members and aggress against out-group members. This implies that people will show reflexive intergroup bias in third-party punishment, favoring in-group over out-group members especially when their capacity for deliberation is impaired. Here we test this hypothesis directly, examining whether intergroup bias in third-party punishment emerges from reflexive, as opposed to deliberative, components of moral cognition. In 3 experiments, utilizing a simulated economic game, we varied participants' group relationship to a transgressor, measured or manipulated the extent to which they relied on reflexive or deliberative judgment, and observed people's punishment decisions. Across group-membership manipulations (American football teams, nationalities, and baseball teams) and 2 assessments of reflexive judgment (response time and cognitive load), reflexive judgment heightened intergroup bias, suggesting that such bias in punishment is inherent to human moral cognition. We discuss the implications of these studies for theories of punishment, cooperation, social behavior, and legal practice. (PsycINFO Database Record

If the aphorism “history will be the judge” is deployed, the active agent of this formulation is the historian. Comparing two great(ly infamous) doctors,John C. Cutler and Alan Berkman, the article considers how historians balance digging for sources, creating meaningful narrative, and acknowledging our own beliefs that embed in the judgments we make. The article explores our responsibility for balance and moral judgment at the same time. Cutler, admonished for his role in the infamous sexually transmitted diseases studies in Tuskegee and Guatemala, also was a well-respected researcher and teacher. Berkman, renowned for his success in global HIV/AIDs activism, was also only the second physician in U.S. history to be charged with accessory to murder after the fact and who served seven hard years for bombings and robbery. The author considers her relationship to these physicians and the effort to create a passionate historical practice.

During World War II, malaria research was conducted in prisons. A notable example was the experiments at Stateville Penitentiary in Illinois, in which prisoner-subjects were infected with malaria for the purpose of testing the safety and efficacy of novel anti-malaria drugs. Over time, commentators have shifted from viewing the malaria research at Stateville as a model of ethical clinical research to seeing the experiments as paradigmatic of abusive human experimentation. This essay undertakes a retrospective ethical assessment of the Stateville malaria research during the 1940s in light of basic ethical principles and the Nuremberg Code, as well as contemporary malaria research. In addition to its historical interest, this case study provides a rich context for addressing basic issues of research ethics, including the voluntariness of consent, the justification of risks, and the exploitation of vulnerable subjects.

Previous studies showed that incidental feelings of disgust could make moral judgments more severe. In the present study, we investigated whether individual differences in mindfulness modulated automatic transference of disgust into moral judgment. Undergraduates were divided into high- and low-mindfulness groups based on the mean score on each subscale of the Five Facet Mindfulness Questionnaire (FFMQ). Participants were asked to write about a disgusting experience or an emotionally neutral experience, and then to evaluate moral (impersonal vs. high-conflict personal) and non-moral scenarios. The results showed that the disgust induction made moral judgments more severe for the low "acting with awareness" participants, whereas it did not influence the moral judgments of the high "acting with awareness" participants irrespective of type of moral dilemma. The other facets of the FFMQ did not modulate the effect of disgust on moral judgment. These findings suggest that being present prevents automatic transference of disgust into moral judgment even when prepotent emotions elicited by the thought of killing one person to save several others and utilitarian reasoning conflict.