To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Benzodiazepine (BZD) prescription rates have increased over the past decade in the United States. Available literature indicates that sociodemographic factors may influence diagnostic patterns and/or prescription behaviour. Herein, the aim of this study is to determine whether the gender of the prescriber and/or patient influences BZD prescription.
Cross-sectional study using data from the Florida Medicaid Managed Medical Assistance Program from January 1, 2018 to December 31, 2018. Eligible recipients ages 18 to 64, inclusive, enrolled in the Florida Medicaid plan for at least 1 day, and were dually eligible. Recipients either had a serious mental illness (SMI), or non-SMI and anxiety.
Total 125 463 cases were identified (i.e., received BZD or non-BZD prescription). Main effect of patient and prescriber gender was significant F(1, 125 459) = 0.105, P = 0 .745, partial η2 < 0.001. Relative risk (RR) of male prescribers prescribing a BZD compared to female prescribers was 1.540, 95% confidence intervals (CI) [1.513, 1.567], whereas the RR of male patients being prescribed a BZD compared to female patients was 1.16, 95% CI [1.14, 1.18]. Main effects of patient and prescriber gender were statistically significant F(1, 125 459) = 188.232, P < 0.001, partial η2 = 0.001 and F(1, 125 459) = 349.704, P < 0.001, partial η2 = 0.013, respectively.
Male prescribers are more likely to prescribe BZDs, and male patients are more likely to receive BZDs. Further studies are required to characterize factors that influence this gender-by-gender interaction.
Psychotropic medications are sometimes used off-label and inappropriately. This may cause harm to adolescents with intellectual disability. However, few studies have analysed off-label or inappropriate prescribing to this group.
To examine the appropriateness of psychotropic prescribing to adolescents with intellectual disability living in the community in south-east Queensland, Australia.
Off-label medication use was determined based on whether the recorded medical condition treated was approved by the Australian Therapeutic Goods Administration. Clinical appropriateness of medication use was determined based on published guidelines and clinical opinion of two authors who specialise in developmental disability medicine (J.N.T. and D.H.).
We followed 429 adolescents for a median of 4.2 years. A total of 107 participants (24.9%) were prescribed psychotropic medications on at least one occasion. Of these, 88 (82.2%) were prescribed their medication off-label or inappropriately at least once. Off-label or inappropriate use were most commonly associated with challenging behaviours.
Off-label or inappropriate use of psychotropic medications was common, especially for the management of challenging behaviours. Clinical decision-making accounts for individual patient factors and is made based on clinical experience as well as scientific evidence, whereas label indications are developed for regulatory purposes and, although appropriate at a population level, cannot encompass the foregoing considerations. Education for clinicians and other staff caring for people with intellectual disability, and a patient-centred approach to prescribing with involvement of families should encourage appropriate prescribing. The effect of the National Disability Insurance Scheme on the appropriateness of psychotropic medication prescribing should be investigated.
OBJECTIVES/GOALS: The overall goal of this study was to determine the effect of early life stress (ELS) on the intestinal CD4+ T cell immune compartment, at homeostasis and after induction of experimental Inflammatory Bowel Disease (IBD). METHODS/STUDY POPULATION: We used a mouse model of ELS, maternal separation with early weaning (MSEW). We used IL-10 reporter mice to enable analysis of IL-10-producing cells. Mice were examined on postnatal day 28 to determine the impact of ELS on gut regulatory T cells. Plasma levels of corticosterone (rodent stress response hormone) was determined by ELISA. Colitis was induced in MSEW and normal rear (NR) mice via intraperitoneal injection of α-IL-10R every 5 days until day 15. Mice were euthanized on days 20 and 30. Colonic tissue sections were stained for histological analysis. Remaining tissue was further processed for flow cytometric analysis of CD4+ T cells and innate lymphoid cells. RESULTS/ANTICIPATED RESULTS: Plasma corticosterone was elevated in MSEW mice compared to their NR counterparts at 4 weeks of age. We observed that the MSEW stress protocol does not affect the baseline colonic CD4+ T cell or innate lymphoid cell populations. There was a reduction in the intestinal CD4+ T cells and regulatory T cells on day 20 in α-IL-10R MSEW mice compared to NR counterparts. This difference disappeared by day 30. Histological scoring showed no difference in disease severity between α-IL-10R treated MSEW and NR mice on day 20. However, on day 30, when α-IL-10R NR mice are recovering from colitis, MSEW mice showed persistent histological inflammation, mainly attributable to sustained epithelial damage. DISCUSSION/SIGNIFICANCE OF IMPACT: Our results suggest that ELS prolongs intestinal inflammation and impairs epithelial repair. Future studies will focus on elucidating the mechanisms responsible for ELS-dependent impairment of mucosal repair in experimental colitis.
Antimicrobial stewardship programs typically use days of therapy to assess antimicrobial use. However, this metric does not account for the antimicrobial spectrum of activity. We applied an antibiotic spectrum index to a population of very-low-birth-weight infants to assess its utility to evaluate the impact of antimicrobial stewardship interventions.
We compared the use of recto-anal mucosal swab (RAMS) culture and faecal culture for the detection of E. coli O157 in a mob of Merino sheep. Fifty Merino wethers and maiden ewes housed in indoor pens were sampled on five occasions. We detected E coli O157 in 32% (16/50) of sheep, with weekly prevalence ranging from 4% (2/50) to 16% (8/50). Overall, 12·5% (2/16) were detected by RAMS culture only, and 37·5% (6/16) were detected by faecal culture only. The level of agreement between the two sampling methods was moderate [kappa statistic = 0·583, 95% confidence interval (CI) 0·460–0·707]. The relative sensitivities of RAMS and faecal culture were 67% (95% CI 41–86) and 57% (95% CI 34–77), respectively. We identified four super-shedding sheep using direct faecal culture. Although the majority of culture-positive sheep were detected at one sampling point only, 3/4 super-shedding sheep were culture-positive at two sampling points, and 1/4 was culture-positive at four sampling points. Persistent culture positivity may indicate sheep that could be considered ‘super-shedders' at some point. The use of immunomagnetic separation further improved the rate of detection of E. coli O157, which was isolated from 1/34 animals that were previously negative by enrichment culture alone. A significant difference between sampling weeks was detected for both faecal (P = 0·021) and RAMS (P = 0·006), with the prevalence at the mid-point of sampling (week 4) significantly (P < 0·05) higher than at the beginning or end of the study. Study conditions (penned sheep) might have been responsible for the high prevalence and the epidemic pattern of infection observed, and could serve as a future model for studies of E. coli O157 transmission, shedding and super-shedding in sheep.
The tenuous claims of cost-benefit analysis to guide policy so as to promote welfare turn on measuring welfare by preference satisfaction and taking willingness-to-pay to indicate preferences. Yet it is obvious that people's preferences are not always self-interested and that false beliefs may lead people to prefer what is worse for them even when people are self-interested. So welfare is not preference satisfaction, and hence it appears that cost-benefit analysis and welfare economics in general rely on a mistaken theory of well-being. This essay explores the difficulties, criticizes standard defences of welfare economics, and then offers a new partial defence that maintains that welfare economics is independent of any philosophical theory of well-being. Welfare economics requires nothing more than an evidential connection between preference and welfare: in circumstances in which people are concerned with their own interests and reasonably good judges of what will serve their interests, their preferences will be reliable indicators of what is good for them.
Michael S. McPherson (1947–) received his Ph.D. from the University of Chicago and taught for many years at Williams College before becoming President of Macalester College and then of the Spencer Foundation. His academic work concerns the economics of higher education and issues at the boundaries of economics and ethics. He and Daniel Hausman founded the journal Economics and Philosophy in 1985 and edited it for its first ten years. They also coauthored Economic Analysis, Moral Philosophy, and Public Policy, from which this essay derives.
Let us begin with an old joke. Brezhnev and other members of the Soviet Central Committee are reviewing a May Day parade in Moscow. Thousands of infantry march by, followed by armored cars, the latest tanks, long range artillery, and progressively larger, sleeker, and more impressive missiles. At the end, a battered flatbed truck rumbles by carrying a half-dozen unathletic and bespectacled middle-aged men and women in dirty raincoats sitting around a card table. The crowd is restless and members of the Central Committee are scandalized. One is bold enough to ask Brezhnev what these nondescript civilians are doing in the midst such a magnificent military parade. Brezhnev replies, “Ah, those are our economists. You'd be amazed at the damage they can do.”
Like most economist jokes, this one is unkind, but its unkindness should not be exaggerated. It refers to the damage economists can do, not to any inevitable harm that they cause. And there is no suggestion that their intentions are evil.
Positive economics is concerned with the explanation and prediction of economic phenomena, while normative economics is concerned with evaluating economic policies, practices, and states of affairs from a moral stand-point. Rationality is a normative notion concerning how people ought to choose, prefer, or reason, so it may seem surprising that it plays a large role in positive economics. Since rationality is different from morality, it may also seem surprising that rationality plays a large role in normative economics. But in fact rationality is ubiquitous in both positive and normative economics.
Rationality and Positive Economics
People's preferences are rational if they are complete and transitive, and people choose rationally if their choices are determined by their preferences. If one adds to this theory of rationality the generalization that consumers are to some extent rational and that they prefer more commodities to fewer, then one has the central principles of the positive theory of consumer choice. Similarly, the traditional theory of the firm maintains that firms or entrepreneurs are rational and that they combine inputs so as to maximize the difference between revenues and costs. Though the theory of consumer choice and the theory of the firm make additional claims, they both take the theory of rational choice to be the theory of actual choice.
Positive economics on both the consumer and the producer side can be formulated without using the word “rational.” Rather than first defining “rational” and then stating that individuals are rational, one can assert that the preferences of individuals are complete and transitive and that individuals choose whatever affordable bundle of commodities they most prefer.
We have repeatedly extolled the virtues of interdisciplinary understanding. A better appreciation of ethics can contribute to economic analysis, and at the same time the tools and distinctions that economists have fashioned can contribute to moral philosophy. We hope that the examples we have already discussed and the detailed comments in the previous chapter concerning applications of mainstream welfare economics have shown that these are not empty slogans – mere reminders that more knowledge and more sensitivity are almost always better than less.
In this our last chapter, we would like to do more to show how ethics and economics can complement one another. We will begin by discussing briefly the examples presented in Chapter 3 concerning involuntary unemployment and the use of overlapping generations models to study retirement savings. Then we will sketch a range of urgent problems that cannot be tackled successfully without an understanding of both ethics and economics.
Involuntary Unemployment and Moral Baselines
While emphasizing the complexities of unemployment, we argued in Chapter 3 that controversies concerning the existence and analysis of involuntary unemployment result in part from conflating voluntary choice and rational choice and in part from normative disagreements among economists. The conflation leads some economists to regard as fully voluntary what are in fact paradigmatically involuntary choices, such as surrendering one's wallet to a robber who threatens death otherwise (Colander quoted in Snowdon and Vane 1999, p. 233).
Both Lawrence Summers's argument that the World Bank should facilitate the transfer of polluting industries to poor countries and the efficiency argument for school vouchers are instances of standard welfare economics. If parents are permitted to choose among competing schools then their preferences will be satisfied at least as well as in a state-sponsored system, and competition among schools will induce cost savings and improvements in quality. Concerns about the distributional consequences can be addressed by a system of vouchers, which can be as generous or stingy toward those who are poor as the citizenry wishes. Similarly, the massive inequalities in incomes, wages, and environmental quality between rich and poor countries and the fact that pollution damage is not a marketable good create opportunities for Pareto improving trades (or industry relocations) between rich and poor countries, which the World Bank can facilitate. Uncompensated transfers of pollution to LDCs (like the simple elimination of public support of education) cannot be justified in this way, since doing so would not be beneficial to all parties. Yet even uncompensated pollution transfers would apparently represent potential Pareto improvements and would be viewed favorably from the perspective of cost–benefit analysis.
We went on to suggest a number of objections to these arguments. In addition to distributive concerns, voucher plans must be responsive to the paternalistic and political reasons why governments support education. In Chapter 2 we suggested that, although these considerations do not necessarily defeat the argument in support of a voucher system, they do support constraints on its structure.
At first glance, morality and mathematics seem as unrelated as martyrdom and MTV. But it is possible to characterize moral notions formally and to prove theorems. Doing so does not banish controversy and cannot replace verbal argument concerning moral matters, because the abstract mathematical characterizations of moral notions require interpretation and defense. Just as there are disagreements concerning the formal definitions of rationality, so are there controversies about formal definitions of moral notions.
Over the last 75 years economists, decision theorists, and game theorists have made exciting progress not only in representing individual rationality but also in characterizing features of human interactions. This work is linked to moral philosophy. Formal models of rationality and game-theoretic studies of incentives hold out the hope of transcending some of the ancient conundrums concerning the relations between morality, rationality and self-interest discussed in Chapter 6. Concepts of “fair” or envy-free allocations, discussed in Chapter 11, facilitate the articulation of egalitarianism. Solution concepts in game theory may enrich the contractarian perspective (discussed in Chapter 12) that morality can be justified in terms of agreement. Theorems in social choice theory explore the implications of plausible axioms and test the consistency of traditional principles concerning how social policies should respond to individual interests. We face an embarrassment of riches, and we can only comment on a few of these developments.
We opened this volume with four examples of work in economics that reflects ethical views. If this book has served its purpose as an analysis of the ethical presuppositions of economics and as an introduction to a range of ethical concepts and theories, it should make the ethical commitments implicit in these cases easier to understand, and it should suggest how they might be influenced by a broader and more self-conscious ethical perspective. We have also – especially in the last two chapters – said a bit about tools that economists have developed that may be of use to moral philosophers, and we wish also to say something about ways in which economists and philosophers can together help to address some of the daunting problems facing the nations of the world.
Accordingly, in the concluding chapters we shall revisit the four cases discussed in Chapters 2 and 3 and offer some remarks about ways in which grasping both ethics and economics might help in identifying good policies and principles for citizens and governments to adopt. In Chapter 15 we shall return to the two examples of normative economics discussed in Chapter 2 – the defense of school vouchers and Larry Summers's proposal that the World Bank encourage polluting industries to locate in poor countries. In particular, Chapter 15 will show how the discussions in Parts II and III of welfare and of nonwelfarist evaluative considerations help one to understand and appraise these arguments.
When people in modern Western cultures think about morality, they first think about what is morally permissible or impermissible, right or wrong. But there are other matters of moral concern. Of special importance among these are questions about what things are good or bad and, more specifically, about what things are good or bad for people.
Exactly what is good for a particular agent, Murphy, will depend on Murphy's character, ability, and circumstances, and what is good for Murphy may be very different from what is good for Marlow. But most of the differences between what is good for Murphy and Marlow concern instrumental goods – things that are good because they are means to something else. If one focuses on intrinsic goods – things that are good in themselves – without regard to their consequences, then there may be much less variation from individual to individual. Size-7 shoes are good for Murphy while size-12 shoes are good for Marlow, but both pairs serve the same end. In strumental goods, like shoes of the right size, are good only if the ends they serve are good. So if nothing were good in itself, then nothing could be good as a means to some other end. There must be intrinsic goods in order for there to be instrumental goods. A central problem of moral philosophy has been to determine what things are intrinsically good for human beings. Thus Aristotle, for example, held that happiness was the sole intrinsic good.