Enduring documents : improving the forms, improving the outcomes

Most Australian states have introduced legislation to provide for enduring documents for financial, personal and health care decision making in the event of incapacity. Since the introduction of Enduring Powers of Attorney (EPAs) and Advance Health Directives (AHDs) in Queensland in 1998, concerns have continued to be raised by service providers, professionals and individuals about the uptake, understanding and appropriate use of these documents. In response to these concerns, the Department of Justice and Attorney-General (DJAG) convened a Practical Guardianship Initiatives Working Party. This group identified the limited evidence base available to address these concerns. In 2009, a multidisciplinary research team from the University of Queensland and the Queensland University of Technology was awarded $90,000 from the Legal Practitioners Interest on Trust Account Fund to undertake a review of the current EPA and AHD forms. The goal of the research was to gather data on the content and useability of the forms from the perspectives of a range of stakeholders, particularly those completing the EPA and AHD, witnesses of these documents, attorneys appointed under an EPA, and health professionals involved in the completion of an AHD or dealing with it in a clinical context. The researchers also sought to gather information from the perspective of Aboriginal and Torres Strait Islander (ATSI) individuals as well people from culturally and linguistically diverse (CALD) groups. Although the focus of the research was on the forms and the extent to which the current design, content and format represents a barrier to uptake, in the course of the research, some broader issues were identified which have an impact on the effectiveness of the EPA and AHD in achieving the goals of planning for financial and personal and health care in advance of losing capacity. The data gathered enabled the researchers to achieve the primary goal of the research: to make recommendations to improve the content and useability of the forms which hopefully will lead to an increased uptake and appropriate use of the forms. However, the researchers thought it was important not to ignore broader policy issues that were identified in the course of the research. These broader issues have been highlighted in this Report, and the researchers have responded to them in a variety of ways. For some issues, the researchers have suggested alterations that could be made to the forms to address the particular concerns. For other issues, the researchers have suggested that Government may need to take specific action such as educating the broader community with some attention to strategies that engage particular groups within communities. Other concerns raised can only be dealt with by legislative reform and, in some of these cases, the researchers have identified issues that Government may wish to consider further. We do note, however, that it is beyond the scope of this Report to recommend changes to the law. This three stage mixed methods project aimed to provide systematic evidence from a broad range of stakeholders in regard to: (i) which groups use and do not use these documents and why, (ii) the contribution of the length/complexity/format/language of the forms as barriers to their completion and/or effective use, and (iii) the issues raised by the current documents for witnesses and attorneys. Understanding and use of EPAs and AHDs were generally explored in separate but parallel processes. A purposive sampling strategy included users of the documents as principals and attorneys, and professionals, witnesses and service providers who assist others to execute or use the forms. The first component of this study built on existing knowledge using a Critical Reference Group and material provided by the DJAG Practical Guardianship Initiatives Working Party. This assisted in the development of the data collection tools for subsequent stages. The second component comprised semi-structured interviews and focus groups with a targeted sample of current users of the forms, potential users, witnesses and other professionals to provide in-depth information on critical issues. Outreach to Aboriginal and Torres Strait Islander Elders and individuals and workers with CALD groups ensured a broad sample of potential users of the two documents. Fifty individual interviews and three focus groups were completed. Most interviews and focus groups focused on perceptions of, and experiences with, either the EPA or the AHD form. In the interviews with Indigenous people and the CALD focus groups, however, respondents provided their perceptions and experiences of both documents. In general, these respondents had not used the forms and were responding to the documents made available in the interview or focus group. In total, seventy-seven individuals were involved in interviews or focus groups. The final component comprised on-line surveys for EPA principals, EPA attorneys, AHD principals, witnesses of EPAs and AHDs and medical practitioners with experience of AHDs as nominated and/or treating doctors. The surveys were developed from the initial component and the qualitative analysis of the interview and focus group data. A total of 116 surveys were returned from major cities and regional Queensland. The survey data was analysed descriptively for patterns and trends. It is important to note that the aim of the survey was to gain insight into issues and concerns relating to the documents and not to make generalisations to the broader population.

Advance directives, autonomy and the refusal of life-sustaining medical treatment

As Australian society 1s agemg, individuals are increasingly concerned about managing their future, including making decisions about the medical treatment they may wish to receive or refuse if they lose decision-making capacity. To date, there has been relatively little research into the extent to which legal regulation allows competent adults to make advance refusals of life-sustaining medical treatment that will bind health professionals and others when a decision needs to be made at a future time. This thesis aims to fill this gap in the research by presenting the results of research into the legal regulation of advance directives that refuse life-sustaining medical treatment. In the five papers that comprise this thesis, the law that governs this area is examined, and the ethical principle of autonomy is used to critically evaluate that law. The principal finding of this research is that the current scheme of regulation is ineffective to adequately promote the right of a competent adult to make binding advance directives about refusal of medical treatment. The research concludes that legislation should be enacted to enable individuals to complete an advance directive, only imposing restrictions to the extent that this is necessary to promote individual autonomy. The thesis first examines the principle of autonomy upon which the common law (and some statutory law) is expressed to be based, to determine whether that principle is an appropriate one to underpin regulation. 1 The finding of the research is that autonomy can be justified as an organising principle on a number of grounds: it is consistent with the values of a liberal democracy; over recent decades, it is a principle that has been even more prominent within the discipline of medical ethics; and it is the principle which underpins the legal regulation of a related topic, namely the contemporaneous refusal of medical treatment. Next, the thesis reviews the common law to determine whether it effectively achieves the goal of promoting autonomy by allowing a competent adult to make an advance directive refusing treatment that will operate if he or she later loses decision-making capacity. 2 This research finds that conunon law doctrine, as espoused by the judiciary, prioritises individual choice by recognising valid advance directives that refuse treatment as binding. However, the research also concludes that the common law, as applied by the judiciary in some cases, may not be effective to promote individual autonomy, as there have been a number of circumstances where advance directives that refuse treatment have not been followed. The thesis then examines the statutory regimes in Australia that regulate advance directives, with a focus on the regulation of advance refusals of life-sustaining medical treatment.3 This review commences with an examination ofparliamentary debates to establish why legislation was thought to be necessary. It then provides a detailed review of all of the statutory regimes, the extent to which the legislation regulates the form of advance directives, and the circumstances in which they can be completed, will operate and can be ignored by medical professionals. The research finds that legislation was enacted mainly to clarify the common law and bring a level of certainty to the field. Legislative regimes were thought to provide medical professionals with the assurance that compliance with an advance directive that refuses life-sustaining medical treatment will not expose them to legal sanction. However, the research also finds that the legislation places so many restrictions on when an advance directive refusing treatment can be made, or will operate, that they have not been successful in promoting individual autonomy.

The acute adaptations of normal and pathological human Achilles tendons to eccentric and concentric exercise

Eccentric exercise is the conservative treatment of choice for mid-portion Achilles tendinopathy. While there is a growing body of evidence supporting the medium to long term efficacy of eccentric exercise in Achilles tendinopathy treatment, very few studies have investigated the short term response of the tendon to eccentric exercise. Moreover, the mechanisms through which tendinopathy symptom resolution occurs remain to be established. The primary purpose of this thesis was to investigate the acute adaptations of the Achilles tendon to, and the biomechanical characteristics of, the eccentric exercise protocol used for Achilles tendinopathy rehabilitation and a concentric equivalent. The research was conducted with an orientation towards exploring potential mechanisms through which eccentric exercise may bring about a resolution of tendinopathy symptoms. Specifically, the morphology of tendinopathic and normal Achilles tendons was monitored using high resolution sonography prior to and following eccentric and concentric exercise, to facilitate comparison between the treatment of choice and a similar alternative. To date, the only proposed mechanism through which eccentric exercise is thought to result in symptom resolution is the increased variability in motor output force observed during eccentric exercise. This thesis expanded upon prior work by investigating the variability in motor output force recorded during eccentric and concentric exercises, when performed at two different knee joint angles, by limbs with and without symptomatic tendinopathy. The methodological phase of the research focused on establishing the reliability of measures of tendon thickness, tendon echogenicity, electromyography (EMG) of the Triceps Surae and the standard deviation (SD) and power spectral density (PSD) of the vertical ground reaction force (VGRF). These analyses facilitated comparison between the error in the measurements and experimental differences identified as statistically significant, so that the importance and meaning of the experimental differences could be established. One potential limitation of monitoring the morphological response of the Achilles tendon to exercise loading is that the Achilles tendon is continually exposed to additional loading as participants complete the walking required to carry out their necessary daily tasks. The specific purpose of the last experiment in the methodological phase was to evaluate the effect of incidental walking activity on Achilles tendon morphology. The results of this study indicated that walking activity could decrease Achilles tendon thickness (negative diametral strain) and that the decrease in thickness was dependent on both the amount of walking completed and the proximity of walking activity to the sonographic examination. Thus, incidental walking activity was identified as a potentially confounding factor for future experiments which endeavoured to monitor changes in tendon thickness with exercise loading. In the experimental phase of this thesis the thickness of Achilles tendons was monitored prior to and following isolated eccentric and concentric exercise. The initial pilot study demonstrated that eccentric exercise resulted in a greater acute decrease in Achilles tendon thickness (greater diametral strain) compared to an equivalent concentric exercise, in participants with no history of Achilles tendon pain. This experiment was then expanded to incorporate participants with unilateral Achilles tendinopathy. The major finding of this experiment was that the acute decrease in Achilles tendon thickness observed following eccentric exercise was modified by the presence of tendinopathy, with a smaller decrease (less diametral strain) noted for tendinopathic compared to healthy control tendon. Based on in vitro evidence a decrease in tendon thickness is believed to reflect extrusion of fluid from the tendon with loading. This process would appear to be limited by the presence of pathology and is hypothesised to be a result of the changes in tendon structure associated with tendinopathy. Load induced fluid movement may be important to the maintenance of tendon homeostasis and structure as it has the potential to enhance molecular movement and stimulate tendon remodelling. On this basis eccentric exercise may be more beneficial to the tendon than concentric exercise. Finally, EMG and motor output force variability (SD and PSD of VGRF) were investigated while participants with and without tendinopathy performed the eccentric and concentric exercises. Although between condition differences were identified as statistically significant for a number of force variability parameters, the differences were not greater than the limits of agreement for repeated measures. Consequently the meaning and importance of these findings were questioned. Interestingly, the EMG amplitude of all three Triceps Surae muscles did not vary with knee joint angle during the performance of eccentric exercise. This raises questions pertaining to the functional importance of performing the eccentric exercise protocol at each of the two knee joint angles as it is currently prescribed. EMG amplitude was significantly greater during concentric compared to eccentric muscle actions. Differences in the muscle activation patterns may result in different stress distributions within the tendon and be related to the different diametral strain responses observed for eccentric and concentric muscle actions.

Intraoperative imaging in hallux valgus surgery

Background: This prospective study investigates the use of intraoperative fluoroscopy in 28 consecutive cases undergoing hallux valgus surgery. To our knowledge there have been no studies validating the use of intraoperative fluoroscopy in hallux valgus surgery. Methods: We performed a prospective investigation of 28 consecutive cases undergoing hallux valgus surgery. Fluoroscopic images were examined intraoperatively and any significant unforseen findings documented. A comparison was made between the fluoroscopic images and weight bearing films taken 6 weeks postoperatively to examine whether the intraoperative images are an accurate representation of the standard films obtained post-operatively. We excluded those patients that went on to have an Akin osteotomy. Results: There were no unforeseen intraoperative events that were revealed by the use of fluoroscopy and no surgical modifications were made as a result of the intraoperative images. The intraoperative films were found to be a reliable representation of the postoperative weight bearing films but a small increase in the hallux valgus angle was noted at six weeks and this is thought to be due to stretching of the medial soft tissue repair. Conclusions: Intraoperative fluoroscopy is a reliable technique. This study was performed at a centre which performs approximately 100 hallux valgus operations per year and that should be taken into consideration when reviewing our findings. We conclude that there may be a role for fluoroscopy for surgeons in the early stages of the surgical learning curve and for those that infrequently perform hallux valgus surgery. We cannot however recommend that fluoroscopy be used routinely in hallux valgus surgery.

Blood cultures for assessment of postoperative fever in arthroplasty patients

Postoperative fever in arthroplasty patients is common. The value of diagnostic workup of fever in this instance is of questionable utility. Studies have shown that blood cultures in this scenario add little to clinical management, but sample sizes have been small and the use of blood cultures in this setting continues. This study aimed to examine the value of blood cultures in the assessment of postoperative fever in a large arthroplasty population. The medical records of 101 patients who had 141 blood culture sets taken during a 2-year period were retrospectively analyzed. Of the 141 blood culture sets, only 2 returned positive results. These were both thought to be as a result of skin contamination at the time of venipuncture. No infectious sequelae occurred in either patient. We conclude that blood cultures have no role to play in the assessment of the febrile, otherwise asymptomatic arthroplasty patient in the early postoperative period.

The subjective experience of negative symptoms : characteristics of emotional withdrawal

According to the diagnosis of schizophrenia in the DSM-IV-TR (American Psychiatric Association, 2000), negative symptoms are those personal characteristics that are thought to be reduced from normal functioning, while positive symptoms are aspects of functioning that exist as an excess or distortion of normal functioning. Negative symptoms are generally considered to be a core feature of people diagnosed with schizophrenia. However, negative symptoms are not always present in those diagnosed, and a diagnosis can be made with only negative or only positive symptoms, or with a combination of both. Negative symptoms include an observed loss of emotional expression (affective flattening), loss of motivation or self directedness (avolition), loss of speech (alogia), and also a loss of interests and pleasures (anhedonia). Positive symptoms include the perception of things that others do not perceive (hallucinations), and extraordinary explanations for ordinary events (delusions) (American Psychiatric Association, 2000). Both negative and positive symptoms are derived from watching the patient and thus do not consider the patient’s subjective experience. However, aspects of negative symptoms, such as observed affective flattening are highly contended. Within conventional psychiatry, the absence of emotional expression is assumed to coincide with an absence of emotional experience. Contrasting research findings suggests that patients who were observed to score low on displayed emotional expression, scored high on self ratings of emotional experience. Patients were also observed to be significantly lower on emotional expression when compared with others (Aghevli, Blanchard, & Horan, 2003; Selton, van der Bosch, & Sijben, 1998). It appears that there is little correlation between emotional experience and emotional expression in patients, and that observer ratings cannot help us to understand the subjective experience of the negative symptoms. This chapter will focus on research into the subjective experiences of negative symptoms. A framework for these experiences will be used from the qualitative research findings of the primary author (Le Lievre, 2010). In this study, the primary author found that subjective experiences of the negative symptoms belonged to one of the two phases of the illness experience; “transitioning into emotional shutdown” or “recovering from emotional shutdown”. This chapter will use the six themes from the phase of “transitioning into emotional shutdown”. This phase described the experience of turning the focus of attention away from the world and onto the self and the past, thus losing contact with the world and others (emotional shutdown). Transitioning into emotional shutdown involved; “not being acknowledged”, “relational confusion”, “not being expressive”, “reliving the past”, “detachment”, and “no sense of direction” (Le Lievre, 2010). Detail will be added to this framework of experience from other qualitative research in this area. We will now review the six themes that constitute a “transition into emotional shutdown” and corresponding previous research findings.

Crime: local and global

Crime: Local and Global covers the way local events (such as prostitution) have wider aspects than previously thought. Links with people traffickers, international organised crime and violence cannot be ignored any longer. Each crime or area of activity selected within this text has a global reach, and is made ever more possible due to the way globalisation has opened up markets, both legitimate and illegitimate. The book's approach and scope emphasises that we can no longer view 'crime' as something which occurs within certain jurisdictions, at certain times and in particular places. For example, the chapter on cybercrime highlights the 'illegal' acts that can be perpetrated by second lifers, anywhere in the world, but are they a crime?

Modern construction economics [Book Review]

The editor, Gerard de Valence, points out in the preface, this book is neither a textbook nor a guide to what is done by construction managers and construction economists – read quantity surveyors and the like. Rather, de Valence notes it comprises a collection of chapters each of which focus on matters at the industry level and, in doing so, illustrates that a substantially improved understanding of the building and construction industry can be gained beyond the economics of delivering projects. Before giving some thought to how far each of the chapters achieve this, it’s worth reflecting on the virtues of developing construction economics as its own discipline or sub-discipline in general economics and the bold manner by which de Valence is proposing we do this. That is, de Valence proposes partitioning industry and project economics - as explained in the preface and in Chapter 1. de Valence’s view that “the time seems right” for these developments is also worthy of some consideration.

Finitude (Mallee:Time)

An interactive installation with full body interface, digital projection, multi-touch sensitive screen surfaces, interactive 3D gaming software, motorised dioramas, 4.1 spatial sound & new furniture forms - investigating the cultural dimensions of sustainability through the lens of 'time'. “Time is change, time is finitude. Humans are a finite species. Every decision we make today brings that end closer, or alternatively pushes it further away. Nothing can be neutral”. Tony Fry DETAILS: Finitude (Mallee:Time) is a major new media/sculptural hybrid work premiered in 2011 in version 1 at the Ka-rama Motel for the Mildura Palimpsest #8 ('Collaborators and Saboteurs'). Each participant/viewer lies comfortably on their back on the double bed of Room 22. Directly above them, supported by a wooden structure, not unlike a house frame, is a semi-transparent Perspex screen that displays projected 3D imagery and is simultaneously sensitive to the lightest of finger touches. Depending upon the ever changing qualities of the projected image on this screen the participant can see through its surface to a series of physical dioramas suspended above, lit by subtle LED spotlighting. This diorama consists of a slowly rotating series of physical environments, which also include several animatronic components, allowing the realtime composition of whimsical ‘landscapes’ of both 'real' and 'virtual' media. Through subtle, non-didactic touch-sensitive interactivity the participant then has influence over both the 3D graphic imagery, the physical movements of the diorama and the 4.1 immersive soundscape, creating an uncanny blend of physical and virtual media. Five speakers positioned around the room deliver a rich interactive soundscape that responds both audibly and physically to interactions. VERSION 1, CONTEXT/THEORY: Finitude (Mallee: Time) is Version 1 of a series of presentations during 2012-14. This version has been inspired through a series of recent visits and residencies in the SW Victoria Mallee country. Further drawing on recent writings by post colonial author Paul Carter, the work is envisaged as an evolving ‘personal topography’ of place-discovery. By contrasting and melding readily available generalisations of the Mallee regions’ rational surfaces, climatic maps and ecological systems with what Carter calls “a fine capillary system of interconnected words, places, memories and sensations” generated through my own idiosyncratic research processes, Finitude (Mallee Time) invokes a “dark writing” of place through outside eyes - an approach that avoids concentration upon what 'everyone else knows', to instead imagine and develop a sense how things might be. This basis in re-imagining and re-invention becomes the vehicle for the work’s more fundamental intention - as a meditative re-imagination of 'time' (and region) as finite resources: Towards this end, every object, process and idea in the work is re-thought as having its own ‘time component’ or ‘residue’ that becomes deposited into our 'collective future'. Thought this way Finitude (Mallee Time) suggests the poverty of predominant images of time as ‘mechanism’ to instead envisage time as a plastic cyclical medium that we can each choose to ‘give to’ or ‘take away from’ our future. Put another way - time has become finitude.

Female genital mutilation : legal, attitudinal and practical reform

Female genital mutilation (FGM) is a cultural practice common in many Islamic societies. It involves the deliberate, non-therapeutic physical modification of young girls’ genitalia. FGM can take several forms, ranging from less damaging incisions to actual removal of genitalia and narrowing or even closing of the vagina. While often thought to be required by religion, FGM both predates and has no basis in the Koran. Rather, it is a cultural tradition, motivated by a patriarchal social desire to control female bodies to ensure virginity at marriage (preserving family honour), and to prevent infidelity by limiting sexual desire. In the USA and Australia in 2010, peak medical bodies considered endorsing the medical administration of a ‘lesser’ form of FGM. The basis for this was pragmatic: it would be preferable to satisfy patients’ desire for FGM in medically-controlled conditions, rather than have these patients seek it, possibly in more severe forms, under less safe conditions. While arguments favouring medically-administered FGM were soon overcome, the prospect of endorsing FGM illuminated the issue in these two Western countries and beyond. This paper will review the nature of FGM, its physical and psychological health consequences, and Australian laws prohibiting FGM. Then, it will scan recent developments in Africa, where FGM has been made illegal by a growing number of nations and by the Protocol to the African Charter on Human and Peoples’ Rights 2003 (the Maputo Protocol), but is still proving difficult to eradicate. Finally, based on arguments derived from theories of rights, health evidence, and the historical and religious contexts, this paper will ask whether an absolute human right against FGM can be developed.

Why perform pro-social behaviours? Understanding the key sources of perceived value in preventative health services

In maintaining quality of life, preventative health is an important area in which the performance of pro-social behaviours provides benefits to individuals who perform them as well as society. The establishment of the Preventative Health Taskforce in Australia demonstrates the significance of preventative health and aims to provide governments and health providers with evidence-based advice on preventative health issues (Preventative Health Taskforce, 2009). As preventative health behaviours are voluntary, for consumers to sustain this behaviour there needs to be a value proposition (Dann, 2008; Kotler and Lee, 2008). Customer value has been shown to influence repeat behaviour (McDougall and Levesque, 2000), word-of-mouth (Hartline and Jones, 1999), and attitudes (Dick and Basu, 2008). However to date there is little research that investigates the source of value for preventative health services. This qualitative study explores and identifies three categories of sources that influence four dimensions of value – functional, emotional, social and altruistic (Holbrook 2006). A conceptual model containing five propositions outlining these relationships is presented. This study provides evidence-based research that reveals sources of value that influence individuals’ decisions to perform pro-social behaviours in the long-term through their use of preventative health services. This research uses BreastScreen Queensland (BSQ), a cancer screening service, as the service context.

Scheduling Trains with Priorities : a no-wait blocking parallel-machine job-shop scheduling model

The paper investigates train scheduling problems when prioritised trains and non-prioritised trains are simultaneously traversed in a single-line rail network. In this case, no-wait conditions arise because the prioritised trains such as express passenger trains should traverse continuously without any interruption. In comparison, non-prioritised trains such as freight trains are allowed to enter the next section immediately if possible or to remain in a section until the next section on the routing becomes available, which is thought of as a relaxation of no-wait conditions. With thorough analysis of the structural properties of the No-Wait Blocking Parallel-Machine Job-Shop-Scheduling (NWBPMJSS) problem that is originated in this research, an innovative generic constructive algorithm (called NWBPMJSS_Liu-Kozan) is proposed to construct the feasible train timetable in terms of a given order of trains. In particular, the proposed NWBPMJSS_Liu-Kozan constructive algorithm comprises several recursively-used sub-algorithms (i.e. Best-Starting-Time-Determination Procedure, Blocking-Time-Determination Procedure, Conflict-Checking Procedure, Conflict-Eliminating Procedure, Tune-up Procedure and Fine-tune Procedure) to guarantee feasibility by satisfying the blocking, no-wait, deadlock-free and conflict-free constraints. A two-stage hybrid heuristic algorithm (NWBPMJSS_Liu-Kozan-BIH) is developed by combining the NWBPMJSS_Liu-Kozan constructive algorithm and the Best-Insertion-Heuristic (BIH) algorithm to find the preferable train schedule in an efficient and economical way. Extensive computational experiments show that the proposed methodology is promising because it can be applied as a standard and fundamental toolbox for identifying, analysing, modelling and solving real-world scheduling problems.

Individuals in a mass market environment: Australian bequest donors seek better communication from charities

Swelling social need and competing calls on government funds have heightened the philanthropic dollar’s value. Yet, Australia is not regarded as having a robust giving culture: while 86% of adults give, a mere 16% plan their giving with those who do donating four times as much as spontaneous givers (Giving Australia, 2005). Traditionally, the prime planned giving example is a charitable bequest, a revenue stream not prevalent here (Baker, 2007). In fact, Baker’s Victorian probate data shows under 5% of estates provide a charitable bequest and just over 1% of estate assets is bequeathed. The UK, in contrast, sources 30% and the US 10% of charitable income through bequests (NCVO, 2004; Sargeant, Wymer and Hilton,2006). Australian charities could boost bequest giving. Understanding the donor market, which has or may remember them in their will is critical. This paper reports donor perceptions of Australian charities’ bequest communication/ marketing. The data forms part of a wider study of Australian donors’ bequest attitudes and behaviour. Charities spend heavily on bequest promotion, from advertising to personal selling to public relations and promotion. Infrastructure funds are scarce so guidance on what works for donors is important. Guy and Patton (1988) made their classic call for a nonprofit marketing perspective and identify the need for charities to better understand the motivations and behaviour of their supporters. In similar vein, this study aims to improve the way nonprofits and givers interact; and ultimately, enhance the giving experience and thus multiply planned giving participation. Academically, it offers insights to Australian bequest motivations and attitudes not studied empirically before.

Editors' introduction

In approaching this Special Issue on Foresight, Innovation and Entrepreneurship (FI&E) we considered that globalisation and rapid modernisation were increasingly creating the need for social reflexivity. We thought that in respect to the production and diffusion of innovations, both social and technical, that the landscape for new enterprise was characterised by widening change horizons and deeper ethical concerns. As a consequence of the greater demand for innovation to achieve economic prosperity, it was conceived that 'unforesightful' innovation may have irreparable affects on social and ecological systems and uncertain implications for our futures. Therefore, we considered a new intellectual alliance between FI&E was potentially a matter of human survival. New approaches to thinking about how and what we innovate, the choices we face for new enterprise creation and the influence of infrastructure for generating entrepreneurship, we considered, would need to emerge if we are to positively impact human and planetary sustainability in the 21st century. Hence this special issue was designed to bring together cross-disciplinary research aimed at exploring the synergies between foresight, innovation and entrepreneurship and the way in which these connections may be taking place in both the practical and theoretical sense.