Feminist ethics and menopause : autonomy and decision-making in primary medical care

The construction of menopause as a long-term risk to health and the adoption of discourses of prevention has made necessary a decision by women about medical treatment; specifically regarding the use of hormone replacement therapy. In a study of general practitioners’ accounts of menopause and treatment in Australia, women's ‘choice’, ‘informed decision-making’ and ‘empowerment’ were key themes through which primary medical care for women at menopause was presented. These accounts create a position for women defined by the concept of individual choice and an ethic of autonomy. These data are a basis for theorising more generally in this paper. We critically examine the construct of ‘informed decision-making’ in relation to several approaches to ethics including bioethics and a range of feminist ethics. We identify the intensification of power relations produced by an ethic of autonomy and discuss the ways these considerations inform a feminist ethics of decision-making by women. We argue that an ‘ethic of autonomy’ and an ‘offer of choice’ in relation to health care for women at menopause, far from being emancipatory, serves to intensify power relations. The dichotomy of choice, to take or not to take hormone replacement therapy, is required to be a choice and is embedded in relations of power and bioethical discourse that construct meanings about what constitutes decision-making at menopause. The deployment of the principle of autonomy in medical practice limits decision-making by women precisely because it is detached from the construction of meaning and the self and makes invisible the relations of power of which it is a part.

Menopause as a long-term risk to health : implications of general practitioner accounts of prevention for women’s choice and decision-making

Over the past two decades medical researchers and modernist feminist researchers have contested the meaning of menopause. In this article we examine various meanings of menopause in major medical and feminist literature and the construction of menopause in a semi-structured interview study of general practitioners in rural South Australia. Three discursive themes are identified in these interviews; (i) the hormonal menopause – symptoms, risk, prevention; (ii) the informed menopausal woman; and (iii) decision-making and hormone replacement therapy. By using the discourse of prevention, general practitioners construct menopause in relation to women's health care choices, empowerment and autonomy. We argue that the ways in which these concepts are deployed by general practitioners in this study produces and constrains the options available to women. The implications of these general practitioner accounts are discussed in relation to the proposition that medical and feminist descriptions of menopause posit alternative but equally-fixed truths about menopause and their relationship with the range of responses available to women at menopause. Social and cultural explanations of disease causality (c.f.Germov 1998, Hardey 1998) are absent from the new menopause despite their being an integral part of the framework of the women's health movement and health promotion drawn on by these general practitioners. Further, the shift of responsibility for health to the individual woman reinforces practice claims to empower women, but oversimplifies power relations and constructs menopause as a site of self-surveillance. The use of concepts from the women's health movement and health promotion have nevertheless created change in both the positioning of women as having ‘choices’ and the positioning of some general practitioners in terms of greater information provision to women and an attention to the woman's autonomy. In conclusion, we propose that a new menopause has evolved from a discursive shift in medicine and that there exists within this new configuration, claiming the empowerment of women as an integral part of health care for menopause, the possibility for change in medical practice which will broaden, strengthen, and maintain this position.

A new first-order decision-making model for the procurement of public sector infrastructure: Procedures and Testing

Given global demand for new infrastructure, governments face substantial challenges in funding new infrastructure and delivering Value for Money (VfM). As part of the background to this challenge, a critique is given of current practice in the selection of the approach to procure major public sector infrastructure in Australia and which is akin to the Multi-Attribute Utility Approach (MAUA). To contribute towards addressing the key weaknesses of MAUA, a new first-order procurement decision-making model is presented. The model addresses the make-or-buy decision (risk allocation); the bundling decision (property rights incentives), as well as the exchange relationship decision (relational to arms-length exchange) in its novel approach to articulating a procurement strategy designed to yield superior VfM across the whole life of the asset. The aim of this paper is report on the development of this decisionmaking model in terms of the procedural tasks to be followed and the method being used to test the model. The planned approach to testing the model uses a sample of 87 Australian major infrastructure projects in the sum of AUD32 billion and deploys a key proxy for VfM comprising expressions of interest, as an indicator of competition.

Analysis and optimisation of the preferences of decision-makers in black-start group decision-making

As the first stage of power system restoration after a blackout, an optimal black-start scheme is very important for speeding up the whole restoration procedure. Up to now, much research work has been done on generating or selecting an optimal black-start scheme by a single round of decision-making. However, less attention has been paid for improving the final decision-making results through a multiple-round decision-making procedure. In the group decision-making environment, decision-making results evaluated by different black-start experts may differ significantly with each other. Thus, the consistency of black-start decision-making results could be deemed as an important indicator in assessing the black-start group decision-making results. Given this background, an intuitionistic fuzzy distance-based method is presented to analyse the consistency of black-start group decision-making results. Moreover, the weights of black-start indices as well as the weights of decision-making experts are modified in order to optimise the consistency of black-start group decision-making results. Finally, an actual example is served for demonstrating the proposed method.

Withholding and withdrawal of ‘futile’ life-sustaining treatment : unilateral medical decision-making in Australia and New Zealand

This article examines the law in Australia and New Zealand that governs the withholding and withdrawal of ‘futile’ life-sustaining treatment. Although doctors have both civil and criminal law duties to treat patients, those general duties do not require the provision of treatment that is deemed to be futile. This is either because futile treatment is not in a patient’s best interests or because stopping such treatment does not breach the criminal law. This means, in the absence of a duty to treat, doctors may unilaterally withdraw or withhold treatment that is futile; consent is not required. The article then examines whether this general position has been altered by statute. It considers a range of suggested possible legislation but concludes it is likely that only Queensland’s adult guardianship legislation imposes a requirement to obtain consent to withhold or withdraw such treatment.

Decision and reasons for calling an ambulance : patients’ perspective

Background: Demand for pre-hospital emergency care is increasing in Australia as in many other countries. Using posthoc criteria such as triage, diagnosis and admission status, some authors view a considerable number of these as "inappropriate". Yet, calling an ambulance at the time of emergency is rarely studied from the patients’ or their carers’ perspective. This study interviewed patients about the decision, circumstances surrounding and reasons for calling an ambulance in Queensland, Australia. Methods: A cross-sectional survey of patients attending a sample of eight public hospital emergency departments in Queensland was undertaken between March and May 2011. In total, 911 questionnaires were collected (response rate: 67%), of whom 226 (24.8%) had arrived by ambulance. Results: In 35.6% of ambulance arrivals, the decision to request an ambulance was made by the patient; 25% by a doctor; 20% by a family member, friend or carer. Other callers included nurse, people at work or school, and passers-by. Reasons to request an ambulance included urgency (87%) and severity (84%) of the condition. Other reasons included requiring special care (76%), getting higher priority at the emergency department (34%), not having a car (34%), and financial concerns (17%). Decision to request an ambulance varied significantly according to the time of illness onset (e.g. on the day, week before), and location (e.g. home, outside). Conclusion: The decision to call an ambulance is made mostly by non-medical professionals in a perceived emergency situation. They call the ambulance for different reasons but mainly take into account the patient’s welfare and safety. Better understanding of these reasons will affect the direction and effectiveness of demand management strategies.

Key attributes underpinning different markup decision between public and private projects : a China study

In the construction industry, contractors have to improve the efficiency of markup decision-making to survive from fierce business competition. The effect of client type on markup decision has been aware in previous studies and contractors are advocated to take account of decision factors properly when they are confronted with different types of projects. Nevertheless, the rationales behind the inclusion of different factors in markup decision-making for different projects sustain unknown. In this study, fifty-three factors were identified after extensive literature review and interviews with professionals. The identified factors were afterwards grouped under the headings of nine attributes and compiled in a questionnaire for survey in China. Using the Hotelling’s T-square test, it is found that three attributes (i.e., project characteristic, client characteristic, and macro condition) can explain the effect of client type on contractors’ markup decision. The research findings provide useful insights into the cognition of bid pricing as well as the improvement of bidding efficiency. While the research works were situated in China, contractors in other countries could benefit from the research findings in a similar vein.

How to Improve Cardiac Surgery Decision Making? In Data Warehousing Perspective

The health system is one sector dealing with very large amount of complex data. Many healthcare organisations struggle to utilise these volumes of health data effectively and efficiently. Therefore, there is a need for very effective system to capture, collate and distribute this health data. There are number of technologies have been identified to integrate data from different sources. Data warehousing is one technology can be used to manage clinical data in the healthcare. This paper addresses how data warehousing assist to improve cardiac surgery decision making. This research used the cardiac surgery unit at the Prince Charles Hospital (TPCH) as the case study. In order to deal with other units efficiently, it is important to integrate disparate data to a single point interrogation. We propose implementing a data warehouse for the cardiac surgery unit at TPCH. The data warehouse prototype developed using SAS enterprise data integration studio 4.2 and data was analysed using SAS enterprise edition 4.3. This improves access to integrated clinical and financial data with, improved framing of data to the clinical context, giving potentially better informed decision making for both improved management and patient care.

Enduring powers of attorney : promoting attorneys' accountability as substitute decision makers

Aim The misuse and abuse of Enduring Powers of Attorney (EPAs) by attorneys, particularly in relation to financial decision-making, is a growing concern. This paper explores the opportunities to enhance accountability of attorneys at the time of the execution of the document in Queensland. Method A four stage multi-method design comprised a critical reference group; semi-structured interviews with 32 principals or potential principals, attorneys and witnesses; two focus groups with service providers and a state wide survey of 76 principals, attorneys and witnesses. Results Across all methods and user groups, understanding the role and obligations of the attorney in an EPA was consistently identified as problematic. Conclusions Promoting accountability and understanding can be addressed by greater attention to the role of the attorney in the forms/ guidelines and in the structure and witnessing of the forms, increased direction about record keeping and access to appropriate advice and support.

Interacting constraints shape emergent decision-making of referees

How and why football referees made decisions was investigated. A constructivist grounded theory methodology was undertaken to tap into the experiential knowledge of referees. The participant cohort comprised 7 A-League referees (aged 23 to 35) and 8 local Brisbane league referees (aged 20 to 50), spanning the lowest to highest levels of competition in men’s football in Australia. Results found that referees used ‘four pillars’ to underpin their judgments, these were conceptual notions of: safety, fairness, accuracy and entertainment. A fifth pillar ‘consistency’ referred to the referee’s ‘contextual sensitivity’. Results were explained using an ecological dynamics framework that emphasises the individual-environment scale of analysis. It was concluded that interacting constraints shape emergent decision-making in referees which are nested in task goals.

Towards green universities : a decision support framework for green roof and living wall implementation

This research examined why university campus development has not fully embraced green technology despite common expectations. Semi-structured interviews and a Delphi Study explored universities’ organisational issues and delivery processes for projects with a sustainability focus. Critical organisational components and their internal relationships were studied, and critical factors for project success identified. A decision-making framework was developed to provide strategic directions for universities to optimise organisational environment and overcome barriers in order to better deliver sustainable projects on campuses.

Strategies for embedding agile decision making in aviation infrastructure

As highlighted by previous work in Normal Accident Theory1 and High Reliability Organisations, 2 the ability of a system to be flexible is of critical importance to its capability to prepare for, respond to, and recover from disturbance and disasters. This paper proposes that the research into ‘edge organisations’3 and ‘agility’4 is a potential means to operationalise components that embed high reliable traits in the management and oversight of critical infrastructure systems. Much prior work has focused on these concepts in a military frame whereas the study reported on here examines the application of these concepts to aviation infrastructure, specifically, a commercial international airport. As a commercial entity functions in a distinct manner from a military organisation this study aims to better understand the complementary and contradictory components of the application of agility work to a commercial context. Findings highlight the challenges of making commercial operators of infrastructure systems agile as well as embedding traits of High Reliability in such complex infrastructure settings.

Re-framing infrastructure investment decision-making processes : a preliminary scoping study for urban flood risk management in Jakarta, Indonesia

Jakarta, Indonesia’s chronic housing shortage poses multiple challenges for contemporary policy-makers. While it may be in the city’s interest to increase the availability of housing, there is limited land to do so. Market pressures, in tandem with government’s desire for housing availability, demand consideration of even marginal lands, such as those within floodplains, for development. Increasingly, planning for a flood resilient Jakarta is complicated by a number of factors, including: the city is highly urbanized and land use data is limited; flood management is technically complex, creating potential barriers to engagement for both decision-makers and the public; inherent uncertainty exists throughout modelling efforts, central to management; and risk and liability for infrastructure investments is unclear. These obstacles require localized watershed-level participatory planning to address risks of flooding where possible and reduce the likelihood that informal settlements occur in areas of extreme risk. This paper presents a preliminary scoping study for determination of an effective participatory planning method to encourage more resilient development. First, the scoping study provides background relevant to the challenges faced in planning for contemporary Jakarta. Second, the study examines the current use of decision-support tools, such as Geographic Information Systems (GIS), in planning for Jakarta. Existing capacity in the use of GIS allows for consideration of the use of an emerging method of community consultation - Multi-Criteria Decision-Making (MCDM) support systems infused with geospatial information - to aid in engagement with the public and improve decision-making outcomes. While these methods have been used in Australia to promote stakeholder engagement in urban intensification, the planned research will be an early introduction of the method to Indonesia. As a consequence of this intervention, it is expected that planning activities will result in a more resilient city, capable of engaging with disaster risk management in a more effective manner.

Modelling the information seeking user by the decision they make

The article focuses on how the information seeker makes decisions about relevance. It will employ a novel decision theory based on quantum probabilities. This direction derives from mounting research within the field of cognitive science showing that decision theory based on quantum probabilities is superior to modelling human judgements than standard probability models [2, 1]. By quantum probabilities, we mean decision event space is modelled as vector space rather than the usual Boolean algebra of sets. In this way,incompatible perspectives around a decision can be modelled leading to an interference term which modifies the law of total probability. The interference term is crucial in modifying the probability judgements made by current probabilistic systems so they align better with human judgement. The goal of this article is thus to model the information seeker user as a decision maker. For this purpose, signal detection models will be sketched which are in principle applicable in a wide variety of information seeking scenarios.

Evolution and innovation in guardianship laws: Assisted decision-making

Guardianship laws in most Western societies provide decision-making mechanisms for adults with impaired capacity. Since the inception of these laws, the principle of autonomy and recognition of human rights for those coming within guardianship regimes has gained prominence. A new legal model has emerged, which seeks to incorporate ‘assisted decision-making’ models into guardianship laws. Such models legally recognise that an adult’s capacity may be maintained through assistance or support provided by another person, and provide formal recognition of the person in that ‘assisting’ role. This article situates this latest legal innovation within a historical context, examining the social and legal evolution of guardianship laws and determining whether modern assisted decision-making models remain consistent with guardianship reform thus far. It identifies and critically analyses the different assisted decision-making models which exist internationally. Finally, it discusses a number of conceptual, legal and practical concerns that remain unresolved. These issues require serious consideration before assisted decisionmaking models are adopted in guardianship regimes in Australia.