A discourse-theoretic perspective on the bioethical-legal framework of genetic counseling

The reflexive nature of reason and the unique relationship reason shares with autonomy in Kant's philosophy is the theoretical basis of this dissertation. The principle of respect for autonomy undergirds the two main legal and ethical tenets of genetic counseling, an emerging profession trying to accommodate the sweeping changes that have occurred in clinical genetics, clinical ethics, and case law applicable to medicine. These two tenets of the counseling profession, informed consent and nondirectiveness, both share a principlist interpretation of autonomy that I argue is flawed due to its connection to: instrumental forms of reasoning, empirical theories of action supporting rational choice, and a liberal paradigm of law. I offer an alternative bioethical-legal framework that is based in the Kantian tradition in law and ethics through the complex theories of Jurgen Habermas. Following Habermas's reconstruction of the mutually constituting notions of private and public autonomy, I will argue for a richer conceptualization of autonomy that can have significant implications for the legal and bioethical concepts supporting the profession of genetic counseling, and which can ultimately change counseling practice. ^

A discourse-theoretic approach to negotiated rulemaking

In 1996 and in 1997, Congress ordered the Secretary of Health and Human Services to undertake a process of negotiated rulemaking, which is authorized under the Negotiated Rulemaking Act of 1990, on three separate rulemaking matters. Other Federal agencies, including the Environmental Protection Agency and the Occupational Health and Safety Administration, have also made use of this procedure. As part of the program to reinvent government, President Clinton has issued an executive order requiring federal agencies to engage in some negotiated rulemaking procedures. I present an analytic, interpretative and critical approach to looking at the statutory and regulatory provisions for negotiated rulemaking as related to issues of democratic governance surrounding the problem of delegation of legislative power. The paradigm of law delineated by Jürgen Habermas, which sets law the task of achieving social or value integration as well as integration of systems, provides the background theory for a critique of such processes. My research questions are two. First, why should a citizen obey a regulation which is the result of negotiation by directly interested parties? Second, what is the potential effect of negotiated rulemaking on other institutions for deliberative democracy? For the internal critique I argue that the procedures for negotiated rulemaking will not produce among the participants the agreement and cooperation which is the legislative intent. For the external critique I argue that negotiated rulemaking will not result in democratically-legitimated regulation. In addition, the practice of negotiated rulemaking will further weaken the functioning of the public sphere, as Habermas theorizes it, as the central institution of deliberative democracy. The primary implication is the need to mitigate further development of administrative agencies as isolated, self-regulating systems, which have been loosened from the controls of democratic governance, through the development of a robust public sphere in which affected persons may achieve mutual understanding. ^

A Comparative Analysis of Hedging in a Corpus of Two Written Legal Discourse Genres

Esta tesis doctoral, que es la culminación de mis estudios de doctorado impartidos por el Departamento de Lingüística Aplicada a la Ciencia y a la Tecnología de la Universidad Politécnica de Madrid, aborda el análisis del uso de la matización (hedging) en el lenguaje legal inglés siguiendo los postulados y principios de la análisis crítica de género (Bhatia, 2004) y empleando las herramientas de análisis de córpora WordSmith Tools versión 6 (Scott, 2014). Como refleja el título, el estudio se centra en la descripción y en el análisis contrastivo de las variedades léxico-sintácticas de los matizadores del discurso (hedges) y las estrategias discursivas que con ellos se llevan a cabo, además de las funciones que éstas desempeñan en un corpus de sentencias del Tribunal Supremo de EE. UU., y de artículos jurídicos de investigación americanos, relacionando, en la medida posible, éstas con los rasgos determinantes de los dos géneros, desde una perspectiva socio-cognitiva. El elemento innovador que ofrece es que, a pesar de los numerosos estudios que se han podido realizar sobre los matizadores del discurso en el inglés general (Lakoff, 1973; Hübler, 1983; Clemen, 1997; Markkanen and Schröder, 1997; Mauranen, 1997; Fetzer 2010; y Finnegan, 2010 entre otros) académico (Crompton, 1997; Meyer, 1997; Skelton, 1997; Martín Butragueňo, 2003) científico (Hyland, 1996a, 1996c, 1998c, 2007; Grabe and Kaplan, 1997; Salager-Meyer, 1997 Varttala, 2001) médico (Prince, 1982; Salager-Meyer, 1994; Skelton, 1997), y, en menor medida el inglés legal (Toska, 2012), no existe ningún tipo de investigación que vincule los distintos usos de la matización a las características genéricas de las comunicaciones profesionales. Dentro del lenguaje legal, la matización confirma su dependencia tanto de las expectativas a macro-nivel de la comunidad de discurso, como de las intenciones a micro-nivel del escritor de la comunicación, variando en función de los propósitos comunicativos del género ya sean éstos educativos, pedagógicos, interpersonales u operativos. El estudio pone de relieve el uso predominante de los verbos modales epistémicos y de los verbos léxicos como matizadores del discurso, estos últimos divididos en cuatro tipos (Hyland 1998c; Palmer 1986, 1990, 2001) especulativos, citativos, deductivos y sensoriales. La realización léxico-sintáctica del matizador puede señalar una de cuatro estrategias discursivas particulares (Namsaraev, 1997; Salager-Meyer, 1994), la indeterminación, la despersonalización, la subjectivisación, o la matización camuflada (camouflage hedging), cuya incidencia y función varia según género. La identificación y cuantificación de los distintos matizadores y estrategias empleados en los diferentes géneros del discurso legal puede tener implicaciones pedagógicos para los estudiantes de derecho no nativos que tienen que demostrar una competencia adecuada en su uso y procesamiento. ABSTRACT This doctoral thesis, which represents the culmination of my doctoral studies undertaken in the Department of Linguistics Applied to Science and Technology of the Universidad Politécnica de Madrid, focusses on the analysis of hedging in legal English following the principles of Critical Genre Analysis (Bhatia, 2004), and using WordSmith Tools version 6 (Scott, 2014) corpus analysis tools. As the title suggests, this study centers on the description and contrastive analysis of lexico-grammatical realizations of hedges and the discourse strategies which they can indicate, as well as the functions they can carry out, in a corpus of U.S. Supreme Court opinions and American law review articles. The study relates realization, incidence and function of hedging to the predominant generic characteristics of the two genres from a socio-cognitive perspective. While there have been numerous studies on hedging in general English (Lakoff, 1973; Hübler, 1983; Clemen, 1997; Markkanen and Schröder, 1997; Mauranen, 1997; Fetzer 2010; and Finnegan, 2010 among others) academic English (Crompton, 1997; Meyer, 1997; Skelton, 1997; Martín Butragueňo, 2003) scientific English (Hyland, 1996a, 1996c, 1998c, 2007; Grabe and Kaplan, 1997; Salager-Meyer, 1997 Varttala, 2001) medical English (Prince, 1982; Salager-Meyer, 1994; Skelton, 1997), and, to a lesser degree, legal English (Toska, 2012), this study is innovative in that it links the different realizations and functions of hedging to the generic characteristics of a particular professional communication. Within legal English, hedging has been found to depend on not only the macro-level expectations of the discourse community for a specific genre, but also on the micro-level intentions of the author of a communication, varying according to the educational, pedagogical, interpersonal or operative purposes the genre may have. The study highlights the predominance of epistemic modal verbs and lexical verbs as hedges, dividing the latter into four types (Hyland, 1998c; Palmer, 1986, 1990, 2001): speculative, quotative, deductive and sensorial. Lexical-grammatical realizations of hedges can signal one of four discourse strategies (Namsaraev, 1997; Salager-Meyer, 1994), indetermination, depersonalization, subjectivization and camouflage hedging, as well as fulfill a variety of functions. The identification and quantification of the different hedges and hedging strategies and functions in the two genres may have pedagogical implications for non-native law students who must demonstrate adequate competence in the production and interpretation of hedged discourse.

Ultrasound in undergraduate medical education: A systematic and critical review

Introduction: Point-of-care ultrasound (POCUS) use in clinical care is growing rapidly, and advocates have recently proposed the integration of ultrasound into undergraduate medical education (UME). The evidentiary basis for this integration has not been evaluated critically or systematically. In this study, we conducted a critical and systematic review framed by the rationales enumerated by advocates of ultrasound in UME in academic publications.

Methods: This research was conducted in two phases. First, the dominant discursive rationales for the integration of ultrasound in UME were identified using techniques from Foucauldian critical discourse analysis (CDA) from an archive of 403 academic publications. We then sought empirical evidence in support of theses rationales, using a critical synthesis methodology also adapted from CDA.

Results: We identified four dominant discursive rationales, with different levels of evidentiary support. Ultrasound was not demonstrated to improve students’ understanding of anatomy. The benefit of ultrasound in teaching physical examination was inconsistent,and rests on minimal evidence. With POCUS, students’ diagnostic accuracy was improved for certain pathologies, but findings were inconsistent for others. Finally, the rationale that ultrasound training in UME will improve quality of patient care was difficult to evaluate.

Discussion: Our analysis has shown that the frequently repeated rationales for the integration of ultrasound in UME are not supported by a sufficient base of empirical research. The repetition of these dominant discursive rationales in academic publications legitimizes them and may preclude further primary research. Since the value of clinical ultrasound use by medical students remains unproven, educators must consider whether the associated financial and temporal costs are justified or whether more research is required.

Discourse and assessment

Many contemporary currents in applied linguistics have favored discourse studies within assessment; there have been calls for cross-fertilization with other areas within applied linguistics, critiques of the positivist tradition within language testing research, and the growing impact of Conversation Analysis (CA) and sociocultural theory. This chapter focuses on the resulting increase in discourse-based studies of oral proficiency assessment techniques. These studies initially focused on the traditional oral proficiency interview but have since been extended to new test formats, including paired and group interaction. We discuss the research carried out on a number of factors in the assessment setting, including the role of the interlocutor, candidate, and rater, and the impact of tasks, task performance conditions, and rating criteria. Recent research has also concentrated more specifically on the assessment of pragmatic competence and on the applications of technology within the assessment of spoken language, including the comparability of semidirect and direct methods for such assessment and the use of computer corpora.

Kids, counsellors and troubles-telling : morality-in-action in talk on an Australian children’s helpline

This chapter investigates one instance of ‘morality-in-action’, which transpires when children describe their troubles to the adult counsellors at Kids Help Line, an Australian national helpline that deals specifically with callers aged approximately 5-18 years. We focus, in particular, on how a young female caller who has forged a medical certificate in relation to a problem with school attendance, determines both what to report, and how this should be disclosed. Throughout the call, the moral implications of the troubles talk are delicately managed by both caller and counsellor. The call takes the form of an extended story (Labov & Waletzky, 1997) that includes a preface (‘I have some problems at school’), an orientation (“I was sick, went to the doctor, stayed home”), a complicating action (“I went back to school and photocopied my certificate from last time”), result (“I got caught”) and evaluation (“I don’t know why it happened”). As the account unfolds, we observe how both the student and counsellor seek to make sense of these actions. While this account is partly about deception, both the caller and counsellor delicately sidestep naming this action, precluding this implication. For example, the counsellor lets stand the caller’s main assessment of the trouble. He simply asks, “so what happened then,” when the caller reports that her forgery was discovered. The caller, from the very beginning of the call, seeks to find out why she could have done this, “you see I don’t know why it happened”. As the call unfolds, the counsellor follows the opening provided by the caller and they put forward motives for consideration. By agreeing that the motives are to be explored, the act takes on a character other than deception.

Negotiating multiple identities between school and the outside world : A critical discourse analysis

This article examines interview talk of three students in an Australian high school to show how they negotiate their young adult identities between school and the outside world. It draws on Bakhtin’s concepts of dialogism and heteroglossia to argue that identities are linguistically and corporeally constituted. A critical discourse analysis of segments of transcribed interviews and student-related public documents finds a mismatch between a social justice curriculum at school and its transfer into students’ accounts of outside school lived realities. The article concludes that a productive social justice pedagogy must use its key principles of (con)textual interrogation to engage students in reflexive practice about their positioning within and against discourses of social justice in their student and civic lives. An impending national curriculum must decide whether or not it negotiates the discursive divide any better.

The criminalisation of medical mistakes in Canada : a review

The issue of health professionals facing criminal charges of manslaughter or criminal negligence causing death or grievous bodily harm as a result of alleged negligence in their professional practice was thrown into stark relief by the recent acquittal of four physicians accused of mismanaging Canada’s blood system in the early 1980s. Stories like these, as well as international reports detailing an increase in the numbers of physicians being charged with (and in some cases convicted of) serious criminal offences as the result of alleged negligence in their professional practice, have resulted in some anxiety about the apparent increase in the incidence of such charges and their appropriateness in the healthcare context. Whilst research has focused on the incidence, nature and appropriateness of criminal charges against health professionals, particularly physicians, for alleged negligence in their professional practice in the United Kingdom, the United States, Japan, and New Zealand, the Canadian context has yet to be examined. This article examines the Canadian context and how the criminal law is used to regulate the negligent acts or omissions of a health care professional in the course of their professional practice. It also assesses the appropriateness of such use. It is important at this point to state that the analysis in this article does not focus on those, fortunately few, cases where a health professional has intentionally killed his or her patients but rather when patients’ deaths or grievous injuries were allegedly as a result of that health professional’s negligent acts or omissions when providing health services to that patient.

Paramedic knowledge of infectious disease aetiology and transmission in an Australian Emergency Medical System

Introduction: Paramedics and other emergency health workers are exposed to infectious disease particularly when undertaking exposure-prone procedures as a component of their everyday practice. This study examined paramedic knowledge of infectious disease aetiology and transmission in the pre-hospital care environment.--------- Methods: A mail survey of paramedics from an Australian ambulance service (n=2274) was conducted.--------- Results: With a response rate of 55.3% (1258/2274), the study demonstrated that paramedic knowledge of infectious disease aetiology and modes of transmission was poor. Of the 25 infectious diseases included in the survey, only three aetiological agents were correctly identified by at least 80% of respondents. The most accurate responses for aetiology of individual infectious diseases were for HIV/AIDS (91.4%), influenza (87.4%), and hepatitis B (85.7%). Poorest results were observed for pertussis, infectious mononucleosis, leprosy, dengue fever, Japanese B encephalitis and vancomycin resistant enterococcus (VRE), all with less than half the sample providing a correct response. Modes of transmission of significant infectious diseases were also assessed. Most accurate responses were found for HIV/AIDS (85.8%), salmonella (81.9%) and influenza (80.1%). Poorest results were observed for infectious mononucleosis, diphtheria, shigella, Japanese B encephalitis, vancomycin resistant enterococcus, meningococcal meningitis, rubella and infectious mononucleosis, with less than a third of the sample providing a correct response.--------- Conclusions: Results suggest that knowledge of aetiology and transmission of infectious disease is generally poor amongst paramedics. A comprehensive in-service education infection control programs for paramedics with emphasis on infectious disease aetiology and transmission is recommended.

A medical data reliability assessment model

There is currently a strong focus worldwide on the potential of large-scale Electronic Health Record (EHR) systems to cut costs and improve patient outcomes through increased efficiency. This is accomplished by aggregating medical data from isolated Electronic Medical Record databases maintained by different healthcare providers. Concerns about the privacy and reliability of Electronic Health Records are crucial to healthcare service consumers. Traditional security mechanisms are designed to satisfy confidentiality, integrity, and availability requirements, but they fail to provide a measurement tool for data reliability from a data entry perspective. In this paper, we introduce a Medical Data Reliability Assessment (MDRA) service model to assess the reliability of medical data by evaluating the trustworthiness of its sources, usually the healthcare provider which created the data and the medical practitioner who diagnosed the patient and authorised entry of this data into the patient’s medical record. The result is then expressed by manipulating health record metadata to alert medical practitioners relying on the information to possible reliability problems.