Cardinal Question Research Articles

Needs, Modes, and Stances: Three Cardinal Questions for Psychotherapy Practice and Training.

Advances in motivational science (Dweck, 2017), personality dynamics (Lazarus & Rafaeli, 2023), and process-based psychotherapy (Hofmann & Hayes, 2019) converge into a pragmatic, integrative, and transtheoretical model of practice and training. The model comprises three elements: a formulation centered on clients' psychological needs which provides guidance regarding the goals and processes most profitable to pursue; a recognition that such pursuit frequently requires contending with a multiplicity of clients' internal self-states (i.e., modes); and an enumeration of pragmatic therapeutic stances likely to help address clients' need-related goals in light of their modes. We distill these elements into three cardinal questions: What needs does this client have that are not currently met, and what are the most profitable ways of remedying that frustration? What mode or modes does this client manifest - both generally and at this very moment? and What stance should I adopt in response to the client's current mode? We suggest that clinicians should be trained to continually pose these questions and seek to answer them collaboratively with their clients. This model - illustrated here using schema therapy terms - offers a process-based approach which serves as a theoretically integrative starting point but is general enough to provide an assimilative integration roadmap for therapists anchored in most primary orientations. Integrative or assimilative therapists trained to attend to needs, modes, and stances are likely to be (and be perceived as) particularly responsive, and thus, to enact "common factor" practices known to be conducive to therapeutic alliance and gains.

R-Spondin 2 governs Xenopus left-right body axis formation by establishing an FGF signaling gradient

Establishment of the left-right (LR, sinistral, dextral) body axis in many vertebrate embryos relies on cilia-driven leftward fluid flow within an LR organizer (LRO). A cardinal question is how leftward flow triggers symmetry breakage. The chemosensation model posits that ciliary flow enriches a signaling molecule on the left side of the LRO that promotes sinistral cell fate. However, the nature of this sinistralizing signal has remained elusive. In the Xenopus LRO, we identified the stem cell growth factor R-Spondin 2 (Rspo2) as a symmetrically expressed, sinistralizing signal. As predicted for a flow-mediated signal, Rspo2 operates downstream of leftward flow but upstream of the asymmetrically expressed gene dand5. Unexpectedly, in LR patterning, Rspo2 acts as an FGF receptor antagonist: Rspo2 via its TSP1 domain binds Fgfr4 and promotes its membrane clearance by Znrf3-mediated endocytosis. Concordantly, we find that at flow-stage, FGF signaling is dextralizing and forms a gradient across the LRO, high on the dextral- and low on the sinistral side. Rspo2 gain- and loss-of function equalize this FGF signaling gradient and sinistralize and dextralize development, respectively. We propose that leftward flow of Rspo2 produces an FGF signaling gradient that governs LR-symmetry breakage.

Attention toward emotions is modulated by familiarity with the expressor: A comparison between bonobos and humans.

Why can humans be intolerant of, yet also be empathic toward strangers? This cardinal question can be tackled by studying emotions in our closest living relatives, bonobos. Their striking xenophilic tendencies make them an interesting model for reconstructing the socioemotional capacities of the last common ancestor of hominids. Within two dot-probe studies, we compared bonobos' and humans' attention toward scenes depicting familiar (kith and kin) or unfamiliar individuals with emotional or neutral expressions. Results show that the attention of bonobos is biased toward emotional scenes depicting unfamiliar bonobos, but not toward emotional groupmates (Study 1). In contrast, Study 2 shows that human attention is biased toward emotional rather than neutral expressions of family and friends, but not toward unfamiliar others. On the one hand, our results show that an attentional bias toward emotions is a shared phenomenon between humans and bonobos, but on the other, both species have their own unique evolutionarily informed biases. These findings support previously proposed adaptive explanations for xenophilia in bonobos that potentially biases them toward emotional expressions of unfamiliar conspecifics, and parochialism in humans, which makes them sensitive to the emotional expressions of close others. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Parent's Attitudes toward Their Children's Oral Health Care during the COVID-19 Pandemic: A Cross-Sectional Study.

The COVID-19 pandemic has significantly impacted global health and presented challenges to maintaining oral health in children. Efficient management and prevention of oral diseases are therefore crucial in this population. This cross-sectional study aimed to assess parents' self-reported oral and dental hygiene habits for their children during the COVID-19 pandemic. A total of 256 parents of primary school children in Qazvin completed an online questionnaire containing demographic, general, and cardinal questions. The collected data were analyzed using SPSS 22 software, and accurate analytical tests were run to reach the results. The study found that 69.1% of parents and 87.1% of children brushed their teeth regularly during the pandemic. Additionally, 80.5% of parents monitored their children while brushing. While some parents expressed concerns about COVID-19 infection, parents from lower socioeconomic status reported a higher willingness to attend dental centers than those from more prosperous areas. These findings suggest that parents' supervision and attitude toward oral health care significantly affect children's oral hygiene habits during the pandemic, possibly due to increased time spent together during lockdowns.

Seven cardinal questions for the patient with ear, nose or throat complaints: Review.

The incidence of otolaryngological problems in general medicine practice is highly seasonal and approaches 25% in some months of the year. Accurate diagnosis in the otolaryngology office often requires the use of binocular microscopy, nasal endoscopy, and flexible laryngoscopy, none of which are available in a general medicine office. Therefore, history taking and physical examination techniques available in the non-otolaryngology office are of utmost importance. Using evidence-based history taking for ear, nose, and throat (ENT) problems facilitates dealing with patients who present with otolaryngologic complaints. In this paper, I present 7 cardinal questions to be asked when taking the history of a patient with ENT complaints.

Amphetamines modulate fentanyl-depressed respiration in a bidirectional manner

BackgroundThe opioid epidemic remains one of the most pressing public health crises facing the United States. Fentanyl and related synthetic opioid agonists have largely driven the rising rates of associated overdose deaths, in part, because of their surreptitious use as substitutes for other opioids and as adulterants in psychostimulants. Deaths involving opioids typically result from lethal respiratory depression, and it is currently unknown how co-use of psychostimulants with opioids affects respiratory toxicity. Considering psychostimulant overdoses have increased over 3-fold since 2013, and half of those co-involved opioids, this is a cardinal question. MethodsNaloxone, d-amphetamine (AMPH), and (±)-methamphetamine (METH) were evaluated for their effects on basal and fentanyl-depressed respiration. Minute volume (MVb) was measured in awake, freely moving mice via whole-body plethysmography to quantify fentanyl-induced respiratory depression and its modulation by dose ranges of each test drug. ResultsNaloxone immediately reversed respiratory depression induced by fentanyl only at the highest dose tested (10 mg/kg). Both AMPH and METH exhibited bidirectional effects on MVb under basal conditions, producing significant (p ≤ 0.05) depressions then elevations of respiration as dose increased. Under depressed conditions the bidirectional effects of AMPH and METH on respiration were exaggerated, exacerbating and then reversing fentanyl-induced depression as dose increased. ConclusionsThese results indicate that co-use of amphetamines with fentanyl may worsen respiratory depression, but conversely, monoaminergic components of the amphetamines may possibly be exploited to mitigate fentanyl overdose.

Towards political cohesion in metropolitan areas. An overview of governance models

As cities grew beyond their administrative borders, the demand for metropolitan governance appeared. The last 50 years proved that there is no one, universal model of metropolitan governance as urban regions are very different all around the world. However, it seems quite obvious that if metropoles are to be the forefront of development, they need to provide a widely defined cohesion within their subordinate territories. Metropolitan political cohesion may be defined as a collaborative public governance which offers tailored managerial solutions for enhancing development based on the subsidiarity principle and the place‐based approach. Drawing on the lessons from major cities in North America and Europe: Copenhagen, Rotterdam, Stockholm, Hannover, London, Wrocław and Toronto the paper intends to dive into a few, selected cases of metropolitan government and the causes behind their failure and reappearance. How have various governments met the cardinal question of metropoles: to provide a resilient match between the functional urban region and the administrative structure? The answer to this question is not straightforward. Metropolitan authorities all over the world manage exceptionally complex systems, where the diversity of actors, complexity of relations and interdependences across an extended, fragmented and dynamic metropolitan region restrain governability. However some general trends in metropolitan governance may be outlined, regarding the recent history, main types of governance and legitimacy of metropolitan administration.

Exploring influence between employee motivation and service quality in the South African Police Service

The South African Police Service (SAPS) Training College, Paarl is facing challenges to reward, motivate and ensure service delivery at the Academy. In any organisation, employees are working to provide service to both internal and external clients for this it is important to take care of employees because they are interacting with these clients. Thus, a cardinal question is how can organisations retain and motivate employees in order to offer a quality service to their clients? The aim of this study was to determine the influence between rewards, motivation and service quality at the SAPS Training College, Paarl. Semi-structured interviews with 10 managers and supervisors utilizing purposive sampling were conducted. The findings revealed that participants at the Training College, Paarl are motivated by only intrinsic as the morale is slow due to a lack of extrinsic factors with particular emphasis on pay or remuneration. Lack of recognition or perceived favouritism with the SAPS where rewards are not linked to performance was identified to be the best de-motivating factor for employees at the SAPS Training College, Paarl. The quality of academic services has a significant effect on the consumer behavior of customers, the students.

Influence of applied voltage and conductive material in DIET promotion for methane generation

The utilization of biological-, electrode- and conductive material-mediated direct interspecies electron transfer (DIET) between exoelectrogenic bacteria and methanogenic archaea for enhancing methane productivity is widely reported in the literature. However, two cardinal questions are still controversial, i.e., which applied voltage value would be more recommended to enhance methane generation? and how the DIET over IIET has the upper hand in enhancing methane productivity? Herein, the influence of different applied voltages to promote biological-, conductive- and electrode-mediated DIET was investigated in MEC-AD reactors with conductive material. Polarized bioelectrodes induced electrode-mediated DIET (eDIET) and biological DIET (bDIET), in addition to cDIET (conductive material-mediated DIET), improved the methane yield to 315.40 mL/g COD r with an applied voltage of 0.9 V. Whereas further increase of applied voltage 1.2 V, lessened methane production efficiency due to high-voltage inhibition and adverse effect on DIET promotion. The anaerobic digestion coupled microbial electrolysis cells with optimal electric potential selectively promotes the DIET through polarized electrodes were confirmed through microbial analysis. As the contribution of DIET increased to 80%, the methane yield increased, and the substrate residue decreased, resulting in a significant improvement in methane production. • DIET improves the conversion of substrate to methane and increases process stability. • At 0.9 V the electrode surfaces are enriched with electroactive microorganisms through DIET. • Polarized electrodes induce cDIET, bDIET, and eDIET, by improving methanogenesis. • Further increase of applied voltage to 1.2 V, showed negative effect in methanogenesis.

A High-Content Microscopy Screening Identifies New Genes Involved in Cell Width Control in Bacillus subtilis.

ABSTRACTHow cells control their shape and size is a fundamental question of biology. In most bacteria, cell shape is imposed by the peptidoglycan (PG) polymeric meshwork that surrounds the cell. Thus, bacterial cell morphogenesis results from the coordinated action of the proteins assembling and degrading the PG shell. Remarkably, during steady-state growth, most bacteria maintain a defined shape along generations, suggesting that error-proof mechanisms tightly control the process. In the rod-shaped model for the Gram-positive bacterium Bacillus subtilis, the average cell length varies as a function of the growth rate, but the cell diameter remains constant throughout the cell cycle and across growth conditions. Here, in an attempt to shed light on the cellular circuits controlling bacterial cell width, we developed a screen to identify genetic determinants of cell width in B. subtilis. Using high-content screening (HCS) fluorescence microscopy and semiautomated measurement of single-cell dimensions, we screened a library of ∼4,000 single knockout mutants. We identified 13 mutations significantly altering cell diameter, in genes that belong to several functional groups. In particular, our results indicate that metabolism plays a major role in cell width control in B. subtilis.IMPORTANCE Bacterial shape is primarily dictated by the external cell wall, a vital structure that, as such, is the target of countless antibiotics. Our understanding of how bacteria synthesize and maintain this structure is therefore a cardinal question for both basic and applied research. Bacteria usually multiply from generation to generation while maintaining their progenies with rigorously identical shapes. This implies that the bacterial cells constantly monitor and maintain a set of parameters to ensure this perpetuation. Here, our study uses a large-scale microscopy approach to identify at the whole-genome level, in a model bacterium, the genes involved in the control of one of the most tightly controlled cellular parameters, the cell width.

Mechanism of activation and the rewired network: New drug design concepts.

Precision oncology benefits from effective early phase drug discovery decisions. Recently, drugging inactive protein conformations has shown impressive successes, raising the cardinal questions of which targets can profit and what are the principles of the active/inactive protein pharmacology. Cancer driver mutations have been established to mimic the protein activation mechanism. We suggest that the decision whether to target an inactive (or active) conformation should largely rest on the protein mechanism of activation. We next discuss the recent identification of double (multiple) same‐allele driver mutations and their impact on cell proliferation and suggest that like single driver mutations, double drivers also mimic the mechanism of activation. We further suggest that the structural perturbations of double (multiple) in cis mutations may reveal new surfaces/pockets for drug design. Finally, we underscore the preeminent role of the cellular network which is deregulated in cancer. Our structure‐based review and outlook updates the traditional Mechanism of Action, informs decisions, and calls attention to the intrinsic activation mechanism of the target protein and the rewired tumor‐specific network, ushering innovative considerations in precision medicine.

Human Rights in Action. Assessing the Positive Impact of the Human Rights Act 1998 in the UK

When the Independent Human Rights Act Review (IHRAR) was announced, the Human Rights in Action (HRiA) team were reassured, on the one hand, to see that its overriding mission would be to consider how the Human Rights Act (HRA) is working in practice and whether any change is needed. But on the other hand, we were concerned, first by the fact that the IHRAR’s “terms of reference frame[d] the review against a politically polarised backdrop - concerning how it allegedly allows the judiciary to usurp the power of the executive for instance” and, secondly, by the fact that the terms of reference “fail to ask the cardinal question of whether the HRA has effectively protected individual rights in the UK”. As academic human rights experts who have observed, analysed and, in collaboration with others, worked to promote – through our scholarship, teaching and public engagement activity – the indisputable positive influence of the HRA in protecting human rights in the UK, we were strongly motivated to join forces, with the ambition of providing comprehensive, evidence-based responses to the key questions being asked by the IHRAR. The HRiA project reflects, and is the mechanism that allows us to pursue, this ambition. In the context of this project, the HRiA team invited some of the foremost human rights experts in their fields to answer the fundamental question of how the HRA has shaped UK law and UK courts over the last two decades, and to consider the questions that the IHRAR asked in its call for evidence. The HRiA submission to the IHRAR comprises 20 contributions by 26 experts which provide answers to some of the IHRAR’s central questions, while taking particular care to highlight the continuous positive impact of the HRA in human rights protection in the UK. The individual expert contributions are reproduced in their entirety in this submission, and we are submitting them to the IHRAR with the hope that they will inform its work. We feel that, read together, they highlight the significant value of the HRA to the lives of everyone in the UK. Taking into account that this report is not a submission from a single author but a product created by a group of independent experts, we have exceeded the suggested maximum word count for a single submission. We have made all of the contributions from the HRiA project available on our website, which we will continue to update with new contributions in the future. In addition to informing the IHRAR’s work, we remain committed to engaging with the wider public to show the positive impact of the HRA and alerting them to the risks inherent in the potential undermining of its key protections.

The reluctant native

Anthropologists, in regular intervals, tend to ask a cardinal question: How do we know what we know? Storms about ethnography and theory, epistemology and representation rage, and in their wake the...

Dosage of anti-PD-1 monoclonal antibodies: a cardinal open question.

Discovery and clinical development of monoclonal antibodies with the ability to interfere in the regulation of the immune response have significantly changed the landscape of oncology in recent years. Among the active agents licensed by the regulatory agencies, nivolumab and pembrolizumab are paradigmatic as the most relevant ones according to the magnitude of available data derived from the extensive preclinical and clinical experience. Although in both cases the respective data sheets indicate well-defined dosage regimens, a review of the literature permits to verify the existence of many issues still unresolved about dosing the two agents, so it must be considered an open question of potentially important consequences, in which to work to improve the effectiveness and efficiency of use.

НА ФОНЕ ПУШКИНА. ЛИНГВИСТИЧЕСКИЙ АСПЕКТ ПУШКИНСКОГО ДИСКУРСА 1920–1930-х гг.

The article focuses on the analysis of linguistic means of adapting the literary heritage of the 19th century by the Soviet cultural space using the example of Pushkin's discourse of the 1920s-1930s. At first glance, it seems that the interpretation of Pushkin's heritage was continuous in Russian culture throughout the centuries with the same semantics: the poet as a symbol of national culture. However, in Pushkin's discourse, there is a breakpoint that occurred in the post-revolutionary decade, during the breakdown of the entire cultural tradition in an attempt to establish a new proletarian culture. In order to set the vector for the development of Soviet culture, the Bolsheviks had to solve the cardinal question of their attitude to the literary heritage of the Russian Empire. The option of full assimilation of the pre-revolutionary cultural heritage was unacceptable for the Bolsheviks. A complete refusal was also impossible since the Bolsheviks as a whole understood that it was difficult to ignore the age-old cultural tradition. As a result, the new regime, with its perception of the cultural tradition as “cultural baggage”, had to use ideological filters for this baggage. From this point of view, the most representative source is the ideological concepts of the history of the 19th century literature presented as a system in the Literary Encyclopedia in 11 volumes (1929-1939) and in the Small Soviet Encyclopedia (1928-1931), as well as the ways of communicating the concepts to the broad Soviet audience. Pushkin's Soviet discourse is the most indicative example of the changes that occurred in the Russian language in the post-revolutionary era when a version of the Russian language started obeying a new system of meanings and attributed to the text a meaning that was not originally implied or intended by the author. One of the instruments for adapting the pre-revolutionary cultural experience to the Soviet ideological space was the expansion of the semantic field of the key concepts democratic and revolutionary with the help of added context. The added context made any phenomenon of pre-revolutionary culture look “proletarian”, especially those ones which could justify continuity between the “Soviet present” and the “Russian past”. Also, this context divided the cultural tradition into “good past” and “bad past”. Moreover, it caused the emergence of oxymorons in the language that brought together very opposite ideas, such as, for example, “noble revolutionaries”. However, despite the internal inconsistency of Pushkin's Soviet discourse, as evidenced by the oxymoronic nature of its basic concepts, the aim of the “Sovietization” of Pushkin was successfully achieved through the purposeful use of linguistic means.

Revisiting the assessment of tremor: clinical review.

Tremor, an involuntary, rhythmic, and oscillatory movement of a body part, is a frequent presenting symptom to general practice and by far the most common movement disorder presentation, impacting up to 15% of such cases.1 A common initial pattern is symmetric upper-limb involvement during posture and action. Although patients are often worried about Parkinson’s disease (PD), PD tremor usually has easily recognisable features.2 This concern tends to lead to frequent referrals for specialist input despite an alternative diagnosis being more likely in a majority of cases. Essential tremor (ET) is the most common diagnosis given to patients with this presentation, which is estimated to affect 0.4–6.0% of the general population.3 This may be an overestimate as the rubric of ET and the relationship between clinical features and underlying pathophysiology is uncertain. These aspects also potentially contribute to variable diagnostic and treatment outcomes.4 A recent Movement Disorder Society consensus on phenotyping charts a course towards more precise classification.5 This will not only be useful for research but also help in clarifying common clinical syndromes seen in everyday practice. This article outlines an approach to upper-limb tremor presentations in adult patients, developing a previously proposed three cardinal question method for neck pain6 while highlighting salient aspects of the consensus statement that could potentially aid in clinical stratification of cases. ### History Characterising the onset age, anatomical distribution (head, voice, hands, and symmetry), and temporal evolution of the tremor is important, forms the first step of the assessment, and aids in determining the underlying syndrome (outlined in subsequent sections). A key aspect to establish early is if the tremor results in functional impairment as this will determine if treatment is warranted (all current treatment options are symptomatic, that is, non-disease modifying).7,8 Useful questions to establish this …

The Influence of Ecosystem and Phylogeny on Tropical Tree Crown Size and Shape

The sizes and shapes of tree crowns are of fundamental importance in ecology, yet understanding the forces that determine them remains elusive. A cardinal question facing ecologists is the degree to which general and non-specific versus ecological and context-dependent processes are responsible for shaping tree crowns. Here, we test this question for the first time across diverse tropical ecosystems. Using trees from 20 plots varying in elevation, precipitation, and ecosystem type (savanna-forest transitions) across the paleo- and neo-tropics, we test the relationship between crown dimensions and tree size. By analyzing these scaling relationships across environmental gradients, biogeographic regions, and phylogenetic distance, we extend Metabolic Scaling Theory (MST) predictions to include how local selective pressures shape variation in crown dimensions. Across all sites, we find strong agreement between mean trends and MST predictions for the scaling of crown size and shape, but large variation around the mean. While MST explained approximately half of the observed variation in tree crown dimensions, we find that local, ecosystem, and phylogenetic predictors account for the half of the residual variation. Crown scaling does not change significantly across regions, but does change across ecosystem types, where savanna tree crowns grow more quickly with tree girth than forest tree crowns. Crowns of legumes were wider and more voluminous than those of other taxa. Thus, while MST can accurately describe the central tendency of tree crown size, local ecological conditions and evolutionary history appear to modify the scaling of crown shape. Importantly, our extension of MST incorporating these differences accounts for the mechanisms driving variation in the scaling of crown dimensions across the tropics. We present allometric equations for the prediction of crown dimensions across tropical ecosystems. These results are critical when scaling the function of individual trees to larger spatial scales or incorporating the size and shape of tree crowns in global biogeochemical models.

Effective diagnostics for vertigo, dizziness and equilibrium disorders

Vertigo, dizziness and equilibrium disorders are symptoms with avariety of causes. First, four cardinal questions (type and duration of the vertigo, triggering factors, accompanying symptoms) must be answered. After that, the search for aspontaneous nystagmus (differentiation of peripheral and central disorder using the HINTS[head impulse, nystagmus, test of skew]-test ) and, as part of apositioning examination, the search for abenign paroxysmal positional vertigo (BPPV) are necessary. If the result is negative an instrument-based receptor-specific examination is carried out. The caloric examination (low-frequency stimulus) tests the horizontal semicircular canal and the superior vestibular nerve, whereas the 3‑D video head impulse test (vHIT, high-frequency stimulus) is used to analyze all three semicircular canals as well as the superior and inferior vestibular nerves. Analysis of the cervical vestibular evoked myogenic potential (cVEMP) checks the function of the sacculus and that of the ocular VEMP (oVEMP) checks the function of the utriculus. The final overall analysis usually gives adefinitive diagnosis or at least provides asuspected diagnosis, which then determines the further diagnostic procedure (e.g. targeted radiological diagnostics if vestibular paroxysmia, superior canal dehiscence or a vestibular schwannoma are suspected).

EU Cohesion Policy and spatial economic growth: trajectories in economic thought

ABSTRACT This paper aims at identifying the current main economic thought influencing the EU Cohesion Policy. Postulates and assumptions on how economic growth spreads spatially in key EU policy framework documents are discussed and compared to different economic theories. Strategic EU documents increasingly foster the urban dimension, and focus resources on cities at the expense of cohesive regional development. The findings indicate large overlaps with Perroux’ ‘growth pole theory’. However, several of the key assumptions of growth pole theory are not met in the new context of post-industrial globalized service economy, which is fundamentally different from its original use. This is a troublesome finding when seen from a strategic planning perspective. Current implications for regional policy and planning boil down to the cardinal question of supporting urban areas and/or peripheries. Taking the strategic EU policy documents and their trajectories in economic thought into consideration, this paper confirms that regional development focuses on cities. Yet, it suggests a new perspective on an urban-centred EU Cohesion Policy, one that normatively requests the ‘responsibility’ of cities towards their hinterland, instead of fostering a further dissociation of cities from their hinterland. This suggests a reorientation towards supporting the linkages between urban areas and peripheries.

Perspective by incongruity: Law and rhetoric in Masterpiece Cakeshop v. Colorado Civil Rights Commission

ABSTRACT The Supreme Court’s ruling in Masterpiece Cakeshop v. Colorado Civil Rights Commission was decided on the narrow ground that the Colorado Civil Rights Commission violated the First Amendment’s Free Exercise Clause because of hostility toward the owner of Masterpiece Cakeshop. This decision failed to answer a cardinal question of constitutional law, whether or not the First Amendment’s Free Speech Clause could undermine nondiscrimination law. In Justice Anthony Kennedy’s majority opinion, he seized on one particular comment made by a Commissioner about religious freedom that justified ruling against the Commission for its use of discriminatory rhetoric. According to Justice Kennedy, the Commission violated the Free Exercise Clause by describing religious expression as despicable and as merely rhetorical. In this report, I argue that Justice Kennedy’s opinion demands heightened attention for two reasons. First, to describe religious freedom as a justification for prejudice as merely rhetorical is a gross underestimation of the power of rhetoric and provides moral encouragement to anti-LGBTQ+ activists using the legal system to advance a heteronormative agenda. Second, Justice Kennedy’s claim that rhetoric is insubstantial and insincere calls into question the role of the Court, the meaning of the law, and the relationship between the law and rhetoric.