Paternalistic Attitudes Research Articles

‘As long as it helps somebody’: why vulnerable people participate in research

In the past, ethics committees and researchers have avoided research among vulnerable groups because of prevailing perceptions that such research is unethical and difficult. Taking an opposite stand, this article will argue that it is in fact unethical not to research vulnerable populations because, by excluding potential participants from research endeavours, they are being deprived of the benefits to be gained from research. Albeit well meaning, people in vulnerable populations are also being subjected to the paternalistic attitudes of those who believe they know what is in the best interests of others. There is ample evidence in existing literature that, not only is research among vulnerable populations unlikely to result in harm, but there are often benefits to be gained by both participants and researchers. Apart from the generic benefits of increased knowledge and improved health interventions, specific benefits for participants might be: therapeutic, cathartic, educational, empowering, altruistic and social. In contrast, the risks associated with researching vulnerable populations appear to be minimal. Yet, there is still evidence that health care professionals and other gatekeepers continue to hinder research amongst vulnerable populations through unilateral decision-making. This article will review existing literature on the topic of research amongst vulnerable populations, as well as contribute to the argument from the author's own study on a sensitive topic.

Between ‘Turkish Islam’ and ‘French Islam’: The Role of the Diyanet in the Conseil Français du Culte Musulman

This article discusses the role of the Directorate of Religious Affairs in Turkey—the Diyanet—in the French Council for Muslim Religion (Conseil Français du Culte Musulman or CFCM). The Diyanet-linked Cordination Committee of Muslim Turks in France (Comité de Coordination des Musulmans Turcs de France, or CCMTF) was one of the constitutive federations of the CFCM, confirming its status as ‘the’ interlocutor for the French state in its relations with the Turkish Muslim community. I argue in this paper that this is mainly for two reasons. First, the Turkish government uses the Diyanet as a foreign-policy instrument, promoting ‘Turkish Islam’ as a moderate and rational religion, compatible with modernity and as a model for ‘European’ or ‘French Islam’. The Diyanet presents itself as the legitimate representative of Muslims of Turkish origin in France, excluding other organisations as radicals. Secondly, the Turkish Muslim community in France still displays loyalty to Turkey in terms of social organisation. The paternalistic attitude of the Turkish state, the immigrants' search for protection of the country of origin, nationality divisions within the CFCM and the long-standing habit of the French state to deal with its Muslim community through foreign governments help to explain the continuing importance of the Diyanet for the Turkish Muslim community and in the CFCM.

La place du patient dans la médecine factuelle

Medical practice has undergone a significant evolution over the last decade due to two important factors: (1) the theory and practice of Evidence-Based Medicine (EBM) has become widely established; (2) the relationship between health-care professionals and patients or clients has been profoundly modified. In this review, we discuss the heterogeneity and variability of patient preference and the need to develop a doctor-patient relationship, which facilitates shared decision-making in preference to previous models based on patient information without choice and paternalistic attitudes. Thus, this modern concept of care based on EBM shifts the focus of interest from the disease entity itself to that of the patient suffering from a disease. The patient has a right to information concerning his illness; this information helps the patient to participate in medical decisions through the laying out of clinical practice guidelines. These aspects of the patient's role in care management are illustrated by a national program in the field of oncology which empower the patient in the decisions arrived at by a multi-disciplinary oncology team.

Ethics and Public Good in a Transforming State: A Study of Estonian Civil Servants

After Estonia's systemic change and restored independence in 1991, Estonian civil servants must re‐conceptualise their relationships with other spheres of society and with what they see as the ‘Public Good’. They are involved in the adoption and creation of new value judgments, professional identities and views of ethical and unethical conduct. This article presents an empirical examination of these processes. Carried out from June 2005 to January 2006, it makes use of group interviews (N = 58) and a national e‐mail questionnaire (N = 960) of civil servants. According to the results, the officially adopted Civil Service Code of Ethics is seldom relied upon. The idea of civil service as a vocation, preference for self‐regulating measures, suspicion towards external control and avoidance of media publicity are indicative of the respondents' view of the overall role of civil service in society. The paternalist attitude inherent in this discourse is considered in this article to be in line with the specific functions of a state still completing its systemic transformation.

Influencia de los profesionales sanitarios en la solicitud de donación

The communication of bad news is an stress generating task for the health professionals and, at the same time, an important human, ethical, medical and legal action. Last years, news transmission has evolved from a paternalistic attitude to an informed consent based relation, covered by our Health General Law. The donation process is immersed in the worst news communication process, the death, and most of the time produced suddenly. Studies made at European hospitals, show that the contact with families of critical patients is an stress generating source for the nursing professional. Our aim is showing the consequences of that communication and presenting how to drive it in a Helping Relationship to the family.

"A Home for Civilization": Nostalgia, Innocence, and the Frontier in Wallace Stegner's Angle of Repose

Wallace Stegner's Angle of Repose tells a classic pioneer story, full of hardship, hope, struggle, tests of faith, and a sometimes-hostile, sometimes-beautiful environment. The novel's main character, Lyman Ward, is a retired historian who is writing the story of his grandparents' lives. Lyman is an ornery storyteller who frequently critiques his own historical moment—in which "Berkeley radicals" are challenging the Victorian morality he holds dear—and expresses nostalgia for the time before history ended, when people had character, ruggedness, patience, aspirations, and a solid work ethic. Stegner's protagonist demands our attention for the ways he represents the West's mythical elements and the ways he succumbs to the nostalgia that too often still colors these elements. In The Sound of Mountain Water , Stegner condemns nostalgia and describes his efforts to depict the "real people of the West," who are "infrequently cowboys and never myths" (31). Angle of Repose is one of Stegner's most admirable attempts to describe the West's "real people" and reestablish continuity between the past and the present without falling prey to nostalgia or myth making. With Stegner's intentions in mind, this essay examines how Lyman helps us "theorize" western life and culture as he narrates the history of his pioneer grandparents and contrasts the "old West" with the "New West." Lyman's attitude toward the counterculture (which closely follows Stegner's own) is accompanied by a form of nostalgia that implicitly celebrates the past by contrasting it with the debilitated contemporary moment. Because he dislikes the counterculture so profoundly, Lyman is predisposed to see his pioneer relatives as more honest, more in touch with the past, and as counterpoints to all that is wrong with the "amputated Present" ( SMW 193). Specifically, he asserts that "the twentieth century [has] tak[en] away the possibility of innocence" (34). This essay uses Lyman's nostalgia as a starting point to examine how his rediscovery of this lost innocence in his grandparents reifies the familiar US history of its frontier settlers as morally righteous—a history that glosses over the violent aspects of the western past. While most scholars of this text foreground how it challenges western myths, this essay identifies the echoes of the Turnerian frontier, even in its multi-layered depictions of this fraught space. Although the environmentalist agenda of the novel is readily apparent, Lyman's nostalgia for pioneer virtue results in a narrative that elides problematic histories, exhibits paternalistic attitudes towards people of color, and reifies nature as the domain of white, privileged Americans. The frontier that emerges is ruthless and it takes casualties, but there is a mystifying substitution at work: innocent white pioneers are the suffering ones, not the people who were displaced, colonized or killed by these pioneers' ancestors. This essay suggests that readers are not sufficiently invited to critique Lyman's view and, as a result, the text reifies what Patricia Limerick has described as an "empire of innocence." The frontier remains largely trapped in its historical role as the violent proving ground for US identity, the site at which civilization battled (and eventually overcame) savagery, and the space where racist and colonial aspirations were made manifest. In making this argument, this essay aims to respect Stegner's intentions, attend to the problems with conflating author and narrator, and develop an analysis that is nuanced and sensitive, rather than inflammatory or accusatory. While the novel is successful in some ways in representing a complex West—for instance, it acknowledges and critiques the economic intersections between Western industry and Eastern financial backing—it is less successful at exposing the problematic interconnections between race, class and the economy. Ultimately, familiar stereotypes lurk in this novel despite Stegner's intentions—stereotypes about civilization, innocence, and the hardy, virtuous pioneers said to embody both.

Moving beyond developmental paradigms: A case study and analysis of a TfD workshop in Bangladesh

The authors give a personal account of a one week Theatre for Development Workshop held in Manmathapur in Northern Bangladesh, sponsored by the British Council. The practice of short, workshops facilitated by urban ‘experts’ in impoverished rural areas is heavily critiqued. This opens into a broader critique of the manipulative and paternalistic attitudes which often undermine the effectiveness of post-colonial development communications, due to global power imbalances. Modesty is urged for the strategizing and practice of such workshops through a return to the participatory principles of Paulo Freire. The paper describes the advantages of ‘Barter Theatre’ as a methodology which attempts to ensure equality in the exchange of skills and ideas between marginalized, host communities and visiting facilitators. The potential of such intercultural ‘bartering’ is linked both to the injustices caused by, and potential resistance to, globalized communications.

Corruption, the Southern African Development Community Anti-corruption Protocol and the principal–agent–client model

Since the 1990s, a number of anti-corruption conventions have been adopted due to pressure from international financial institutions, donor countries and governments of major industrialised nations. One of these conventions is the Anti-corruption Protocol adopted by the Southern African Development Community. This article examines this Convention against the backdrop of the principal–agent–client (PAC) model which influences much of the current anti-corruption measures ranging from legal and civil service reform through to privatisation of the public sector. In focusing on the efforts to fight and prevent corruption through legal and public sector reform, this paper highlights the limitations of externally imposed solutions largely driven by donors. Using Tanzania, a country that has seen extensive technical input from donor agencies in reforming the law and bureaucratic structures, as an illustration, this article argues that the limited success of such donor-driven anti-corruption strategies is attributable to a number of reasons ranging from reform policies of donors and paternalistic attitudes to political shifts and antipathy towards external demands for reforms that are fuelled by the colonial past. This paper recommends that for a recipient country to take ownership of the anti-corruption strategies it is important to tailor the PAC model to the cultural, social and political context of the recipient country so that the solutions are seen as an indigenous initiative, thus enabling sustainable change in attitudes and behaviour.

Informed consent in genetic research and biobanking in India: some common impediments

The principle of informed consent, codified in the Declaration of Helsinki, has been widely seen as fundamental to bio-medical and research ethics. The importance of informed consent is increasing in procedures regulating the acquisition, possession and use of personal information, including genetic and medical information. Informed consent, it is believed, ensures that patients and research subjects can decide autonomously whether to permit or refuse actions that affect them. In response to this assurance, there are numerous guidelines at local, national and international levels that recognise the importance of informed consent, especially in research related to healthcare in developing countries. However, complications arise in applying these guidelines to a particular situation, especially under conditions that are prevalent in developing societies, for instance in India. This article discusses common forms of impediments or hindrances encountered while exercising the principles of informed consent in the context of genetic and genomics related research among the tribal and rural caste communities in India. These hindrances include: illiteracy, poverty, paternalistic attitudes, socio-cultural barriers, ineffective regulatory mechanism and procedural inconsistency among others. The data used in this article is based on an ethnographic study conducted between December 2006 and May 2007 using social-science qualitative research techniques. We observe that three areas require attention: first, the ways in which informed public debate on bioethical issues can be held, and how the application of genetics and genomics in Indian society can be discussed; second, the readiness with which researchers, IRB members and the state appreciate and wish to map the genetic diversity in Indian society; and, third, the risks associated with the application of bioethical principles at a micro-level.

The Dictatorship of Sex: Lfestyle Advice for the Soviet Masses by Frances Lee Bernstein (review)

REVIEWS 381 mixup thedetailsofwhatthey weredestined tosee,hearordo manydecades ago. Moreover,theyofteninterpret thoseeventsfromthevantagepointof their contemporary ideological standof,say,Communists turned Zionists and Americanpatriots. In otherwords,in theirrecollections informants reveal their present-day perception oftheperception thatthey had at thetimeofthe events. For all that,Shternshis - whoseresearch projectsoughtto establish how theSovietmachinery ofJewish culture had beenperceived bythepopulation - conducted 225in-depth interviews withpeoplebornon theterritory ofthe SovietUnionno laterthan1930.She metsomeofherinformants in Russia, butthemajority ofthemwereimmigrants livingin Americaand Germany. She knewthattheirstories had to be manytimesfiltered beforefinding a place in herbook.As a result, she is confident that' [c]ross-examination of testimonies witharchival andpublished datagivesusthefullest picture todate ofthedailylivesofSoviet Jewsduring thisperiod'(p.xviii). Methodologically, Soviet andKosher can be seen as an exampleof successful utilization of oral history. The title, Soviet andKosher, reflects themainthesisoftheresearch: Jewish traditions did notdisappear, butweresignificantly transformed in theSoviet environment. Whilein urbansettings acculturation was verystrong and the younger urbanités' Jewish identity was,toborrowthewordsoftheAmerican historianArcadius Kahan [EssaysinJewishSocialandEconomic History, Chicago, IL, 1986,p. 189)'leftonlyas a mythical, almostmystical qualityincomprehensiveto theirenvironment and one thatcould become incomprehensible to themselves', olderpeople did notreplacetheirfaith in God by a faithin Communism. Old-timers had a chanceto preserve theirtraditional lifestyle, especiallyiftheychose to stayput in the shtetl.Meanwhile,the younger generation was takenin bytheKremlin'spropagandaand underwent rapid Sovietization. Still,the generationinterviewed by Shternshis could speak Yiddishand remembered songs,sayings, legendsand otherelements ofEast EuropeanJewish lore. Thanksto thiswell-written and informative study, the Soviet-and-kosher population appearslessenigmatic. In anycase,one can easierunderstand the problems ofgauging the(post-) Soviet Jewish identity byapplying toitWestern yardsticks ofJewishness. Skirball Department ofHebrew and Judaic Studies G. Estraikh NewYork University Bernstein, Frances Lee. TheDictatorship ofSex:Ltfestyle Advice for theSoviet Masses.NorthernIllinoisUniversity Press,DeKalb, IL, 2007. xvii + 246 pp. Illustrations. Notes.Bibliography. Index.$42.00. Frances Lee Bernstein'sTheDictatorship ofSexcontinues thehistorical investigation ofRussia'smedicalprofession by NancyFriedenand Laura Engelstein ,as wellas thatofRussiansexuality by IgorKon, Engelstein and Eric Naiman. By comparisonto these other scholars,Bernsteindraws more overtly upon Foucaultto explainhow the earlySovietmedicalprofession 382 SEER, 87, 2, APRIL 2OO9 constructed sexand sexuality foruse as a knowledge-technology in itsbidfor authority and power.Sovietsexologists 'weremotivated bothbythedesireto contribute tosocialist society and thepressing needtoassert andmaintain the independence and integrity of theirprofession and theirinstitutions' writes Bernstein (p. 4), who further argues:'The sexual knowledge producedby medicalenlighteners and themethods usedtoassert their professional authorityoversexuality in the1920swouldpave thewayforthestate'sadoptionof repressive policiestowardsex duringthe 1930s'(p. 5). Of course,physicians had no wayofseeingwhatlayahead,buttheirgoal to dictatetheterms by whichsexwas tobe understood and practised servesas further evidencethat the Stalinist dictatorship resulted fromtrendsoriginating 'below' as wellas 'above'. Before theonsetofwhatBernstein admitsis thecontroversial notion ofthe'GreatRetreat', Russianaetiology differed from Bolshevism insofar as itportrayed 'healthy' sexuality in negative terms. This paradigmsupposedly provedunsustainable whenfacedbythefive-year plans'demandsforhuman as wellas material productivity. Sovietsexologists differed fromtheirEuropean counterparts, too.Despiteattending international conferences and readingmanyof thesamejournals,theydid not sharethenotionthatmutual pleasurewaskeytoa couple'shealthy sexlife.Alluding to Orthodoxy and its traditional exaltation ofsuffering, Bernstein nevertheless failsto accountfor thisprudery. Medicos wereprimarily concernedwithdefining 'normal'sexuality and rigidly defining genderroles.In thechaptercalled'MakingSex', Bernstein's graspofperiodicalliterature allowsherto showhowphysicians medicalized discursively-constructed cultural assumptions ofmasculinity and femininity by aligning themto theories ofglandularactivity. Havingestablished normsof appearanceand behaviour,theycould pathologizeanything outsidethese definitions. The resultant (and inevitable) conclusion was thatRussia'swas a sexuallysicksocietyurgently requiring physicians' expertise, treatment and precautions. Bernstein insists theirvestedinterest in sucha diagnosisshould notlead one to concludethattheywantedtheir patients to remainsickand dependent, butthis isillogical. Although mostphysicians undoubtedly believed themselves trueto theirHippocraticoaths,theNEP's facilitation ofmarket forces createda situation inwhichsexologists' powerand authority absolutely dependedon maintaining thisdiagnosis. Quitesimply, itwastheir raison d'être. As Bernstein's own evidenceshows,theyapplied the diagnosisso widely it perversely accountedforthevastmajority, not minority, of the general population. The Dictatorship ofSexpresents an impressive amountofinformation detailing how Sovietsexuality was constructed duringthe1920s.The extent to which physicians hoped to create 'new people' by informing themabout what did and did not constitute appropriate sexual acts and desiresperpetuated the intelligentsia's traditional paternalistic attitude towardthe 'masses'and amounted toa socialengineering project runbycivilian authorities. However, whyandhowthestatecutshort this medicaldictatorship isnotwellexplained, and thisposesa problemforBernstein's assertion thatitpaved thewayfor Stalinist sexualrepression. Also,thetextisrepetitive and consists oftoomany lengthy synopses ofjournalarticles andtoolittle analysis ofthem. Forexample, thereaderistoldseveral times thatphysicians inveighed against masturbation REVIEWS 383 in thebeliefthatit led to impotenceand lassitudeand therefore rendered youngpeople unserviceable to nationalneeds. But what thissays about physicians' attachment to a service-state ethosis leftundeveloped. Similarly, Bernstein quotesrepeatedly from a 'Commissar Semashko'whoseinitials...

Your Sexism Predicts My Sexism: Perceptions of Men’s (but not Women’s) Sexism Affects One’s Own Sexism Over Time

The effects of perceived normative (societal) levels of benevolent (BS) and hostile sexism (HS) on one’s own sexist attitudes were examined over a four-month period in an undergraduate New Zealand sample (76 women, 26 men). Perceptions of normative levels of men’s BS produced longitudinal change in one’s own BS, and this effect was invariant across gender. However, contrary to previous research suggesting that women endorse BS when men are high in HS for its protective benefits, women instead expressed subjectively positive paternalistic attitudes toward their gender to the extent that they perceived BS as normative in men. The transmission of patriarchical-defined ideologies is tempered by the degree to which such ideologies espouse benevolent versus more overtly hostile attitudes toward women.

Meg Wilson, Health Behaviors of Homeless Women: Using a Cross-selectional, Descriptive, and Non Experimental Design

If the housing crisis be lined with any silver at all, it is the possibility of a more nuanced picture of the homeless in America, and especially the homeless woman. While the total number has recently skyrocketed across the sociological spectrum, homeless families headed by single females represent the fastest single growing subgroup, representing some 40% of the total. As this situation is unlikely to change dramatically in the near future, the study by Meg Wilson on Health Behaviors of Homeless Women, recently published in Germany though in English, is a welcome contribution to an understanding of the challenges faced by this endangered population. While its principal target audience is the nursing community, the book is short and readable, easily accessible to a wider audience. By way of background, Dr. Wilson observes that the relationship among the factors contributing to the health and wellbeing of homeless women is insufficiently understood. Her study is designed to explore some of those factors in order to arrive at better practices not only among the assistance community, including especially nurses, but also the subjects themselves. She believes, with good reason, that homelessness is not synonymous with hopelessness. Not only do more effective, compassionate nursing practices contribute a great deal to advancing that difference; the women themselves, the subjects at risk, must find the strength required to emerge from the predicament of a shelter existence. Too often, caregivers assume a paternalistic (or maternalistic) attitude, however unconsciously. No matter how well meaning, such an approach is often counterproductive. This is particularly true in the area of health promotion. Increasingly popular, though still imperfectly understood, ‘‘health promotion’’ refers to behavior motivated by a desire for positive change in a person’s level of wellbeing, to a person’s overall lifestyle and attitude that includes both physical and psychological dimensions. By contrast, what is commonly known as ‘‘health care’’ refers to

Construction of the child question in early republican Turkey and social services as an art of government

This paper discusses the child question in Turkey through an inquiry into social services as an art of government. The ideological reference in the formation of the ‘social’ in the early Republican period was solidarism, which was planned to function as the pattern for new social relations of the new society because the problem was not to provide social assistance, but rather to make human beings productive individuals. Children were seen both as the symbols of modernism and western Turkey, and the carriers of nationalistic values as the owners of the future. Therefore, the education and protection of children was a ‘national’ matter; child care was of the quality of a national service. The goal was to create a healthy, sportive, smart and industrious new generation. In accordance with the solidarist ideals of the state, making orphans who are protected by a paternalist attitude into useful and productive individuals marked the earlier periods as a technique of government of the new regime.

Obstacles to European research projects with data and tissue: Solutions and further challenges

Most European biomedical research projects are about data. Research with tissue is about data as well; data will accompany the tissue, and data will be derived from analysing the tissue. Data can be merged with data from various sources, copied and re-analysed in the context of European projects. Privacy enhancing technologies (PET) should be used for transferring data from participating centres to the level where data are being merged. PET provide coding techniques which allow donors to be anonymised and still uniquely discernable. It is defended that under certain conditions two-way coded data can be considered as anonymous data in the sense of the European Data Protection Directive. Divergent interpretations of this Directive and most of all about the concept of coded-anonymised data is one of the main obstacles to observational research in Europe. The Data Protection Authorities will have to relax the extremely high threshold before data cannot be considered personal data anymore. Arguments are given for such relaxation. Besides the logic and logistics of data transfer in European projects, it is also about trust and a realistic risk assessment. In spite of the massive dataflow in European research projects no breach of confidentiality has ever been reported. The ethical rationale of such projects can be based on the principles of citizenship and solidarity provided that certain safeguards are met by which that research will remain observational. However, if the project does not preclude individual feed-back on the outcomes of research, as in theory would be possible with two-way coded tissue, that tissue cannot be considered anonymous. It is argued that in most tissuebanking projects individual feed-back should be excluded. Tissuebanking for research should not turn into medical screening without applying the established criteria for screening to it. If individual feed-back is not foreseen, two-way tissue should be considered anonymous, under the same conditions as two-way coded data. Good research governance is proposed as the way forward in the longer run. Good research governance is about a fair balance between the interests of all stakeholders. It should make the basic principles transparent on which observational research projects are based in line with European solidarity-based healthcare systems. It should encompass principles on how the general results of research will be disseminated, ‘conflict of interests’ policies, how the issues of intellectual property rights are dealt with, how the confidentiality of personal data of donors is maintained, etc. This should not become an extra bureaucratic layer. A good research governance framework should not establish rules but principles which provide enough flexibility for the specifics of a project, according to the ‘comply or explain’ principle. Such research governance should be developed bottom-up, by researchers together with the most interested stakeholders, patient organisations. Patients as ‘biosocial citizens’ are the natural allies of researchers against the ‘paternalistic attitudes’ of some ethicists and regulators.

Chivalry and the Moderating Effect of Ambivalent Sexism: Individual Differences in Crime Seriousness Judgments

Previous studies have shown that female offenders frequently receive more lenient judgments than equivalent males. Chivalry theories argue that such leniency is the result of paternalistic, benevolent attitudes toward women, in particular toward those who fulfill stereotypical female roles. Yet to date, studies have not examined whether such leniency is indeed associated with paternalistic societal attitudes toward women. The present study goes beyond the investigation of demographics and employs Glick and Fiske's (1996) concepts of hostile and benevolent sexism. We use these concepts to highlight the role of individual differences in attitudes toward women as a key to our understanding of lenient attitudes toward female offenders. Eight hundred forty respondents from a national sample of Israeli residents evaluated the seriousness of hypothetical crime scenarios with (traditional and nontraditional) female and male offenders. As hypothesized, hostile and benevolent sexism moderate the effect of women's “traditionality” on respondents' crime seriousness judgments and on the severity of sentences assigned.

RESPONSE LETTER TO VAN DER STEEN ET AL.

To the Editor: van der Steen et al. offer the alternative explanation that cultural differences between European and American medicine, and not awareness of prior publications in the field, may explain the differences between our results and those of previous studies.1 Although their remark is pertinent, there is no proof for either of the two explanations. The UK data we cite and a recent German study of end-of-life care suggest that lack of a comfort plan and provision of active life-sustaining treatment can also be quite common in Europe.2, 3 We disagree with their suggestion that advance directives are mainly useful in the United States. Such directives provide some protection not only from overaggressive treatment, but also from paternalistic attitudes, where family and physicians decide what they believe is best for the patient. They may also help relieve the emotional burden of surrogates when difficult decisions are required.4 We thank van der Steen et al. for their interesting comments and look forward to the results of ongoing prospective studies that should lead to improved care of dying demented patients on both sides of the Atlantic. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklists provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this letter. Author Contributions: All authors were involved in manuscript preparation and approved of the final submitted version. Sponsor's Role: No role.

“We Grandmothers Know Plenty”: Breastfeeding, complementary feeding and the multifaceted role of grandmothers in Malawi

This paper has two purposes: first of all, we examine grandmothers' role and views of child feeding practices in northern Malawi, and their influence on younger women's practices. Secondly, we consider the implications of these findings for health promotion activities and models of health education. Data were collected from semi-structured interviews, focus groups and a participatory workshop. Findings demonstrate that, to address child feeding practices which have an effect on nutrition, attention must be paid to the broader context that influences child nutrition, including extended family relations. Paternal grandmothers have a powerful and multifaceted role within the extended family in northern Malawi, both in terms of childcare and in other arenas such as agricultural practices and marital relations. Grandmothers often differ in their ideas about early child feeding from conventional Western medicine. Some practices have existed in the area at least since colonial times, and have strong cultural significance. Despite the important integrated role, older women have within households and communities in this part of Malawi, hospital personnel often have disparaging and paternalistic attitudes towards ‘grannies’ and their knowledge. Health education rarely involves grandmothers, and even if they are involved, their perspectives are not taken into consideration. Hospital staff often reject grandmother knowledge as part of a broader modernization paradigm which views ‘traditional knowledge’ as backward. Grandmothers view current child health conditions within a broader context of changing livelihood conditions and a high prevalence of HIV/AIDS. The paper concludes by discussing the challenges of involving grandmothers in health education, and the difficulties of incorporating local knowledge into a medical system that largely rejects it.

JOHANNESBURG LUNCH-HOUR 1951–1963

Framing the concerns of this paper are two short photographic essays published in Drum, a South African picture magazine modelled on the British Picture Post and the US Life. Both essays take as their subject the activities of black South Africans during a typical lunch-hour in Johannesburg; the first was published (un-credited) in September 1951, the second by Peter Magubane was published in July 1963. I argue that they represent the beginning and the endpoint in the development of, and possibilities for, a particular genre of photography in South Africa: a highpoint for post-war humanist photography. “Johannesburg Lunch-Hour” is the first photographic essay of its kind to be published in Drum, which up until that point had taken a largely paternalistic attitude towards its black audience. This essay signalled a new focus on the lives of “ordinary” urban Africans, and a more creative and vibrant practice of photography. “Lunch-Hour: A Photographic Essay”, although almost identical in theme and style, was published in a period of tightening apartheid legislation and increasingly brutal repression, which impacted on photographic practice and publishing—by April 1965 Drum had ceased publication as an independent monthly magazine. The paper is part of a larger study to research the development of social documentary photography in Drum, to examine its main themes and characteristics, and consider the social vision it projected. The paper is based on archival research and interviews with Drum photographers and editors.

Consentement éclairé ou choix informé ? Un dilemme éthique en pratique quotidienne

How articulate information, mutidisciplinary practice, choice and decision of the treatment in a good patient-doctor relationship, an ethical relationship ? Doctor is an expert who gets the information (patients have more and more others sources of information). Choice of the treatment depends of the facts (the evidence) and personal values (the preferences). The selection between the different options (most often they are several options) may be done by the physician or by physicians in a multidisciplinary clinics, in the presence of the patient or not. The final decision to do or not the treatment belongs to the patient (who is not always aware of that). Initial sharing of the information between patient and doctor may permit the patient to choose himself the best option. More complete is sharing of the information, more the patient is able to do a free choice (without the influence of the doctor). It is often possible (genetics, prevention, screening, adjuvant treatments) to share in full the available information (knowing its relativity and limits). In oncology, the full sharing of the information is not always realistic, neither asked by the patient. Nevertheless, it is possible to go progressively with the patient to a preferred choice through a deliberative process, a co-construction of the decision. But often, the doctor refer to a pre-established protocol, build by physicians, representing the choice of the majority (doctors and/or patients) in the "same" situation. Only one option is offered to the patient from whom consent is asked, the information been then delivered to explain the choice already done. This paternalistic attitude is very effective, comfortable and don't alter the satisfaction of the majority of the patients, however, it limits the patient's autonomy. The patient is not allowed to choose between all the possibilities but accept or refuse the doctor's choice. With the extreme variability of the situations, it would be illusive to defend a unique attitude. Doctor has yet to try to adapt himself to every single case.

Responding to violence against women: Social science contributions to legal solutions

Violence against women represents a serious problem in America. Not only does intimate partner violence represent a significant threat to women, but it also counts among its victims, children living in the violent household. By its very nature, intimate partner or domestic violence may be approached as either a legal or a social problem. However, there is a shortage of legal approaches that have been informed by sound social science research. One promising framework for developing such integrated responses to intimate partner violence is therapeutic jurisprudence, which encourages legal professionals to work closely with social scientists to develop system responses based on empirical data. Such an approach contrasts sharply with the current practice of developing law based on assumptions, which frequently reflect traditional paternalistic and sexist attitudes toward women. This paper begins by examining the current theories and scientific knowledge on domestic violence with particular emphasis on the supporting data. A theoretical framework for conceptualizing domestic violence characterized as patriarchal terrorism as distinct from common couple violence is examined and offered as a means of explaining inconsistencies in research findings. Following a review of current legal responses to domestic violence, the paper concludes by outlining alternative strategies and recommendations for future efforts that are supported by current theory and research.