The Effect of Spatial Smoothing on Representational Similarity in a Simple Motor Paradigm

Multi-voxel pattern analyses (MVPA) are often performed on unsmoothed data, which is very different from the general practice of large smoothing extents in standard voxel-based analyses. In this report, we studied the effect of smoothing on MVPA results in a motor paradigm. Subjects pressed four buttons with two different fingers of the two hands in response to auditory commands. Overall, independent of the degree of smoothing, correlational MVPA showed distinctive patterns for the different hands in all studied regions of interest (motor cortex, prefrontal cortex, and auditory cortices). With regard to the effect of smoothing, our findings suggest that results from correlational MVPA show a minor sensitivity to smoothing. Moderate amounts of smoothing (in this case, 1−4 times the voxel size) improved MVPA correlations, from a slight improvement to large improvements depending on the region involved. None of the regions showed signs of a detrimental effect of moderate levels of smoothing. Even higher amounts of smoothing sometimes had a positive effect, most clearly in low-level auditory cortex. We conclude that smoothing seems to have a minor positive effect on MVPA results, thus researchers should be mindful about the choices they make regarding the level of smoothing.

Just health: replies and further thoughts

This paper responds to discussion and criticism contained in a mini-symposium on Just health: meeting health needs fairly. The replies clarify existing positions and modify or develop others, specifically in response to the following: Thomas Schramme criticises the claim that health is of special importance because of its impact on opportunity, and James Wilson argues that healthcare is not of special importance if social determinants of health have a major causal impact on population health. Annette Rid is concerned that the relevance condition in accountability for reasonableness is unclear and does little work. Harald Schmidt aims to flesh out where an account of responsibility for health should go since one is under-developed in Just health. Michael Schefczyk and Susanne Brauer challenge aspects of the prudential lifespan account. Samia Hurst asks what impact a population view should have on clinician obligations.

Emergence of Salmonella enteritidis phage type 4 in the Caribbean: case-control study in Trinidad and Tobago, West Indies

A prospective case-control study involving 46 case patients and 92 age- and neighborhood-matched control subjects was conducted in Trinidad and Tobago (T&T) between March 1998 and May 1999 to determine the etiology, sources, and risk factors for Salmonella enteritidis (SE) infection. SE infection in T&T was found to be associated with the consumption of shell eggs, and in particular raw or undercooked eggs. SE isolates from 30 (88%) of 34 patients and from 9 implicated egg or egg-containing food samples were phage type 4. Homemade eggnog and ice cream, cake batter, and egg-containing beverages were the main raw egg-containing foods, reflecting the cultural practices of the people of T&T. Public health education on the risks of eating raw or undercooked eggs, thorough cooking of all egg dishes, and refrigeration of shell eggs and egg dishes; studies tracing infected eggs to their sources; and testing of flocks of layer chickens for SE are needed to reduce the incidence of this infection.

Justice, health, and healthcare

Healthcare (including public health) is special because it protects normal functioning, which in turn protects the range of opportunities open to individuals. I extend this account in two ways. First, since the distribution of goods other than healthcare affect population health and its distribution, I claim that Rawls's principles of justice describe a fair distribution of the social determinants of health, giving a partial account of when health inequalities are unjust. Second, I supplement a principled account of justice for health and healthcare with an account of fair process for setting limits of rationing care. This account is provided by three conditions that comprise "accountability for reasonableness."

Normal functioning and the treatment-enhancement distinction

The treatment-enhancement distinction draws a line between services or interventions meant to prevent or cure (or otherwise ameliorate) conditions that we view as diseases or disabilities and interventions that improve a condition that we view as a normal function or feature of members of our species. The line drawn here is widely appealed to in medical practice and medical insurance contexts, as well as in our everyday thinking about the medical services we do and should assist people in obtaining.

Benchmarks of fairness for health care reform: a policy tool for developing countries

Teams of collaborators from Colombia, Mexico, Pakistan, and Thailand have adapted a policy tool originally developed for evaluating health insurance reforms in the United States into "benchmarks of fairness" for assessing health system reform in developing countries. We describe briefly the history of the benchmark approach, the tool itself, and the uses to which it may be put. Fairness is a wide term that includes exposure to risk factors, access to all forms of care, and to financing. It also includes efficiency of management and resource allocation, accountability, and patient and provider autonomy. The benchmarks standardize the criteria for fairness. Reforms are then evaluated by scoring according to the degree to which they improve the situation, i.e. on a scale of -5 to 5, with zero representing the status quo. The object is to promote discussion about fairness across the disciplinary divisions that keep policy analysts and the public from understanding how trade-offs between different effects of reforms can affect the overall fairness of the reform. The benchmarks can be used at both national and provincial or district levels, and we describe plans for such uses in the collaborating sites. A striking feature of the adaptation process is that there was wide agreement on this ethical framework among the collaborating sites despite their large historical, political and cultural differences.

Benchmarks of fairness: a moral framework for assessing equity

The health care systems of most advanced industrialized countries are currently undergoing extensive reforms. In Europe, in addition to economic and political issues, issues of "equity" and "solidarity" are very much on the minds of some health care reformers. Elsewhere in Europe, economics and politics dominate health care reform, and concerns about fairness are either absent or of secondary importance. Similarly, the recent health care debates in the United States were largely carried out in terms of payment schemes, cost-containment and outcome measures, campaign strategies, and political concessions. Issues of fairness were either hidden in the many features of the competing proposals and the debates about them, or totally ignored. In both cases, there has been no practical way to gauge how a given change would alter the equity or fairness of existing health care services. This article addresses that void by presenting ten scorable benchmarks of fairness.

Decisions about access to health care and accountability for reasonableness

Insurers make decisions that directly limit access to care (e.g., when deciding about coverage for new technologies or formulary design) and that indirectly limit access (e.g., by adopting incentives to induce physicians to provide fewer or different services). These decisions raise questions about legitimacy and fairness. By holding health plans accountable for the reasonableness of their decisions, it is possible to address these questions. Accountability for reasonableness involves providing publicly accessible rationales for decisions and limiting rationales to those that all "fair-minded" persons can agree are relevant to meeting patient needs fairly under resource constraints. This form of accountability is illustrated by examining its implications for the three examples of direct and indirect limit setting noted here.

The ethics of accountability in managed care reform

Two notions of accountability embodied in proposals to reform managed care have different ethical implications. Market accountability requires plans to inform purchasers and consumers about performance and options, in theory legitimizing limits to care through consumer choice. Recognizing the limits of consumer choice, accountability for reasonableness requires that the rationales for limits to services be public and be based on reasons or rules that "fair-minded" people can agree are relevant to pursuing appropriate patient care under necessary resource constraints. Accountability for reasonableness educates clinicians and patients about the need for limits and empowers a more focused public deliberation in which ultimate authority for limiting care rests with democratic processes.