By Q. Lars. Indiana University Northwest. 2018.
The term "less aggressive" sug- gests the same symbolism as that of "natural" cheap sildenafil 75 mg amex, but with the added con- notation of pejorative judgment on traditional medicine sildenafil 25 mg mastercard, which is seen as "harsh" and "aggressive". Here we find a dichotomy that is encouraged by consumer protec- tion trends that impinge on the medical field, among others. Being a more knowledgeable consumer, in terms of medicine or patamedicine, means preferring medicine that is "risk free", "natural" (in the sense of "closer to nature"), "inexpensive" (with the insinuation that it is acces- 10 From Alternative Medicine to Patamedicine sible to everyone, including inhabitants of the Third and Fourth W orlds), as distinguished from a type of medicine that is "aggressive" (or based on chemistry or physics, products of a market economy), "artificial" (and thus polluting), and "expensive" (and thus reserved to the developed nations whose economies are devastating the planet). Some of the arguments used by the advocates of patamedicine are judicious and it is true that our W estern society at the down of the new millennium has not done a great job of managing the gains in medical achievement. The economic stakes often take precedence over the pa- tients’ interests; many invented formulas are put on the market without sufficient study; and finally, the pharmaceutical companies generally prefer marketing over scientific proof. Even so, must we reject all ra- tionality and place our health, and sometimes our lives, in the hands of the healers, alchemists, sibyls and soothsayers of the modern world? For the last 25 years, the psychology of the patient/consumer has been evolving, and at the same time his sense of belonging to a specific th social group has diminished. W hile the first half of the 20 century witnessed the establishment of the great social protection programs and gradually integrated the citizen into a health care system related to his economic station (individual plans, trade union plans, etc. The "social" security system gave way to "illness" insur- ance — and budgetary considerations took precedence over health re- quirements. The social fabric unraveled, leaving the citizen/patient to his own devices, pondering in relative isolation how best to "come to terms" with the system. So-called traditional medicine was suspect, because of its ambigu- ous relations with the pharmaceutical "producers", because of its elite 11 Healing or Stealing? Changing morals and the new constraints that weigh upon the individual led people to give themselves a new sense of freedom by opening up to the choice of non- traditional healthcare practices. Over the course of time, the two-way bond between patient and doctor was weakened, damaged by the third-party payment system (insurance), which ends up controlling the patient, the doctor and the care that is provided. The failure of contrac- tual and friendly policies has led to increasingly heavy-handed state intervention to the detriment of the doctor-patient partnership, which has split into two parties with sometimes antinomical interests. Ac- cess to the best care (often the most recent, sometimes the most expen- sive) does not necessarily agree with budgetary considerations. Faced with growing constraints, the patient tends to escape more and more often toward the arenas of medical freedom that the "non-traditional" practitioners represent, and this with the blessing of the public organi- zations and insurance companies who are, for the time being, dis- charged from the responsibility of paying for certain procedures. The conventional doctor is more constrained than the unconventional one, who in turn is more constrained than the practitioner who is not a doctor at all. As the level of social and professional freedom increases, the prescribed "therapy" has less need to abide by any rule. The increase in anomalous practices is accompanied by a decrease in technical skills and expertise, which are reduced proportionally. Only the supreme control of crimi- nal law remains, which often proves unable to tell the difference be- 12 From Alternative Medicine to Patamedicine tween sensible practices and scams, for lack of laws governing "patamedicine". Released from the medical-insurance yoke, the patient finds alter- native medicines all the more attractive since their spiel generally takes a global view of the individual himself, and then of the individual in society, and finally of the individual in the cosmos — an approach that permits talk loaded with philosophical, political, even moralistic con- notations. The patient is presented as responsible for his own actions and thus for his disease, but also as a victim of a social system that pro- duces pathologies. The mechanistic aspect of the traditional medical approach is replaced by language whose orientation corresponds to the subject’s unacknowledged instincts and propensities. Now the patient can "live naturally, free, without constraints, becoming master of his own destiny, by seeing his acts in the context of a cosmic destiny". Moreover, choosing nontraditional medicine permits the subject to make adjustments and to take a graduated response to his pathology. Nontraditional medicine takes the lead if traditional medicine is failing and the prognosis looks grim. Thus, many practitio- ners of alternative medicine avoid the risk of having the validity of their treatment put to the test. Most pathologies thus treated are "self- curing" without resorting to any therapy whatsoever — and alternative medicine generally plays the part of a placebo drug. W hen it is coupled with traditional medicine, alternative medi- cine only interferes with the real care. It becomes a waste of time for the rational practitioner, who finds himself having to explain why, in spite of the 30 H C Perlimpinpinus pills prescribed by the pataphysi- cian, one must also take antibiotics. The real problems surface when, under the pretext of freedom of choice, patients afflicted with serious illnesses refuse traditional medicine outright, choosing to trust in a charlatan of nontraditional medicine instead. In fact, patamedicines of all kinds are generally addressed to two audiences: individuals who do not need any care at all, and those whose pathology is sufficiently grave to present a dire prognosis which, as a side effect, saps the credibility of traditional medicine. The Arguments of Official Medicine and of Alternative Medicines The reports of the study groups reflecting on alternative medi- cines accurately highlight the arguments of both sides. It is not very likely that the "official" arguments can convince those who believe in alternative medicines, and yet they to appear to be founded on common sense: x Medicine should accept only those therapies that have been proven effective and harmless; x This harmlessness and this effectiveness must be proven by experi- ence and experimentation; x Such tests are incompatible with the mystery that is maintained around certain practices and the metaphysical-religious character of others; x The "alternative" practitioner must not shelter behind a "secret"; he must prove — if not explain — the effectiveness of his nontradi- tional procedures. The 1985 report summarized these reservations: One of the greatest dangers that alternative or unproven medicines present to the patient is that they can persuade him that they are gen- erally harmless, even if they may not always be effective. Then there is the great risk that before a proven course of treatment is begun, patients afflicted with serious illnesses will waste precious time that can never be regained; this wasted time, during which the patient’s 14 From Alternative Medicine to Patamedicine condition will worsen, must be accounted as a pathogenic effect of these forms of "medicine". Ultimately, the following opinion, the most generally accepted in the realm of "official" medicine, concisely summarizes these various argu- ments: alternative medicine encompasses a range of practices that have never truly been proven reliable. Given the current state of our knowledge, one could tolerate these practices as long as they do not claim to apply to grave illnesses, thus making the patient miss other chances of being cured. Still, something has to be done to address the problem, taking into account the current situation. The success these forms of medicine enjoy in public opinion is easily explained by the French taste for the paradoxical, for the weird, for everything that seems to be opposed to the established order, and by the fairly favorable treatment they receive in certain of the media.
However buy cheap sildenafil 50 mg on line, with the ascendancy of managed care as a major force in healthcare generic sildenafil 50 mg online, other healthcare organizations began to adopt this term. Thus, providers who contracted to provide services for members of a health plan began to think in terms of enrollees. This represents a sig- nificant shift in nomenclature, as an enrollee has different attributes from a patient. The Four Ps of Marketing The marketing mix is the set of controllable variables that an organization involved in marketing uses to influence the target market. The four Ps have long been the basis for marketing strategy in other industries and are increasingly being con- sidered by healthcare organizations. However, as discussed here, these aspects of the marketing mix do not necessarily have the same meaning for health professionals as they do for marketers in other contexts. Product The first P—the product of healthcare—represents what healthcare providers are marketing. The product represents goods, services, or ideas offered by a healthcare organization. The product is difficult to precisely define in healthcare, creating a challenge for healthcare marketers. A good refers to a tangible product typically purchased in an impersonal setting on a one-at-a-time basis. It is more difficult to quantify services, and consumers evaluate them differently from more tangible products. For health plans, for exam- ple, the product may be thought of as the sense of security and protection against financial hardship or catastrophe that could arise from a serious ill- ness or injury and the assurance that personal finances will not stand in the way of getting needed care. Healthcare providers have seldom given much thought to the prod- uct concept in the past. A surgical procedure was considered just that, not something that had to be packaged. Today, however, the design of the product, its perceived attributes, and its packaging are all becoming more important concerns for both healthcare providers and marketers. Basic M arketing Concepts 91 Price The flip side of product benefits is product costs to the purchaser. Price refers to the amount charged for a product, including the fees, charges, premium contributions, deductibles, copayments, and other out-of-pocket costs to consumers for health services. In economics, the price is thought of in terms of exchanges—that is, a healthcare provider offers a service in exchange for its customers’ dollars. An employee paying an annual pre- mium to a health plan, an insurance company reimbursing a physician’s fee, and a consumer purchasing over-the-counter drugs are all exchanges involving a specified price. These costs could also include the pain, dis- comfort, embarrassment, anxiety, frustration, and other emotional costs of dealing with providers, plans, and the disease or injury that prompts the experience. That these costs must be at least perceived to be worth the investment, considering the benefits available from the relationship, reflects the reality of marketing and the definition of the value of the product for the price. The issue of pricing for health services is becoming a growing con- cern for marketers as the healthcare environment changes, and a number of factors are contributing to the greater role of the pricing variable in developing marketing strategy. For marketers the challenge is in develop- ing (1) an understanding of what a customer is willing to exchange for some want-satisfying good or service and (2) a pricing approach compatible with the goals of the organization and its cost constraints. Place The third P—place—represents the manner in which goods or services are distributed for use by consumers. Increasingly, as more healthcare organiza- tions establish relationships with managed care plans, the place variable assumes a more critical role. Companies offering health plans must consider location and primary-care access for potential enrollees. While in past years a physician could establish an office in a location convenient for him or her, today the consumer increasingly dictates the role of place in the marketing mix. Place relates to all factors of the transaction or relationship expe- rience that make it easy rather than difficult for consumers to obtain an organization’s products. While the obvious factors of location and lay- out are included, so are hours, access procedures, obstacles, waits for appointments, claims payment, and so on. In most cases the negative place aspects of the encounter impose costs such as lost time, frustration in finding the service site, parking fees, boredom, or other emotional 92 arketing Health Services burdens. Positive place aspects minimize such costs, as when a physician who offers early morning or evening hours enables patients to obtain care on the way to or from work and thus avoid time off from work, travel costs, and lost wages. In some cases place factors may enhance perceptions of the quality of the product, as when the physician’s office or hospital is in a trendy loca- tion or on a campus that facilitates efficiency of care. Doctors who make house calls may be the only way that homebound patients can get routine care. Systems or health plans may speed up or hinder the setting of appoint- ments by making them available through online communications, for exam- ple. Offering health-plan sign-up and status access and benefit-change capacity online at a worksite kiosk or home computer adds place value. The ability to have one’s medical record available online has added a different dimension to the concept of place. Promotion represents any way of informing the marketplace that the organization has developed a response to meet its needs and includes the mechanisms available for facilitating the hoped-for exchange. Promotion involves a range of tactics involving publicity, adver- tising, and personal selling (Berkowitz 1996). The promotional mix refers to the various communication techniques such as advertising, personal sell- ing, sales promotion, and PR or product publicity available to the marketer to achieve specific goals. Because promotion covers all forms of marketing communication, it includes communications that deliver value in addition to those that entice transactions. For example, health plans can devise communications that enable new members to better understand their coverage and rules for accessing care, enabling them to avoid frustration and get better use of their coverage in addition to promoting member satisfaction and reten- tion. Providers can advise new patients on how to avoid place frustrations and costs and address symptoms and concerns online prior to appointments to improve quality and patient satisfaction.
In short buy sildenafil 25 mg with visa, you’ve done about as much with it as you can discount 25mg sildenafil mastercard, and as talks go, it is not at all bad. We’ve all had to endure speakers who can’t be heard, or who look all wrong, or who display some thoroughly irritating mannerism that completely distracts from what they’re trying to get across. Or, perhaps more realistically, how can you at least make sure that you don’t get too much in the way of your own presentation? Here are a few basic tips – most of which I have to confess I learnt the hard way – to help you avoid the likeliest own-goals. Get there early The first piece of advice is: make sure you arrive in plenty of time. The chairman looks anxiously at the clock, wondering whether to bring the coffee break forward. Stumbles onto stage, knocks over microphone, scrabbles for projector switch, shoves on first overhead upside-down, and generally kyboshes the entire proceedings. There are several advantages: • It gives you an opportunity to pick up the "mood" of the meeting and the issues that may have a bearing on your talk. Grappling with an unfamiliar sound system is a classic elephant trap for hapless speakers. The usual disasters are failing to switch on the microphone, failing to make sure that it’s pointing in the right direction, constantly clunking the lead, or speaking so closely that you sound like a Dalek with laryngitis in a thunderstorm. Spend a few minutes before your session starts to do a sound check – and if necessary make a few adjustments. If you’re using a microphone on a stand– either a floor-stand, table-stand or fixed to the podium – adjust it so that it’s pointing at your mouth, but is positioned slightly to one side of the direct line of fire of your breath as you speak. This is to avoid "popping" – those periodic explosions accompanying every "P" that punctuates a presentation. The microphone should be about 6 in (15 cm) from your mouth, and on the side nearer the screen because if you happen to turn your head away from it, to look at the screen for example, your voice may disappear. Instead of the time-worn "testing, one, two, three, testing", I would recommend "Peter Piper picked a peck of pickled pepper" to sort out the pops from the snaps and crackles. The lapel microphone may be a marvel of miniaturisation, but it can cause tons of trouble. First, there’s the agony of where to clip it – a particular challenge for presenters without lapels. Women often find themselves in this awkward situation – and occasionally have to resort to holding the thing in position. With a radio microphone, the box of works can provide an even more difficult problem. But if there is no podium, or if you’re standing at the overhead projector, you could find yourself with both hands full. I remember one particular female presenter who performed a remarkably nimble impromptu juggling act with a clip-on microphone, its black box, and a profusion of wildly haphazard overheads. And then there is the pitfall of failing to disconnect 47 HOW TO PRESENT AT MEETINGS yourself at the end of your talk. This can either result in half your apparel being yanked away as you attempt to leave the podium, or, with a radio mike, the much more disastrous consequence of inadvertently leaving the thing switched on and accidentally telling everyone what dumb questions you felt you’d just been asked. By that I don’t mean you have to don your best Armani – which might provoke antibodies in some quarters. I mean looking self-assured and confident, knowing how to stand and move, and generally having poise and style. If you appear to be comfortably in command of the situation it will help people focus more on what you have to say rather than the struggle you’re having saying it. What would be appropriate for a small informal lunchtime session for GPs might not be at all right for an international conference. My advice is to try to strike a balance between what you perceive is expected by the organisers, and what you feel comfortable in. If there is a golden rule, I would say it’s not to wear anything that either distracts or detracts from the message or impression you want to put across. So, fight temptation and leave that favourite ultra-loud tie or those knock-’em-dead sparklers firmly at home. Standing and moving It was once rather unfairly observed of the accident-prone US ex-President Gerald Ford that he couldn’t walk down stairs and chew gum at the same time. Certainly many speakers do develop acute dystaxia when they get up on stage and have to cope with talking, following their notes, pressing buttons, changing overheads and pointing at things on the screen, all more-or-less simultaneously. I’ve already mentioned being familiar with the set-up, so that you know exactly which buttons to press. It also pays to have your notes (if you have any) clearly page-numbered, with bold headings, so that you can quickly navigate your way through them and instantly find your place again when you look up at your 48 HOW TO APPEAR ON STAGE audience. Overheads should have their backing sheets already removed (to avoid them looking too freshly made), and be interleaved with plain paper (so you can see what they are, and also to prevent them sticking together). They should be numbered (just in case you drop the lot) and, if possible, already placed in position on the OHP projector side-table, with a space to stack them again after use. As soon as you hear yourself being introduced, go straight into successful presenter mode and walk confidently up those steps, smiling at the chairman who hopefully has said a few nice things about you. When you reach your position, place your notes, check the microphone, smile at the audience, and launch forth.
Harsh laxatives in particular should be avoided purchase 75 mg sildenafil with amex, because basically they are chemical irritants of the bowel tract buy cheap sildenafil 75 mg on-line. Softer laxatives, which should only be taken occasionally, can lead to passing motions in 10–12 hours. These should be used only very occasionally because the bowel may become dependent on them if they are used frequently. You may have to be patient to try and ﬁnd the right combination of strategies that works for you. It is likely that a successful overall strategy will consist of a good ﬂuid intake, a diet with high ﬁbre, as much exercise as possible, and a regular time for a bowel movement – 30 minutes after a meal is usually the most opportune time. Recent research has revealed that something like two-thirds of people with MS have some bowel problems and, over several months, nearly half, in one study, had some degree of what is described as ‘faecal’ or ‘bowel incontinence’. Of course, what appears to be an involuntary release of faeces produces a very unpleasant situation. There may be a link between urinary and bowel incontinence (from weakened muscles, from spasms in the intestinal area induced by MS, or from a full bowel pressing on the bladder), but the link is not always clear. The exact causes of bowel incontinence are not always easy to ﬁnd, even in the few centres with special facilities for investigating these issues, but there are several pointers to what may be happening in many cases. Involuntary spasms in the muscles affecting the bowel area are probably the most common causes of such incontinence. Sensation may be reduced in the bowel area and you may not be aware that there has been a build-up of faecal material, until an involuntary movement of the anal sphincter occurs. Prior constipation might lead to this build-up and release of faecal material, as well as a lack of coordination in the muscles controlling bowel movements. There are a number of ways in which the problems of faecal incontinence may be helped. It is important to ensure that you have bowel movements (and thus bowel evacuation) on a regular basis. You should avoid substances that irritate the bowels such as alcohol, caffeine, spicy foods, and any other triggers to involuntary bowel action that you can identify. For such a symptom, antibiotics may be a trigger, thus you need to avoid their unnecessary use. It is also important to eliminate the possibility that the faecal incontinence is caused by a bowel infection – to test for this possibility you will need to consult your doctor. Changes in diet and supplementary bulking agents may be all that is required to deal with this problem. In addition to checking your diet, making a regular time of day in which you try and have a bowel movement can be very helpful. Once this regular time is established, it is important that you stick to it – even though you may not feel the urge to go. You may ﬁnd that drinking some warm liquid, such as tea, coffee or water, will help. This ‘retraining’ is not an easy task and may take some weeks or even months to achieve, but there is some evidence that it can reduce both constipation and bowel incontinence. You can undergo some complex tests for difﬁcult problems with bowel incontinence, but there are still relatively few specialist centres to assess and help manage these problems. Thus for most people with MS, a tried and tested combination of everyday techniques will probably be a good ﬁrst step. The issues associated with how best to manage sexual activity and MS have in the past often proved difﬁcult to discuss with others. However, increasingly, both doctors and other health professionals concerned with MS are aware of the importance of such issues and are able to offer helpful support and advice. In this chapter, we address some of the common worries that men and women with MS, and their partners, may have. Multiple sclerosis – the ‘at your ﬁngertips’ guide contains more information on this subject. We start with a discussion about problems with erections, common issues affecting men with MS, and their sexual relationships. Problems for women In general women’s sexual problems are centred on a lack of desire, arousal and orgasm. It can also be triggered by family concerns, illness or death, ﬁnancial or job worries, childcare responsibilities, managing a career and children, previous or current physical and emotional abuse, fatigue and depression – as well as by the MS itself. Thus the issue is often trying to deal with a range of factors in managing sexual problems. Nonetheless there is a particular set of problems that may occur as a result of the MS, particularly centred on arousal, and subsequent problems of lubrication. The process of sexual arousal is similar in women to that in men: in women the engorgement of the sexual organs (the clitoris and the inner and outer labia round the vagina), and lubrication by internal secretions, occur. For many women such a process is not just an aid to sexual intercourse, but also a considerable aid to sexual pleasure. In MS 59 60 MANAGING YOUR MULTIPLE SCLEROSIS nervous system control of the process of engorgement is likely to fail – parallel to the process of erection in men. The usual – and it must be said – still relatively common view in such circumstances is that artiﬁcial lubrication, through the use of a lubricant such as K-Y Jelly, is sufﬁcient to deal with problems such as vaginal dryness but, whilst such lubrication can help sexual intercourse, it may well not deal with the complex range of other issues that surround sexual arousal and fulﬁlment in women. Exercises for women Although there are several possible causes of your loss of sexual drive, and thus several possible approaches to managing the difﬁculty, as far as some of the physical components are concerned, the female orgasm involves – amongst other things – the contraction of several sets of muscles around the vagina. There is increasing evidence that exercising these muscles can assist in providing the conditions for better sexual responsiveness. Relevant exercises involve periodically squeezing and then releasing the pubococcygeus muscle – the one that starts and stops urination in mid ﬂow – several times a day if possible. This can help tone the muscles, and possibly enhance vaginal sensations, which may help responsiveness.
UTILITY AND THE PAST In explaining rational choice as it is usually defined order sildenafil 50 mg with visa, Robyn Dawes states that one criterion of such choice is that it is based on the possible future consequences of the choice discount sildenafil 25mg with visa. Even when the future costs of continued involvement clearly outweigh the future benefits, we tend to enter the sunk costs into the balance as future costs of abandonment 144 CHAPTER 5 or, conversely, benefits of continuance. Jung once said that he would not divulge Sigmund Freud’s dreams, told to him in confidence, even though Freud had been dead for decades. But is it not possible that Jung might have gotten far more gratification out of telling Freud’s dreams than keeping them a secret, and yet still have remained loyal to the deceased Freud? Is it not possible that we do some things because our acts nourish our characters (souls, to use another word) and because we want integrity itself, not just good feelings about apparent integrity? To decide that anything past should be honored only if doing so makes us feel good is a large leap from the simple observation that sometimes it is a good idea to quit a losing cause. The narratives of our lives are not properly carried out only by considering their endings in isolation from what has gone before. The outcome of a piece of music is not the same as the end: it is the integrated whole. The long sweep of living reaches back, confirms, affirms, respects, regrets, justifies, embraces and rejects aspects of the past. We cannot just "put a thing behind us" as though it was disconnected from our present selves, without diminishing those selves. This is why economic talk about "sunk costs" is not sufficient to dismiss much concern about the past. I will go so far as to assert that our present and future acts and experiences actually have a sort of consequence for the past. What whole sections of the past are in terms of value, can be altered and completed in the present and future. It can be argued that the past is not final because in the qualitative sense it is not wholly over. Jung’s action affected not only himself and his contemporary world, but even Freud, although Freud was not aware of it. Actions have all sorts of "effects" on their antecedents: on how we must interpret those antecedents, and on how we remember, value and evaluate them. This means that while we can and should write off some things as "sunk costs," and while we need to let go of old convictions, hopes, plans and goals in the appro- PREFERENCE, UTILITY AND VALUE IN MEANS AND ENDS 145 priate circumstances, we cannot write off the past as a whole. BROADER REASONING ABOUT ENDS The rational use of instruments (means) just cannot be separated for most purposes from the reflective consideration of ends. The many shortcomings of "utility" already enumerated render it unfit as a standard for judging the worth of ends. Several authors have suggested ways that ends cannot only be described but also justified. Perhaps there is some reasonable "logic of values" even if such logic does not absolutely compel assent as demonstrative proof would. Michael Stocker Michael Stocker, in Plural and Conflicting Values, argues that rational deliberation about ends is indeed possible even in the presence of true value multivalence. The existence of plural values47 means that internal and interpersonal conflict cannot be merely averaged over. However quantitative weighing is not necessarily the only means of adjudication among them. Stocker suggests that disparate vectors of value, representative of the qualitative differences among our goals, could be conceptualized as directions on a pan. Quantities could be represented by weights and intensities or intricacies perhaps by distances. If we imagine a pan suspended on a cord through its center, we can also imagine many different arrays of weights at various positions on the pan, some affording balance and others not. Stocker posits that contrasting values need to be in equilibrium, represented as a balanced array on the pan. Many possible arrangements of that equilibrium could correspond, conceptually, to different ways of balancing the pan. With this model, however, qualitative differences, contrasts and other relations are retained, an infinite number of equilibria are feasible, and arguments can be constructed to show that many constellations of value are not in equilibrium and thus mutually upsetting. Such a metaphorical arrangement of coherent values, or desirable states, of course does not lend itself easily if at all to mathematical treatment. The simplicity of expected utility allows for the success of a rational actor calculus in the realm of games and their strict analogues. Stocker notes that the mutual determination of values and virtues described by Aristotle is so complex that " we might as well expect there to be no algorithm giving us the mean of each and all – at least none available to us. And the comparability of incommensurables also seems to ensure the impossibility of an algorithm for discerning the best or even a good mix of values. Thus, we see 146 CHAPTER 5 the need for practical wisdom and why practical wisdom ineliminably involves judgment. Our lives and choices can be fulfilling in one respect such as pleasure and deficient in another, such as wisdom. Decisions about ends truly may involve giving something special up, not just getting less than the maximum of that common coin, "utility. Any putative "logic of values" would have to consider types and levels of values and relationships among them. This logic should afford at least some reasonable way to bring them into beneficial relationship with each other so as to bear on practical problems. If "Disease is Imbalance" there could be more than one "Balance" potentially attainable, depending on person, place or time. Robert Nozick Robert Nozick, in The Nature of Rationality, also indicates that thinking about ends lies within the scope of rationality. Rationality extends well beyond the bounds of "instrumental rationality," narrowly taken.
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