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Japan’s pursuit of counterstrike capability exposes tensions between the self-defense limits in Article 9 of its constitution, the evolution of an exclusively defensive defense posture, and international legal standards. Expanding self-defense to include counterstrike requires reconciling constitutional constraints, strategic necessity, and strict tests of necessity and proportionality under Article 51 of the UN Charter. These pressures show that counterstrike is not a technical upgrade but a fundamental challenge to Japan’s legal identity, strategic doctrine, and credibility in the Indo-Pacific.
This study examined whether intolerance of uncertainty and decision-making styles were associated with theoretical START triage knowledge among paramedic students. Secondary exploratory analyses assessed psychosocial differences according to self-rated decision-making under stress, perceived coping with uncertainty, professional motivation, and challenges in prehospital emergency care.
Methods
In this cross-sectional study, 121 students from a First and Emergency Aid Program completed a self-administered paper-based questionnaire including a sociodemographic form, the Decision-Making Styles Scale, the Intolerance of Uncertainty Scale-12, and the START Triage Knowledge Test. Data were collected in classroom settings under researcher supervision between May and June 2025 and analyzed using descriptive statistics, group comparisons, and correlation analyses.
Results
The mean theoretical START triage knowledge score was 69.99 ± 14.76. START knowledge was not significantly associated with intolerance of uncertainty or decision-making style subscale scores. Exploratory analyses identified associations between psychosocial scores and self-rated decision-making under stress, coping with uncertainty, professional motivation, and perceived challenges.
Conclusions
Theoretical START triage knowledge was not associated with intolerance of uncertainty or decision-making styles. Secondary findings were limited to self-reported psychosocial associations. The study assessed declarative knowledge and did not evaluate START application in simulated or field settings. Future studies should use simulation-based, scenario-based, or observational outcomes.
Orphan drug reimbursement remains a contested area in health technology assessment (HTA), as decision makers must balance limited evidence, high unmet need, patient-relevant value, and affordability. Multi-criteria decision analysis (MCDA) has been proposed to make such trade-offs more explicit and transparent, yet empirical applications in European national HTA settings remain scarce.
Methods
We developed and piloted an MCDA framework for orphan drug reimbursement in Belgium. Candidate criteria were identified through a systematic literature review. A multidisciplinary expert panel (comprising representatives from the national reimbursement agency, sickness funds, patient organizations, pharmaceutical companies, clinicians, and bioethicists) participated in four focus group discussions to select and define criteria. Criterion weights were elicited through a three-round Delphi process. The framework was piloted on four orphan drugs previously appraised in Belgium: ponatinib, pirfenidone, onasemnogene abeparvovec, and metreleptin.
Results
Seven quantitative and three qualitative contextual criteria were selected. Unmet medical need received the highest weight, followed by comparative effectiveness and impact on patient-reported outcomes. Onasemnogene abeparvovec achieved the highest overall MCDA score (0.77), followed by metreleptin (0.65), pirfenidone (0.47), and ponatinib (0.39). The pilot also generated policy-relevant insights on criterion design, handling residual uncertainty, separating value assessment from reimbursement feasibility (through cost criteria), and using scores to support–rather than replace–deliberation.
Conclusion
This study presents the first MCDA framework for orphan drug reimbursement in Belgium and illustrates how criterion weights and scores can structure committee deliberation, complemented by contextual appraisal, to support more transparent, consistent, and accountable decision making.
A brand new chapter to this Edition of the Course Manual. Preterm birth considers the emergency care required in an unplanned preterm birth. The global burden of preterm birth is significant, therefore recognition, investigation and management of preterm birth to optimise condition of the fetus before born is key. Key learning points: Preterm birth rates are increasing globally. Preterm birth is associated with neonatal morbidity and mortality that can be reduced by effective optimisation strategies. Good care requires the accurate diagnosis of preterm labour. Care should be personalised to reduced over-treatment and to improve outcomes. Good communication and planning with the neonatal team, including place and mode of birth, is vital. Good communication and information to support decision making with parents is important.
Decades of research in judgment and decision making highlight the significant impact of defaults, in which individuals tend to accept preselected options. While some scholars argue that individuals exhibit ‘default neglect’, failing to strategically use defaults for economic or social gain, others suggest people are default aware and capable of using defaults to their advantage. To further investigate default neglect, we conducted 3 experiments in which participants acted as default setters in a decision-making ‘card game’ involving players with aligned, misaligned, unknown, or neutral interests. Across experiments, participants consistently selected high-value cards as defaults for aligned players and low-value cards for opponents. In Experiment 2, they were also willing to override preselected defaults even at a hypothetical cost when it benefited their interests. Experiment 3 revealed that participants could accurately infer which option was better based on the default-setting behavior of others, suggesting they expect others to use defaults strategically. Across all experiments, participants chose the optimal default in over 80% of trials. Together, the results challenge the idea of default neglect and suggest that individuals are attuned to and capable of leveraging defaults to influence others.
This study aims to investigate the awareness, practices, needs, and challenges of hospital-based health technology assessment (HB-HTA) in China’s tertiary public hospitals, drawing on perspectives from both hospital management and clinical practice.
Methods
Semi-structured interviews were conducted with seventeen participants representing six major tertiary public hospitals in China. Respondents included vice presidents, clinical department directors, and heads of pharmacy. The questionnaire explored four dimensions consistent with China’s national performance appraisal framework: medical quality, operational efficiency, sustainable development, and satisfaction. Data were analyzed using NVivo 14 for qualitative responses and Excel 2021 for quantitative metrics.
Results
The findings revealed that 82.35 percent (14/17) of hospitals lacked dedicated HB-HTA teams, with decisions made primarily by coordination between Medical Affairs Offices (28.89 percent, 13/45) and Pharmacy Departments (22.22 percent, 10/45). Safety (28.26 percent, 13/46), effectiveness (23.91 percent, 11/46), and cost-effectiveness (19.57 percent, 9/46) were prioritized criteria, yet only 29.41 percent (5/17) of institutions used formal HB-HTA tools. Divergence persisted between administrators’ organizational priorities and clinicians’ patient-centered perspectives. Despite barriers reported by 62.8 percent (27/43) of respondents’ institutions, 88.24 percent (15/17) expressed an urgent or recognized need for HB-HTA implementation.
Conclusions
For effective HB-HTA implementation in China, addressing capacity deficits and reconciling stakeholder perspectives is essential. A project-based strategy, supported by government real-world data platforms and interdisciplinary teams, is recommended for contextually-appropriate evaluation frameworks.
Early health technology assessment (HTA) has recently been defined as a process for evaluating the “potential value” of technologies at early development stages. This analysis examines how value is characterized in early stages compared to standard HTA. Using the MAPS framework (Methods, Attributes, Procedures, and Social Preferences), the findings indicate that a broader value framework may be applicable to early HTA relative to standard HTA. This framework includes systematic consideration of attributes beyond health-related benefits, such as real option value and innovation, as well as additional methods like fiscal impact analysis and social return on investment. Additionally, there is potential for less variation in early HTA processes globally, given that these assessments are less tied to local funding decisions. Finally, the role of social preferences in early HTA may also involve considering trade-offs and impact modifiers that are particularly relevant in initial stages, and which deserve further research.
Focusing on the third-person formulation of many of the texts on the question tablets, and drawing on psychological and narratological research, this essay explores the mind-set of those who came to consult Zeus, asking if these texts reveal a sense of the self as fragmented in the face of crisis – which may also suggest how processes of consultation at an oracle could have provided psychological relief to pilgrims. Using analytical approaches from cognitive linguistics, this essay examines these texts for what they may reveal in terms of a cognitive blending of Viewpoints – both mortal and divine – aiding self-integration and, thus, decision making. Finally, this essay argues that awe in the face of the divine may have been a key component of the experience of consultation, with significant impacts on our brain and body.
Over the past decade, organizational impact (OI) has gained recognition as a key dimension in health technology assessment (HTA) in France, particularly for medical devices. Despite the publication of a national framework by the Haute Autorité de Santé in 2020, the absence of standardized methodologies continues to hinder its integration into decision making.
Methods
This commentary article traces the evolution of OI in French HTA, highlights real-world examples, and analyzes existing methodological tools, many adapted from other disciplines, that could enhance OI assessment.
Results
It emphasizes the need for flexible, context-sensitive approaches and proposes recommendations to improve the robustness, reproducibility, and relevance of OI evaluations.
Conclusions
The article also explores the implications for pricing and reimbursement decisions, as well as hospital-based HTA practices, aiming to support more structured and evidence-informed integration of organizational considerations into HTA processes in France and beyond.
The introduction of the Assisted Decision Making (Capacity) Act in Ireland and developments in capacity law elsewhere prompt further consideration of our understanding of capacity and how we assess it.
Methods:
This is a perspective piece on the role of emotion in the decision-making process, and how this impacts on our understanding of capacity. Both normal and pathological emotional states are reviewed in terms of their influence on decision-making. Capacity assessments are then considered, and whether sufficient account is taken of emotions here.
Results:
The paper considers whether we need to change the legal test for capacity to take sufficient account of emotions, based on the foregoing discussion.
Conclusion:
Finally the paper makes recommendations for supporting capacity in light of our knowledge of the impact of emptions on decision-making.
People living with dementia (PLWD) want – and have the right – to participate in research that impacts them. However, barriers in legislation, institutional practices, and/or biases may jeopardize inclusion.
Objective and Methods
Interviews with 33 Canadian dementia researchers were conducted to explore understandings of research consent with regard to dementia, research practices, and approaches in everyday research contexts.
Findings
Analysis of these interviews revealed challenges in negotiating the space between best practices and institutional requirements; gaps in knowledge, procedures, and guidelines on inclusion and consent; tensions regarding who should be involved in decision making; and how assumptions of presumed incapacity and/or the ‘protection’ of vulnerable groups create and/or sustain the exclusion of PLWD from research.
Discussion
Moving forward, findings suggest that advancing the meaningful inclusion of PLWD in Canadian dementia research will require clear, consistent standardized guidelines, flexible and ongoing consent processes, accessibility accommodations, and a stronger focus on rights-based practices.
As artificial intelligence (AI) plays an increasing role in operations on battlefields, we should consider how it might also be used in the strategic decisions that happen before a military operation even occurs. One such critical decision that nations must make is whether to use armed force. There is often only a small group of political and military leaders involved in this decision-making process. Top military commanders typically play an important role in these deliberations around whether to use force. These commanders are relied upon for their expertise. They provide information and guidance about the military options available and the potential outcomes of those actions. This article asks two questions: (1) how do military commanders make these judgements? and (2) how might AI be used to assist them in their critical decision-making processes? To address the first, I draw on existing literature from psychology, philosophy, and military organizations themselves. To address the second, I explore how AI might augment the judgment and reasoning of commanders deliberating over the use of force. While there is already a robust body of work exploring the risks of using AI-driven decision-support systems, this article focuses on the opportunities, while keeping those risks firmly in view.
In this article, we maintain that the anticipated integration of artificial intelligence (AI)-enabled systems into state-level decision making over whether and when to wage war will be accompanied by a hitherto neglected risk. Namely, the incorporation of such systems will engender subtle but significant changes to the state’s deliberative and organisational structures, its culture, and its capacities – and in ways that could undermine its adherence to international norms of restraint. In offering this provocation, we argue that the gradual proliferation and embeddedness of AI-enabled decision-support systems within the state – what we call the ‘phenomenon of “Borgs in the org”’ – will lead to four significant changes that, together, threaten to diminish the state’s crucial capacity for ‘institutional learning’. Specifically, the state’s reliance on AI-enabled decision-support systems in deliberations over war initiation will invite: (i) disrupted deliberative structures and chains of command; (ii) the occlusion of crucial steps in decision-making processes; (iii) institutionalised deference to computer-generated outputs; and (iv) future plans and trajectories that are overdetermined by past policies and actions. The resulting ‘institutional atrophy’ could, in turn, weaken the state’s responsiveness to external social cues and censure, thereby making the state less likely to engage with, internalise, and adhere to evolving international norms of restraint. As a collateral effect, this weakening could contribute to the decay of these norms themselves if such institutional atrophy were to become widespread within the society of states.
This article prefaces our Special Issue on “AI and the Decision to Go to War.” We begin by introducing the prospect of artificial intelligence (AI)-enabled systems increasingly infiltrating state-level decision making on the resort to force, clarifying that our focus is on existing technologies, and outlining the two general ways that this can conceivably occur: through automated self-defense and AI-enabled decision-support systems. We then highlight recent, on-going developments that create a backdrop of rapid change and global uncertainty against which AI-enabled systems will inform such deliberations: (i) the widespread tendency to misperceive the latest AI-enabled technologies as increasingly “human”; (ii) the changing role of “Big Tech” in the global competition over military applications of AI; (iii) a conspicuous blind spot in current discussions surrounding international regulation; and (iv) the emerging reality of an AI-nuclear weapons nexus. We suggest that each factor will affect the trajectory of AI-informed war initiation and must be addressed as scholars and policymakers determine how best to prepare for, direct, and respond to this anticipated change. Finally, turning to the pressing legal, ethical, sociotechnical, political, and geopolitical challenges that will accompany this transformation, we revisit four “complications” that have framed the broader project from which this Special Issue has emerged. Within this framework, we preview the other 13 multidisciplinary research articles that make up this collection. Together, these articles explore the risks and opportunities that will follow AI into the war-room.
Willingness to help a needy person may depend on whether the person is perceived as responsible for their predicament. However, information regarding the cause is not always available, and people often ‘look the other way’ when it is. The present research explores whether potential donors choose to obtain information about the cause of the other’s need and, more importantly, how this choice to pursue information is affected by the donors’ feelings of entitlement. Across four studies, we find that decision makers who pursue information about why others are in need are more likely to offer help. Yet we also measure and manipulate the feelings of entitlement and find that those who are high in entitlement are more likely to seek the information regarding the person in need. Their higher tendency to pursue more information makes them more likely to help than they would otherwise.
Economic evaluation supports public funding decisions about the use of health technologies within the Portuguese National Health System (NHS). The methods guide for economic evaluation in Portugal serves both companies preparing economic evaluation submissions and the independent commission appraising the evidence submitted.
Methods
This article presents the revised methods guide for economic evaluation in Portugal. The revisions reflect advances in economic evaluation, updates to regulatory policies, and responses to the evolving economic context. The paper highlights the most significant changes to the guidance, comparing the new Portuguese guidelines to those from the United Kingdom and Canada. The discussion is framed around key comments received during public consultation.
Results
The updated guidelines recommend cost-effectiveness analyses based on quality-adjusted life years and advocate for long-term modelling, a 4 percent discount rate, and a focus on NHS costs. New features include guidance on the identification and management of uncertainty within a dynamic appraisal process with regular contract negotiations (which can trigger reappraisals). The guide also covers how cost-effectiveness models, typically centrally developed, should be adapted to the Portuguese context. It highlights the key role of structured expert elicitation to address uncertainties in evidence, including those related to model adaptation.
Conclusions
The revision was developed through stakeholder consultations and aligns with international best practices, offering more explicit and transparent methods to support health resource allocation decisions.
Over the last three decades, European Union regulation of the internal market has become highly pervasive, affecting practically all domains of European citizens' lives. Many studies have focused on understanding the process and causes of regulatory change, but with limited attempts to analyse the more general sources of regulatory reform. This article focuses on the determinants of stability and change in EU regulation. An original dataset of 169 pieces of legislation (regulations, directives and decisions) across eight different sectors is developed and the dynamics of regulatory reform in the EU are analysed. Using time‐series analysis of count data, evidence is found that the number of winning coalitions in the Council and the size of EU membership have a significant impact on regulatory reform in the EU. By contrast, the ideological composition of the EU's legislative bodies is not systematically related to regulatory reform.
Although evidence shows that it is challenging to implement, many authors state that participatory management is a distinctive attribute of social enterprises. This paper presents case study research exploring how participatory management is manifest in Chile, a country where a paternalistic and autocratic management style prevails thereby constraining the adoption of more collaborative approaches. We found that a majority of the twenty social enterprises considered, despite having very different sizes, governance structure and activity sectors, involved employees and stakeholders in shared decision-making processes. Participatory management was exhibited in distinctive and diverse ways ranging from common agreement on strategic decisions through to the presentation of new proposals by members. We conclude that social enterprises in Chile differ from conventional enterprises not only in their focus on trying to solve social problems, but also in the fact that they may provide a vehicle to promote more innovative and participatory approaches to decision making.
This article suggests theoretical refinements to the multiple streams framework (MSF) that make it applicable to parliamentary systems and the decision‐making stage of the policy process. Regarding the former, the important role of political parties in parliamentary democracies is highlighted. Party policy experts are expected to be members of the policy communities in the policy stream and to promote viable policy alternatives in their respective parties, while the party leadership is concerned with adopting policies in the political stream. With regard to the latter, the introduction of a second coupling process to analyse decision making more rigorously is suggested. Moreover, the article provides operational definitions of the framework's key concepts when applied to parliamentary systems and derives a systematic set of falsifiable hypotheses for agenda‐setting and decision making in these systems, thus addressing one of the main critiques against the MSF – namely that no hypotheses can be derived from it.
This article explores the different ways governments express dissent in the Council of the European Union (EU) through ‘No’ votes, abstentions and recorded negative statements. A game‐theoretical model is presented that studies voting behaviour and analyses how the national parliaments’ levels of control over their governments’ EU policies affect it. It is concluded that governments that are strongly controlled by their parliaments are not more likely to express dissent. However, when they do express dissent, they vote ‘No’ more often. Parliamentary control depends on the presence of formal oversight institutions as well as the motivation of parliamentarians to hold their governments accountable. Empirical support is found in an analysis of votes on 1,387 legislative proposals that represent more than a decade of Council decision making in the period 2004–2014. This article contributes to the discussion on the involvement of national parliaments in EU affairs, and clearly distinguishes the different forms of dissent in Council decision making.