Journal articles on the topic 'Automatically happened outcomes'

Recently, the statistical definition of probability introduced by von Mises, which was based on the outcomes of actually performed experimentation, has been extended to the situation where the outcomes of the trials happened automatically. This extended definition of probability has been applied in estimating the probability distribution of rainy days in each of the 12 months at four stations in southern part of India, namely Bangalore, Chennai, Hyderabad & Trivandrum, with a view of obtaining a picture of tendency of rainfall there. This article presents the findings of estimates obtained in the study. It has been found from the study that at each of the four stations, there does not exist any month that is certainly non-rainy and there exists months that are certain rainy.

Definition of probability based on the data on automatically happened outcomes, formulated in a recent study by the application of the logic behind concept of empirical probability, has been applied in estimating most likely number of rainy days at each of the four stations in India namely Chennai, Kolkata, Mumbai, and New Delhi to be occurred in each of the 12 months. It has been found from the study that rainfall is almost certain to be occurred in each of the months from June to November at Chennai, from May to October at Kolkata, from June to September at Mumbai and from June to August at New Delhi while rainfall is certain to be occurred in each of the months from September to November at Chennai, from June to September at Kolkata, from July to September at Mumbai and from July to August at New Delhi. On the other hand, non-occurrence of rainy day or equivalently non-occurrence of rainfall is not certain in any month at any of the four stations.    

An attempt has been made on determining the favorable number of outcomes associated with a natural phenomenon by the inverse application of the classical definition of probability and the direct application of the extension of its empirical definition extended to the situation where outcomes of the associated trials happen automatically with a numerical example of estimating the number of days favorable to be rainy in each of the 12 months at the 30 stations in India with a view to obtaining a picture of tendency of rainfall at  the stations.  

Loss of follow-up is a concern when tracking long-term clinical outcomes after bariatric surgery. The results of patients who are “lost to follow-up” are not known. After bariatric surgery, the lack of follow-up may result in less weight loss for patients. This study investigated the hypothesis that there are differences between patients who do not automatically return for their annual follow-up and those that do return. Patients who were greater than 14 months postoperative after laparoscopic gastric bypass were contacted if they had not returned for their annual appointment. They were seen in clinic and/or a phone interview was performed for follow-up. These patients (Group A) were compared with patients who returned to see us for their annual appointment (Group B) without us having to notify them. There were 105 consecutive patients, with 48 patients who did not automatically return for their annual appointment. Only six of these patients could not ultimately be contacted. There was no difference in preoperative body mass index between the two groups. Percentage excess body weight loss was greater in Group B (76 vs 65%; P < 0.003). More patients had successful weight loss (defined as within 50% of ideal body weight) in Group B (50 [88%] vs 28 [67%]; P < 0.02). We found that a significant number of patients will not comply with regular follow-up care after laparoscopic gastric bypass unless they are prompted to do so by their bariatric clinic. These patients have worse clinical outcome ( i.e., less weight loss). Caution should be taken when examining the results of any bariatric study where there is a significant loss to follow-up.

In the world of Internet of Things, Event Condition Action rules are the secret sauce for smart device interaction. An Event triggers the rule. If a specific Condition is met, then an Action happens automatically. This article addresses trigger–action platforms, which empower users to define custom behaviors for IoT devices and web services through conditional rules. While these platforms enhance user creativity in automation, they also pose significant risks, such as unintentional disclosure of private information or exposure to cyber threats. The proposed solution leverages Natural Language Processing techniques to identify automation rules within these platforms that may compromise user security or privacy. Natural Language Processing based models are applied to analyze the semantic and contextual information of trigger–action rules, utilizing classification techniques on various rule features. Evaluation on the If-This-Then-That platform, using a dataset of 76,741 rules labeled through an ensemble of three semi-supervised learning techniques, demonstrates that the results from the Bidirectional Encoder Representations from Transformers based model training demonstrate promising outcomes, with an average validation accuracy of 89% over 2 epochs. The Test Accuracy of around 90.65% is achieved. Predicted outputs showcase the model's ability to categorize applets into different risk classes, including instances of cyber security threats and physical harm.

IntroductionFace-touching behaviour often happens frequently and automatically, and poses potential risk for spreading infectious disease. Mindfulness-based interventions (MBIs) have shown its efficacy in the treatment of behaviour disorders. This study aims to evaluate an online mindfulness-based brief intervention skill named ‘STOP (Stop, Take a Breath, Observe, Proceed) touching your face’ in reducing face-touching behaviour.Methods and analysisThis will be an online-based, randomised, controlled, trial. We will recruit 1000 participants, and will randomise and allocate participants 1:1 to the ‘STOP touching your face’ (both 750-word text and 5 min audio description by online) intervention group (n=500) and the wait-list control group (n=500). All participants will be asked to monitor and record their face-touching behaviour during a 60 min period before and after the intervention. Primary outcome will be the efficacy of short-term mindfulness-based ‘STOP touching your face’ intervention for reducing the frequency of face-touching. The secondary outcomes will be percentage of participants touching their faces; the correlation between the psychological traits of mindfulness and face-touching behaviour; and the differences of face-touching behaviour between left-handers and right-handers. Analysis of covariance, regression analysis, χ2 test, t-test, Pearson’s correlations will be applied in data analysis. We will recruit 1000 participants from April to July 2020 or until the recruitment process is complete. The follow-up will be completed in July 2020. We expect all trial results to be available by the end of July 2020.Ethics and disseminationThe study protocol has been approved by the Ethics Committee of Sir Run Run Shaw Hospital, an affiliate of Zhejiang University, Medical College (No. 20200401-32). Study results will be disseminated via social media and peer-reviewed publications.Trial registration numberNCT04330352.

Abstract - Pulmonary Disease is one of the leading causes of Cancer related deaths world wide and its early diagnosis and treatment are essential to cure the patient normally indicated by small growths in the lungs called nodules. It usually happens because cells in the lungs start increasing uncontrollably. Finding these Lung nodules is important for detecting lung Cancer, these nodules are typically detected through CT scans, but manual interpretation can be time-consuming and prone to human error. Through a process of feature extraction and selection, our model was trained to identify patterns and subtle abnormalities indicative of lung cancer within the imaging data. Machine learning and deep learning models have shown promise in enhancing the accuracy and efficiency of lung cancer detection. Convolutional Neural Networks (CNN), a type of deep learning technique, have recently shown promising results in image-based medical diagnosis. Identifying lung cancer from a healthcare picture collection using a CNN-based approach, with an emphasis on histological image data. The suggested CNN method uses the inherent hierarchical properties of medical images to automatically identify distinguishing elements that point to lung cancer. The limitations of small healthcare picture datasets are effectively addressed through transfer learning from large image datasets and refining taught models. A large dataset of patients with lung cancer is used to create and evaluate the CNN model that makes use of the VGG-19 architecture. Cancer may be automatically diagnosed using the power of Machine Learning (ML) with medical images. ML can classify cancer cell images more accurately with less time and lower cost. This research modifies the Convolutional Neural Network (CNN) model as pre-trained Visual Geometry Group19 (VGG19) for classifying lung cancer biopsy images with improved augmentation technique. By enhancing VGG19's generalizability to large-scale datasets and optimizing it for medical imaging, our study seeks to address these issues. According to experimental data, our method improves early diagnosis and detection performance, lowering false positives and facilitating more efficient lung cancer screening and treatment planning. The results observed with fine-tuned VGG19 model with improved augmentation technique are up to 98.73% accuracy. By harnessing the power of the Convolutional Neural Network, we offer a promising solution for early detection, thereby facilitating timely interventions and ultimately enhancing patient outcomes in the fight against lung cancer. A large dataset of patients with lung cancer is used to create and evaluate the CNN model that makes use of the VGG-19 architecture. Keywords: Lung cancer detection, feature extraction, model evaluation, nodule detection, Convolutional Neural Networks

The theoretical lenses, empirical measures and analytical tools associated with social network analysis comprise a wealth of knowledge that can be used to analyse networked learning. This has popularized the use of the social network analysis approach to understand and visualize structures and dynamics in online learning networks, particularly where data could be automatically gathered and analysed. Research in the field of social network learning analysis has (a) used social network visualizations as a feedback mechanism and an intervention to enhance online social learning activities (Bakharia & Dawson, 2011; Schreurs, Teplovs, Ferguson, de Laat, & Buckingham Shum, 2013), (b) investigated what variables predicted the formation of learning ties in networked learning processes (Cho, Gay, Davidson, & Ingraffea, 2007), (c) predicted learning outcomes in online environments (Russo & Koesten, 2005), and (d) studied the nature of the learning ties (de Laat, 2006). This paper expands the understanding of the variables predicting the formation of learning ties in online informal environments. Reddit, an online news sharing site that is commonly referred to as ‘the front page of the Internet’, has been chosen as the environment for our investigation because conversations on it emerge from the contributions of members, and it combines perspectives of experts and non-experts (Moore & Chuang, 2017) taking place in a plethora of subcultures (subreddits) occurring outside traditional settings. We study two subreddit communities, ‘AskStatistics’, and ‘AskSocialScience’, in which we believe that informal learning is likely to happen in Reddit, and which offer avenues for comparison both in terms of the communication dynamics and learning processes occurring between members. We gathered all the interactions amongst the users of these two subreddit communities for a 1-year period, from January 1st, 2015 until December 31st, 2015. Exponential Random Graph models (ERGm) were employed to determine the endogenous (network) and exogenous (node attributes) factors facilitating the networked ties amongst the users of these communities. We found evidence that Redditors’ networked ties arise from network dynamics (reciprocity and transitivity) and from the Redditors’ role as a moderator in the subreddit communities. These results shed light into the understanding of the variables predicting the formation of ties in informal networked learning environments, and more broadly contribute to the development of the field of social network learning analysis.

Artificial intelligence (AI) has the potential to speed up the exponential growth of cutting-edge technology, much way the Internet did. Due to intense competition from the private sector, governments, and businesspeople around the world, the Internet has already reached its peak as an exponential technology. In contrast, artificial intelligence is still in its infancy, and people all over the world are unsure of how it will impact their lives in the future. Artificial intelligence, is a field of technology that enables robots and computer programmes to mimic human intellect by teaching a predetermined set of software rules to learn by repetitive learning from experience and slowly moving toward maximum performance. Although this intelligence is still developing, it has already demonstrated five different levels of independence. Utilized initially to resolve issues. Next, think about solutions. Third, respond to inquiries. Fourth, use data analytics to generate forecasts. Fifth, make tactical recommendations. Massive data sets and "iterative algorithms," which use lookup tables and other data structures like stacks and queues to solve issues, make all of this possible. Iteration is a strategy where software rules are regularly adjusted to patterns in the data for a certain number of iterations. The artificial intelligence continuously makes small, incremental improvements that result in exponential growth, which enables the computer to become incredibly proficient at whatever it is trained to do. For each round of data processing, the artificial intelligence tests and measures its performance to develop new expertise. In order to address complicated problems, artificial intelligence aims to create computer systems that can mimic human behavior and exhibit human-like thought processes [1]. Artificial intelligence technology is being developed to give individualized medication in the field of healthcare. By 2030, six different artificial intelligence sectors will have considerably improved healthcare delivery through the utilization of larger, more accessible data sets. The first is machine learning. This area of artificial intelligence learns automatically and produces improved results based on identifying patterns in the data, gaining new insights, and enhancing the outcomes of whatever activity the system is intended to accomplish. It does this without being trained to learn a particular topic. Here are several instances of machine learning in the healthcare industry. The first is the IBM Watson Genomics, which aids in rapid disease diagnosis and identification by fusing cognitive computing with genome-based tumour sequencing. Second, a project called Nave Bayes allows for the prediction of diabetes years before an official diagnosis, before it results in harm to the kidneys, the heart, and the nerves. Third, employing two machine learning approaches termed classification and clustering to analyse the Indian Liver Patient Data (ILPD) set in order to predict liver illness before this organ that regulates metabolism becomes susceptible to chronic hepatitis, liver cancer, and cirrhosis [2]. Second, deep learning. Deep learning employs artificial intelligence to learn from data processing, much like machine learning does. Deep learning, on the other hand, makes use of synthetic neural networks that mimic human brain function to analyse data, identify relationships between the data, and provide outputs based on positive and negative reinforcement. For instance, in the fields of Magnetic Resonance Imaging (MRI) and Computed Tomography (CT), deep learning aids in the processes of picture recognition and object detection. Deep learning algorithms for the early identification of Alzheimer's, diabetic retinopathy, and breast nodule ultrasound detection are three applications of this cutting-edge technology in the real world. Future developments in deep learning will make considerable improvements in pathology and radiology pictures [3]. Third, neural networks. The artificial intelligence system can now accept massive data sets, find patterns within the data, and respond to queries regarding the information processed because the computer learning process resembles a network of neurons in the human brain. Let's examine a few application examples that are now applicable to the healthcare sector. According to studies from John Hopkins University, surgical errors are a major contributor to medical malpractice claims since they happen more than 4,000 times a year in just the United States due to the human error of surgeons. Neural networks can be used in robot-assisted surgery to model and plan procedures, evaluate the abilities of the surgeon, and streamline surgical activities. In one study of 379 orthopaedic patients, it was discovered that robotic surgery using neural networks results in five times fewer complications than surgery performed by a single surgeon. Another application of neural networks is in visualising diagnostics, which was proven to physicians by Harvard University researchers who inserted an image of a gorilla to x-rays. Of the radiologists who saw the images, 83% did not recognise the gorilla. The Houston Medical Research Institute has created a breast cancer early detection programme that can analyse mammograms with 99 percent accuracy and offer diagnostic information 30 times faster than a human [4]. Cognitive computing is the fourth. Aims to replicate the way people and machines interact, showing how a computer may operate like the human brain when handling challenging tasks like text, speech, or image analysis. Large volumes of patient data have been analysed, with the majority of the research to date focusing on cancer, diabetes, and cardiovascular disease. Companies like Google, IBM, Facebook, and Apple have shown interest in this work. Cognitive computing made up the greatest component of the artificial market in 2020, with 39% of the total [5]. Hospitals made up 42% of the market for cognitive computing end users because of the rising demand for individualised medical data. IBM invested more than $1 billion on the development of the WATSON analytics platform ecosystem and collaboration with startups committed to creating various cloud and application-based systems for the healthcare business in 2014 because it predicted the demand for cognitive computing in this sector. Natural Language Processing (NLP) is the fifth. This area of artificial intelligence enables computers to comprehend and analyse spoken language. The initial phase of this pre-processing is to divide the data up into more manageable semantic units, which merely makes the information simpler for the NLP system to understand. Clinical trial development is experiencing exponential expansion in the healthcare sector thanks to NLP. First, the NLP uses speech-to-text dictation and structured data entry to extract clinical data at the point of care, reducing the need for manual assessment of complex clinical paperwork. Second, using NLP technology, healthcare professionals can automatically examine enormous amounts of unstructured clinical and patient data to select the most suitable patients for clinical trials, perhaps leading to an improvement in the patients' health [6]. Computer vision comes in sixth. Computer vision, an essential part of artificial intelligence, uses visual data as input to process photos and videos continuously in order to get better results faster and with higher quality than would be possible if the same job were done manually. Simply put, doctors can now diagnose their patients with diseases like cancer, diabetes, and cardiovascular disorders more quickly and at an earlier stage. Here are a few examples of real-world applications where computer vision technology is making notable strides. Mammogram images are analysed by visual systems that are intended to spot breast cancer at an early stage. Automated cell counting is another example from the real world that dramatically decreases human error and raises concerns about the accuracy of the results because they might differ greatly depending on the examiner's experience and degree of focus. A third application of computer vision in the real world is the quick and painless early-stage tumour detection enabled by artificial intelligence. Without a doubt, computer vision has the unfathomable potential to significantly enhance how healthcare is delivered. Other than for visual data analysis, clinicians can use this technology to enhance their training and skill development. Currently, Gramener is the top company offering medical facilities and research organisations computer vision solutions [7]. The usage of imperative rather than functional programming languages is one of the key difficulties in creating artificial intelligence software. As artificial intelligence starts to increase exponentially, developers employing imperative programming languages must assume that the machine is stupid and supply detailed instructions that are subject to a high level of maintenance and human error. In software with hundreds of thousands of lines of code, human error detection is challenging. Therefore, the substantial amount of ensuing maintenance may become ridiculously expensive, maintaining the high expenditures of research and development. As a result, software developers have contributed to the unreasonably high cost of medical care. Functional programming languages, on the other hand, demand that the developer use their problem-solving abilities as though the computer were a mathematician. As a result, compared to the number of lines of code needed by the programme to perform the same operation, mathematical functions are orders of magnitude shorter. In software with hundreds of thousands of lines of code, human error detection is challenging. Therefore, the substantial amount of ensuing maintenance may become ridiculously expensive, maintaining the high expenditures of research and development. As a result, software developers have contributed to the unreasonably high cost of medical care. Functional programming languages, on the other hand, demand that the developer use their problem-solving abilities as though the computer were a mathematician. As a result, compared to the number of lines of code needed by the programme to perform the same operation, mathematical functions are orders of magnitude shorter. The bulk of software developers that use functional programming languages are well-trained in mathematical logic; thus, they reason differently than most American software developers, who are more accustomed to following step-by-step instructions. The market for artificial intelligence in healthcare is expected to increase from $3.4 billion in 2021 to at least $18.7 billion by 2027, or a 30 percent annual growth rate before 2030, according to market research firm IMARC Group. The only outstanding query is whether these operational reductions will ultimately result in less expensive therapies.

In health center, there was still errors in filling in disease codes. In this case was on cases of injury, poisoning and external cause codes that were not coded up to the 5th character. This happened because doctors and nurses did not understand the coding procedures. This study aims to identify coding process, calculate the percentage of code accuracy, identify factors causing inaccuracy in coding injuries, poisoning and external causes at the Bambanglipuro Health Center. The provision of disease diagnosis codes at health center was carried out after the nurse had finished filling in the assessment, doctor input diagnosis in SIMPUS, and ICD code automatically appeared. The percentage of correct diagnosis codes for cases of poisoning injuries and external causes of outpatients at Bambanglipuro Health Center, Bantul in period 2023 from a total sample of 71 medical records, number of correct diagnosis codes was 20 medical records (28%), and number of incorrect diagnosis codes was 51 medical records (72%). The cause was human factor (human), namely human resources who did not meet the competence of medical creators, special training had not been provided for coding officers and external causes were not coded. Method factors are that there is no SOP on disease coding system. Measuring implementation of disease diagnosis coding is carried out by re-examination by medical record officers who have competence in disease coding. Fulfilment of human resources according to qualifications affects work outcomes in UKRM. The ICD database on SIMPUS needs to be reviewed and data updated by vendors so that code selection can be available more specifically. Classification of code determination with ICD rules can describe the journey of a patient's medical record history more specifically.

AbstractWe consider a situation in which two parties have concluded an efficient contract corresponding to one major bargaining solution. After the parties have agreed on one particular contract, an unanticipated shock may change the contract outcomes in a way that benefits one party but harms the other party. If this happens, they have the option to either stay with the original exchange contract or adjust some contract parameters such as the price. We propose a model to perform such adjustments automatically, to obtain the same bargaining solution as in the initial contract under the restriction that the new contract dominates the outcomes of the original contract. We study several bargaining solutions within this general framework. These bargaining solutions offer various sharing rules to distribute the benefit between the parties. To reflect practical considerations, we only consider adjustments made via one contract parameter (the price), while all other parameters result from the original contract and the random shock. To evaluate the efficiency of the proposed approach, we also compare it to a full re-negotiation scenario, in which all parameters can be modified within the boundaries resulting after the random shock. However, waiting and re-negotiation might be costly compared to the situation when the smart contract executes the adjustment automatically. Therefore, the automatic adjustment might be more efficient compared to the other types of contracts. We present several numerical examples and run large random simulations, which we also check statistically.

Brain tumor, due to uncontrolled development of abnormal cells, is one of the hazardous illnesses that happen in the brain. A fully automatic brain tissue segmentation using improved k means segmentation is discussed in this paper. Generally the brain tumor tissue can appear at any location at different size and shapes. Manual brain tumor detection is not only time-consuming, it is also linked to human errors and depends on the expertise and experience of a medical pathologist. Automatic detection is required in a computer-aided detection system (CAD) for medical images such as MRI. This automatic detection includes pre-processing, segmentation and medical image classification. The preprocessing techniques eliminate noise. Separate the region of interest from the background picture using the segmentation methods. Finally, the classification is conducted to identify brain tumor automatically. The outcomes are also compared between the suggested method and the current methods

ABSTRACTResearch Question/IssueScholars and practitioners view boardroom dissent as central to the functioning of boards of directors. However, there is a lack of consensus on what dissent is, who is involved, when and where it happens, and whether it is a behavioral or cognitive phenomenon. This conceptual unclarity and related fragmentation of empirical results call for an integrative literature review to build a coherent agenda for future research.Research Findings/ResultsA content‐analysis of 73 articles published between 1997 and 2023 reveals three distinct research clusters that explore the empirical phenomenon: (1) dissent as expressed through voting, (2) dissent as diverging views, and (3) dissent as behavior in and around the boardroom. Three overarching challenges hamper the advancement of the field: (1) conceptual inconsistencies, (2) several methodological challenges, and (3) a need for further theorizing connected to boardroom dissent.Theoretical ImplicationsWe propose a novel working definition for boardroom dissent to inspire new work related to its constituent parts and to facilitate advancing its measurement. In combination with alternative methods, it stands to advance the boardroom dissent literature. Furthermore, there is a need for future research to integrate competing explanations theorizing how boardroom dissent relates to outcomes at different levels and to examine how boundary conditions constrain these relationships.Practitioner/Policy ImplicationsThe article provides new nuances to reflect on boardroom dissent and related behaviors. The review highlights that there is no one‐size‐fits‐all approach automatically resulting in positive outcomes.

Abstract Background Open visiting refers to the principle of unrestricted visiting hours in the hospital setting to enable relatives, families and carers to visit at any time. There has been recognition that open visiting supports the principle of patient and family supported care and improves communication. Despite this there has been difficulty in implementing open visiting and barriers identified. The aims of this study were therefore to evaluate the implementation of open visiting, the barriers to implementation, sustainability and the impact of open visiting on communication between health care professionals, families and carers. Methods The study was conducted on two large acute wards for the older person. Realist evaluation methods were used to understand ‘what works well, how, for whom and to what extent.’ Mixed methods were employed including qualitative interviews and descriptive analyses of routine data sets. Following the methodology of realist evaluation, programme theories were identified a long with the context, mechanisms and outcomes of implementation, to better understand the implementation process. Results The results of this study identified some key findings, demonstrating that open visiting does improve communication and can help to build trusting relationships between families/carers and health care professionals (HCP). Barriers to implementation were based on the belief that it would impinge on routines within the ward setting. To achieve the principles of patient and family/carer centred care, the key mechanisms are the confidence and skills of individual nurses and health care assistants to engage with relatives/carers, whilst retaining a sense of control, particularly when care is being delivered to other patients. Conclusion In summary, open visiting creates a positive culture which fosters better relationships between families/carers and HCPs. Involving families/carers as partners in care does not happen automatically in an environment where open visiting is the policy, but requires engagement with staff to encourage and support relatives/carers.

Abstract Background Out of the pressure of Digital Transformation, the major industrial domains are using advanced and efficient digital technologies to implement processes that are applied on a daily basis. Unfortunately, this still does not happen in the same way in the medical domain. For this reason, doctors usually do not have the time or knowledge to evaluate all alternative treatment options for each patient accurately and individually. However, physicians can reduce their workload by using recommender systems, still having every decision under control. In this way, they also get an insight into how other physicians make treatment decisions in each situation. In this work, we report the development of a novel recommender system that uses predicted outcomes based on continuous-valued logic and multi-criteria decision operators. The advantage of this methodology is that it is transparent, since the model outcomes emulate logical decision processes based on the hierarchy of relevant physiological parameters, and second, it is safer against adversarial attacks than conventional deep learning methods since it drastically reduces the number of trainable parameters. Methods We test our methodology in a patient population with diabetes and heart insufficiency that becomes a therapy (beta-blockers, ACE or Aspirin). The original database (Pakistan database) is publicly available and accessible via the internet. However, to explore methods to protect the patient's identity and guarantee data privacy we implemented a methodology on a variable-by-variable basis by fitting a sequence of regression models and drawing synthetic values from the corresponding predictive distributions using linear regressions and norm rank. Furthermore, we implemented a deep-learning model based on logical gates modeled by perceptrons with fixed weights and biases. While a first trainable layer automatically recognizes a meaningful parameter hierarchy, the implemented Logic-Operator Neuronal Network (LONN) simulates cognitive processes like a rational, logical thinking process, considering that this logic is joined by fuzziness, i.e., logical operations are not exact but essentially fuzzy due to the implemented continuous-valued operators. The predicted outcomes of the model (kind of therapy-ACE, Aspirin or beta-blocker- and expected therapy time of the patient) are then implemented in a recommender system that compares two different models: model 1 trained on a population excluding negative outcomes (patient group 1, with no patient dead and long therapy times) and a model 2 trained on the whole patient population (patient group 2). In this way, we provide a recommendation of the best possible therapy based on the outcome of the model and the confidence of this recommendation when the outcome of model 1 is compared with the outcome of model 2. Results With the applied method for data synthetization, we obtained an error of about 1% for all the relevant parameters. Furthermore, we demonstrate that the LONN models reach an accuracy of about 75%. After comparing the LONN models against conventional deep-learning models we observe that our implemented models are less accurate (accuracy loss of about 8%). However, the loss of accuracy is compensated by the fact that LONN models are transparent and safe because the freezing of training parameters makes them less prone to adversarial attacks. Finally, we predict the best therapy as well as the expected therapy time. We were able to predict individualized therapies, which were classified as optimal (binary value) when the prediction fully matched predictions made with models 1 and 2. The results provided by the recommender system are displayed using a graphical interface. The current is a proof of concept to improve the quality of the disease management, while the methods are continuously visualized to preserve transparency for the customers. Conclusions This work contributes to simplify administrative functions and boost the quality of management of patients improving the quality of healthcare with models that are both transparent and safe. Our methodology can be extended to different clinical scenarios where recommender systems can be applied. The acceptance and further development of the app is one of the next important steps and still requires further development depending on specific requirements of the health management, the physicians or health professionals, and the patent population.

In January of this year, artist Christian Marclay’s 24-hour video installation The Clock came to Melbourne. As Ben Lerner explains in 10:04, the autofictional novel Lerner published in 2014, The Clock by Christian Marclay “is a clock: it is a twenty-four hour montage of thousands of scenes from movies and a few from TV edited together so as to be shown in real time; each scene indicates the time with a shot of a timepiece or its mention in dialogue, time in and outside of the film is synchronized” (52). I went to see The Clock at ACMI several times, with friends and alone, in the early morning and late at night. Each time I sank back into the comfortable chairs and settled into the communal experience of watching time pass on a screen in a dark room. I found myself sucked into the enforced narrative of time, the way in which the viewer – in this case myself, and those sharing the experience with me – sought to impose a sort of meaning on the arguably meaningless passing of the hours. In this essay, I will explore how we can expand our thinking of the idea of autofiction, as a genre, to include contemporary forms of digital media such as social media or activity trackers, as the authors of these new forms of digital media act as author-characters by playing with the divide between fact and fiction, and requiring their readers to ascertain meaning by interpreting the clues layered within. I will analyse the ways in which the meaning of autofictional texts—such as Lerner’s 10:04, but also including social media feeds, blogs and activity trackers—shifts depending on their audience. I consider that as technology develops, we increasingly use data to contextualise ourselves within a broader narrative – health data, media, journalistic data. As the sociologist John B. Thompson writes, “The development of the media not only enriches and transforms the process of self-formation, it also produces a new kind of intimacy which did not exist before … individuals can create and establish a form of intimacy which is essentially non-reciprocal” (208). New media and technologies have emerged to assist in this process of self-formation through the collection and publication of data. This essay is interested in analysing this process of self-formation, and its relationship to the genre of autofiction.Contemporary Digital Media as AutofictionWhile humans have always recorded themselves throughout history, with the rise of new technologies the instinct to record the self is increasingly becoming an automatic one; an instinct we can tie to what media theorist Nick Couldry terms as “presencing”: an “emerging requirement in everyday life to have a public presence beyond one’s bodily presence, to construct an objectification of oneself” (50). We are required to participate in ‘presencing’ by opting-in to new media; it is now uncommon – even unfavourable – for someone not to engage in any forms of social media or self-monitoring. We are now encouraged to participate in ‘presencing’ through the recording and online publication of data that would have once been considered private, such as employment histories and activity histories. Every Instagram photo, Snapchat or TikTok video contributes to an accumulating digital presence, an emerging narrative of the self. Couldry notes that presencing “is not the same as calling up a few friends to tell them some news; nor, although the audience is unspecific, is it like putting up something on a noticeboard. That is because presencing is oriented to a permanent site in public space that is distinctively marked by the producer for displaying that producer’s self” (50).In this way, we can see that in effect we are all becoming increasingly positioned to become autofiction authors. As an experimental form of literature, autofiction has been around for a long time, the term having first been introduced in the 1970s, and with Serge Doubrovsky widely credited with having introduced the genre with the publication of his 1977 novel Fils (Browning 49). In the most basic terms, autofiction is simply a work of fiction featuring a protagonist who can be interpreted as a stand-in for its author. And while autofiction is also confused with or used interchangeably with other genres such as metafiction or memoir, the difference between autofiction and other genres, writes Arnaud Schmitt, is that autoficton “relies on fiction—runs on fiction, to be exact” (141). Usually the reader can pick up on the fact that a novel is an autofictional one by noting that the protagonist and the author share a name, or key autobiographical details, but it is debatable as to whether the reader in fact needs to know that the work is autofictional in the first place in order to properly engage with it as a literary text.The same ideas can be applied to the application of digital media today. Kylie Cardell notes that “personal autobiographical but specifically diaristic (confessional, serial, quotidian) disclosure is increasingly positioned as a symptomatic feature of online life” (507). This ties in with Couldry’s idea of ‘presencing’; confession is increasingly a requirement when it comes to participation in digital media. As technology advances, the ways in which we can present and record the self evolve, and the narrative we can produce of the self expands alongside our understanding of the relationship between fact and fiction. Though of course we have always fabricated different narratives of the self, whether it be through diary entries or letter-writing, ‘presencing’ occurs when we literally present these edited versions of ourselves to an online audience. Lines become blurred between fiction and non-fiction, and the ability to distinguish between ‘fake’ and ‘real’ becomes almost impossible.Increasingly, such a distinction fails to seem important, and in some cases, this blurred line becomes the point, or a punchline; we can see this most clearly in TikTok videos, wherein people (specifically, or at least most typically, young people—Generation Z) play with ideas of truth and unreality ironically. When a teenager posts a video of themselves on TikTok dancing in their school cafeteria with the caption, “I got suspended for this, don’t let this flop”, the savvy viewer understands without it needing to be said that the student was not actually suspended – and also understands that even less outlandish or unbelievable digital content is unreliable by nature, and simply the narrative the author or producer wishes to convey; just like the savvy reader of an autofiction novel understands, without it actually being said, that the novel is in part autobiographical, even when the author and protagonist do not share a name or other easily identifiable markers.This is the nature of autofiction; it signals to the reader its status as a work of autofiction by littering intertextual clues throughout. Readers familiar with the author’s biography or body of work will pick up on these clues, creating a sense of uneasiness in the reader as they work to discern what is fact and what is not.Indeed, in 10:04, Lerner flags the text as a work of autofiction by sketching a fictional-not-fictional image of himself as an author of a story, ‘The Golden Vanity’ published in The New Yorker, that earned him a book deal—a story the ‘real’ Ben Lerner did in fact publish, two years before the publication of 10:04: “a few months before, the agent had e-mailed me that she believed I could get a “strong six-figure” advance based on a story of mine that had appeared in The New Yorker” (Lerner 4).In a review of 10:04 for the Sydney Review of Books, Stephanie Bishop writes:we learn that he did indeed write a proposal, that there was a competitive auction … What had just happened? Where are we in time? Was the celebratory meal fictional or real? Can we (and should we) seek to distinguish these categories?Here Lerner is ‘presencing’, crafting a multilayered version of himself across media by assuming that the reader of his work is also a reader of The New Yorker (an easy assumption to make given that his work often appears in, and is reviewed in, The New Yorker). Of course, this leads to the question: what becomes of autofiction when it is consumed by someone who is unable to pick up on the many metareferences layered within its narrative? In this case, the work itself becomes a joke that doesn’t land – much like a social media feed being consumed by someone who is not its intended audience.The savvy media consumer also understands that even the most meaningless or obtuse of media is all part of the overarching narrative. Lerner highlights the way we try and impose meaning onto (arguably) meaningless media when he describes his experience of watching time pass in Marclay’s The Clock:Big Ben, which I would come to learn appears frequently in the video, exploded, and people in the audience applauded… But then, a minute later, a young girl awakes from a nightmare and, as she’s comforted by her father (Clark Gable as Rhett Butler), you see Big Ben ticking away again outside their window, no sign of damage. The entire preceding twenty-four hours might have been the child’s dream, a storm that never happened, just one of many ways The Clock can be integrated into an overarching narrative. Indeed it was a greater challenge for me to resist the will to integration. (Lerner 52-53)This desire to impose an overarching narrative that Lerner speaks of – and which I also experienced when watching The Clock, as detailed in the introduction to this essay – is what the recording of the self both aims to achieve and achieves by default; it is the point and also the by-product. The Self as DataThe week my grandmother died, in 2017, my father bought me an Apple Watch. I had recently started running and—perhaps as an outlet for my grief—was looking to take my running further. I wanted a smart watch to help me record my runs; to turn the act of running into data that I could quantify and thus understand. This, in turn, would help me understand something about myself. Deborah Lupton explains my impulse here when she writes, “the body/self is portrayed as a conglomerate of quantifiable data that can be revealed using digital devices” (65). I wanted to reveal my ‘self’ by recording it, similar to the way the data accumulated in a diary, when reflected upon, helps a diarist understand their life more broadly. "Is a Fitbit a diary?”, asks Kylie Cardell. “The diary in the twenty-first century is already vastly different from many of its formal historical counterparts, yet there are discursive resonances. The Fitbit is a diary if we think of diary as a chronological record of data, which it can be” (348). The diary, as with the Apple Watch or Fitbit, is simply just a record of the self moving through time.Thus I submitted myself to the task of turning as much of myself into digital data as was possible to do so. Every walk, swim, meditation, burst of productivity, lapse in productivity, and beat of my heart became quantified, as Cardell might say, diarised. There is a very simple sort of pleasure in watching the red, green and blue rings spin round as you stand more, move more, run more. There is something soothing in knowing that at any given moment in time, you can press a button and see exactly what your heart is doing; even more soothing is knowing that at any given time, you can open up an app and see what your heart has been doing today, yesterday, this month, this year. It made sense to me that this data was being collected via my timepiece; it was simply the accumulation of my ‘self,’ as viewed through the lens of time.The Apple Watch was just the latest in a series of ways I have tasked technology with the act of quantifying myself; with my iPhone I track my periods with the Clue app. I measure my mental health with apps such as Shine, and my daily habits with Habitica. I have tried journaling apps such as Reflectly and Day One. While I have never actively tracked my food intake, or weight, or sex life, I know if I wanted to I could do this, too. And long before the Apple Watch, and long before my iPhone, too, I measured myself. In the late 2000s, I kept an online blog. Rebecca Blood notes that the development of blogging technology allowed blogging to become about “whatever came to mind. Walking to work. Last night’s party. Lunch” (54). Browning expands on this, noting that bloggingemerged as a mode of publication in the late ’90s, expressly smudging the boundaries of public and private. A diaristic mode, the blog nonetheless addresses (a) potential reader(s), often with great intimacy — and in its transition to print, as a boundary-shifting form with ill-defined goals regarding its readership. (49)(It is worth noting here that while of course many different forms of blogging exist and have always existed, this essay is only concerned with the diaristic blog that Blood and Browning speak of – arguably the most popular, and at least the most well known, form of blog.)My blog was also ostensibly about my own life, but really it was a work of autofiction, in the same way that my Apple Watch data, when shared, became a work of autofiction – which is to say that I became the central character, the author-character, whose narrative I was shaping with each post, using time as the setting. Jenny Davis writes:if self-quantifiers are seeking self-knowledge through numbers, then narratives and subjective interpretations are the mechanisms by which data morphs into selves. Self-quantifiers don’t just use data to learn about themselves, but rather, use data to construct the stories that they tell themselves about themselves.Over time, I became addicted to the blogging platform’s inbuilt metrics. I would watch with interest as certain posts performed better than others, and eventually the inevitable happened: I began – mostly unconsciously – to try and mould the content of my blogs to achieve certain outcomes – similar to the way that now, in 2019, it is hard to say whether I use an app to assist myself to meditate/journal/learn/etc, or whether I meditate/journal/learn/etc in order to record myself having done so.David Sedaris notes how the collection of data subconsciously, automatically leads to its manipulation in his essay collection, Calypso:for reasons I cannot determine my Fitbit died. I was devastated when I tapped the broadest part of it and the little dots failed to appear. Then I felt a great sense of freedom. It seemed that my life was now my own again. But was it? Walking twenty-five miles, or even running up the stairs and back, suddenly seemed pointless, since, without the steps being counted and registered, what use were they? (Sedaris, 49)In this way, the data we collect on and produce about ourselves, be it fitness metrics, blog posts, Instagram stories or works of literature or art, allows us to control and shape our own narrative, and so we do, creating what Kylie Cardell describes as “an autobiographical representation of self that is coherent and linear, “excavated” from a mass of personal data” (502).Of course, as foregrounded earlier, it is important to highlight the way ideas of privacy and audience shift in accordance with the type of media being consumed or created. Within different media, different author-characters emerge, and the author is required to participate in ‘presencing’ in different ways. For instance, data that exists only for the user does not require the user, or author, to participate in the act of ‘presencing’ at all – an example of this might be the Clue app, which records menstruation history. This information is only of interest to myself, and is not published or shared anywhere, with anyone. However even data intended for a limited audience still requires participation in ‘presencing’. While I only ‘share’ my Apple Watch’s activity with a few people, even just the act of sharing this activity influences the activity itself, creating an affect in which the fact of the content’s consumption shapes the creation of the content itself. Through consumption of Apple Watch data alone, a narrative can be built in which I am lazy, or dedicated, an early riser or a late sleeper, the kind of person who prefers setting their own goals, or the kind of person who enjoys group activities – and knowing that this narrative is being built requires me to act, consciously, in the experience of building it, which leads to the creation of something unreal or fictional interspersed with factual data. (All of which is to admit that sometimes I go on a run not because I want to go on a run, but because I want to be the sort of person who has gone on a run, and be seen as such: in this way I am ‘presencing’.)Similarly, the ephemeral versus permanent nature of data shared through media like Snapchat or Instagram dictates its status as a work of autofiction. When a piece of data – for instance, a photograph on Instagram – is published permanently, it contributes to an evolving autofictional narrative. The ‘Instagrammed’ self is both real and unreal, both fictional and non-fictional. The consumer of this data can explore an author’s social media feed dating back years and consume this data in exactly the way the author intends. However, the ‘stories’ function on Instagram, for instance, allows the consumption of this data to change again. Content is published for a limited amount of time—usually 24 hours—then disappears, and is able to be shared with either the author’s entire group of followers, or a select audience, allowing an author more creative freedom to choose how their data is consumed.Anxiety and AutofictionWhy do I feel the need to record all this data about myself? Obviously, this information is, to an extent, useful. If you are a person who menstruates, knowing exactly when your last period was, how long it lasted and how heavy it was is useful information to have, medically and logistically. If you run regularly, tracking your runs can be helpful in improving your time or routine. Similarly, recording the self in this way can be useful in keeping track of your moods, your habits, and your relationships.Of course, as previously noted, humans have always recorded ourselves. Cardell notes that “although the forms, conditions, and technology for diary keeping have changed, a motivation for recording, documenting, and accounting for the experience of the self over time has endured” (349). Still, it is hard to ignore the fact that ultimately, we seem to be entering some sort of age of digital information hoarding, and harder still to ignore the sneaking suspicion that this all seems to speak to a growing anxiety – and specifically, an anxiety of the self.Gayle Greene writes that “all writers are concerned with memory, since all writing is a remembrance of things past; all writers draw on the past, mine it as a quarry. Memory is especially important to anyone who cares about change, for forgetting dooms us to repetition” (291). If all writers are concerned with memory, as Greene posits, then perhaps we can draw the conclusion that autofiction writers are concerned with an anxiety of forgetting, or of being forgotten. We are self-conscious as authors of autofictional media; concerned with how our work is and will continue to be perceived – and whether it is perceived at all. Marjorie Worthington believes that that the rise in self-conscious fiction has resulted in an anxiety of obsolescence; that this anxiety in autofiction occurs “when a cultural trope (such as 'the author' is deemed to be in danger of becoming obsolete (or 'dying')” (27). However, it is worth considering the opposite – that an anxiety of obsolescence has resulted in a rise of self-conscious fiction, or autofiction.This fear of obsolescence is pervasive in new digital media – Instagram stories and Snapchats, which once disappeared forever into a digital void, are now able to be saved and stored. The fifteen minutes of fame has morphed into fifteen seconds: in this way, time works both for and against the anxious author of digital autofiction. Technologies evolve quicker than we can keep up, with popular platforms becoming obsolete at a rapid pace. This results in what Kylie Cardell sees as an “anxiety around the traces of lives accumulating online and the consequences of 'accidental autobiography,' as well as the desire to have a 'tidy,' representable, and 'storied' life” (503).This same desire can be seen at the root of autofiction. The media theorist José van Dijck notes thatwith the advent of photography, and later film and television, writing tacitly transformed into an interior means of consciousness and remembrance, whereupon electronic forms of media received the artificiality label…writing gained status as a more authentic container of past recollection. (15)Autofiction, however, disrupts this tacit transformation. It is a co-mingling of a desire to record the self, as well as a desire to control one’s own narrative. The drive to represent oneself in a specific way, with consideration to one’s audience and self-brand, has become the root of social media, but is so pervasive now that it is often an unexamined, subconscious one. In autofiction, this drive is not subconscious, it is self-conscious.ConclusionAs technology has developed, new ways to record, present and evaluate the self have emerged. While an impulse to self-monitor has always existed within society, with the rise of ‘presencing’ through social media this impulse has been made public. In this way, we can see presencing, or the public practice of self-performing through media, as an inherently autofictional practice. We can understand that the act of presencing stems from a place of anxiety and self-consciousness, and understand that is in fact impossible to create autofiction without self-consciousness. As we begin to understand that all digital media is becoming inherently autofictional in nature, we’re increasingly required to force to draw our own conclusions about the media we consume—just like the author-character of 10:04 is forced to draw his own conclusions about the passing of time, as represented by Big Ben, when interacting with Marclay’s The Clock. By analysing and comparing the ways in which the emerging digital landscape and autofiction both share a common goal of recording and preserving an interpretation of the ‘self’, we can then understand a deeper understanding of the purpose that autofiction serves. ReferencesBishop, Stephanie. “The Same but Different: 10:04 by Ben Lerner.” Sydney Review of Books 6 Feb. 2015. <https://sydneyreviewofbooks.com/10-04-ben-lerner/>.Blood, Rebecca. "How Blogging Software Reshapes the Online Community." Communications of the ACM 47.12 (2004): 53-55.Browning, Barbara. "The Performative Novel." TDR: The Drama Review 62.2 (2018): 43-58. Davis, Jenny. “The Qualified Self.” Cyborgology 13 Mar. 2013. <http://thesocietypages.org/cyborgology/2013/03/13/the-qualified-self/>.Cardell, Kylie. “The Future of Autobiography Studies: The Diary.” a/b: Auto/Biography Studies 32.2 (2017): 347-350.Cardell, Kylie. “Modern Memory-Making: Marie Kondo, Online Journaling, and the Excavation, Curation, and Control of Personal Digital Data.” a/b: Auto/Biography Studies 32.3 (2017): 499-517.Couldry, Nick. Media, Society, World: Social Theory and Digital Media Practice. Great Britain: Polity Press, 2012.Greene, Gayle. “Feminist Fiction and the Uses of Memory.” Signs 16.2 (1991): 290-321.Lerner, Ben. 10:04. London: Faber and Faber, 2014.Lerner, Ben. “The Golden Vanity.” The New Yorker 11 June 2012. <https://www.newyorker.com/magazine/2012/06/18/the-golden-vanity>.Lupton, Deborah. “You Are Your Data: Self-Tracking Practices and Concepts of Data.” Lifelogging. Ed. Stefan Selke. Wiesbaden: Springer, 2016. 61-79.Schmitt, Arnaud. “David Shields's Lyrical Essay: The Dream of a Genre-Free Memoir, or beyond the Paradox.” a/b: Auto/Biography Studies 31.1 (2016): 133-146.Sedaris, David. Calypso. United States: Little Brown, 2018.Thompson, John B. The Media and Modernity: A Social Theory of the Media. California: Stanford University Press, 1995.Van Dijck, José. Mediated Memories in the Digital Age. Stanford: Stanford UP, 2007.Worthington, Marjorie. The Story of "Me": Contemporary American Autofiction. Nebraska: University of Nebraska Press, 2018.

A common criticism of the rhythm video games genre — including series like Guitar Hero and Rock Band, is that playing musical simulation games is a waste of time when you could be playing an actual guitar and learning a real skill. A more serious criticism of games cultures draws attention to the degree of e-waste they produce. E-waste or electronic waste includes mobiles phones, computers, televisions and other electronic devices, containing toxic chemicals and metals whose landfill, recycling and salvaging all produce distinct environmental and social problems. The e-waste produced by games like Guitar Hero is obvious in the regular flow of merchandise transforming computer and video games stores into simulation music stores, filled with replica guitars, drum kits, microphones and other products whose half-lives are short and whose obsolescence is anticipated in the annual cycles of consumption and disposal. This paper explores the connection between e-waste and obsolescence in the games industry, and argues for the further consideration of consumers as part of the solution to the problem of e-waste. It uses a case study of the PC digital distribution software platform, Steam, to suggest that the digital distribution of games may offer an alternative model to market driven software and hardware obsolescence, and more generally, that such software platforms might be a place to support cultures of consumption that delay rather than promote hardware obsolescence and its inevitability as e-waste. The question is whether there exists a potential for digital distribution to be a means of not only eliminating the need to physically transport commodities (its current 'green' benefit), but also for supporting consumer practices that further reduce e-waste. The games industry relies on a rapid production and innovation cycle, one that actively enforces hardware obsolescence. Current video game consoles, including the PlayStation 3, the Xbox 360 and Nintendo Wii, are the seventh generation of home gaming consoles to appear within forty years, and each generation is accompanied by an immense international transportation of games hardware, software (in various storage formats) and peripherals. Obsolescence also occurs at the software or content level and is significant because the games industry as a creative industry is dependent on the extensive management of multiple intellectual properties. The computing and video games software industry operates a close partnership with the hardware industry, and as such, software obsolescence directly contributes to hardware obsolescence. The obsolescence of content and the redundancy of the methods of policing its scarcity in the marketplace has been accelerated and altered by the processes of disintermediation with a range of outcomes (Flew). The music industry is perhaps the most advanced in terms of disintermediation with digital distribution at the center of the conflict between the legitimate and unauthorised access to intellectual property. This points to one issue with the hypothesis that digital distribution can lead to a reduction in hardware obsolescence, as the marketplace leader and key online distributor of music, Apple, is also the major producer of new media technologies and devices that are the paragon of stylistic obsolescence. Stylistic obsolescence, in which fashion changes products across seasons of consumption, has long been observed as the dominant form of scaled industrial innovation (Slade). Stylistic obsolescence is differentiated from mechanical or technological obsolescence as the deliberate supersedence of products by more advanced designs, better production techniques and other minor innovations. The line between the stylistic and technological obsolescence is not always clear, especially as reduced durability has become a powerful market strategy (Fitzpatrick). This occurs where the design of technologies is subsumed within the discourses of manufacturing, consumption and the logic of planned obsolescence in which the product or parts are intended to fail, degrade or under perform over time. It is especially the case with signature new media technologies such as laptop computers, mobile phones and portable games devices. Gamers are as guilty as other consumer groups in contributing to e-waste as participants in the industry's cycles of planned obsolescence, but some of them complicate discussions over the future of obsolescence and e-waste. Many gamers actively work to forestall the obsolescence of their games: they invest time in the play of older games (“retrogaming”) they donate labor and creative energy to the production of user-generated content as a means of sustaining involvement in gaming communities; and they produce entirely new game experiences for other users, based on existing software and hardware modifications known as 'mods'. With Guitar Hero and other 'rhythm' games it would be easy to argue that the hardware components of this genre have only one future: as waste. Alternatively, we could consider the actual lifespan of these objects (including their impact as e-waste) and the roles they play in the performances and practices of communities of gamers. For example, the Elmo Guitar Hero controller mod, the Tesla coil Guitar Hero controller interface, the Rock Band Speak n' Spellbinder mashup, the multiple and almost sacrilegious Fender guitar hero mods, the Guitar Hero Portable Turntable Mod and MAKE magazine's Trumpet Hero all indicate a significant diversity of user innovation, community formation and individual investment in the post-retail life of computer and video game hardware. Obsolescence is not just a problem for the games industry but for the computing and electronics industries more broadly as direct contributors to the social and environmental cost of electrical waste and obsolete electrical equipment. Planned obsolescence has long been the experience of gamers and computer users, as the basis of a utopian mythology of upgrades (Dovey and Kennedy). For PC users the upgrade pathway is traversed by the consumption of further hardware and software post initial purchase in a cycle of endless consumption, acquisition and waste (as older parts are replaced and eventually discarded). The accumulation and disposal of these cultural artefacts does not devalue or accrue in space or time at the same rate (Straw) and many users will persist for years, gradually upgrading and delaying obsolescence and even perpetuate the circulation of older cultural commodities. Flea markets and secondhand fairs are popular sites for the purchase of new, recent, old, and recycled computer hardware, and peripherals. Such practices and parallel markets support the strategies of 'making do' described by De Certeau, but they also continue the cycle of upgrade and obsolescence, and they are still consumed as part of the promise of the 'new', and the desire of a purchase that will finally 'fix' the users' computer in a state of completion (29). The planned obsolescence of new media technologies is common, but its success is mixed; for example, support for Microsoft's operating system Windows XP was officially withdrawn in April 2009 (Robinson), but due to the popularity in low cost PC 'netbooks' outfitted with an optimised XP operating system and a less than enthusiastic response to the 'next generation' Windows Vista, XP continues to be popular. Digital Distribution: A Solution? Gamers may be able to reduce the accumulation of e-waste by supporting the disintermediation of the games retail sector by means of online distribution. Disintermediation is the establishment of a direct relationship between the creators of content and their consumers through products and services offered by content producers (Flew 201). The move to digital distribution has already begun to reduce the need to physically handle commodities, but this currently signals only further support of planned, stylistic and technological obsolescence, increasing the rate at which the commodities for recording, storing, distributing and exhibiting digital content become e-waste. Digital distribution is sometimes overlooked as a potential means for promoting communities of user practice dedicated to e-waste reduction, at the same time it is actively employed to reduce the potential for the unregulated appropriation of content and restrict post-purchase sales through Digital Rights Management (DRM) technologies. Distributors like Amazon.com continue to pursue commercial opportunities in linking the user to digital distribution of content via exclusive hardware and software technologies. The Amazon e-book reader, the Kindle, operates via a proprietary mobile network using a commercially run version of the wireless 3G protocols. The e-book reader is heavily encrypted with Digital Rights Management (DRM) technologies and exclusive digital book formats designed to enforce current copyright restrictions and eliminate second-hand sales, lending, and further post-purchase distribution. The success of this mode of distribution is connected to Amazon's ability to tap both the mainstream market and the consumer demand for the less-than-popular; those books, movies, music and television series that may not have been 'hits' at the time of release. The desire to revisit forgotten niches, such as B-sides, comics, books, and older video games, suggests Chris Anderson, linked with so-called “long tail” economics. Recently Webb has queried the economic impact of the Long Tail as a business strategy, but does not deny the underlying dynamics, which suggest that content does not obsolesce in any straightforward way. Niche markets for older content are nourished by participatory cultures and Web 2.0 style online services. A good example of the Long Tail phenomenon is the recent case of the 1971 book A Lion Called Christian, by Anthony Burke and John Rendall, republished after the author's film of a visit to a resettled Christian in Africa was popularised on YouTube in 2008. Anderson's Long Tail theory suggests that over time a large number of items, each with unique rather than mass histories, will be subsumed as part of a larger community of consumers, including fans, collectors and everyday users with a long term interest in their use and preservation. If digital distribution platforms can reduce e-waste, they can perhaps be fostered by to ensuring digital consumers have access to morally and ethically aware consumer decisions, but also that they enjoy traditional consumer freedoms, such as the right to sell on and change or modify their property. For it is not only the fixation on the 'next generation' that contributes to obsolescence, but also technologies like DRM systems that discourage second hand sales and restrict modification. The legislative upgrades, patches and amendments to copyright law that have attempted to maintain the law's effectiveness in competing with peer-to-peer networks have supported DRM and other intellectual property enforcement technologies, despite the difficulties that owners of intellectual property have encountered with the effectiveness of DRM systems (Moore, Creative). The games industry continues to experiment with DRM, however, this industry also stands out as one of the few to have significantly incorporated the user within the official modes of production (Moore, Commonising). Is the games industry capable (or willing) of supporting a digital delivery system that attempts to minimise or even reverse software and hardware obsolescence? We can try to answer this question by looking in detail at the biggest digital distributor of PC games, Steam. Steam Figure 1: The Steam Application user interface retail section Steam is a digital distribution system designed for the Microsoft Windows operating system and operated by American video game development company and publisher, Valve Corporation. Steam combines online games retail, DRM technologies and internet-based distribution services with social networking and multiplayer features (in-game voice and text chat, user profiles, etc) and direct support for major games publishers, independent producers, and communities of user-contributors (modders). Steam, like the iTunes games store, Xbox Live and other digital distributors, provides consumers with direct digital downloads of new, recent and classic titles that can be accessed remotely by the user from any (internet equipped) location. Steam was first packaged with the physical distribution of Half Life 2 in 2004, and the platform's eventual popularity is tied to the success of that game franchise. Steam was not an optional component of the game's installation and many gamers protested in various online forums, while the platform was treated with suspicion by the global PC games press. It did not help that Steam was at launch everything that gamers take objection to: a persistent and initially 'buggy' piece of software that sits in the PC's operating system and occupies limited memory resources at the cost of hardware performance. Regular updates to the Steam software platform introduced social network features just as mainstream sites like MySpace and Facebook were emerging, and its popularity has undergone rapid subsequent growth. Steam now eclipses competitors with more than 20 million user accounts (Leahy) and Valve Corporation makes it publicly known that Steam collects large amounts of data about its users. This information is available via the public player profile in the community section of the Steam application. It includes the average number of hours the user plays per week, and can even indicate the difficulty the user has in navigating game obstacles. Valve reports on the number of users on Steam every two hours via its web site, with a population on average between one and two million simultaneous users (Valve, Steam). We know these users’ hardware profiles because Valve Corporation makes the results of its surveillance public knowledge via the Steam Hardware Survey. Valve’s hardware survey itself conceptualises obsolescence in two ways. First, it uses the results to define the 'cutting edge' of PC technologies and publishing the standards of its own high end production hardware on the companies blog. Second, the effect of the Survey is to subsequently define obsolescent hardware: for example, in the Survey results for April 2009, we can see that the slight majority of users maintain computers with two central processing units while a significant proportion (almost one third) of users still maintained much older PCs with a single CPU. Both effects of the Survey appear to be well understood by Valve: the Steam Hardware Survey automatically collects information about the community's computer hardware configurations and presents an aggregate picture of the stats on our web site. The survey helps us make better engineering and gameplay decisions, because it makes sure we're targeting machines our customers actually use, rather than measuring only against the hardware we've got in the office. We often get asked about the configuration of the machines we build around the office to do both game and Steam development. We also tend to turn over machines in the office pretty rapidly, at roughly every 18 months. (Valve, Team Fortress) Valve’s support of older hardware might counter perceptions that older PCs have no use and begins to reverse decades of opinion regarding planned and stylistic obsolescence in the PC hardware and software industries. Equally significant to the extension of the lives of older PCs is Steam's support for mods and its promotion of user generated content. By providing software for mod creation and distribution, Steam maximises what Postigo calls the development potential of fan-programmers. One of the 'payoffs' in the information/access exchange for the user with Steam is the degree to which Valve's End-User Licence Agreement (EULA) permits individuals and communities of 'modders' to appropriate its proprietary game content for use in the creation of new games and games materials for redistribution via Steam. These mods extend the play of the older games, by requiring their purchase via Steam in order for the individual user to participate in the modded experience. If Steam is able to encourage this kind of appropriation and community support for older content, then the potential exists for it to support cultures of consumption and practice of use that collaboratively maintain, extend, and prolong the life and use of games. Further, Steam incorporates the insights of “long tail” economics in a purely digital distribution model, in which the obsolescence of 'non-hit' game titles can be dramatically overturned. Published in November 2007, Unreal Tournament 3 (UT3) by Epic Games, was unappreciated in a market saturated with games in the first-person shooter genre. Epic republished UT3 on Steam 18 months later, making the game available to play for free for one weekend, followed by discounted access to new content. The 2000 per cent increase in players over the game's 'free' trial weekend, has translated into enough sales of the game for Epic to no longer consider the release a commercial failure: It’s an incredible precedent to set: making a game a success almost 18 months after a poor launch. It’s something that could only have happened now, and with a system like Steam...Something that silently updates a purchase with patches and extra content automatically, so you don’t have to make the decision to seek out some exciting new feature: it’s just there anyway. Something that, if you don’t already own it, advertises that game to you at an agreeably reduced price whenever it loads. Something that enjoys a vast community who are in turn plugged into a sea of smaller relevant communities. It’s incredibly sinister. It’s also incredibly exciting... (Meer) Clearly concerns exist about Steam's user privacy policy, but this also invites us to the think about the economic relationship between gamers and games companies as it is reconfigured through the private contractual relationship established by the EULA which accompanies the digital distribution model. The games industry has established contractual and licensing arrangements with its consumer base in order to support and reincorporate emerging trends in user generated cultures and other cultural formations within its official modes of production (Moore, "Commonising"). When we consider that Valve gets to tax sales of its virtual goods and can further sell the information farmed from its users to hardware manufacturers, it is reasonable to consider the relationship between the corporation and its gamers as exploitative. Gabe Newell, the Valve co-founder and managing director, conversely believes that people are willing to give up personal information if they feel it is being used to get better services (Leahy). If that sentiment is correct then consumers may be willing to further trade for services that can reduce obsolescence and begin to address the problems of e-waste from the ground up. Conclusion Clearly, there is a potential for digital distribution to be a means of not only eliminating the need to physically transport commodities but also supporting consumer practices that further reduce e-waste. For an industry where only a small proportion of the games made break even, the successful relaunch of older games content indicates Steam's capacity to ameliorate software obsolescence. Digital distribution extends the use of commercially released games by providing disintermediated access to older and user-generated content. For Valve, this occurs within a network of exchange as access to user-generated content, social networking services, and support for the organisation and coordination of communities of gamers is traded for user-information and repeat business. Evidence for whether this will actively translate to an equivalent decrease in the obsolescence of game hardware might be observed with indicators like the Steam Hardware Survey in the future. The degree of potential offered by digital distribution is disrupted by a range of technical, commercial and legal hurdles, primary of which is the deployment of DRM, as part of a range of techniques designed to limit consumer behaviour post purchase. While intervention in the form of legislation and radical change to the insidious nature of electronics production is crucial in order to achieve long term reduction in e-waste, the user is currently considered only in terms of 'ethical' consumption and ultimately divested of responsibility through participation in corporate, state and civil recycling and e-waste management operations. The message is either 'careful what you purchase' or 'careful how you throw it away' and, like DRM, ignores the connections between product, producer and user and the consumer support for environmentally, ethically and socially positive production, distribrution, disposal and recycling. This article, has adopted a different strategy, one that sees digital distribution platforms like Steam, as capable, if not currently active, in supporting community practices that should be seriously considered in conjunction with a range of approaches to the challenge of obsolescence and e-waste. References Anderson, Chris. "The Long Tail." Wired Magazine 12. 10 (2004). 20 Apr. 2009 ‹http://www.wired.com/wired/archive/12.10/tail.html›. De Certeau, Michel. The Practice of Everyday Life. Berkeley: U of California P, 1984. Dovey, Jon, and Helen Kennedy. Game Cultures: Computer Games as New Media. London: Open University Press,2006. Fitzpatrick, Kathleen. The Anxiety of Obsolescence. Nashville: Vanderbilt UP, 2008. Flew, Terry. New Media: An Introduction. South Melbourne: Oxford UP, 2008. Leahy, Brian. "Live Blog: DICE 2009 Keynote - Gabe Newell, Valve Software." The Feed. G4TV 18 Feb. 2009. 16 Apr. 2009 ‹http://g4tv.com/thefeed/blog/post/693342/Live-Blog-DICE-2009-Keynote-–-Gabe-Newell-Valve-Software.html›. Meer, Alec. "Unreal Tournament 3 and the New Lazarus Effect." Rock, Paper, Shotgun 16 Mar. 2009. 24 Apr. 2009 ‹http://www.rockpapershotgun.com/2009/03/16/unreal-tournament-3-and-the-new-lazarus-effect/›.Moore, Christopher. "Commonising the Enclosure: Online Games and Reforming Intellectual Property Regimes." Australian Journal of Emerging Technologies and Society 3. 2, (2005). 12 Apr. 2009 ‹http://www.swin.edu.au/sbs/ajets/journal/issue5-V3N2/abstract_moore.htm›. Moore, Christopher. "Creative Choices: Changes to Australian Copyright Law and the Future of the Public Domain." Media International Australia 114 (Feb. 2005): 71–83. Postigo, Hector. "Of Mods and Modders: Chasing Down the Value of Fan-Based Digital Game Modification." Games and Culture 2 (2007): 300-13. Robinson, Daniel. "Windows XP Support Runs Out Next Week." PC Business Authority 8 Apr. 2009. 16 Apr. 2009 ‹http://www.pcauthority.com.au/News/142013,windows-xp-support-runs-out-next-week.aspx›. Straw, Will. "Exhausted Commodities: The Material Culture of Music." Canadian Journal of Communication 25.1 (2000): 175. Slade, Giles. Made to Break: Technology and Obsolescence in America. Cambridge: Harvard UP, 2006. Valve. "Steam and Game Stats." 26 Apr. 2009 ‹http://store.steampowered.com/stats/›. Valve. "Team Fortress 2: The Scout Update." Steam Marketing Message 20 Feb. 2009. 12 Apr. 2009 ‹http://storefront.steampowered.com/Steam/Marketing/message/2269/›. Webb, Richard. "Online Shopping and the Harry Potter Effect." New Scientist 2687 (2008): 52-55. 16 Apr. 2009 ‹http://www.newscientist.com/article/mg20026873.300-online-shopping-and-the-harry-potter-effect.html?page=2›. With thanks to Dr Nicola Evans and Dr Frances Steel for their feedback and comments on drafts of this paper.

There are spells in the world: incantations that can transform reality through the power of procedural utterances. The marriage vow, the courtroom sentence, the shaman’s curse: these words are codes that change reality. (Finn 90) Introduction As a child, stories on magic were “opportunities to escape from reality” (Brugué and Llompart 1), or what Rosengren and Hickling describe as being part of a set of “causal belief systems” (77). As an adult, magic is typically seen as being “pure fantasy” (Rosengren and Hickling 75), while Bever argues that magic is something lost to time and materialism, and alternatively a skill that Yeats believed that anyone could develop with practice. The etymology of the word magic originates from magein, a Greek word used to describe “the science and religion of the priests of Zoroaster”, or, according to philologist Skeat, from Greek megas (great), thus signifying "the great science” (Melton 956). Not to be confused with sleight of hand or illusion, magic is traditionally associated with learned people, held in high esteem, who use supernatural or unseen forces to cause change in people and affect events. To use magic these people perform rituals and ceremonies associated with religion and spirituality and include people who may identify as Priests, Witches, Magicians, Wiccans, and Druids (Otto and Stausberg). Magic as Technology and Technology as Magic Although written accounts of the rituals and ceremonies performed by the Druids are rare, because they followed an oral tradition and didn’t record knowledge in a written form (Aldhouse-Green 19), they are believed to have considered magic as a practical technology to be used for such purposes as repelling enemies and divining lost items. They curse and blight humans and districts, raise storms and fogs, cause glamour and delusion, confer invisibility, inflict thirst and confusion on enemy warriors, transform people into animal shape or into stone, subdue and bind them with incantations, and raise magical barriers to halt attackers. (Hutton 33) Similarly, a common theme in The History of Magic by Chris Gosden is that magic is akin to science or mathematics—something to be utilised as a tool when there is a need, as well as being used to perform important rituals and ceremonies. In TechGnosis: Myth, Magic & Mysticism in the Age of Information, Davis discusses ideas on Technomysticism, and Thacker says that “the history of technology—from hieroglyphics to computer code—is itself inseparable from the often ambiguous exchanges with something nonhuman, something otherworldly, something divine. Technology, it seems, is religion by other means, then as now” (159). Written language, communication, speech, and instruction has always been used to transform the ordinary in people’s lives. In TechGnosis, Davis (32) cites Couliano (104): historians have been wrong in concluding that magic disappeared with the advent of 'quantitative science.’ The latter has simply substituted itself for a part of magic while extending its dreams and its goals by means of technology. Electricity, rapid transport, radio and television, the airplane, and the computer have merely carried into effect the promises first formulated by magic, resulting from the supernatural processes of the magician: to produce light, to move instantaneously from one point in space to another, to communicate with faraway regions of space, to fly through the air, and to have an infallible memory at one’s disposal. Non-Fungible Tokens (NFTs) In early 2021, at the height of the pandemic meta-crisis, blockchain and NFTs became well known (Umar et al. 1) and Crypto Art became the hot new money-making scheme for a small percentage of ‘artists’ and tech-bros alike. The popularity of Crypto Art continued until initial interest waned and Ether (ETH) started disappearing in the manner of a classic disappearing coin magic trick. In short, ETH is a type of cryptocurrency similar to Bitcoin. NFT is an acronym for Non-Fungible Token. An NFT is “a cryptographic digital asset that can be uniquely identified within its smart contract” (Myers, Proof of Work 316). The word Non-Fungible indicates that this token is unique and therefore cannot be substituted for a similar token. An example of something being fungible is being able to swap coins of the same denomination. The coins are different tokens but can be easily swapped and are worth the same as each other. Hackl, Lueth, and Bartolo define an NFT as “a digital asset that is unique and singular, backed by blockchain technology to ensure authenticity and ownership. An NFT can be bought, sold, traded, or collected” (7). Blockchain For the newcomer, blockchain can seem impenetrable and based on a type of esoterica or secret knowledge known only to an initiate of a certain type of programming (Cassino 22). The origins of blockchain can be found in the research article “How to Time-Stamp a Digital Document”, published by the Journal of Cryptology in 1991 by Haber, a cryptographer, and Stornetta, a physicist. They were attempting to answer “epistemological problems of how we trust what we believe to be true in a digital age” (Franceschet 310). Subsequently, in 2008, Satoshi Nakamoto wrote The White Paper, a document that describes the radical idea of Bitcoin or “Magic Internet Money” (Droitcour). As defined by Myers (Proof of Work 314), a blockchain is “a series of blocks of validated transactions, each linked to its predecessor by its cryptographic hash”. They go on to say that “Bitcoin’s innovation was not to produce a blockchain, which is essentially just a Merkle list, it was to produce a blockchain in a securely decentralised way”. In other words, blockchain is essentially a permanent record and secure database of information. The secure and permanent nature of blockchain is comparable to a chapter of the Akashic records: a metaphysical idea described as an infinite database where information on everything that has ever happened is stored. It is a mental plane where information is recorded and immutable for all time (Nash). The information stored in this infinite database is available to people who are familiar with the correct rituals and spells to access this knowledge. Blockchain Smart Contracts Blockchain smart contracts are written by a developer and stored on the blockchain. They contain the metadata required to set out the terms of the contract. IBM describes a smart contract as “programs stored on a blockchain that run when predetermined conditions are met”. There are several advantages of using a smart contract. Blockchain is a permanent and transparent record, archived using decentralised peer-to-peer Distributed Ledger Technology (DLT). This technology safeguards the security of a decentralised digital database because it eliminates the intermediary and reduces the chance of fraud, gives hackers fewer opportunities to access the information, and increases the stability of the system (Srivastava). They go on to say that “it is an emerging and revolutionary technology that is attracting a lot of public attention due to its capability to reduce risks and fraud in a scalable manner”. Despite being a dry subject, blockchain is frequently associated with magic. One example is Faustino, Maria, and Marques describing a “quasi-religious romanticism of the crypto-community towards blockchain technologies” (67), with Satoshi represented as King Arthur. The set of instructions that make up the blockchain smart contracts and NFTs tell the program, database, or computer what needs to happen. These instructions are similar to a recipe or spell. This “sourcery” is what Chun (19) describes when talking about the technological magic that mere mortals are unable to comprehend. “We believe in the power of code as a set of magical symbols linking the invisible and visible, echoing our long cultural tradition of logos, or language as an underlying system of order and reason, and its power as a kind of sourcery” (Finn 714). NFTs as a Conceptual Medium In a “massively distributed electronic ritual” (Myers, Proof of Work 100), NFTs became better-known with the sale of Beeple’s Everydays: The First 5000 Days by Christie’s for US$69,346,250. Because of the “thousandfold return” (Wang et al. 1) on the rapidly expanding market in October 2021, most people at that time viewed NFTs and cryptocurrencies as the latest cash cow; some artists saw them as a method to become financially independent, cut out the gallery intermediary, and be compensated on resales (Belk 5). In addition to the financial considerations, a small number of artists saw the conceptual potential of NFTs. Rhea Myers, a conceptual artist, has been using the blockchain as a conceptual medium for over 10 years. Myers describes themselves as “an artist, hacker and writer” (Myers, Bio). A recent work by Myers, titled Is Art (Token), made in 2023 as an Ethereum ERC-721 Token (NFT), is made using a digital image with text that says “this token is art”. The word ‘is’ is emphasised in a maroon colour that differentiates it from the rest in dark grey. The following is the didactic for the artwork. Own the creative power of a crypto artist. Is Art (Token) takes the artist’s power of nomination, of naming something as art, and delegates it to the artwork’s owner. Their assertion of its art or non-art status is secured and guaranteed by the power of the blockchain. Based on a common and understandable misunderstanding of how Is Art (2014) works, this is the first in a series of editions that inscribe ongoing and contemporary concerns onto this exemplar of a past or perhaps not yet realized blockchain artworld. (Myers, is art editions). This is a simple example of their work. A lot of Myers’s work appears to be uncomplicated but hides subtle levels of sophistication that use all the tools available to conceptual artists by questioning the notion of what art is—a hallmark of conceptual art (Goldie and Schellekens 22). Sol LeWitt, in Paragraphs on Conceptual Art, was the first to use the term, and described it by saying “the idea itself, even if not made visual, is as much a work of art as any finished product”. According to Bailey, the most influential American conceptual artists of the 1960s were Lucy Lippard, Sol LeWitt, and Joseph Kosuth, “despite deriving from radically diverse insights about the reason for calling it ‘Conceptual Art’” (8). Instruction-Based Art Artist Claudia Hart employs the instructions used to create an NFT as a medium and artwork in Digital Combines, a new genre the artist has proposed, that joins physical, digital, and virtual media together. The NFT, in a digital combine, functions as a type of glue that holds different elements of the work together. New media rely on digital technology to communicate with the viewer. Digital combines take this one step further—the media are held together by an invisible instruction linked to the object or installation with a QR code that magically takes the viewer to the NFT via a “portal to the cloud” (Hart, Digital Combine Paintings). QR codes are something we all became familiar with during the on-and-off lockdown phase of the pandemic (Morrison et al. 1). Denso Wave Inc., the inventor of the Quick Response Code or QR Code, describes them as being a scannable graphic that is “capable of handling several dozen to several hundred times more information than a conventional bar code that can only store up to 20 digits”. QR Codes were made available to the public in 1994, are easily detected by readers at nearly any size, and can be reconfigured to fit a variety of different shapes. A “QR Code is capable of handling all types of data, such as numeric and alphabetic characters, Kanji, Kana, Hiragana, symbols, binary, and control codes. Up to 7,089 characters can be encoded in one symbol” (Denso Wave). Similar to ideas used by the American conceptual artists of the 1960s, QR codes and NFTs are used in digital combines as conceptual tools. Analogous to Sol LeWitt’s wall drawings, the instruction is the medium and part of the artwork. An example of a Wall Drawing made by Sol LeWitt is as follows: Wall Drawing 11A wall divided horizontally and vertically into four equal parts. Within each part, three of the four kinds of lines are superimposed.(Sol LeWitt, May 1969; MASS MoCA, 2023) The act or intention of using an NFT as a medium in art-making transforms it from being solely a financial contract, which NFTs are widely known for, to an artistic medium or a standalone artwork. The interdisciplinary artist Sue Beyer uses Machine Learning and NFTs as conceptual media in her digital combines. Beyer’s use of machine learning corresponds to the automatic writing that André Breton and Philippe Soupault of the Surrealists were exploring from 1918 to 1924 when they wrote Les Champs Magnétiques (Magnetic Fields) (Bohn 7). Automatic writing was popular amongst the spiritualist movement that evolved from the 1840s to the early 1900s in Europe and the United States (Gosden 399). Michael Riffaterre (221; in Bohn 8) talks about how automatic writing differs from ordinary texts. Automatic writing takes a “total departure from logic, temporality, and referentiality”, in addition to violating “the rules of verisimilitude and the representation of the real”. Bohn adds that although “normal syntax is respected, they make only limited sense”. An artificial intelligence (AI) hallucination, or what Chintapali (1) describes as “distorted reality”, can be seen in the following paragraph that Deep Story provided after entering the prompt ‘Sue Beyer’ in March 2022. None of these sentences have any basis in truth about the person Sue Beyer from Melbourne, Australia. Suddenly runs to Jen from the bedroom window, her face smoking, her glasses shattering. Michaels (30) stands on the bed, pale and irritated. Dear Mister Shut Up! Sue’s loft – later – Sue is on the phone, looking upset. There is a new bruise on her face. There is a distinction between AI and machine learning. According to ChatGPT 3.5, “Machine Learning is a subset of AI that focuses on enabling computers to learn and make predictions or decisions without being explicitly programmed. It involves the development of algorithms and statistical models that allow machines to automatically learn from data, identify patterns, and make informed decisions or predictions”. Using the story generator Deep Story, Beyer uses the element of chance inherent in Machine Learning to create a biography on herself written by the alien other of AI. The paragraphs that Deep Story produces are nonsensical statements and made-up fantasies of what Beyer suspects AI wants the artist to hear. Like a psychic medium or oracle, providing wisdom and advice to a petitioner, the words tumble out of the story generator like a chaotic prediction meant to be deciphered at a later time. This element of chance might be a short-lived occurrence as machine learning is evolving and getting smarter exponentially, the potential of which is becoming very evident just from empirical observation. Something that originated in early modernist science fiction is quickly becoming a reality in our time. A Metamodern Spell Casting Metamodernism is an evolving term that emerged from a series of global catastrophes that occurred from the mid-1990s onwards. The term tolerates the concurrent use of ideas that arise in modernism and postmodernism without discord. It uses oppositional aspects or concepts in art-making and other cultural production that form what Dember calls a “complicated feeling” (Dember). These ideas in oscillation allow metamodernism to move beyond these fixed terms and encompass a wide range of cultural tendencies that reflect what is known collectively as a structure of feeling (van den Akker et al.). The oppositional media used in a digital combine oscillate with each other and also form meaning between each other, relating to material and immaterial concepts. These amalgamations place “technology and culture in mutual interrogation to produce new ways of seeing the world as it unfolds around us” (Myers Studio Ltd.). The use of the oppositional aspects of technology and culture indicates that Myers’s work can also be firmly placed within the domain of metamodernism. Advancements in AI over the years since the pandemic are overwhelming. In episode 23 of the MIT podcast Business Lab, Justice stated that “Covid-19 has accelerated the pace of digital in many ways, across many types of technologies.” They go on to say that “this is where we are starting to experience such a rapid pace of exponential change that it’s very difficult for most people to understand the progress” (MIT Technology Review Insights). Similarly, in 2021 NFTs burst forth in popularity in reaction to various conditions arising from the pandemic meta-crisis. A similar effect was seen around cryptocurrencies after the Global Financial Crisis (GFC) in 2007-2008 (Aliber and Zoega). “The popularity of cryptocurrencies represents in no small part a reaction to the financial crisis and austerity. That reaction takes the form of a retreat from conventional economic and political action and represents at least an economic occult” (Myers, Proof of Work 100). When a traumatic event occurs, like a pandemic, people turn to God, spirituality (Tumminio Hansen), or possibly the occult to look for answers. NFTs took on the role of precursor, promising access to untold riches, esoteric knowledge, and the comforting feeling of being part of the NFT cult. Similar to the effect of what Sutcliffe (15) calls spiritual “occultures” like “long-standing occult societies or New Age healers”, people can be lured by “the promise of secret knowledge”, which “can assist the deceptions of false gurus and create opportunities for cultic exploitation”. Conclusion NFTs are a metamodern spell casting, their popularity borne by the meta-crisis of the pandemic; they are made using magical instruction that oscillates between finance and conceptual abstraction, materialism and socialist idealism, financial ledger, and artistic medium. The metadata in the smart contract of the NFT provide instruction that combines the tangible and intangible. This oscillation, present in metamodern artmaking, creates and maintains a liminal space between these ideas, objects, and media. The in-between space allows for the perpetual transmutation of one thing to another. These ideas are a work in progress and additional exploration is necessary. An NFT is a new medium available to artists that does not physically exist but can be used to create meaning or to glue or hold objects together in a digital combine. Further investigation into the ontological aspects of this medium is required. The smart contract can be viewed as a recipe for the spell or incantation that, like instruction-based art, transforms an object from one thing to another. The blockchain that the NFT is housed in is a liminal space. The contract is stored on the threshold waiting for someone to view or purchase the NFT and turn the objects displayed in the gallery space into a digital combine. Alternatively, the intention of the artist is enough to complete this alchemical process. References Aldhouse-Green, Miranda. Caesar’s Druids: Story of an Ancient Priesthood. New Haven: Yale UP, 2010. Aliber, Robert Z., and Gylfi Zoega. “A Retrospective on the 2008 Global Financial Crisis.” The 2008 Global Financial Crisis in Retrospect: Causes of the Crisis and National Regulatory Responses. Eds. Robert Z. Aliber and Gylfi Zoega. Cham: Springer International Publishing, 2019. , 1–15. 9 June 2023 <https://doi.org/10.1007/978-3-030-12395-6_1>. Belk, Russell. “The Digital Frontier as a Liminal Space.” Journal of Consumer Psychology (2023): 1–7. Bailey, Robert. “Introduction: A Theory of Conceptualism.” Durham: Duke UP, 2017. 1–36. 28 July 2023 <https://read.dukeupress.edu/books/book/1938/chapter/234969/IntroductionA-Theory-of-Conceptualism>. Bever, Edward. “Witchcraft Prosecutions and the Decline of Magic.” Journal of Interdisciplinary History 40.2 (2009): 263–293. 27 July 2023 <https://muse.jhu.edu/pub/6/article/315257>. Beyer, S. “Digital Combines.” Sue Beyer | Visual artist, 2023. 22 July 2023 <https://www.suebeyer.com.au/combines.html>. ———. “Digital Combines: A Metamodern Oscillation of Oppositional Objects and Concepts in Contemporary Interdisciplinary Art Practice.” International Journal of Contemporary Humanities 6 (2022). Bohn, Willard. One Hundred Years of Surrealist Poetry: Theory and Practice. New York: Bloomsbury Academic, 2022. Brugué, Lydia, and Auba Llompart. Contemporary Fairy-Tale Magic: Subverting Gender and Genre. Boston: Brill, 2020. Cassino, Dan. “Crypto, Meme Stocks, and Threatened Masculinity.” Contexts 22.2 (2023): 18–23. ChatGPT 3.5. “ML vs AI.” Chat.openai.com, 18 June 2023. <https://chat.openai.com/share/4e425ff8-8610-4960-99d1-16e0451d517a>. Chintapali, Rohit. “Simplest Guardrail for AI Hallucinations? Be Skeptical, Double Check Outcomes & Don’t Anthropomorphise AI.” Business World 24 Mar. 2023. 28 June 2023 <https://www.proquest.com/docview/2790033991/abstract/9FD03495815D4956PQ/1>. Christie’s. “Beeple (b. 1981), EVERYDAYS: THE FIRST 5000 DAYS.” Christie’s, 2023. 7 June 2023 <https://onlineonly.christies.com/s/beeple-first-5000-days/beeple-b-1981-1/112924>. Chun, Wendy Hui Kyong. Programmed Visions: Software and Memory. Cambridge: MIT P, 2011. Davis, E. “TechGnosis: Magic, Memory and the Angels of Information.” Magic. Ed. J. Sutcliffe. Cambridge, Mass.: MIT P, 2021. 114–121 ———. TechGnosis: Myth, Magic & Mysticism in the Age of Information. 2nd ed. Berkeley: North Atlantic Books, 2015. DeepStory.ai. “DeepStory.” DeepStory, 2023. 18 June 2023 <https://www.deepstory.ai/#!/>. Dember, G. “What Is Metamodernism and Why Does It Matter?” The Side View, 2020. 22 July 2023 <https://thesideview.co/journal/what-is-metamodernism-and-why-does-it-matter/>. Denso Wave Inc. “History of QR Code.” QRcode.com, n.d. 27 June 2023 <https://www.qrcode.com/en/history/>. Droitcour, Brian. “The Outland Review, Vol. 01.” Outland, 4 May 2023. 20 July 2023 <https://outland.art/the-outland-review-vol-01-julian-opie-taproot-wizards/>. Faustino, Sandra, Inês Faria, and Rafael Marques. “The Myths and Legends of King Satoshi and the Knights of Blockchain.” Journal of Cultural Economy 15.1 (2022): 67–80. 23 July 2023 <https://www.tandfonline.com/doi/full/10.1080/17530350.2021.1921830>. Finn, Ed. What Algorithms Want: Imagination in the Age of Computing. EPub Version 1.0. Cambridge, Mass.: MIT P, 2017. Franceschet, Massimo. “The Sentiment of Crypto Art.” CEUR Workshop Proceedings. Aachen: RWTH Aachen, n.d. 310–318. 25 Nov. 2022 <https://ceur-ws.org/Vol-2989/long_paper10.pdf>. Goldie, Peter, and Elisabeth Schellekens. Who’s Afraid of Conceptual Art? Florence: Taylor and Francis, 2009. Gordon, Melton J. “Magic.” Encyclopedia of Occultism and Parapsychology. Ed Melton J. Gordon. 5th ed. Detroit, MI: Gale, 2001. 956–960. 21 July 2023 <https://link.gale.com/apps/doc/CX3403802897/GVRL?sid=bookmark-GVRL&xid=00061628>. Gosden, Chris. The History of Magic: From Alchemy to Witchcraft, from the Ice Age to the Present. London: Penguin, 2020. Haber, S., and W.S. Stornetta. “How to Time-Stamp a Digital Document.” Journal of Cryptology 3.2 (1991): 99–111. Hackl, Cathy, Dirk Lueth, and Tommaso di Bartolo. Navigating the Metaverse: A Guide to Limitless Possibilities in a Web 3.0 World. Ed. John Arkontaky. Hoboken, NJ: John Wiley & Sons, 2022. Hart, Claudia. “Digital Combine Paintings – Claudia Hart.” Claudia Hart, 2021. 15 Nov. 2022 <https://claudiahart.com/Digital-Combine-Paintings>. ———. “The Ruins Timeline – Claudia Hart.” Claudia Hart, 2020. 3 June 2023 <https://claudiahart.com/The-Ruins-timeline>. IBM. “What Are Smart Contracts on Blockchain?” IBM, n.d. 5 June 2023 <https://www.ibm.com/topics/smart-contracts>. LeWitt, Sol. “Paragraphs on Conceptual Art.” Art Forum (1967): n.p. 28 July 2023 <http://arteducation.sfu-kras.ru/files/documents/lewitt-paragraphs-on-conceptual-art1.pdf>. ———. “Wall Drawing 11.” Massachusetts Museum of Contemporary Art. MASS MoCA, 2023. 16 June 2023 <https://massmoca.org/event/walldrawing11/>. MIT Technology Review Insights. “Embracing the Rapid Pace of AI.” Business Lab, 20 May 2021. 28 July 2023 <https://www.technologyreview.com/2021/05/19/1025016/embracing-the-rapid-pace-of-ai/>. Morrison, Benjamin A., et al. “Life after Lockdown: The Experiences of Older Adults in a Contactless Digital World.” Frontiers in Psychology 13 (2023): 1–14. 28 July 2023 <https://www.frontiersin.org/articles/10.3389/fpsyg.2022.1100521>. Myers, Rhea. “Bio.” rhea.art, n.d. 1 July 2023 <https://rhea.art/bio>. ———. “is art editions.” rhea.art, 2023. 22 July 2023 <https://rhea.art/is-art-editions>. ——— [@rheaplex]. “My Little Penny: Bitcoin is Magic.” Tweet. Twitter, 2014. 8 June 2023 <https://twitter.com/rheaplex/status/439534733534298112>. ———. Proof of Work: Blockchain Provocations 2011-2021. UK: Urbanomic Media, 2023. Myers Studio Ltd. “The Home Base of Rhea and Seryna Myers.” Myers Studio, 2021. 17 Nov. 2022 <http://myers.studio/>. Nash, Alex. “The Akashic Records: Origins and Relation to Western Concepts.” Central European Journal for Contemporary Religion 3 (2020): 109–124. Otto, Bernd-Christian, and Michael Stausberg. Defining Magic: A Reader. London: Taylor & Francis Group, 2014. Riffaterre, Michael. Text Production. Trans. Terese Lyons. New York: Columbia UP, 1983. Rosengren, Karl S., and Anne K. Hickling. “Metamorphosis and Magic: The Development of Children’s Thinking about Possible Events and Plausible Mechanisms.” Imagining the Impossible. Ed. Karl S. Rosengren, Carl N. Johnson, and Paul L. Harris, 75–98. Cambridge UP, 2000. Srivastava, N. “What Is Blockchain Technology, and How Does It Work?” Blockchain Council, 23 Oct. 2020. 17 Nov. 2022 <https://www.blockchain-council.org/blockchain/what-is-blockchain-technology-and-how-does-it-work/>. Sutcliffe, J., ed. Magic. Cambridge, Mass.: MIT P, 2021. Thacker, Eugene. “Foreword (2015): ‘We Cartographers of Old…’” TechGnosis: Myth, Magic & Mysticism in the Age of Information. Kindle Edition. Berkeley: North Atlantic Books, 2015. Location 111-169. Tumminio Hansen, D. “Do People Become More Religious in Times of Crisis?” The Conversation, 2021. 9 June 2023 <http://theconversation.com/do-people-become-more-religious-in-times-of-crisis-158849>. Van den Akker, R., A. Gibbons, and T. Vermeulen. Metamodernism: Historicity, Affect, and Depth after Postmodernism. London: Rowman & Littlefield, 2019. Umar, Zaghum, et al. “Covid-19 Impact on NFTs and Major Asset Classes Interrelations: Insights from the Wavelet Coherence Analysis.” Finance Research Letters 47 (2022). 27 July 2023 <https://linkinghub.elsevier.com/retrieve/pii/S1544612322000496>. Wang, Qin, et al. “Non-Fungible Token (NFT): Overview, Evaluation, Opportunities and Challenges.” arXiv, 24 Oct. 2021. 28 July 2023 <http://arxiv.org/abs/2105.07447>. Yeats, W.B. “Magic.” Essays and Introductions. Ed. W.B. Yeats. London: Palgrave Macmillan, 1961. 28–52. 27 July 2023 <https://doi.org/10.1007/978-1-349-00618-2_3>.

Health Promotion and Risk Factors: A Closer Look at Building a Healthier Society By  Aniket Gangatire Shruti Bhatjire Guided by – Moldoev M I Department Of Public Health OSH STATE UNIVERSITY INTERNATIONAL MEDICAL FACULTY Abstract Health isn’t just about going to the doctor when you’re sick—it’s about everything that shapes our lives, from the air we breathe to the food we eat, the neighborhoods we live in, and the policies that guide our choices. Health promotion is the practice of helping people and communities live healthier lives—not just by preventing disease, but by creating environments that make the healthy choice the easy choice. This piece explores health promotion through the lens of real-world challenges and solutions. It highlights how health is influenced by individual behaviors (like diet and exercise), social connections, environmental factors (like clean air and safe spaces), and broader systems like education, income, and public policy. Using the Ottawa Charter and the Social-Ecological Model as guiding frameworks, we unpack strategies that work—like community-driven programs, smart policy changes, and personalized digital tools—and stress the importance of evaluating whether these strategies truly improve lives. We also dive into emerging trends, including AI in health coaching, climate-resilient planning, and precision prevention tailored to genetics. Finally, we reflect on the ethics behind health promotion. How do we balance personal freedom with public good? How can we ensure that health efforts are fair and reach those most in need? And how do we hold powerful industries accountable when they profit from poor health? Introduction 1. Health Promotion: More Than Just Preventing Disease Health promotion is about more than telling people not to smoke or to eat more vegetables. It’s a proactive, empowering approach that helps individuals and communities take control of their health—physically, mentally, and socially. The Ottawa Charter for Health Promotion (1986) gave us a powerful framework that still holds true today. Here’s what it says we should focus on: 1. Build Healthy Public Policy This means weaving health into every area of life—not just in hospitals or clinics. For example:  • A city that designs bike lanes encourages people to cycle instead of drive.  • Taxes on sugary drinks can reduce consumption and help prevent diabetes.  • Agricultural policies shape the types of food that end up on our plates. 2. Create Supportive Environments People thrive when their surroundings support healthy living:  • Smoke-free parks and restaurants protect everyone, not just smokers.  • Clean water and air reduce disease risk.  • Even well-lit, green urban spaces can reduce stress and increase physical activity. 3. Strengthen Community Action Real change often starts from the ground up. When communities get involved in their health decisions:  • They grow community gardens in neighborhoods with few grocery stores.  • Seniors create walking clubs that also reduce social isolation.  • People with diabetes lead education programs, sharing lived experience. 4. Develop Personal Skills Health education isn’t just about knowing the food pyramid. It’s about building life skills:  • Understanding food labels and meal planning  • Managing stress in healthy ways  • Knowing how to navigate online health information 5. Reorient Health Services Health care shouldn’t just kick in when someone gets sick. It should help prevent illness in the first place:  • Free health screenings catch problems early.  • Mental health services are integrated into routine care.  • Programs help people adopt healthier lifestyles before chronic diseases develop. 2. The Social-Ecological Model: Health Happens in Context Health doesn’t exist in a vacuum. Why someone skips the gym or eats fast food isn’t just about willpower—it’s about their entire environment. The Social-Ecological Model helps us understand all the layers that influence behavior:  • Individual: Your choices, habits, genetics, and beliefs  • Interpersonal: Friends, family, and peer pressure  • Organizational: School policies, job benefits, health care systems  • Community: Your neighborhood’s walkability, safety, and food availability  • Policy: Laws, taxes, and government programs Telling people to “just eat healthier” doesn’t help if their nearest grocery store is miles away or junk food is cheaper than vegetables. 3. Risk Factors: What Really Affects Our Health A. Behavioral Risks: What We Do Matters  1. Tobacco Use  • It’s still one of the biggest killers—not just through lung cancer, but also strokes, heart disease, and even infertility.  • Secondhand smoke is deadly too, especially for kids and vulnerable adults.  2. Physical Inactivity  • Sitting all day is the new smoking. It’s linked to dementia, obesity, and even depression.  • Even short walks throughout the day can make a big difference.  3. Poor Diet  • Ultra-processed foods are cheap, convenient—and everywhere. But they’re loaded with salt, sugar, and fats.  • Portion sizes have exploded, and ads often target kids.  4. Alcohol  • A little might be okay for some, but heavy drinking is linked to liver disease, cancer, and car crashes.  • The societal cost is huge—over $249 billion per year in the U.S. B. Environmental Risks: Health is Where We Live  1. Air Pollution  • Tiny particles from cars, factories, and fires can cause breathing problems and even shorten lives.  • Poorer communities often face the worst air quality.  2. Water Issues  • Safe water is still a luxury in many parts of the world.  • Contaminants like PFAS (“forever chemicals”) and microplastics are raising new concerns.  3. The Built Environment  • Some areas are “food swamps” full of fast food and no healthy options.  • If there are no parks, sidewalks, or public transit, being active is harder. C. Social Determinants: Life Conditions Shape Health  1. Income  • The poorer you are, the higher your health risks. It’s not just about money—it’s about chronic stress, poor housing, and fewer choices.  2. Education  • People with more education tend to live longer and healthier lives.  • Health literacy—understanding health info—is critical to making good decisions.  3. Social Environment  • Loneliness can be as harmful as smoking.  • Supportive relationships and community ties protect health. 4. What Works? Strategies That Actually Help On the Individual Level  • Motivational Interviewing: Instead of lecturing, providers help patients talk through their ambivalence. It works especially well for quitting smoking, substance use, and other tough behavior changes.  • Nudge Theory: Small design tweaks can make healthier choices easier:  • Automatically enrolling people in wellness programs  • Putting fruit at the front of the cafeteria line In Communities  • Participatory Action Research: Let communities lead the way. When people design solutions for their own problems, change sticks.  • Social Marketing Campaigns: Catchy, culturally relevant campaigns can change norms. Think of the Truth campaign against tobacco—it made smoking uncool. At the Policy Level  • Taxes and Subsidies: Making unhealthy choices more expensive and healthy ones cheaper changes behavior.  • Regulations: Banning trans fats, requiring nutrition labels, or limiting alcohol outlets saves lives.  • Urban Design: Adding bike lanes, green spaces, and healthy food access isn’t just nice—it’s essential. 5. Measuring What Matters Health promotion is only as good as its outcomes. That means tracking:  • Process: Are we reaching people? Are they engaged?  • Outcomes: Are behaviors changing? Are health indicators improving?  • Economics: Are we saving money in the long run? 6. What’s Next? The Future of Health Promotion The world is changing, and so is how we approach health.  1. Digital Health  • Apps, wearables, and even AI coaches are helping people make better choices.  • Gamifying behavior (like fitness challenges) boosts engagement.  2. Precision Prevention  • Using your genes or microbiome to tailor prevention plans could be the next frontier.  • Imagine personalized nutrition advice based on your biology.  3. Climate and Health  • Health promotion now includes preparing for heatwaves, natural disasters, and food shortages caused by climate change.  4. Life Course Approach  • Starting early matters. Investing in child health and maintaining wellness across life stages sets the stage for healthy aging. 7. Ethics: Doing Health Promotion the Right Way  • Balancing Freedom and Protection: Should we ban soda in schools—or let kids choose? It’s a tricky balance between autonomy and responsibility.  • Health Equity: Not everyone starts from the same place. Health promotion must address deep-rooted inequities and respect cultural differences.  • Holding Corporations Accountable: Industries that profit from harmful products (like tobacco, alcohol, or junk food) shouldn’t be setting the rules. Watch for conflicts of interest and push for transparency. Bottom Line: Health promotion is about creating the conditions for everyone—not just the privileged few—to live their healthiest life. That means working at every level: from individual habits to global policies. It’s not easy, but it’s worth it. Because when we build healthier environments, we build stronger, fairer communities. References Foundational Frameworks & Models  1. World Health Organization. (1986). Ottawa Charter for Health Promotion. https://www.who.int/publications/i/item/ottawa-charter-for-health-promotion  2. McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351–377. https://doi.org/10.1177/109019818801500401 Behavioral Risk Factors  3. U.S. Department of Health and Human Services. (2020). Smoking cessation: A report of the Surgeon General. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf  4. Warburton, D. E. R., & Bredin, S. S. D. (2017). Health benefits of physical activity. Current Opinion in Cardiology, 32(5), 541–556. https://doi.org/10.1097/HCO.0000000000000437  5. Monteiro, C. A., Cannon, G., Moubarac, J.-C., Levy, R. B., Louzada, M. L., & Jaime, P. C. (2018). The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutrition, 21(1), 5–17. https://doi.org/10.1017/S1368980017000234  6. Rehm, J., & Shield, K. D. (2019). Global burden of disease and the impact of alcohol. Current Addiction Reports, 6(4), 449–457. https://doi.org/10.1007/s40429-019-00297-2 Environmental Risk Factors  7. Cohen, A. J., Brauer, M., Burnett, R., et al. (2017). Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution. The Lancet, 389(10082), 1907–1918. https://doi.org/10.1016/S0140-6736(17)30505-6  8. World Health Organization. (2022). Progress on household drinking water, sanitation and hygiene 2000–2020. https://www.who.int/publications/i/item/9789240030848  9. Swinburn, B. A., et al. (2019). The global syndemic of obesity, undernutrition, and climate change. The Lancet Commission Report. https://doi.org/10.1016/S0140-6736(18)32822- Social Determinants of Health  10. Marmot, M. (2005). Social determinants of health inequalities. The Lancet, 365(9464), 1099–1104. https://doi.org/10.1016/S0140-6736(05)71146-6  11. Berkman, L. F., & Kawachi, I. (Eds.). (2000). Social Epidemiology. Oxford University Press.  12. Woolf, S. H., Aron, L. (Eds.). (2013). U.S. Health in International Perspective: Shorter Lives, Poorer Health. National Academies Press. https://doi.org/10.17226/13497 Evidence-Based Strategies  13. Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). Guilford Press.  14. Thaler, R. H., & Sunstein, C. R. (2008). Nudge: Improving Decisions About Health, Wealth, and Happiness. Yale University Press.  15. Wakefield, M. A., Loken, B., & Hornik, R. C. (2010). Use of mass media campaigns to change health behaviour. The Lancet, 376(9748), 1261–1271. https://doi.org/10.1016/S0140-6736(10)60809-4 Policy & Public Health Interventions  16. Brownell, K. D., & Frieden, T. R. (2009). Ounces of prevention—the public policy case for taxes on sugary beverages. New England Journal of Medicine, 360(18), 1805–1808. https://doi.org/10.1056/NEJMp0902392  17. Frieden, T. R. (2010). A framework for public health action: the health impact pyramid. American Journal of Public Health, 100(4), 590–595. https://doi.org/10.2105/AJPH.2009.185652 Future & Ethics in Health Promotion  18. Topol, E. (2019). Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again. Basic Books.  19. Kickbusch, I., Allen, L., & Franz, C. (2016). The commercial determinants of health. The Lancet Global Health, 4(12), e895–e896. https://doi.org/10.1016/S2214-109X(16)30217-0  20. Gollust, S. E., & Cappella, J. N. (2014). Understanding public resistance to messages about health disparities. Health Affairs, 33(11), 1782–1789. https://doi.org/10.1377/hlthaff.2014.0126                                                                                            

Photo by niu niu on Unsplash ABSTRACT Shackling prisoners has been implemented as standard procedure when transporting prisoners in labor and during childbirth. This procedure ensures the protection of both the public and healthcare workers. However, the act of shackling pregnant prisoners violates the principles of ethics that physicians are supposed to uphold. This paper will explore how shackling pregnant prisoners violates the principle of justice and beneficence, making the practice unethical. INTRODUCTION Some states allow shackling of incarcerated pregnant women during transport and while in the hospital for labor and delivery. Currently, only 22 states have legislation prohibiting the shackling of pregnant women.[1] Although many states have anti-shackling laws prohibiting restraints, these laws also contain an “extraordinary circumstances” loophole.[2] Under this exception, officers shackle prisoners if they pose a flight risk, have any history of violence, and are a threat to themselves or others.[3] Determining as to whether a prisoner is shackled is left solely to the correctional officer.[4] Yet even state restrictions on shackling are often disregarded. In shackling pregnant prisoners during childbirth, officers and institutions are interfering with the ability of incarcerated women to have safe childbirth experiences and fair treatment. Moreover, physicians cannot exercise various ethical duties as the law constrains them. In this article, I will discuss the physical and mental harms that result from the use of restraints under the backdrop of slavery and discrimination against women of color particularly. I argue that stereotypes feed into the phenomenon of shackling pregnant women, especially pregnant women of color. I further assert that shackling makes it difficult for medical professionals to be beneficent and promote justice. BACKGROUND Female incarceration rates in the United States have been fast growing since the 1980s.[5] With a 498 percent increase in the female incarceration population between 1981 and 2021, the rates of pregnancy and childbirth by incarcerated people have also climbed.[6],[7] In 2021, over 1.2 million women were incarcerated in the United States.[8] An estimated 55,000 pregnant women are admitted to jails each year.[9],[10] Many remain incarcerated throughout pregnancy and are transported to a hospital for labor and delivery. Although the exact number of restrained pregnant inmates is unclear, a study found that 83 percent of hospital prenatal nurses reported that their incarcerated patients were shackled.[11] I. Harms Caused by Shackling Shackling has caused many instances of physical and psychological harm. In the period before childbirth, shackled pregnant women are at high risk for falling.[12] The restraints shift pregnant women’s center of gravity, and wrist restraints prevent them from breaking a fall, increasing the risk of falling on their stomach and harming the fetus.[13] Another aspect inhibited by using restraints is testing and treating pregnancy complications. Delays in identifying and treating conditions such as hypertension, pre-eclampsia, appendicitis, kidney infection, preterm labor, and especially vaginal bleeding can threaten the lives of the mother and the fetus.[14] During labor and delivery, shackling prevents methods of alleviating severe labor pains and giving birth.[15] Usually, physicians recommend that women in labor walk or assume various positions to relieve labor pains and accelerate labor.[16] However, shackling prevents both solutions.[17] Shackling these women limits their mobility during labor, which may compromise the health of both the mother and the fetus.[18] Tracy Edwards, a former prisoner who filed a lawsuit for unlawful use of restraints during her pregnancy, was in labor for twelve hours. She was unable to move or adjust her position to lessen the pain and discomfort of labor.[19] The shackles also left the skin on her ankles red and bruised. Continued use of restraints also increases the risk of potentially life-threatening health issues associated with childbirth, such as blood clots.[20] It is imperative that pregnant women get treated rapidly, especially with the unpredictability of labor. Epidural administration can also become difficult, and in some cases, be denied due to the shackled woman’s inability to assume the proper position.[21] Time-sensitive medical care, including C-sections, could be delayed if permission from an officer is required, risking major health complications for both the fetus and the mother.[22] After childbirth, shackling impedes the recovery process. Shackling can result in post-delivery complications such as deep vein thrombosis.[23] Walking prevents such complications but is not an option for mothers shackled to their hospital beds.[24] Restraints also prevent bonding with the baby post-delivery and the safe handling of the baby while breast feeding.[25] The use of restraints can also result in psychological harm. Many prisoners feel as though care workers treat them like “animals,” with some women having multiple restraints at once— including ankles, wrists, and even waist restraints.[26] Benidalys Rivera describes the feeling of embarrassment as she was walking while handcuffed, with nurses and patients looking on, “Being in shackles, that make you be in stress…I about to have this baby, and I’m going to go back to jail. So it’s too much.”[27] Depression among pregnant prisoners is highly prevalent. The stress of imprisonment and the anticipation of being separated from their child is often overwhelming for these mothers.[28] The inhumane action has the potential to add more stress, anxiety, and sadness to the already emotionally demanding process of giving birth. Shackling pregnant prisoners displays indifference to the medical needs of the prisoner.[29] II. Safety as a Pretense While public safety is an argument for using shackles, several factors make escape or violence extremely unlikely and even impossible.[30] For example, administering epidural anesthesia causes numbness and eliminates flight risk.[31] Although cited as the main reason for using shackles, public safety is likely just an excuse and not the main motivator for shackling prisoners. I argue that underlying the shackling exemplifies the idea that these women should not have become pregnant. The shackling reflects a distinct discrimination: the lawmakers allowing it perhaps thought that people guilty of crimes would make bad mothers. Public safety is just a pretense. The language used to justify the use of restraint of Shawanna Nelson, the plaintiff in Nelson v. Correctional Medical Services, discussed below, included the word “aggressive.”[32] In her case, there was no evidence that she posed any danger or was objectively aggressive. Officer Turnesky, who supervised Nelson, testified that she never felt threatened by Nelson.[33] The lack of documented attempts of escape and violence from pregnant prisoners suggests that shackling for flight risk is a false pretense and perhaps merely based on stereotypes.[34] In 2011, an Amnesty International report noted that “Around the USA, it is common for restraints to be used on sick and pregnant incarcerated women when they are transported to and kept in hospital, regardless of whether they have a history of violence (which only a minority have) and regardless of whether they have ever absconded or attempted to escape (which few women have).”[35] In a 2020 survey of correctional officers in select midwestern prisons, 76 percent disagreed or strongly disagreed with restraining pregnant women during labor and delivery.[36] If a correctional officer shackles a pregnant prisoner, it is not because they pose a risk but because of a perception that they do. This mindset is attributed to select law enforcement, who have authority to use restraints.[37] In 2022, the Tennessee legislature passed a bill prohibiting the use of restraints on pregnant inmates. However, legislators amended the bill due to the Tennessee Sherriff Association’s belief that even pregnant inmates could pose a “threat.”[38] Subjecting all prisoners to the same “precautions” because a small percentage of individuals may pose such risks could reflect stereotyping or the assumption that all incarcerated people pose danger and flight risk. To quell the (unjustified) public safety concern, there are other options that do not cause physical or mental harm to pregnant women. For example, San Francisco General Hospital does not use shackles but has deputy sheriffs outside the pregnant women’s doors.[39] III. Historical Context and Race A. Slavery and Post-Civil War The treatment of female prisoners has striking similarities to that of enslaved women. Originally, shackling of female slaves was a mechanism of control and dehumanization.[40] This enabled physical and sexual abuses. During the process of intentionally dehumanizing slaves to facilitate subordination, slave owners stripped slave women of their feminine identity.[41] Slave women were unable to exhibit the Victorian model of “good mothering” and people thought they lacked maternal feelings for their children.[42] In turn, societal perception defeminized slave women, and barred them from utilizing the protections of womanhood and motherhood. During the post-Civil War era, black women were reversely depicted as sexually promiscuous and were arrested for prostitution more often than white women.[43] In turn, society excluded black women; they were seen as lacking what the “acceptable and good” women had.[44] Some argue that the historical act of labeling black women sexually deviant influences today’s perception of black women and may lead to labeling them bad mothers.[45] Over two-thirds of incarcerated women are women of color.[46] Many reports document sexual violence and misconduct against prisoners over the years.[47] Male guards have raped, sexually assaulted, and inappropriately touched female prisoners. Some attribute the physical abuse of black female prisoners to their being depicted or stereotyped as “aggressive, deviant, and domineering.”[48] Some expect black women to express stoicism and if they do not, people label them as dangerous, irresponsible, and aggressive.[49] The treatment of these prisoners mirrors the historical oppression endured by black women during and following the era of slavery. The act of shackling incarcerated pregnant women extends the inhumane treatment of these women from the prison setting into the hospital. One prisoner stated that during her thirty-hour labor, while being shackled, she “felt like a farm animal.”[50] Another pregnant prisoner describes her treatment by a guard stating: “a female guard grabbed me by the hair and was making me get up. She was screaming: ‘B***h, get up.’ Then she said, ‘That is what happens when you are a f***ing junkie. You shouldn’t be using drugs, or you wouldn’t be in here.”[51] Shackling goes beyond punishing by isolation from society – it is an additional punishment that is not justified. B. Reproductive Rights and “Bad Mothers” As with slaves not being seen as maternal, prisoners are not viewed as “real mothers.” A female prison guard said the following: “I’m a mother of two and I know what that impulse, that instinct, that mothering instinct feels like. It just takes over, you would never put your kids in harm’s way. . . . Women in here lack that. Something in their nature is not right, you know?”[52] This comment implies that incarcerated women lack maternal instinct. They are not in line with the standards of what society accepts as a “woman” and “mother” and are thought to have abandoned their roles as caretakers in pursuit of deviant behaviors. Without consideration of racial discrimination, poverty issues, trauma, and restricted access to the child right after delivery, these women are stereotyped as bad mothers simply because they are in prison. Reminiscent of the treatment of female black bodies post-civil war and the use of reproductive interventions (for example, Norplant and forced sterilization) in exchange for shorter sentences, I argue that shackles are a form of reproductive control. Justification for the use of shackles even includes their use as a “punitive instrument to remind the prisoner of their punishment.”[53] However, a prisoner’s pregnancy should have no relevance to their sentence.[54] Using shackles demonstrates to prisoners that society tolerates childbirth but does not support it.[55] The shackling is evidence that women are being punished “for bearing children, not for breaking the law.”[56] Physicians and healthcare workers, as a result, are responsible for providing care for the delivery and rectifying any physical problems associated with the restraints. The issues that arise from the use of restraints place physicians in a position more complex than they experience with regular healthy pregnancies. C. Discrimination In the case of Ferguson v. City of Charleston, a medical university subjected black woman to involuntary drug testing during pregnancy. In doing so, medical professionals collaborated with law enforcement to penalize black women for their use of drugs during pregnancy.[57] The Court held the drug tests were an unreasonable search and violated the Fourth Amendment. Ferguson v. City of Charleston further reveals an unjustified assumption: the medical and legal community seemed suspicious of black women and had perhaps predetermined them more likely to use drugs while pregnant. Their fitness to become mothers needed to be proven, while wealthy, white women were presumed fit.[58] The correctional community similarly denies pregnant prisoners’ medical attention. In the case of Staten v. Lackawanna County, an African American woman whose serious medical needs were treated indifferently by jail staff was forced to give birth in her cell.[59] This woman was punished for being pregnant in prison through the withholding of medical attention and empathy. IV. Failure to Follow Anti-Shackling Laws Despite 22 states having laws against shackling pregnant prisoners, officers do not always follow these laws. In 2015, the Correctional Association of New York reported that of the 27 women who gave birth under state custody, officers shackled 23 women in violation of the anti-shackling laws.[60] The lawyer of Tracy Edwards, an inmate who officers shackled unlawfully during her twelve-hour labor stated, “I don’t think we can assume that just because there’s a law passed, that’s automatically going to trickle down to the prison.”[61] Even with more restrictions on shackling, it may still occur, partly due to the stereotype that incarcerated women are aggressive and dangerous. V. Constitutionality The Eighth Amendment protects people from cruel and unusual punishment. In Brown vs. Plata, the court stated, “Prisoners retain the essence of human dignity inherent in all persons.”[62] In several cases, the legal community has held shackling to be unconstitutional as it violates the Eighth Amendment unless specifically justified. In the case of Nelson v. Correctional Medical Services, a pregnant woman was shackled for 12 hours of labor with a brief respite while she pushed, then re-shackled. The shackling caused her physical and emotional pain, including intense cramping that could not be relieved due to positioning and her inability to get up to use a toilet.[63] The court held that a clear security concern must justify shackling. The court cited a similar DC case and various precedents for using the Eighth Amendment to hold correctional facilities and hospitals accountable.[64] An Arkansas law similarly states that shackling must be justified by safety or risk of escape.[65] If the Thirteenth Amendment applied to those convicted of crimes, shackling pregnant incarcerated people would be unconstitutional under that amendment as well as the Eighth. In the Civil Rights Cases, Congress upheld the right “to enact all necessary and proper laws for the obliteration and prevention of slavery with all its badges and incidents.”[66] Section two of the Thirteenth Amendment condemns any trace or acts comparable to that of slavery. Shackling pregnant prisoners, stripping them of their dignity, and justification based on stereotypes all have origins in the treatment of black female slaves. Viewed through the lens of the Thirteenth Amendment, the act of shackling would be unconstitutional. Nonetheless, the Thirteenth Amendment explicitly excludes people convicted of a crime. VI. Justice As a result of the unconstitutional nature of shackling, physicians should have a legal obligation, in addition to their ethical duty, to protect their patients. The principle of justice requires physicians to take a stand against the discriminatory treatment of their patients, even under the eye of law enforcement.[67],[68] However, “badge and gun intimidation,” threats of noncompliance, and the fear of losing one’s license can impede a physician’s willingness to advocate for their patients. The American College of Obstetricians and Gynecologists (ACOG) finds the use of physical restraints interferes with the ability of clinicians to practice medicine safely.[69] ACOG, The American Medical Association, the National Commission on Correctional Health Care, and other organizations oppose using restraints on pregnant incarcerated people.[70] Yet, legislators can adopt shackling laws without consultation with physicians. The ACOG argues that “State legislators are taking it upon themselves to define complex medical concepts without reference to medical evidence. Some of the penalties [faced by OBGYNs] for violating these vague, unscientific laws include criminal sentences.”[71] Legislation that does not consider medical implications or discourages physicians’ input altogether is unjust. In nullifying the voice of a physician in matters pertaining to the patient’s treatment, physicians are prevented from fulfilling the principle of justice, making the act of shackling patients unethical. VII. Principle of Beneficence The principle of beneficence requires the prevention of harm, the removal of harm, and the promotion of good.[72] Beneficence demands the physician not only avoid harm but benefit patients and promote their welfare.[73] The American Board of Internal Medicine Foundation states that physicians must work with other professionals to increase patient safety and improve the quality of care.[74] In doing so, physicians can adequately treat patients with the goal of prevention and healing. It is difficult to do good when law enforcement imposes on doctors to work around shackles during labor and delivery. Law enforcement leaves physicians and healthcare workers responsible not only to provide care for the delivery, but also rectify any ailments associated with the restraints. The issues arising from using restraints place physicians in a position more complex than they experience with other pregnancies. Doctors cannot prevent the application of the shackles and can only request officers to take them off the patient.[75] Physicians who simply go along with shackling are arguably violating the principle of beneficence. However, for most, rather than violating the principle of beneficence overtly, physicians may simply have to compromise. Given the intricate nature of the situation, physicians are tasked with minimizing potential harm to the best of their abilities while adhering to legal obligations.[76] It is difficult to pin an ethics violation on the ones who do not like the shackles but are powerless to remove them. Some do argue that this inability causes physicians to violate the principle of beneficence.[77] However, promoting the well-being of their patients within the boundaries of the law limits their ability to exercise beneficence. For physicians to fulfill the principle of beneficence to the fullest capacity, they must have an influence on law. Protocols and assessments on flight risks made solely by the officers and law enforcement currently undermine the physician’s expertise. These decisions do not consider the health and well-being of the pregnant woman. As a result, law supersedes the influence of medicine and health care. CONCLUSION People expect physicians to uphold the four major principles of bioethics. However, their inability to override restraints compromises their ability to exercise beneficence. Although pledging to enforce these ethical principles, physicians have little opportunity to influence anti-shackling legislation. Instead of being included in conversations regarding medical complexities, legislation silences their voices. Policies must include the physician's voice as they affect their ability to treat patients. Officers should not dismiss a physician's request to remove shackles from a woman if they are causing health complications. A woman's labor should not harm her or her fetus because the officer will not remove her shackles.[78] A federal law could end shackling pregnant incarcerated people. Because other options are available to ensure the safety of the public and the prisoner, there is no ethical justification for shackling pregnant prisoners. An incarcerated person is a human being and must be treated with dignity and respect. To safeguard the well-being of incarcerated women and the public, it is essential for advocates of individual rights to join forces with medical professionals to establish an all-encompassing solution. - [1] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [2] S983A, 2015-2016 Regular Sessions (N.Y. 2015). https://legislation.nysenate.gov/pdf/bills/2015/S983A [3] Chris DiNardo, Pregnancy in Confinement, Anti-Shackling Laws and the “Extraordinary Circumstances” Loophole, 25 Duke Journal of Gender Law & Policy 271-295 (2018) https://scholarship.law.duke.edu/djglp/vol25/iss2/5 [4] Chris DiNardo (2018) [5] U.S. Bureau of Justice Statistics. 1980. " Prisoners in 1980 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/content/pub/pdf/p80.pdf). [6] U.S. Bureau of Justice Statistics. 2022. " Prisoners in 2021 – Statistical Tables”. Retrieved April 20, 2023 (https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/p21st.pdf). [7] U.S. Bureau of Justice Statistics (1980) [8] Sufrin C, Jones RK, Mosher WD, Beal L. Pregnancy Prevalence and Outcomes in U.S. Jails. Obstet Gynecol. 2020;135(5):1177-1183. doi:10.1097/AOG.0000000000003834 [9] Kramer, C., Thomas, K., Patil, A., Hayes, C. M., & Sufrin, C. B. (2022). Shackling and pregnancy care policies in US prisons and jails. Maternal and Child Health Journal, 27(1), 186–196. https://doi.org/10.1007/s10995-022-03526-y [10] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [11] Goshin, L. S., Sissoko, D. R., Neumann, G., Sufrin, C., & Byrnes, L. (2019). Perinatal nurses’ experiences with and knowledge of the care of incarcerated women during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic & Neonatal Nursing, 48(1), 27–36. https://doi.org/10.1016/j.jogn.2018.11.002 [12] Shackling and separation: Motherhood in prison. (2013). AMA Journal of Ethics, 15(9), 779–785. https://doi.org/10.1001/virtualmentor.2013.15.9.pfor2-1309 [13] King, L. (2018). Labor in chains: The shackling of pregnant inmates. Policy Perspectives, 25, 55–68. https://doi.org/10.4079/pp.v25i0.18348 [14] King, L. (2018). [15] AMA Journal of Ethics (2013) [16] Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews, (8). [17] Association of Women’s Health, Obstetric and Neonatal Nurses. (2011). AWHONN position statement: Shackling incarcerated pregnant women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(6), 817–818. doi:10.1111/j.1552-6909.2011.01300.x [18] Ferszt, G. G., Palmer, M., & McGrane, C. (2018). Where does your state stand on shackling of Pregnant Incarcerated Women? Nursing for Women’s Health, 22(1), 17–23. https://doi.org/10.1016/j.nwh.2017.12.005 [19] Thompson, E. (2022, August 30). Woman sues NC state prison system for mistreatment while pregnant. North Carolina Health News. Retrieved March 12, 2023, from https://www.northcarolinahealthnews.org/2022/05/25/woman-sues-nc-state-prison-system-for-mistreatment-while-pregnant/ [20] CBS Interactive. (2019, March 13). Shackling pregnant inmates is still a practice in many states. CBS News. Retrieved March 12, 2023, from https://www.cbsnews.com/news/shackling-pregnant-inmates-is-still-a-practice-in-many-states/ [21] Griggs, Claire Louise. "Birthing Barbarism: The Unconstitutionality of Shackling Pregnant Prisoners." American University Journal of Gender Social Policy and Law 20, no. 1 (2011): 247-271. [22] American Civil Liberties Union. (2012, October 12). ACLU briefing paper: The shackling of pregnant women & girls in U.S ... American Civil Liberties Union (ACLU). https://www.aclu.org/wp-content/uploads/legal-documents/anti-shackling_briefing_paper_stand_alone.pdf [23] King.L (2018) [24] Griggs, Claire Louise (2011) [25] American Civil Liberties Union. (2012) [26] Clarke, J. G., & Simon, R. E. (2013). Shackling and separation: Motherhood in prison. AMA Journal of Ethics, 15(9), 779–785. https://doi.org/10.1001/virtualmentor.2013.15.9.pfor2-1309 [27] Berg, M. D. (2014, April 18). Pregnant prisoners are losing their shackles - The Boston Globe. BostonGlobe.com. Retrieved March 12, 2023, from https://www.bostonglobe.com/magazine/2014/04/18/taking-shackles-off-pregnant-prisoners/7t7r8yNBcegB8eEy1GqJwN/story.html [28] Levi, R., Kinakemakorn, N., Zohrabi, A., Afanasieff, E., & Edwards-Masuda, N. (2010). Creating the bad mother: How the U.S. approach to pregnancy in prisons violates the right to be a mother. UCLA Women's Law Journal, 18(1). https://doi.org/10.5070/l3181017816 [29] Chris DiNardo (2018) [30] Griggs, Claire Louise (2011). [31] Allen, J. E. (2010, October 21). Shackled: Women Behind Bars Deliver in Chains. ABC News. https://abcnews.go.com/Health/WomensHealth/pregnant-shackled-women-bars-deliver-chains/story?id=11933376&page=1 [32] Nelson v. Correctional, 533 F.3d 958 (8th Cir. 2009) [33] Nelson v. Correctional(2009) [34] House, K. T., Kelley, S., Sontag, D. N., & King, L. P. (2021). Ending restraint of incarcerated individuals giving birth. AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.364 [35] Amnesty International USA. (1999, March). “Not part of my sentence” Violations of the Human Rights of Women in Custody. Amnesty International USA. Retrieved March 12, 2023, from https://www.amnestyusa.org/reports/usa-not-part-of-my-sentence-violations-of-the-human-rights-of-women-in-custody/ [36] Pendleton, V., Saunders, J. B., & Shlafer, R. (2020). Corrections officers' knowledge and perspectives of maternal and child health policies and programs for pregnant women in prison. Health & justice, 8(1), 1. https://doi.org/10.1186/s40352-019-0102-0 [37] Elizabeth Alexander, Unshackling Shawanna: The Battle Over Chaining Women Prisoners during Labor and Delivery, 32 U. ARK. LITTLE ROCK L. REV. 435 (2010). Available at: https://lawrepository.ualr.edu/lawreview/vol32/iss4/1 [38] Hernandez, J. (2022, April 22). More states are restricting the shackling of pregnant inmates, but it still occurs. NPR. Retrieved March 12, 2023, from https://www.npr.org/2022/04/22/1093836514/shackle-pregnant-inmates-tennessee [39] Sufrin, C. (2012, June 24). End practice of shackling pregnant inmates. SFGATE. Retrieved March 12, 2023, from https://www.sfgate.com/opinion/openforum/article/End-practice-of-shackling-pregnant-inmates-3176987.php [40] Mullings, L. (1997). On our own terms: Race, class, and gender in the lives of African American women. Routledge [41] Ocen, Priscilla A., (2011). [42] Ladd-Taylor, M. (1998). "Bad" mothers: The politics of blame in Twentieth-century America. New York Univ. Press. [43] Hine, D. C. (1998). Hine Sight: Black women and the re-construction of American history. Indiana University Press. [44] Baldwin, L. (2019). Excluded from good motherhood and the impact of prison: Motherhood and Social Exclusion, 129–144. https://doi.org/10.2307/j.ctvk12qxr.13 [45] Ocen, Priscilla A., Punishing Pregnancy: Race, Incarceration, and the Shackling of Pregnant Prisoners (October 3, 2011). California Law Review, Vol. 100, 2012, Available at SSRN: https://ssrn.com/abstract=1937872 [46] Johnson, P. C. (2004). Inner lives: Voices of african american women in prison. New York University Press. [47] Thomas, D. Q. (1996). All too familiar: Sexual abuse of women in U.S. state prisons. Human Rights Watch. [48] Ocen, Priscilla A., (2011). [49] Ashley W. The angry black woman: the impact of pejorative stereotypes on psychotherapy with black women. Soc Work Public Health. 2014;29(1):27-34. doi: 10.1080/19371918.2011.619449. PMID: 24188294. [50] CBS Interactive. (2019, March 13). Shackling pregnant inmates is still a practice in many states. CBS News. Retrieved March 12, 2023, from https://www.cbsnews.com/news/shackling-pregnant-inmates-is-still-a-practice-in-many-states/ [51] Guardian News and Media. (2020, January 24). Pregnant and shackled: Why inmates are still giving birth cuffed and bound. The Guardian. Retrieved March 25, 2023, from https://www.theguardian.com/us-news/2020/jan/24/shackled-pregnant-women-prisoners-birth [52] Oparah, J. C. (2015). Birthing justice: Black women, pregnancy, and childbirth. Routledge. [53] Chris DiNardo (2018) [54] Griggs, Claire Louise (2011). [55] Chris DiNardo (2018) [56] Griggs, Claire Louise (2011). [57] Song, Ji Seon, Policing the Emergency Room (June 10, 2021). 134 Harvard Law Review 2646 (2021), Available at SSRN: https://ssrn.com/abstract=3864225 [58] Ocen, Priscilla A., (2011). [59] Staten v. Lackawanna Cnty., No. 4:07-CV-1329, 2008 WL 249988, at *2 (M.D. Pa. Jan. 29, 2008) [60] Lovett, K. (2018, April 9). Pregnant inmates at New York prisons will no longer be shackled under new law. New York Daily News. Retrieved March 12, 2023, from https://www.nydailynews.com/new-york/new-york-pregnant-inmates-no-longer-shackled-article-1.2474021 [61] Thompson, E. (2022, August 30). Woman sues NC state prison system for mistreatment while pregnant. North Carolina Health News. Retrieved March 12, 2023, from https://www.northcarolinahealthnews.org/2022/05/25/woman-sues-nc-state-prison-system-for-mistreatment-while-pregnant/ [62] Brown v. Plata, 563 U.S. 493 (2011) [63] Nelson v. Correctional Medical Serices, et al., Nelson v. Correctional Med. Servs, 583 F.3d 522 (8th Cir. 2009) [64] Nelson citing Women Prisoners of D.C. Dep't of Corr. v. District of Columbia, 877 F.Supp. 634, 668-69 (D.D.C. 1994), modified in part on other grounds, 899 F.Supp. 659 (D.D.C. 1995). [65] Ark. Dep't of Corr. Admin. Reg. 403 § V (1992) [66] Civil Rights Cases, 109 U.S. 3 (1883) [67] Physician charter. ABIM Foundation. (2022, October 18). Retrieved March 10, 2023, from https://abimfoundation.org/what-we-do/physician-charter#:~:text=Principle%20of%20social%20justice.&text=Physicians%20should%20work%20actively%20to,or%20any%20other%20social%20category. [68] Riddick FA Jr. The code of medical ethics of the american medical association. Ochsner J. 2003 Spring;5(2):6-10. PMID: 22826677; PMCID: PMC3399321. [69] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). Reproductive Health Care for Incarcerated Pregnant, Postpartum, and Nonpregnant Individuals: ACOG Committee Opinion, Number 830. Obstetrics and gynecology, 138(1), e24–e34. https://doi.org/10.1097/AOG.0000000000004429 [70] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). [71] American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). [72] Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics. Oxford University Press. [73] Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119 [74] Medical professionalism in the new millennium: A physician charter. (2002). Annals of Internal Medicine, 136(3), 243. https://doi.org/10.7326/0003-4819-136-3-200202050-00012 [75] Allen, J. E. (2010, October 21). Shackled: Women Behind Bars Deliver in Chains. ABC News. https://abcnews.go.com/Health/WomensHealth/pregnant-shackled-women-bars-deliver-chains/story?id=11933376&page=1 [76] Jonsen, A. R. (2010). The Birth of Bioethics. Oxford University Press. [77] Beauchamp, T. L., & Childress, J. F. (2019). [78] Amnesty International USA. (1999, March). “Not part of my sentence” Violations of the Human Rights of Women in Custody. Amnesty International USA. Retrieved March 12, 2023, from https://www.amnestyusa.org/reports/usa-not-part-of-my-sentence-violations-of-the-human-rights-of-women-in-custody/