This dissertation aims to contribute to the literature of cooperation and social preferences. We use experimental and computational methods to understand the role and extent of reciprocity on cooperation. The first paper is a methodological contribution to the large literature on conditional preferences of cooperation. Cooperation generated by this type of preferences is notoriously unstable, as individuals reduce their contributions to the public good in reaction to other subjects' free-riding. This has led to the widely-shared conclusion that cooperation observed in experiments (and its collapse) is mostly driven by imperfect reciprocity. In this study, we explore the possibility that reciprocally cooperative preferences may themselves be unstable. We do so by observing the evolution of subjects' preferences in an anonymously repeated social dilemma. Our unsettling result is that, in the course of the experiment, a significant fraction of reciprocally cooperative subjects become egoistic, while the reverse is rarely observed. The non-selfish preferences that appear to be more stable are those most easily attributed to confusion. We are thus driven to the conclusion that egoism is more resistant to exposure to social dilemmas than reciprocity. The second paper the evolutionary success of conditional preferences by using simulations. We use an agent-based model in which agents play a variation of the iterated Prisoner's Dilemma game. We estimate the likelihood of cooperation levels as well as the likelihood of the existence of conditional types for different continuation probabilities. We show that an all-or-none type of conditional cooperation strategy together with the perfect conditional cooperation strategy are most likely to emerge when the continuation probability is sufficiently high. Our most surprising finding is related to the so-called hump-shaped strategy, a conditional type that is commonly observed in experiments. Our simulations show that those types are likely to thrive for intermediate levels of the continuation probability due to their relative advantage when probability of interaction is not enough to sustain a full-cooperation, but instead merely sustains mid-level cooperation. The third paper aims to understand the underlying reciprocal motives in altruistic behavior. We argue that the altruism that is revealed in dictator games can be explained by what we call presumptive reciprocity. Subjects may display non-selfish preferences because they presume that the other subjects would have revealed similar, non-selfish preferences if the roles had been reversed. This kind of intuitive reasoning, although partially captured by indirect reciprocity, is overlooked in the literature on social preferences, especially when it comes to explaining the behavior that appears to be purely altruistic. The experimental evidence we provide shows that people's choices reveal mostly presumptive reciprocity, while purely altruistic preferences play a much smaller role.

Syfte Syftet med denna studie är att analysera skillnader i betydelse mellan komponenterna: etisk bedömning, etisk avsikt och etisk plikt i förhållande till uppfattad betydelse av ett etiskt problem i den etiska beslutsprocessen.  Metod En analys av tidigare forskning genomfördes för att skapa en teoretisk referensram samt få en god översikt över forskningsområdet. En kvantitativ metod användes därefter för att samla in empiriskt material. Detta gjordes med hjälp av en enkät som bestod av scenarion som respondenterna fick ta ställning till. Den empiriska informationen analyserades i SPSS, där utfördes deskriptiv statistik, korrelationsanalys, faktoranalys samt regressionsanalys. Resultaten presenterades, diskuterades och utmynnade i en slutsats samt förslag till fortsatt forskning.  Slutsats De slutsatser som kan dras utifrån studien är att den etiska bedömningen har störst påverkan på den uppfattade betydelsen. Det kan även konstateras att den etiska avsikten samt den etiska plikten inte har någon signifikant påverkan på den upplevda betydelsen när ett etiskt dilemma ses som mindre allvarligt.  Uppsatsens bidrag Studien bidrar till en ökad förståelse för fastighetsmäklares attityder gentemot etiska dilemman, samt att den etiska beslutsprocessen är mer komplex än vad som tidigare presenterats. Vi belyser även hur säljchefer kan påverka sina anställda till ett mer etiskt agerande genom att uppföra etiska koder samt arbeta för ett gott etiskt klimat. / Purpose The purpose of this study is to analyse the differences in importance between the components: ethical judgement, moral intent and moral obligation relative to the perceived importance of an ethical issue in the ethical decision making process.  Method An analysis of previous studies was made in order to create a theoretical framework and to obtain an overview of the field of research. A quantitative method was used to collect the empirical data. This was made by using a survey where the respondents had to take a stand to ethical dilemmas presented with vignettes. The empirical data was analysed in SPSS, where descriptive statistics, correlation analysis, factor analysis and regression analysis were created. The results were presented, discussed and lead to a conclusion and suggestions for future research.  Conclusion The conclusions that can be drawn from the study are that ethical judgement has the biggest impact on the perceived importance of an ethical issue. It is also possible to establish that the moral intent and moral obligation does not have a significant influence on the perceived importance when an ethical dilemma is perceived as less important.  Contribution The study contributes to a deeper understanding of real estate agents’ attitudes towards ethical dilemmas. It also shows that the ethical decision making process is more complex than earlier presented. We also highlight how sales managers can influence their employees to a more ethical approach by setting ethical codes and work for a good ethical climate.

O dilema do prisioneiro (DP) é um dos principais jogos da teoria dos jogos. No dilema do prisioneiro discreto (DPD), dois prisioneiros têm as opções de cooperar ou desertar. Um jogador cooperador não delata seu comparsa, já um desertor delata. Se um cooperar e o outro desertar, o cooperador fica preso por cinco anos e o desertor fica livre. Se ambos cooperarem, ficam presos por um ano e, se ambos desertarem, ficam presos por três anos. Quando o DP é repetido, a cooperação pode emergir entre agentes egoístas. Realizamos um estudo analítico para o DPD, que produziu uma formulação da evolução do nível médio de cooperação e da tentação crítica (valor de tentação que causa mudança abrupta do nível de cooperação). No dilema do prisioneiro contínuo (DPC), cada jogador apresenta um nível de cooperação que define o grau de cooperação. Utilizamos o DPC para estudar o efeito da personalidade dos jogadores sobre a emergência da cooperação. Para isso, propusemos novas estratégias: uma baseada na personalidade dos jogadores e outras duas baseadas na comparação entre o ganho obtido e a aspiração do jogador. Todas as estratégias apresentavam algum mecanismo de cópia do estado do vizinho com maior ganho na vizinhança, mecanismo este, herdado da estratégia darwiniana. Os resultados mostraram que o DPC aumenta o nível médio de cooperação do sistema, quando comparado ao DPD. No entanto, as diferentes estratégias não aumentaram a cooperação comparado à cooperação obtida com a estratégia darwiniana. Então propusemos o uso do coeficiente de agrupamentos, coeficiente de Gini e entropias de Shannon, Tsallis e Kullback-Leibler para classificar os sistemas, em que os agentes jogam o DPD com a estratégia darwiniana, quanto ao nível de cooperação. Como analisamos valores de médias configuracionais, tais classificadores não foram eficientes ao classificar os sistemas. Isso é consequência da existência de distribuições de extremos nos resultados que compõem as médias. As distribuições de extremos suscitaram uma discussão acerca da definição do regime de cooperação no dilema do prisioneiro. Discutimos também as consequências de utilizar apenas valores médios nos resultados ignorando seus desvios e as distribuições. / Prisoner\'s dilemma (PD) is one of the main games of game theory. In discrete prisoner\'s dilemma (DPD), two prisoners have the options to cooperate or to defect. A cooperator player does not defect his accomplice, while a defector does. If one player cooperates and the other defects, the cooperator gets jailed for five years and the defector goes free. If both cooperate, they get jailed during one year and if both defect, they get jailed during three years. When this game is repeated, cooperation may emerge among selfish individuals. We perform an analytical study for the DPD, that produced a formulation for the evolution of the mean cooperation level and for the critical temptation values (temptation values that promote abrupt modifications in the cooperation level). In continuous prisoner\'s dilemma (CPD), each player has a level of cooperation that defines his/her degree of cooperation. We used the CPD to study the effect of the players\' personality on the emergence of cooperation. For this, we propose new strategies: one based on the players\' personality and two others based on the comparison between the player\'s obtained payoff and the desire one. All strategies present some mechanism that copies the state of the neighbor with the highest payoff in the neighborhood, mechanism inherited from the Darwinian strategy. The results showed that the CPD increases the average cooperation level of the system when compared to DPD. However, different strategies do not increased the cooperation compared to cooperation obtained with the Darwinian strategy. So, we propose the use of cluster coefficient, Gini coefficient and entropy of Shannon, Tsallis and Kullback-Leibler as classifiers to classify systems, in which the individuals play DPD with Darwinian strategy, by the cooperation level. As configurational averages were analyzed, such classifiers were not efficient in classifying the systems. This is due to the existence of distributions with extreme values of the results that compose the means. Distributions with extremes values emerged a discussion about the definition of the cooperation state in the prisoner\'s dilemma. We also discussed the consequences of using only average results in the analysis ignoring their deviations and distributions.

「成功、成熟且領導中的既有企業為何失敗？」從Christensen 1997年發表書中定義創新者的兩難(The Innovator’s Dilemma) :「管理階層為企業成功所做出的理性而智慧的決策，正是促使企業失去領導地位的主因」，說明既有企業高階經理人將資源分配給主流高階市場，忽略新進企業從非主流市場進入的破壞性創新(disruptive innovation)的取代性，導致既有企業的產品逐漸被取代而失去領導地位。後續補充破壞式創新的文獻，認為除了資源依賴與分配外，動態能耐、組織文化是重要的補充研究構面，但仍缺乏相關企業產權議題構面的探討。 本研究以Milgrom(1992)及李仁芳(1993, 1999a,b)的企業產權理論，補充創新者兩難理論中對企業產權解釋的不足，在企業的管理權與所有權的過度分離下，會讓經理人自利的理性決策偏向企業短期收益，而損害長期股東權益，這樣讓破壞式創新對企業產生無法妥協的組織兩難衝突，才是導致企業無法存活在破壞式創新的浪潮中的原因之一。 為驗證本研究的理論推理，藉由軟片產業及電腦顯示器產業作跨產業多個案的實證研究。比較柯達軟片、富士軟片在軟片產業中受到數位顯影技術的取代衝擊，以及我國CRT電腦顯示器廠商誠洲、中強、碧悠、源興、美格、華映、瑞軒及皇旗受到LCD技術的取代衝擊，在相同破壞式創新下區分成功轉型及失敗消失的兩組對照，比較策略因應與對應產權結構的差異。 研究發現企業所有權與管理權集中者容易為破壞式創新的適應者；相對的所有權與管理權分離者，容易成為破壞式創新的淘汰者。企業的產權結構差異影響了決策過程，造成不同策略選擇，是影響企業面對破壞式創新轉型成功的關鍵因素之一。在實務上，意涵企業平時的產權結構就應未來的技術發展做因應規劃，而在面對破壞式創新威脅時刻，更應積極透過股權結構再造的方式讓所有權與管裡權有某種程度的重疊，這是因應破壞式創新浪潮轉型的重要力量來源。 / Why successful, mature and leading incumbent companies fail? From the definition of “The Innovator’s Dilemma” in Christensen’s book (1997), what management makes rational and intelligent decision is the cause firms lose their leading position, which may explain that management level of established firms allocate resource on high margin market by following main customers and ignore low margin from “disruptive innovation” market by new entrant firms. In addition to resource dependence and allocation, the extant literature pertaining to disruptive innovation has been categorized into organizational structure, organizational culture and dynamic capability. However, the impact of enterprise ownership structure on disruptive innovation rarely has been studied. This study tried to complement innovation dilemma theory with ownership theory. The over separation of ownership and management of corporation would contribute to self-interest management decision tending to short-term revenue rather than long term development of firms, which cause unbalanced organizational dilemma under disruptive innovation condition. It would be one of main reason that leading firms fail to transform in the wave of disruptive innovation. In order to test the organizational dilemma theory, this study comprised multiple cases research method of 2 multinational film companies and 8 computer monitor manufacturers in Taiwan. Comparing two film makers, Kodak with Fujifilm, under digital camera technology replacement and 8 Taiwan CRT computer monitor manufacturers under LCD technology replacement their coping strategy and corresponding ownership structure. One of major findings of this study is that integration of ownership and management would easily adapt to disruptive innovation wave. On the contrary, the separation of ownership and management would be eliminated from disruptive innovation wave. The ownership structure of enterprise influences decision making process and choice of coping strategy, which play major role in transforming firms successfully into disruptive innovation. In practice, the implication of this research is that ownership structure of firms is corresponding to future technology development. While facing the disruptive innovation emerging, the necessary of integration between ownership and management is critical by financial restructure, which would be main power to transform firms into new disruptive innovation.

Over time, the state has undertaken various reforms to govern the development of education. The issue of using new media may be seen as such an example. A change in the use of media in education imposes great challenges on both municipalities and teachers. This thesis aims to visualise and discuss governance in the contradictions that arise in practical activities aimed at integrating new media in school teaching, based on three actors’ perspectives, namely the dilemmas of the teacher, the media pedagogue and the media developer. The study is based on systemic thinking about governance and I employ both activity theory and the concept of governmentality to visualise and discuss the governance. The study is conducted in the form of a case study. The case consists of a municipality where, based on the curriculum’s mission, teachers have tried to find ways to integrate new media into their teaching. My own connection to the case consists of having been a driving and governing force in the work as a teacher, media pedagogue and media developer. The case was chosen because the municipality’s work on the national level and via the media has been held up as a good example. The empirical part consists of both my own life narrative and studies of different documents, texts, images, films and sound recordings that show how govern­mentalities are formed and take shape on the micro, macro and meso levels. I use a methodological prism, a combination of different analytical perspectives, discourse, activity, narratives and governmentality. The results reveal that the driving actors are innovatively handling the systemic contradictions that arise in the work of carrying out the curriculum’s mission. The governance of the activities is based on a trust rationality. The more the use of new media is spread in the municipality’s schools, the more contradictory it becomes for the middle level’s actors. The trust rationality has been superseded by a distrust rationality, creating a growing gap between the administration and the activities.

Background When cure is no longer possible, medical care should aim for a transition to palliative care regardless of disease. Patients with incurable cancer are often treated with palliative chemotherapy (PCT), starting with the intent to prolong life and increase quality of life. Eventually, in the late stages of the disease, the patient reaches a transition phase when further PCT neither prolongs life nor adds any predominantly positive effects. Aim of the thesis Study I: To analyse the proportion of patients with incurable cancer who received palliative chemotherapy during the last month of life, and to identify their discriminative characteristics. Study II: To develop a questionnaire assessing performance status in palliative chemotherapy, and to test its psychometric properties. Study III: To explore challenging situations experienced by registered nurses when administering palliative chemotherapy to patients with incurable cancer. Study IV:  To investigate whether routine use of the Performance Status in Palliative Chemotherapy (PSPC) questionnaire in PCT would affect the proportion of patients receiving PCT during the last month of life, hospital admissions, notifications of performance status, documented decisions of ceasing PCT in the medical records, and/or place of death. A secondary aim was to gather registered nurses’ experiences of PSPC in clinical use. Methods In Studies I and IV, information from the medical records of deceased patients with epithelial cancers was used in descriptive analyses of the proportions of patients receiving PCT in counties in northernmost Sweden. A quantitative design was chosen, using non-parametric statistical methods. In Study II, a brief patient-completed questionnaire assessing performance status was developed and psychometrically tested. In Study III, data from research interviews with registered nurses were analysed qualitatively with a narrative thematic approach. Results Studies I and IV showed that about 25% of patients receiving PCT were treated during the last month of life. This group of patients had more hospital admissions, were less likely to die at home, and had fewer instances of documentation of the decision to cease PCT. The questionnaire developed in Study II was shown to have acceptable psychometric qualities such as reliability, validity, and sensitivity to detect deterioration in performance status. Study IV showed that the questionnaire gave nurses valuable information about patients’ performance status. The results also showed that 97% of nurses and 48% of physicians documented their patients’ performance status in the medical records. Study III demonstrated that when nurses administered PCT they considered futile, they could experience dilemmas created by the unforeseeable outcomes of PCT or stemming from insufficient communication between nurses, patients, next-of-kin, and physicians. Conclusions Administration of PCT can create dilemmatic situations for both the patient and medical staff when approaching end-of-life. This is underlined by the finding that some 25% of treated patients received their last round of PCT as late as during the last month of life. The decisions to cease PCT were less likely to be documented for patients who had received PCT within a month before death. Nurses described situations where they felt they were in the middle of the decision-making process regarding whether or not to continue PCT. They found the treatments were given on the authority of someone else; the physician’s recommendation or the patient’s and/or relatives’ request. The unpredictability of PCT was a continuous theme in the work described in this thesis, emphasizing the necessity of individually assessing every patient before PCT in order to minimize the risk of futile treatments. The attempt to develop a reliable and valid questionnaire for systematic assessment of performance status has increased future possibilities to monitor this parameter in PCT when approaching end-of-life. The questionnaire developed as part of this thesis has provided nurses with increased knowledge of patients’ performance status. If routinely used, it may help decrease the proportion of patients receiving PCT during the last month of life, though this remains to be rigorously proven. Further research efforts are needed to progress in the task of optimizing rather than maximizing the use of PCT when approaching end-of-life. / Bakgrund Cytostatikabehandling som ges vid obotlig cancersjukdom kan minska tumörbörda och besvärande symtom som t. ex smärta. Behandlingen ökar livskvalitet och överlevnadstid i många fall och bör därför erbjudas alla patienter som kan ha nytta av den. Dock är cytostatika potenta läkemedel som kan ge besvärliga biverkningar. Diskussionen i många studier pekar på att den förväntade överlevnaden bör överstiga en månad för att behandlingen ska kunna ha avsedd effekt. Då cytostatikabehandling vid obotlig cancersjukdom inte kan bota patienten är det alltid en tidsfråga innan nyttan med behandlingen avtar för att till sist helt upphöra. Fortsatt behandling med cytostatika innebär då risk för enbart negativa effekter i form av ökad trötthet, nedsatt immunförsvar och till och med livsförkortning. Möjligheterna att klara av fortsatt cytostatikabehandling bedöms inför varje behandling med blodprover och klinisk bedömning. På sjukhus utan tjänstgörande onkologspecialist träffar patienten sjuksköterskan som ger behandlingen. Ansvarig läkare kontaktas när provsvar eller något i patientens tillstånd avviker från det vanliga. När sjukdomen framskrider och patientens allmänstillstånd börjar svikta, bör syftet med behandlingen utvärderas och överväganden göras huruvida den ska fortsätta, regimen förändras eller avslutas. Min erfarenhet, ur ett sjuksköterskeperspektiv, av palliativ vård och cytostatikabehandlingar givna till patienter med obotlig cancersjukdom, fick mig att vilja undersöka hur många patienter som behandlas i livets slutskede. Jag ville också ta reda på hur bedömningen av patienten inför behandlingen gick till och om den kunde förbättras, samt hur sjuksköterskan upplevde att ge cytostatikabehandlingar i sent sjukdomsskede. Syften Att utforska andelen patienter med obotlig cancer som behandlas med palliativ cytostatika under sista levnadsmånaden samt att finna utmärkande karakteristika för denna grupp patienter. Att utveckla och psykometriskt testa en kortfattad enkät utformad för bedömning av patientens allmäntillstånd vid palliativ cytostatikabehandling. Att identifiera situationer som sjuksköterskor kan uppleva som utmanande vid cytostatikabehandling av palliativa patienter med cancer. Att undersöka om rutinmässig användning av enkäten utvecklad i studie II påverkat andelen patienter som behandlas med palliativ cytostatika under sista levnadsmånaden, andel sjukhusinläggningar, dokumentation av allmäntillstånd, dokumentation av avslutande av behandling i journal och/eller dödsplats. Metod Alla inkluderade patienter i studierna hade cytostatikabehandlats med anledning av obotlig, epitelial cancer (utgående från organens slemhinneceller) och var 20 år eller äldre.  Deltagande sjuksköterskor arbetade på cytostatikabehandlingsmottagningar/avdelningar. Både pati-enter och sjuksköterskor kom från Jämtland, Västerbotten och/eller Norrbotten. I studie I jämfördes journaldata från avlidna patienter som cytostatikabehandlats under sista levnadsmånaden med dem som avslutat behandlingarna tidigare. I studie II erbjöds patienter att delta i utvecklingen av en enkät som tagits fram för att mäta allmäntillståndet före cytostatikabehandling. I studie III intervjuades sjuksköterskor som arbetar med att ge cytostatika och deras berättelser analyserades med narrativ metod. I studie IV jämfördes journaldata för avlidna patienter som använt enkäten från studie II med matchade kontroller och i tillämpliga frågor data från studie I. Resultat Studie I visade att 23 % av alla patienter som cytostatikabehandlats någon gång under sista året före sin död även fick cytostatikabehandling under sista levnadsmånaden. Studien visade också en samvariation mellan behandling sista levnadsmånaden och fler sjukhusvistelser inom en månad efter sista behandling, färre dokumenterade beslut att avsluta behandlingen samt att färre patienter från denna grupp avled i hemmet. I Studie II konstaterades att den utformade enkäten uppvisade tecken på såväl reliabilitet, validitet som förmåga att detektera när patientens allmäntillstånd försämrades. Studie III visade att palliativa cytostatika kan upplevas som potenta och oförutsägbara läkemedel, som kan skapa dilemman för de sjuksköterskor som genomför behandlingarna när de ges till patienter som är försvagade av sin cancersjukdom. Sjuksköterskorna upplevde att de ibland stod mitt emellan läkare, patienter och närstående inför behandlingsbeslut. Studie IV visade ingen statistiskt säkerställd effekt av rutinmässig monitorering av allmäntillståndet med det i studie II framtagna formuläret. Varken behandling under sista månaden i livet, sjukhusvistelser, dokumenterade beslut att avsluta behandling eller dödsplats påverkades. Däremot rapporterade sjuksköterskorna att formuläret gav dem värdefull information om patientens allmäntillstånd inför behandling. Klinisk nytta för framtiden Fynden i studien kan vara till nytta för alla inblandade i cytostatikabehandlingen; patienten, närstående, sjuksköterskan och läkaren. Särskilt i beslutsprocessen om cytostatikabehandlingen ska fortsättas eller avbrytas. Metoder för att bättre bedöma prognostiska faktorer inför cytostatikabehandling behöver utvecklas ytterligare. I en framtida studie skulle formuläret kunna vidareutvecklas för datoriserad användning så resultaten förs in i patientjournalen, där både sjuksköterska och läkare enklare skulle ha tillgång till dem innan behandlingsbeslut. Slutsatser Behandling med palliativ cytostatika nära livets slutskede kan skapa situationer som upplevs som dilemman, både för patienten och för vårdpersonalen. I studierna behandlades 23-25 % av patienterna med cytostatika under sista levnadsmånaden. Dessa patienter vårdades oftare på sjukhus och färre av dem dog i hemmet. Sjuksköterskorna beskrev att de i vissa fall upplevde sig vara "mitt i mellan" i beslutsprocessen om cytostatikabehandling skulle ges eller inte. Cytostatikabehandlingens oförutsägbarhet visade sig vara ett genomgående tema i avhandlingen. Oförutsägbarheten leder till att individanpassning för varje enskild patient är av största vikt. Försöket till formulärutveckling skulle kunna öka möjligheten att mer objektivt använda allmäntillstånd som en parameter inför behandlingsbeslut när patienten nalkas livets slut. Formuläret visade sig ge sjuksköterskorna värdefull information om patienternas upplevda allmäntillstånd även om denna studie inte visade statistiskt säkerställda skillnader mellan de som använde formuläret och kontrollgruppens patienter. För att ytterligare optimera beslutsfattandet vid palliativ cytostatikabehandling när livets slutskede nalkas krävs fortsatt forskning. / Tausta Parantumattoman syöpäsairauden yhteydessä annettu sytostaattihoito voi vähentää kasvainkuormaa ja haittaavia oireita kuten esim. kipua. Monissa tapauksissa hoito parantaa potilaiden elämänlaatua ja antaa lisää elinaikaa. Siksi hoitoa on tarjottava kaikille potilaille, jotka voivat hyötyä siitä. Sytostaatit ovat kuitenkin potentteja lääkkeitä, joilla voi olla voimakkaat vaikutukset ja haittavaikutukset. Tutkimukset viittaavat siihen, että jäljellä olevan odotetun eliniän tulee olla yli kuukausi, jotta hoidolla olisi toivottu teho.  Koska parantumattoman syöpäsairauden yhteydessä annettu sytostaattihoito ei voi parantaa potilasta, on aina ajan kysymys, milloin hoidon teho alkaa vähetä loppuakseen viimein kokonaan. Silloin jatkettu sytostaattihoito merkitsee potilaalle vain negatiivisten vaikutusten riskiä lisääntyneen väsymyksen, heikentyneen vastustuskyvyn ja jopa eliniän lyhentymän muodossa. Potilaan mahdollisuus selvitä jatketusta sytostaattihoidosta arvioidaan ennen hoidon aloittamista verikokeiden ja kliinisen arvion perusteella. Jos sairaalassa ei ole päivystävää onkologian erikois-lääkäriä, potilas tapaa sairaanhoitajan. Vastaavaan lääkäriin otetaan yhteyttä silloin, kun koevastauksissa tai potilaan tilassa on jotain tavallisuudesta poikkeavaa. Kun sairaus etenee ja yleistila alkaa heiketä, potilaan elämänlaatu usein heikkenee ja elinaika lyhenee. Tällöin on syytä arvioida hoidon tarkoitusta ja pohtia, jatketaanko vai muutetaanko hoitoa, vai lopetetaanko se kokonaan. Kokemukseni sairaanhoitajana parantumattomien syöpäpotilaiden palliatiivisesta hoidosta ja sytostaattihoidosta herätti minussa halun tutkia, kuinka moni potilas saa hoitoa elämän loppuvaiheessa. Halusin myös tutkia, miten potilaat arvioidaan ennen hoitoa, onko arvioinnissa parantamisen varaa ja miten sairaanhoitajat kokevat elämän loppuvaiheessa annettavat sytostaatti-hoidot. Tavoitteet Tutkia, kuinka suuri osa parantumatonta syöpää sairastavista potilaista saa palliatiivista sytostaattihoitoa viimeisen elinkuukautensa aikana sekä löytää tämän potilasryhmän erottavat tekijät. Kehittää ja testata psykometrisesti lyhyt lomake, jolla mitataan potilaan yleistila palliatiivisen sytostaattihoidon yhteydessä. Tunnistaa tilanteita, jotka sairaanhoitajat voivat kokea ongelmallisina syöpäpotilaille annettavan palliatiivisen sytostaattihoidon yhteydessä. Tutkia, onko tutkimuksessa II laaditun lomakkeen rutiininomainen käyttö vaikuttanut viimeisen elinkuukautensa aikana sytostaattihoitoa saavien potilaiden osuuteen, sairaalahoitojaksojen osuuteen, yleistilan dokumentointiin, päättyneen lääkityksen dokumentointiin potilaskertomuksessa ja/tai kuolinpaikkaan.  Menetelmä Kaikki tutkimuksen potilaat olivat saaneet sytostaattihoitoa parantumattomaan, elinten limakalvosoluista lähtöisin olevaan epiteelisyöpään. Potilaat olivat 20 vuotta täyttäneitä ja asuivat Jämtlannin, Västerbottenin tai Norrbottenin alueella. Tutkimukseen osallistuneet sairaanhoitajat työsken-telivät saman alueen sytostaattivastaanotoilla tai -osastoilla. Tutkimuksessa I verrattiin tilastollisia menetelmiä käyttäen kuolleiden, viimeisen elin-kuukautensa aikana sytostaattihoitoa saaneiden potilaiden potilaskerto-mustietoja niihin potilaisiin, joiden hoito oli lopetettu ennen viimeistä elinkuukautta.  Tutkimuksessa II potilaille tarjottiin mahdollisuus osallistua sellaisen lomakkeen kehittämiseen, joka on laadittu mittaamaan potilaiden yleistilaa ennen sytostaattihoitoa. Tutkimuksessa III haastateltiin sairaan-hoitajia, ja heidän kertomuksensa analysoitiin narratiivisia menetelmiä käyttäen. Tutkimuksessa IV verrattiin kuolleiden, tutkimuksen II lomaketta käyttäneiden potilaiden potilaskertomustietoja sopivaan vertailuryhmään ja soveltuvissa osin tutkimuksen I tietoihin.  Tulokset Tutkimus I osoitti, että 23 % kaikista potilaista, jotka olivat saaneet sytostaattihoitoa viimeisen elinvuotensa aikana, saivat sitä myös viimeisenä elinkuukautenaan. Tutkimus osoitti myös, että viimeisen elinkuukauden aikana annetulla sytostaattihoidolla oli yhteisvaihtelua seuraavien tekijöiden kanssa: useat sairaalahoidot kuukauden sisällä viimeisestä sytostaatti-hoidosta, vähemmän hoidon lopettamispäätöksiä ja harvemmat ryhmään kuuluvista potilaista kuolivat kotona. Tutkimuksessa II todettiin, että laadittu lomake osoitti merkkejä sekä reliabiliteetista, validiteetista että kyvystä havaita erot sellaisten potilaiden välillä, joiden yleistila heikkeni tutkimuksen aikana.  Tutkimus III osoitti, että palliatiiviset sytostaatit voidaan kokea potentteina ja ennalta arvaamattomina lääkkeinä. Ne voivat kuitenkin olla ongelmallisia hoitaville sairaanhoitajille silloin, kun sytostaattihoitoa annetaan potilaille, jotka ovat syöpäsairautensa heikentämiä. Sairaanhoitajat kokivat, että he joskus hoitopäätöksiä tehtäessä joutuivat lääkäreiden, potilaiden ja läheisten "väliin" olematta kuitenkaan itse osallisia kommunikaatiosta. Tutkimus IV ei osoittanut, että tutkimuksessa II laaditun lomakkeen avulla suoritetulla rutiininomaisella yleistilan monitoroinnilla olisi mitään tilastollisesti osoitettavaa tehoa. Sillä ei ollut vaikutusta viimeisen elin-kuukauden aikana annettuun hoitoon, sairaalahoitojaksoihin, doku-mentoituihin hoidon lopettamispäätöksiin tai potilaan kuolinpaikkaan. Sairaanhoitajat ilmoittivat kuitenkin, että lomake antoi heille arvokasta tietoa potilaan yleiskunnosta ennen hoitoa. Kliininen hyöty tulevaisuudessa Tutkimuksen tuloksista voivat hyötyä kaikki sytostaattihoitoon osalliset, potilas, läheiset, sairaanhoitaja ja lääkäri; päätösprosessissa, joka koskee hoidon jatkamista tai lopettamista. On kehitettävä entistä parempia menetelmiä yleistilan arvioimiseksi ennen sytostaattihoidon aloittamista. Tulevassa tutkimuksessa voitaisiin tutkimuksen lomakkeesta kehittää sähköinen lomake, jolla tulokset kirjataan potilaskertomukseen, josta sekä sairaanhoitajat että lääkärit saavat tiedot ennen hoitopäätösten tekemistä. Johtopäätökset Elämän loppuvaiheessa annettu palliatiivinen sytostaattihoito voi aiheuttaa tilanteita, jotka voidaan kokea ongelmallisina sekä potilaan että hoitohenkilökunnan kannalta. Tutkimuksissa 23–25 % potilaista sai sytostaatti-hoitoa viimeisen elinkuukautensa aikana. Näitä potilaita hoidettiin useammin sairaalassa ja harvemmat heistä saivat kuolla kotonaan. Omien kuvaustensa mukaan sairaanhoitajat kokivat tietyissä tapauksissa joutuneensa "väliin" sytostaattihoidon jatkamista tai lopettamista koske-vassa päätösprosessissa. Sytostaattihoidon ennalta arvaamattomuus osoittautui tutkielman läpikäyväksi teemaksi.  Tämä ennalta arvaamattomuus merkitsee sitä, että on erittäin tärkeä räätälöidä hoito jokaiselle potilaalle yksilöllisesti.  Tutkielman puitteissa laadittu lomake voisi antaa lisämahdollisuuksia käyttää entistä objektiivisemmin yleistilaa parametrina, kun tehdään hoitopäätöksiä potilaan elämän loppuvaiheessa. Osoittautui, että lomake antaa sairaanhoitajille tärkeää tietoa potilaiden kokemasta yleistilasta vaikka tämä tutkimus ei osoittanutkaan tilastollisesti vahvistettavia eroja lomaketta käyttäneiden ja vertailuryhmän potilaiden välillä. Vaaditaan lisätutkimusta, jotta voitaisiin optimoida päätökset, jotka koskevat palliatiivista sytostaatti-hoitoa elämän loppuvaiheen lähestyessä.

O dilema do prisioneiro (DP) é um dos principais jogos da teoria dos jogos. No dilema do prisioneiro discreto (DPD), dois prisioneiros têm as opções de cooperar ou desertar. Um jogador cooperador não delata seu comparsa, já um desertor delata. Se um cooperar e o outro desertar, o cooperador fica preso por cinco anos e o desertor fica livre. Se ambos cooperarem, ficam presos por um ano e, se ambos desertarem, ficam presos por três anos. Quando o DP é repetido, a cooperação pode emergir entre agentes egoístas. Realizamos um estudo analítico para o DPD, que produziu uma formulação da evolução do nível médio de cooperação e da tentação crítica (valor de tentação que causa mudança abrupta do nível de cooperação). No dilema do prisioneiro contínuo (DPC), cada jogador apresenta um nível de cooperação que define o grau de cooperação. Utilizamos o DPC para estudar o efeito da personalidade dos jogadores sobre a emergência da cooperação. Para isso, propusemos novas estratégias: uma baseada na personalidade dos jogadores e outras duas baseadas na comparação entre o ganho obtido e a aspiração do jogador. Todas as estratégias apresentavam algum mecanismo de cópia do estado do vizinho com maior ganho na vizinhança, mecanismo este, herdado da estratégia darwiniana. Os resultados mostraram que o DPC aumenta o nível médio de cooperação do sistema, quando comparado ao DPD. No entanto, as diferentes estratégias não aumentaram a cooperação comparado à cooperação obtida com a estratégia darwiniana. Então propusemos o uso do coeficiente de agrupamentos, coeficiente de Gini e entropias de Shannon, Tsallis e Kullback-Leibler para classificar os sistemas, em que os agentes jogam o DPD com a estratégia darwiniana, quanto ao nível de cooperação. Como analisamos valores de médias configuracionais, tais classificadores não foram eficientes ao classificar os sistemas. Isso é consequência da existência de distribuições de extremos nos resultados que compõem as médias. As distribuições de extremos suscitaram uma discussão acerca da definição do regime de cooperação no dilema do prisioneiro. Discutimos também as consequências de utilizar apenas valores médios nos resultados ignorando seus desvios e as distribuições. / Prisoner\'s dilemma (PD) is one of the main games of game theory. In discrete prisoner\'s dilemma (DPD), two prisoners have the options to cooperate or to defect. A cooperator player does not defect his accomplice, while a defector does. If one player cooperates and the other defects, the cooperator gets jailed for five years and the defector goes free. If both cooperate, they get jailed during one year and if both defect, they get jailed during three years. When this game is repeated, cooperation may emerge among selfish individuals. We perform an analytical study for the DPD, that produced a formulation for the evolution of the mean cooperation level and for the critical temptation values (temptation values that promote abrupt modifications in the cooperation level). In continuous prisoner\'s dilemma (CPD), each player has a level of cooperation that defines his/her degree of cooperation. We used the CPD to study the effect of the players\' personality on the emergence of cooperation. For this, we propose new strategies: one based on the players\' personality and two others based on the comparison between the player\'s obtained payoff and the desire one. All strategies present some mechanism that copies the state of the neighbor with the highest payoff in the neighborhood, mechanism inherited from the Darwinian strategy. The results showed that the CPD increases the average cooperation level of the system when compared to DPD. However, different strategies do not increased the cooperation compared to cooperation obtained with the Darwinian strategy. So, we propose the use of cluster coefficient, Gini coefficient and entropy of Shannon, Tsallis and Kullback-Leibler as classifiers to classify systems, in which the individuals play DPD with Darwinian strategy, by the cooperation level. As configurational averages were analyzed, such classifiers were not efficient in classifying the systems. This is due to the existence of distributions with extreme values of the results that compose the means. Distributions with extremes values emerged a discussion about the definition of the cooperation state in the prisoner\'s dilemma. We also discussed the consequences of using only average results in the analysis ignoring their deviations and distributions.

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This paper provides an analysis of Bradshaw and Colleagues' model of military healthcare professionals' moral distress experiences. Using novel interview data collected from Canadian Forces healthcare professionals, the steps of the model are validated or potential refinements are suggested. / Military healthcare professionals (HCPs) may experience moral distress during international deployment. Moral distress is experienced when a HCP faces a moral dilemma, e.g., knows the morally correct course of action but is blocked from taking it, or where all available courses of action require something of moral significance be given up. While the literature indicates that moral distress often negatively impacts the mental health of the individual and the effectiveness of the organization, limited research has examined moral distress amongst military HCP. Many similar stressors and psychological health problems are present for both civilian and military HCP; however, the unique context of deployment necessitates further examination. This thesis explores the military HCP experience with moral distress by using Bradshaw and colleague’s model of progression from the encounter with a moral dilemma to the impact on individuals and organizations. Through the analysis of novel interviews collected by the Ethics in Military Medicine Research Group (EMMRG), Bradshaw and colleague’s model of military moral distress is compared to participant’s experiences and qualitatively analysed, with the results outlining where the model is supported and where refinement is recommended. These challenges were then supported by a literature review from the disciplines of virtue and feminist ethics, moral psychology, bioethics, and civilian HCP moral distress research. Two novel and significant revisions to the model are suggested: representing and integrating the cumulative experience of moral distress, and re-conceptualizing the resolution process based on the consideration of contextual controllability on moral responsibility. / Thesis / Master of Science (MS) / This thesis examines the experience of moral distress in military healthcare professionals (HCPs) while working abroad, where a HCP faces a moral dilemma, e.g., knows the morally correct course of action but is blocked from taking it or it requires something of moral significance be given up. This thesis analyses the most recent model of military HCP moral distress (Bradshaw, et al., 2010) by comparing it to the experiences described by participants in the Ethics in Military Medicine Research Group (EMMRG) study. The results outline support for the model as well as novel suggestions for revision, which are supported by literature from a variety of disciplines. Two adjustments to Bradshaw and colleague’s model are suggested: clearer representation of the cumulative nature of moral distress as well as a reconceptualization of the resolution process to consider the influence of the immediate and extended environment on moral responsibility.

Vi vill i denna studie lyfta barns perspektiv genom att undersöka barns uppfattningar av inkludering och exkludering i förhållande till kamratrelationer på förskolan samt dilemmat ”alla får vara med”. Studien bygger på gruppintervjuer med förskolebarn. För att undersöka och få svar på studiens frågeställningar genomfördes 15 gruppintervjuer med totalt 50 barn i 4 - 6 års ålder på tre olika förskolor i Halland. Studien tar sin teoretiska utgångspunkt i dilemmaperspektivet, vilket innebär att dilemman diskuteras utifrån flertalet synvinklar utan att fastställa en rätt eller fel sanning. Resultat och analys visar att barnen satte inkludering och exkludering i relation till att få vara med eller inte få vara med och hur det kan kännas. Barnen uttryckte sig verbalt om detta i relation till ett filmavsnitt från serien ”Djuren på Djuris”, men även i förhållande till kamratrelationer. Slutsatsen visar att barnen verbalt uttryckte att det fanns ett dilemma gällande att få vara med eller inte i lek med andra. Detta framgick då barnen nämnde att det var lika viktigt att inkludera kamrater i lek som att få sin röst hörd i att vilja att alla inte alltid måste vara med i alla lekar. / In this study we want to highlight children’s perspective by examining children’s perceptions of inclusion and exclusion connected to peer relationships in preschool and the dilemma of “everyone gets to join”. The study is based on interviews with preschool children. We interviewed a total of 15 groups with a total of 50 children in the ages 4 – 6 years old in 3 different preschools in Halland, to answer the questions posed in this study. The study takes its theoretical starting point from the dilemmaperspective which means that dilemmas are discussed based on the majority of points of views without establishing a right or wrong truth. The results and analysis show that the children mainly expressed themselves verbally about inclusion or exclusion in relation to being allowed to participate or not and how that can feel. The children verbally expressed this both in relation to the characters in the episode in the series “Djuren på djuris”, but also in connection to peer relationships. The conclusion shows a dilemma regarding being allowed to participate in play with others as the children mentioned that it was just as important to include peers in play as to having their voices heard in wanting that everyone does not always have to join.