The laws and ethical guidelines governing decision making for incompetent patients evolved from controversies in which family members refused life-sustaining interventions. These cases led to a consensus that advance directives to limit interventions should be respected and that a surrogate designated by the patient or specified by statute could refuse interventions, even when other relatives disagreed. Surrogate decision-making statutes and ethical principles about respect for delegated autonomy promote an active role for family members or other surrogates in medical decisions for (...) incompetent patients. Inviting surrogates to participate actively in medical decisions recognizes the importance of the patient's personal community and assures that decisions will reflect the patient's own preferences and values.The standard approach to decisions for incompetent adults gives advance directives priority over a surrogate's substituted judgment, which in turn has priority over assessments of the patient's best interest. A patient may express advance directives by appointing a proxy, stating specific preferences, or articulating general values. We use case examples to illustrate the limitations of all three types of advance directives. (shrink)

“[A] murder prosecution is a poor way to design an ethical and moral code for doctors,” observed the California Court of Appeal in 1983. Yet, physicians who have chosen to help terminally ill patients to commit suicide have trespassed on illegal ground. When skilled medical care fails to relieve the pain of terminally ill patients, some people believe that physicians may assist in these suicides. Others reject any kind of physician involvement. The debate on assisted suiczide and active euthanasia has (...) focused on whether these acts can ever be acceptable. We propose to shift the debate to a less divisive issue: whether a caring physician who provides a suffering and ill patient with a prescription for a lethal dose of medication should be prosecuted as a felon. Even assisted suicide's opponents may object to such criminal prosecution. We propose to modify existing criminal laws to give physicians who assist their terminally ill patients in suicide, under carefully defined circumstances, a legal defense against criminal charges. (shrink)

La diminution du poids institutionnel des religions dans notre société ne signifie pas pour autant que les hommes se détournent d'interrogations fondamentales touchant à leur identité profonde, à leur origine et à leur destination, au sens de leur vie ici-bas, à l'éventualité d'une vie après la mort. Que ces questions continuent d'occuper la pensée humaine, chacun est à même d'en faire le constat, et la science elle-même les a investies avec des moyens renouvelés. Ce qui a changé dans les dernières (...) décennies, c'est peut-être la manière d'appréhender ces interrogations fondamentales : on recueillait autrefois les réponses en se référant à sa religion d'appartenance ou en puisant dans un ensemble de discours et de pratiques proprement ésotériques ; aujourd'hui, la recherche de principes directeurs qui soient à même de donner un sens à l'existence n'échappe pas au mouvement général de sécularisation et de globalisation qui a radicalement transformé nos cultures. Anticipant cette tendance, Ostad Elahi s'était interrogé, il y a plus de cinquante ans, sur les conditions d'une sagesse contemporaine partagée, capable d'intégrer la dimension spirituelle, et fondée sur les principes fondamentaux communs aux différentes religions. Sous le titre Quelle sagesse pour notre temps?, cet ouvrage entend ouvrir une réflexion sur les modalités que peut prendre la recherche d'une telle sagesse adaptée à notre époque, à la fois conforme à l'idéal d'autonomie de l'individu moderne et ouverte à ses aspirations les plus profondes. Quels en seraient les principes? Parviendra-t-on à les dégager en s'accordant sur des valeurs éthiques et spirituelles universelles? Et si oui, comment est-il possible de les mettre en oeuvre? Une recherche de ce genre relève-t-elle d'une démarche strictement individuelle, ou peut-elle être également conduite de manière collective, à un niveau académique et plus généralement institutionnel? (shrink)

Este ensayo relaciona, por una parte, el pensamiento inclusivo con la cuestión moral del reconocimiento y, por otra, con el problema existencial del resentimiento y la técnica en la globalización híper-industrial. Se contrastan e integran perspectivas como las de Anne Phillips, Axel Honneth, María Pía Lara, Bernard Stiegler y Cynthia Fleury, para argumentar que los desarrollos tecnoeconómicos y sociales de la última década obligan a recuperar el problema del reconocimiento, para replantearlo por fuera de una racionalidad normativa, esto es, (...) a la luz de sus dimensiones psíquicas y existenciales. Dado que las condiciones tecnoeconómicas actuales parecen eliminar la posibilidad de un reconocimiento genuino —o una igualdad sin condición—, el problema del pensamiento inclusivo se revela, en el fondo, como el del resentimiento ante el descrédito de las promesas morales y políticas de la modernidad. El ensayo termina con una reflexión sobre las implicaciones de este argumento para una consideración responsable del pensamiento inclusivo, en tanto fenómeno cultural situado. El libro Desde los zulos (2023), de la escritora feminista Dahlia de la Cerda, nos permite mostrar que no hay determinismo tecnoeconómico o metafísico total, sino agujereado, y que de los agujeros brota, a veces, algo así como el reconocimiento. Al mismo tiempo, deja abierta la cuestión de si eso que emerge le pertenece a un nuevo sujeto estético-político, o si sucede, sin más, como la diferencia absoluta entre vida y política. (shrink)

Two significant, apparently unrelated, trends have emerged in American society and medicine. First, American medicine is reexamining its approach to dying. The Institute of Medicine, the American Medical Association and private funding organizations have recognized that too many dying people suffer from pain and other distress that clinicians can prevent or relieve. Second, this past decade has marked a sharp increase in the number of physicians prosecuted for criminal negligence based on arguably negligent patient care. The case often cited as (...) a watershed is People u. Einaugfer, which involved a New York nursing home patient whose physician was convicted in 1993 of two criminal misdemeanors after he ordered an elderly dialysis patient to be tube fed through a peritoneal dialysis Catheter.How is the growing awareness of dying patients’ pain and the increasing willingness of prosecutors to charge physicians with crimes connected? Pain at the end of life is frequently treated with narcotics, prescription drugs that are closely regulated by state and federal law. That complex web of laws—and a growing fear of legal sanctions—has deterred physicians from prescribing controlled substances. As those legal sanctions move from disciplinary actions to criminal charges, physicians’ fears may expand. (shrink)

Web 2.0 innovations may enhance informed patient decision-making, but also raise ethical concerns about inaccurate or misleading information, damage to the doctor-patient relationship, privacy and confidentiality, and health disparities. To increase the benefits and decrease the risks of these innovations, we recommend steps to help patients assess the quality of health information on the Internet; promote constructive doctor-patient communication about new information technologies; and set standards for privacy and data security in patient-controlled health records and for point-of-service advertising.

This important, rigorous, and thoughtful study surveyed U.S. bioethicists (Pierson et al. 2024). One concern is that the respondents are not representative of many bioethicists who carry out clinic...

Financial relationships between physicians and industry are widespread. Highly publicized financial relationships between physicians and industry raised disturbing questions about the trustworthiness of clinical research, practice guidelines, and clinical care decisions. Recent incidents spurred calls for stricter conflict of interest policies and led to new federal laws and NIH regulations. These stricter policies have evoked praise, concerns, and objections. Because these new federal requirements need to be interpreted and implemented, spirited discussions of conflicts of interest in medicine will continue.

Highlights of this edition include: / Important new material addressing federal privacy regulations, disclosure of medical errors, limits on residents'...

Recently, we reported that melanoma risk in redheads is linked not only to pale skin, but also to the synthesis of the pigment – called pheomelanin – that gives red hair its color. We demonstrated that pheomelanin synthesis is associated with increased oxidative stress in the skin, yet we have not uncovered the chemical pathway between the molecule pheomelanin and the DNA damage that drives melanoma formation. Here, we hypothesize two possible pathways. On one hand, pheomelanin might generate reactive oxygen (...) species (ROS) that directly or indirectly cause oxidative DNA damage. On the other hand, pheomelanin synthesis might consume cellular antioxidant stores and make the cell nucleus more vulnerable to other endogenous ROS. Uncovering the mechanistic pathway between pheomelanin and oxidative DNA damage will be an important step in developing strategies to lower melanoma risk in redheads. (shrink)

Adequate treatment of pain is essential to alleviate suffering, yet studies show that patients with terminal or serious illness receive inadequate pain relief. In the case of terminally ill patients, adequate palliation of pain may be likely to reduce requests for physician-assisted suicide. This issue of the journal addresses barriers to effective pain relief and suggests how treatment of pain can be improved. The symposium features the Pain Relief Act, which is designed to provide practitioners who prescribe controlled substances for (...) pain with protection from inappropriate legal sanctions. The Act is the product of the Project on Legal Constraints on Access to Effective Pain Relief, whose principal investigators were Nancy Neveloff Dubler, LL.B., Sandra H. Johnson, J.D., LL.M., Robert J. Levine, M.D., and Benjamin W. Moulton, J.D., M.P.H.The Project was supported by the Mayday Fund and the Emily Davie and Joseph S. Kornfeld Foundation. (shrink)

In an historic first, two ethics committees - one from Laos, the other from France - met in Vientiane in October 2015. Researchers examined a multitude of ethical issues related to health, the environment, and societies in countries in the Mekong region. Urgent, universal questions were discussed in local contexts ; productive debates illustrated a complex array of possible solutions. This book, born out of that meeting, serves as a guide for those working across the spectrum of scientific fields on (...) paths to promote justice and reduce suffering. Like the Mekong River, the field of research ethics does not run in a straight line ; and like that river, everyone it touches discovers that what may initially appear to separate us ultimately serves to bring us together. (shrink)

We wholeheartedly agree with Schmidt and colleagues’ efforts to promote equity in intensive care unit triage. We also take issue with their characterisation of the New Jersey allocation framework for ICU beds and ventilators, which is modelled after the multi-principle allocation framework we developed early in the pandemic. They characterise it as a two-criterion allocation framework and claim—without evidence—that it will ‘compound disadvantage for black patients’. However, the NJ triage framework—like the model allocation policy we developed—actually contains four allocation criteria: (...) the two criteria that the authors mentioned and two criteria that they failed to mention which we included to promote equity: giving priority to frontline essential workers and giving priority to younger patients. These omissions are problematic both for reasons of factual accuracy and because the two criteria they failed to acknowledge would likely mitigate rather than exacerbate racial disparities during triage. (shrink)

The author presents his view of the start of clinical medical ethics and ideas on where the broader field of bioethics is heading. In addition to clinical medical ethics, people with training in clinical ethics can enlarge the scope of their work in order to have additional real-world impact. Important opportunities abound in empirical research on medical ethics, the ethics of healthcare institutions, ethical issues regarding biomedical research, and public policy. Three topics for bioethics scholars to address are artificial intelligence (...) in clinical care, health disparities, and communicating persuasively to broader audiences beyond academia. (shrink)

In his monumental 1687 work, _Philosophiae Naturalis Principia Mathematica_, known familiarly as the _Principia_, Isaac Newton laid out in mathematical terms the principles of time, force, and motion that have guided the development of modern physical science. Even after more than three centuries and the revolutions of Einsteinian relativity and quantum mechanics, Newtonian physics continues to account for many of the phenomena of the observed world, and Newtonian celestial dynamics is used to determine the orbits of our space vehicles. This (...) authoritative, modern translation by I. Bernard Cohen and Anne Whitman, the first in more than 285 years, is based on the 1726 edition, the final revised version approved by Newton; it includes extracts from the earlier editions, corrects errors found in earlier versions, and replaces archaic English with contemporary prose and up-to-date mathematical forms. Newton's principles describe acceleration, deceleration, and inertial movement; fluid dynamics; and the motions of the earth, moon, planets, and comets. A great work in itself, the _Principia_ also revolutionized the methods of scientific investigation. It set forth the fundamental three laws of motion and the law of universal gravity, the physical principles that account for the Copernican system of the world as emended by Kepler, thus effectively ending controversy concerning the Copernican planetary system. The illuminating Guide to Newton's _Principia_ by I. Bernard Cohen makes this preeminent work truly accessible for today's scientists, scholars, and students. (shrink)

Stem cells derived from pluripotent cells offer the hope of new treatments for diseases for which current therapy is inadequate. Clinical trials are essential in developing effective and safe stem cell therapies and fulfilling this promise. However, such clinical trials raise ethical issues that are more complex than those raised in clinical trials using drugs, cord blood stem cells, or adult stem cells. Several clinical trials are now being carried out with stem cells derived from pluripotent cells, and many more (...) can be expected in light of the rapid scientific progress in the field.Degenerative neurological diseases are desirable targets for stem cell clinical trials. The FDA has approved Phase 1 clinical trials of neural stem cell transplantation for Batten Disease, Pelizaeus-Merzbacher Disease, and spinal cord injury. In Parkinson Disease, stem cell transplantation could correct the primary pathophysiological defect — inadequate levels of the neurotransmitter dopamine. Current treatment is unsatisfactory in late-stage PD. (shrink)

Although international research is increasing in volume and importance, there remains a dearth of knowledge on similarities and differences in “national human research ethics”, that is, national ethical guidelines, Institutional Review Boards, and research stakeholder’ ethical attitudes and behaviors. We begin to address this situation by reporting upon our experiences in conducting a multinational study into the mental health of children who had a parent/carer in prison. The study was conducted in 4 countries: Germany, Great Britain, Romania, and Sweden. Data (...) on NHREs were gathered via a questionnaire survey, two ethics-related seminars, and ongoing contact between members of the research consortium. There was correspondence but even more so divergence between countries in the availability of NEGs and IRBs and in researcher’ EABs. Differences in NHREs have implications particularly in terms of harmonization but also for ethical philosophy and practice and for research integrity. (shrink)

“Exercise starts and ends in the brain”: this was the title of a review article authored by Dr. Bengt Kayser back in 2003. In this piece of work, the author highlights that pioneer studies have primarily focused on the cardiorespiratory-muscle axis to set the human limits to whole-body exercise tolerance. In some circumstances, however, exercise cessation may not be solely attributable to these players: the central nervous system is thought to hold a relevant role as the ultimate site of exercise (...) termination. In fact, there has been a growing interest relative to the “brain” response to exercise in chronic cardiorespiratory diseases, and its potential implication in limiting the tolerance to physical exertion in patients. To reach these overarching goals, non-invasive techniques, such as near-infrared spectroscopy and transcranial magnetic stimulation, have been successfully applied to get insights into the underlying mechanisms of exercise limitation in clinical populations. This review provides an up-to-date outline of the rationale for the “brain” as the organ limiting the tolerance to physical exertion in patients with cardiorespiratory diseases. We first outline some key methodological aspects of neuromuscular function and cerebral hemodynamics assessment in response to different exercise paradigms. We then review the most prominent studies, which explored the influence of major cardiorespiratory diseases on these outcomes. After a balanced summary of existing evidence, we finalize by detailing the rationale for investigating the “brain” contribution to exercise limitation in hitherto unexplored cardiorespiratory diseases, an endeavor that might lead to innovative lines of applied physiological research. (shrink)

Last month, a fifty-eight-year old man developed bleeding into his cheek and oozing from sites where previously he had had blood samples drawn. This bleeding was caused by disseminated intravascular coagulation, a complication of colon cancer that had spread to his liver and lungs. This complication occurred even though he was on chemotherapy for the cancer. In the hospital, he received transfusions and was administered medicine to stop the bleeding. However, his condition did not improve. He developed more bruises. When (...) he tried to go to the bathroom without assistance, he fell, struck his head, requiring stitches, and developed a black, swollen eye. The patient, a successful businessman, had already overcome another type of cancer—lymphoma—through chemotherapy, twenty-five years ago. In a few days, this dynamic individual who expected to start experimental chemotherapy now saw his quality of life deteriorate steadily.We talked about more chemotherapy, about hospice, and about withholding attempts at resuscitation if his heart should stop. (shrink)

Physicians and patients rely on medical journals as trusted sources of medical information. Unfortunately, in multiple instances conflicts of interest have undermined the credibility of the medical literature.The primary sources of conflict of interest at medical journals are authors, reviewers, editors, and journals. Consider these examples.

L’épreuve projective intitulée « spatiographie projective familiale » a pour objectif de comprendre l’image inconsciente du corps familial à travers l’analyse du dessin groupal de la « maison de rêve ». Par cette méthodologie, les auteurs peuvent établir un diagnostic de la structure des liens inconscients de la famille et en faire un objet médiateur pour la prise en charge psychothérapique et une épreuve projective groupale familiale pour le diagnostic. Le dessin de la « maison de rêve » est un (...) outil original qui investigue les dimensions diachronique et synchronique permettant une approche complète de la structuration de l’image du corps familial. (shrink)

In this paper we revise Reinforcement Learning and adaptiveness in Multi-Agent Systems from an Evolutionary Game Theoretic perspective. More precisely we show there is a triangular relation between the fields of Multi-Agent Systems, Reinforcement Learning and Evolutionary Game Theory. We illustrate how these new insights can contribute to a better understanding of learning in MAS and to new improved learning algorithms. All three fields are introduced in a self-contained manner. Each relation is discussed in detail with the necessary background information (...) to understand it, along with major references to relevant work. (shrink)

We appreciate the opportunity to respond to Schneiderman and colleagues’ opinions on the recent Multiorganization Policy Statement, “An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units”. We will first point out three areas in which Schneiderman and colleagues seem to perceive a disagreement where there is none, then we will respond to their main criticisms of the Multiorganization Policy Statement. In doing so, we will point out areas in which we believe Schneiderman and (...) colleagues have either misunderstood or misrepresented the statement. First, we agree with Schneiderman and... (shrink)

Book reviewed in this article: Learning to Heal: The Development of American Medical Education. By Kenneth M. Ludmerer Getting Rid of Patients: Contradictions in the Socialization of Physicians. By Terry Mizrahi.

Executive control of attention refers to processes that detect and resolve conflict among competing thoughts and actions. Despite the high-level nature of this faculty, the role of awareness in executive control of attention is not well understood. In this study, we used interocular suppression to mask the flankers in an arrow flanker task, in which the flankers and the target arrow were presented simultaneously in order to elicit executive control of attention. Participants were unable to detect the flanker arrows or (...) to reliably identify their direction when masked. There was a typical conflict effect (prolonged reaction time and increased error rate under flanker-target incongruent condition compared to congruent condition) when the flanker arrows were unmasked, while the conflict effect was absent when the flanker arrows were masked with interocular suppression. These results suggest that blocking awareness of competing stimuli with interocular suppression prevents the involvement of executive control of attention. (shrink)

Administraation of antiretroviral therapy to women during pregnancy, labor and delivery, and to infants postnatally can dramatidy reduce mother-to- child HIV transmission. However, pregnant women need to know that they are HIV-infected to take advantage of antiretroviral therapy, and many women do not know their HIV status. One-half of HIV-infected infants in the United States were bornto women who had not been tested for HIV or for whom the time of testing was not known. Although fewer than 400infants are infected (...) perinatally in the United States each year, that number could be reduced even further through policies aimed at HIV testing during pregnancy.The reasons toadopt such a policy are strong: the pathophysiology of perinatal transmission is clear, prophylaxis is effective and safe, and the intended beneficiaries of the intervention - babies - cannot protect themselves. (shrink)