High-resolution neuroimaging modalities are used often in studies involving healthy volunteers. Subsequently, a significant increase in the incidental discovery of asymptomatic intracranial abnormalities raised the important ethical issues of when follow-up and treatment may be necessary. We examined the literature to establish a practical set of criteria for approaching incidental findings. Our objective is to develop an algorithm for when follow-up may be important and to provide recommendations that would increase the likelihood of follow-up. A systematic literature search was performed (...) using the PubMed and MEDLINE databases to identify articles describing brain tumors and intracranial aneurysms. The treatment algorithm we present suggests that incidental intracranial masses suspicious for glioma should be biopsied or resected, while other masses are to be followed with serial imaging based on the expected growth pattern. Lack of follow-up can result in adverse outcomes that can be mitigated by using technology to facilitate communication and improve follow-up care. The importance of training physicians to be good communicators is also stressed. New technology including automated telephone systems, texting and email will improve access to patients and hopefully encourage compliance and follow-up. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:To Be or Not to Be:Waiving Informed Consent in Emergency ResearchCharles R. McCarthy (bio)The requirements for prior, legally authorized informed consent constitute a necessary condition for recruiting subjects into biomedical or behavioral research. However, informed consent requirements pose a serious problem for most research conducted in emergency care settings. For this reason, the Food and Drug Administration's (FDA) regulations governing investigational devices and the Department of Health and Human (...) Services' (HHS) regulations for the protection of human subjects allow narrow exceptions to the general requirements of informed consent. In a joint effort to clarify the applicability of the current FDA regulations and to better understand the intent of the HHS regulations as they apply to emergency research, the FDA and the National Institutes of Health (NIH) cosponsored a public forum on the ethical conduct of emergency research in January 1995.Although the forum was not designed as a consensus conference and participants vigorously disagreed on some of the details, a broad consensus emerged on several major points: (1) both HHS and FDA regulations should, in the immediate future, be interpreted to allow for randomized clinical trials in emergency situations so long as the subjects are carefully protected; and (2) consideration should be given to producing new, closely harmonized regulations from both agencies that will provide greater clarity concerning what kinds of emergency research may be allowed without obtaining prior informed consent.The FDA-NIH forum in January was occasioned primarily by controversy about the hypothermia research protocol described below, but it is obvious that many other kinds of emergency research also await the outcome of deliberations concerning waiver of informed consent in emergency situations. These include research into the care and treatment of: occlusive stroke; subarachnoid hemorrhage due to intracranial aneurysm; metabolic coma; status epilepticus; cardiac arrest; myocardial infarction; cardiac arrhythmia; hemorrhagic shock; pulmonary embolism; acute asthmatic attack; and poisoning. All of these conditions [End Page 155] are encountered in emergency settings where obtaining informed consent from the patient-subjects to participate in research is seldom possible, and obtaining consent from legally authorized representatives of the subjects is either not feasible, or, if obtained, is of doubtful validity.The Hypothermia Research Case and HHS RegulationsA $7.2 million grant for research on the use of hypothermia in the treatment of severe head trauma, the largest award ever made to the University of Texas Health Sciences Center at Houston, is in danger of expiring before the study is completed. The protocol, which involves the use of cooling blankets to induce hypothermia in patients suffering from severe head injuries, is designed to test the hypothesis that: "Early lowering of the body temperature of patients suffering from severe head trauma to approximately 91 degrees Fahrenheit will slow patients' metabolism and will/will not, as a consequence, reduce the rates of both morbidity and mortality in these patients." The protocol was approved by seven Institutional Review Boards (IRBs), each of which waived the requirement to obtain informed consent from research subjects in accordance with Sec. 46. 116(d) of the HHS Regulations for the Protection of Human Subjects.1However, NIH's Office for Protection from Research Risks (OPRR), which is responsible for assuring compliance with the HHS regulations, has taken a controversial regulatory position by requiring informed consent from a legally authorized representative of each subject to be entered in the hypothermia trial. Because the obtaining of surrogate consent has proved to be very difficult, OPRR's position has slowed the research to a point where it may have to be terminated.At issue in the controversy is a fundamental question of ethics and public policy. Is it ever permissible to involve incompetent subjects in research without either their consent, or the consent of their legally authorized representatives? Pertinent HHS regulations for the protection of human subjects seem to answer the question affirmatively by allowing local IRBs to waive some or all of the elements of informed consent under carefully limited circumstances (45 CFR 46 116(d)). Nevertheless, OPRR has signalled the research community that use of the informed consent waiver provision for the Houston hypothermia study is not permitted under the regulations. OPRR judged that the risks... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Whisper Before You GoJohn K PettyDavid came with a bang.1A momentary prelude from a dysphonic chorus of pagers announce “Level 1 Pediatric Trauma—MVC ejected” before the abrupt crescendo of the trauma bay doors opening. He is maybe two. Maybe three–years–old. It is hard to tell when a child is strapped in, strapped down, nonverbal, intubated, and alone.The flight team speaks for him, “Four–year–old boy improperly restrained in a single–vehicle (...) crash into a ditch. He was partially ejected. He was unresponsive and pulseless at the scene. He got CPR and code drugs, and they got a pulse back. Emergency medical service (EMS) took him to the nearest hospital where they needled his chest, called for air transport, and scanned him up. He has been shocky for us since we picked him up. Glasgow Coma Scale (GCS) has been three the whole time. They said his head scan showed subarachnoid hemorrhage.”With the words of the flight team as background narrative, we get about doing our thing—hopefully more method and less madness. Bang, bang, bang! Check the tube. Vital signs. IV fluids. Place a chest tube. Hang the blood. Quick X–ray. Neuro exam—nothing. Get him off the board. Warm him up. Place the orogastric (OG) tube. Bang, bang, bang!The neurosurgery resident opens the CT scans from the other hospital. The brain and cervical spine scans show a disaster: some swelling and bleeding in the higher brain, but the worst damage is in the lower brain, brainstem, and top of the spinal cord. I have heard a neurosurgeon describe this pattern before as “internal decapitation.” Such language never makes it into the patient’s chart. For David the last two words of the neurosurgery consult note will eventually read, “Prognosis grim.”He remains unstable in the trauma bay. Inaction is death. We ultrasound his heart, abdomen, and pelvis. He has fluid that shouldn’t be around his heart. He is dying of the neuro injury we cannot control, but the pericardial fluid might be giving him shock, and we can control that. We can’t ignore the fluid. Shouldn’t ignore it. At least, wouldn’t ignore it. So, we bang up to the operating room. Squeezing blood. Spiking fluid. Oxygen tank and crash cart. Up we go.In the operating room, we do much and we do well. We release the fluid around the heart and find it was CPR, not heart injury that put it there. In the pericardial flash we get a view of the cardiac athlete, pounding like the 26th mile of the marathon. We explore the abdomen and find it swollen but innocent of an injury that would take his life. We place our lines and tubes as the neurosurgeons place theirs. If nothing else, we will be able to measure what lies ahead.“Good work, team,” and we bump the door on the way to the pediatric intensive care unit (PICU).The care in the PICU is more Apache brave than Gaelic knight—more bottles, fewer scissors. The curtains and carpets mute the tones. Our efforts continue, but I get a word that David’s father has arrived. He is sitting in a small, private waiting room off of the main PICU waiting room. The PICU staff colloquially refer to this as “the bad news room.” I take a seat next to a solitary man who is having the worst day of his life. His worst day so far.“I am Dr. Petty, and I am one of the doctors who is taking care of your son. I am very sorry about what has happened. Maybe you can tell me a little bit about what you understand is going on, and I’ll tell you what I know.” [End Page 17]He tells me that his wife was driving David back from her sister’s house, just the two of them. He doesn’t know what happened, but he got a call from the other hospital about the crash. His wife was badly hurt. He heard that David had died, but they got him back. Both were transferred up to the... (shrink)

This paper presents a case in whom a differential diagnosis of akinetic mutism with a disorder of consciousness was made using diffusion tensor tractography. A 69-year-old female patient was diagnosed with subarachnoid hemorrhage, intraventricular hemorrhage, and intracerebral hemorrhage produced by the subarachnoid hemorrhage. She exhibited impaired consciousness with a Coma Recovery Scale-Revised score of 13 until 1 month after onset. Her impaired consciousness recovered slowly to a normal state according to the Coma Recovery Scale-Revised (...) at 7 weeks after onset. On the other hand, she exhibited the typical clinical features of akinetic mutism. On the DTT performed at 1-month, the upper, and lower dorsal ascending reticular activating systems, which are related to a disorder of consciousness, showed an almost normal state. In contrast, the prefronto-caudate and prefronto-thalamic tracts, which are related to akinetic mutism, showed severe injuries. These DTT results suggested that the patient's main clinical features were not a disorder of consciousness but akinetic mutism. Therefore, DTT for the ascending reticular activating system, and the prefronto-caudate and prefronto-thalamic tracts could provide additional evidence for a differential diagnosis of DOC and AM at the early stages of stroke. (shrink)

Institute for Biomedical Ethics, Geneva University Medical School * Corresponding author: Médecins Sans Frontières (OCG), rue de Lausanne 78, CH-1211 Geneva 21, Switzerland. Tel.: +41 (0)22 849 89 29; Fax: +41 (0)22 849 84 88; Email: philippe_calain{at}hotmail.com ' + u + '@' + d + ' '//--> Abstract Outbreaks of filovirus (Ebola and Marburg) hemorrhagic fevers in Africa are typically the theater of rescue activities involving international experts and agencies tasked with reinforcing national authorities in clinical management, biological diagnosis, sanitation, (...) public health surveillance and coordination. These outbreaks can be seen as a paradigm for ethical issues posed by epidemic emergencies, through the convergence of such themes as: isolation and quarantine, privacy and confidentiality and the interpretation of ethical norms across different ethnocultural settings. With an emphasis on the boundaries between public health investigations and research, this article reviews specific challenges, past practices and current normative documents relevant to the application of ethical standards in the course of outbreaks of filovirus hemorrhagic fevers. Aside from commonly identified issues of informed consent and institutional review processes, we argue for more clarity over the specification of which communities are expected to share benefits, and we advocate for the use of collective definitions of duty to care and standard of care. We propose new elaborations around existing normative instruments, and we suggest some pathways toward more comprehensive approaches to the ethics of research in outbreak situations. CiteULike Connotea Del.icio.us What's this? (shrink)

BackgroundThe prognosis of hypertensive intracerebral hemorrhage is poor at high altitudes. The objective of this study was to explore whether hyperbaric oxygen can improve the results of computed tomography perfusion imaging and the neurological function of patients with HICH, and influence the hemoglobin concentration.MethodThe patients with HICH were treated with puncture and drainage. Twenty-one patients were treated with HBO after the operation, and the other patients received conventional treatment. CTP was performed twice, and all indices were measured. Scatter plots (...) were used to determine the effect of hemoglobin concentration on CTP imaging. Receiver operating characteristic curves were plotted to analyze the effects of hemoglobin concentration and hematoma volume on recovery results. The patients were followed up for 6 months.ResultsForty-one patients with HICH were treated with puncture and drainage. In total, 21 were treated with HBO after the operation, and 20 received conventional treatment as the control group. No significant differences in the CBV and CBF values of the two groups were noted before treatment. After 10 days, the values of CBV and CBF in the HBO group were significantly higher than those in the control group. A scatter diagram showed there was no significant in the HBO group, but significant correlation for the CBV and CBF values in the control group’s hematoma center and margin. The ROC curves showed that hematoma volume had an influence on prognosis of the control group. The Glasgow Coma Scale scores of the HBO group were significantly higher than those of the control group.ConclusionsHBO therapy can improve the postoperative CBV and CBF values of patients with HICH and ameliorate their prognoses. There was no significant correlation between HBO group and hemoglobin concentration on admission. (shrink)

When a Jehovah’s Witness patient is traumatically injured, the lack of uniform professional consensus guidelines and the cultural knowledge deficit of many clinicians adds an additional layer of legal and ethical complexity to the inherent difficulty of managing a critically ill patient. We present here the case of an incapacitated Jehovah's Witness patient with severe traumatic hemorrhagic shock. We go on to discuss the historical and contemporary case law on proxy refusal of blood transfusion for the incapacitated adult, as well (...) as the ethics of self-determination and the application of the principle of proportionate reason in the management of the critically injured Jehovah's Witness patient. (shrink)

This study is a kind of applied phenomenology, or more precisely, of applied phenomenological hermeneutics. I argue that phenomenologists hardly analyze concrete phenomena but prefer to engage in theoretical debates, and therefore I call for more applied studies. The case of a patient who suffered a cerebralhemorrhage is used in order to reconstruct how she slowly regained everyday sense-connexions. The case is very interesting as the patient was rather disoriented when waking up from an artificial coma of several weeks, and (...) it took her many years to fully recover. The goal of this paper is to describe some aspects of this process from a subjective perspective as well as from a participant observer’s viewpoint. The data used for this chapter mainly stem from in-depth qualitative interviews. The structures of the life-world of Alfred Schutz are used to analyze the processes of sense constitution. This proves helpful but the data also suggest a revision of Schutz’s analyses in some respects. (shrink)

This study aimed to establish a correlation between Education, mobility, efforts to eradicate mosquito nests (MNE), and the presence of mosquito larvae with the incidence of DHF. This analysis is a quantitative analysis performed from a case-control point of view. In 2015-2019 there were 632 patients. The large samples, the box and the control, for example, were 490 pieces. Data collection tools through questionnaires. Random sampling technique achieved. This study is quantitative analysis research with a case-control approach. The population of (...) DHF sufferers in 2015-2019 was 632 cases. Large samples as case and control amounted to 490 pieces. Data collection instruments using questionnaires. Sampling technique using a disproportionate stratified random sampling technique. There was no significant relationship between Education and the incidence of DHF cases. (P = 0.543), there is no essential relationship between population mobility and DHF events (P value = 0.860); there is a significant relationship between MNE activity and the incidence of DHF cases (P value = 0.001) with an OR of 14.20, meaning that there is a risk of 14.20 times respondents who do not do MNE activities experience DHF events compared to respondents who do MNE activities. MNE activities carried out by respondents are related to controlling the incidence of DHF cases and are at risk of experiencing DHF cases. Managing the DHF case incident program requires optimizing MNE activities through cross-program, cross-sect cooperation and empowering religious and traditional leaders. (shrink)

Deep brain stimulation (DBS) of the globus pallidus interna and subthalamic nucleus has restored some degree of motor control in many patients in advanced stages of Parkinson’s disease. DBS has also been used to treat dystonia, essential tremor (progressive neurological condition causing trembling), chronic pain, obsessive-compulsive disorder, Tourette’s syndrome, major depressive disorder, obesity, cerebral palsy, and the minimally conscious state. Although the underlying mechanisms of the technique are still not clear, DBS can modulate underactive or overactive neural circuits and restore (...) disrupted communication between and among groups of neurons in interacting regions of the brain. This can control and relieve many symptoms associated with a range of neurological and psychiatric disorders.But the procedures of implanting and stimulating the electrodes are brain-invasive and entail significant risks. Some patients receiving DBS have experienced intracerebral hemorrhage, infection, cognitive disturbances such as impulsive behavior, and affective disturbances such as mania. It is not known whether continuous electrical stimulation of the brain would reshape synaptic connectivity and permanently alter neural circuits in ways that may not be salutary. The risk of these effects indicates that DBS should be used only when a patient’s condition is refractory to all other interventions and when there is a high probability that the technique will benefit the patient and improve his or her quality of life. If a patient’s quality of life is poor and all other treatment options have been exhausted, then the likelihood of benefit can justify physicians’ exposing patients to some risk. The clinical and ethical significance of the risk in DBS underscores the obligation of physicians to obtain fully informed consent from patients undergoing the procedure. (shrink)

The idea that acquired brain injury (ABI) caused by stroke, hemorrhage, infection or traumatic insult to the brain can result in post-traumatic growth (PTG) for individuals is increasingly attracting psychological attention. However, PTG also attracts controversy as a result of ambiguous empirical findings. The extent that demographic variables, injury factors, subjective beliefs, and psychological health are associated with PTG following ABI is not clear. Consequently, this systematic review and meta-analysis explores the correlates of variables within these four broad areas (...) and PTG. From a total of 744 published studies addressing PTG in people with ABI, eight studies met inclusion criteria for detailed examination. Meta-analysis of these studies indicated that growth was related to employment, longer education, subjective beliefs about change post-injury, relationship status, older age, longer time since injury, and lower levels of depression. Results from homogeneity analyses indicated significant inter-study heterogeneity across variables. There is general support for the idea that people with ABI can experience growth, and that various demographics, injury-related variables, subjective beliefs and psychological health are related to growth. The contribution of social integration and the forming of new identities post-ABI to the experience of PTG is explored. These meta-analytic findings are however constrained by methodological limitations prevalent in the literature. Clinical and research implications are discussed with specific reference to community and collective factors that enable PTG. (shrink)

At the time of this writing, a widely publicized, waived-consent trial is underway. Sponsored by Northfield Laboratories, Inc. (Evanston, IL) the trial is intended to evaluate the emergency use of PolyHeme®, an oxygen-carrying resuscitative fluid that might prevent deaths from uncontrolled bleeding. The protocol allows patients in hemorrhagic shock to be randomized between PolyHeme® and saline in the field and, still without consent, randomized between PolyHeme® and blood after arrival at an emergency department. The Federal regulations that govern the waiver (...) of consent restrict its applicability to circumstances where proven, satisfactory treatments are unavailable. Blood - the standard treatment for hemorrhagic shock - is not available in ambulances but is available in hospitals. The authors argue that the in-hospital stage of the study fails to meet ethical and regulatory standards. (shrink)

While ethics and evidence‐based medicine are often viewed as separate domains of inquiry and practice, what we know influences what we can ethically justify doing, and what we see as our moral obligations shapes the way we interpret evidence. The boundaries between the moral and epistemic spheres become particularly blurred when the health of people is at stake and even more so when no “officially” recommended medical intervention is available to help a patient in need. The treatment of major hemorrhages (...) using recombinant factor VIIa (rFVIIa), which was originally approved under orphan drug legislation to treat hemophilia, is a case in point.Following reports in the late 1990s that rFVIIa was success­fully used to stop bleeding in gunshot trauma, there was much excitement about its potential to help patients with uncontrolled bleeding in other clinical settings, leading to wide‐spread off‐label use of the drug. In recent years, new evidence has raised questions about the off‐label use of rFVIIa for severe bleeding. Nonetheless, while some clini­cians are now adamantly opposed to prescribing rFVIIa for massive bleed­ing, many remain determined to continue the practice. This raises the question: why do clinicians have such variable responses to the same body of evidence?We analyzed the debate around off‐label use of rFVIIa and character­ized its main conceptual features and tensions. We did not seek to provide a normative analysis as to whether the evidence supports the case for off‐label prescribing, nor did we try to provide a historical analysis of how attitudes and clinical practice have changed. Rather, we sought to make visible the moral and epistemic values underpinning stakeholders’ opinions and practices. On the basis of our analysis, which is described in this ar­ticle, we suggest that debates such as those surrounding rFVIIa will not be resolved simply by conducting more studies and that, therefore, there is also a need for conceptual and pro­cedural frameworks that more sys­tematically incorporate values into clinical policy‐making. (shrink)

Biodefense and emerging infectious disease animal research aims to avoid or ameliorate human disease, suffering, and death arising, or potentially arising, from natural outbreaks or intentional deployment of some of the world’s most dreaded pathogens. Top priority research goals include finding vaccines to prevent, diagnostic tools to detect, and medicines for smallpox, plague, ebola, anthrax, tularemia, and viral hemorrhagic fevers, among many other pathogens (National Institute of Allergy and Infectious Diseases [NIAID] priority pathogens). To this end, increased funding for conducting (...) research, developing research facilities, and purchasing (stockpiling) developed vaccines, diagnostic tools, and therapeutics .. (shrink)

As of January 1, 2008, over 98,000 people are waiting for organ transplants in the United States of America. Of those, nearly 75,000 are waiting for a kidney. In this calendar year, fewer than 15,000 will receive a kidney transplant from a deceased donor. The average waiting time for a deceased donor kidney now exceeds five years in virtually all metropolitan areas. Sadly, nearly as many people die waiting as there are deceased donors each year, despite monumental efforts by the (...) entire transplant community to increase both the number of organ donors and the number of organs recovered from each donor. The imbalance between demand and supply has led to considerable efforts to expand the criteria for what is considered an acceptable organ donor by the Organ Procurement and Transplant Network, thereby hoping somewhat to assuage the shortfall of donor organs. So-called Expanded Criteria Donors may be older than 50, have history of hypertension, or have died from intracerebral hemorrhage and/or have impaired renal function. ECDs now make up nearly 40% of the donor population. (shrink)

At the time of this writing, a widely publicized, waived-consent trial is underway. Sponsored by Northfield Laboratories, Inc. (Evanston, IL) the trial is intended to evaluate the emergency use of PolyHeme®, an oxygen-carrying resuscitative fluid that might prevent deaths from uncontrolled bleeding. The protocol allows patients in hemorrhagic shock to be randomized between PolyHeme® and saline in the field and, still without consent, randomized between PolyHeme® and blood after arrival at an emergency department. The Federal regulations that govern the waiver (...) of consent restrict its applicability to circumstances where proven, satisfactory treatments are unavailable. Blood—the standard treatment for hemorrhagic shock—is not available in ambulances but is available in hospitals. The authors argue that the in-hospital stage of the study fails to meet ethical and regulatory standards. (shrink)

Should surgeons offer uterus transplants to women who want to become pregnant but do not have a functioning uterus? The debate reminds us that society often neglects the interests of the infertile. Only a handful of uterus transplants have been reported worldwide—including two this past September—but advances in technique may make the transplants available more widely. Some women are born without a functioning uterus; others have hysterectomies for cancer, postpartum hemorrhage, or other reasons. Many of these women want to (...) become mothers and carry their own pregnancies. However, the prospect of uterus transplantation has elicited sharp criticism. According to ethics professor Rebecca Kukla, the surgery is not, “in any traditional sense, therapeutic.”. (shrink)

University of Colorado, Boulder If there are laws of psychology, they would seem to hold only ceteris paribus (c.p., hereafter), i.e., other things being equal. If a person wants that q and believes that doing a is the most efficient way to make it the case that q, then she will attempt to do a—but not, however, if she believes that a carries with it consequences much more hated than q is liked, or she believes she is incapable of doing (...) a, or she gets distracted from her goal that q, or she suddenly has a severe brain hemorrhage, or.... No one can say precisely where the list ends, but the idea is supposed to be clear enough: normally the law holds, but there are many cases, exceptions, one might say, in which the law does not; the difficulty of characterizing these exceptions invites the qualification ‘c.p.’ as a catch-all. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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Background: SNOMED CT is a large terminology system designed to represent all aspects of healthcare. Its current form and content result from decades of bottom-up evolution. Due to SNOMED CT’s formal descriptions, it can be considered an ontology. The Basic Formal Ontology (BFO) is a foundational ontology that proposes a small set of disjoint, hierarchically ordered classes, supported by relations and axioms. In contrast, as a typical top-down endeavor, BFO was designed as a foundational framework for domain ontologies in the (...) natural sciences and related disciplines. Whereas it is mostly assumed that domain ontologies should be created as extensions of foundational ontologies, a post-hoc harmonization of consolidated domain ontologies in use, such as SNOMED CT, is known to be challenging. Methods: We explored the feasibility of harmonizing SNOMED CT with BFO, with a focus on the SNOMED CT Clinical Finding hierarchy. With more than 100,000 classes, it accounts for about one third of SNOMED CT’s content. In particular, we represented typical SNOMED CT finding/disorder concepts using description logics under BFO. Three representational patterns were created and the logical entailments analyzed. Results: Under a first scrutiny, the clinical intuition that diseases, disorders, signs and symptoms form a homogeneous ontological upper-level class appeared incompatible with BFO’s upper-level distinction into continuants and occurrents. The Clinical finding class seemed to be an umbrella for all kinds of entities of clinical interest, such as material entities, processes, states, dispositions, and qualities. This suggests the conclusion that Clinical finding would not be a suitable upper-level class from an BFO perspective. On closer inspection of the taxonomic links within this hierarchy and the implicit meaning derived thereof, it became clear that Clinical finding classes do not characterize the entity (e.g. a fracture, allergy, tumor, pain, hemorrhage, seizure, fever) in a literal sense but rather the condition of a patient having that fracture, allergy, pain etc. This gives sense to the current characteristic of the Clinical Finding hierarchy, in which complex classes are modeled as subclasses of their constituents. Most of these taxonomic links are inferred, as the consequence of the ‘role group’ design pattern, which is ubiquitous in SNOMED CT and has often been subject of controversy regarding its semantics. Conclusion: Our analyses resulted in the proposal of (i) equating SNOMED CT’s ‘role group’ property with the reflexive and transitive BFO relation ‘has occurrent part’; and (ii) reinterpreting Clinical Findings as Clinical Occurrents, i.e. temporally extended entities in an organism, having one or more occurrents as temporal parts that occur in continuants. This re-interpretation was corroborated by a manual analysis of classes under Clinical Finding, as well as the identification of similar modeling patterns in other ontologies. As a result, SNOMED CT does not require any content redesign to establish compatibility with BFO, apart from this re-interpretation, and a suggested re-labeling. Regarding the feasibility of harmonizing terminologies with principled foundational ontologies post-hoc, our results provide support to the assumption that this does not necessarily require major redesign efforts, but rather a careful analysis of the implicit assumptions of terminology curators and users. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My Circumcision Decision:A Journey of Inquiry, Courage and DiscoveryLaurie EvansBefore becoming a mother, I was teaching parents to massage their babies and offering trainings for professionals. To promote my work, in 1984, I exhibited at the Whole Life Expo in New York City. When I returned to my booth after a break, I noticed someone had left a pamphlet by Edward Wallerstein, who wrote "Circumcision: An American Health Fallacy." (...) Since I am naturally curious, I read it. Disturbed, I thought of tossing it. But, how could I be teaching a nurturing technique for newborns and avoid this topic? As a Jewish woman, how would I make the decision for my own future sons? Little did I know this one piece of paper would lead me on a path of inquiry that would change my life.One of the presenters at this conference was Dr. Robert Mendelsohn, an Orthodox pediatrician. Although Dr. Mendelsohn realized some parents would allow circumcision for religious reasons, he was honest enough to dispel every medical myth and explain the harm of removing normal functioning tissue. He also described possible complications from removing the foreskin, including infection, hemorrhage, and although rare, death.To learn more, I read whatever I could find on the topic. I attended midwifery and childbirth conferences to promote my work and prepare for when I became pregnant. I decided to ask about circumcision, but the conversations were awkward and I received little helpful information. I found that circumcision was a taboo topic; few people wanted to talk about it. Why? Doctors who perform circumcisions, nurses who recommend it, and parents who consent to it do not want to face the reality of the harm they cause. Instead of facing the pain, they avoid the topic, and the procedure continues. Most men do not want to discuss or think about their own circumcisions. I learned that we need to have compassion during these conversations.A Jewish ritual ceremony (bris) is performed on the eighth day after the boy's birth, and includes circumcision and prayers. At a bris, friends and relatives are invited to observe and celebrate. It is part of my heritage. I tried to talk to my relatives about the information I had found, but everyone refused to discuss it. This avoidance made my decision very difficult. Then, for the first time, I was invited to a bris; I didn't want to attend. However, I had been at the boy's birth, so I decided to go to offer support. During the circumcision, my reaction was intense: I wanted to take the baby and run. I felt like an accomplice. I wanted to grab people by the [End Page E2] shoulders and scream, "How dare you?" I vowed I would never attend another bris, and I made the decision to write publicly instead of anonymously.I still had doubts, because I didn't know one intact adult male. What if I were to have a son, keep him intact, and he developed a complication later in life? I have learned that doctors are not taught non-invasive solutions, so most circumcisions performed after infancy are unnecessary. A Jewish doctor recommended a circumcision for a seventynine year old man who had a persistent rash that would not respond to treatment. Our organization suggested that he apply topical acidophilus. After he followed the recommendation, the rash disappeared, so he canceled the circumcision.In 1985, I became pregnant. Like many women I spoke to, I didn't want to face the circumcision decision, so I prayed for a girl. Our childbirth educator shared about male circumcision, which led to conversations with my husband. These tense interactions ended in an impasse. I wondered how this decision would impact my marriage. I experienced immense relief that my firstborn was a girl. Time was on my side.One day while walking in New York City, I serendipitously crossed paths with my childbirth educator. She was going to the United Nations to oppose female circumcision. I was in my 30s and had a master's degree in teaching. I had studied massage and anatomy. Yet, I had never heard about this tribal ritual. I had... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:An Epidemic of Difficult PatientsKeva SouthwellAs the opioid epidemic marches on, we have all become familiar with a particular breed of "difficult patient," the intravenous drug user. Most teams try to get through these admissions with as few interactions as possible. Nurses will tell you how much they hate caring for these patients, often citing "they did this to themselves" as they experience prolonged admissions due to infections resulting (...) from Intravenous Drug Use (IVDU). Most services try to get out of admitting these patients, saying they are more appropriate with infectious disease, cardiology, or "anywhere but with me." These patients often use drugs in the hospital, threaten to leave AMA, and are dangerous, liable to assault or abuse the very staff trying to help them. The general consensus is that taking care of these patients is a dirty job … why do I have to do it?That's where I come in. It's a dirty job … and that's exactly why I do it. I run a unique service, where my preferred patients are those admitted for 6–8 weeks of IV antibiotics to treat their endocarditis. Some of these patients survive after discharge, but most don't. I know this. But it's my job to help them anyway. It just turns out that in these cases, help doesn't always look the way you think it will.In a perfect world, having a life-threatening infection would be the rock bottom these young people need to embrace a new way of life. Unfortunately, this world is far from perfect. Just as having diabetes doesn't make you stop wanting junk food, having endocarditis does not make you stop wanting drugs. In fact, it can be the opposite. [End Page 26] Drugs are often the coping tool these patients turn to. Happy? Use drugs. Sad? Use drugs. Scared? Use drugs. That's why it's hard. Addiction defies logic; it can be cunning, baffling, and powerful. Until you understand addiction, you'll never really find a way to treat these patients, let alone a way to enjoy treating them.We all have patients who change things for us. They shift our perspective, make us view our practice, our patients, and ourselves differently; patients who teach us the lessons not learned in school. I will never forget Jack, one of those "difficult patients." He taught me how to care for people who really can't be medically helped. It's a lesson that can take years to learn: You've got to let go of the outcome, and some solutions don't look the way you think they should. In this way, he helped me continue in this difficult work.I was a nearly new hospitalist, having just moved into this work from outpatient addiction care. Jack was a young man, 32 years old. He had presented to our hospital with endocarditis of the aortic and tricuspid valves secondary to IVDU. He was referred to my service when he was ineligible for valve replacement due to septic emboli in his brain and subsequent micro hemorrhage. The surgery team wanted him to recover from these events before considering surgical treatment.Jack was a big guy, over 6'2", with a weight to match. He was covered in tattoos—his back, arms, chest, and neck—not an inch was bare. His physical presence might be considered intimidating. Jack was a man of few words: he complained of very little, was often asleep during medical visits, never really left his room, and had no visitors. About four days after his arrival, nursing became concerned about illicit drug use. Despite the fact he had no orders for narcotics or other sedating meds, he was sleeping all the time. His drug screens were negative. Despite the lack of specific evidence, I was asked to take measures to ensure he was not using illicit drugs, which included placing him on a contract and ordering 1:1 observation.His fatigue was concerning, though not for drug use. A repeat ECHO showed that his aortic insufficiency was worsening. His tricuspid insufficiency was very bad from the start. His belly began to swell, followed by his... (shrink)

: Research in emergency settings (RES) has become a major public issue with urgent policy implications. Significant attention has focused recently on RES in response to the trial of PolyHeme, a synthetic blood substitute, in trauma victims in hemorrhagic shock. Unfortunately, the discussion of the PolyHeme trial in the popular and scholarly press leaves important questions unanswered. This paper articulates three important lessons from the PolyHeme trial that have significant policy implications. First, the RES regulations should be re-visited, particularly the (...) requirement that existing treatments be unproven or unsatisfactory in order for research to be acceptable without consent. Second, further conceptual and empirical scholarship is needed to accomplish the goal of effectively involving communities. Third, a more subtle analysis is needed regarding how to balance the needs of maintaining public trust and protecting confidential trade information in the context of RES. (shrink)

As the aftershocks of the latest economic meltdown reverberate throughout the world, and people organize to physically occupy the major financial centers of the West, few experts and even fewer governments have dared to consider a world without the powerful markets that brought on the crash. Yet, as François Morin explains in _A World Without Wall Street?_, this is the very step that needs to be taken as quickly as possible to avoid a perpetual future of dehumanizing working conditions, devastated (...) ecosystems, and the submission of public policies to private interests. In this insightful and radical take on global finance, Morin recommends nothing less than a revolutionary reconstruction of the international monetary system. More, he recommends that the laws of societies be reformed so that the power of management may be shared among all of the actors involved in production, not concentrated in the hands of the few. This shift, argues Morin, will transform the monetary system into a common good for all of humanity, rich or poor. With Wall Street at the center of the very power structure that needs to be dismantled, Morin takes broad aim at the purely speculative financial games and arcane instruments by which the global economy and its citizens are held captive. In this very timely and provocative book, Morin bravely offers a way forward—instead of simply triaging a hemorrhaging system, he persuasively asks us to consider a subversive reinvention. (shrink)

This paper is about a drug called misoprostol and its controversial clinical and social lives. Although originally developed as a prevention for gastric ulcers, in the 1980s, it developed an off-label reputation as an abortifacient. The drug’s association with clandestine abortion has profoundly shaped its social life as a marginal and suspect character in the realm of global maternal and reproductive health where it has the potential to prevent two major causes of maternal death––postpartum hemorrhage and unsafe abortion. The (...) social life of misoprostol has also been shaped by the question of authoritative practice, that is, the question of who can deliver medicine. Both issues are about the specters of misuse of misoprostol: off-label, illegal, immoral, or by unlicensed providers. In this paper, I focus ethnographically on two women’s health nongovernmental organizations that have been conducting clinical testing and advocacy for the use of misoprostol for reproductive indications in global maternal health settings. Drawing on the notions of pharmaceutical activism and protocol feminism, I describe and analyze how the tools of evidence and authoritative practice have been reassembled in new networks of expertise toward the social justice goals of life, access, and dignity for women. (shrink)

Suppose that three patients each independently confront the same high-stakes treatment decision. Perhaps it is an option to terminate a high-risk pregnancy, or to accept a blood transfusion after a catastrophic hemorrhage. Suppose further that the three patients approach their choice in radically different ways. The divergence lies not in the choice made, but in the pathway followed in arriving at it. P1 is a classic analytical reasoner. She enumerates the potential costs and benefits of each option, reviews the (...) probabilities, and makes a decision on the basis of her analysis. P2 does none of that analytical work. She has a settled and robust prior... (shrink)

As the aftershocks of the latest economic meltdown reverberate throughout the world, and people organize to physically occupy the major financial centers of the West, few experts and even fewer governments have dared to consider a world without the powerful markets that brought on the crash. Yet, as François Morin explains in A World Without Wall Street?, this is the very step that needs to be taken as quickly as possible to avoid a perpetual future of dehumanizing working conditions, devastated (...) ecosystems, and the submission of public policies to private interests. In this insightful and radical take on global finance, Morin recommends nothing less than a revolutionary reconstruction of the international monetary system. More, he recommends that the laws of societies be reformed so that the power of management may be shared among all of the actors involved in production, not concentrated in the hands of the few. This shift, argues Morin, will transform the monetary system into a common good for all of humanity, rich or poor. With Wall Street at the center of the very power structure that needs to be dismantled, Morin takes broad aim at the purely speculative financial games and arcane instruments by which the global economy and its citizens are held captive. In this very timely and provocative book, Morin bravely offers a way forward—instead of simply triaging a hemorrhaging system, he persuasively asks us to consider a subversive reinvention. (shrink)

From 1991 to 1994 the Dutch Health Insurance Council financed research on Extracorporeal Membrane Oxygenation (ECMO). This is a technique for providing cardiopulmonary bypass to patients with pulmonary and/or cardiac failure. Most often, these patients are premature neonates. During ECMO, blood is drained from the right atrium, pumped along a membrane where gas exchange takes place, and then redirected to the aorta. To prevent blood clotting, heparin is added. However, with the heparin added, the risk of hemorrhage is considerably (...) increased. Therefore, both the chance of surviving and the chance of severe disability are higher with ECMO than with conventional treatment (i.e., ventilator support). (shrink)

From 1991 to 1994 the Dutch Health Insurance Council financed research on Extracorporeal Membrane Oxygenation . This is a technique for providing cardiopulmonary bypass to patients with pulmonary and/or cardiac failure. Most often, these patients are premature neonates. During ECMO, blood is drained from the right atrium, pumped along a membrane where gas exchange takes place, and then redirected to the aorta. To prevent blood clotting, heparin is added. However, with the heparin added, the risk of hemorrhage is considerably (...) increased. Therefore, both the chance of surviving and the chance of severe disability are higher with ECMO than with conventional treatment. (shrink)

Ever since its foundation in 1540, the Society of Jesus had had one mission—to restore order where Luther, Calvin and the other instigators of the Reformation had brought chaos. To stop the hemorrhage of believers, the Jesuits needed to form a united front. No signs of internal disagreement could to be shown to the outside world, lest the congregation lose its credibility. But in 1570s two prominent Jesuits, Cristophorus Clavius and Benito Perera, had engaged in a bitter controversy. The (...) issue at stake had apparently nothing to do with the values on which Ignazio of Loyola had built the Society of Jesus. And yet the dispute between Clavius and Perera was matter of concern for the entire Jesuit community. They were... (shrink)

Although many phrases are invoked to describe the precarity of democracy today, perhaps none resonates more than "post-truth." The rapid rise of disinformation, conspiracy theories, and the loss of confidence in the possibility of impartial evidence has led to a situation in which highly partisan opinions threaten to devolve into a state where no one believes anything anymore. In the face of this danger, it seems imperative to affirm the existence of objective Truth. However, falling prey to the ideal of (...) Truth is as dangerous for democracy as being truth denialists. In this book, political theorist Linda M. G. Zerilli considers what happens when we take seriously the Socratic idea that there is truth in opinion. Drawing on the work of Arendt, Foucault, and Wittgenstein, A Democratic Theory of Truth critically interrogates the concept of truth presupposed in the "post-truth" debate. Whatever their disagreements, the critical literature on post-truth sees in the ongoing hemorrhaging of objective facts to subjective opinion a genuinely new threat to democracy. In Zerilli's reading, the part played by citizen subjects in determining the existence or value of truth is given in the structure of truth itself. This book restores the rightful place of plurality, dissent, and citizen opinion in the democratic debate about truth and truthfulness today. (shrink)

Ten years ago, Megan Shinal sought the care of neurosurgeon Steven Toms for the surgical treatment of a recurrent nonmalignant tumor in the pituitary region of her brain. In their twenty-minute meeting, Shinal did not make a final decision about which surgical approach she wished to pursue. Subsequently, she spoke with Tom's physician assistant once by phone and once in person, when she signed the consent form, which did not appear to designate which surgical approach she had chosen. During the (...) operation—a total resection—Toms perforated Shinal's carotid artery, resulting in hemorrhage, stroke, brain injury, and partial blindness. The jury found that Toms had fulfilled his informed-consent obligations prior to performing the resection; however, in June 2017, the Supreme Court of Pennsylvania overturned the decision, relying on the Pennsylvania Medical Care Availability and Reduction of Error Act. The court found that the language of the act is unambiguous in its requirement that “a physician's duty to provide information to a patient sufficient to obtain her informed consent is non-delegable.” Presumably, this rule of nondelegation applies beyond the surgical theater to other major treatment decisions. And it is unclear whether it applies to other professionals in a subordinate position to the treating physician, such as residents and fellows. (shrink)

In the outpatient ultrasound suite of a major urban medical center, the mood is somber. A young woman lies tense and anxious. Pregnant for the first time, she has experienced early first-trimester bleeding. The radiologist relates the ultrasound findings: there has been a small hemorrhage, but there is a six-week-size fetus with normal cardiac activity. Translation: the baby is alive! The woman quietly sobs, happy but apprehensive.Across the drive, in the main hospital building, a young boy lies unresponsively comatose (...) in the Pediatric Intensive Care Unit. He was hit by a car while riding his bicycle. He is relying on a ventilator to breath, but his cardiovascular system is supporting itself. After a series... (shrink)

IntroductionCerebral visual impairment results from damage to cerebral visual processing structures. It is the most common cause of pediatric visual impairment in developed countries and rising in prevalence in developing nations. There is currently limited understanding on how neurologic, developmental, and ophthalmic factors predict outcome for pediatric CVI.MethodA retrospective manual chart review of pediatric CVI patients seen at the tertiary pediatric hospital neurology and neuro-ophthalmology service between 2010 and 2019 was conducted. Patients were stratified into severity groups, and followed over (...) time to identify outcome predictors. Collected baseline characteristics included perinatal, genetic, developmental, and neurologic history, along with neuroimaging and fundoscopic findings on examination. Longitudinal data collected included age, seizure control, and type of therapy received. Linear mixed-effect models were used for longitudinal CVI grade outcome analysis.ResultsA total of 249 individuals spanning 779 patient visits were identified. Mean age at diagnosis was 18.8 ± 16.8 months. About 64.3% were born at term age. Perinatal history revealed hypoxic ischemic encephalopathy in 16.5%, intraventricular hemorrhage in 11.6%, and seizures in 21.7%. At presentation, 60.3% had a diagnosis of cerebral palsy and 84.7% had developmental delay. Among all subjects, 78.6% had epilepsy; 33.8% had an epileptic encephalopathy, with spasms/hypsarrhythmia being most common. Abnormal neuroimaging was present in 93.8%. Genetic anomalies were present in 26.9%. Baseline visual examination revealed no blink-to-light in 24.5%; only BTL in 34.5%, fixation/tracking in 26.5%, and optokinetic drum follow in 14.4%. Longitudinal data analysis showed that perinatal history of HIE, a positive epilepsy history, using multiple epilepsy medications, cerebral palsy, and abnormal fundoscopic findings were all negatively associated with CVI grade change over time. After controlling for significant confounders, receiving any type of therapy [early childhood intervention, physical and occupational therapy, refractive error correction or glasses] was significantly associated with longitudinal improvement in CVI grade compared to patients who did not receive any therapy, with glasses yielding the largest benefit.ConclusionThis study offers extensive insights into neurologic, developmental and ophthalmologic features in patients with moderate to severe CVI. In concordance with previous findings, aspects of perinatal history and epilepsy/seizure control may help inform severity and prognosis in the general neurology or ophthalmology clinic. Conversely, these aspects, as well as genetic and specific epilepsy traits may alert vision health care providers in the clinic to pursue visual evaluation in at-risk individuals. Longitudinal follow-up of CVI patients showed that interventional therapies demonstrated vision function improvement greater than no therapy and maturational development. (shrink)

Tissue plasminogen activator (tPA) is administered to patients with suspected ischemic stroke to improve blood flow to the brain In rare cases, patients present with complaints of stroke symptoms that appear to be non-organic due to malingering, factitious disorder, or conversion disorder (psychogenic stroke mimics). Deciding whether or not to administer tPA to these patients can be challenging. The risk of hemorrhage after administration of tPA is low, but not zero. The ethical principles of beneficence and nonmaleficence need to (...) be weighed carefully in these situations. We present two cases of patients with suspected psychogenic stroke mimics to illustrate the ethical challenges faced in identifying and managing psychogenic stroke mimics. Further research is needed to demonstrate effective treatment strategies for patients with acute stroke symptoms of psychogenic etiology. (shrink)

A new interpretation of human menstruation is presented, resulting from a cross‐disciplinary investigation of evolution, developmental biology, and physiology. A process evolutionarily associated with childbirth expresses itself as menstruation in women for whom frequent and continual failure to conceive has become the default situation. In humans and Old World primates, contractile uterine spiral arterioles evolved as the complement of the highly invasive hemochorionic placenta and is the selected phenotype. Placental progesterone withdrawal during the last stage of birth leads to arrested (...) blood flow through maternal spiral arterioles, allowing detachment of the deciduous placenta with minimal maternal hemorrhage. In nonpregnant females, progesterone withdrawal from a degenerating corpus luteum initiates menstruation and stops blood flow through uterine spiral arterioles. Both events share similar physiological mechanisms and sequences. This explanation may improve our understanding of a recurrent event experienced by half of the human population and for a quarter of their adult reproductive life. (shrink)

As a philosophical counselor, I encounter many individuals who live with an almost inexpressible grief, hopelessness, and despair. This paper argues that two macro-causes of these affects are philosophical and structural. This paper sets up a distinction between (1) biotic, ontological, rational value, and (2) abiotic, hyperreal, nihilistic value. Abiotic “value” now constitutes the hemorrhagic nihilism of our time. Kant, Nietzsche, Baudrillard, and Kierkegaard will be utilized to construct the philosophical argument tracing the movement from the biotic to the abiotic. (...) This is the first valence of trauma, the cognitive/imaginative valence. Ruin porn, environmental grief, and structurally induced precarity will be utilized to provide historical evidence for the movement from the biotic to the abiotic. This is the second valence of trauma, the somatic-structural valence. The paper concludes that the double valence of hemorrhagic nihilism is, in essence, traumatic. Consequently, addiction to hyperreality has become the pandemic of our time. (shrink)

LANGUAGE NOTE | Document text in Chinese; abstract also in English. 世界衛生組織(WHO)在歷經自1976年伊波拉病毒病(EbolaHemorrhagicFever, 伊波拉出血熱)爆發以來，處理疫情爆發當中出現的種種倫理問題之後，於2016年出版“Guidance for Managing Ethical Issues in Infectious Disease Outbreaks”（中文暫譯：《傳染病爆發處理倫理議題之指引》）一書，其中整理出「正義、行善、效益、尊重自主、自由、團結、互惠」等七項倫理原則，於今面對新冠肺炎（COVID-19）的疫情上，各國防疫 政策，亦可作為應對。作為一名當代墨者，本文即以此為基礎，由醫療的角度，結合國內情況，企欲在墨學義理內作一生命倫理的反思，並試圖對後疫情時代給予具體作為之建議。 In response to various ethical problems that emerged after the 1976 Ebola hemorrhagic fever epidemic, WHO published the book Guidance for Managing Ethical Issues in Infectious Disease Outbreaks in 2016. The content of the book was organized around seven ethical principles, namely, justice, beneficence, benefit, respect for autonomy, freedom, reciprocity, and unity. These seven ethical principles can be used as (...) a framework for countries to develop policies for coping with the COVID-19 pandemic. Drawing from contemporary Mohism, this paper reflects on the situation in Taiwan through the lens of these seven ethical principles. It aims to arrive at a Mohist understanding of bioethics and proposes concrete actions for the post-epidemic era. (shrink)

This elegant treatise examines the nature of kindness through the fascinating lenses and contexts of ancient, medieval and contemporary philosophy, natural history, theories of mind, of natural selection, eco-psychology and sociobiology. It challenges the reader to consider the myriad potential consequences of human behavior, examining various iconographic moments from the history of art and science as a precursor to the concept and vital potentials for ecological conversion. Focusing on the fundamental mechanisms of reciprocity among humans, other species, communities and nations, (...) Tobias and Morrison lead readers on a remarkable journey whose itinerary, and the provocative questions explored, seek to affirm a pattern in evolution and in human thought that is emphatically oriented towards benevolence, not tyranny. Prosociality in all species - making others happy, kind gestures at any and every juncture of life - has, as a discipline of enquiry, enjoyed a social scientific renaissance during the last decade. Can natural selection move rapidly enough to meet that ultimate challenge? Can our species re-evolve in real time, moving from the ideas, to the ideals, to their applied engineering in a real world that is ecologically hemorrhaging? Which all the critical moral and cognitive changes in social communion such new human nature, as the Authors suggest, clearly requires? This groundbreaking work of ecological philosophy, with its roots in ancient Greek thought, represents a radical break with nearly every traditional scientific paradigm, in exploring the intuitive geography and dramatic questions of ourselves - each and every one of us - that will prove crucial to the survival of our species, and all those we co-habit this miraculous planet with. (shrink)