Bioethics, Volume 35, Issue 7, Page 696-703, September 2021.

A 24-year-old Hispanic male came into the emergency room of a large public teaching hospital with acute cardiac failure and chest pain. He was admitted and diagnosed with rheumatic heart disease and regurgitation and stenosis of both mitral and aortic valves. Medical judgment concluded that the patient needed to be medically stabilized and then undergo cardiac surgery to repair heart valves. The patient spoke only Spanish. Investigation through an interpreter revealed that he was an illegal alien from a (...) Central American country who has lived in this country for five to seven years. He came to the United States so that he could receive treatment for his heart condition, evidently fearing that he would not receive treatment in his home country. The patient entered this country through the assistance of some distant relatives. He did not have a strong support system. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Bringing Cancer Care to Those who Don't Have ItLawrence N. ShulmanI have been treating cancer patients in the Harvard Medical School hospitals since 1977, and in those 35 years we have made tremendous progress. Though work still needs to be done, and far too many patients still die of cancer, many are cured. In particular, children and young adults have a high rate of cure from such diseases as (...) Hodgkin's lymphoma, non-Hodgkin's lymphoma, acute lymphoblastic leukemia, and childhood sarcoma. Patients with breast cancer in the US have a greater than 80% chance for long-term survival. The death rate from cervical cancer in the US is very low. These results have been achieved by making diagnoses earlier, in many cases surgical excision, and often systemic therapies such as chemotherapy, hormonal therapy, radiation therapy, and more recently by using so-called "targeted" therapies—those directed at particular molecular characteristics of the cancer cells.Princess Dina Mired has said that the opportunity to survive cancer should not be an accident of geography. In cases where we already have effective and inexpensive tools to cure cancer, these treatments should be considered a basic human right, a life-saving medical service.I met Patty, a young woman living in the U.S. during November of her senior year in high school, after she discovered a small lump above her left collar bone. Though she felt entirely well, she called her primary care doctor who saw her the next day, felt the enlarged lymph node, and referred her to a surgeon, who did a biopsy later that week. Her primary care doctor also called me, and we scheduled a visit when the pathology results were available. The following week the pathologist notified Patty's pediatrician that the biopsy showed Hodgkin's lymphoma. When I met Patty, she was a bright and focused young woman, waiting to hear about her college applications and enjoying her senior year. Her cancer diagnosis was completely out of context with her life as she planned it, but with the support of her family and boyfriend, she seemed prepared to take things one step at a time. A PET CT scan demonstrated a modest mass in the mediastinum (chest), but no other disease. She was in an early stage of the disease with an excellent prognosis. We recommended and administered six months of chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine—four chemotherapy agents that are off-patent, and relatively inexpensive. She lost her hair, not a trivial issue for her, but otherwise felt reasonably well during the treatment. She was determined to graduate with her classmates, and was able continue to attend school and keep up with her work. In June, seven months into her cancer diagnosis and treatment, she graduated with honors, and was on track to enroll in college in September.Like other 18-year-old women with Hodgkin's lymphoma, Patty had an over 80% chance for cure with the potential for a long and productive life ahead of her because we could perform a biopsy, make a diagnosis, and safely and effectively treat her with four inexpensive, off-patent, chemotherapy drugs. She had nearly the same likelihood of living a long and fruitful life as her classmates, and had the same chances for childbearing. In my line of work, with the knowledge we now possess, to allow someone like Patty to die without a chance of curative care is simply unacceptable. Treatment of curable cancers should be considered on par with the right to clean water, adequate nutrition, treatment for infectious disease, and access to maternal and child healthcare services.But in many places in the world, people with cancers we could easily eradicate in Boston have no access to cancer services, and do die unnecessarily. The local healthcare infrastructure has no [End Page E10] capacity to evaluate a patient, perform or process a biopsy, make a diagnosis, or treat the patient with potentially curative surgery, chemotherapy and radiation. I have rounded on the wards of hospitals in developing countries, stopping to talk with numerous patients like Patty: young women, some of whom might have had Hodgkin's lymphoma, but no... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Feminist Studies 41, no. 3. © 2015 by Feminist Studies, Inc. 571 Moving through Cancer: An Interview with Carol Collins Artist Carol Collins spoke with Feminist Studies editorial collective member Stephanie Gilmore about her experience of cancer, treatment, and recovery and how it gave rise to an art series that examines what nature means in the midst of unnatural treatments. SG: Carol, thank you for the opportunity to speak (...) with you about your artwork. Having just lost my sister to cancer, your work reminds me of much pain and loss, but also of love and the desire to survive. Before we discuss the work itself, I would like to hear about your journey through cancer, treatment, and recovery. CC: The breast cancer patient’s journey is complex and perilous. When I was healthy, I was ignorant about the magnitude of suffering many cancer patients undergo. And, although I am a private person, I’m now publicly sharing my cancer experience in order to be a voice for those who have suffered through similar treatments—and worse—and those who sadly are no longer with us to tell their story. Being bald and nauseated are not the most awful possible side effects of the treatments, although they are the most well known. Some women survive the cancer but can die from the treatments, or others suffer through the treatments and die anyway. Often, it seems many believe patients can overcome their 572 Carol Collins adversity solely with positive thinking and persistence. However, not discussing the array of physical and psychological damage that even those with good prognoses incur propagates ignorance about this malady. I hope that my artwork and story will promote a deeper understanding of a breast cancer patient’s plight and will encourage more support for research for individualized therapies and prevention. My cancer journey began when I received a breast cancer diagnosis in January 2014. Life just before that point was good; the future was bright. Tendon pain, caused by my flat feet and a lot of exercising, was my only known ailment. But one day a routine mammogram revealed three tumors in my right breast. The radiology oncologist said the masses were highly likely to be cancerous, so he immediately did painful core biopsies at the sites of my three tumors. The next day, it became clear that we needed to act quickly. The biopsy results revealed I had a very aggressive invasive breast cancer with estrogen, progesterone, and HER2 receptors. Breast cancer in premenopausal women grows quickly due to the high level of hormones present. The oncologists and surgeons said I would, at a minimum, need a mastectomy and possibly lymph node resection, and they warned that I would likely need chemotherapy, which would destroy my eggs and ovaries. After learning of my limited options, I approved the removal of one breast and my sterilization. I knew I needed to think rationally and face the giant raven before me head on. However, I did not realize the magnitude and multitude of physical and psychological pains, illnesses, and losses that were soon to come. The first year of cancer treatments inflicted much physical pain. I received three extremely painful injections into my right breast with a radiolabeled colloid just prior to the mastectomy. The pain came from the injected dye, not from the needle. The modified radical mastectomy was more excruciatingly painful than I anticipated, even with painkillers and overnight hospitalization. Breast reconstruction was an option that added more pain and discomfort from weekly fillings of the installed “expander” and additional surgeries. Extreme pain after the mastectomy prevented me from lying down for months. Foolishly, I did not get an injection port installed in my chest. Instead, I endured numerous deep (and often unsuccessful) needle pricks into the seemingly few veins of my left arm (which still had its lymph nodes) that were appropriate for infusions over the period of a year. Shooting pains across my chest and arm were the norm. Carol Collins 573 In addition to the surgically induced physical pain, the chemotherapy quickly caused a myriad of undesirable physical side effects. It is scary to realize that the medical community does not often fully understand... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Bittersweet Score:A Father’s Account of His Family’s 20-Year Journey After a Pediatric Brain Tumor DiagnosisChristopher RileyI hadn’t seen him for 20 years, not since the day he drilled a hole in Peter’s head and left the stainless steel drill and bloody bit on the bedside table. He figured prominently in the story I often told of that day when he, a doctor in training, [End Page 3] informed (...) my wife Kathy and me that, “Wow,” our five-year-old son had “an impressive tumor” in his brain. He announced it with the admiration I reserve for a touchdown pass or stunning sunset. Since that day, he had become a venerable physician. Back then he was the resident who met us in the ER after our pediatrician told us that the MRI of Peter’s brain was “not normal,” that “there might be a growth.” As if there might not be. I imagined that Peter’s brain might simply have an unusual shape, or that the scan revealed some undiscovered fracture and the authorities only wanted to lock me up and all with my son would be well. The thrilled young doctor slew those hopes with an ice pick: “Wow, that’s an impressive tumor.” I said, “That’s the first time anyone has used the word tumor.” The doctor appeared mortified and started over.Now 20 years later we found ourselves at the same party and I felt a compulsion to introduce myself, remind him we’d met that day in 1993, and tell him what had become of Peter and his family in the decades since he’d made that mortifying mistake, one I hoped had become for him a defining moment. To my disappointment, he didn’t seem to remember.Peter was my red-haired boy. Fearless and whip smart, he told a stream of knock-knock jokes and performed dance routines choreographed by his 8-year-old sister Rachel. Six months of headaches, vomiting and clumsy falls led to discovery of the tumor. When I phoned my parents with the news, I couldn’t speak the words, words that felt as if they spelled my boy’s doom. My body refused to pronounce them.The war for Peter’s life began with surgery. I sat with Kathy in the surgical waiting area, fearing every minute that I would see the surgeon approaching with his shoulders slumped in mortal defeat. I learned during those hours that fear of your child’s death is a physical pain, a constriction in the chest, a suffocation. At the end of that wait, the surgeon told us the tumor was out and Peter had survived. The pathology indicated the tumor was a medulloblastoma. Without additional treatment, including radiation, it was certain to come back. Kathy’s knees buckled. Having just endured one life-and-death battle, we were plunged into another. To complicate matters, Peter wasn’t waking from surgery. Even after the anesthesia wore off, Peter remained groggy, unable to move or focus his eyes.Through the following days, Peter failed to rouse or speak. Sores formed at the back of his neck where his unswallowed saliva pooled. Neurologists doubted he knew us. His doctors hoped Peter would recover but it was possible he would remain as he was indefinitely. As I sat holding his useless hand, watching his useless body, I thought I’d never loved him as much as I did now.Peter’s doctors presented two treatment options. The first consisted of relatively high doses of daily radiation, the most effective known method for preventing the return of the cancer. But radiation wasn’t good for young brains. It “shaved IQ points,” they said in wild understatement. So they offered a second, experimental option, one that reduced radiation by a third and added months of chemotherapy. The doctors hoped this new regimen would be as effective as the old but cause less cognitive damage. They asked us to choose. It seemed impossible. We gathered the scant available data. We weighed the risks. We prayed. We took a leap. Without asking him, we made a decision for Peter we knew... (shrink)

The case presented here is tragic, not just in the sense of being a sad story, but in the dramatic meaning of tragedy. It presents us with a situation where there is no clear path, where moral ambiguity exists, and where no possible solution could unequivocally be declared the right or good one. Ethical deliberation can help here, but only as a way of clarifying the issues and offering reasonable solutions. It cannot show us the one right way.Baby G has (...) profound medical conditions, including respiratory failure, a chest wall deformity that will require surgery, and profound neurodevelopmental disability. Even a best case scenario portends a shortened lifespan and.. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Editors’ NoteJames M. DuBois, Ana S. Iltis, and Heidi A. WalshFrom childhood, David Slakter had undergone tests and invasive procedures to monitor his nephritis. It was not a surprise when in 2015, doctors told him he needed a kidney transplant. The wife of a childhood friend was a close match and gave him one of her kidneys. Before his transplant, aerobic exercise was difficult; a few months after transplant, (...) Slakter could ride his bike, hike, and work out with a personal trainer. He no longer had to weigh food or gauge his potassium consumption, a concern for people with kidney failure. For Slakter, “life post-transplant has been a significant improvement.”Individuals or family members of those who have received an organ transplant from a living or deceased donor share their stories in this issue of Narrative Inquiry in Bioethics. The symposium is titled “Receiving the Gift of Life: Stories from Organ Transplant Recipients.” Organ transplantation can extend an individual’s life by decades. It can also greatly improve an individual’s quality of life, as was Slakter’s experience. At the same time, organ transplantation is expensive and stressful. Recipients can experience complications, including organ rejection, and there are few appealing alternatives.After her heart transplant, author Leilani R. Graham required four open-heart surgeries, ECMO, and an intra-aortic balloon pump. She experienced delirium, necrotizing pneumonia, and severe muscular atrophy that required her to re-learn how to walk. She struggled with weight gain, explosive mood swings, hair loss, and was terrified that her body would reject the new heart. For Graham, “[Transplant] was not the miracle [she] was hoping for.” Graham says she felt unprepared for and inadequately informed about what to expect after her transplant, which left her “battered, beaten, and bruised” with a 12-inch line from neck to navel and “bullet holes” up and down her torso from the chest tubes. When reflecting on her experience post-transplant, Graham says, “It wasn’t the physical trauma that hurt the most. It was that no one seemed surprised [by the aftereffects of transplant].” Seemingly no one, that is except Graham, who calls on transplant providers to “prioritize empathy.”The symposium editors are Jason T. Eberl and Tristan McIntosh. Three commentary articles, written by Macey Leigh Levan, Heather Lannon, and Vidya A. Fleetwood, Roslyn B. Mannon & Krista L. Lentine, offer important insights into the authors’ stories. The editors thank Mid-America Transplant, the UCSF Lung Transplant Program, Donor Connect, William L. Freeman, MD, MPH, MJIL, CIP, Janet Monk, and the individuals who gave anonymous donations to support the publication of this issue, an open-access VOICES edition of the symposium, and accompanying teaching guides.The research article in this issue, “‘A Shell of My Former Self’: Using Figurative Language to Promote Communication about Patient Suffering,” was written by Tyler Tate, Elizabeth Stein, and Robert A. Pearlman. The relief of suffering is a primary goal of medicine. However, the authors note that clinicians often miss or ignore suffering because they focus on the causes rather than the experience of suffering, or the subjective nature of suffering makes it difficult to discuss. The authors believe that “the key to communicating about suffering lies in finding [End Page vii] the right kind of words to describe the experience” and say that figurative language offers a promising approach. In their research, the authors performed qualitative analysis on 52 works of literature and identified 254 excerpts of figurative language with themes of non-physical or psychological suffering. The authors found 13 salient themes: brokenness, diminishment, disorientation, drowning, emptiness, imprisonment, battle, darkness, isolation, invisibility, lifelessness, punishment, and torture. The authors reiterate that developing a shared language of suffering could foster a therapeutic patient-clinician relationship and improve clinicians’ ability to recognize and address a patient’s experience of suffering.María Susana Ciruzzi wrote the first of two case studies included in this issue. “The Sword of King Solomon” addresses a tragic and difficult subject—how to navigate the situation posed by conjoined twins when “any decision will produce damage and suffering.” The case involves two infant male patients born at 37 weeks gestation as omphalo-ischiopagus conjoined twins... (shrink)

Despite what I wrote in my medical school applications, my relationship with medicine wasn't always the torrid love affair I made it out to be. Organic chemistry wasn't really my favorite class (or my second favorite, or my third). My heart didn't actually skip a beat as I waited for protein isolates to complete their snail‐paced race across an agarose gel. And while I certainly enjoyed the surgeries I scrubbed into as an undergraduate, even they lost their charm during the (...) fifth hour of standing at attention, hands glued to my chest, petrified I would break the sterile field or pass out from starvation. For me, a career in medicine was a leap of faith. I had to trust that those flashes of meaningful human interaction I experienced early on would increase in frequency and intensity over the course of my career. Fortunately, I have not been disappointed thus far. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Moral Distress for the Physician AssistantSharyn L. KurtzMy morning rounds as an inpatient medical oncology physician assistant began as usual. I arrived at the hospital early to receive 7 a.m. sign out from the covering resident. The overnight report began favorably. All patients remained stable. Even my patient, whom I will call Mrs. Walker,* had a quiet night. However, given her tenuous admission presentation, including altered mental status, hypercalcemia (...) (high levels of calcium in the blood), atrial fibrillation with rapid ventricular response (irregular, rapid heart function), widespread metastatic lung cancer, and recent neurosurgery to stabilize her spine, I decided to prioritize Mrs. Walker’s morning evaluation.Examining her medical chart proved reassuring. Her tachycardia (rapid heart rate) had been better controlled over the past two days. Her hypercalcemia had been treated, such that she was no longer somnolent. In fact, she was now arousable, conversant, and able to offer some input regarding her healthcare wishes. However, because she was experiencing intermittent delirium, her husband continued to act as her primary medical decision–maker.As her health care proxy, Mr. Walker had experienced conflict with the medical team during his wife’s prior hospital admission. However, even though Mr. Walker lived greater than 45 minutes from the hospital and was not able to visit regularly, he and I spoke daily by phone, which allowed me the opportunity to offer regular medical updates. Mr. Walker felt overwhelmed with his wife’s condition, but he was comfortable with the care the medical team had provided thus far. He was encouraged by the small improvements we had noted since her hospital admission five days prior.Mr. Walker stated on hospital admission that he wished for DNR/I orders to be placed, since this cohered with his wife’s previously stated wishes. However, he still wanted “everything else done” in terms of treating his wife’s medical conditions, including treatment of her atrial fibrillation, pain, and electrolyte anomalies. Most of all, he hoped Mrs. Walker would soon have increased mobility, which he felt would grant his wife the best quality of life possible. He was adamant that “being active” was what Mrs. Walker wished for, and that she had never wanted to be confined to bed.Mr. Walker’s requests seemed reasonable. Although Mrs. Walker’s lung cancer was widespread, and although many on the medical team felt she would not improve to the point where palliative chemotherapy could be considered, [End Page E13] she had stabilized. Her recent spine surgery had been successful, and she was healing adequately. The neurosurgeons had cleared Mrs. Walker for increased activity out of bed as soon as she could be fitted with a lumbar brace. The pain and palliative care specialists felt that Mrs. Walker’s residual back pain and delirium could be well managed with oral medications.Prior to my entering Mrs. Walker’s room to begin her physical evaluation, I was met by her seasoned nurse, whom I will call Amy. “Sharyn,” Amy warned, “Mrs. Walker’s heart rate is 150 and she is complaining of chest pain.” I entered Mrs. Walker’s room, and she was notably uncomfortable, grasping her chest. The monitor showed that Mrs. Walker’s heart rate was in fact in the 150’s. She was pale, short of breath, and wheezing. “Mrs. Walker,” I asked, “how severe is your chest pain on a scale from 1 to 10?” Mrs. Walker replied, “Nine.” I asked Amy to obtain an EKG, to provide oxygen, and to administer an IV medication that would slow Mrs. Walker’s heart rate. I stepped out of the room to place the computer orders, and I paged my attending physician to let him know about Mrs. Walker’s change in status. After hearing the update, my attending physician, whom I will call Dr. Clark, stated that he agreed with all of my treatment decisions thus far. He was on his way into the hospital. I planned out my next steps with him on the phone and returned to the patient’s room.The monitor gave evidence that Mrs. Walker’s heart rate was improving. Mrs. Walker reported that her pain was now “4 out of... (shrink)

Mr. Galanas, an eighty‐six‐year‐old man, intentionally shot himself in the chest and abdomen. Surprisingly, the bullet damaged only his distal pancreas and part of his colon, requiring a diverting colostomy to prevent leakage of bowel fluids into his abdomen. After being admitted, he lies intubated in the intensive care unit awaiting surgery to repair his colon. He is responsive but does not demonstrate clear decision‐making capacity. He grudgingly accepts pain medications but refuses antibiotics and antidepressants. He has a (...) living will that gives his wife durable power of attorney and also explicitly states a desire to refuse all medical interventions if he is permanently unconscious or in an end‐stage condition. Mrs. Galanas reports frequent conversations in which her husband said he would not want to be sustained on life support. She also says that he often mentioned he would not want an ostomy bag—a likely, albeit temporary, outcome of the proposed surgery. His physicians are nervous about withholding medical interventions when Mr. Galanas's injury is the result of a suicide attempt and his prognosis is good. Should the care team surgically repair his injured colon, regardless of the patient's capacity, his advance directive, and his wife's statement that he would not want surgery or other life‐sustaining treatment? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Tincture of the Doctor's TimeHolland KaplanI first thought of Mr. H as a "difficult patient" while reading the written hand-off I received on him as I was preparing to take over an inpatient general medicine service—"He leaves all the time to smoke." I don't think the statement was meant to imply anything about the patient; if anything, it may have been included for context to prepare me for (...) the patient's intermittent absence. But, reading this, I felt a familiar sense of annoyance rising in my chest. Every few months, I take care of a patient who seems to never be in his room. The patient is consistently out smoking, in the cafeteria, or in another unknown location, seemingly doing an undisclosed activity. This is frustrating because it means I have to work around the patient's schedule of smoke breaks and jaunts to the cafeteria to evaluate the patient on a daily basis. The thoughts inevitably cross my mind: Does this patient even want care in the hospital if he's never in his room? Is he actually sick enough to need to be in the hospital if he's able to spend so much time outside of the hospital? Why is he leaving so frequently—is he doing drugs?This particular patient had been in perfect health until two months before I met him when he was shot multiple times during an encounter at a gas station. One of the bullets had lodged in his back, shattering a vertebra. Another had decimated the bones in his right upper arm, which were now held in place by screws and plates. Several had landed in his abdomen, necessitating the removal of part of his bowel. Finally, a bullet had sliced through the lower part of his right kidney, shredding his ureter and mandating surgical reconstruction of his urinary system. After over a month in the intensive care unit with multiple reparative surgeries, he was discharged to a rehabilitation facility. But he started having fevers and fast heart rates; ultimately, he was admitted to the hospital again for multiple infected fluid collections that had formed at the sites of his surgeries. He left the hospital prior to getting treated for these infections, purportedly "against medical [End Page 12] advice." And now, several weeks later, he was here in the hospital for the same reason.The first time I went to see Mr. H, he was, of course, not in his room. I went to the nursing station to ask if the clerk knew where he was. She knowingly said, "Oh yeah, he goes out a lot. I can give him a call to let him know the doctor is here to see him if you'd like." I assented, thanked the clerk for calling him, and proceeded, annoyed, in seeing the rest of my patients. I considered how I would address Mr. H's behavior when I was finally able to talk to him. I had seen others take many different approaches—negotiation about the timing and frequency of these extramural expeditions, ultimatums about getting discharged, mandating urine drug screens upon return, and silent, frustrated tolerance. I resolved to wait to speak to him to determine which approach might be most suitable. An hour later, I received a call from the clerk that Mr. H had returned to his room to see me.The first time I met Mr. H, he informed me he had taken the bus to midtown to make a run to the grocery store. I was internally incredulous. He felt well enough to go to the grocery store? Why was he in the hospital then? At that moment, I opted not to discuss his frequent departures yet, as I was frustrated and realized I wouldn't be able to identify the best way to address them. I reviewed his medical issues with him, asked specific questions about how he was feeling, performed a physical exam, and reiterated his current plan of care. Mr. H made it very clear that he would like to get out of the hospital as soon as possible. I tried to set the expectation that he... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Lessons Learned in Room 208Katherine BakkeAuthor's Note. Parts of this story were previously shared here: https://theinterstitium.home.blog/2020/06/01/journeying-to-a-time-of-death/I remember the first time I saw a patient die. I was a medical student on my surgery rotation. Pushed to the sidelines of the resuscitation bay while the trauma team tended to a teenager injured in a motorcycle crash, my attention was drawn to the drama unfolding next door. There, a team (...) of physicians performed CPR on a man. While a curtain and a comforting social worker separated the patient's wife and daughter from the horrors of the resuscitation, I had a full view of everything. I watched as each chest compression threw the man's belly upward, like he had a bad bout of the hiccups. I watched as each pulse check yielded no return of blood flow. I watched as his wife and daughter clenched their hands in prayer, muttering, "Please, please, please." Then, the physician called the code. The instant the doctor pronounced him dead, I felt the presence of one less person in the room. I was surprised by how visceral this departure felt. It seemed like a sacred moment, a small proof that our bodies do indeed house our souls.I started paying close attention to how surgeons talked about death. Discussions of death seemed frequent in windowless work rooms amongst doctors, or in hushed conversations at the nurses station. Discussions of death were notably absent when talking with patients or their families. Sometimes, it seemed that the sicker the patient, the less likely their possible death was acknowledged. I [End Page E12] was fascinated by how challenging it was to speak honestly about our inevitable mortality. I began reading everything I could find about discussing end-of-life issues. I even conducted and published a systematic review on the subject. When it came time for me to begin my own surgical training, I carried with me a naive confidence, eager to engage in these conversations at the bedside.My time finally came eight months into my intern year. I was working in the intensive care unit and was "up" for the next admission. I got a call from the emergency department, saying a 68-year-old woman needed an ICU bed for a heart failure exacerbation. Her breathing was labored. They had given her IV Lasix, but I was told she might need BiPAP or other respiratory support while her heart failure was managed.Ten minutes later, she rolled into Room 208, and the ICU nurses started their work transferring her from the stretcher to the bed, applying EKG leads, a blood pressure cuff, and a pulse oximeter. I stood at the foot of the bed and quickly realized I had never taken care of a patient so ill. Her head drooped to her chest, every ounce of energy used to draw her next breath. She could only mumble indiscernible words; she hardly had the energy to open her eyes. I glanced at the monitor displaying her vitals: heart rate 120, SpO2 84%, BP 70/40. A foley catheter hung at the bedside, and no urine was present. "They gave her Lasix downstairs, right?" I asked the nurse. We both looked at the foley bag, and then at each other. I glanced at the patient's lips, which were dry and cracked. I pinched the skin at the top of the patient's hand, and it tented. I was pleased with my exam skills, and my ability to deduce that she was dehydrated. "This isn't heart failure," I thought, as I considered other reasons for her illness. The nurse awoke me from my self-congratulating stupor and reminded me sternly, "We need orders."The situation rapidly became more critical. The patient's arterial blood gas (ABG) showed a pattern of impending respiratory failure. Her daughters arrived at the bedside; one was wearing hospital scrubs. I introduced myself to them as the resident doctor caring for their mom. I asked if the daughter wearing scrubs had a healthcare background, foolishly thinking that doing so would build rapport. She curtly replied, "I... (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)

In lieu of an abstract, here is a brief excerpt of the content:Fault LinesLaura A. KatersI first meet Shawn in person on the 46th day of his most recent hospitalization. We sit outside of a community hospital on a wooden bench dedicated as a place to “sit, pause, and reflect.” It’s a biting cold November afternoon and I try to keep my shivering at bay by thinking of warm things. Shawn is wearing only a thin hospital gown and socks, but (...) the cold doesn’t seem to bother him. I’m his self-appointed chaperone so he can sit outside and vape.“I hope you don’t think you’re doing me a favor,” he says. “I should be able to do this in my room.”What Shawn doesn’t realize is that I’ve turned my day upside down for him and this vape. He is off balance and at high risk for falls and so he can’t leave his room without someone watching him. I yearned to do something human for Shawn and so I spent hours chasing for permission from his primary medical team. We etch out an agreement that just because I am offering to take Shawn outside, he shouldn’t expect the same from others.Shawn is gaunt and toxic appearing, and visitors stare at us as they enter the hospital with one patron mouthing to me, “Are you alright?” as if I’m there against my will, but I see what they see. I watch as a stringy mess of brown hair falls away from his upturned face; his eyes are closed against the sunlight. I’m overwhelmed by the odor of urine and feces and staleness because he refuses to let anyone help him bathe. We sit in an awkward silence initially, but nothing about Shawn is straightforward. After yet another prolonged hospital admission, he’s already made the clearest decision of his life. He’s 32 years old.I learn that Shawn was diagnosed with Crohn’s disease, an inflammatory bowel disease (IBD), only two years prior. Such were the ravages of his illness and its lack of response to conventional medications and treatment modalities that he lost sight of himself, literally. His body morphed from strong and athletic to cachectic, his skin turned translucent. The first surgery after his diagnosis was an emergent one for a perforated bowel that nearly killed him and was rife with complications. Afterward, Shawn was frequently admitted to various hospitals with complex abdominal pain, followed by more surgeries.This admission is different, however, because Shawn also has an abdominal infection so severe that it limits his ability to eat or drink. The nurses placed a peripherally inserted central catheter, or PICC line, which allows for intravenous delivery of nutrition and fluids, and he is made terminally NPO. Nothing by mouth.Shawn’s abdominal infection also coincides with terrific pain that is never adequately alleviated. One night, out of a desperate attempt to momentarily escape his illness and reality, Shawn crushed the opioids he is given every few hours, mixed them with tap water, and injected them directly into his PICC line. He later admitted to doing this for years every time he had a PICC or IV access outside the hospital, which was often. Unbeknownst to him was that the nondigestible parts of the pills such as talc and cellulose—the bits that hold the pills together—end up in the veins as wells. These fragments travel to the lungs where they lodge in the alveoli and create an irreversible condition called “excipient lung disease,” leading to pulmonary hypertension, inflammation, and early mortality. Shawn had experienced increasing shortness of breath over the last year, and ground glass opacities on his chest [End Page 26] CT-imaging could reflect this rare phenomenon. Most notable, however, was how upset he became that no one warned him that injecting crushed pills into his PICC line could result in such damage.“You see how desperate I’ve become,” he earnestly told his medical team. “Why wouldn’t you help me protect myself?”From what I know, it’s evident that Shawn needs a PICC line to survive outside the hospital, yet because of his misuse of the... (shrink)

As the patient drew her last breaths, with her daughter at her bedside, and the curtain closed across the room, my resident, whom I will call Emma, talked me through what was happening. She explained that the patient's only hope for survival had been surgery, yet surgery would surely have killed her. Emma talked about the different ways different families approach withdrawing the level of care provided in the intensive care unit, allowing a loved one's death. She talked (...) about how hard it is to leave behind everything that happens in this job when she goes home. An intern arrived to make the declaration of death, and Emma encouraged me to go back into the patient's room for this. I placed my stethoscope on the patient's still chest, confirming what we already knew to be true. Death was palpable in that room, and my response was visceral. I did my best to leave the ICU calmly and then ran down five flights of stairs to the hospital chapel and sobbed. When I returned, Emma could see that I was shaken. “It's human,” she told me. In the afternoon, I felt the deep tiredness that I always feel after really crying. In that haze of emotion, I wasn't sure quite how to respond when Emma's next activity for us was to find a patient who needed an arterial blood gas. (shrink)

SIRThere are some important flaws in Michael Ardagh's reasoning.11. Cardiopulmonary resuscitation is a “blanket term” for different interventions. Curative and supportive treatments have different ethical contexts and cannot be discussed at the same level. It is imperative to ascribe curative interventions within CPR the same status as any other curative intervention, such as antibiotics for infections or surgery for appendicitis. Then we will be able to discuss the ethical context of purely supportive measures such as chest compressions. To (...) address the “ethics of CPR” is a dangerous misnomer.The preferences of emergency personnel2 suggest the willingness to undergo curative interventions early during CPR, but not protracted supportive interventions. Conversely, withholding curative interventions during CPR should only be considered when any curative treatments would also be withheld.2. Cardiopulmonary resuscitation is performed to offer the patient a benefit. However, CPR as a whole is only marginally effective. …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content: -/- I gathered it in my hands as it fell from my hair-brush, too saturated to hold anymore. It felt as if I were inside a movie and waiting for someone to yell “Cut!” but no call came. It continued to fall, feather-like onto the ground, individual strands glinting in the light of the bathroom window. My hair, nearly all of it, was gone. Between the time of (...) my heart transplant and the moment my hair began to fall out, I arguably had suffered enough. Transplant brought four open-heart surgeries, ten days on ECMO, an intra-aortic balloon pump, delirium, necrotizing pneumonia, and so much muscular atrophy that I had to re-learn how to walk. CPR, broken ribs, and the scar of a tricuspid clip from a botched biopsy: it was not the miracle I was hoping for. The internal trauma had certainly taken its toll. I no longer knew how I really felt, thanks to copious pain meds that altered my mind and body. Each limb was foreign as I re-acclimated to how one grabs hold of a cup, signs their name, touches their legs. Externally, I was a mess: covered in deep purple bruises across my torso from the diabetes treatments, dead skin pooling in unwashed pores, my ankles swollen and indiscernible from my legs. But lacking a good mirror (or the desire to find one), I still felt like “myself” during my forty-five day hospital stay. I could feel my cheekbones protruding from thinning skin, saw through unfocused eyes from the tempestuous blood sugars, and my hair sat in a rat’s nest atop my head; but I was still me. -/- Arriving home, I felt like a newborn being brought into the real world for the first time. I needed help with everything—showers, sitting up, putting on shoes, even going to the bathroom. At age twenty-four, I felt I had regressed to the point of no return as I relied on others to do the simplest tasks. In addition, I was quarantined inside for three months, due to the risk of obtaining a fungal infection from the outside. Caged, and alone in my body, I a trapped and wounded tiger: angry, hurting, and scared. [End Page 109]When I had been prepared for transplant—and I use “prepared” loosely because the information packet I was handed was insulting at best—I knew to expect the scars. I had no issue with that, having been cut open at my throat and chest for previous surgeries. I knew to expect a 12-inch line from neck to navel: the most evident sign I would now carry that I was disabled. -/- What I did not expect were the bullet holes— the sealed entrances of thick chest tubes that now dotted my lower torso. I did not anticipate the bruises on my arms and groin from arterial pokes. I felt violated as if I had walked into some kind of abduction and was rolled out, beaten, bruised, and, worst, touched. But it wasn’t the physical trauma that hurt the most. It was that no one seemed surprised. Immediately after transplant, the team’s focus is purely on survival. Survive the 30 days post-surgery. Survive the year. Metrics, uncomfortably tied to transplant center success statistics, funding, and clout have little to do with the patients themselves. What did I care to only survive a year? I wanted years. I wanted decades. It felt I wanted more than anyone was willing to pay attention to. -/- The conversation was narrowed to high-risk issues: infection, rejection, or other life-threatening conditions. While this makes sense on a clinical level, what constitutes a major event for a clinician may not be of the same emotional value to the patient. In my case, I was less occupied by how the steroids were working and more obsessed with their side effects, such as how much weight I was rapidly gaining. I walked into the clinic one day with the beginnings of stretch marks and a week later had claw-like ripples down my sides. My mood swings were explosive... (shrink)

Chest pain is the pain felt in the chest by infants, children and adolescents. In most cases the pain is not associated with the heart. It is mainly recognized by the observance or report of pain by the infant, child or adolescent by reports of distress by parents or care givers. Chest pain is not unusual in children. Lots of children are seen in ambulatory clinics, emergency rooms and hospitals and cardiology clinics. Usually there is a benign (...) cause for the pain for utmost children. Certain patients have conditions that are serious and perhaps life-threatening. Chest pain in pediatric patients needs careful physical examination and a detailed history that would point to the possibility of a serious cause. Researches of pediatric chest pain are scarce. It has been difficult to create evidence-based guidelines for evaluation. In this paper we propose an expert system to help doctors and parents, and care giver in diagnosing chest pain in infants and children. This expert System is design and implemented in SL5 Object language. (shrink)

This article critically explores the tension between perceptions of weight loss surgery as a last resort and as a tool. This tension stems from patients’ doubt and insecurity whether expectations for a healthy life will come through. Thus, even after surgery, traditional weight loss methods, including diets and exercise, are considered paramount. Drawing on a series of interviews with Norwegian women, we argue that the commercialization of weight loss surgeries as well as the moral stigmas attached to such (...) operations serve to perpetuate this tension. More specifically, the women were advised to leave their old habits behind, and embrace a healthier and more active lifestyle. In such a climate, we argue that undergoing surgery without subsequently embodying dietary and exercise norms is hardly an option. On the contrary, these become a moral obligation that modern women need to relate to—and perhaps negotiate—in order to repudiate stigmas attached to weight loss surgeries as a quick fix for those incapable of losing weight in the “proper” manner. (shrink)

This article applies a theoretical framework developed by the late American sociologist Anselm Strauss to the discovery of a new resuscitation technique, closed-chest cardiac massage. The discovery, which took place in the laboratories of Johns Hopkins University between 1956 and 1960, is analyzed as the collective management of a trajectory over time. The article follows the discovery trajectory from its origins in defibrillator research to the establishment of closed-chest cardiac massage and cardiopulmonary resuscitation as a universal life-saving method. (...) The analytical focus on the experimental, clinical, and promotional activities performed by the different actors interacting with the emerging technology allows one to critically question the value of concepts such as closure, stabilization, and black boxing in sociology of science and technology. Instead of prematurely freezing the analysis of technoscience, a trajectory conceptual framework emphasizes the ongoing dynamic between actors and medical technology to define the scope, effectiveness, and multiple interpretations of the technology-actor interaction. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

_Background:_ Weight-related stigma is reported frequently by higher body-weight patients in healthcare settings. Bariatric surgery triggers profound weight loss. This weight loss may therefore alleviate patients' experiences of weight-related stigma within healthcare settings. In non-clinical settings, weight-related stigma is associated with weight-inducing eating patterns. Dietary adherence is a major challenge after bariatric surgery. _Objectives:_ (1) Evaluate the relationship between weight-related stigma and post-surgical dietary adherence; (2) understand if weight loss reduces weight-related stigma, thereby improving post-surgical dietary adherence; and (...) (3) explore provider and patient perspectives on adherence and stigma in healthcare settings. _Design:_ This mixed methods study contrasts survey responses from 300 postoperative bariatric patients with ethnographic data based on interviews with 35 patients and extensive multi-year participant-observation within a clinic setting. The survey measured experiences of weight-related stigma, including from healthcare professionals, on the Interpersonal Sources of Weight Stigma scale and internalized stigma based on the Weight Bias Internalization Scale. Dietary adherence measures included patient self-reports, non-disordered eating patterns reported on the Disordered Eating after Bariatric Surgery scale, and food frequencies. Regression was used to assess the relationships among post-surgical stigma, dietary adherence, and weight loss. Qualitative analyses consisted of thematic analysis. _Results:_ The quantitative data show that internalized stigma and general experiences of weight-related stigma predict worse dietary adherence, even after weight is lost. The qualitative data show patients did not generally recognize this connection, and health professionals explained it as poor patient compliance. _Conclusion:_ Reducing perceptions of weight-related stigma in healthcare settings and weight bias internalization could enhance dietary adherence, regardless of time since patient's weight-loss surgery. (shrink)

Innovative surgery raises four kinds of ethical challenges: potential harms to patients; compromised informed consent; unfair allocation of healthcare resources; and conflicts of interest. Lack of adequate data on innovations and lack of regulatory oversight contribute to these ethical challenges. In this paper these issues and the extent to which problems may be resolved by better evidence-gathering and more comprehensive regulation are explored. It is suggested that some ethical issues will be more resistant to resolution than others, owing to (...) special features of both surgery and innovation. (shrink)

BackgroundBariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open (...) and transparent decision making process.DiscussionA wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.SummaryPerforming bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents. (shrink)

In the recent past, several papers have pointed to the possibility that tumour removal generates a permissive environment in which tumour growth is potentiated. This phenomenon has been coined “perioperative tumour growth” and whilst it represents a departure in terms of our attitude to the surgical process, this concept was first hinted at by Paget1Sir James Paget (1814–1899) was a surgeon and physiologist who is widely held (along with Rudolph Virchow) to be the father of the science of pathology. Paget (...) described Paget's disease of the nipple as well as Paget's disease of bone. himself. Despite this, the time interval immediately before and after cancer surgery (i.e. the perioperative period) remains an underutilised interval during which chemotherapeutic regimens are rarely implemented. Herein, we present a summarised review of the literature that supports the concept that tumour removal may potentiate the growth of residual neoplastic disease. We also outline current knowledge regarding underlying mechanisms and in this manner highlight potential therapeutic entry points. Finally, we emphasise the urgent need for trials of agents that could protect patients against the harmful host–tumour interactions that may occur during the perioperative period. BioEssays 28: 433–437, 2006. © 2006 Wiley Periodicals, Inc. (shrink)

In 2008 the Human Fertilisation and Embryology Act amendments made deliberately choosing to bring disability into the world, using assisted reproduction, a criminal offence. This paper considers whether the legal prohibition above, should influence other policy areas concerning the welfare of future children such as new possibilities presented by foetal surgery and in utero gene therapy. If we have legal duties to avoid disability in one context should this influence our avoidance of disability in this other context? This paper (...) investigates whether the State might have a stake in wider promotion of practices to reduce the degree of disability in foetuses that will come to exist. Not selecting for disability does not affect the welfare of any future individual, whereas treating in utero abnormalities can optimize the eventual child’s welfare; antenatal interventions stand to improve clinical outcomes and welfare should that specific child be born. I explore why the State may want to intervene in the antenatal setting and to what extent, if at all; the State should implement these technologies. I argue that if the State is justified in intervening to outlaw the choosing to create disabled lives using assisted reproductive techniques, it is also justified in putting pressure on prospective parents to accept therapies in utero to help their child be born less disabled. However, I qualify this with the argument that the State is not justified in using force or the criminal law in this situation during pregnancy. (shrink)

La historia de la Cirugía Pediátrica cubana está pendiente de ser documentada científicamente. Se estableció como objetivo definir las etapas de desarrollo de la especialidad en Cuba, para lo cual se hizo un análisis histórico y se identificó cuatro períodos fundamentales. Este artículo tiene una significación práctica puesto que permite conocer en qué momento se encuentra la especialidad para modelar el futuro de la misma. The history of Cuban pediatric surgery is pending of being scientifically documented. It was established (...) as an objective to define the stages of the development of the specialty in Cuba. For this purpose a historical analysis was carried out and four main periods were identified. This study has a practical importance because it allows knowing the stage in which the specialty is to model its future. (shrink)

The market for cosmetic surgery tourism is growing with an increase in people travelling abroad for cosmetic surgery. While the reasons for seeking cosmetic surgery abroad may vary the most common reason is financial, but does cheaper surgery abroad carry greater risks? We explore the risks of poorly regulated cosmetic surgery to society generally before discussing how harm might be magnified in the context of cosmetic tourism, where the demand for cheaper surgery drives the (...) market and makes surgery accessible for increasing numbers of people. This contributes to the normalisation of surgical enhancement, creating unhealthy cultural pressure to undergo invasive and risky procedures in the name of beauty. In addressing the harms of poorly regulated surgery, a number of organisations purport to provide a register of safe and ethical plastic surgeons, yet this arguably achieves little and in the absence of improved regulation the risks are likely to grow as the global market expands to meet demand. While the evidence suggests that global regulation is needed, the paper concludes that since a global regulatory response is unlikely, more robust domestic regulation may be the best approach. While domestic regulation may increase the drive towards foreign providers it may also have a symbolic effect which will reduce this drive by making people more aware of the dangers of surgery, both to society and individual physical wellbeing. (shrink)

Sham surgery is a controversial and rarely used component of randomised clinical trials evaluating surgical interventions. The recent use of sham surgery in trials evaluating efficacy of intracerebral fetal tissue grafts in Parkinson’s disease has highlighted the ethical concerns associated with sham surgery controls. Macklin, and Dekkers and Boer argue vigorously against use of sham surgery controls. Macklin presents a broad argument against sham surgery controls while Dekkers and Boer present a narrower argument that sham (...) surgery is unnecessary in the specific setting of fetal tissue engraftment for Parkinson’s disease. I defend sham surgery controls against both these criticisms. Appropriate clinical trial design, sometimes including sham surgery, is needed to ensure that false positive trial results do not occur and endanger public safety. Results of a completed trial of fetal tissue grafting for Parkinson’s disease are used to illustrate the potential benefits of, and problems associated with, sham surgery controls. Sham surgery controls, however, should be employed only when absolutely necessary. I suggest criteria for appropriate use of sham surgery controls. (shrink)

When Kai Kupferschmidt writes about CRISPR-based gene editing in German, he faces an obstacle: there's no exact translation for “editing” that has the same connotations as it has in English. Instead, as he explained last fall at The Hastings Center's preconference symposium on new genetic technologies at the World Conference of Science Journalists, he draws on a variety of phrases, including “genome surgery,” which conveys precision in Kupferschmidt's assessment, and “gene scissors,” which communicates CRISPR's mechanistic nature. But in any (...) language, explaining CRISPR is difficult. It's a challenge I face at The Hastings Center, where I write about biotechnology for a public audience. (shrink)

The lack of access to gender-affirming surgery represents a significant unmet health care need within the transgender community, frequently resulting in depression and self-destructive behavior. While some transgender people may have access to gender reassignment surgery, an overwhelming majority cannot afford facial feminization surgery. The former may be covered as a “medical necessity,” but FFS is considered “cosmetic” and excluded from insurance coverage. This demarcation between “necessity” and “cosmetic” in transgender health care based on specific body parts (...) is in direct opposition to the scientific community’s understanding of gender dysphoria and professional guidelines for transgender health. GRS affects one’s ability to function in an intimate relationship, while FFS has the same impact on social interactions an, therefore may have a far greater implication for one’s quality of life. FFS is a cost-effective intervention that needs to be covered by insurance policies. The benefits of such coverage far exceed the insignificant costs. (shrink)

Leading feminist scholars have been brought together for the first time in this comprehensive volume to reveal the complexity of feminist engagements with the exponentially growing cosmetic surgery phenomenon. Offering a diversity of theoretical, methodological and political approaches Cosmetic Surgery: A Feminist Primer presents not only the latest, cutting-edge research in this field but a challenging and unique approach to the issue that will be of key interest to researchers across the social sciences and humanities.

Video recording is widely available in modern operating rooms. Here, I argue that, if patient consent and suitable technology are in place, video recording of surgery is an ethical duty. I develop this as aduty to protect,arguing for professional and institutional duties, as distinguished forduties of rescue.A professional duty to protect is described in mental healthcare. Practitioners have to take reasonable steps to prevent serious, foreseeable harm to their clients and others, even if that entails a non-consensual breach of (...) confidentiality. I argue surgeons have a similar duty to patients which means that, provided the patient consents, surgery should be routinely videoed. This avoids non-consensual breaches of patient confidentiality and is aligned with stated professional obligations.An institutional duty to protect means institutions have to take reasonable steps to prevent serious, foreseeable harm at the hands of their surgeons. Rulli and Millum highlighted how institutions can meet their duty using a more consequentialist approach that balances wider interests.To test the force and scope of such duties, I examine potential impacts of routine videoing on aspects of autonomy, justice, beneficence and non-maleficence. I find routine videoing can benefit areas including safety, candour, consent and fairness in access (to surgical careers and expertise). Countervailing claims, for example, on liability, confidentiality and privacy can be resisted—such that where consent and the technology are in place, routine videoing meets aduty of easy protection. In other words, its use should be standard of care. (shrink)

Surgical clinical trials have seldom used a "sham" or placebo surgical procedure as a control, owing to ethical concerns. Recently, several ethical commentators have argued that sham surgery is either inherently or presumptively unethical. In this article I contend that these arguments are mistaken and that there are no sound ethical reasons for an absolute prohibition of sham surgery in clinical trials. Reflecting on three cases of sham surgery, especially on the recently reported results of a sham-controlled (...) trial of arthroscopic surgery for arthritis of the knee, I present an ethical analysis that focuses on the methodological rationale for use of sham surgery, risk-benefit assessment, and informed consent. (shrink)

Recently, there has been a shift in attitude among some feminists towards the practice of cosmetic surgery away from that of outright rejection. Kathy Davis, for instance, offers a guarded `defence' of the practice as a strategy that enables women to exercise a degree of control over their lives in circumstances where there are very few other opportunities for self-realization. Others, such as Kathryn Morgan, Anne Balsamo and Orlan, though highly critical of the current practice of cosmetic surgery, (...) go even further than Davis in advocating its redeployment as a tool to subvert the dominant patriarchal ideals of feminine beauty. In this article I critically appraise this `rehabilitation' of cosmetic surgery, arguing, in the case of Davis, that she leaves unchallenged the social structures of inequality responsible for women's dissatisfaction with their bodies. The proposal to use cosmetic surgery as a tool of political critique is equally problematic insofar as it shares with the cosmetic industry its instrumentalization of the body as mere matter, which is almost infinitely transformable, and also effaces the economic inequalities within which such body transformations occur. (shrink)

Although scholars have examined the oral and gustatory terms used by medieval authors to describe speech and other verbal phenomena, the significant role of the chest in medieval accounts of verbal experience has been largely ignored. Medieval authors commonly describe speech as issuing from the chest, often without mentioning the mouth at all; and they associate the chest with not only individual speech acts but also the faculty of speech as well as the psychological functions relating to (...) speech and to language generally. Old English literature, among others, widely manifests this tendency to describe speech and other verbal functions in pectoral terms. Although Old English poetry sometimes mentions the mouth in connection with speech, many contexts instead specify the chest as the source of utterance and as the center of verbal activity, usually without any mention of the mouth. As a corrective to the tendency of “orality” and similar terms to deflect attention from the chest's significant verbal role, this essay uses the term “pectorality” to describe the chest's various verbal functions in Old English poetry and other literature. (shrink)

Elective surgery can be cancelled when resources are overwhelmed by emergency cases. We hypothesized that such cancellations, on psychological grounds, are followed also by inferior clinical results and we conducted a retrospective survey of patients following joint replacement surgery. Sixty patients having suffered from administrative cancellation prior to their operation during an 18-month period and with six months follow-up were identified and compared with another 60 matched patients after having the same type of surgery but without prior (...) cancellation. All patients received questionnaires on complications and on visual analogue scale (VAS) assessment on subjective wellbeing and quality of life (QoL) at follow-up. The study group reported 50 complications versus 33 for controls (P < 0.03). A borderline significant difference was found for myocardial infarction, 4 versus 0 (P < 0.05). There was no difference in VAS registration and QoL measurements did not quite reach statistical significance (P = 0.06). Cancellations (postponements) of elective surgery for administrative reasons may be followed by inferior clinical results, and this merits further prospective study. (shrink)

Recent debates over the use of sham surgery as a control for studies of fetal tissue transplantation for Parkinson’s disease have focused primarily on rival interpretations of the US federal regulations governing human-subjects research. Using the core ethical and methodological considerations that underwrite the equipoise requirement, we nd strong prima facie reasons against using sham surgery as a control in studies of cellular-based therapies for Parkinson’s disease and more broadly in clinical research. Additionally, we believe that these reasons (...) can be generalized to apply to the use of other placebo controls that carry signi cant risks of positive harms in and of themselves. As a result, our arguments are centrally relevant to the emerging drive to subject therapies with a surgical component to the same rigorous standards of evaluation as those governing the approval of new pharmaceuticals. (shrink)

Bruineberg et al. provide compelling clarity on the roles Markov blankets could (and perhaps should) play in the study of life and mind. However, here we draw attention to a further role blankets might play: as a hypothesis about cognition itself. People and other animals may use blanket-like representations to model the boundary between themselves and their worlds.

While fetal surgery—and pregnancy termination as a possible therapeutic alternative—have been examined in a number of studies, very few have addressed the issues and tensions that arise when prenat...

In this paper, I analyse the issue of conscientious objection in relation to cosmetic surgery. I consider cases of doctors who might refuse to perform a cosmetic treatment because: (1) the treatment aims at achieving a goal which is not in the traditional scope of cosmetic surgery; (2) the motivation of the patient to undergo the surgery is considered trivial; (3) the patient wants to use the surgery to promote moral or political values that conflict with (...) the doctor's ones; (4) the patient requires an intervention that would benefit himself/herself, but could damage society at large. (shrink)

In this article, we explore the relation between bodies and selves evident in the narratives surrounding aesthetic surgery. In much feminist work on aesthetic surgery, such narratives have been discussed in terms of the normalising consequences of the objectifying, homogenising, cosmetic gaze. These discussions stress the ways in which we model our bodies, under the gaze of others, in order to conform to social norms. Such an objectified body is contrasted with the subjective body; the body-for-the-self. In this (...) article, however, we wish to make sense of the narratives surrounding such surgery by invoking the expressive body, which fits on neither side of this binary. We wish to explore how the modification of the body’s anatomical features (physiology) is taken to be a modification of its expressive possibilities, and therefore a modification of possibilities for inter-subjective relations with others. It is such expressive possibilities that, we suggest, underlie decisions to undergo surgical procedures. The possibility of modification of the expressive possibilities of the body, by the modification of its anatomical features, rests on the social imaginaries attached to anatomical features. In the context of such imaginaries, individual decisions to undergo or promote surgery can be both intelligible and potentially empowering. However, the social consequences of such acts are an increasing normalisation of the ‘body under the knife’ and an intolerance of bodily difference. This, we suggest, can only be changed by a re-visioning of bodily imaginaries so that expressive possibilities can be experienced across bodies with a range of physiological features. (shrink)

The 84-year-old man's incessant yelling caused him to be unmanageable in all settings--at home with his aged wife, in nursing homes, and on the medical and psychiatric floors of a Veterans Administration Medical Center. A host of behavioural and pharmaceutical interventions were attempted unsuccessfully. Finally, it was proposed that a single, recurrent laryngeal nerve be crushed in order to 'render his voice to be a very acceptable soft tone'.