Volume 19, Issue 9, September 2019, Page W1-W2.

This article presents an analysis of contractual relations in sport from the standpoint of the Croatian legislative system. Due to the complexity of the subject matter, the author considers only a small fragment of it - the significance and the role of sport in Croatian society and the law of contracts „as a cornerstone on which „sports law“ has been built and which is of primary importance in most areas where there is an interface between sport and the law, irrespective (...) of whether the sport is being played at an elite level or at a more humble one“. Bearing in mind the limited extent of this article, the autor tries to provide some clarifications and some guidance on how to deal with the designation and the determination of the applicable law for contracts in the sporting context. Considering that there are different legal regimes which may come into play with regard to the designation of the law applicable to contracts in the sporting context, the author first presents the determination of the applicable law according to the Rome I Regulation and then according to the Croatian Arbitration Act, Swiss Private International Law Act and the CAS Code of Sports-related Arbitration, as the most common in sports practice. Then, the author deals with contracts concluded with minor athletes and the determination of the law applicable to some preliminary questions. Finally, the author presents her perception of the problems encountered and some suggestions for the improvement of the existing legal framework. (shrink)

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, how (...) decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

In the United States, screening the urine of employees or job applicants for the presence of drugs has become commonplace. A survey of 794 large- and mediumsized companies, conducted by the American Management Association in January 1994, found that 87 percent of them now test job applicants for drug use. In 1987, a similar survey found that 22 percent screened job applicants. Federally mandated drug testing programs with random testing requirements affect millions of workers in the transportation industry, the nuclear (...) power industry, and the United States civil and military services.As some of these programs pass their fifth anniversary since being instituted, it is important to assess the forces that led to their creation. Whether or not these programs are considered successful depends on what one expects to achieve by such widespread testing. (shrink)

What the Doctor Didn’t Say, by Jerry Menikoff and Edward P. Richards, is a courageous and well-written volume that examines some of the fundamental debates pertaining to the ethics of clinical research. The volume deserves a careful reading by anyone with a potential role in clinical research: clinicians who might serve as investigators or refer patients to clinical trials; research staff; Institutional Review Board members and administrators; sponsors who design clinical trials; and the book’s intended audience, namely, potential research (...) participants and their families. A cursory reading of this volume might lead one to think that Menikoff and Richards have declared war on clinical research. They have not. Instead, they offer an in-depth study of the conduct and oversight of clinical research through the lens of law and ethics. They shed light on old issues and initiate discussion of new questions, challenging readers to think critically about the relationship between medical ethics, research ethics, the law, and the conduct of clinical research. (shrink)

Contributing reviewersThe editors of BMC Medical Ethics would like to thank all our reviewers who have contributed to the journal in Volume 16 (2015).

Rationale and objectives: Medical humanities are becoming increasingly recognized as positively impacting medical education and medical practice. However, the extent of medical humanities teaching in medical schools is largely unknown. We reviewed medical school curricula in Canada, the UK and the US. We also explored the relationship between medical school ranking and the inclusion of medical humanities in the curricula. -/- Methods: We searched the curriculum websites of all accredited medical schools in Canada, the UK and the US to check (...) which medical humanities topics were taught, and whether they were mandatory or optional. We then noted rankings both by Times Higher Education and U.S. News and World Report and calculated the average rank. We formally explored whether there was an association between average medical school ranking and medical humanities offerings using Spearman's correlation and inverse variance weighting meta-analysis. -/- Results: We identified 18 accredited medical school programmes in Canada, 41 in the UK, and 154 in the US. Of these, nine (56%) in Canada, 34 (73%) in the UK and 124 (80%) in the US offered at least one medical humanity that was not ethics. The most common medical humanities were medical humanities (unspecified), history, and literature (Canada); sociology and social medicine, medical humanities (unspecified), and art (UK); and medical humanities (unspecified), literature and history (US). Higher ranked medical schools appeared less likely to offer medical humanities. -/- Conclusions: The extent and content of medical humanities offerings at accredited medical schools in Canada, the UK and the US varies, and there appears to be an inverse relationship between medical school quality and medical humanities offerings. Our analysis was limited by the data provided on the Universities' websites. Given the potential for medical humanities to improve medical education and medical practice, opportunities to reduce this variation should be exploited. (shrink)

Contributing reviewersThe editors of BMC Medical Ethics would like to thank all our reviewers who have contributed to the journal in Volume 15 (2014).

LIU W, MANIAS E and GERDTZ M. Nursing Inquiry 2011; 18: 290–302 Understanding medication safety in healthcare settings: a critical review of conceptual modelsCommunication can impact on the way in which medications are managed across healthcare settings. Organisational cultures and the environmental context provide an added complexity to how communication occurs in practice. The aims of this paper are: to examine six models relating to medication safety in various hospital and community settings, to consider the strengths and (...) limitations of each model and to explore their applications to medication safety practices. The models examined for their ability to address the complexity of the medication communication process include causal models, such as the Human Error Model and the System Analysis to Clinical Incidents Model, and exploratory models, such as the Shared Decision‐Making Model, the Medication Decision‐Making and Management Model, the Partnership Model and the Medication Communication Model. The Medication Communication Model provides particular insights into possible interactions between aspects that influence medication safety practices. The implications of all six models for healthcare practice and future research are also discussed. (shrink)

Medical ethics committees are increasingly called on to assist doctors, patients, and families in resolving difficult ethics issues. Although committees are becoming more sophisticated in the substance of medical ethics, little attention has been given to the processes these committees use to facilitate decision-making. In 1990, the National Institute for Dispute Resolution in Washington, D.C., provided a planning grant from its Innovation Fund to the Institute of Public Law of the University of New Mexico School of Law to look at (...) what ethics committees can learn from facilitation and mediation techniques. The study's thesis was that, if adapted for use by medical ethics committees, facilitation and mediation techniques can be helpful to those bodies in case review consultations and in other internal committee processes. This article reports on that project. (shrink)

Global short-term medical volunteerism is growing, and properly conducted, is a tool in the fight for greater global health equity. It is intrinsically ethical (i.e., it involves ethics at every step) and depends upon ethical conduct for its success. At present, ethical guidelines remain in their infancy, which presents a unique opportunity. This paper presents a set of basic ethical principles, building on prior work in this area and previously developed guidelines for international clinical research. The content of these principles, (...) and the benchmarks used to evaluate them, remain intentionally vague and can only be filled by collaboration with those on-the-ground in local communities where this work occurs. Ethical review must additionally take into consideration the different obligations arising from the type of institution, type of intervention, and type of relationship involved. This paper argues that frequent and formalized ethical review, conducted from the beginning with the local community (where this community helps define the terms of debate), remains the most important ethical safeguard for this work. (shrink)

The Open Access Movement maintains that all scientific and scholarly literature should be available to all for free via the Internet. This concept is not new. Some scholars trace its roots as far back as 1963 when “hypertext” was first introduced. Although the Open Access Movement may have originated more than fifty years ago, it has been fueled by more recent events, including the unremitting escalation of journal subscription prices over the last two decades, resulting in massive cancellations of journals (...) by academic libraries; the ubiquitous nature of the Internet and the parallel explosion of electronic resources; and the desire of authors to find a new publishing model which continues to offer the benefits of peer review while providing for more rapid publication and wide-spread distribution than the current labor-intensive, time-consuming model.The Open Access Movement has resulted in a number of online repositories devoted to legal analysis and policy. This column explores the genesis of the movement, its value to researchers and policymakers, and provides an overview of the two principal open access products in the legal arena. (shrink)

BackgroundAn analysis of the position statements of secular US medical and surgical professional societies on physician-assisted suicide (PAS) and euthanasia have not been published recently. Available statements were evaluated for position, content, and sentiment.MethodsIn order to create a comprehensive list of secular medical and surgical societies, the results of a systematic search using Google were cross-referenced with a list of societies that have a seat on the American Medical Association House of Delegates. Societies with position statements were identified. These statements (...) were divided into 5 categories: opposed to PAS and/or euthanasia, studied neutrality, supportive, acknowledgement without statement, and no statement. Linguistic analysis was performed using RapidMinder in order to determine word frequency and sentiment respective to individual statements. To ensure accuracy, only statements with word counts > 100 were analyzed. A 2-tailed independentttest was used to test for variance among sentiment scores of opposing and studied neutrality statements.ResultsOf 150 societies, only 12 (8%) have position statements on PAS and euthanasia: 11 for PAS (5 opposing and 4 studied neutrality) and 9 for euthanasia (6 opposing and 2 studied neutrality). Although the most popular words used in opposing and studied neutrality statements are similar, notable exceptions exist (suicide,medicine, andtreatmentappear frequently in opposing statements, but not in studied neutrality statements, whereaspsychologists,law, andindividualsappear frequently in studied neutrality statements, but not in opposing statements). Sentiment scores for opposing and studied neutrality statements do not differ (mean, 0.094 vs. 0.104;P = 0.90).ConclusionsFew US medical and surgical societies have position statements on PAS and euthanasia. Among them, opposing and studied neutrality statements share similar linguistic sentiment. Opposing and studied neutrality statements have clear differences, but share recommendations. Both opposing and studied neutrality statements cite potential risks of PAS legalization and suggest that good palliative care might diminish a patient’s desire for PAS. (shrink)

Efforts to reform medical education have emphasized the need to formalize instruction in medical ethics. However, the discipline of medical ethics education is still searching for an acceptable identity among North American medical schools; in these schools, no real consensus exists on its definition. Medical educators are grappling with not only what to teach (content) in this regard, but also with how to teach (process) ethics to the physicians of tomorrow. A literature review focused on medical ethics education among (...) North American medical schools reveals that instruction in ethics is considered to be vitally important for medical students. Agreement by medical educators on a possible core curriculum in ethics should be explored. To develop such a curriculum, deliberative curriculum inquiry by means of a targeted Delphi technique may be a useful methodology. However, the literature reveals that medical curricular change is notoriously slow. General implications for medical ethics education as a discipline are discussed. (shrink)

This article considers proposals to reform the law in response to recent high profile cases concerning the medical treatment of children, currently before Parliament in the Access to Palliative Care and Treatment of Children Bill 2019–21. It considers the proposed procedural change, to introduce a requirement for mediation before court proceedings, and argues that dispute resolution processes should be a matter of good practice rather than enshrined in law. It argues that the proposed substantive change to determination of best interests (...) would not result in different outcomes because the best interests analysis co-exist with the legal and professional duties of doctors to children in their care. It argues that if there is to be reform of the law it needs to follow from a comprehensive review of all the issues in which the minimum standards imposed by law fit together with good practice standards and not in response to individual cases. (shrink)

Advanced new therapies, such as stem cell and gene therapies and xenotransplantation, represent challenges for regulatory and ethical review. Major drug agencies, such as in the U.S., India, and Europe, have asserted regulatory authority and require ethics review by local ethics review committees, using the same strict requirements as those for standard drug approvals. In spite of this, unapproved and undocumented stem cell clinics flourish in all of these places, suggesting that current approaches do not offer patients (...) sufficient protection. Japan has attempted another approach, requiring approvals at local levels for all regenerative medical procedures, and a faster approval of promising new interventions. The Japanese approach has, however, also been criticized as not striking a proper balance between early access and a proper assessment of safety and effectiveness. For smaller and less-resourced countries, such as Thailand, one major challenge is limited expertise to conduct the evaluation of these advanced new therapies. This article provides an overview of the issues facing regulators and proposes that countries should restrict the early adoption of advanced new therapies to specialized clinics with appropriate scientific and ethical expertise for review. Review in these institutions should focus on expert clinical benefit assessments for individual patients being offered such interventions, independently of whether they are offered as research or therapy. (shrink)

Background Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be (...) successfully introduced and implemented, where legislations allow it. Methods Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders’ well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria. Results Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders. Conclusion The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD. (shrink)

This paper reviews the ethical literature on conflicts between health professionals and parents about medical decision-making for children. We present the results of a systematic review which addressed the question ‘when health professionals and parents disagree about the appropriate course of medical treatment for a child, under what circumstances is the health professional ethically justified in overriding the parents’ wishes?’ We identified nine different ethical frameworks that were put forward by their authors as applicable across various ages and clinical (...) scenarios. Each of these frameworks centred on a different key moral concept including harm, constrained parental autonomy, best interests, medically reasonable alternatives, responsible thinking and rationality. (shrink)

The purpose of the study was to assess medical journals’ conflicts of interest in the publication of book reviews. We examined book reviews published in 1999, 2000, and 2001 in five leading medical journals: Annals of Internal Medicine, British Medical Journal, Journal of the American Medical Association, Lancet, and New England Journal of Medicine. The main outcome measure was journal publication of reviews of books that had been published by the journal’s own publisher, that had been edited or authored by (...) a lead editor of the journal, or that posed another conflict of interest. We also surveyed the editors-in-chief of the five journals about their policies on these conflicts of interests. During the study period, four of the five journals published 30 book reviews presenting a conflict of interest: nineteen by the BMJ, five by the Annals, four by JAMA, and two by the Lancet. These reviews represent 5.8%, 2.7%, 0.7%, and 0.7%, respectively, of all book reviews published by the journals. These four journals, respectively, published reviews of 11.9%, 25.0%, 0.9%, and 1.0% of all medical books published by the journals’ publishers. Only one of the 30 book reviews included a disclosure statement addressing the conflict of interest. None of the journals had a written policy pertaining to the conflicts of interest assessed in this study, although four reported having unwritten policies. We recommend that scientific journals and associations representing journal editors develop policies on conflicts of interest pertaining to book reviews. (shrink)

The Ethics and Regulation of Research with Human Subjects, edited by Professors Carl Coleman of Seton Hall, Jerry Menikoff of the University of Kansas, Jesse Goldner of Saint Louis University, and Nancy Dubler of the Albert Einstein College of Medicine, is an up-to-date and authoritative collection of readings on ethical, legal, and policy issues in research with human subjects. The authors have modeled their text on the casebook style commonly used in law schools. At 746 pages, plus front matter and (...) an appendix, this book contains just about everything one needs to know for a thorough grasp on human subjects research, including federal and state regulations governing this research, interpretive guidance from federal agencies, international guidelines and codes, court decisions, historical documents and case studies, and selected readings from scholarly articles and books. The book includes written comments and questions to help students understand and interpret the readings. (shrink)

Arising from four conferences held in Europe and the United States, this volume contains eighteen essays written mostly by Roman Catholics with the exception of select contributions from Jewish, Protestant, and Orthodox perspectives. Most essays pay particular attention to the distribution of scarce medical resources in terms of intensive care units (ICUs) which use some 38% of all medical expenditures in the U.S. each year, one percent of the GNP. The essays often make reference to one another and a wide (...) variety of Catholic perspectives are represented. The essays offer a good reflection of the contemporary state of Catholic moral thought with its strengths and diversity and are nicely framed by the ‘outside voices’ of the non-Catholics represented. Philosophers will find some essays almost exclusively theological. (shrink)

The objective of this study was to review the design and delivery of medical ethics education within medical programs across Australia and New Zealand, how current teaching has been informed by the proposed core curriculum published in 2001 by the ATEAM and how it could look moving forward. We conducted a mixed methods study using an online questionnaire consisting of 51 items. This included both binary and open-ended questions to categorise and explore similarities and differences in medical ethics curricula (...) in medical programs accredited by the Australian Medical Council across ANZ. Participants were asked about curriculum design format, duration, goals, assessments, content areas of their own ME curriculum. Convenors from 18 universities responded. The main commonality was that ME curricula were integrated both longitudinally and laterally with other content. There was also commonality in content areas addressed. The goals, format, educators, and assessments of the ME curricula were highly variable. Most respondents described a curriculum which prioritised knowledge and skill development related to ME. Although the core goals of including knowledge, skills, and attitudinal development in ME curricula are still present, there is no uniformity in terms of format, delivery, or assessment across medical programs in ANZ. This is an area for collaborative development. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:(P)rescription Narratives: Feminist Medical Fiction and the Failure of American Censorship. by Stephanie Peebles TaveraEtta M. MaddenStephanie Peebles Tavera. (P)rescription Narratives: Feminist Medical Fiction and the Failure of American Censorship. Edinburgh: Edinburgh University Press, 2022. Hardback, xii + 220 pp. ISBN 978-1-4744-9319-2.Utopian Studies readers first saw Stephanie Peebles Tavera’s work in print in her 2018 essay on reproductive health in Charlotte Perkins Gilman’s Herland. More recently, in (P)rescription (...) Narratives, she gives readers a view of the much broader historical scope of her scholarship in literary and cultural studies. Tavera’s analysis of what she labels “feminist medical fiction” considers not only novels and short stories but also literary reviews, dramas, and documentary films, many of which will be unfamiliar to readers of utopian and dystopian literature. Yet the book contextualizes the ways in which these works capture the “utopian possibilities” of women writers who pushed for breaking the boundaries of the dystopian strictures of embodied life. The literary works “rescript” what had been prescribed by others as “normalized behavior,” from the latter-nineteenth century through the Progressive Era (5, 37). As Tavera illustrates through her detailed analysis, these women’s narratives provide “interventions that... interrupt the dissemination of false [End Page 612] narratives of the female body” and “alter the course of cultural development toward greater inclusivity” (5).To establish the temporal boundaries for the project, Tavera emphasizes the Comstock Law, established in 1873, and the death of its author Anthony Comstock in 1915. While Comstock’s work often has been understood as restricting pornography, she explains the Comstock Law as more than merely that. Comstock sought to control what he and others saw as sexual deviation, which included birth control in any form. Tavera also bookends the project with lawsuits associated with Victoria Woodhull and Margaret Sanger, both women who advocated for abortion and birth control as means of allowing women to avoid the strictures over their bodies. Additionally, she explains, Comstock’s racism caused him to completely overlook Black women, ironically allowing a space in which Black women’s feminist medical fiction especially rescripts “normalized behavior” (37)—a topic she pursues in two parts of the book.The book follows a roughly chronological path as it examines four topics related to women’s health, brilliantly organized into “(p)rescriptions,” indicated by Rx, rather than chapters with numbers. Rx1, “Crip Medicine,” illustrates how authors such as Charlotte Perkins Gilman pointed to the socially constructed status of “hysteria” in a patriarchal culture that saw women as deviant by nature. Instead, these authors advocated for a more holistic examination of women’s health, impacted by the environments in which they lived. Drawing from Lyman Tower Sargent’s widely accepted view of utopianism as dreaming of a place “considerably better than the society in which the author lived,” she underscores “the utopian impulse underlies much of the work of feminist medical fiction” (39). In particular, writers of feminist medical fiction were “driven by failure.”Perhaps most familiar to illustrate this point is Gilman’s work, such as “The Yellow Wallpaper,” which illustrated how the culture failed certain characters. The narrator of that story suffers postpartum depression and is made worse by Dr. S. Weir Mitchell’s rest cure. Consequently, Gilman proceeded to write other works, such as Moving the Mountain (1911) and then Herland (1915), which push readers to envision “alternative societies” without such destructive patriarchal medical practices (39). But Tavera also explains how Louisa May Alcott’s Eight Cousins, or the Aunt-Hill (1875) critiques contemporary culture by providing a “domestic utopia” in the female domain of Aunt-Hill, wherein the male Dr. Alec Campbell demonstrates “a better way... of caring for the female body” (55). And another key example is Rebecca Harding [End Page 613] Davis’s Kitty’s Choice: A Story of Berrytown (1875). Berrytown is described as “the Utopia in actual laths, orchards, and bushel-measures of the advance guard of the reform party in the United States” (qtd. in Tavera 55). Through its two physicians, Dr. Muller and Dr. McCall, who represent homeopathic and allopathic practitioners, readers see that the society... (shrink)

The national ethical guidelines relevant to assisted reproductive technology have recently been reviewed by the National Health and Medical Research Council. The review process paid particular attention to the issue of non-medical sex selection, although ultimately, the updated ethical guidelines maintain the pre-consultation position of a prohibition on non-medical sex selection. Whilst this recent review process provided a public forum for debate and discussion of this ethically contentious issue, the Victorian case of JS and LS v Patient (...) class='Hi'>Review Panel [2011] VCAT 856 provides a rare instance where the prohibition on non-medical sex selection has been explored by a court or tribunal in Australia. This paper analyses the reasoning in that decision, focusing specifically on how the Victorian Civil and Administrative Tribunal applied the statutory framework relevant to ART and its comparison to other uses of embryo selection technologies. The Tribunal relied heavily upon the welfare-of-the-child principle under the Assisted Reproductive Treatment Act 2008. The Tribunal also compared non-medical sex selection with saviour sibling selection. Our analysis leads us to conclude that the Tribunal’s reasoning fails to adequately justify the denial of the applicants’ request to utilize ART services to select the sex of their prospective child. (shrink)

Limited data exist in the specific content of pediatric outpatient ethics consults as compared to inpatient ethics consults. Given the fundamental differences in outpatient and inpatient clinical care, we aimed to describe the distinctive nature of ethics consultation in the ambulatory setting. This is a retrospective review at a large, quaternary academic center of all outpatient ethics consults in a 6-year period. Encounter-level demographic data was recorded, and primary ethical issue and contextual features were identified using qualitative conceptual content (...) analysis. A total of 48 consults were identified representing 44 unique patients. The most common primary ethical issue was beneficence and best interest concern comprising 20 (42%) consults, followed by refusal of recommended treatment comprising 11 (23%) consults and patient preference/assent comprising 5 (10%) consults. The most common contextual features were staff-family communication dispute/conflict comprising 28 (58%) consults, followed by legal involvement comprising 25 (52%) consults and quality of life comprising 19 (40%) consults. The most common consulting specialty was hematology/oncology. Ethical issues encountered in the provision of outpatient pediatric care are distinct and differ from those in inpatient consults. Further research is necessary to identify strategies and educational gaps in outpatient ethics consultation to increase its effectiveness and utilization. (shrink)

As medical technology has advanced, the question of medical futility has become a topic of intense debate both within the medical community and within society as a whole. However, a unanimous definition thereof is yet to be decided—some commentators are sceptical as to whether an agreement will ever be reached—and this continues to lead to difficulties, tension, and even legal action when a treating physician disagrees with a patient and/or a patient’s family regarding care and treatment options. Although living in (...) a pluralistic society presents one of the major reasons as to why, despite 30 years of intense discussion, no consensus has been made; the issue of medical futility will always be complex as it is, by nature, multifaceted, and numerous elements—including possible risks, evidence of the probability of benefit, the wishes of the patient (and family), professional standards, and cost—interact. Nevertheless, the global medical community has seen the development of two distinctly different approaches to medical futility: one in which the autonomy of patients is of paramount importance in the decision whether or not to pursue a treatment; and one in which beneficence and primum non nocere—first do no harm—are almost entirely the clinician’s prerogative, and whereby he/she has a duty to refuse any treatment for which the potential risks outweigh the potential benefits for the patient. Recently, however, there has been a rejection of this dichotomous view of medical futility and the apparent “power struggle” between physician and patient, and a positive movement towards a more collaborative decision-making process that highlights the necessity of communication, aiming to result in the obtainment of the best possible outcome for each patient as an individual. (shrink)

Over 40 years of research have shown that traumatic brain injury affects brain volume. However, technical and practical limitations made it difficult to detect brain volume abnormalities in patients suffering from chronic effects of mild or moderate traumatic brain injury. This situation improved in 2006 with the FDA clearance of NeuroQuant®, a commercially available, computer-automated software program for measuring MRI brain volume in human subjects. More recent strides were made with the introduction of NeuroGage®, commercially available software that is based (...) on NeuroQuant® and extends its utility in several ways. Studies using these and similar methods have found that most patients with chronic mild or moderate traumatic brain injury have brain volume abnormalities, and several of these studies found—surprisingly—more abnormal enlargement than atrophy. More generally, 102 peer-reviewed studies have supported the reliability and validity of NeuroQuant® and NeuroGage®. Furthermore, this updated version of a previous review addresses whether NeuroQuant® and NeuroGage® meet the Daubert standard for admissibility in court. It concludes that NeuroQuant® and NeuroGage® meet the Daubert standard based on their reliability, validity, and objectivity. Due to the improvements in technology over the years, these brain volumetric techniques are practical and readily available for clinical or forensic use, and thus they are important tools for detecting signs of brain injury. (shrink)

There are many challenges to be met when writing an introductory treatise on an academic topic. The subject matter must be presented in a simple but not oversimplified manner. Enough theory must be included to ground the discussion of specific issues but not so much as to overwhelm or bore the readers. The text should be long enough to do justice to the subject matter but short enough to be readily accessible, especially for readers such as healthcare professionals, whose primary (...) concerns lie elsewhere.There are additional challenges in a relatively novel interdisciplinary field such as bioethics. The scope and methodology of bioethics are matters of great controversy, as are its relations with related subjects such as professionalism and human rights. The field is so broad that a single author cannot claim expertise on all topics. Rivalries between law and ethics and among medicine, other health professions, and disciplines such as philosophy complicate efforts to produce a broadly acceptable text. Finally, national and cultural differences pose major challenges to anyone trying to write for a truly international readership.The difficulty of meeting all these challenges in producing the WMA Medical Ethics Manual provides ample opportunity for criticism, especially from bioethics experts. The three expert reviewers of the manual in this issue of the journal are remarkably restrained in pointing out its shortcomings.1–3 I am grateful for both their positive evaluations and their constructive criticism. In what follows, I will respond to each of them in turn, focusing in particular on their suggestions as to how the Manual could have been improved.Before addressing these suggestions, I wish to clarify a matter raised by Søren Holm, namely, to what degree the manual …. (shrink)

Emergency departments are challenging research settings, where truly informed consent can be difficult to obtain. A deeper understanding of emergency medical patients’ opinions about research is needed. We conducted a systematic review and meta-summary of quantitative and qualitative studies on which values, attitudes, or beliefs of emergent medical research participants influence research participation. We included studies of adults that investigated opinions toward emergency medicine research participation. We excluded studies focused on the association between demographics or consent document features and (...) participation and those focused on non-emergency research. In August 2011, we searched the following databases: MEDLINE, EMBASE, Google Scholar, Scirus, PsycINFO, AgeLine and Global Health. Titles, abstracts and then full manuscripts were independently evaluated by two reviewers. Disagreements were resolved by consensus and adjudicated by a third author. Studies were evaluated for bias using standardised scores. We report themes associated with participation or refusal. Our initial search produced over 1800 articles. A total of 44 articles were extracted for full-manuscript analysis, and 14 were retained based on our eligibility criteria. Among factors favouring participation, altruism and personal health benefit had the highest frequency. Mistrust of researchers, feeling like a ‘guinea pig’ and risk were leading factors favouring refusal. Many studies noted limitations of informed consent processes in emergent conditions. We conclude that highlighting the benefits to the participant and society, mitigating risk and increasing public trust may increase research participation in emergency medical research. New methods for conducting informed consent in such studies are needed. (shrink)

The clinical ethics literature is striking for the absence of an important genre of scholarship that is common to the literature of clinical medicine: systematic reviews. As a consequence, the field of clinical ethics lacks the internal, corrective effect of review articles that are designed to reduce potential bias. This article inaugurates a new section of the annual "Clinical Ethics" issue of the Journal of Medicine and Philosophy on systematic reviews. Using recently articulated standards for argument-based normative ethics, we (...) provide a systematic review of the literature on concealed medication for the management of psychiatric disorders. Four steps are completed: identify a focused question; conduct a literature search using key terms relevant to the focused question; assess the adequacy of the argument-based methods of the papers identified; and identify conclusions drawn in each paper and whether they apply to the focused question. We identified seven papers and provide an assessment of them. While none of the papers fully meet the standards of argument-based ethics, they did provide rationales for the use of concealed medications, with the important requirement such a practice be accountable in explicit organizational policy to prevent abuse of patients with mental illness or dementia. (shrink)