Language-related potentials are increasingly used to objectify adaptive neuroplasticity in stroke-related aphasia recovery. Using preattentive [mismatch negativity ] and attentive phonologically related paradigms, neuroplasticity in sensory memory and cognitive functioning underlying phonological processing can be investigated. In aphasic patients, MMN amplitudes are generally reduced for speech sounds with a topographic source distribution in the right hemisphere. For P300 amplitudes and latencies, both normal and abnormal results have been reported. The current study investigates the preattentive and attentive phonological discrimination ability (...) in 17 aphasic patients at two timepoints during aphasia recovery. Between the two timepoints, a significant improvement of behavioral language performance in both languages is observed in all patients with the MMN latency at timepoint 1 as a predictive factor for aphasia recovery. In contrast to monolinguals, bilingual aphasic patients have a higher probability to improve their processing speed during rehabilitation, resulting in a shortening of the MMN latency over time, which sometimes progresses toward the normative values. (shrink)

In 2009, an influential and remarkable report to the French highest health authorities written by Claire Compagnon, a patients' advocate, and Véronique Ghadi, a legal scholar, has brought to public attention a phenomenon that had gone unnoticed in medical ethics: the report's authors called it "ordinary abuse".1 They argue that the term describes a widespread and invisible form of mistreatment in the hospital setting, which they distinguish from abuse proper, a phenomenon, they argue, which is far less common and (...) controversial. "Ordinary abuse," they write, occurs for example when patients have to accept "interminable and inexplicable... (shrink)

BackgroundThe European Charter of Patients' Rights (ECPR) presents basic patients' rights in health care. We analysed the characteristics of patients' complaints about their rights submitted through the official complaints system and to a non-governmental organization in Croatia.MethodsThe official system for patients’complaints in Croatia does not have a common pathway but offers different modes for addressing patient complaints. In this cross-sectional study, we analysed the reports about patients’ complaints from the official regional committees sent to the (...) Ministry of Health. We also analysed the complaints received by the Croatian Association for the Protection of Patient’s Rights (CAPR) and mapped them to the ECPR.ResultsThe aggregated official data from the Ministry of Health in 2017 and 2018 covered only 289 individual complaints from 10 out of 21 counties. Complaints were most frequently related to secondary and tertiary healthcare institutions and details were not provided. CAPR received a total of 440 letters, out of which 207 contained 301 complaints about violations of patients’ rights in 2017–2018. The most common complaint was the Right of Access to health care (35.3%) from the ECPR, followed by the Right to Information (29.9%) and the Right to Safety (21.7%). The fewest complaints were about the Right to Complain (1.9%), Right to Innovation (1.4%), Right to Compensation (1.4%), and Right to Preventive Measures (1.0%).ConclusionsReporting and dealing with patients’ complaints about violations of their patients’ rights does not appear to be effective in a system with parallel but uncoordinated complaints pathways. Mapping patient's complaints to the ECPR is a useful tool to assess the perception of patients’ rights and to plan actions to improve the complaints system for effective health care. (shrink)

In Morals and Medicine a leading Protestant theologian comes to grips with the problems of conscience raised by new advances in medical science and technology. They arise as issues at the start or making of a life, in preserving its health, and in facing its death. They are the problems of Everyman: some are new problems of conscience, such as artificial insemination; some are old problems in new dimensions, such as euthanasia. Modern medicine provides such a high degree of control (...) over health and vital processes that men must inevitably shoulder the burden of intelligent decision, and shoulder it as rationally as possible. Thus far, only Roman Catholic moralists have worked out a coherent ethics of medical care. Morals and Medicine is a new and independent analysis of the morals of life and death, striking out along the line of the values of personality rather than of mere physiological life itself. It offers a modern and at the same time Christian concept of right and wrong for all who are involved: the patient, the doctor and nurse, the pastor, and the family and friends. Originally published in 1954. The Princeton Legacy Library uses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished backlist of Princeton University Press. These editions preserve the original texts of these important books while presenting them in durable paperback and hardcover editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905. (shrink)

AimsThis preliminary study aimed to investigate therapy-induced electrophysiological changes in persons with primary progressive aphasia. The investigated event-related potential components associated with language processing were the mismatch negativity, P300, N400, and P600.MethodsA linguistic ERP test battery and standardized language assessment were administered in four patients with PPA of which two received speech-language therapy and two did not receive therapy. The battery was administered twice with approximately 6 months in between in each patient. The results of the follow-up assessments were (...) compared to the results of the initial assessments.ResultsAlthough the results of the behavioral language assessment remained relatively stable between the initial and follow-up assessments, changes in the mean amplitudes, onset latencies, and duration of the ERP components were found in the four patients. In the two patients that did not receive SLT, an increased delay in 50% and a decreased mean amplitude in 25% of the measured ERP components were found. The electrophysiological changes found in the patients that received SLT were variable. Interestingly, the mismatch negativity and the N400 effect elicited by the categorical priming paradigm were less delayed and had an increased mean amplitude at the follow-up assessment in the patient with the non-fluent variant who received SLT. In this patient, the P600 component was absent at the initial assessment but present at the follow-up assessment.ConclusionAlthough no clear patterns in electrophysiological changes between patients who received SLT and patients who did not receive SLT were found by our preliminary study, it seems like the SLT induced improvements or compensation mechanisms in some specific language comprehension processes in the patient with the NFV. The results of this study are still preliminary because only four heterogeneous patients were included. Future studies should include larger patient groups of the three clinical variants because the therapy-induced electrophysiological changes might differ depending on the clinical variant and the underlying pathology. (shrink)

“It was the best of times. It was the worst of times.” Charles Dickens easily could have been describing our time and the dilemma in which victims of nonmalignant chronic pain find themselves.I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life.The morning of February 1983 severed my (...) life into “before” and “after,” as clearly as if it has been cut by a sharp knife. The “before” included my career as an oncology nurse, a college nursing professor, and a writer; but that was abruptly ended by the catastrophic rupture of a deep cerebral aneurysm. Surgery saved my life, but something unforeseen occurred during the procedure; and so, in the “after,” I have had to live with a serious seizure disorder and memory loss. (shrink)

Medical students lack opportunities to have authentic conversations with patients with cancer in busy hospitals. An improved understanding of what such communication might look like may provide a framework for end-of-life curricula. The authors performed thematic analysis using written correspondence between patient and student participants in the University of California, San Francisco’s Firefly Program whose letters discussed death or dying. Four themes emerged: (1) turmoil, (2) grief, (3) making peace, and (4) past, present, and future. Medical students expressed (...) a fifth theme: unmet student expectations. The study provides educators with a unique perspective to help inform curriculum development and patient care. (shrink)

“It was the best of times. It was the worst of times.” Charles Dickens easily could have been describing our time and the dilemma in which victims of nonmalignant chronic pain find themselves.I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life.The morning of February 1983 severed my (...) life into “before” and “after,” as clearly as if it has been cut by a sharp knife. The “before” included my career as an oncology nurse, a college nursing professor, and a writer; but that was abruptly ended by the catastrophic rupture of a deep cerebral aneurysm. Surgery saved my life, but something unforeseen occurred during the procedure; and so, in the “after,” I have had to live with a serious seizure disorder and memory loss. (shrink)

Les études sur le corps du siècle des Lumières se sont longtemps appuyées sur les traités de médecine, reprenant ainsi les représentations médicales plutôt que celles des malades. Les écrits ordinaires, parmi lesquels on peut compter les consultations épistolaires, permettent toutefois d’appréhender les perceptions corporelles des femmes du xviiie siècle. Ces lettres, envoyées par les malades à leur médecin, forment de véritables biographies médicales et constituent des sources d’une grande richesse pour explorer les écritures féminines du corps. On peut ainsi (...) mettre en évidence des manières spécifiques d’écrire le corps au féminin tout en soulignant les points communs avec les écritures masculines. (shrink)

Euthanasia and physician-assisted suicide (PAS) by request and/or based on an advance directive are legal in The Netherlands under strict conditions, thus providing options for patients with Huntington's disease (HD) and other neurodegenerative diseases to stay in control and choose their end of life. HD is an inherited progressive disease characterised by chorea and hypokinesia, psychiatric symptoms and dementia. From a qualitative study based on interviews with 15 physicians experienced in treating HD, several ethical issues emerged. Consideration of these (...) aspects leads to a discussion about the professional role of a physician in relation to the personal autonomy of a patient. Such a discussion can raise awareness that talking about end-of-life wishes with an HD patient is part of the legal, professional and moral responsibility of the physician, and that a letter of intent on behalf of the physician can improve active participation in the process. Discussion of these issues can help to advance the debate on euthanasia and PAS in HD and other neurodegenerative diseases. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Patient Self-Determination ActElizabeth Leibold McCloskey (bio)What are the ethics of extending the length of life? We know that we cannot artificially end life (Thou Shalt not Kill), but how about artificially extending life? Is that always good, sometimes good?... In ethics, is keeping people alive the highest good? Should our priority be to keep people breathing?... What does basic religious ethics say about this?(John C. Danforth, letter to (...) the author, 19 August 1989)The Patient Self-Determination Act, signed into law as part of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) last November, marks the first time that Congress has passed legislation concerning the ethics of life-sustaining medical treatment. The bill was spearheaded by Senator John C. Danforth (RMO), who has a special interest in this area. An Episcopal priest, Danforth was formerly an assistant chaplain at New York's Memorial Sloan-Kettering Cancer Center and now sits as a senior member of the Senate Finance Committee, which oversees Medicare and Medicaid. Although Senator Danforth's legislative initiative was not a result of the Cruzan case, it was in his state of Missouri that the U.S. Supreme Court case involving removal of Nancy Cruzan's feeding tube arose (Cruzan v. Director of Missouri Department of Health, U.S. Supreme Court, 58 LW 4916, 26 June 1990). From his unique vantage point, he felt it was time to craft a legislative response to some of the difficult issues surrounding prolongation of life.The short answer to Senator Danforth's questions about when to artificially extend life is simple enough: people must be free to determine that for themselves. Common law and common sense dictate such a conclusion; living will and health care proxy statutes, enacted in almost every state, codify that right. The Catholic moral tradition teaches that one is not morally obligated to use extraordinary means to prolong life, a tradition shared both by the mainline Protestant and the reform and conservative Jewish community. Yet most people are unaware of their fundamental legal right to make such decisions, and as court cases from Quinlan (In re Quinlin, 137 N.J. Super. 227, 1975) to Cruzan demonstrate, few know [End Page 163] how to make arrangements for this right to be exercised if they become incapacitated.Meanwhile, health care practices are often driven by a denial of death. When Senator Danforth and Senator Daniel Patrick Moynihan (D-NY) introduced the bill on October 17, 1989, Senator Danforth said:More and more it is arguable that we play God by subjecting people to unwanted and sometimes unnecessary treatment, treatment that unnaturally prolongs the dying process. Our health care system has become obsessed with extending life, at times neglecting the caring component of medicine and trampling on the rights of patients.(Congressional Record 1989, 135:5.13566)The American Hospital Association estimates that 70 percent of deaths now occur after a determination to withhold or withdraw medical treatment. Many of those decisions are made without the benefit of an incapacitated patient's views, yet a Harvard study revealed that 95 percent of the population would like to prepare in advance for such decisions. Only 4 percent of hospitals have a systematic method of asking patients if they have an advance directive. Family members confront painful choices in the face of uncertainty about their loved one's wishes and it can be even more painful when a family knows the patient's desires but providers and the courts act otherwise because clear evidence is lacking.The Patient Self-Determination Act is rooted in the belief that people should be given information that enables them to specify the extent of medical treatment they wish to receive should they become incapacitated. The public should be educated about applicable state laws that protect the individual's right to make such choices through the use of an advance directive.The Act moves toward that goal by promoting knowledge of state laws. It requires every hospital, nursing home, home health agency, hospice, and health maintenance organization that participates in Medicaid or Medicare to routinely give all adult patients information about advance directives. Patients will also be given information on the... (shrink)

About one third of patients with epilepsy have seizures refractory to the medical treatment. Electrical stimulation mapping is the gold standard for the identification of “eloquent” areas prior to resection of epileptogenic tissue. However, it is time-consuming and may cause undesired side effects. Broadband gamma activity recorded with extraoperative electrocorticography during cognitive tasks may be an alternative to ESM but until now has not proven of definitive clinical value. Considering their role in cognition, the alpha and beta bands could (...) further improve the identification of eloquent cortex. We compared gamma, alpha and beta activity, and their combinations for the identification of eloquent cortical areas defined by ESM. Ten patients with intractable focal epilepsy participated in a delayed-match-to-sample task, where syllable sounds were compared to visually presented letters. We used a generalized linear model approach to find the optimal weighting of each band for predicting ESM-defined categories and estimated the diagnostic ability by calculating the area under the receiver operating characteristic curve. Gamma activity increased more in eloquent than in non-eloquent areas, whereas alpha and beta power decreased more in eloquent areas. Diagnostic ability of each band was close to 0.7 for all bands but depended on multiple factors including the time period of the cognitive task, the location of the electrodes and the patient’s degree of attention to the stimulus. We show that diagnostic ability can be increased by 3–5% by combining gamma and alpha and by 7.5–11% when gamma and beta were combined. We then show how ECoG power modulation from cognitive testing can be used to map the probability of eloquence in individual patients and how this probability map can be used in clinical settings to optimize ESM planning. We conclude that the combination of gamma and beta power modulation during cognitive testing can contribute to the identification of eloquent areas prior to ESM in patients with refractory focal epilepsy. (shrink)

Background:The theoretical framework of Jϋrgen Habermas suggests that effective communication requires competent participants with an objective attitude that complies with the rules and worlds designated as objective, social and subjective. This situation determines communicative action, which stimulates the search for mutual understanding and results in a process of interaction that promotes self-determination.Objectives:In this study, the discharge letters of patients with myocardial infarction were explored regarding the provision of information. The patient’s right to information and the duty of informing (...) were analysed according to the perspective of Jϋrgen Habermas.Research design:This was a cross-sectional analysis (from a broader longitudinal study) of all discharge letters that were directly related to nursing interventions regarding the provision of information to 106 patients. In this major study, the difficulties faced by patients who experienced a myocardial infarction and the changes in their lifestyles were analysed based on the type of information received.Ethical considerations:The hospital Ethics Committee approved the study, which complied with ethical principles and required informed consent.Findings:In the nursing letters, interventions related to the provision of information were conducted at an average of 3.59 interventions per patient. For 8.5% of the patients, however, no interventions related to the provision of information were performed. The most common area of information during hospitalisation was related to the management of signs and symptoms and applied to 90.6% patients.Discussion:The nursing interventions did not cover patient education, transition processes or awareness of the disease. Thus, the right to information can be questioned.Conclusion:Information is a right, and communication is extremely important. Health professionals should be aware of this importance regarding both care management and the satisfaction guarantee. The sharing of information by health professionals based on their competency is essential for patients to exercise their right to self-determination and decision-making. (shrink)

Patient education materials have the potential to strengthen the health literacy of patients. Previous studies indicate that readability and suitability may be improved. The aim of this study was to explore and analyze discourses inherent in patient education materials since analysis of discourses could illuminate values and norms inherent in them. Clinics in Sweden that provided colorectal cancer surgery allowed access to written information and ‘welcome letters’ sent to patients. The material was analysed by means of discourse (...) analysis, embedded in Derrida's approach of deconstruction. The analysis revealed a biomedical discourse and a hospitality discourse. In the biomedical discourse, the subject position of the personnel was interpreted as the messenger of medical information while that of the patients as the carrier of diagnoses and recipients of biomedical information. In the hospitality discourse, the subject position of the personnel was interpreted as hosts who invite and welcome the patients as guests. The study highlights the need to eliminate paternalism and fosters a critical reflective stance among professionals regarding power and paternalism inherent in health care communication. (shrink)

A letter from Howard C. Berkowitz about “Impact of a Clinical Trials Information Handbook on Patient Knowledge, Perceptions, and Likelihood of Participation”.

We have examined healthcare staff attitudes of toward a blogging cancer patient who publishes critical posts about her treatment and their possible effect on patient-staff relationships and treatment decisions. We used two versions of a questionnaire containing a vignette based on a modified real case involving a 39-year-old cancer patient who complained on her blog about how she was encountered and the treatment she received. Initially she was not offered a new, and expensive treatment, which might have influenced her perception (...) of further encounters. In one version of the vignette, the team decides to put extra effort into both encounters and offers the expensive new cancer treatment. In the other version, the team decides to follow the clinic’s routine to the letter. Subsequently, blog postings became either positive or negative in tone. We also divided participants into value-neutral and value-influenced groups by asking how their trust in healthcare would be affected if the team’s suggestion were followed. A total of 56 % of the respondents faced with a team decision to ‘do something-extra’ in encounters would act in accordance with this ambition. Concerning treatment, 32 % would follow the team’s decision to offer a new and expensive treatment. A large majority of those who received the “follow-routine” version agreed to do so in encountering [94 % ]. Similar proportions were found regarding treatment [86 % ]. A total of 83 % of the value-neutral participants who received the “do-something-extra” version stated that they would act as the team suggested regarding encounters, while 57 % would do so in regard to treatment. Among the value-influenced participants who received the “do-something-extra” version, 45 % stated that they would make an extra effort to accommodate the patient and her needs, while the proportion for treatment was 22 %. Among those who had received the “follow-routine” version, a large majority agreed, and no difference was indicated between the value-neutral and the value-influenced participants. The present study indicates that healthcare staff is indeed influenced by reading a patient’s critical blog entries, largely regarding encounters, but also concerning treatment is concerned. Value-neutral healthcare personnel seem to exhibit a pragmatic attitude and be more inclined to heed and respond to a patient whose criticism may well be warranted. The study also indicates that healthcare staff is partly positive or negative to future blogging patients depending on how the issue has been framed. For future research we suggest as a bold hypothesis that the phrase “clinical routine” might conceal power aspects masquerading as adopted ethical principles. (shrink)

This paper explores evolving treatments for hysteria in the eighteenth century by examining a selection of works by both physician-writers and educated literary women. The treatments I identify—which range from aggressive bloodlettings, diets, and beatings, to exercise, fresh air, and writing cures—reveal a unique culture of therapy in which female sufferers and doctors exert an influence on one another's notions of what constitutes appropriate management of women's mental illness. A scrutiny of this exchange of ideas suggests that female patients (...) were not simply oppressed and silenced by male practitioners; rather, their collective voice, intellect, and expertise helped to form progressive treatments for eighteenth-century hysteria. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:LettersMaxwell J. Mehlman, Susan R. Massey, Ronald M. Green, and Fred RosnerPhysicians and the Allocation of Scarce ResourcesMadam: We read with interest Dr. Pellegrino's commentary on our article in the December 1994 issue of the Kennedy Institute of Ethics Journal, and commend him for pointing out so well the different ways that law and ethics approach the issue of physician allocation of scarce resources.We wish to make one clarification. (...) Dr. Pellegrino states that we propose that fiduciary duties be abolished. Quite the contrary, our position is that fiduciary obligations are essential to the maintenance of trust—which we believe to be an efficient as well as an ethical element of the patient-provider relationship. If fiduciary duties are undercut, as we pointed out they are by the Oregon Medicaid legislation, then some other method of promoting trust must be established, and, as we point out in the article, it is difficult to identify what that method could be.Maxwell J. MehlmanandSusan R. MasseyThe Law Medicine CenterArter & HaddenCase Western Reserve UniversityCleveland, OHSchool of LawCleveland, OHReport of the Human Embryo Research PanelMadam: In the December 1994 issue of the Kennedy Institute of Ethics Journal, I reported on the controversy surrounding the work of the NIH Human Embryo Research Panel and the conclusions reached in its report, which was formally presented to NIH Director Harold Varmus on September 27, 1994. At that time, the report was to be reviewed by the Advisory Committee to the Director (ACD) until its next meeting in early December. I am writing to update your readers on the fate of the Panel's report.On the morning of December 2, 1994, following a previous afternoon of animated discussion, the ACD unanimously accepted the Report of the Human Embryo Research Panel. Panel members and members of the NIH staff who were present and had worked for nearly a year on the Report were gratified by this vote of confidence and by the strong support of NIH Director Harold Varmus.We had little time to enjoy this success. Within a matter of hours, the White House issued a press release in which President Clinton thanked the committee for its work and then, in a remark overruling one of the key recommendations in our report, stated: "I do not believe that federal funds should be used to support the creation of human embryos for research purposes, and I have directed that NIH not allocate any resources for such research." [End Page 83]As a Panel member and active participant in that day's events, my initial response was one of shock. I was particularly distressed that the President and his advisors chose a moment so late in the process to make their views known. Why had we worked for months, I asked, without a word of concern from the White House? Although Panel members were guided primarily by our perceptions of the ethical and scientific issues involved, some were close to the political realities of Washington and would have introduced these concerns into the Panel's deliberations.Within a matter of days, my own sense of outrage had diminished. First of all, it was clear that whatever the personal sources of the President's objections to the Panel's recommendations, this high level political intervention was inevitable. Less than a month before, on November 8, with the election of a majority House and Senate, the political environment for embryo research had changed dramatically. The previous June, 32 congressmen, most of them members of a minority Republican party, had signed a letter protesting the Panel's work. Now, one of the signers of that letter, Newt Gingrich, was destined to be Speaker of the House.Second, it became clear that the damage was not total. The President has forbidden NIH to support work involving the deliberate creation of embryos for research. Without exception, members of the Panel had come to the conclusion that some development of "research embryos" must be permitted to reduce the risks of new assisted reproductive technologies, to enhance scientific knowledge, and to develop new therapies for a range of serious diseases. All these... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:An Open Letter to Certified Nursing Assistants:Lessons from a Life Well Lived1Margaret FletcherI can't be sure what I want to say, or how to say it. Seeing as how I'm now eighty years old, and somewhat forgetful, I cease remembering the good old days.I have written a lot of short articles for the Nursing Assistant Program. My journey of life has been very interesting, very wonderful and fully blessed.My (...) career as a nursing assistant started in my 16th year back in 1947. Once I was involved in the work, [End Page 155] I understood about the journey of life and all the things that living brings into a life of a human being.I learned being a nursing assistant is not just a job and a paycheck. It's a beautiful and wonderful life of kindness, honesty, courtesy, fairness, pity, help, trust and forgiveness.Its principles will take hold of your lifestyle and future. If we realize we are a valuable and unique person, then accepting life with optimism, making sure of our goals, striving to give our best, and growing in awareness helps us learn to be productive and efficient in our work.Understand that everyone and every thing around us has something to teach us. It's not just the classroom learning that's going to put us on the road of good caregiving with a kind loving heart.It's going to take desire, concern and total devotion with lots of hard work. We must learn from the day-to-day needs and expectations of our patients or residents, doctors, wing nurses and the patients' or residents' families.There will be changes, and these changes can be frequent. Therefore, we will need to know and be aware what is expected of us.Now as an old fogy, I'd like to point out that experience is required for developing expertise. And that a sound educational base is necessary for acquiring advanced skills because it forms the best position for developing our ability to sort through concepts and facts. And to focus on the aspects of the various types of patient care situations. It will indicate priorities and offer guidelines for action. Even in seemingly routine situations the nursing assistant must be alert to special circumstances and adapt their care accordingly.Never once did I regret my choice of becoming a caregiver. I can remember one kindhearted doctor who always had his special way for chitchats, telling me, "What you leave behind is not engraved in stone, but what is woven into the lives of other human beings, you must always make the right connections." Then, jokingly, the good doctor asked, "If a cabbage, a tomato, and a faucet ran a race, who would win?" His answer, "The cabbage would be a head, the tomato would ketch up, and the faucet would still be running. Which would you be most like?" My answer, "but doctor, I'm not running a race, I'm on a journey." That journey is life and love. Life is so precious. Where there is love, love makes us whole.No matter what obstacles we face, love gives us the strength to overcome them. As a writer, I'll share in this story. It should be as though we're all family now. Our world is as great as we make it.Realize we all deserve a little lift now and then, but we also need to realize there is no cosmetic for beauty, like happiness. A very personal happiness is what you say and do as a nursing assistant making life better for those entrusted in our care.Down through the years my patients and residents have taught me well what love is really all about. I want to share my lesson with you. Love is friendship that has caught fire, it is quiet understanding, mutual confidence, sharing and forgiving. It is loyalty through good and bad times. Love settles for less than perfection and makes allowances for human weaknesses. Love is content with the present, love hopes for the future, but doesn't brood over the past. Love: it's the day-in... (shrink)

Title III of the Americans with Disabilities Act (ADA) grants people with disabilities access to public accommodations, including the offices of medical providers, equal to that enjoyed by persons without disabilities. The Department of Justice (DOJ) has unequivocally declared that the law requires effective communication between the medical provider and the Deaf patient. Because most medical providers are not fluent in sign language, the DOJ has recognized that effective communication calls for the use of appropriate auxiliary aids, including sign language (...) interpreters. The final decision on what to offer the Deaf patient is the doctor's, and under current DOJ regulations, the doctor does not have to consult with the patient or give "primary consideration" to the patient's choice of auxiliary aid as long as what the doctor offers results in effective communication. However, given the great variation in people's communication styles and skills, a standard, one-size-fits-all auxiliary aid would fail to achieve effective communication in many cases, harming not only that Deaf patient, but also the medical provider, who would be potentially liable for violating the ADA as well as hamstrung in getting accurate information for purposes of diagnosis and treatment. Moreover, most doctors are not savvy about Deafness and Deaf culture. Thus, the best way to ensure effective communication would be to require the medical provider to ask the Deaf patient for his or her choice of auxiliary aid and to give "primary consideration" to the patient's expressed choice of auxiliary aid. Such an approach is required under Title II of the ADA, which makes it mandatory for state and local governments to consult with people with disabilities and give "primary consideration" to the patient's choice of auxiliary aid. Given that there is no difference between a public doctor and a private doctor that would justify the two different approaches and that cost is not a factor, since under either title, a medical provider cannot pass on the costs to the person with a disability, the DOJ should revise its interpretation of Title III in order to bring in into line with its interpretation of Title II. To fail to do so would operate to frustrate both the letter and the spirit of the ADA. Until the DOJ brings the titles into line, the courts should decline to give controlling weight to the DOJ's interpretation of Title III. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“Can They Do This?” Dealing with Moral Distress after Third–Party Termination of the Doctor–Patient RelationshipSusan McCammonNot so long ago, a storm badly damaged the tertiary care hospital in which I practice surgical oncology. In the aftermath of the storm, the institution determined it was no longer able to provide unreimbursed cancer care, and many of my patients were terminated by a form letter from the hospital. The helplessness (...) and outrage that I experienced when I was first handed one of these letters, crumpled from the damp fist of one of my patients, was immense, and frightening in its unfamiliarity: “Can they do this?” I asked repeatedly, ascending a hierarchy of authority, which was increasingly reticent and then elusive. In short, the answer was “yes.”While this decision was made by the administration, its enactment was delegated to the physicians. Thus, not only were the physicians not involved in the decision to terminate their patients, they shouldered the burden of telling their patients that they would no longer be treated. The reason given—storm devastation—was contradicted by the orderly flow of insured patients in and out of unaffected clinics and hospitals.In those months, when the operating rooms were closed, I took to the road and learned about hospice and palliative care medicine on the ground. I drove from city to smaller city to the devastated countryside, locating my patients and providing all the care that I could with only my hands and mind and heart. I struggled with the limitations of the health care system and worked to rebuild a sustainable infrastructure at my own institution, all while trying to come to terms with bioethicist Haavi Morreim’s (1995) caution that “... it is not the physician who owes the resources at all. He cannot owe what others own and control, because moral obligations can only be assigned to those capable of fulfilling them” (p. 87).In considering my experience of moral distress over this period of time, I have reflected on the different connotations of the word, “practice.” I grappled with the philosophical terms “practice,” “praxis,” and “phronesis,” and I questioned their relevance to the word, as used in my professional life. However, in struggling to understand my moral obligations after the storm, when I was learning to do what I could, even when I couldn’t do what I felt like I should, I reconsidered. The elements of immersion, repetition, particularity, and utility that pervade this language of philosophers and artists turned out to be what preserved my ability [End Page 109] to practice medicine in a space holding only patient and practitioner.Many of the patients that I take care of are very poor. Many more are working but uninsured. This is a result of both their risk factors and the demographics and resources in my geographic catchment area. Their access to care was disrupted after a natural disaster and concerted efforts to reestablish it have not succeeded. Since then, I have learned how to tell people that they will die of cancer because they don’t have enough money. This is not a skill I was taught in medical school. I can talk about death, imminent or not, feared or anticipated. I can talk about unresectable tumors, treatments that have more risk than benefit (or no benefit at all), suffering beyond what has yet been experienced or imagined, helplessness, futility and grief. I could be neither surgeon nor oncologist without some facility with these. But I was unprepared for this move from medical to economic “can’t,” the nexus where an institutional “won’t” becomes a personal “can’t.”I should say here that I was not blind to the expense and technological hype of the American medico–industrial complex or our systematic marginalization of public health or the ever–present cries for health care reform. I understood that I was a steward and that I served both the individual and the society and had at my disposal what I was told were limited resources. These values, however, were only just being incorporated into the training of medical professionals; certainly they played no role in my own education. Morreim’s (1995) conclusion... (shrink)

The risk of transmission of HIV or hepatitis B from infectious health care workers to patients is low. However, inadvertent exposure causes great concern amongst patients of an infected health care worker.The patients of a Scottish dentist diagnosed hepatitis B e antigen positive were informed by letter of their exposure. A sample of patients was sent a postal questionnaire. Most respondents reported feeling anxious on receiving the letter but almost all thought patients should always be (...) informed following treatment by an infectious health care worker, although the risk was very small.We discuss clinical and ethical factors relating to informing patients following exposure to an infectious health care worker. We suggest that a balance should be struck between patients' wishes to know of risks to which they have been exposed, however small, and the professional view that when risks are negligible, patients need not be informed. (shrink)

Long awaited and eagerly anticipated, this remarkable volume allows English-speaking readers to experience a profound dialogue between the German philosopher Martin Heidegger and the Swiss psychiatrist Medard Boss. A product of their warm friendship, _Zollikon Seminars_ chronicles an extraordinary exchange of ideas. Heidegger strove to transcend the bounds of philosophy while Boss and his colleagues in the scientific community sought to understand their patients and their world. The result: the best and clearest introduction to Heidegger's philosophy available. Boss approached (...) Heidegger asking for help in reflective thinking on the nature of Heidegger's work. Soon they were holding annual two-week meetings in Boss's home in Zollikon, Switzerland. The protocols from these seminars, recorded by Boss and reviewed, corrected, and supplemented by Heidegger himself, make up one part of this volume. They are augmented by Boss's record of the conversations he had with Heidegger in the days between seminars and by excerpts from the hundreds of letters the philosopher wrote to Boss between 1947 and 1971. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:LettersJames L. Walsh, Moira M. McQueen, Kevin O'Rourke, and Jean deBloisEarly Delivery of the Anencephalic InfantMadam:In the March 1994 issue of the Kennedy Institute of Ethics Journal, Kevin O'Rourke and Jean deBlois have replied to an article of ours (KIEJ, December 1993) on the early induction of the anencephalic fetus. They agree with our conclusion that such early delivery may be morally acceptable, but argue that our justification is (...) flawed. Exchanges on the subject probably could continue ad nauseam; here we simply state some of the elements of their article that leave us perplexed.1. The phrase "prolonging the life of" (p. 49) has one meaning in the case of artificial life supports, which may be unwarranted interventions, but it has a different meaning when it refers to not interfering with a person's enjoyment of necessary natural means of preserving his or her life. Inducing labor prior to viability, which denies the natural means of life support without a possible substitute, has more in common with smothering a dying patient than the nonemployment of or withdrawing of artificial means of life support. To refer to the death of the fetus here as an effect is rather like saying that I suffocated you and the effect of the suffocation is your death. This is quite different from induction after viability where the induction can have different effects.2. If the authors were correct that "the prohibition on inducing delivery before viability is predicated upon the assumption that the fetus in utero is a human being with the potential for further development" (p. 49) and the anencephalic has none, why is there need to employ the principle of double effect? They say that there is no moral obligation to prolong the life of the anencephalic fetus. Just as there is no need for the principle in cases of withdrawing unwarranted artificial life support, so there would be no need for it here. Because the authors seem to perceive a complete disjunction between direct and indirect killing (allowing to die being in the category of indirect killing), it seems that they are unable to let their argument rest here, but have to justify the death that occurs.3. The example concerning smothering and the nonemployment of aggressive interventions (p. 49) explains well the difference between killing and allowing to die. But allowing to die is not indirectly killing since it occurs as a result of the disease and not from the causality of the agent.4. How can we cause something and not intend it? There are instances in which we simply "permit" evil events, but where we are not the cause. For example, evil events may be attributable to the bad will of others. Legislators make just laws knowing that some people of bad will will break them for their own advantage. Here the legislators really do permit evil. Neither are we the cause of death when we allow a person to die by not imposing unwarranted means of life support; we permit his or her death. But can we so readily designate by "permit" [End Page 184] what we knowingly choose to bring about? O'Rourke and deBlois use interchangeably "indirectly intended" and "unintended" for what is caused by our actions; "indirectly intended" is a better designation than "unintended." The whole package, including all foreseen effects, is intended. Evil "happening" (p. 51) as a result of an action that I place can refer either to evil as caused by my action or to evil as arising from a cause apart from my action. Only in this latter sense do I permit evil and not intend it, either directly or indirectly.5. The fourth condition of the principle of double effect is given as follows: "There must be a proportionately grave reason for placing the act. The greater the evil, the more cogent the reason must be for performing the act" (p. 50). How the authors can abstract from balancing goods and evils here is beyond us.6. We cannot follow the authors' use of the term "morally good" with respect to the induced delivery (p. 50). The problem is concerned with the morally right... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:LettersJames L. Walsh, Moira M. McQueen, Kevin O'Rourke, and Jean deBloisEarly Delivery of the Anencephalic InfantMadam:In the March 1994 issue of the Kennedy Institute of Ethics Journal, Kevin O'Rourke and Jean deBlois have replied to an article of ours (KIEJ, December 1993) on the early induction of the anencephalic fetus. They agree with our conclusion that such early delivery may be morally acceptable, but argue that our justification is (...) flawed. Exchanges on the subject probably could continue ad nauseam; here we simply state some of the elements of their article that leave us perplexed.1. The phrase "prolonging the life of" (p. 49) has one meaning in the case of artificial life supports, which may be unwarranted interventions, but it has a different meaning when it refers to not interfering with a person's enjoyment of necessary natural means of preserving his or her life. Inducing labor prior to viability, which denies the natural means of life support without a possible substitute, has more in common with smothering a dying patient than the nonemployment of or withdrawing of artificial means of life support. To refer to the death of the fetus here as an effect is rather like saying that I suffocated you and the effect of the suffocation is your death. This is quite different from induction after viability where the induction can have different effects.2. If the authors were correct that "the prohibition on inducing delivery before viability is predicated upon the assumption that the fetus in utero is a human being with the potential for further development" (p. 49) and the anencephalic has none, why is there need to employ the principle of double effect? They say that there is no moral obligation to prolong the life of the anencephalic fetus. Just as there is no need for the principle in cases of withdrawing unwarranted artificial life support, so there would be no need for it here. Because the authors seem to perceive a complete disjunction between direct and indirect killing (allowing to die being in the category of indirect killing), it seems that they are unable to let their argument rest here, but have to justify the death that occurs.3. The example concerning smothering and the nonemployment of aggressive interventions (p. 49) explains well the difference between killing and allowing to die. But allowing to die is not indirectly killing since it occurs as a result of the disease and not from the causality of the agent.4. How can we cause something and not intend it? There are instances in which we simply "permit" evil events, but where we are not the cause. For example, evil events may be attributable to the bad will of others. Legislators make just laws knowing that some people of bad will will break them for their own advantage. Here the legislators really do permit evil. Neither are we the cause of death when we allow a person to die by not imposing unwarranted means of life support; we permit his or her death. But can we so readily designate by "permit" [End Page 184] what we knowingly choose to bring about? O'Rourke and deBlois use interchangeably "indirectly intended" and "unintended" for what is caused by our actions; "indirectly intended" is a better designation than "unintended." The whole package, including all foreseen effects, is intended. Evil "happening" (p. 51) as a result of an action that I place can refer either to evil as caused by my action or to evil as arising from a cause apart from my action. Only in this latter sense do I permit evil and not intend it, either directly or indirectly.5. The fourth condition of the principle of double effect is given as follows: "There must be a proportionately grave reason for placing the act. The greater the evil, the more cogent the reason must be for performing the act" (p. 50). How the authors can abstract from balancing goods and evils here is beyond us.6. We cannot follow the authors' use of the term "morally good" with respect to the induced delivery (p. 50). The problem is concerned with the morally right... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt with pain medications that might (...) have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

Soon after the discovery of insulin in the early 1920s, the popular press celebrated the miraculous discovery. Although insulin had no curative effect on the chronic state of diabetes, it was frequently heralded as a “cure.” This paper examines how the discovery of insulin intersected with the rise of diabetic technology and the transfer of medical technology to the home setting. By analyzing diabetic manuals written for patients and physicians, letters exchanged between patient and physician, medical journals, magazines (...) and newspapers, I trace how patients learned about insulin and more significantly how patients adopted measurement technologies designed to allow better home administration of insulin. This included acquiring knowledge about nutritional content and scales, maintaining sterile glass syringes, sharpening needles, using chemistry to measure sugar in the urine, and recording various measurements into meaningful text for patient-physician dialogue. As diabetes was re-imagined as a chronic and controllable illness, patients and physicians alike grappled with the promises and limitations of new medical technologies. This historical perspective offers a lens for better understanding the process of implementing diabetic treatment plans that required home testing, measurement, and recording of medical data. Such processes centered the importance of patient-centered work and the value of diabetic technologies. Much of this discourse is outlined in diabetic manuals of the 1920s. (shrink)

Doctor and patient meet in a circle of feelings determined by suffering. Sensitivity to the suffering is an axis determining the nature of the doctor and patient relationship. The patient's experience of an illness is individual, private, and very often difficult to describe. But the possibility to understand the suffering of another person comes from the fact that suffering is a universal feeling. We propose to enter the world of patient's experience by writing a letter to a doctor, which would (...) reflect their experiences and expectations towards him. This was the task required for 120 students of the second year of medicine and dentistry education. (shrink)

Volume 17 of Progress in Self Psychology, _The Narcissistic Patient Revisited_, begins with the next installment of Strozier's "From the Kohut Archives": first publication of a fragment by Kohut on social class and self-formation and of four letters from his final decade. Taken together, Hazel Ipp's richly textured "Case of Gayle" and the commentaries that it elicits amount to a searching reexamination of narcissistic pathology and the therapeutic process. This illuminating reprise on the clinical phenomenology Kohut associated with "narcissistic (...) personality disorder" accounts for the volume title. The ability of modern self psychology to integrate central concepts from other theories gains expression in Teicholz's proposal for a two-tiered theory of intersubjectivity, in Brownlow's examination of the fear of intimacy, and in Garfield's model for the treatment of psychosis. The social relevance of self psychology comes to the fore in an examination of the experience of adopted children and an inquiry into the roots of mystical experience, both of which concern the ubiquity of the human longing for an idealized parent imago. Among contributions that bring self-psychological ideas to bear on the arts, Frank Lachmann's provocative "Words and Music," which links the history of music to the history of psychoanalytic thought in the quest for universal substrata of psychological experience, deserves special mention. Annette Lachmann's consideration of empathic failure among the characters in Shakespeare's _Othello_ and Silverstein's reflections on Schubert's self-states and selfobject needs in relation to the specific poems set to music in his Lieder round out a collection as richly broad based as the field of self psychology itself. (shrink)

In April 1996, two men working at a convalescent center wrote a letter to the journal Nature proposing that a new word be adopted to designate a person who is the last in the lineage: endling. This had come up because of patients who were dying and thought of themselves as the last of their family line. The word was not picked up in medical circles. But, in 2001, when the National Museum of Australia (NMA) opened its doors, it (...) featured a gallery called Tangled Destinies and endling reappeared. On the wall facing a case with a thylacine specimen was written: Endling (n.) The last surviving individual of a species of animal or plant. Since that appearance, the word endling has slowly seeped into popular culture, appearing in symphonic music, performance art, science fiction stories, comics, and other art works. This paper examines the cultural power of the concept of endling as the last of a species and the history of its mobilization in a world facing extinction around every corner. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt with pain medications that might (...) have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

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

In April 1996, two men working at a convalescent center wrote a letter to the journal Nature proposing that a new word be adopted to designate a person who is the last in the lineage: endling. This had come up because of patients who were dying and thought of themselves as the last of their family line. The word was not picked up in medical circles. But, in 2001, when the National Museum of Australia (NMA) opened its doors, it (...) featured a gallery called Tangled Destinies and endling reappeared. On the wall facing a case with a thylacine specimen was written: Endling (n.) The last surviving individual of a species of animal or plant. Since that appearance, the word endling has slowly seeped into popular culture, appearing in symphonic music, performance art, science fiction stories, comics, and other art works. This paper examines the cultural power of the concept of endling as the last of a species and the history of its mobilization in a world facing extinction around every corner. (shrink)

When the University of Toronto withdrew a contract it held with me in December 2000, it initiated a sequence of events that led to a public letter to the University from senior figures in the world psychopharmacology community protesting against the infringement of academic freedom involved and a first ever legal action, undertaked by this author, seeking redress for a violation of academic freedom. The issues of academic freedom surrounding this case have been intertwined with a debate about the possibility (...) that the selective serotonin reuptake inhibitor (SSRI) group of antidepressants have the potential to trigger suicidality in a subgroup of patients. Whether the SSRIs do trigger suicidality or not, exploration of this issue has given rise to a number of worrying sets of observations. First, in my view, there is evidence that pharmaceutical companies have miscoded raw data on suicidal acts and suicidal ideation. Second, this author also maintains that there is a growing body of examples of ghostwriting of articles in the therapeutics domain. Many of the tensions evident in this case, therefore, can be linked to company abilities to keep clinical trial data out of the public domain — this is the point at which the pharmaceutical python gets a grip on academia. (shrink)

I was asked to evaluate M by her medical oncologist, Dr. T. As a psychiatrist, I was to perform the duties of a mental health specialist in the care of this fifty‐eight‐year‐old woman with metastatic breast cancer who had requested physician aid in dying. Dr. T had no specific concerns, but she was adhering to the letter of the law by referring the patient to me—a “mental health specialist”—because, according to the patient’s medical history, there was “evidence of a mental (...) disorder.” That evidence was comprised of depression treated in the remote past. Some years before California passed its End of Life Options Act in 2015, M had begun talking with Dr. T about the circumstances under which she might no longer want to be alive and might even choose to take active steps to end her life. She had fairly specific and durable criteria for knowing “when the time had come.” In our interview, she asserted very clearly that the time had not come but that, with the law now active, she hoped to have access to a lethal prescription in case it did. (shrink)

Dear Norm,Thank you for sharing such a personal and heartfelt essay. I have been asked by the editors to comment. Reading it inspires me to do so in a similarly heartfelt way. Although I don't know you well, I thought I'd write to you as if you were my patient.I share your sense that Alzheimer disease is a terrible scourge. I've seen much of this disease over a lifetime of practice, and I deeply understand its ravages and the debility and (...) suffering it causes. But what you propose is not a good solution for the problems that Alzheimer disease poses for patients, families, and society. It will ultimately do far more harm than good. Please let me try to explain. (shrink)

Frances Burney is primarily known as a novelist and playwright, but in recent years there has been an increased interest in the medical writings found within her private letters and journals. John Wiltshire advocates Burney as the unconscious pioneer of the modern genre of pathography, or the illness narrative. Through her dramatic accounts of distinct medical events, such as her own infamous operation without anaesthetic, to those she witnessed, including the 'madness' of George III and the inoculation of her (...) son against smallpox, Burney exposes the ethical issues and conflicts between patients and doctors. Her accounts are linked to a range of modern narratives in which similar events occur in the changed conditions of the public hospital. The genre that Burney initiated continues to make an important contribution to our understanding of medical practice in the modern world. (shrink)

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

Dysfunction in motor skills can be linked to alterations in motor processing, such as the anticipation of forthcoming graphomotor sequences. We expected that the difficulties in motor processing in schizophrenia would be reflected in a decrease of motor anticipation. In handwriting, motor anticipation concerns the ability to write a letter while processing information on how to produce the following letters. It is essential for fast and smooth handwriting, that is, for the automation of graphomotor gestures. In this study, we (...) examined motor anticipation by comparing the kinematic characteristics of the first l in the bigrams ll and ln written on a digitiser. Previous studies indicated that the downstroke duration of the first l is modulated by the anticipation of the local constraints of the following letter. Twenty-four adult individuals with diagnosis of schizophrenia and 24 healthy adults participated in the study. The classic measures of duration, trajectory, and dysfluency were used for the kinematic analysis of the upstroke and downstroke. In the control group, the duration of the downstroke of the l was longer in ln than ll whereas no differences were found for the group with schizophrenia. Likewise, the control group showed a longer DS trajectory for the l of ln than ll in downstrokes, while the group of patients failed to show this effect. These results suggest that the motor alterations in patients with schizophrenia could also affect their ability for motor anticipation. (shrink)

Although informed consent models for prescribing hormone replacement therapy are becoming increasingly prevalent, many physicians continue to require an assessment and referral letter from a mental health professional prior to prescription. Drawing on personal and communal experience, the author argues that assessment and referral requirements are dehumanising and unethical, foregrounding the ways in which these requirements evidence a mistrust of trans people, suppress the diversity of their experiences and sustain an unjustified double standard in contrast to other forms of clinical (...) care. Physicians should abandon this unethical requirement in favour of an informed consent approach to transgender care. (shrink)

The assumption was verified that for patients suffering from cancer levels of anxiety and self-esteem differ compared to other patients before surgery. 120 patients of urology were assigned to subgroups according to diagnosis and the duration of hospitalization. Patients suffering from cancer declared higher anxiety than other patients. Longer hospitalization was connected to higher anxiety. A threat-congruent difference in explicit self-esteem was revealed only between two groups: 1. cancer and long hospitalization and 2. non-cancer and (...) short hospitalization. For implicit self-esteem the phenomenon of implicit compensation of self-esteem was predicted and confirmed: among cancer-sufferers the Name Letter Effect was greater than among other patients. Also, in the cancerpatients group, the result of Rudman et al. was replicated: increasing anxiety was connected with increasing implicit self-esteem. (shrink)

Background:: Over the past few years, research ethics committees have increasingly demanded explicit consent before archival tissue samples can be used in research projects. Current UK guidance in this area requires an assessment of whether it is “practical” to obtain explicit consent. Ethics committees have little experience or evidence to help them to judge what is “practical” in this context.Methods:: We attempted to obtain general consent for research use of surplus tissue from renal transplant biopsies from the entire patient population (...) of the renal transplant unit in Leicester. The nature of this patient population would be expected to facilitate this task.Results:: A total of 495 letters were sent. Attempts were made to contact non-responders when they attended the outpatient clinic. One year after the initiation of the project, the opinions of 26% of the patients had still not been ascertained.Conclusions:: The results confirm that the vast majority of patients are happy for “surplus” biopsy material to be used for research; the situation does not parallel the use of autopsy tissue. A requirement to obtain explicit consent for the study of archival tissue is likely, however, to block or at least seriously delay research, which is contrary to the public interest and specifically may harm the interests of the patients concerned. In the UK, the problem of tissue being used against the wishes of the donor has now been largely replaced by the problem of prohibition of tissue use against the wishes of the donor. (shrink)

Cicero's use of the term is hardly a joke, and has to do with medicine, not logic. He says that his predecessor as governor of Cilicia, App. Claudius Pulcher, is like a doctor whose patient has been transferred to another practitioner, and who takes offence when the new man alters the treatment.

Cicero's use of the term is hardly a joke, and has to do with medicine, not logic. He says that his predecessor as governor of Cilicia, App. Claudius Pulcher, is like a doctor whose patient has been transferred to another practitioner, and who takes offence when the new man alters the treatment.

In lieu of an abstract, here is a brief excerpt of the content:The Misnomer of Freud's "Seduction Theory"Hall TriplettSigmund Freud's theory of 1896 was buried without a name in 1897, less than two years after it appeared. The process by which it acquired a name, "seduction theory," and the role this name played in the history of psychoanalysis are essential parts of the legend-making in Freud's biography. The label, bestowed half a century after publication, reflected two major rhetorical transformations. First, (...) from a theory presented with highly general claims of infant sex abuse, assault, and trauma, the theory was repackaged as a theory of seduction. Second, from a theory reportedly based in actual, traumatic experience, followed by repressed memory, it was transformed into one of fantasy. The name "seduction theory" has therefore operated as a misleading, strategic misnomer for the theory that Freud published in 1896.Freud announced his theory in three publications, referred to here in order of publication as the Paris paper,1 the Berlin paper,2 and "The Aetiology of Hysteria," published in Vienna.3 In his final publication the emphasis on trauma was greatest. In the space of five pages in the Standard Edition of Freud's works he used the word "traumatic" or "traumatically" fifteen times.4 Although he was extending the traumatic memory theory that he had shared with Josef Breuer in 1895,5 he touted his new modification as "the discovery of a caput [End Page 647] Nili [source of the Nile] in neuropathology."6 Sixteen months later he would privately renounce it. The theory was resurrected in the 1980s as support for the recovered memory movement.7It is essential to recall that the issuance of scientific claims is quite different from scientific validation. Getting the name of a theory right more than a century after publication is one matter only; assessing the basis of its underlying claims raises yet another challenge, particularly when the theory has been transformed with such extensive variation as Freud's theory of 1896.Therefore, the early death of the theory, described only in private letters to Wilhelm Fliess, is critical to an understanding of the entire historical episode. It is essential also to note that when Freud published his retrospective revisions of the theory, he did not know that his contemporary letters to his intimate friend would become competing evidence of the actual events of the mid-1890s.8When Freud secretly abandoned his theory on 21 September 1897 he wrote to Fliess, "I no longer believe in my neurotica."9 Implied already is the fact that Freud's belief in his theory was all that had supported it. One of his retrospective comments unwittingly substantiates this fact. In 1914, in his "History of the Psycho-analytic Movement," he conceded that his theory "broke down under the weight of its own improbability."10Furthermore, abandoning a theory in secrecy with no public defense is itself tantamount to a confession that supporting evidence is missing. Freud had acknowledged the absence of supporting data in his Berlin paper when he stated, "In this kind of communication it is not possible to bring forward the evidence needful to support my assertions, but I hope to fulfill this obligation later in a detailed presentation."11 His claim that it was "not possible to bring forward the evidence" must be challenged. Presenting scientific evidence is always possible when one has it. Moreover, in his "later" paper, by far the longest of 1896, he evaded the presentation of "actual material," opting instead to discuss potential objections.12 He did not present a single case history of hysteria, arguing that this would have taken too much time; yet he had closed his Berlin paper with a case history of paranoia that was purportedly based in the female patient's "sexual relationship" with her brother during childhood.13 [End Page 648] This case is not persuasive, but it demonstrates Freud's eagerness in 1896 to share a case when he believed that he had one to share.The style of a live lecture in "The Aetiology of Hysteria," as though Freud were speaking to an audience of potential objectors, is highly misleading, even fictional. As he explained in his letters... (shrink)

Letter to editor of the Hastings Center Report on R. Kukla’s “Conscientious Autonomy: Displacing Decisions in Health Care” (HCR 35(2), 2005: 34-44).