Aim: To evaluate health-related quality of life of chronic hepatitis B and hepatitis B virus related cirrhosis patients and analyzed specific differences in all dimensions of HRQoL.Methods: A total of 349 patients met selection criteria were enrolled. The 36-Item Short-Form Health Survey was adopted.Results: Results showed that the physiological HRQoL of the cirrhotic group was significantly lower than that of the non-cirrhotic group, the psychological HRQoL was also lower. HRQoL was significantly negatively correlated with liver stiffness. We further (...) evaluated the risk factors associated with poor HRQoL in HBV-related cirrhosis patients. Results showed that positive HBV DNA viral load and HCC family history were independent factors associated with HRQoL in HBV-related cirrhosis. For better risk stratification of patients, multivariable analyses were conducted to explore the independent factors that affected specific physiological and psychological HRQoL. In specific physiological HRQoL, results show that marital status, positive HBV DNA viral load and antiviral drugs were independent factors associated with physiological HRQoL in cirrhosis patients. In psychological HRQoL, only HCC family history was independent risk factors associated with psychological HRQoL.Conclusion: We found that the impaired HRQoL dimensions of HBV related cirrhosis patients differ between the various subpopulations. According to our results, risk stratification, medical decision making and personalizing interventions could be made. (shrink)

In the setting of transplant medicine, decision making needs to take into account the multiple clinical and psychosocial case variables, rather than turn to arbitrary rules that cannot be scientifically supportedThe yearly demand for liver transplants far exceeds the supply of available organs .1 Additionally, alcoholic cirrhosis has been a controversial indication for transplant as these recipients can be viewed as having caused their own illness—an illness that is preventable by abstaining from alcohol . While not categorically denying (...) liver transplantation to those with alcoholic cirrhosis, many hospitals have incorporated a six month alcohol abstinence criterion 2 in an effort to select optimal candidates. The six month rule has two purposes; namely, allowing the liver a chance to recover in the absence of alcohol , and also observation of the patient to verify that he/she remains alcohol free, with the hope of reducing the risk of relapse. Everhart et al,3 determined that 85% of US liver transplant programmes and 43% of third party payers require a defined period of abstinence—for example, three or six months—as part of the waiting list process.Liver transplantation does not cure alcoholism, as evidenced by the fact that roughly 20% of these patients use alcohol following transplant, with one third exhibiting “repetitive or heavy drinking”.4 Arguments abound as to the scientific merit of a six month abstinence criterion in reducing the risk of alcohol relapse following transplant. Some propose that a minimum of six months abstinence itself predicts a lower relapse rate,5 while others argue that six months is not predictive or that other factors—for example, illicit drug use—in combination with a minimum number of months abstinent is predictive.6,7 Even the United …. (shrink)

Johanna Knapstein,1 Daniel Grimm,1 Marcus A Wörns,1 Peter R Galle,1 Hauke Lang,2 Tim Zimmermann111st Department of Internal Medicine, Johannes Gutenberg-University, Mainz, Germany; 2Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg-University, Mainz, GermanyIntroduction: Hepatitis C virus reinfection occurs universally after liver transplantation, with accelerated cirrhosis rates of up to 30% within 5 years after liver transplantation. Dual antiviral therapy with pegylated interferon-2a and ribavirin only reaches sustained virological response rates of ~30% after liver transplantation. With the (...) approval of viral NS3/4A protease inhibitors telaprevir, boceprevir, and simeprevir and the NS5B polymerase inhibitor sofosbuvir, combination therapy offers new therapeutic options for HCV-infected patients, resulting in considerably higher sustained virological response rates in the nontransplant setting. Case presentation: We report three cases of TVR-based triple antiviral therapy in HCV genotype 1 reinfected patients after liver transplantation, of whom a 57-year-old Caucasian female and a 43-year-old Caucasian male were therapy naïve, and a 49-year-old Caucasian male patient was pretreated ineffectively. After 4 weeks of therapy, viral load decreased one to three log10 and became negative in weeks 6 to 8 in the therapy naïve patients. The pretreated patient showed a negative viral load in week 4. TVR was administered over 12 weeks, 750 mg thrice daily. Doses of immunosuppression with cyclosporine were reduced four to six fold. Initial peg-IFN and RBV doses ranged from 135–180 µg/week and 800–1,200 mg/day, according to the patient's body weight. Doses of peg-IFN and RBV were adapted to 90–135 µg/week and 400–800 mg/day after 2 to 12 weeks of protease inhibitor therapy. Dual therapy was continued for 36 weeks with total treatment duration of 48 weeks in the therapy naïve patients leading to a sustained virological response 12 weeks after the end of therapy. In the pretreated patient a breakthrough was detected in week 24 and therapy was discontinued. Overall, antiviral therapy was well tolerated. Side effects included dysgeusia and anemia leading to erythropoietin application and blood transfusions. Conclusion: This case series emphasizes that triple therapy with TVR is an efficient treatment for therapy naïve HCV genotype 1 reinfected patients after liver transplantation. But therapeutic options for pretreated patients require improvement. Keyword: cyclosporine, interferon, ribavirin, hepatitis C, protease inhibitor. (shrink)

BackgroundThis study aimed to translate the negative and positive items of the Psychological Consequences Questionnaire into German, to adapt this version to the context of screening for cirrhosis and fibrosis of the liver, and to test its psychometric properties.Materials and methodsThe three subscales were translated into German using a forward-backward translation method. Furthermore, we adapted the wording to the context of liver diseases. In sum, the PCQ comprises twelve negative items and ten positive items. We tested the (...) acceptability, distribution properties, internal consistency, scale structure, and the convergent validity using an analysis sample of 443 patients who were screened for cirrhosis or fibrosis of the liver.ResultsWe found low non-response and non-unique answer rates on the PCQ items in general. However, positive items had higher non-response rates. All items showed strong floor effects. McDonald’s Omega was high for both the negative and the positive PCQ scale, as well as for the total PCQ scale. Confirmatory factor analysis could reproduce the three dimensions that the PCQ intends to measure. However, it suggests not summing up a total PCQ score and instead treat the subscales separately considering a higher order overall construct. Convergent validity with the short form of the Spielberger State-Trait Anxiety Inventory was acceptable.ConclusionOverall, our study results report a successful adaptation of the German PCQ with good performance in terms of acceptability, internal consistency, scale structure, and convergent validity. Floor-effects limit the content validity of the PCQ, which needs to be addressed in future research. However, the German version of the PCQ is a useful measurement for both negative and positive screening consequences - even in a non-cancer setting. (shrink)

Rather paradoxically, the personal and intellectual roots of Sir Isaiah Berlin, an influential contributor to liberal political theory and Western political thought, stem from East-European autocra...

Expecting Saving Mr. Banks to be a jolly jaunt about the creative development of the movie Mary Poppins (1964), I found myself waiting endlessly for the “jolliness” to begin—it never did. In fact, rather than joy, there was an ever-present sensation of tension as I watched the film. Having moved house myself in recent days (during a Queensland heat wave), the scenes of the Goff family leaving their home and trekking across hot, dusty Queensland were very emotional. However, seeing the (...) family patriarch Travers Goff (played by Colin Farrell) swig from an alcohol flask in a desperate manner told me that his was no “routine” family move. And, certainly, arriving at their destination—a dilapidated ranch home—shed even more light on the Goff family’s predicament: alcoholism and the cycle of employment and unemployment. Further, it is the downstream consequences of the family predicament that fuel the identity and behaviour of Mary Poppins—a fictional character created by Travers’ daughter, a. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vertical Transmission:The Patient, the Student, the TeacherMiguel PaniaguaHe did not ask for this fate, nor did he deserve it, particularly considering the tragic circumstances. Lì presented to the campus health provider one month prior with fatigue, abdominal pain, and jaundice. He and his parents immigrated to the United States from China when he was a child. He was well aware that he had hepatitis B from what is termed (...) "vertical transmission." His mom unknowingly passed on this virus to him during her pregnancy. In most countries with a high prevalence of the virus, prenatal screening is routinely undertaken, and prophylaxis administered. I am not certain this occurred in Lì's case and at this point it did not matter. Lì knew he would live with this for the duration of his life. In fact, he told me he had gone his whole life to this point without any symptoms whatsoever. What is known about chronic hepatitis B infection is that in most people affected, it can be considered a chronic disease where most live a long full life. The risk of advancing to liver cirrhosis or cancer in general is low. This unfortunately was not the case with Lì.What transpired was what they most feared. As he was studying for his final exams, Lì endured days of worsening fatigue, malaise, and nausea. He noticed his skin was a tinge of yellow and he was having some itching that was unusual. He noticed his clothes fitting more loosely and found he had unintentionally lost twenty pounds. He visited the campus health center and after a series of tests and imaging studies, Lì was diagnosed with advanced hepatocellular carcinoma, an unfortunate sequela of this chronic infection. It was then that he put school on hold and returned home to get further care.I first met Lì in the hospital as a consultant for the palliative medicine service. "He won't listen." "He is so difficult." "He is in denial." These were examples of some of the care team's exasperated assessments of his demeanor as a patient. What I did not realize prior to visiting him the first time was that Lì was a pre-clinical medical student. When I first met him, he did not want to talk very much; he was preoccupied and distant. In retrospect, I can see that he was suffering on so many levels. His appearance was gaunt and cachectic. The lights in the room cast shadows in the concave areas of his temples and his collarbones were the most prominent feature of his torso through his hospital gown. He glowed yellow from jaundice. When I examined him on this first visit, I noticed that his liver, a now grossly enlarged hard and nodular structure, occupied most of his abdomen. I found that speaking to him as a colleague, even calling him "doctor," helped him feel respected and enabled me to build rapport with him. At one point, I described to him the findings I felt in his abdomen. "I can palpate the edge of your liver here, what seems to be eight centimeters below your costal margin. There are many palpable nodularities on the ventral surface." It was at this point I invited him to palpate what I was feeling. I gently guided his own hand over his abdomen and noticed him studying the features as if they were not his own, like a skilled diagnostician.Over the course of three weeks, I visited with Lì when I was on service. The last time I saw him, he had declined rapidly, his disease progressing [End Page 17] cruelly, and he was very short of breath and becoming more somnolent. I noticed his mother in the room, standing by his bed, and crying inconsolably as he lay suffering. I felt deep anguish and remorse, wondering if she said these words to herself "It is all my fault," considering the source of his initial illness. I cannot even imagine.As I assisted the team in titrating his comfort medications, I sat with him. He shook my hand with all the strength left that he could muster and said, "you are a good doctor." I... (shrink)

I hope to show that mental disorders are not analogous to physiological diseases. I hope to show that a mental disorder like bipolar disorder cannot be located in the brain in the way a physiological disease like cirrhosis can be located in the liver. Mental disorders, unlike physiological diseases, lack a locatable corporeal basis to serve as a visible fulcrum on which to be based. However, I hope to also demonstrate that it is a mistake to infer the (...) inexistence of disorders from such an absence of a locatable corporeal basis. There are countless phenomena including the force fields pointed out by physics that lack such a basis but whose reality isn’t doubted; by the fact of such absence alone, we have no reason to doubt the existence of mental disorders, nor, for that matter, the existence of the minds thatexperience them. (shrink)

The ethics committee of the University of São Paulo Medical College Hospital and Clinics has authorized partial liver transplantation from living donors. The request for this type of transplantation was brought to the committee by a team of professors of surgery operating at the university, headed by Dr. Silvano Raia. Their request and justification are presented here, with discussion following.

This paper discusses the views of 17 healthcare practitioners involved with transplantation on the ethics of live liver donations . Donations between emotionally related donor and recipients increased the acceptability of an LLD compared with those between strangers. Most healthcare professionals disapproved of altruistic stranger donations, considering them to entail an unacceptable degree of risk taking. Participants tended to emphasise the need to balance the harms of proceeding against those of not proceeding, rather than calculating the harm-to-benefits ratio of (...) donor versus recipient. Participants’ views suggested that a complex process of negotiation is required, which respects the autonomy of donor, recipient and HCP. Although they considered that, of the three, donor autonomy is of primary importance, they also placed considerable weight on their own autonomy. Our participants suggest that their opinions about acceptable risk taking were more objective than those of the recipient or donor and were therefore given greater weight. However, it was clear that more subjective values were also influential. Processes used in live kidney donation were thought to be a good model for LLD, but our participants stressed that there is a danger that patients may underestimate the risks involved in LLD if it is too closely associated with LKD. (shrink)

Background and aims: Liver transplantation provides an opportunity of survival for patients with liver failure, however, this procedure is known to be psychologically and physically fatiguing for patients and their informal caregivers. The aim of this study was to investigate how perceived social support and the distribution of dependency were associated with the psychological wellbeing of patients waiting for liver transplantation and their caregivers, as a dyad. Methods: The present was a cross sectional study. 95 participants were (...) recruited at a hospital in Northern Italy, during the psychological evaluation for inclusion in the transplantation list: 51 patients (19 with alcohol-related illness), and 44 family caregivers. Both patients and caregivers filled in a Symptom Checklist and Kelly's Dependency Grids. Patients also compiled the Medical Outcomes Study Social-Support Survey, and caregivers the Family Strain Questionnaire Short- Form. Results: Caregivers reported important levels of strain, also strongly related to a worsening of their own and patients’ symptoms Patients with alcohol-related pathologies had a narrower social network, which corresponded to an increase in family strain. On the sample as a whole, regression analyses showed that perceived social support and dependency measures did not predict patients’ and caregivers’ symptoms. Nevertheless, cluster analysis identified a group of caregivers who distributed their dependency more and experienced lower levels of depression, anxiety and strain. Conclusions: These results suggest the usefulness of a dyadic approach in the research, prevention and care of liver diseases. A deeper comprehension of the functioning of dyads will help practitioners in the identification of situations at risk. (shrink)

Splitting livers allows two people to receive a liver transplant from one donated adult liver, but the risks to the adult recipient are greater than if they had received the equivalent whole liver. It has been suggested, therefore, that splitting livers harms adult recipients. Without liver splitting, however, there would be few livers available for children, and paediatric waiting time and waiting list mortality would significantly increase. In this paper, we argue that although splitting livers makes (...) adults worse off, this should be considered sub-optimal benefit rather than harm. We explore justifications for sub-optimally benefitting adults in this way and consider alternatives to the current approach. We argue that splitting livers masks the more fundamental problem of low paediatric donation rates and that increasing the number of paediatric donations would improve the situation for both adult and paediatric liver patients. (shrink)

Living donation provides important access to organ transplantation, which is the optimal therapy for patients with end-stage liver or kidney failure. Paired exchanges have facilitated thousands of kidney transplants and enable transplantation when the donor and recipient are incompatible. However, frequently willing and otherwise healthy donors have contraindications to the donation of the organ that their recipient needs. Trans-organ paired exchanges would enable a donor associated with a kidney recipient to donate a lobe of liver and a donor (...) associated with a liver recipient to donate a kidney. This article explores some of the ethical concerns that trans-organ exchange might encounter including unbalanced donor risks, the validity of informed consent, and effects on deceased organ donation. (shrink)

Is it possible to invoke the use of moral responsibility as part of the selection criteria in the allocation of livers for transplant? Criticism has been applied to the difficulties inherent in including such a criterion and also the effect that employing such a judgement might have upon the relationship between the physician and patient. However, these criticisms rely on speculation and conjecture and do not relate to all the arguments put forward in favour of applying moral responsibility. None of (...) the present arguments against using moral responsibility in the allocation of livers for transplant are good enough to warrant its dismissal. (shrink)

Many believe that it is morally wrong to give lower priority for a liver transplant to alcoholics with end-stage liver disease than to patients whose disease is not alcohol-related. Presumably, alcoholism is a disease that results from factors beyond one's control and therefore one cannot be causally or morally responsible for alcoholism or the liver failure that results from it. Moreover, giving lower priority to alcoholics unfairly singles them out for the moral vice of heavy drinking. I (...) argue that the etiology of alcoholism may involve enough control for the alcoholic to be responsible for his condition and accordingly have a weaker claim to receive a new liver than someone who acquires the disease through no fault of his own. In addition, I show why it is more plausible to reframe the question of priority in terms of control and responsibility rather than virtue and vice. Given that medical resources like livers are scarce, some people may justifiably be given lower priority than others in receiving these resources. (shrink)

In a provocative 1991 paper, Alvin Moss and Mark Siegler argued that it may be fair to give individuals with alcohol-related end-stage liver disease lower priority for a liver transplant than those who develop end-stage liver disease from other factors. Like other organs, there is a substantial gap between the available livers for transplantation and the number of people who need liver transplants. Yet, unlike those with end-stage renal disease, who can survive for some time on (...) dialysis before receiving a kidney transplant, those with liver failure will die without a liver transplant. (shrink)

In this work, a system for the classification of liver dynamic contest- enhanced CT images is presented. The system simultaneously analyzes the images with the same slice location, corresponding to three typical acquisition moments. At first, the texture features are extracted separately for each acquisition mo- ment. Afterwards, they are united in one “multiphase” vector, characterizing a triplet of textures. The work focuses on finding the most appropriate features that characterize a multi-image texture. At the beginning, the features which (...) are unstable and dependent on ROI size are eliminated. Then, a small subset of remaining features is selected in order to guarantee the best possible classification accuracy. In total, 9 extraction methods were used, and 61 features were calculated for each of three acquisition moments. 1511 texture triplets, corresponding to 4 hepatic tissue classes were recognized. As a classifier, an adaptive boosting algorithm with a C4.5 tree was used. Experiments show that a small set of 12 features is able to ensure classification accuracy exceeding 90%, while all of the 183 features provide an accuracy rate of 88.94%. (shrink)

The decline in organs donated after brain death has been countered by an increase in organs donated after circulatory death. Organs donated after circulatory death present an increased risk of complications for their eventual recipients when compared with organs donated after brain death, so the likelihood of successful transplantation is decreased. If organ donation is considered to be in the best interests of the patient, interventions that facilitate successful donation and transplantation might be permissible. This paper seeks to establish whether (...) it is ethically permissible to manage the end-of-life care of a dying patient to maximize the chances of successful transplantation, and if so, whether it is permissible to further maximize these chances by managing the potential donor to enable donation after brain death rather than donation after circulatory death. (shrink)

Split liver transplantation (SLT) provides an opportunity to divide a donor liver, offering transplants to two small patients (one or both could be a child) rather than keeping it whole and providing a transplant to a single larger adult patient. In this article, we attempt to address the following question that is identified by the Organ Procurement and Transplant Network and United Network for Organ Sharing: ‘Should a large liver always be split if medically safe?’ This article (...) aims to defend an answer—‘not always’—and clarify under what circumstances SLT is ethically desirable. Our answer will show why a more dynamic approach is needed to the ethics of SLT. First, we discuss a case that does not need a dynamic approach. Then, we explain what is meant by a dynamic approach and why it is needed. (shrink)

Limited Aggregation is the view that when there are competing moral claims that demand our attention, we should sometimes satisfy the largest aggregate of claims, depending on the strength of the claims in question. In recent years, philosophers such as Patrick Tomlin and Alastair Norcross have argued that Limited Aggregation violates a number of rational choice principles such as Transitivity, Separability, and Contraction Consistency. Current versions of Limited Aggregation are what may be called Comparative Approaches because they involve assessing the (...) relative strengths of various claims. In this paper, we offer a non-comparative version of Limited Aggregation, what we call the Threshold Approach. It states that there is a non-relative threshold that separates various claims. We demonstrate that the Threshold Approach does not violate rational choice principles such as Transitivity, Separability, and Contraction Consistency, and we show that potential concerns regarding such a view are surmountable. (shrink)

The United Network for Organ Sharing recently changed the policy by which donor livers are allocated to liver failure patients in the United States. Formerly, all liver failure patients were characterized as status 1 and placed at the top of the transplant list. Under the new policy, only patients with liver failure due to acute illness () are eligible for status 1; patients with liver failure due to chronic liver disease () are characterized as status (...) 2. Since donor organs are allocated first to status 1 patients and then to status 2 patients, the new policy moves all CLF patients down on the waiting list relative to all ALF patients. This means that some livers that would have gone to CLF patients under the old policy will now go to ALF patients. Accordingly, while the new policy will likely increase the number of ALF patients saved, it will also increase the number of deaths among CLF patients waiting for a transplant. (shrink)

Over eighty years ago, a third, previously unidentified copy of the Anglo-Norman prose chronicle, Le Livere de Reis de Engleterre,was discovered in John Rylands French MS 64. Despite this discovery, and the paucity of witnesses to this chronicle, scholars of LRE generally pass over the version contained in the John Rylands manuscript. Through an examination of the sources and variant readings of LRE, this article argues that this previously overlooked copy of LRE is more authoritative than the other two. The (...) superiority of the John Rylands manuscript enables us to determine best text readings of LRE with improved accuracy. It also allows us to date the chronicle with greater precision than previously possible, and provides grounds for tentatively locating the origins of the chronicle to northeastern England. (shrink)

The world’s first living donor liver transplant from an HIV-positive mother to her HIV-negative child, performed by our team in Johannesburg, South Africa in 2017, was necessitated by disease profile and health system challenges. In our country, we have a major shortage of donor organs, which compels us to consider innovative solutions to save lives. Simultaneously, the transition of the HIV pandemic, from a death sentence to a chronic illness with excellent survival on treatment required us to rethink our (...) policies regarding HIV infection and living donor liver transplantation. Although HIV infection in the donor is internationally considered an absolute contraindication for transplant to an HIV-negative recipient, there have been a very small number of unintentional transplants from HIV-positive deceased donors to HIV-negative recipients. These transplant recipients do well on antiretroviral medication and their graft survival is not compromised. We have had a number of HIV-positive parents in our setting express a desire to be living liver donors for their critically ill children. Declining these parents as living donors has become increasingly unjustifiable given the very small deceased donor pool in SA; and because many of these parents are virally suppressed and would otherwise fulfil our eligibility criteria as living donors. This paper discusses the evolution of HIV and transplantation in SA, highlights some of the primary ethical considerations for us when embarking on this case and considers the new ethical issues that have arisen since we undertook this transplant. (shrink)

Background: Allocation of scarce organs for transplantation is ethically challenging. Artificial intelligence (AI) has been proposed to assist in liver allocation, however the ethics of this remains unexplored and the view of the public unknown. The aim of this paper was to assess public attitudes on whether AI should be used in liver allocation and how it should be implemented. Methods: We first introduce some potential ethical issues concerning AI in liver allocation, before analysing a pilot survey (...) including online responses from 172 UK laypeople, recruited through Prolific Academic. Findings: Most participants found AI in liver allocation acceptable (69.2%) and would not be less likely to donate their organs if AI was used in allocation (72.7%). Respondents thought AI was more likely to be consistent and less biased compared to humans, although were concerned about the “dehumanisation of healthcare” and whether AI could consider important nuances in allocation decisions. Participants valued accuracy, impartiality, and consistency in a decision-maker, more than interpretability and empathy. Respondents were split on whether AI should be trained on previous decisions or programmed with specific objectives. Whether allocation decisions were made by transplant committee or AI, participants valued consideration of urgency, survival likelihood, life years gained, age, future medication compliance, quality of life, future alcohol use and past alcohol use. On the other hand, the majority thought the following factors were not relevant to prioritisation: past crime, future crime, future societal contribution, social disadvantage, and gender. Conclusions: There are good reasons to use AI in liver allocation, and our sample of participants appeared to support its use. If confirmed, this support would give democratic legitimacy to the use of AI in this context and reduce the risk that donation rates could be affected negatively. Our findings on specific ethical concerns also identify potential expectations and reservations laypeople have regarding AI in this area, which can inform how AI in liver allocation could be best implemented. (shrink)

Caffeine, a known CNS stimulant is given as an adjunct component in most abused drugs which could be fatal with repeated administration in many circumstances. This paper presents a study to investigate the effect of repeated administration of caffeine at high dose on rat liver, and discusses ethical and policy issues of caffeine use. Long Evans rats were treated with pure caffeine solution in distilled water through intragastric route once daily for consecutive 56 days. Three groups of rats recognized (...) as low dose, high dose and control group received 6mg caffeine / kg BW, 12mg caffeine / kg BW and distilled water, respectively. Rat plasma was examined for liver transaminases and alkaline phosphatases concentrations which were significantly increased in plasma as compared to the control. Both rat plasma and liver homogenate were subjected to estimate malondialdehyde, advanced oxidation protein product, nitric oxide, antioxidant enzyme catalase, glutathione and superoxide dismutase activity. MDA, AOPP, NO levels increased and SOD activity decreased significantly in both plasma and liver as compared to those of control where as CAT and GSH activity remain unchanged. Rat liver tissues were studied histochemically with Hematoxylin and Eosin, and Picro Sirius Red staining. Significantly increased infiltration of inflammatory cells and progressive deposition of collagen fibre were visible in liver tissue of caffeine treated both dose groups as compared to the control. Long term administration of caffeine at higher dose, significantly contributes to liver inflammation and consequent fibrogenesis. This raises significant ethical and policy issues. (shrink)

The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined. This survey with 502 participants examines how urgency and benefit are weighted by different stakeholders. Liver (...) transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care. An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs. The strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules. (shrink)

Background The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined. Methods This survey with 502 participants examines how urgency and benefit are weighted by different stakeholders. (...) Results Liver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care. An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs. Conclusions The strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules. (shrink)

La conception américaine de la convergence technologique, promue par le programme NBIC (Nano-Bio-Info-Cogno), est orientée vers la recherche d’une intégration de tous les domaines du réel (la nature, la vie, l’esprit, la société) dans la représentation unitaire d’un monde constitué de systèmes hiérarchiques complexes et couplés entre eux. Il s’agit par conséquent d’une vision totalisante, témoignant d’un idéal de contrôle et de maîtrise que rien ne paraît devoir limiter. Les Grecs avaient un...

Desires matter. How are we to understand the intentionality of desire? According to the two classical views, desire is either a positive evaluation or a disposition to act: to desire a state is to positively evaluate it or to be disposed to act to realize it. This Ph.D. Dissertation examines these conceptions of desire and proposes a deontic alternative inspired by Meinong. On this view, desiring is representing a state of affairs as what ought to be or, if one prefers, (...) as what should be. Desire involves a deontic manner of representing: a norm of the ought-to-be type features in desire’s intentional mode, as opposed to content. The dissertation is structured in three parts. In order to defend this conception, I formulate three main desiderata for a promising theory of the intentionality of desire in the introduction (§0). The first concerns desire’s direction of fit, i.e. the intuition that the world should conform to our desires. The second concerns the death of desire principle, i.e. the intuition that one cannot desire what one represents as actual. The last pertains to desire’s role in psychological explanations, i.e. the intuition that desires can explain some mental states and be explained by other mental states. The first part examines the main conceptions of desire in light of these desiderata. I argue that the classical pictures of desire do not adequately meet our desiderata. The first chapter is devoted to the evaluative conception (§1), while the second examines the motivational approach (§2). Following these criticisms, I then present the deontic view of desire (§3). In the second part, I defend this conception with the help of three arguments. The main idea is that appealing to norms of the ought-to-be type can satisfy our chief desiderata: the world should conform to norms (world-to-mind direction of fit, §4), norms are grounded on values and in turn ground obligations (explanation, §5), and norms are about non-actual states of affairs (death of desire principle, §6). In the last part, I develop the deontic view to draw a cartography of the various types of desire. Some desires are correct, while others are inappropriate. This distinction is explained by the deontic conception, as it matches that between states of affairs that ought to obtain and states that should not obtain (§7). Two study cases are examined: caprice and the impermissibility of desire aggregation. Intuitively, hopes, wishes, or urges are types of desire. The next chapter presents a typology inspired by the deontic view and the type of norms there are (§8). The last chapter discusses the main objections to the deontic approach (§9). In conclusion, I show the relevance of the deontic view for several debates in philosophy of mind and ethics. Desires are crucial because they are the ‘eye’ of what should be. (shrink)

The dominant model for bioethical inquiry taught in medical schools is that of principlism. The heritage of this methodology can be traced to the Enlightenment project of generating a universalizable justification for normative morality arising from within the individual, rational agent. This project has been criticized by Alasdair MacIntyre who suggests that its failure has resulted in a fragmented and incoherent contemporary ethical framework characterized by fundamental intractability in moral debate. This incoherence implicates principlist conceptions of bioethics. Medical ethics as (...) practiced, though, is partially in keeping with teleological alternatives to principlism. Nonetheless, the hegemony of principlism threatens to harm the practice of good medicine whenever it is used to provide justification for the sanction or prohibition of practices, despite not being equipped to grant moral authority to such justifications. An example of this failure and its resulting harm is expressed in the growing obsolescence of living donor liver transplantation. (shrink)

Organ transplantation has increased worldwide while the number of organ donors have not increased similarly. Consequently, the waiting period for transplant candidates is prolonged. Patient narratives have uncovered physical and psychosocial suffering in the transplantation process. However, relatively few studies have explored patients’ experiences in the actual waiting period. This qualitative study was conducted in Norway and aimed to describe patients’ experiences of being accepted as recipients of a new liver and their waiting following this decision. A sample of (...) 21 patients with end‐stage liver disease, placed on the ordinary waiting list for a liver transplant, were interviewed in the hospital before they went home to wait for a compatible liver. Uncertainty related to life and death was a major issue, both in the waiting period and as a response to being put on the waiting list. Another central issue was their overwhelming lack of energy. Patients inferred a linear relationship between lack of energy, physical limitations and mental distress. Despite major advances in medical treatment, little follow‐up was given during the waiting period and most of the patients seemed resigned to the inevitability of their suffering. This raises issues of health personnel responsibility and a need to heighten awareness about patient suffering during the waiting period. (shrink)