Where we once spoke in military terms, we now often wield the language of the market: health care is a “product” and we are its “providers” and “consumers.” The market metaphor constrains in various ways our vision of the goals we pursue in making health policy, of the options available to us in pursuing them, indeed—because policy implies a certain view of moral agency—of the way we relate to each other.

Wijdicks and colleagues1 recently presented the Full Outline of UnResponsiveness (FOUR) scale as an alternative to the Glasgow Coma Scale (GCS)2 in the evaluation of consciousness in severely brain-damaged patients. They studied 120 patients in an intensive care setting (mainly neuro-intensive care) and claimed that “the FOUR score detects a locked-in syndrome, as well as the presence of a vegetative state.”1 We fully agree that the FOUR is advantageous in identifying locked-in patients given that it specifically tests for eye movements (...) or blinking on command. This is welcomed given that misdiagnosis of the locked-in syndrome has been shown to occur in more than half of the cases (see Laureys and colleagues3 for review). As for the diagnosis of the vegetative state, the scale explicitly tests for visual pursuit, and hence can disentangle the vegetative state from the minimally conscious state (MCS). The diagnostic criteria for MCS have been proposed4 only recently, but Wijdicks and colleagues1 do not mention the existence of this clinical entity in their article. As for the vegetative state, MCS can be encountered in the acute or subacute setting as a transitional state on the way to further recovery, or it can be a more chronic or even permanent condition. The MCS refers to patients showing inconsistent, albeit clearly discernible, minimal behavioral evidence of consciousness (eg, localization of noxious stimuli, eye fixation or tracking, reproducible movement to command, or nonfunctional verbalization).4 The FOUR scale does not test for all of the behavioral criteria required to diagnose MCS.4 It is known from the literature (see Majerus and colleagues5 for review) that about a third of patients diagnosed with vegetative state are actually in MCS, and this misdiagnosis can lead to major clinical, therapeutic, and ethical consequences. We tested the ability of the newly proposed FOUR scale to correctly diagnose the vegetative state in an acute (intensive care and neurology ward) and chronic (neurorehabilitation) setting.. (shrink)

Increasingly through the 1990s, tobacco control advocates questioned the practice of public institutions investing in tobacco company stocks. The questioning was framed in at least three ways. First, is it ethical to fund public expenditures with profits from a product that causes addiction and disease? Second, is it sound social policy to derive public income from a product that increases healthcare costs and reduces worker productivity? Finally, is it sound fiscal policy to invest in an historically profitable industry facing multiplying (...) legal and regulatory challenges? While the tobacco industry preferred to restrict discussion to the fiscal question, and offered an affirmative answer, its position was weakened by depressed stock prices brought on by actions of the industry as much as by tobacco control activism. As part of a campaign to restore its credibility as an investment vehicle with public fund managers, Philip Morris (PM) commissioned a report from the influential investment managers/advisors Wilshire Associates. However, Wilshire had only recently conducted such a study for the Washington State Investment Board (WSIB), assuring the board that the value tobacco stocks added to an investment portfolio – if any – was too small to be measured. Nonetheless, within a year, Wilshire produced a report for PM which appeared to laud the investment value of tobacco and to dismiss tobacco-excluded investment alternatives. This paper examines how Wilshire produced apparently diametrically opposed reports for clients with different interests. It reveals a pattern of potential conflicts of interest among tobacco companies, financial analysis firms, investment authorities, and institutional fund managers. It demonstrates substantial violations of two generally accepted ethical principles of business consulting: veracity and transparency. (shrink)