Le recueil d'études Contempler l'infini invite le lecteur à étudier la fonction de l'acte contemplatif dans son rapport à l'espace et au temps, en s'interrogeant notamment sur la valeur et la portée épistémiques de cet acte (d'un point de vue mathématique, philosophique, phénoménologique, esthétique, artistique, linguistique et poétique) lorsqu'il se détermine en relation à une réalité représentée comme "infinie" (Dieu, âme, cosmos, etc.). Ce livre est conçu dans un contexte éminemment interdisciplinaire, l'objectif étant de comprendre comment cette articulation subtile des (...) deux concepts peut être abordée selon des méthodologies et des lexiques très différents mais bien souvent complémentaires sur le plan épistémologique. Le recueil regroupe les études et les réflexions des chercheurs français et hongrois de différentes spécialités (mathématiques, philosophie, esthétique. phénoménologie, théologie, linguistique et littérature). (shrink)

This volume examines mystical experiences as portrayed in various ways by "authors" such as philosophers, mystics, psychoanalysts, writers, and peasant women. These "mystical authors" have, throughout the ages, attempted to convey the unsayable through writings, paintings, or oral stories. The immediate experience of God is the primary source and ultimate goal of these mystical expressions. This experience is essentially ineffable, yet all mystical authors, either consciously or unconsciously, feel an urge to convey what they have undergone in the moments of (...) rapture. At the same time they are in the role of intermediaries: the goal of their self-expression - either written, painted or oral - is to make others somehow understand or feel what they have experienced, and to lead others toward the spiritual goal of human life. This volume studies the mystical experiences and the way they have been described or portrayed in West-European culture, from Antiquity to the present, from an interdisciplinary perspective, and approaches the concept of "immediate experience" in various ways. (shrink)

De facture classique, la philosophie de Simone Weil ne forme pas moins un ensemble de doctrines qu'unifie une intuition morale de portée métaphysique. La prescription de l'obéissance, de l'humilité, de la pauvreté traduisent une conception du moi qui, ayant une condition métaphysique illégitime de centre du monde, est appelé à renoncer à soi, à s'abandonner. Bref, créature jouissant d'une position usurpée de centre, il ne réalise sa vérité que par la décréation, mettant fin à la prétention d'un individu de valoir (...) comme une fin en soi exclusive... (shrink)

Retinopathy of prematurity (ROP) is a complex neonatal disorder with multiple contributing factors. In this paper we have mounted the evidence in support of the proposal that neonatal sepsis meets all requirements for being a cause of ROP (not a condition, mechanism, or even innocent bystander) by means of initiating the early stages of the pathomechanism of ROP occurrence, systemic inflammation. We use the model of etiological explanation, which distinguishes between two overlapping processes in ROP causation. It can be (...) shown that sepsis can initiate the early stages of the pathomechanism via systemic inflammation (causation process) and that systemic inflammation can contribute to growth factor aberrations and the retinal characteristics of ROP (disease process). The combined contribution of these factors with immaturity at birth (as intrinsic risk modifier) and prenatal inflammation (as extrinsic facilitator) seems to provide a cogent functional framework of ROP occurrence. Finally, we apply the Bradford Hill heuristics to the available evidence. Taken together, the above suggests that neonatal sepsis is a causal inducer of ROP. (shrink)

The activation of leukocytes by bacterial cell wall lipopolysaccharide (LPS) contributes to the pathogenesis of septic shock. It is well established that, in the presence of plasma LPS‐binding protein (LBP), LPS binds with high affinity to CD14. The binding of LPS to CD14 has been associated with the activation of cells, although available evidence indicates that CD14 itself does not transduce intracellular signalling. The physiological function of this interaction is to promote host defense mechanisms of cells to combat the infection (...) and clear LPS from the circulation. At higher concentrations of LPS, however, the activation of cells can take place in the absence of LBP and CD14, presumably through a distinct low‐affinity signalling LPS receptor. On the evidence published by us and others, we propose that in neutrophils, and possibly other leukocytes, L‐selectin can act as a low‐affinity LPS receptor. (shrink)

To date researchers planning experiments have always lived by the mantra that 'using equal sample sizes gives the best results' and although unequal groups are also used in experimentation, it is not the preferred method of many and indeed actively discouraged in literature. However, during live study planning there are other considerations that we must take into account such as availability of study participants, statistical power and, indeed, the cost of the study. These can all make allocating equal sample sizes (...) difficult, and sometimes near impossible. This, some might say, means that the study would not adhere to rigorous statistical standard (Rosenbaum and Rubin, 1985). However, here we present evidence that, not only is this a false assumption, but that we may actually gain more power in the study by actually using unequal groups. Here, data from a Sepsis Biomarker study is used, in which the aim is to predict, by biomarker level and presence, whether the patient would go on to develop sepsis. It was found that larger control groups may give more power to studies looking for an effect in the mid range but not for large or small effects. This study shows merit in the hypothesis that more power can be achieved when a larger control group is used. Published by the Ministry of Defence at dstl - Reference DSTLTR92592 P2PP2R-2016-02-23T13:39:45. (shrink)

During the set-up phase of an international study of genetic influences on outcomes from sepsis, we aimed to characterise potential differences in ethics approval processes and outcomes in participating European countries. Between 2005 and 2007 of the FP6-funded international Genetics Of Sepsis and Septic Shock project, we asked national coordinators to complete a structured survey of research ethic committee approval structures and processes in their countries, and linked these data to outcomes. Survey findings were reconfirmed or modified in (...) 2017. Eighteen countries participated in the study, recruiting 2257 patients from 160 ICUs. National practices differed widely in terms of composition of RECs, procedures and duration of the ethics approval process. Eight countries used a single centralised process for approval, seven required approval by an ethics committee in each participating hospital, and three required both. Outcomes of the application process differed widely between countries because of differences in national legislation, and differed within countries because of interpretation of the ethics of conducting research in patients lacking capacity. The RECs in four countries had no lay representation. The median time from submission to final decision was 1.5 months; in nine approval was received within 1 month; six took over 6 months, and in one 24 months; had all countries been able to match the most efficient approvals processes, an additional 74 months of country or institution-level recruitment would have been available. In three countries, rejection of the application by some local RECs resulted in loss of centres; and one country rejected the application outright. The potential benefits of the single application portal offered by the European Clinical Trials Regulation will not be realised without harmonisation of research ethics committee practices as well as national legislation. (shrink)

Genetic testing has historically been performed in the context of chronic disease and cancer diagnostics. The timelines for these tests are typically measured in days or weeks, rather than in minutes. As such, the concept that genetic information might be generated and then used to alter management in the acute setting has, thus far, not been feasible. However, recent advances in genetic technologies have the potential to allow genetic information to be generated significantly quicker. The m.1555A>G genetic variant is present (...) in one in 500 individuals and predisposes to profound hearing loss following the administration of aminoglycoside antibiotics. These antibiotics are used frequently in cases of neonatal sepsis and it is estimated that approximately 180 neonates in the UK are at risk of antibiotic induced hearing loss each year because of this genetic change. Knowledge of this variant in the acute setting would allow clinicians to prescribe alternative antibiotics. The Pharmacogenetics to Avoid Loss of Hearing study will implement a genetic point of care test for the m.1555A>G variant within two major UK based neonatal intensive care units. This represents the first trial of a genetic POCT aimed at altering management in the acute setting. This round table discussion outlines the novel ethical issues faced in the development of this trial and the legal barriers to implementation. We ask five stakeholders to provide their opinions on this trial and their perspectives on the concept of genetic testing in the acute setting.Trial registration numberISRCTN-13704894. (shrink)

The Supreme Court has ruled in the case of Y that there is no requirement to seek the approval of the Court of Protection in decisions to withdraw clinically assisted nutrition and hydration from patients in a prolonged disorder of consciousness.1 Mr Y was 52-year-old man who suffered a cardiac arrest after a myocardial infarction as a result of coronary artery disease. It was not possible to resuscitate him for well over 10 min, resulting in severe cerebral hypoxia which caused (...) extensive brain damage. Mr Y’s family and the NHS Trust treating him agreed that Mr Y would not want to be kept alive through the provision of CANH given his poor prognosis. They sought a declaration that it was not mandatory for applications of withdrawal of CANH to come before the court, which was granted by Mrs Justice O’Farrell in the first instance.2 Permission was granted for the appeal to ‘leapfrog’ the Court of Appeal and to proceed to the Supreme Court for consideration. In the interim, Mr Y died after contracting acute respiratory sepsis, but the Supreme Court determined that the appeal should go ahead in light of the general importance of the issues raised. In delivering the opinion of the Supreme Court on 30 July 2018, Lady Justice Black rejected the historical distinction that had been drawn between patients in PDOC and non-PDOC patients, in a way that had justified judicial involvement for patients in PDOC but not for others.3 She was clear that the correct approach to all cases involving CANH was to make a decision based on what was in the best interests of the patient. She further outlined that: > The documentation supplied to us shows that the difficulty that there is in assessing the patient and in …. (shrink)

Developing a simple test to identify swiftly neonates with sepsis who carry the genetic variant which means that one dose of the recommended antibiotic, gentamicin, will cause the child to become profoundly deaf looks like an admirable objective. The baby needs antibiotics and needs them within 1 hour of admission to the neonatal intensive care unit. Conventional genetic tests take much longer to yield results. The test being trialled produces results in 25 min; a baby who carries the variant (...) can be treated with a different antibiotic. All the test requires is a gentle swab of the baby’s inner cheek. Babies can be treated for potentially fatal sepsis without the risk that the drugs designed to save their lives will cost them their hearing. Parents and healthcare staff are relieved of worry—a great idea? PALOH is not a trial of the safety or efficacy of the test, only to assess how feasible it will be to carry out this test in a busy NICU, without disrupting the care of the baby. A tiny painless ‘scrape’ will take a sample of DNA—what’s the fuss about? Several other invasive and painful procedures will be carried out without a fuss.1 The problem is DNA. Genetic information must be safeguarded from falling into the wrong hands. In section 45 of Human Tissue Act 2004, Parliament legislated to prohibit non-consensual DNA testing.1 It fits uncomfortably in a statute designed to regulate retention and uses of human material, after revelations that organs and tissue from the …. (shrink)

During times of crisis, institutions tend to focus on maintaining or restoring public trust, as well as on measures to insulate themselves (and their leadership) from potential legal liability. This is because institutions reflexively turn to lawyers, risk managers, crisis consultants, and public relations firms that focus on what they euphemistically call the “optics.” In this essay, I highlight the vital importance of addressing underlying reasons for an institution's loss of public trust—in particular, the loss (or erosion) of its integrity (...) and trustworthiness. Loss of public trust generates one kind of crisis—which I term “opsis.” But there is another kind of institutional crisis that so often remains unrecognized. Just as medical sepsis in the human body is a critical condition that endangers life, the loss of an institution's integrity and trustworthiness constitutes a type of sepsis—ethical sepsis—that poses an existential threat to the institution if unaddressed. (shrink)

Plasma protein therapies are a group of essential medicines extracted from human plasma through processes of industrial scale fractionation. They are used primarily to treat a number of rare, chronic disorders ensuing from inherited or acquired deficiencies of a number of physiologically essential proteins. These disorders include hemophilia A and B, different immunodeficiencies and alpha 1-antitrypsin deficiency. In addition, acute blood loss, burns and sepsis are treated by PPTs. Hence, a population of vulnerable and very sick individuals is dependent (...) on these products. In addition, the continued well-being of large sections of the community, including pregnant women and their children, travelers and workers exposed to infectious risk is also subject to the availability of these therapies. Their manufacture to adequate amounts requires large volumes of human plasma as the starting material of a complex purification process. Mainstream blood transfusion services run primarily by the not-for-profit sector have attempted to provide this plasma through the separation of blood donations, but have failed to provide sufficient amounts to meet the clinical demand. The collection of plasma from donors willing to commit to the process of plasmapheresis, which is not only time consuming but requires a long term, continuing commitment, generates much higher amounts of plasma and has been an activity historically separate from the blood transfusion sector and run by commercial companies. These companies now supply two-thirds of the growing global need for these therapies, while the mainstream government-run blood sector continues to supply a shrinking proportion. The private sector plasmapheresis activity which provides the bulk of treatment products has been compensating the donors in order to recognize the time and effort required. Recent activities have reignited the debate regarding the ethical and medical aspects of such compensation. In this work, we review the landscape; assess the contributions made by the compensated and non-compensated sectors and synthesize the outcomes on the relevant patient communities of perturbing the current paradigm of compensated plasma donation. We conclude that the current era of “Patient Centeredness” in health care demands the continuation and extension of paid plasma donation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Helping a Muslim Family to Make a Life–and–Death Decision for Their Beloved Terminally Ill FatherBahar BastaniI live in a city in the Midwest with a population of around two million people. There are an estimated 2,000 Iranians living in this city, the vast majority of which belong to Shia sect of Islam. [End Page 190] However, the vast majority is also not very religious. Over the past two decades (...) that I have been living in this city, professionally in the capacity of a physician and university faculty at a school of medicine, and socially as one of the community leaders with a particular role in religious matters, I have acquired the trust of my community. Following one of my yearly routine travels to my homeland, Iran, I had just returned to work when I received a phone call from one of the Iranian community members. He informed me that his father was very ill and was hospitalized, and that the physicians had introduced the idea of stopping life support. The family was experiencing a significant emotional, moral and religious dilemma as to whether they could consent to this. I was requested by the patient’s children to help them make the right decision.I requested that the oldest son, who had called me, to ask the three other siblings and their mother to be present at the bedside of the patient that night, so that we could discuss the matters face–to–face. That same night, all requisite family members and myself gathered at the bedside of this 88–year–old husband and father, who had developed multi–organ failure, which commenced with an infection following a heart valve replacement, followed by bacteremia and sepsis. Moreover, the patient was hypotensive, had developed respiratory failure requiring intubation and artificial ventilation, and had also developed hematologic coagulation abnormalities secondary to sepsis. Because of the sepsis, hypotension, and multiple drugs, including antibiotics and vasopressors, his kidneys had also failed, and there was a need to start hemodialysis if his life was to be maintained. After speaking with the intensive care physicians who were taking care of this elderly gentleman, it became clear to me that further care was futile, and there was absolutely no hope for him to recover from his multiple organ failure. I presented all the facts that I had acquired to the family members, and expressed my own viewpoint that I agreed with those physicians and that further care of their beloved, terminally ill husband and father was futile and only extended his dying. My assurances made it easier for the family members, particularly for his four sons who were present, to come to the decision to withdraw life support. After I informed the intensive care physicians of the family’s decision, the patient was heavily sedated with morphine, and the intravenous fluids, antibiotics, vasopressors, and the ventilator machine were all stopped. Over the next several minutes, the patient developed agonal breathing, his blood pressure dropped to zero, and his heart stopped. During the last few minutes of his life, I held the hands of the family members, we all prayed Islamic prayers to bless his soul while departing from his body. The next day, I supported the family with funeral services that included the Islamic prayers for the dead, the ceremonial religious washing of the body of the deceased, and the ceremonial religious burial.The dilemma that this family faced was multi-factorial: (1) the children had spent all of their adult life in America, and were unfamiliar with Islamic end of life and funeral traditions; (2) they had been asked by their father’s physicians to make a decision regarding the withdrawal of life support, which posed a moral and ethical dilemma; (3) they did not know whether it was religiously acceptable to withdraw life support; and (4) they did not know what type of funeral service would be acceptable to the religious beliefs of their deceased father.My presence as a trusted community leader, physician and religious leader was reassuring to the family members that the decision to stop life support for their loved one with a terminal illness and multiple organ... (shrink)

A 4-day-old female was admitted into a Nigerian Hospital, with neonatal tetanus, jaundice, and sepsis. Four days into the treatment, her clinical condition continued to deteriorate. The family requ...

You are what you eat – this well‐known phrase properly describes the phenomenon of the effects of diet on acute and chronic inflammation. Several lipids and lipophilic compounds that are delivered with food or are produced in situ in pathological conditions exert immunomodulatory activity due to their interactions with the plasma membrane. This group of compounds includes cholesterol and its oxidized derivatives, fatty acids, α‐tocopherol, and polyphenols. Despite their structural heterogeneity, all these compounds ultimately induce changes in plasma membrane architecture (...) and fluidity. By doing this, they modulate the dynamics of plasma membrane receptors, such as TLR4. This receptor is activated by lipopolysaccharide, triggering acute inflammation during bacterial infection, which often leads to sepsis and is linked with diverse chronic inflammatory diseases. In this review, we discuss how the impact on plasma membrane properties contributes to the immunomodulatory activity of dietary compounds, pointing to the therapeutic potential of some of them.Also watch the Video Abstract. (shrink)

Replacing animal procedures with methods such as cells and tissues in vitro, volunteer studies, physicochemical techniques and computer modelling, is driven by legislative, scientific and moral imperatives. Non‐animal approaches are now considered as advanced methods that can overcome many of the limitations of animal experiments. In testing medicines and chemicals, in vitro assays have spared hundreds of thousands of animals. In contrast, academic animal use continues to rise and the concept of replacement seems less well accepted in university research. Even (...) so, some animal procedures have been replaced in neurological, reproductive and dentistry research and progress is being made in fields such as respiratory illnesses, pain and sepsis. Systematic reviews of the transferability of animal data to the clinical setting may encourage a fresh look for novel non‐animal methods and, as mainstream funding becomes available, more advances in replacement are expected. BioEssays 29:918–926, 2007. © 2007 Wiley Periodicals, Inc. (shrink)

Mr. M. was a 77-year-old decisionally incapacitated long-term nursing home resident with chronic schizophrenia who was admitted to the hospital with a bacterial pneumonia. His past medical history was notable for deteriorating functional status over the past 2-3 years, urinary retention requiring chronic indwelling bladder catheterization, and two recent hospitalizations for urinary tract infections leading to sepsis. He developed respiratory failure soon after admission and was intubated and placed on mechanical ventilation. Follow-up studies suggested worsening pneumonia and acute respiratory (...) distress syndrome, as well as worsening kidney function. (shrink)

BackgroundClinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital.MethodsSemi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. (...) All documents were analysed by two researchers independently.ResultsTwenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43–96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1–65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases.ConclusionsTo the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:You Can't Say "No" to That!(A "Difficult Patient" Story)Ingrid BergAs a sequela of COVID-19, my rural Wisconsin hospital has been jam-packed for months with patients for whom we routinely provide care and many for whom we do not. An exodus of health care workers and other constraints have made the transfer of critically ill patients very difficult. In this disquieting "new-normal" of our work life, we routinely must call (...) bigger cities throughout our state to find beds for complex patients.So, it was not surprising when a young patient, an IV drug user in sepsis from a heart infection, was admitted to me in the middle of the night. In less disheartening times, before the pandemic, this patient would have been transferred promptly to the big-city hospital. Now, though, the possibility of finding an open bed is next to impossible. Resigned, I placed admission orders, continued antibiotics and fluids, and crossed my fingers. Then the unexpected happened: a bed opened up, and we could send her at once!The patient had a harsh heart murmur. It was likely that a "vegetation" was clinging to the valve, between the right upper and lower chambers of her heart. A vegetation is a clump of debris, such as platelets, clotting proteins, and bacteria that is a menace to the body. Her chest imaging looked like her infection had already spread to her lungs.A definitive diagnosis for endocarditis requires a special ultrasound with a probe that goes down through the esophagus, a procedure performed by cardiologists. It's a serious infection, one that requires weeks of IV antibiotics and is best monitored by infectious disease specialists. Sometimes, cardiothoracic surgeons are called upon to strip away the infection at the site, depending on how badly the valve has been slayed or the size of the vegetation. My only recommendation for a young, otherwise healthy patient in this scenario, is transfer.All of these reasons for transfer were lolling around in my tired head when the night-time [End Page 14] nursing supervisor approached me and said, "We have a problem." When the patient was updated about the transfer, she balked: "She says she is tired and refusing to go," the supervisor began. "She doesn't feel like getting into an ambulance in the middle of the night and she doesn't care if her condition is life-threatening. She knows we can't force her to go and she will only talk about it again in the morning."The cartoon version of myself at that moment had bugged-out eyes, a dropped jaw, fists tight and clenched at my sides, and steam coming out of my head. I can look past a patient's self-neglect, poor medication adherence, abysmal communication, alcohol and drug addiction, and other crimes. But saying no to a bed at a tertiary care facility? Unacceptable!I marched down the quiet hallway and into her room. She was lying on her side, facing the door, one IV in a thin arm. I was confident I could reason with her once I explained the scarcity of beds and the medical necessity of transfer. But she was having none of it. I was calm until I could no longer maintain my cool: "You can't give up this bed!""Maybe in the morning," she insisted, yawning. "But not now. I am tired and want to rest!""But there might not be a bed in the morning," I countered. "And your infection can be life-threatening." (This is true, but we both knew she wasn't dying at this very moment.)"I am not going anywhere!" She raised her voice and then closed her eyes.And she was right. I had no choice but to keep her. I could not kick her out of the hospital because she was making a poor choice, and I was frustrated for having to manage the fallout of that decision. Giving her antibiotics and fluid boluses to bolster her blood pressure was certainly within my scope of practice. And fretting. Fretting is always within my scope of practice; not that my scope of practice matters when all the big... (shrink)

The essay that follows is, in substance, a lecture delivered in Brussels on 7 December 2016 to the 2nd International Conference of the European Network of Japanese Philosophy. In it I argue that the strategy of qualifying nothingness as an “absolute,” which was adopted by Kyoto School thinkers as a way to come to grips with fundamental problems of Western philosophy, is inherently ambiguous and ultimately weakens the notion of nothingness itself. In its place, a proposal is made to define (...) nothingness in terms of “connectedness.” The discussion is bound on both ends by an apology for transgressing established academic boundaries. On one end, I open with a brief digression on a common ground for philosophies East and West as a mestizaje to which no tradition can claim dominance. On the other, I close with an appeal for restoring respect for the role of mythical narration as a way to bridge the connection between theory and practice without having to revert to moral absolutes, particularly as it relates to safeguarding this fragile planet of ours from the ongoing sepsis of economic “progress.”. (shrink)

In this response article, we challenge a core assumption that lies at the centre of a round table discussion regarding the Pharmacogenetics to Avoid Loss of Hearing trial. The round table regards a genetic test for a variant that increases the risk of deafness if a carrier is given the antibiotic gentamicin. The idea is that rapid testing can identify neonates at risk, providing an opportunity to prevent giving an antibiotic that might cause deafness. We challenge the assumption that a (...) positive test unequivocally guides antibiotic choice because, aside from the risk of deafness, all antibiotics for neonatal sepsis are equivalent. We argue that this assumption is faulty and has particularly troubling moral consequences. We claim that giving an alternative to gentamicin is potentially providing inferior treatment and thereby may increase the risk of death. Parents and doctors are faced with a terrible choice as a result of positive point-of-care testing : give gold-standard treatment and risk deafness or give second line care and risk death. While we do not indicate an answer to this choice, what we do argue is that such a deep and difficult choice is one that may make parents wish genetic testing was never undertaken, and therefore, contra some authors in the round table, provides a reason to gain specific consent for POCT. (shrink)

BackgroundEmergency separation of conjoined twins is performed when one twin is already dead or dying and threatens the survival of the other. The particular decision to perform an emergency separation of conjoined twins provides an ethical dilemma that needs special attention. Adding to the complexity of surgical and postsurgical management in emergency separation, ethical and sociocultural aspects further complicate decision-making.Case presentationFrom 1987 to 2022, 18 conjoined twin separations were performed in our centre. This paper describes three conjoined twin emergency separations. (...) In the first case of thoracoomphalopagus babies at nine days of age, one baby was diagnosed with necrotizing enterocolitis with frequent desaturation and seizures, and the other baby was healthy. Emergency separation was performed on the twelfth day of age; unfortunately, neither baby survived the surgery. In the second case, emergency separation was performed on the 110th day of life due to sepsis in one baby. The nonseptic twin passed away six hours after surgery, while the septic twin died 12 days after surgery due to wound dehiscence and abdominal sepsis. The third case was of an omphalopagus conjoined twin with a parasitic twin. The healthy baby was deemed nonviable but found to be healthy upon birth. Immediate emergency separation was performed at 2 h of age. The living baby survived the surgery but passed away two months later.ConclusionsWhen separation is deemed necessary to save one twin, it becomes difficult to apply standard ethical medical reasoning. The decision to separate results in most cases in very high-risk surgeries with poor outcomes during surgery and postsurgery. Compounded by the complexity of the case, sociocultural and religious aspects further add to the dynamics of decision-making. A multidisciplinary team must work together with a health ethics committee and navigate through this ethical conundrum with the patient and family at its decision-making centre to decide on the best plan of care. (shrink)

To help eliminate perinatal HIV transmission, the US Department of Health and Human Services recommends against breastfeeding for women living with HIV, regardless of viral load or combined antiretroviral therapy status. However, cART radically improves HIV prognosis and virtually eliminates perinatal transmission, and breastfeeding's health benefits are well-established. In this setting, pregnancy is increasing among American women with HIV, and a harm reduction approach to those who breastfeed despite extensive counseling is suggested. We assess the evidence and ethical justification for (...) current policy, with attention to pertinent racial and health disparities. We first review perinatal transmission and breastfeeding data relevant to US infants. We compare hypothetical risk of HIV transmission from breastmilk to increased mortality from sudden infant death syndrome, necrotizing enterocolitis and sepsis from avoiding breastfeeding, finding that benefits may outweigh risks if mothers maintain undetectable viral load on cART. We then review maternal health considerations. We conclude that avoidance of breastfeeding by women living with HIV may not maximize health outcomes and discuss our recommendation for revising national guidelines in light of autonomy, harm reduction and health inequities. (shrink)

Ms. X is a person with cerebral palsy and schizophrenia. She has intractable bedsores that are a result of her immobility and to poor wound care related to her delusional thinking. Despite intensive community support, the wounds have worsened to the point that she has needed multiple hospitalizations to prevent systemic sepsis, a life‐threatening condition. She is capable of placement decisions and wishes for independence at home but is incapable of making wound care decisions and does not appreciate that (...) immediately returning home from the hospital, instead of going into a special care facility, would likely result in sepsis. The resulting dilemma about discharge planning highlights the complexity involved in weighing concerns around mental illness and capacity for treatment and placement of care. The extent of the care that is required and available in a community or health care system and the slow but relatively certain progression of the symptoms also make the decision challenging. Two commentaries take very different approaches in exploring the question whether Ms. X should be supported to go home or to a special care facility. (shrink)

James is a seventy‐two‐year‐old man with end‐stage dementia who was transferred from another hospital. At the time of transfer James had sepsis from two multidrug‐resistant organisms, respiratory failure requiring ventilatory support, renal insufficiency, pancytopenia, and hypotension requiring vasopressors. He has severe contractures and foot drop, has a feeding tube, and has been nonverbal for several months. His son, Paul, is requesting full code and treatment focused on recovery despite James's extremely poor prognosis.Paul is James's only child, and James's wife (...) is deceased. Paul says he has the “gift of prophecy” and knows for certain when God is speaking to him. “God,” he says, “doesn't lie.” He says that he and his father spent years preaching together and have witnessed many healings. He believes that they are being “rebuked” because at a time when his father was too tired to travel much, they held fewer revivals and did not save enough souls.James's condition has worsened slowly. He has almost no urine output and does not breathe over the ventilator. He is extremely volume overloaded; his toenails have bloodied and popped off. By hospital‐day twenty‐one, he had only corneal reflexes. The medical team is troubled; if James is to stay on the ventilator, he will need a tracheostomy, but this would only further prolong what has already been an agonizingly prolonged dying process.Paul continues to pray for his father to get up. (shrink)

This article will reveal how local scientific determination and ambition, in the face of rejection by funders, navigated a path to success and to influence in national policy and international medicine. It will demonstrate that Birmingham, England's ‘second city’, was the key centre for cutting-edge biological psychiatry in Britain in the 1920s and 1930s. The ambitions of Frederick Mott – doyen of biochemistry, neuropathology and neuropsychiatry, until now celebrated as a London figure – to revolutionize psychiatric treatment through science, chimed (...) with those of the City and University of Birmingham's Joint Board of Research for Mental Diseases. Under Mott's direction, shaped by place and inter-professional working, the board's collaborators included psychiatrist Thomas Chivers Graves and world-renowned physiologist J.S. Haldane. However, starved of external money and therefore fresh ideas, as well as oversight, the ‘groupthink’ that emerged created the classic UK focal sepsis theory which, it was widely believed, would yield a cure for mental illness – a cure that never materialized. By tracing the venture's growth, accomplishments and contemporary potential for biochemical, bacterial and therapeutic discoveries – as well as its links with scientist and key government adviser Solly Zuckerman – this article illustrates how ‘failure’ and its ahistorical assessment fundamentally obscure past importance, neglect the early promise offered by later unsuccessful science, and can even hide questionable research. (shrink)

Mr. M is an eighty-five-year-old who presented to the hospital with congestive heart failure exacerbation, pneumonia, altered mental status, and sepsis. A physician determines that he lacks capacity, and the team in the intensive care unit looks to the patient's daughter, Celia, as his surrogate decision-maker because she is named as an agent in his medical power of attorney form. While in the ICU, Mr. M suffers acute respiratory distress secondary to pneumonia and thus requires intubation. Celia accepts several (...) life-sustaining interventions, but she sporadically refuses other medically indicated therapies. Although providers explain the importance of the ICU insulin regimen for glucose control, she either refuses the insulin or requests a lower dose. The health care team believes that it is providing substandard care and that Celia's medical decisions are not in the patient's best interests, so they request an ethics consultation. When the clinical ethicist attempts to talk with Celia, she refuses to speak with him, saying flatly, “I am not interested in talking with you.” The clinical ethicist meets with Celia on a couple of occasions, but she consistently refuses to have a conversation with him. He wonders if the patient's surrogate decision-maker can refuse a clinical ethics consultation and is unsure what his next steps should be. (shrink)

A 72-year-old widowed woman known to have an organic brain syndrome was hospitalised owing to gangrene of her lower limbs. The gangrene had been caused by an adduction contracture of her hip resulting in pressure on the medial surface of her left leg. In addition she had pressure sores over both trochanters and the sacrum. The smell of putrefication could be sensed from a distance and on examination large white worms could be seen slithering in the decomposing tissue. The patient (...) was pyrexial, oblivious of her surroundings, and without pain. Surgery--limb amputations--would not restore the patient to a cognitive state nor improve here quality of life, but abstinence posed an inherent threat of sepsis, and revulsion to the attendants. The sacral pressure sore was so large that surgical closure was impossible. The question of surgical intervention is discussed. (shrink)

Jeff Nisker describes his personal experience of a diagnosis of advanced prostate cancer and the kindnesses he received from friendly doctors. He claims that this narrative account supports the promotion of Prostate Specific Antigen screening for asymptomatic men and impugns statisticians, mistakenly thinking that their opposition to PSA screening derives from concerns about financial cost. The account inadvertently demonstrates the danger of over-reliance on a single ethical tool for critical analysis. In the first part of this response, we describe the (...) statistical evidence. The most reliable Cochrane meta-analyses have not shown that PSA screening saves lives overall. Moreover, the high false positive rate of PSA screening leads to overinvestigation which results in unnecessary anxiety and increased cases of unnecessary sepsis, urinary incontinence and sexual dysfunction. Then we describe how narrative ethics alone is an insufficient tool to make claims about policies, such as PSA screening, which have hidden harms. Although Nisker’s story-telling is compelling and evokes emotions, narrative ethics of this sort have an inherent bias against people who would be harmed by the counterfactual. Particular care must be taken to look for and consider those untellable stories. Ethicists who only consider narratives which are readily at hand risk harming those who are voiceless or protected by the status quo. PSA screening is the wrong tool to reduce prostate cancer deaths and narrative ethics is the wrong tool to appraise this policy. It is vital that the correct theoretical tools are applied to the medical and ethical questions under scrutiny. (shrink)

We present the perspective of a Bioethics Consultation Service operating in an urban hospital in Dayton, Ohio, USA, as it adapted to treating Sars-CoV-2 patients throughout 2020. Since the first case of COVID-19 was reported in Ohio on 9 March 2020, until 1 January 2021, the Bioethics Consultation Service was consulted 60 times, a 22.5% increase from the same period of 2019. The most common diagnoses requiring consultation included end-stage renal disease requiring dialysis, out-of-hospital cardiac arrest, and sepsis. Only (...) 10% of consultations were for patients hospitalized with COVID-19. This is a qualitative analysis of the cases we saw and a discussion of factors that affected our service while adapting to COVID-19 standards of care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Transformative Journey of TransplantationValen KeeferThe moisture from the ocean floated effortlessly through the air as it glided over the rocky cliff. The steady stream of mist covered my face and frizzy hair with beaded water droplets. I had been sitting on a bench alone for hours admiring the Northern California coast at a magnificent overlook featuring a bird’s-eye view of the endless sea and campground I called home (...) for the past month. The stunning mountain landscape behind me, the soothing colors of the coastal shrubbery, and the smell of eucalyptus made for a trifecta of surreal beauty. The ocean disappeared from my view and I became engulfed in the precipitation and felt like I was suspended in a cloud. I was soaking in every moment as it was the last day of my solo RV trip.The fog slowly separated and exposed bits and pieces of the ocean again and then a breathtaking rainbow came into sight. Each end appeared to be touching either side of the campground like it was giving it a hug. I was eye-level with the center and highest point of the rainbow, arching above our home on wheels. I stood on the bench with my arms wide open, embracing nature and the gift of life in all its glory. This moment would not have possessed such deep meaning if it wasn’t for the journey that came before it—the transformative journey of transplantation.Some may think of transplantation as a singular event when in reality, it’s a lifelong journey that can start with a diagnosis many years prior. My transplant journey began when I was diagnosed with polycystic kidney disease (PKD) at 10-years-old. Being diagnosed with a hereditary disease that has deeply impacted multiple generations of our family and with no known treatment or cure was a lot to carry as a child.My youth was full of love from my parents and filled with illness and the limitations and long-term impacts of growing up with multiple chronic illnesses. My education on PKD was the brutal real-life experiences of enduring it firsthand—with no support groups, resources, or internet to seek answers. I always felt different during a time when you’d do anything to fit in. I couldn’t play sports and had to sit on the sidelines in gym class. I was often in the nurse’s office, hospital, or recovering from a surgery. I hid my scars and unattractive body while changing in gym class. Friendships were really hard. Relationships were even harder.Growing up with chronic illnesses takes away from the fun of dreaming. It’s like that bright future full of endless possibilities is blocked by a huge mountain you know you have to summit first with no supplies, no friends, and no paved path to follow.Complications from PKD followed me from high school right into college, when I spent almost a year in the hospital. Both of my kidneys were removed, I was on dialysis, had pancreatitis, received over 70 blood transfusions, survived an internal bleed, and was in dire need of a lifesaving kidney transplant.At 19-years-old, I was too sick to be placed on the transplant waiting list, but needed a kidney to survive. My parents were living at the Ronald McDonald House, wondering if they would be the next ones to lose their teenage daughter. A close family friend forever changed our lives when she restored my health by selflessly donating her kidney to me. While it was an arduous path to transplantation, in some ways, the journey was just beginning.Fifteen years following my kidney transplant and summiting what I thought was going to be the most challenging mountain of my health journey, I found myself back on death’s doorstep with another battle ahead. I was in need of a second miracle, this time a lifesaving liver transplant. It was PKD again. The bile ducts in my liver were so gnarly that they looked like limbs of an oak tree rather than the desired smooth straw-like appearance. Their malformations led to chronic liver infections and multiple sepsis... (shrink)

In the wake of two recent high-profile, controversial cases involving the prosecution and conviction of Drs Bramhall and Bawa-Garba, this article considers when it is socially desirable to criminalise doctors’ behaviour, exploring how the matters of harm, public wrongs and the public interest can play out to justify—or not, as the case may be—the criminal law’s intervention. Dr Bramhall branded his initials on patients’ livers during transplant surgery, behaviour acknowledged not to have caused his patients any harm by way of (...) injury to their organs. Dr Bawa-Garba misdiagnosed and failed to properly assess a 6-year-old boy with pneumonia and sepsis under her care, who subsequently died. Taking account of contextual and public interest concerns, can and should there be exceptions to imposing criminal liability where a doctor’s behaviour is deemed grossly negligent and a significant contribution to a patient’s death? And is it really appropriate to subject a doctor to penal sanction where he may have committed a private wrong against a patient, but does not set back their interests? (shrink)