Hitoshi Arima’s article on double-effect sedation (DES) presents a strong challenge to moral assumptions in end-of-life medical care.1 He argues that in many cases, physicians administering drugs such as midazolam or morphine foresee, rely on and often intend the reduction of consciousness as a necessary part of achieving comfort for the patient. This challenges the moral applicability of the Doctrine of Double Effect (DDE), which traditionally permits harmful outcomes only when they are an unintended side effect of a morally (...) permissible action. If, as Arima argues, unconsciousness is often an intended means to an end, then the ethical status of such interventions must be reassessed. This argument has significant implications within Islamic bioethics, where the question of moral intention ( niyyah ) is the cornerstone of ethical evaluation.2 Islamic moral thought, drawing from legal theory, theology and metaphysical understandings of the human being, provides a framework in which actions cannot be morally assessed without clarity about what is truly intended. In the context of end-of-life care, this framework also insists on honouring the sanctity of consciousness, the rights of the dying and the moral weight of the final moments of life.2 3 Islamic ethics treats niyyah, the internal intention behind an act, as a foundational element in determining its moral and legal status.2 In legal theory ( uṣūl al-fiqh ), intention distinguishes acts that may appear identical on the surface. The same external behaviour, such as administering a sedative, may be classified as allowed ( ḥalāl ) or prohibited ( ḥarām ) depending entirely on whether the goal is to relieve physical suffering without compromising dignity or to suppress consciousness as a shortcut to emotional or institutional ease.4 In Arima’s account, the common justification for DES is that sedation is not …. (shrink)

The use of a morphine pump for an ill patient is not inherently a form of euthanasia. A morphine pump is typically used to manage severe pain and provide comfort to patients, especially those who are in palliative care or facing terminal illnesses. The primary goal of this pain management is to alleviate suffering and improve the patient’s quality of life.

Dr Anne Merriman is the founder of Hospice Africa and Hospice Africa Uganda. She is presently Director of Policy and International Programmes. Here she tells the story of how HAU was founded. Dr Richard Harding is an academic researcher working on palliative care in Sub-Saharan Africa. This paper described Dr Merriman's experience in pioneering palliative care provision. In particular it examines the steps to achieving wider availability of opioids for pain management for those with far advanced disease. Hospice Africa Uganda (...) has been a model facility in achieving high quality clinical care embedded in a strategy of advocacy and education, using a multifaceted approach that has addressed logistical, policy and legislative barriers. Until 1990 control of severe pain in Sub-Saharan Africa was non-existent except in Zimbabwe and S Africa. Oral affordable morphine was brought to Kenya through Nairobi Hospice that year, and to Uganda through Hospice Africa Uganda in 1993. This paper offers an example of a highly effective and cost efficient model of care that has transformed the ability to humanely manage the problems of those with terminal illness, and to offer a culturally appropriate. (shrink)

The ethics of palliative sedation has been debated intensely. Recently, it has been emphasised that many drugs with sedating effects are also effective in reducing specific symptoms like pain and seizures. For example, midazolam is commonly used to sedate terminally ill patients but it can also reduce seizures. Hence, when midazolam is administered to a patient suffering from seizures, it may also lower the patient’s consciousness. Similarly, morphine is useful in the management of end-stage pain and dyspnoea, but can (...) also reduce the patient’s consciousness, especially when administered in large doses. Cases in which a drug thus alleviates a symptom as well as lowers patient consciousness are called double-effect sedation (DES). Many claim that the decrease in consciousness in DES is merely a side effect and not an intended consequence, even if its occurrence was foreseen in advance or it will be maintained for some time until the patient dies. Additionally, it is often contended that DES is therefore justifiable by the doctrine of double effect (DDE) even though the decrease in consciousness is bad. The purpose of this paper is to examine these claims. I argue that the claims, while sometimes correct, are very frequently false. It will be shown that physicians often intend to reduce consciousness in DES. In such cases, as I conclude, DDE may not serve to justify DES, and DES should be subject to the same rigorous moral evaluations as the use of sedating drugs that do not reduce specific symptoms. (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)

John Adams and Thomas Jefferson, respectively the second and third presidents of the new United States of America, died on the same day, July 4, 1826. Both were old men and ill. What could explain this and what would the implications be for reflection in bioethics about the end of life? There are at least six principal avenues to explore, but all of them raise further issues: coincidence, divine intervention, “hanging on”, being allowed or caused to die by others (intervention (...) by physician or family), allowing oneself to die, and causing oneself to die. All six possibilities these explanations raise are central to the very questions about death and dying that are so controversial today, almost two hundred years after the deaths of Adams and Jefferson, as disputes over withdrawing and withholding treatment, allowing to die, the overuse of morphine, terminal sedation, physician-assisted suicide, and euthanasia play huge roles in friction over modern medicine. (shrink)

This paper examines the evolution of ideas about narcotic addiction. In the eighteenth and early nineteenth centuries, addiction was not viewed as a medical condition, but as a ‘bad habit’. The contemporary reaction to De Quincey's Confessions demonstrates the general lack of medical involvement. The question of opium eating and longevity, first generated by the Mar case, brought increased medical interest and an embryo connection with the anti-opium crusade. In the second half of the century, addiction was more fully ‘medicalised’ (...) through the profession's involvement in the question of hypodermic morphine and the allied development of a disease theory of addiction. The ‘problem’ of hypodermic morphine owed much to medical perceptions; and the disease theory, too, was not scientifically autonomous. Medical thinking developed in close alliance with moral biases, temperance and anti-opium beliefs. Treatment structures and methods were elaborated in line with increased medical interest. In the early twentieth century there was a distinct move on the part of the government, and the Home Office in particular, to defeat the ‘disease’ view, and to substitute a penal policy. The 1926 Rolleston Report marked not simply a reassertion of the earlier moral-cum-medical emphasis, but a recognition of partnership between doctors and the state in which the limited nature of narcotic addiction at first ensured a liberal reaction. (shrink)

You have not opened the wrong journal!The police have a duty to protect the public and to investigate any, and all, serious crimes. The article by Lynøe and Leijonhufvud raises important issues about the interaction between hospital staff and police in cases in which suggested medical negligence crosses into the arena of serious legal offences, which range from murder and homicide to serious assault.1Although arising in Sweden, the issues raised in this case are generalisable. While our understanding is limited to (...) the journal article there seem several uncontested facts: a children's intensive care doctor was arrested, charged and acquitted of the mercy killing of an infant in a Swedish hospital. The baby had sustained severe brain injury prior to this clinician's involvement, either due to birth asphyxia or to an accidental overdose of salt. The baby died after withdrawal of life-sustaining treatment with parental agreement. At a later stage, the family asked the police to investigate the initial salt incident. Despite the team attending the baby after WLST stating that only a morphine infusion was administered, a 25-day postmortem femoral artery sample showed ‘an extremely high level of thiopentone’, although no control sample was analysed.Healthcare staff are subject to the laws of their country. However, Lynøe and Leijonhufvud raise the issue of a conflict between what they term ‘soft law’—the rules, regulations and ethics of healthcare practice and the law of the land. …. (shrink)

Mr. Paul Mills suffered from cancer of the esophagus. Three major surgeries were unsuccessful in correcting the problem, and other treatment methods likewise failed. His condition deteriorated to the point where there was no longer any hope of recovery. Dr. Morrison, who was Mr. Mills's intensive care physician at the Queen Elizabeth II Health Sciences Centre in Halifax, and Mr. Mills's family agreed that active life support should be discontinued. Dr. Morrison then removed Mr. Mills's ventilator. To everyone's surprise, and (...) dismay, Mr. Mills did not die. He continued to breathe spontaneously and started to show signs of distress. Dr. Morrison increased the dosage of morphine, to no effect. She increased it again to the point where death could reasonably be expected to occur; signs of distress continued. Dr. Morrison at this point administered a dose of potassium chloride and Mr. Mills died. (shrink)

Disturbed milk ejection (DME) can occur under various conditions in practical dairy farms. As a consequence udder emptying at milking is incomplete. If milk ejection is completely lacking, only the cisternal milk fraction is available, i.e., only 0–20% of the milk stored in the udder. The disturbance is due to an insufficient release of oxytocin in response to tactile udder stimulation. In all known situations in practical dairy farming, exogenous oxytocin even at a low dosage is suitable to overcome the (...) disturbance. However, due to the short half-life of oxytocin this treatment is only effective for a short time, i.e., for one milking event. A sustainable therapy to activate endogenous oxytocin release in response to teat stimulation is currently not yet available. In some cases, albeit not always, vaginal instead of teat stimulation leads to a sufficient oxytocin release to induce milk ejection. DME can occur in primiparous cows during the first weeks postpartum, in unfamiliar surroundings (e.g., after the changeover to a new milking system) or during peak estrus. Also in housing systems where dairy cows are kept in contact with their calves DME at machine milking has been observed in some farms. Except for clinical mastitis or inadequate milking machine settings causing pain to the cow disturbed milk ejection can mostly not be linked to obviously observed stress. Also, typical stress-related hormones such as adrenaline have not been elevated at disturbed milk ejection, and exogenous cortisol or catecholamines do not inhibit the release of oxytocin during milking. Endogenous opioids may be involved in the disturbance as beta-endorphin has been elevated in some studies during DME, and exogenous morphine caused an inhibition of oxytocin release during machine milking. DME is mostly treated by oxytocin injection at each milking. However, all commercially available oxytocin preparations can be used only at a massive overdose causing circulating blood concentrations far beyond the physiological range. Whereas endogenously released oxytocin decreases immediately to baseline after milking, the injected oxytocin remains often elevated for several hours after injection. The consequence is the development of a reduced sensitivity of the mammary gland to oxytocin within a few days of repeated treatments. Even if the oxytocin release from the pituitary is normal, the high dosage oxytocin treatment cannot be stopped before the next dry off. Therefore, exogenous oxytocin treatment needs to be recommended at a dosage as low as possible and for the shortest possible period. The i.v. injection of 0.5–1 i.u. of oxytocin instead of the often used 20–50 i.u. is sufficient to empty the udder at machine milking. This is only possible if the oxytocin product is diluted in physiological saline to achieve a volume which can be injected from a practical point of view, i.e., to inject several ml instead of μl. Besides the reduced milk harvest with a direct impact on the farm income, periods of low or no milk flow during milking cause an increased mechanical load on the teat tissue through high vacuum both at the teat end and at the mouthpiece chamber of the liner. This in turn increases the risk of hyperkeratosis and increased teat tip callosity, and hence susceptibility to mastitis. Studies to detect a genetic background of the likelihood of disturbed milk ejection were without unambiguous results until today. It remains unclear why only some individual animals show disturbed milk ejection. (shrink)

Objectives: To investigate why physicians label end-of-life acts as either ‘euthanasia/ending of life’ or ‘alleviation of symptoms/palliative or terminal sedation’, and to study the association of such labelling with intended reporting of these acts. Methods: Questionnaires were sent to a random, stratified sample of 2100 Dutch physicians. They were asked to label six hypothetical end-of-life cases: three ‘standard’ cases and three cases randomly selected, that varied according to type of medication, physician’s intention, type of patient request, patient’s life expectancy and (...) time until death. We identified the extent to which characteristics of cases are associated with physician’s labelling, with multilevel multivariable logistic regression. Results: The characteristics that contributed most to labelling cases as ‘euthanasia/ending of life’ were the administration of muscle relaxants or disproportional morphine. Other important factors were an intention to hasten death and a life expectancy of several months. Physicians were much more willing to report cases labelled as ‘euthanasia’ or ‘ending of life’ than other cases. Conclusions: Similar cases are not uniformly labelled. However, a physicians’ label is strongly associated with their willingness to report their acts. Differences in how physicians label similar acts impede complete societal control. Further education and debate could enhance the level of agreement about what is physician-assisted dying, and thus should be reported, and what not. (shrink)

In the present article we consider general anesthesia as a means of exploring questions regarding unconscious influence. The primary questions addressed in the research are whether surgical patients who are under adequate general anesthesia unconsciously perceive auditory information and whether they can benefit from such information. In addition, we consider the relevance of individual hypnotic ability for perceptual processing in this context. Ninety-six adult patients, undergoing elective abdominal hysterectomy, were randomly allocated to one of four tape-recorded conditions: therapeutic suggestions, melodies, (...) suggestions-plus-melodies, or silence. Double-blind conditions were satisfied in every respect. Patients received a standardized, but typical, "balanced" anesthetic, and level of anesthesia was adequately monitored. Following surgery, all patients received their analgesic medication from a patient-controlled device. Patients who were played therapeutic suggestions used a significantly smaller dose of morphine than patients who were not played suggestions. Although hypnotic ability was not significantly associated with therapeutic outcome, high but not low hypnotizable patients accurately guessed whether they were played suggestions. No compelling evidence for memory of melodies was obtained. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“We Need to Cut the Neck!”Confronting Psychological and Moral Distress during Emergency Cricothyrotomy1Stephanie CooperEnoughYou didn’t die in the ER, but rather, began your inexorable demise. The last, first, and only words I ever heard you utter was the weak mewl “tight, tight” as the blood pressure cuff constricted your left arm. You were 98–years–old, bed–bound, at the end. Your world was already partitioning itself from us, your brain tunneling (...) down the uneven corridors of consciousness. A concretion of otoliths muffled your hearing, and fatigue burdened your ancient heart.Your name–band encircled your skinny ankle like a bird. Deformed by arthritis, you were caged within yourself, imprisoned by senescence. You could not declare yourself to us. Words disintegrated into moans and your grimace became animal.When you came back from x–ray—hypotensive with multiple neck fractures confirmed—you could speak no more. Your pulse slowed, your blood pressure plummeted. I jammed a gloved finger against your femoral pulse, faint and tired. [End Page E5]“What’s her DNR status?” I gravely asked your nurse.The DNR paperwork for once had arrived with the patient. “No CPR” she said with relief. But then the paperwork went on, forcing me—the waitress of tragedy—to serve up the hash of an impossible menu.As health care providers, we are all often tasked with performing contradictory actions: the pain of IV insertion followed by the morphine push, drilling deeper into broken bone in order to plate it, the inadvertent cracking of ribs during chest compressions. We sometimes must perform violent action in the hope of sustaining and resurrecting life. We are asked to perform the impossible, the contradictory, the painful. And sometimes the actions we must take catalyze an inexorable chain reaction of actions, which can end in death–prolonging and painful interventions that we did not intend.Although our culture may imagine that one can choose one’s meal at the end–of–life fast–food franchise of death, such is not the case. You can’t suddenly decide you’re a vegetarian. You can’t order the cheeseburger without the cheese—and we all are getting the burger, in the end. Ordering the heart–squeezing drugs without the CPR to circulate them, or the antibiotics without the fluid to counter dehydration, is like ordering the burger without the bun. Sometimes the possible choices are not necessarily realistic choices. You get served what you get served, and perhaps we should question the assumption that we have the ability to choose at all.Your DNR form proclaimed no CPR but then said that antibiotics and intubation were okay—the cheeseburger without the cheese. An unfortunate choice for you, me, and the rest of us, as your death menu led to a very unhappy meal.You were comatose. I stuck a tongue blade deep into your desiccated throat. You did not gag. This means I should have intubated you, but morally, I couldn’t. To what end? You were 98 years old, broken, moribund. If you hadn’t suffered multiple neck fractures, or if you were a vibrant elder who had just walked off Mt. Rainier, maybe the story would have been different. But you? I doubted that you truly had a chance of ever feeling joy again. You were somebody’s wife, somebody’s mother. I knew this step would lead to the domino of unstoppable steps. I refused to flog your corpse.I called your daughter Kay on her cell phone, told her that you were in critical condition and that she should come to the ER immediately. But how to begin to tell a daughter her mother is dying, let alone over a cell phone? Gentle but surreal and impersonal, my voice tried to tell your daughter that the interventions you needed would likely kill you. I have seen enough human suffering to know. To me, the choices were clear: death by nature’s irrefutable course, versus a more painful, protracted, and violent death by what we’d do to you.Kay arrived in a wheelchair and scooted up to your bedside. Like all daughters, she wasn’t ready for you... (shrink)

It has long been thought that by using morphine to alleviate the pain of a dying patient, a doctor runs the risk of causing his death. In all countries this kind of killing is explicitly or silently permitted by the law. That permission is usually explained by appealing to the doctrine of double effect: If the use of morphine shortens life, that is only an unintended side effect. The paper evaluates this view, finding it flawed beyond repair and (...) proposing an alternative explanation. It is not the intention of the doctor that counts, but the availability of an “objective” palliative justification. (shrink)

The spinal mechanisms of action of opioids under normal conditions are reasonably well understood. The spinal effects of opioids can be enhanced or reduced depending on pathology and activity in other segmental and nonsegmental pathways. This plasticity will be considered in relation to the control of different pain states using opioids. The complex and contradictory findings on the supraspinal actions of opioids are explicable in terms of heterogeneous descending pathways to different spinal targets using multiple transmitters and receptors – therefore (...) opioids can both increase and decrease activity in descending pathways. These pathways could exhibit considerable plasticity. There is increasing evidence that delta opioid receptor agonists have the potential to replace morphine as major analgesics with reduced side-effect profiles. The concept of preemptive analgesia, based on preventing the induction of some of the negative plastic influences on opioid controls and the detrimental effects of pain, is sound, but experimental verification in the clinical setting is difficult. For example, a delayed compensatory upregulation of inhibitory systems, particularly in inflammation, may counter persistent painful inputs. Combination therapy with opioids may be beneficial in many pain states where either negative influences are blocked or inhibitory controls are enhanced. Finally, developmental aspects of these systems are discussed in connection with the treatment of pain in young children, where inhibitory systems in the spinal cord are immature. (shrink)

Drug addiction is viewed as a maladaptive memory induced by contextual cues even in the abstinent state. However, the variations of hedonia and appetite induced by the context during the abstinence have been neglected. To distinguish the representative behaviors between hedonia and appetite, micro-behaviors in abstinent animal such as psycho-activity and drug seeking behaviors were observed in morphine conditioned place preference (CPP). To confirm the different effects of reward between drug and natural reward, a palatable food CPP paradigm was (...) compared in current work. After a 10-day training in CPP with morphine or food, the preference was tested on day 1, 14, 28, and the changes of micro-behaviors were analyzed further. Our data showed that tree shrews treated with morphine performed more jumps on day 1 and more visits to saline paired side on day 28, which indicated a featured behavioral transition from psycho-activity to seeking behavior during drug abstinence. Meanwhile, food-conditioned animals only displayed obvious seeking behaviors in the three tests. The results suggest that the variations of micro-behaviors could imply such a transition from hedonic response to appetitive behaviors during morphine abstinence, which provided a potential behavioral basis for further neural mechanism studies. (shrink)

In March 2004, the European Court of Human Rights awarded Carol Glass and her son David 10 000 Euros compensation after doctors treated David contrary to his mother’s wishes, without a court order.1 Although dismissed by UK courts, the ECHR held that David’s article 8 right to privacy, and in particular his right to physical integrity, had been breached.Born in 1986, David Glass is severely mentally and physically disabled, requiring 24 hour care. In July 1998 after surgery to alleviate an (...) upper respiratory tract obstruction, David became critically ill and was put on a ventilator. Doctors thought he was dying. His condition improved briefly and he returned home only to be readmitted a few days later when doctors discussed the option of morphine to alleviate his distress. His mother refused, believing it would compromise his chance of recovery. She also made clear that she wanted David resuscitated if his heart stopped. Although the doctor managing David’s care noted the possible need for a court order in such cases of total disagreement, no order was sought. On 20 October 1998, diamorphine was administered to David and a DNAR notice placed on his medical notes. Relations between the Glass family and the doctors deteriorated rapidly, culminating in a fight in which two doctors were injured. Ms Glass applied unsuccessfully for a judicial review of the hospital’s decisions and was refused permission to appeal. Subsequently, the General Medical Council found the doctors innocent of serious professional misconduct and the Crown Prosecution Service declined to bring charges against them. Ms Glass then took her case to the European Court of Human Rights.The Glass family argued that when the dispute arose, the hospital should have involved the courts to clarify whether, despite his mother’s objections, the …. (shrink)

The Mighty Morphin Power Rangers may be the most popular children's program since the inception of television. While the program is a commercial success, it also generates much controversy. For example, with an average of 211 acts of violence per hour, is Power Rangers too violent for children to watch? The show's U.S. producers rebut by claiming that Power Rangers is perhaps the most multicultural children's program available in the United States and should be encouraged. How is this so-called multiculturalism (...) presented to millions of children across America 6 days a week? Can such expression be so valuable that it outweighs the controversy surrounding the program? Through textual analysis this paper concludes that the multiculturalism in Mighty Morphin Power Rangers is, at most, a mirage. The ethical implications of such mirage multicultualism are examined. (shrink)

ABSTRACT In this survey we have investigated the experiences and attitudes of Danish physicians regarding end‐of life decisions. Most respondents have made decisions that involve hastening the death of a patient, and almost all find it acceptable to do so. Such decisions are made more often, and considered ethically more acceptable, with the informed consent of the patient than without. But both non‐resuscitation decisions, and decisions to provide pain relief in doses that will shorten the patient's life, have been made (...) and found acceptable by at least 50% of the respondents, even when there is no informed consent. Furthermore, 12% have doubled morphine dosages with fixed intervals, thus providing doses substantially higher than that necessary to control pain, without the informed consent of the patient. Two per cent have helped in assisted suicide, and 5% have administered a lethal injection at the patient's request. Respectively 37% and 34% find these last two practices ethically acceptable. Amongst those that do not find them acceptable, the most important reasons to be opposed are, the doctrine of double effect, the doctrine of doing and allowing, and the view that human life is sacred. Amongst supporters, the most important reasons mentioned are, that the patient's right to self‐determination should be respected, the view that a patient should not be forced to suffer, and the view that the patient has a right to be helped to a dignified death. (shrink)

This paper addresses the oldest controversy in the phenomenology of pain, which concerns the intentional nature of pain experience. First, I present the central reasons that underlie the view that originates in Carl Stumpf’s writings, which suggests that pain is a non-intentional feeling-sensation. Second, I present the evidence that underlies the Brentanian perspective, which suggests that pain is an irreducibly intentional experience. Third, I argue that Edmund Husserl’s schema, “apprehension—content of apprehension,” enables one to reconcile these positions. In this regard, (...) I argue that this schema provides the conceptual basis for defending two claims: (1) pain is an irreducibly stratified phenomenon; (2) while some of its strata are non-intentional, others are marked by intentionality. Fourth, with the aim of demonstrating the philosophical significance of this schema in the framework of phenomenological pain research, I open a brief dialogue between phenomenology and cognitive science. I show how this schema can clarify the experiential structures of lobotomized, cingulotomized as well as morphinized patients as well as how it can shed light on such syndromes as threat hypersymbolia, pain asymbolia and congenital analgesia. (shrink)

Not everyone finds a in suffering. Indeed, even those who do subscribe to this interpretation recognize the responsibility of each individual to show not only sensitivity and compassion but render assistance to those in distress. Pharmacologic hypnosis, morphine intoxication, and terminal sedation provide their own type of medical to the terminally ill patient suffering unremitting pain. More and more states are enacting legislation that recognizes this need of the dying to receive relief through regulated administration of controlled substances. Wider (...) legislative recognition of this need would go far toward allowing physicians, in the exercise of their reasonable medical judgment, to administer a range of narcotics and barbiturates to the terminally ill without fear of legal sanctions. Sadly, social attitudes and governmental concerns about the spread of drug addiction provide an undeniable policy nexus that impedes unduly a rational approach or exception for the treatment of pain experienced by the dying. (shrink)

Rat performance under a fixed-ratio schedule of food reinforcement was analyzed in terms of distributions of intervals between successive responses (IRTs). A 20-mg/kg IP injection of morphine increased the proportion of longer IRTs without affecting the modal IRT, and increased mean IRT at all positions in the ratio. Fixed-ratio performance returned to baseline during repeated administration of the drug.

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Acts of Enjoyment: Rhetoric, Žižek, and the Return of the SubjectJames J. Brown Jr. and Joshua GunnActs of Enjoyment: Rhetoric, Žižek, and the Return of the Subject by Thomas Rickert. Pittsburgh: University of Pittsburgh Press, 2007. Pp. x + 252. $24.95, hardcover.Thomas Rickert had a falling-out with his brother, and this distresses him so much that his disrupted relation is described as “traumatic.” Rickert reports that while listening (...) to a portable CD player during a run on an unexpectedly warm winter day, a song by the now defunct jazz/rock band Morphine reminded him of a happy time at a pool hall with his brother (24). Mediated—or better, medicated—by music, the homological happiness of running in the sun and a positive past memory also resurfaced a painful relational rupture, the reason of which Rickert omits to underscore that mysterious, “little detail or object” of the Real that marks his singular finitude as a writing subject (216 n. 11). We’ll want to come back to this curiously deliberate omission, but for the present we note Rickert is not simply an undead author but a human being with relations and feelings. He is not just a gifted scholar or a bundle of reflections, but a nexus of body and movement and words and affect. If there is anything that Rickert’s study can be said to work through with brilliance, humor, and grace, it is the reality of complex personhood.Rickert’s brotherly confession comes in Chapter 1 as a way to introduce a psychoanalytic understanding of subjectivity, and more specifically, to help illustrate how trauma works itself out as an afterwardness or “belatedness” ( Nachträglichkeit ): traumatic events from the past are not reckoned with or worked-through until some coincidence or reminder, such as a similar [End Page 183] sensory experience, reintroduces the event in doubled re-presentation (18–27). This implies the “subject” (a paradigm person) is a kind of timedelay, a self-conscious temporal moving that becomes this way through re-presentation. The rhetorical subject is analogously a retrojected reckoning with events past (not all traumatic) that Rickert identifies as a scene of writing, a locus that has important implications for rhetorical studies in general and writing pedagogy in particular. Rickert’s logic is as follows: if we agree that the subject is a belated one in the psychoanalytic sense, then how we teach rhetoric needs to change. Rickert opens the book with the observation that his students are producing excellent cultural critiques but that such critiques do not lead the students to change their actions (1–7), perhaps evidence enough that something is not quite right in a classroom grounded by “cultural studies pedagogy” and ideology critique—or at the very least, proof that something has changed. The opening gambit is simply that a “postpedagogy” premised on an understanding of rhetorical subjectivity as belatedness is better than a status quo rooted in the rational subject of the Enlightenment.Mostly through a Žižek-filtered, Lacanian lens, Acts of Enjoyment then undertakes a retake of the rhetorical field, frequently scanning from the traumatic ontology of the rhetorical subject to that domain of knowledge that we hold dear, the subject of rhetoric. In Chapter 2, the (primal) scene thus shifts from the slo-mo subject to rhetorical studies, initially through a reassessment of Kinneavy’s “communications triangle,” but ultimately in response to the shock treatment of poststructuralism. The initial theoretical traumas introduced by Victor Vitanza, Diane Davis, Sharon Crowley, and others discussed in Chapter 1 are threaded into an account of “poststructural” redress in Chapter 2: as is true of all forms of trauma, the initial poststructural jolt delivered to the concept of subjectivity was deadened; poststructural theory was eventually used to “shore up rather than challenge Kinneavy’s triangle” (37). To truly work-through our traumatized subject in both senses, we need a second trauma: Lacanian psychoanalysis. Presumably, “poststructuralist thought” is to be opposed because it has no account of the subject (21–24); “Lacan,” after all, “is not a poststructuralist” (48). The remainder of the chapter is then used to deploy Lacan’s conceptual lexicon.Just as... (shrink)

Bei der „terminalen Sedierung“ wird ein unheilbar kranker und schwer leidender Patient für den Rest seines Lebens in ein tiefes Koma versetzt. Das hierzu verwendete Morphin bzw. Midazolam kann lebensverkürzend wirken. Ist dies also eine Maßnahme, die das Leben des Patienten beendet, auf seinen Wunsch hin oder nicht? Gewöhnlich wird diese Frage mit nein beantwortet, wenn die lebensverkürzende Wirkung nur vorhersehbar, aber nicht beabsichtigt ist. Allerdings ist der Zugang der Menschen auch zu ihren eigenen Intentionen fallibel, so dass sogar ihre (...) Selbstangaben in komplexen Fällen nicht sehr zuverlässig sind. Wenn ein Arzt sagt, dass er „beabsichtigt“, das Leben eines Patienten zu verkürzen, meint er damit möglicherweise nur, dass dieses vorhersehbare Ergebnis ein erwünschtes ist. Diese Art der Einschätzung kann nicht als solche moralisch diskreditiert werden, weil sie bei anderen allgemein akzeptierten Entscheidungen unvermeidlich ist, z. B. von einer „vergeblichen“ Behandlung Abstand zu nehmen. Legitimerweise können wir von einem Fachmann erwarten, dass er begründet handelt. Deshalb sollte unsere Klassifikation von ärztlichem Handeln als „terminale Sedierung“ oder „Beendigung des Lebens des Patienten“ nicht von den Intentionen des Arztes abhängen, sondern von den in dieser speziellen Krankheitsphase bei diesem speziellen Patienten verwendeten Dosierungen. (shrink)

Despite being written in 1941–1942, Long Day’s Journey into Night wasn’t released until 1956, two years after the author’s death. The Tyrone family is at the centre of the narrative, advancing the plot and creating further avenues for the characters to develop. The article explores the various aspects of the play that indicate that the Tyrones are a dysfunctional family. The critical analysis of the play and its various themes conclude that Tyrone in “Long Day’s Journey into Night” displays many (...) characteristics of a dysfunctional family while certain behavioural patterns of each one of the family are enough to show that the family is dysfunctional. The article presents a critical analysis of Eugene O’Neill’s Long Day’s Journey into Night. Various modes of reading were employed, including thematic analysis, close reading of the text, and a deconstructive reading of the play. These methods support the exploration of how the Tyrones are depicted as a dysfunctional family. James and Mary’s children, Edmund and Jamie, are central to the drama. Edmund is suffering from tuberculosis, while Mary struggles with a morphine addiction. The play is set at the Tyrones' Monte Cristo Cottage in seaside Connecticut, on a single day in August 1912, from roughly 8:30 a.m. until 12:00 a.m. The Tyrones are painted in a highly negative light as a dysfunctional family, as the parents and sons accuse, lash out, and harbor grudges against one another and in various situations. They possess traits that encourage pitiful and futile endeavours as well as strong desires for their circumstances to improve. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Joint and Grief AchesHeer HendrySomething that surprised me when I started my clinical rotations in medical school was how often we discussed proper footwear. In the lulls of rounds, I've heard healthcare providers talk about how worn-down shoes or inadequate arch support have caused them joint and back pains. We spend hours on our feet and bring the aches home with us, a reminder of our workday as we (...) walk our dogs or grocery shop. Embarrassingly, this is what was on my mind as I was starting a 12-hour shift wearing a new pair of shoes that an ICU nurse had recommended.It was the third day of my emergency medicine rotation, and my team received descriptions and plans for the 23 patients in the department precisely at 0700. I scribbled notes about each patient on my notepad, learning to distinguish which aspects of each patient were important to carry into this next shift for good continuity of care. For one patient, my note read: "aspiration, sepsis, hospice."My resident and I walked into each room and introduced ourselves, confirmed their story, and updated them on the next steps that we would be working on. The 4th patient on our list was the one I noted above—an 87-year-old male who was brought in after repeated bouts of emesis (vomiting) and choking. This was his fifth hospital visit this year for similar chief complaints, two of which resulted in ICU stays. Hours earlier, his two sons and two daughters had made the decision to place him on hospice.Upon entering the room, I saw an elderly patient lying on a stretcher with his eyes closed, grimacing and breathing rapidly. There was a younger man at his bedside staring at the patient while drumming his fingers on a coffee cup from a gas station next to the hospital. He didn't notice us walk in and was startled as we began to introduce ourselves. He identified himself as the patient's son, telling us he had just arrived at the hospital but had been on a conference call with his other siblings and palliative care earlier. His eyes darted between us and his father's rapid, shallow breaths.We updated him on his father's condition, explaining that we'd been making him comfortable with morphine and benzodiazepines. We talked about his blood lactic acid, his electrolytes, and his feeding tube. He continued drumming his fingers on the cup and nodding as we discussed trying to find an inpatient bed for his father. We informed him about the unpredictability of how much longer he would be alive and the unlikelihood of discharge. We asked if we could answer any questions for him, and he shook his head, but as we opened the door to leave, he asked: "So, the morphine is shutting down his body, right?" We clarified the purpose of the morphine, explaining that the morphine was making him comfortable and pain-free, but that his body was shutting down on its own."But in a way I'm still killing him?" he asked. My chest squeezed tight at that question. My goal for this patient immediately changed from getting him a bed in the inpatient unit to convincing his son that he was not harming his father. We started from the beginning and explained the lab markers and prognosis once again and asked if he'd like to speak to palliative care in person. He simply nodded as we exited to give him privacy.Leaving that room, it was barely 7:00 am. We still had 19 other patients to check on. My chest was still tight, but I could not allow my mind to remain in that room while the other patients were still pending exams, workups, and admissions. I acknowledged to myself that reflection would have to occur later, and yet, as we walked to the next [End Page e16] room, I wondered if the resident I was with had lost anyone in his life as I have in mine. Seeing the son trying to process and understand the situation in real time triggered my memories of past times... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Acts of Enjoyment: Rhetoric, Žižek, and the Return of the SubjectJames J. Brown Jr. and Joshua GunnActs of Enjoyment: Rhetoric, Žižek, and the Return of the Subject by Thomas Rickert. Pittsburgh: University of Pittsburgh Press, 2007. Pp. x + 252. $24.95, hardcover.Thomas Rickert had a falling-out with his brother, and this distresses him so much that his disrupted relation is described as “traumatic.” Rickert reports that while listening (...) to a portable CD player during a run on an unexpectedly warm winter day, a song by the now defunct jazz/rock band Morphine reminded him of a happy time at a pool hall with his brother (24). Mediated—or better, medicated—by music, the homological happiness of running in the sun and a positive past memory also resurfaced a painful relational rupture, the reason of which Rickert omits to underscore that mysterious, “little detail or object” of the Real that marks his singular finitude as a writing subject (216 n. 11). We’ll want to come back to this curiously deliberate omission, but for the present we note Rickert is not simply an undead author but a human being with relations and feelings. He is not just a gifted scholar or a bundle of reflections, but a nexus of body and movement and words and affect. If there is anything that Rickert’s study can be said to work through with brilliance, humor, and grace, it is the reality of complex personhood.Rickert’s brotherly confession comes in Chapter 1 as a way to introduce a psychoanalytic understanding of subjectivity, and more specifically, to help illustrate how trauma works itself out as an afterwardness or “belatedness” ( Nachträglichkeit ): traumatic events from the past are not reckoned with or worked-through until some coincidence or reminder, such as a similar [End Page 183] sensory experience, reintroduces the event in doubled re-presentation (18–27). This implies the “subject” (a paradigm person) is a kind of timedelay, a self-conscious temporal moving that becomes this way through re-presentation. The rhetorical subject is analogously a retrojected reckoning with events past (not all traumatic) that Rickert identifies as a scene of writing, a locus that has important implications for rhetorical studies in general and writing pedagogy in particular. Rickert’s logic is as follows: if we agree that the subject is a belated one in the psychoanalytic sense, then how we teach rhetoric needs to change. Rickert opens the book with the observation that his students are producing excellent cultural critiques but that such critiques do not lead the students to change their actions (1–7), perhaps evidence enough that something is not quite right in a classroom grounded by “cultural studies pedagogy” and ideology critique—or at the very least, proof that something has changed. The opening gambit is simply that a “postpedagogy” premised on an understanding of rhetorical subjectivity as belatedness is better than a status quo rooted in the rational subject of the Enlightenment.Mostly through a Žižek-filtered, Lacanian lens, Acts of Enjoyment then undertakes a retake of the rhetorical field, frequently scanning from the traumatic ontology of the rhetorical subject to that domain of knowledge that we hold dear, the subject of rhetoric. In Chapter 2, the (primal) scene thus shifts from the slo-mo subject to rhetorical studies, initially through a reassessment of Kinneavy’s “communications triangle,” but ultimately in response to the shock treatment of poststructuralism. The initial theoretical traumas introduced by Victor Vitanza, Diane Davis, Sharon Crowley, and others discussed in Chapter 1 are threaded into an account of “poststructural” redress in Chapter 2: as is true of all forms of trauma, the initial poststructural jolt delivered to the concept of subjectivity was deadened; poststructural theory was eventually used to “shore up rather than challenge Kinneavy’s triangle” (37). To truly work-through our traumatized subject in both senses, we need a second trauma: Lacanian psychoanalysis. Presumably, “poststructuralist thought” is to be opposed because it has no account of the subject (21–24); “Lacan,” after all, “is not a poststructuralist” (48). The remainder of the chapter is then used to deploy Lacan’s conceptual lexicon.Just as... (shrink)

Maternal opioid use during pregnancy is a growing national problem and can lead to newborns developing neonatal opioid withdrawal syndrome soon after birth. Recent data demonstrates that nearly every 15 min a baby is born in the United States suffering from NOWS. The primary treatment for NOWS is opioid replacement therapy, commonly oral morphine, which has neurotoxic effects on the developing brain. There is an urgent need for non-opioid treatments for NOWS. Transcutaneous auricular neurostimulation, a novel and non-invasive form (...) of electrostimulation, may serve as a promising alternative to morphine. tAN is delivered via a multichannel earpiece electrode worn on and around the left ear, targeting two cranial nerves—the vagus and trigeminal nerves. Prior research suggests that auricular neurostimulation exerts an anxiolytic effect on the body by releasing endogenous opioids and reduces withdrawal symptoms in adults actively withdrawing from opioids. In this first-in-human prospective, open-label trial, we investigated tAN as an adjuvant to morphine therapy in eight infants >33 weeks gestational age suffering from NOWS and receiving oral morphine treatment. Infants received tAN for 30 min 1 h before receiving a morphine dose. tAN was delivered at 0.1 mA below perception intensity at two different nerve targets on the ear: Region 1, the auricular branch of the vagus nerve; and Region 2, the auriculotemporal nerve. tAN was delivered up to four times daily for a maximum of 12 days. The primary outcome measures were safety [heart rate monitoring, Neonatal Infant Pain Scale, and skin irritation] and morphine length of treatment. tAN was well-tolerated and resulted in no unanticipated adverse events. Comparing to the national average of 23 days, the average oral morphine LOT was 13.3 days and the average LOT after tAN initiation was 7 days. These preliminary data suggest that tAN is safe and may serve as a promising alternative adjuvant for treating NOWS and reducing the amount of time an infant receives oral morphine. (shrink)

I discuss the Principle of Double Effect (PDE) as a means of exploring aspects of the motivation of active voluntary euthanasia (a.v.e.). It is argued that the objective of a.v.e. is not death but the relief of suffering. Nor is death the means, it is a concomitant I entertain no hope of convincing the typical proponent of PDE that a.v.e. is morally acceptable. However, I point out that a central strength of the PDE is its insistence on due proportionality between (...) outcomes. When a.v.e. is appropriate, as sometimes it is, death is not out of proportion to the relief of suffering. (shrink)

For more than two decades euthanasia and assisted suicide have been openly debated in the Netherlands. This development started in 1973 when the Regional Court in Leeuwarden decided a case in which a physician had administered a deadly dose of morphine to her terminally ill mother on the mother's serious and persistent request. In this case the court concluded that the average Dutch physician no longer considered it his or her duty to prolong a patient's life under all circumstances. (...) The court accepted that in specific cases a physician is allowed to prevent serious and irreversible suffering, even if the patient's life is short ened. This case was the first in which a legal opening for euthanasia or assisted suicide was created. In this specific case the physician was formally declared guilty, but the court gave her a suspended sentence of one week imprisonment. This decision started a debate on euthanasia and assisted suicide throughout all levels of Dutch society. (shrink)

The prelims comprise: Conceptual Issues Arguments concerning AS, E, or TT Doctors and Ending Life Advance Directives Notes References.

Kamm’s response to Tse’s comments deals with the following issues (among others): (1)the relevance of empirical facts to moral arguments about physician assisted suicide (PAS); (2) the moral relevance of the difference between foreseen risk and certainty of death as well as the difference between certain death and immediate death; (3) whether intention matters to the permissibility of giving morphine for pain relief (MPR) and whether objective factors can be the same whether one intends MPR or death in giving (...) morphine; (4) the relevance of the permissibility of MPR or terminating life-saving treatment for the permissibility of PAS. (shrink)

This chapter examines some of David Velleman's objections to physician-assisted suicide as presented in his “A Right of Self-Termination?” It addresses two main issues: Does any objection to physician-assisted suicide that his account raises show that physician-assisted suicide for pain relief in particular is wrong? If it does, must it also rule out giving morphine for pain relief (MPR) when it is foreseen with certainty that the morphine will soon cause death?

The Liverpool Care Pathway is intended as a palliative care regime at the end of life. Even its critics agree that certain of its recommendations may be useful and appropriate. Additionally, critics are aware that there are occasions when death may be a foreseen side effect of perfectly licit palliation whose primary ends are not homicidal at all. It is evident that treatment may be over-expensive, over-burdensome or simply futile. There is no suggestion that critics of the Pathway adhere irrationally (...) to what is known in medical ethics as the error of vitalism, the commitment to excessive, extraordinary or futile treatment, or over-burdensome care at the end of life. However, to ask whether treatment is futile, over-burdensome or over-expensive is very different to the discriminatory question about the futility, burden or expense of a frail and vulnerable patient. The sedation-dehydration aspect of the Pathway attracts much proper opposition. Doctors and families have found that those on the Pathway recovered when they intervened to take the patient off it. Senior medics have stepped forward, in the face of managerial opposition to argue that it is often impossible to know with certainty whether a person is imminently dying. One problem with the Pathway is that where a patient is misdiagnosed as terminal, the combination of morphine and dehydration has a self-fulfilling character and is likely to undermine a patient’s capacity. Persistent dehydration of even fit and healthy sedated patients will kill them. This was the difficulty highlighted by concerned medical professionals many years ago. The independent inquiry ordered in response to Freedom of Information Act requests performed in 2012 demonstrating a staggering increase in the number of people dying on the Pathway once it was financially incentivised needs to ensure certain investigations take place. What is needed, however, is not a whitewash but an independent inquiry with all interests declared and data sets interrogated and collated. These will cover a time-series medical history of each anonymised patient on the Pathway, duration until death, information about interventions provided during the period, monthly raw data from each trust, hospice or care home, medical histories, removals from the Pathway, information about journals that were corrected once a patient recovered, demographic data, location information and an audit trail of all data management. (shrink)

This paper examines whether physician-assisted suicide is morally permissible, and whether it should be legalised in the sense that those seeking or performing such procedure will be immune from prosecution. The issues of moral and legal permissibility1 are closely connected. One way to argue for the permissibility of PAS is grounded in the argument that a patient has the right to refuse life-saving equipment, or to have it withdrawn,2 and then to further argue that there is no relevant distinction between (...) refusal/withdrawal and PAS, if the patient consents. This is essentially the argument raised in “The Philosophers’ Brief ”, filed by six distinguished philosophers. However, this argument has been soundly criticised. Frances Kamm points out that the general claim on which Dworkin et al. rely—that there is no moral difference per se between killing and letting die—is false. This is because a patient has the right to refuse treatment even when this is against his interest because the alternative would be forced treatment, but it is not true to say that a patient has the right to PAS even when it is against his interest. Also at issue is the Doctrine of Double Effect, according to which there is a moral distinction between an action that is intended to cause death and one that is merely foreseen to cause death. [End Page 224] In section I of this paper, I shall argue against DDE, which purports to disallow PAS but not refusal/withdrawal. I shall argue that since it is permissible for a physician to prescribe morphine to a patient suffering excruciating pain, it is also permissible for her to prescribe such a drug to a patient suffering pain, with the intention that he be killed and hence relieved of the suffering. The grounds on which I rely is the thesis that intention is irrelevant to permissibility, as proposed by Judith Thomson and T.M. Scanlon. In section II, I shall discuss David Velleman’s argument that termination of life is morally impermissible. I proceed to examine in section III the theoretical version of the Slippery Slope Argument. In section IV, I shall consider the practical version of the Slippery Slope Argument. In section V, I shall discuss other consequentialist objections to the legalisation of PAS. In the final section, I shall consider the view that even if PAS is morally permissible, it does not follow that it should be legalised. The argument I consider is the consequentialist one that legalising PAS may have a very different significance—when we consider the total consequences—than if there is only a single act of PAS, considered in isolation. While I agree that consequences are generally very important, I shall argue that we should approach the issue from a contractualist rather than a utilitarian perspective.3. (shrink)

A young man, terminally ill and in extreme suffering, asks to be removed from life support, requesting morphine first so he'll be asleep when the machine stops. His physician agrees, but the hospital's chief administrator intervenes, arguing that the morphine might itself cause death, leaving the physician open to criminal indictment for murder. To placate the administrator, the doctor and patient reach a grim compromise: life support will be disconnected first, and only after manifest signs of suffering appear (...) will the physician administer the morphine, to alleviate pain. The patient's request is ultimately respected, but many staff members feel he has been made to suffer needlessly. This is just one of many cases Ruth Macklin discusses in Enemies of Patients, an eye-opening look at the growing number of forces that are hostile to the interests of patients, including hospital administrators, lawyers who represent hospitals, insurance companies, government regulations, and even some well intentioned physicians. Macklin, a highly regarded medical ethicist, the author of Mortal Choices and the subject of a New York Times Magazine cover story, provides a behind-the-scenes look at how the patient's ethical rights are often violated. She describes, for instance, how a new breed of hospital administrator, the risk manager, acts consistently as an enemy of the patient, often urging physicians to continue aggressive, expensive treatments for critically ill patients--even when the patient and doctor agree the treatment should cease--for fear of lawsuits, bad publicity, or criminal indictment. (Macklin points out, for instance, that even though no physician has ever been convicted of a crime for withdrawing treatment from a patient in a permanent vegetative state, hospital lawyers and risk managers regularly assert that there is a danger of criminal liability in such cases.) The government also can become an enemy of patients. The most egregious case, according to Macklin, is the Federal government's "gag rule" which has prohibited health care facilities that receive Title X funds from discussing abortion with pregnant women, violating the patient's right to full information. And physicians themselves can become enemies of patients. Some, seeing themselves as fiscal gatekeepers, ration expensive health care procedures on financial rather than medical grounds. Some physicians refuse to treat patients who don't follow their advice (a cardiologist, for instance, who will not take care of patients who smoke) and others won't treat patients who pose a threat of lawsuit (such as a California woman in need of life-sustaining dialysis, who had previously sued another physician). Packed with numerous case histories drawn from the author's experience in a major urban medical center, Enemies of Patients will give readers a better understanding of their rights as patients and show them how to forge an alliance with their doctors against common enemies. (shrink)

The management of an infant after a decision to withdraw active treatment creates dilemmas. Both lingering death and active killing are undesirable, but palliative interventions can hasten death. We investigated what staff on our neonatal unit thought were the limits of acceptable practice and why. We administered a structured interview to elucidate their views, and asked them to justify their answers. The interviews were analysed quantitatively and qualitatively. A total of 25 participants (15 nurses and 10 doctors) were recruited. 80% (...) emphasized the importance of pain relief following withdrawal, 60% mentioned meeting parental needs at that time. 76% agreed that death can be a desired consequence of withdrawal, yet 52% felt that death should never be hastened. 96% felt that morphine is acceptable after withdrawal, and 72% would give a higher than normal dose if necessary. 56% would stop paralysis at extubation but not reverse it, while 24% would continue paralysis. 16% would consider a drug that ended life instantly in some cases. A wide variety of views emerged, but there were two main positions, a cautious majority, and a more proactive minority. Apparent contradictions within the majority position could be explained using the doctrine of double effect and the acts and omissions distinction. (shrink)

Studies investigating memory for events during anesthesia show a confusing pattern of positive and negative results. To establish whether there are any consistent patterns of findings across studies, we conducted a meta-analysis of the data from 2517 patients in 44 studies. The meta-analysis included two measures of the effects of positive suggestions on postoperative recovery: the duration of postoperative hospitalization and the amount of morphine administered via patient-controlled anesthesia, as well as two measures of memory for specific information presented (...) during anesthesia: direct tests and indirect tests. The meta-analysis indicated that positive suggestions presented during anesthesia have little or no effect on postoperative recovery. On the other hand, the meta-analysis showed that specific information is remembered following surgery, as long as testing is not delayed longer than 36 h. Studies of memory for events during anesthesia provide a useful avenue for exploring unconscious cognition. (shrink)