bluuebunny/crossref_metadata_2025 huggingface dataset:
Texture gradient studies of a Cu‐tube by the robot at STRESS‐SPEC
Authors: Al‐hamdany N. , Brokmeier H.‐G. , Randau C. , Gan W. M. , Völler M.
Published: October 2014

The handling of larger samples for texture studies is limited when we using the Eulerian cradle. The robot Stäubli RX160 installed at STRESS‐SPEC offers much more freedom in sample manipulation on one hand to perform pole figure scanning and on the other hand to position the sample for a texture mapping. A key problem is that slit systems cannot be positioned close to large samples due to safety reasons which makes corrections more important. A very simple solution was tested to correct the scattered intensity for each pole figure point for constant volume and anisotropic absorption. A simple method to make these corrections is needed because engineering samples such as semi‐finished products have a large variety of shapes and weights and an ideal slit system is only seldomly available. The test sample was a Cu‐tube of 140 mm in diameter with an average wall thickness of 10 mm. To compare the corrections three kind of samples were measured, first a cube of 10 × 10 × 11 mm³ without any correction, second an 11 mm long tube segment and third a tube segment of 250 mm (12 kg weight) in length. Orientation Distribution Function (ODF) analysis of the average texture over the tube wall by the iterative series expansion method has shown that sufficient intensity corrections can be done to describe the texture gradient around the circumference of the Cu‐tube related to low ovality and eccentricity of the Cu‐tube.
Enhanced Visible‐Light Photocatalytic H2 Production by ZnxCd1−xS Modified with Earth‐Abundant Nickel‐Based Cocatalysts
Authors: Ran Jingrun , Zhang Jun , Yu Jiaguo , Qiao Shi Zhang
Published: October 2014

The application of various earth‐abundant Ni species, such as NiS, Ni, Ni(OH)2, and NiO, as a co‐catalyst in a ZnxCd1−xS system for visible‐light photocatalytic H2 production was investigated for the first time. The loading of Ni or NiS enhanced the photocatalytic activity of ZnxCd1−xS because they could promote the electron transfer at the interface with ZnxCd1−xS and catalyze the H2 evolution. Surprisingly, Ni(OH)2‐loaded ZnxCd1−xS exhibits a very high photocatalytic H2‐production rate of 7160 μmol h−1 g−1 with a quantum efficiency of 29.5 % at 420 nm, which represents one of the most efficient metal sulfide photocatalysts without a Pt co‐catalyst to date. This outstanding activity arises from the pronounced synergetic effect between Ni(OH)2 and metallic Ni formed in situ during the photocatalytic reaction. However, the loading of NiO deactivated the activity of ZnxCd1−xS because of their unmatched conduction band positions. This paper reports the optimization of the ZnxCd1−xS system by selecting an appropriate Ni‐based co‐catalyst, Ni(OH)2, from a series of Ni species to achieve the highest photocatalytic H2‐production activity for the first time and also reveals the roles of these Ni species in the photocatalytic activity.
Variability in sperm form and function in the context of sperm competition risk in two Tupinambis lizards
Authors: Blengini Cecilia S. , Sergio Naretto , Gabriela Cardozo , Giojalas Laura C. , Margarita Chiaraviglio
Published: October 2014

In polyandrous species, sperm morphometry and sperm velocity are under strong sexual selection. Although several hypotheses have been proposed to explain the role of sperm competition in sperm trait variation, this aspect is still poorly understood. It has been suggested that an increase in sperm competition pressure could reduce sperm size variation or produce a diversity of sperm to maximize male fertilization success. We aim at elucidating the variability of sperm morphometric traits and velocity in two Tupinambis lizards in the context of sperm competition risk. Sperm traits showed substantial variation at all levels examined: between species, among males within species, and within the ejaculate of individual males. Sperm velocity was found to be positively correlated with flagellum: midpiece ratio, with relatively longer flagella associated with faster sperm. Our results document high variability in sperm form and function in lizards.
Diuretic response in patients with acute decompensated heart failure: characteristics and clinical outcome—an analysis from RELAX‐AHF
Authors: Voors Adriaan A. , Davison Beth A. , Teerlink John R. , Felker G. Michael , Cotter Gad , Filippatos Gerasimos , Greenberg Barry H. , Pang Peter S. , Levin Bruce , Hua Tsushung A. , Severin Thomas , Ponikowski Piotr , Metra Marco ,   for the RELAX‐AHF Investigators
Published: October 2014

Aims

We studied the characteristics and clinical outcome related to diuretic response and the effects of serelaxin in patients hospitalized for acute heart failure (AHF).

Methods and results

RELAX‐AHF was a double‐blind, placebo‐controlled trial, enrolling 1161 patients admitted to hospital for AHF who were randomized to 48 h i.v infusions of placebo or serelaxin (30 µg/kg per day) within 16 h from presentation. Diuretic response was defined as Δ weight kg/[(total i.v. dose)/40 mg] + [(total oral dose)/80 mg)] furosemide (or equivalent loop diuretic dose) up to day 5. Median diuretic response was −0.42 (−1.00, −0.14) kg/40 mg. A poor diuretic response was independently associated with Western‐like region (Western Europe, North America, Israel, and Poland), lower diastolic blood pressure, the absence of oedema, higher blood urea nitrogen, and lower levels of aspartate aminotransferase and potassium (all P < 0.01). Randomization to serelaxin was associated with lower doses of i.v. loop diuretics and slightly less weight loss, resulting in a neutral effect on diuretic response. Worse diuretic response was independently associated both with less relief of dyspnoea, measured with a visual analogue scale (VAS) at day 5 (primary endpoint; P = 0.0002), and with a higher risk of cardiovascular death or rehospitalization for heart failure or renal failure through day 60 (secondary endpoint, P < 0.0001), but not with increased 180‐day cardiovascular mortality (P = 0.507).

Conclusions

In patients hospitalized for AHF, a poor diuretic response was associated with a poor in‐hospital and early post‐discharge clinical outcome. Serelaxin had a neutral effect on diuretic response.

Trial registration: NCT00520806
Fasudil mediates cell therapy of EAE by immunomodulating encephalomyelitic T cells and macrophages
Authors: Liu Chun‐Yun , Guo Shang‐De , Yu Jie‐Zhong , Li Yan‐Hua , Zhang Hui , Feng Ling , Chai Zhi , Yuan Hai‐Jun , Yang Wan‐Fang , Feng Qian‐Jin , Xiao Bao‐Guo , Ma Cun‐Gen
Published: October 2014

Although Fasudil has shown therapeutic potential in EAE mice, the mechanism of action are still not fully understood. Here, we examined the immunomodulatory effect of Fasudil on encephalitogenic mononuclear cells (MNCs), and tested the therapeutic potential of Fasudil‐treated MNCs in active EAE. Fasudil inhibited expression of CCL20 on T cells and migration of T cells, decreased CD4+IFN‐γ+ and CD4+IL‐17+ T cells, but increased CD4+IL‐10+ and CD4+TGF‐β+ T cells. Fasudil reduced expression of CD16/32 and IL‐12, while elevating expression of CD206, CD23, and IL‐10. Fasudil also decreased levels of iNOS/NO, enhanced levels of Arg‐1, and inhibited the TLR‐4/NF‐κB signaling and TNF‐α, shifting M1 macrophage to M2 phenotype. These modulatory effects of Fasudil on T cells and macrophages were not altered by adding autoantigen MOG35–55 to the culture, i.e., autoantigen‐independent. Further, we observed that, in vitro, Fasudil inhibited the capacity of encephalitogenic MNCs to adoptively transfer EAE and reduced TLR‐4/p‐NF‐κB/p65 and inflammatory cytokines in spinal cords. Importantly, Fasudil‐treated encephalitogenic MNCs exhibited therapeutic potential when injected into actively induced EAE mice. Together, our results not only provide evidence that Fasudil mediates the polarization of macrophages and the regulation of T cells, but also reveal a novel strategy for cell therapy in MS.
Calculator Use on the GRE® revised General Test Quantitative Reasoning Measure
Authors: Attali Yigal
Published: October 2014

Previous research on calculator use in standardized assessments of quantitative ability focused on the effect of calculator availability on item difficulty and on whether test developers can predict these effects. With the introduction of an on‐screen calculator on the Quantitative Reasoning measure of the GRE® revised General Test, it is possible to explore calculator use in more detail. This study investigates calculator usage for the GRE examinee population across examinee and item characteristics. Results suggest that calculator usage in the GRE is very common (75% of responses used a calculator) but is less prevalent for low and high ability examinees and for male, Black, and Hispanic examinees. Items associated with lower levels of calculator usage tended to be more difficult, required less time to answer, and did not present a real‐world application. Quantitative comparison items were also associated with less calculator usage, but other item type and content distinctions showed small differences in usage. Most items exhibited a positive relation between calculator usage and response accuracy (after controlling for examinee ability), that is, responses that used the calculator were more likely to be correct. Items that did not show an association between calculator use and accuracy tended to be easier and had less overall usage of the calculator.
New Perspectives on the Validity of the GRE® General Test for Predicting Graduate School Grades
Authors: Klieger David M. , Cline Frederick A. , Holtzman Steven L. , Minsky Jennifer L. , Lorenz Florian
Published: October 2014

Given the serious consequences of making ill‐fated admissions and funding decisions for applicants to graduate and professional school, it is important to rely on sound evidence to optimize such judgments. Previous meta‐analytic research has demonstrated the generalizable validity of the GRE® General Test for predicting academic achievement. That research does not address predictive validity for specific populations and situations or the predictive validity of the GRE Analytical Writing section introduced in October 2002. Furthermore, much of the past GRE predictive validity research is primarily based on approaches that are correlational and univariate only. Stakeholders familiar with GRE predictive validity mainly in the form of zero‐order correlation coefficients might automatically interpret the usefulness of the GRE solely through the prism of Cohen's (1988) guidelines for judging effect sizes and without regard to the larger context. However, by using innovative and multivariate approaches to conceptualize and measure GRE predictive validity within the larger context, our investigation reveals the substantial value of the GRE General Test, including its Analytical Writing section, for predicting graduate school grades.
The antioxidant and anti‐cadmium toxicity properties of garlic extracts
Authors: Boonpeng Suwannaporn , Siripongvutikorn Sunisa , Sae‐wong Chutha , Sutthirak Pornpong
Published: October 2014

Cadmium (Cd) contamination is a highly dangerous international problem because it can transfer into the food chain and become bioaccumulated, endangering human health. Cd detoxication is very interesting particularly the method providing no undesirable side effects. Cd also causes lipid oxidation that leads to undesired food quality. Garlic (Allium sativum L.) has been used as conventional food and in herbal therapy and folklore medicine as an antibacterial, antitumorogenic, and antioxidant agent for over 5000 years. In the present work, fresh garlic and pickled garlic extracted with distilled water was brought to determine antioxidant activities in terms of 1,1‐diphenyl‐2‐picrylhydrazyl (DPPH) radical scavenging assay, 2,2′‐azino‐bis‐3‐ethylbenzthiazoline‐6‐sulphonic acid (ABTS) radical scavenging assay, ferric reducing ability power (FRAP) assay, chelating activities, superoxide, and hydroxyl scavenging assay. The data showed that pickled garlic extracts significantly possessed more DPPH, ABTS, FRAP, superoxide, and hydroxyl scavenging assays as 11.86, 13.74, 4.9, 46.67, and 15.33 g trolox equivalent/g sample, respectively, compared with fresh one as 7.44, 7.62, 0.01, 4.07, and 8.09 g trolox equivalent/g sample, respectively. However, iron chelating activity of fresh garlic extract was higher than that of pickled garlic while there was no significant difference in the copper chelating activity of both extracts. For anti‐Cd properties, pickled garlic was more effective than fresh garlic and contained less toxicity than standard diallyl disulfide (DADS). Therefore, therapeutic properties of pickled garlic favored its consumption compared with fresh and standard DADS for its antioxidant and anti‐Cd properties.
A molecular diagnostic approach able to detect the recurrent genetic prognostic factors typical of presenting myeloma
Authors: Boyle Eileen M. , Proszek Paula Z. , Kaiser Martin F. , Begum Dil , Dahir Nasrin , Savola Suvi , Wardell Christopher P. , Leleu Xavier , Ross Fiona M. , Chiecchio Laura , Cook Gordon , Drayson Mark T. , Owen Richard G. , Ashcroft John M. , Jackson Graham H. , Anthony Child James , Davies Faith E. , Walker Brian A. , Morgan Gareth J.
Published: October 2014

Risk stratification in myeloma requires an accurate assessment of the presence of a range of molecular abnormalities including the differing IGH translocations and the recurrent copy number abnormalities that can impact clinical behavior. Currently, interphase fluorescence in situ hybridization is used to detect these abnormalities. High failure rates, slow turnaround, cost, and labor intensiveness make it difficult and expensive to use in routine clinical practice. Multiplex ligation‐dependent probe amplification (MLPA), a molecular approach based on a multiplex polymerase chain reaction method, offers an alternative for the assessment of copy number changes present in the myeloma genome. Here, we provide evidence showing that MLPA is a powerful tool for the efficient detection of copy number abnormalities and when combined with expression assays, MLPA can detect all of the prognostically relevant molecular events which characterize presenting myeloma. This approach opens the way for a molecular diagnostic strategy that is efficient, high throughput, and cost effective. © 2014 The Authors. Genes, Chromosomes & Cancer Published by Wiley Periodicals, Inc.
The Report and Wiley‐Blackwell
Authors: KAEBNICK GREGORY E.
Published: October 2014

This issue marks the beginning of a new publishing venture for The Hastings Center. After forty‐plus years of publishing the Hastings Center Report independently, the Center has decided to collaborate with Wiley‐Blackwell to get the Report out into the world. Hastings retains ownership and full editorial and artistic control; we will put the Report together just as we have always done. But for all of the things that I think of as going under the heading of publishing services—primarily printing, online hosting, mailing, and subscription services—we will now collaborate with Wiley‐Blackwell. The relationship will broaden the Report's reach and improve its services, but will not change the Report's appearance or content.
Accept No Substitutes: The Ethics of Alternatives
Authors: Marks Joel
Published: October 2014

It is common to argue that animal experimentation is justified by its essential contribution to the advancement of medical science. But note that this argument actually contains two premises: an empirical claim that animal experimentation is essential to the advancement of medical science and an ethical claim that if research is essential to the advancement of medical science, then it is justified. Neither premise looks weak; the first premise is an article of faith for most biomedical researchers, and the second is usually considered so obviously true that it goes unstated. In fact, however, both are open to challenge. In the logic of the case, only one of the premises needs to be shown false or moot in order to refute the argument. A number of other commentators have questioned the first, but it is the ethical premise that I find particularly wanting.
A Rationale in Support of Uncontrolled Donation after Circulatory Determination of Death
Authors: Munjal Kevin G. , Wall Stephen P. , Goldfrank Lewis R. , Gilbert Alexander , Kaufman Bradley J. , Dubler, on behalf of The New York City uDCDD Study Group Nancy N.
Published: October 2014

Most donated organs in the United States come from brain dead donors, while a small percentage come from patients who die in “controlled,” or expected, circumstances, typically after the family or surrogate makes a decision to withdraw life support. The number of organs available for transplant could be substantially if donations were permitted in “uncontrolled” circumstances–that is, from people who die unexpectedly, often outside the hospital. According to projections from the Institute of Medicine, establishing programs permitting “uncontrolled donation after circulatory determination of death,” or uDCDD, throughout the United States has the potential to provide 22,000 more donation opportunities annually. In contrast, U.S. controlled donation after circulatory determination of death, or cDCDD, cases have increased progressively over the past decade from 87 to 848 donors, but currently account for only 10.6 percent of all deceased donors. Following the IOM recommendations, several projects exploring the feasibility of uDCDD were funded by the federal government, including a grant from the Health Resources and Services Administration that supported a pilot project in New York City in which the authors of this article participated.

A key feature of our protocol, and indeed of many uDCDD protocols, is the initiation of preservation methods such as chest compressions and extracorporeal membrane oxygenation shortly after death in order to perfuse and preserve the donor's organs. Critics of uDCDD argue that the means of determining death deviates from generally ascribed principles. They assert that reinstituting circulation in order to preserve organs has the effect of “undoing” the prior determination of death. The result is that cDCDD is widely accepted and practiced routinely even though it only marginally increases the number of organs available for transplantation, and uDCDD is widely considered unacceptable despite being ethically embraced and proven to significantly increase organ donation opportunities in other countries. This article explores the evolution of this counterintuitive state of affairs and calls for a policy that, in line with the IOM report, allows for both cDCDD and uDCDD protocols.
Obesity: Chasing an Elusive Epidemic
Authors: Callahan Daniel
Published: October 2014

Obesity may be the most difficult and elusive public health problem this country has ever encountered. Unlike the classical infectious diseases and plagues that killed millions in the past, it is not caused by deadly viruses or bacteria of a kind amenable to vaccines for prevention, nor are there many promising medical treatments so far. While diabetes, heart disease, and kidney failure can be caused by obesity, it is easier to treat those conditions than one of their causes. I call obesity elusive partly because of the disturbingly low success rate in treating it, but also because it requires changing the patterns, woven deeply into our social fabric, of food and beverage commerce, personal eating habits, and sedentary lifestyles. It also raises the most basic ethical and policy questions: how far can government and business go in trying to change behavior that harms health, what are the limits of market freedom for industry, and how do we look upon our bodies and judge those of others?.
Respecting Donors to Biobank Research
Authors: Tomlinson Tom
Published: October 2014

The research importance of biobanked biological materials and their derived data is growing, especially as these are increasingly linked with individual and population‐level medical and health information. The number, diversity, and size of biobanks are growing in tandem. So, too, is the number of individuals whose donations are being used in biobank‐supported research, with or without their knowledge. Pretty soon, we all will be “participants” in a variety of research projects we know nothing about. Until recently, our leftover tissue or deidentified medical information could be used for research without our consent or even our knowledge. Even if we've been asked–as the current regulations require when research uses are anticipated‐we were most likely asked to give a blanket consent to any future use, with no prospect of learning about or controlling how our material is later used. This is an ethically problematic state of affairs, but there are options for improving it.
Reasons and Freedom
Authors: Giubilini Alberto , Minerva Francesca
Published: October 2014

One of three commentaries on ‐Scholarly Discussion of Infanticide?” by Mirko D. Garasic, and “Reflections from a Troubled Stream: Giubilini and Minerva on ‘After‐Birth Abortion,’” by Michael Hauskeller, from the July‐August 2012 issue.
The Authors Reply
Authors: Garasic Mirko D.
Published: October 2014

A reply by the author of “Scholarly Discussion of Infanticide?” to “The Arguments Matter,” by Don Marquis, “The Importance of Rationality,” by G. Owen Schaeffer, and “Reasons and Freedom,” by Alberto Giubilini and Francesca Minerva.
The Undocumented Unwell
Authors: Marks Jonathan H.
Published: October 2014

Nell Toussaint is not well. In recent years, she has been diagnosed with uterine fibroids, uncontrolled hypertension, nephrotic syndrome, poorly controlled diabetes, hyperlipidemia, and a pulmonary embolism. She also suffers from decreased mobility, shortness of breath, and‐perhaps not surprisingly, given her other ailments‐anxiety. Toussaint is an indigent undocumented immigrant living in Canada who has been trying to secure medical coverage in the federal courts. In the process, she has sacrificed the medical confidentiality that most of us ordinarily enjoy.

Toussaint first came to Canada from Grenada as a visitor in 1999 and remained after the term of her visa expired. At first, she earned enough to sustain a living, but in 2006, her health began to deteriorate, and she was no longer able to work. Although she has received some medical care since then, it has been sporadic, on an emergency basis, and at great expense. When Toussaint applied for medical health coverage under Canada's Interim Medical Health Program, which covers the cost of emergency medical care for legally admitted indigents, her application was rejected. She challenged the decision in federal court on the grounds that her right to life and security of the person under the Canadian Charter had been violated and that the denial of coverage was discriminatory.
A Second Chance
Authors: Blumenthal Nancy P. , Mendez James D. , Smith Martin L. , Hyland Beth
Published: October 2014

Mr. F. is a fifty‐year‐old father of two school‐aged daughters. Six years ago, he received a double lung transplant because he was suffering from interstitial lung disease, a fatal illness that causes suffocation by progressive scarring of the lungs. He is now experiencing chronic rejection of the transplant and is being considered to receive another. Without it, he is expected to survive only a year and a half. With it, his prognosis will improve, but the numbers are still not good.

Three years after his lung transplant, Mr. F. stopped attending his office visits. For a period of sixteen months he went without the studies and attention essential to posttransplant care. He stopped performing the required daily self‐monitoring of his lung function about eight months after his transplant, but he has maintained a regular exercise regimen. While lost to follow‐up, he continued to take his immunosuppressant medications, but he stopped taking medicine to control his high blood pressure because of its expense.
State Health Insurance Exchanges: Progress and Challenges
Authors: Collins Sara R. , Garber Tracy
Published: October 2014

By 2014, each of the fifty states and the District of Columbia will have a new health insurance exchange, or marketplace, established under the Patient Protection and Affordable Care Act. These exchanges are the centerpiece of the reform law: they will be the main portals where people who do not have health insurance coverage through their jobs and small businesses will go, either in person or online, to find a health plan and to learn about and apply for federal subsidies. The most immediate challenge facing all fifty‐one exchanges is fulfilling their most basic role: ensuring that all who are eligible to enroll in qualified health plans and to receive federal subsidies in fact enroll.
The Research‐Treatment Distinction:A Problematic Approach for Determining Which Activities Should Have Ethical Oversight
Authors: Kass Nancy E. , Faden Ruth R. , Goodman Steven N. , Pronovost Peter , Tunis Sean , Beauchamp Tom L.
Published: October 2014

The rise of quality improvement research and comparative effectiveness research in health care settings constitutes progress toward the goal of what the Institute of Medicine has called a “learning healthcare system,” in which we are “drawing research closer to clinical practice by building knowledge development and application into each stage of the healthcare delivery process.” As clinical research and clinical practice move closer to a deliberately integrated system, the distinction between the two is increasingly blurred, although the sharp distinction in U.S. regulations and research ethics literature remains in place. In the 1970s and for two decades thereafter, this distinction was helpful: for some forms of research, it sheds light on which activities require ethical oversight. Research that is closely integrated with health care—notably, health delivery research—was then uncommon, however. That is no longer the case, and regulations and research ethics need to change to accommodate the new landscape.

In this paper, we argue that conceptual, moral, and empirical problems surround the received view that we can and should draw sharp distinctions between clinical research and clinical practice. We start with the history of the research‐practice distinction in the reports of a U.S. national commission and in U.S. federal regulations, and then offer a critical assessment of five characterizations of research that have been used in policy documents and the scholarly literature to try to make a sharp distinction between research and practice. We challenge the clarity and the tenability of these characterizations as a way of distinguishing research from practice. We argue that the received view of the research‐practice distinction leads to overprotection of the rights and interests of patients in some cases and to underprotection in others. We contend that a new ethical foundation needs to be developed that facilitates both care and research likely to benefit patients, and that provides oversight that, rather than being based on a distinction between research and practice, is commensurate with risk and burden in both realms.
A Prescription for Ethical Learning
Authors: Largent Emily A. , Miller Franklin G. , Joffe Steven
Published: October 2014

We argued last year in this journal that extensive integration of research and care is a worthy goal of health system design, and we second the call from Ruth Faden and colleagues to move toward learning health care systems. As they recognize, learning health care systems demand the coordination of research and medical ethics—two sets of normative commitments that have long been considered distinct. In offering a novel ethics framework for such systems, Faden et al. advance the scholarly debate about how best to do this and challenge us to think more deeply about its practical implications. However, we believe that at least three issues they raise require additional attention. First, the research‐care distinction has more normative bite than they are willing to concede. Second, the role for independent oversight requires clarification. Finally, they neglect the concept of stewardship as a guiding obligation of learning health care systems.
Evaluation as Part of Operations: Reconciling the Common Rule and Continuous Improvement
Authors: Platt Richard , Grossmann Claudia , Selker Harry P.
Published: October 2014

Understanding the components of clinical care that work best is a cornerstone of improving health care. And yet, the more we improve the quality of quality improvement and move to continuous learning about clinical care more broadly, the more we find ourselves in a regulatory environment that makes evaluation more difficult, expensive, and, in some situations, impossible. In their paper on the ethical underpinnings of the distinction between research and treatment, Ruth Faden and colleagues raise important implications for a wide array of situations. These points give reason to rethink the definition of routine clinical operations to include evaluation of the processes and outcomes of care and dissemination of findings. We concur with the assertion by Faden and colleagues, and with previous work from The Hastings Center, that conducting continuous improvement activities such as these is an obligation of health systems and clinicians. We believe that rigorous, systematic evaluation should be considered part of normal, expected operations, rather than exceptional behavior that requires extraordinary regulatory control.
Should We Call It Fraud?
Authors: CAULFIELD TIMOTHY
Published: October 2014

I recently had the opportunity to chair an interdisciplinary workshop on stem cell tourism—the practice, that is, of marketing unproven stem cell therapies for a wide range of diseases and disabilities, drawing patients from around the world. The goal of the event was to produce a statement to educate Canadian family physicians about this troubling and exploitative phenomenon. We wanted to keep the statement basic and straightforward. “Let's simply call stem cell tourism what it is. It is fraud,” someone suggested. I wrote the word “fraud” on the flipchart at the front of the room, and everyone seemed comfortable with this frank declaration. But when I went to write up the first draft of our statement, I hesitated.
Medicine's Metaphysics
Authors: Dugdale Lydia S.
Published: October 2014

The scenario could not have been more grim. Mrs. Carr had been fitted with a breathing tube for surgery, but the doctors were unable to wean her from the ventilator due to recurrent episodes of life‐threatening infection. She could not eat because of the ventilator, so she received nutrition through a tube in her stomach. At some point, her kidneys shut down and she started dialysis treatments. Between recurrent infection and dialysis, her blood pressure bottomed out, and the medical team frequently jump‐started her heart with intravenous adrenaline‐type medications. Without aggressive support of her lungs, kidneys, nutrition, and cardiovascular system, Mrs. Carr would be dead. “What is going on here?” Anna wondered aloud. “Is this life?”

Philosopher and physician Jeffrey Bishop might argue that this is not life. Rather, medicine has created a body in perpetual motion. Contemporary medicine, he contends, has redefined human life as human function; doctors simply replace the broken or dead parts of the human machine with other machines—a ventilator for the lungs, dialysis for the kidneys, and so forth—and the body stays in motion indefinitely. Bishop argues that the discipline of medicine needs to reexamine its metaphysical assumptions—its current approach is detrimental to human flourishing. Should a metaphysics of efficient causation be replaced with a more expansive metaphysics of final causes?
From Evidence‐Based Medicine to Evidence‐Based Practice
Authors: Meyer Michelle N.
Published: October 2014

As a recent special report in the Hastings Center Report demonstrates, many bioethicists are rethinking the way we regulate both biomedical research and clinical practice, as well as the sharp boundary that the field has assumed can and should exist between them. Such a rethinking is long overdue. There is surely a meaningful normative distinction between activities whose expected risk‐benefit profile is and is not “reasonable” for participants (to echo the language in the Common Rule—the core set of human research guidelines found in many federal regulations). But neither the research‐practice distinction nor the criteria underlying it—the intention of the actor, whether the activity is “systematic,” and whether its results are “generalizable”—closely track good and bad outcomes for research participants and patients or justify either the bureaucratic, paternalistic licensing system that governs human subjects research or the comparatively lax governance of medical practice.

The specious distinction between research and practice is especially ripe for dismantling in light of the embarrassing fact that evidence‐based medicine remains more aspiration than reality.
Whose Bed?
Authors: Tong Bonnie , Lipman Hannah I.
Published: October 2014

Richard, a sixty‐seven‐year‐old man, has been admitted to Midtown University Center for difficulty breathing. He has a significant medical history that includes pulmonary fibrosis and subsequent heart failure, and he depends on supplemental oxygen to breathe. Upon admission and after discussing his prognosis with his family and doctors, Richard decided to sign a do‐not‐resuscitate order stating that if his heart stops or he stops breathing, he does not want to undergo cardiopulmonary resuscitation or other life‐sustaining measures.

On his third day in the hospital, the nurse practitioner who is caring for Richard notices that his breathing is becoming more labored and that his blood pressure is steadily dropping. She thinks he requires closer observation and treatment in the cardiac intensive care unit. Dr. P, the physician in the intensive care unit at the time, Dr. P does not want to accept Richard into the CICU because of his prognosis and his DNR order. He believes that Richard should be cared for on a regular hospital floor, and that the last bed in the CICU should be held for its intended user—a patient suffering a life‐threatening heart attack who requires intensive care.

Should Richard be admitted to the CICU?
Why We Should All Pay for Fertility Treatment: An Argument from Ethics and Policy
Authors: Johnston Josephine , Gusmano Michael K.
Published: October 2014

Since 1980, the number of twin births in the United States has increased 76 percent, and the number of triplets or higher‐order multiples has increased over 400 percent. These increases are due in part to increased maternal age, which is associated with spontaneous twinning. But the primary reason for these increases is that more and more people are undergoing fertility treatment. Despite an emerging (but not absolute) consensus in the medical literature that multiples, including twins, should be a far less frequent outcome of fertility treatment, American clinicians currently practice fertility medicine in ways likely to result in twins and, occasionally, triplets—often, they tell us, at the request of their patients. At first blush, one might conclude that these practice patterns show that patients and their doctors have weighed the risks associated with twins against the benefits of swiftly completing their families and decided that the risks are worth taking. That is, their requests for twins must represent their free and informed choices. But there are reasons to be skeptical of this interpretation, including that the preferences of many patients seem to be very strongly shaped, if not sometimes completely constrained, by concerns about costs—costs that mainly result from the routine exclusion of in vitro fertilization from health insurance coverage. It is quite possible, we believe, that these cost concerns actually undermine the autonomy of fertility patients, pushing many of them to take risks with their health and the health of their hoped‐for future children.
The Increasingly Compelling Moral Responsibilities of Life Scientists
Authors: Relman David A.
Published: October 2014

As a member of the National Science Advisory Board for Biosecurity, I was involved in early deliberations about the appropriateness of publishing this avian influenza research when manuscripts were referred to us from two scientific journals during their review process, via the U.S. government. As described by David Resnik in this issue, we grappled with benefits and risks, and in our initial, unanimous decision recommended limited publication, alerting the world to the possibility of evolved transmissibility in these viruses but with redaction of the exact genetic mutations that would enable anyone skilled in the art to synthesize these potentially dangerous viruses. However, after additional discussion, both internal and external to the board, we were asked to reconsider the situation, and this time a majority voted in favor of full publication. I was one of the minority that opposed full publication.

Resnik points to the difficulties of performing a formal risk‐benefit assessment without the means of quantifying these two terms and suggests application of reasoning based on the precautionary principle instead. This makes sense. But there are three other issues that should be highlighted.
H5N1 and the Politics of Truth
Authors: Bennett Gaymon
Published: October 2014

The social fact of disease means the ethical dimensions of H5N1 research are not only fraught but empirical. Any account of the reality of research that leaves out its ethical dimensions leaves out reality. For this reason alone—and quite apart from his carefully reasoned analysis—David Resnik deserves our thanks: his attention in this issue to the ethics of knowledge focuses our attention on the fact that the possible harms and benefits of H5N1 turn as much on the “politics of truth”—how work is conducted and talked about—as the biology itself. Sufficient discussion of this ethical dimension, as Resnik points out, requires attending to all stages of research, its premises and its ramifications. Resnik focuses on questions of publication and risk, offering philosophical, legal, and political insight. For my part, I would like to bolster (if complicate) Resnik's assessment by offering a few anthropological notes.
Preventing Sin: The Ethics of Vaccines Against Smoking
Authors: Lieber Sarah R. , Millum Joseph
Published: October 2014

The alarming rates of smoking, obesity, and substance abuse pose an enormous challenge for parents and public health officials: how do we prevent children and adolescents from adopting unhealthy behaviors? One new option that may soon be available is the use of nicotine vaccines. Immunological therapies to help smokers stop smoking have shown promise in phase I and II trials; similar therapies could combat smoking addiction before it starts. Nicotine vaccines are distinctive because they confer protection not against infection—the normal target for vaccines—but against enticing pleasures that lead to unhealthy behaviors. As a result, using them preventively in children would be likely to arouse some novel ethical concerns that should be addressed before the vaccines become commonly available and their off‐label use as a preventive measure becomes a real option.

In this paper, we consider whether it would be ethical for parents to vaccinate their children against smoking if a nicotine vaccine were to be proven effective as a preventive intervention for children or adolescents. We begin by explaining the current state of nicotine vaccine science and suggesting some likely ethical concerns about allowing parents to have their children receive a vaccine. We then present a preliminary argument for making vaccination permissible, at least if nicotine vaccination substantially reduces the probability that someone subsequently becomes a smoker. We consider a series of possible ethical objections, which are useful for identifying the conditions under which it would be ethical for parents to vaccinate their children against smoking. We conclude that it would be permissible for parents to give their child a nicotine vaccine if the following conditions were met: the vaccine is expected to result in a net benefit to each individual vaccinated, the expected harms from the side effects of the vaccine are lower than the nonvoluntary harms caused by smoking, and there are no other, less manipulative methods available that are as effective at preventing smoking initiation.
Health Reform and the Uninsured: The New Requirements of the Old Ethics
Authors: Tunzi Marc
Published: October 2014

U.S. health reform will raise many familiar ethical issues over the next several years‐old issues in new forms. One of these is the fate of individuals who will still be uninsured after implementation of the Patient Protection and Affordable Care Act. One way to think about meeting their needs is to appeal to the "social contract" around which the American Medical Association was originally formed. The AMA Code of Medical Ethics directs physicians to promote "access to medical care for all people" and to "share in providing care to the indigent." I propose that a minimum standard of public service activities be defined and required by all U.S. medical specialties in order to maintain board certification and/or professional society membership.
PEPFAR's Antiprostitution “Loyalty Oath”: Politicizing Public Health
Authors: Gostin Lawrence O.
Published: October 2014

Can Congress require AIDS service organizations to pledge fidelity to the government's view opposing prostitution as a condition of receiving funding? This term, the Supreme Court will decide whether the First Amendment permits such censorship in USAID v. Alliance for Open Society International (AOSI).

The 2008 legislation reauthorizing the President's Emergency Plan for AIDS Relief (PEPFAR) requires host countries to support “activities promoting abstinence, delay of sexual début, monogamy, and fidelity.” PEPFAR's “conscience clause” allows organizations with a moral or religious objection to opt out of providing services to patients with a sexual orientation of which they disapprove. In addition, the law requires grantees to adopt “a policy explicitly opposing prostitution” and to refrain from any speech or activities the government deems “inconsistent” with that policy. The antiprostitution pledge extends not only to what a recipient says or does with PEPFAR funds, but even to what it says or does with its own private funds. The government, however, has not enforced the pledge against U.S.‐based nongovernmental organizations partly because of a preliminary injunction granted by the lower courts. That injunction is now at risk if the Supreme Court upholds the loyalty oath.
“Yet the Body Is His Book”: Plastinated Bodies and the Book of Common Bioethics
Authors: Nelson James Lindemann
Published: October 2014

John Donne, poet laureate of the human body, was much troubled by its fate. Scorning Plato's picture of the body as the soul's prison, Donne imagined souls as leaving their bodies reluctantly and as yearning to return to the very one from which they had departed. In poems like “The Ecstasy,” he depicts the union of lovers’ souls, hints at a similar love of souls for bodies, and suggests that it is through the body—“his book”—that the lover comes to know love's spiritual mysteries. John Lantos also thinks bodies important, and that some among their possible fates, anyway, can be troubling.

A review of Controversial Bodies: Thoughts on the Public Display of Plastinated Corpses, edited by John D. Lantos.
Ethical Challenges in Refugee Health: A Global Public Health Concern
Authors: Aaron Eliana
Published: October 2014

Medications of choice, necessary supplies, and evidence‐based health care now seem like luxuries. The contrast between my experience at a well‐funded health unit and the Lev El Lev (“heart to heart”) African Refugee Clinic in Tel Aviv, Israel, is staggering. The complex personal, social, health, psychological, educational, and economic difficulties create a unique ethical environment for the health care provider.
Great Challenges
Authors: Gilbert Susan
Published: October 2014

We first got to know TEDMED, a partner of TED (known for its entertaining talks on important ideas), in November 2011, when Jay Walker, its ebullient curator and chairman, visited The Hastings Center to discuss our common interests. What took place was an energizing conversation with Hastings Center staff and several members of the center's board of directors about some of the most intractable health care problems. Jay sketched his vision of marshaling creative and motivated leaders from business, public policy, and medicine to address them. He imagined these people drawing on their areas of expertise to make unforeseen connections—perhaps some insight from business would spark a new idea for combatting childhood obesity or eliminating medical errors. They would use their influence to put the best ideas into practice. Soon after, Walker's colleagues were back in touch with a plan for launching his movement: The Great Challenges of Health and Medicine program.
A Win‐Win?
Authors: Kaebnick Gregory E.
Published: October 2014

There is widespread agreement that medical care offered at the end of a life ought to accord with the preferences of the person whose life it is, at least if the care requested would not be futile. There is considerable evidence, too, that making care more “patient‐centered” in this way would tend to lower the cost of care, for the simple reason that people in those straits often prefer to avoid the most intrusive and therefore most expensive care. So patient‐centered care could be a win‐win of sorts: there could be a collective benefit of lowering costs along with the individual benefit of conforming care better to what the patient wants. But to what degree should the collective benefit be an express goal of health reform, in light of the fact that a given patient might want whatever intrusive, aggressive interventions stand a chance of prolonging life? This question animates several items in this issue of the Report.
Public Health Service Research in Guatemala: Toward New Scholarship
Authors: Spector‐Bagdady Kayte
Published: October 2014

A commentary on “‘Ever Vigilant’ in ‘Ethically Impossible’: Structural Injustice and Responsibility in PHS Research in Guatemala,” from the May‐June 2013 issue.
The Author Replies
Authors: Johnston Josephine , Gusmano Michael
Published: October 2014

A response to Anne Haehl's commentary, “Fertility Treatment: Medically Necessary?”
There Oughta Be a Law
Authors: Hall Mark A.
Published: October 2014

“Unconscionable.” “Outrageous.” “Indefensible.” These are just some of the tamer descriptions for the billing practices of most hospitals, and also many physicians, that have recently come to the public's attention. Earlier this year, Time magazine published an extraordinary 24,000‐word exposé—the longest article it has ever published—detailing how even charitable hospitals routinely price‐gouge their patients.1 With characteristic flare for telling details, journalist Steven Brill documented ten‐fold markups of charges over costs at some prominent hospitals for common services like X rays and lab tests, and one‐hundred‐fold mark‐ups on mundane supplies such as gauze pads and generic aspirin. Just as the buzz from Brill's article was abating, the Centers for Medicare & Medicaid Services released a comprehensive data set in May that galvanized local and national media across the country.

This news tsunami caught hospital managers flat‐footed and tongue‐tied. Typical responses conceded that hospitals’ pricing practices are based neither on actual cost structures nor rational marketplace dynamics. Instead, hospitals attempted to deflect blame by noting that hardly anyone actually pays list prices, and they characterized their indefensible pricing as a symptom of a broken system that is beyond them to fix.

There are two glaring faults in these standard defenses.