bluuebunny/crossref_metadata_2025 huggingface dataset:
Channel‐like NH3 flux by ammonium transporter AtAMT2
Authors: Neuhäuser Benjamin , Dynowski Marek , Ludewig Uwe
Published: July 2009

Prokaryotes, plants and animals control ammonium fluxes by the regulated expression of ammonium transporters (AMTs) and/or the related Rhesus (Rh) proteins. Plant AMTs were previously reported to mediate electrogenic transport. Functional analysis of AtAMT2 from Arabidopsis in yeast and oocytes suggests that is the recruited substrate, but the uncharged form NH3 is conducted. AtAMT2 partially co‐localized with electrogenic AMTs and conducted methylamine with low affinity. This transport mechanism may apply to other plant ammonium transporters and explains the different capacities of AMTs to accumulate ammonium in the plant cell.
Evaluating buyer–supplier relationship–performance spirals: A longitudinal study
Authors: Autry Chad W. , Golicic Susan L.
Published: July 2009

Interorganizational relationships and their impact on firm performance have been studied at length in various business literatures, with many studies predicting that in dyadic exchange contexts strong relationships should lead to better performance for both parties involved. However, some studies reverse this causal ordering, arguing that the performance gains attributed to prior relational activity predict the strength of the dyadic relationship in future time periods. While supported, both of these perspectives on relationship strength/performance dynamics are incomplete, as the research studies are only cross‐sectional snapshots of the phenomenon. We remedy this gap in the existing literature by examining the dynamic cyclical linkage between relationship strength and performance of a buyer–supplier relationship in a longitudinal setting, using a relationship strength–performance spiral model. Results of testing a multiyear sample of 323 buyer–supplier relationships in the construction industry indicate not only that relationships tend to spiral positively following relationship initiation, but also that positive relationship spirals will self‐correct following multiple associations of alternating increases. These findings advance theory on buyer–supplier relationships, and provide insight for companies looking to improve supply chain outcomes through superior relationship management.
Analysis of Outcomes of Vascularized Flap Reconstruction in Patients with Advanced Mandibular Osteoradionecrosis
Authors: Alam Daniel S. , Nuara Michael , Christian James
Published: July 2009

OBJECTIVE

To examine outcomes of vascularized bone flap reconstruction of end‐stage osteoradionecrosis of the mandible.

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary care academic hospital.

SUBJECTS

Patients with end‐stage radiation‐induced osteoradionecrosis (ORN) refractory to conservative therapy with wound complications including chronic infections, fistula formation, and pathologic fracture were included.

RESULTS

Outcomes of 33 patients were prospectively collected and analyzed, making this the largest series on this subject in the literature and the only one with planned data collection. Data on preoperative variables including radiation dose, sub‐site location, treatment date, and prior therapy, along with intraoperative issues and postoperative outcomes, were tracked and are presented. ORN was seen to develop in a bimodal distribution based on the timing of interval surgical intervention. The extent of local soft tissue injury often required the use of contralateral recipient vessels. Local wound complication rates were higher than that seen in primary reconstructions.

CONCLUSIONS

Successful reconstruction was achieved in all of the patients in this series. Long‐term resolution of infectious complication and disease resolution was seen in 91 percent of the patients in this series.
Importance of Treatment Institution in Head and Neck Cancer Radiotherapy
Authors: Kubicek Gregory J. , Wang Fen , Reddy Eashwar , Shnayder Yelizaveta , Cabrera Cristina E. , Girod Douglas A.
Published: July 2009

OBJECTIVE

The treatment for head and neck cancer (HNC) often involves radiotherapy. Many HNC patients are treated at the academic center (AC) where the initial surgery or diagnosis was made. Because of the lengthy time course for radiotherapy, some patients are treated at community radiation facilities (non‐AC) rather than the AC despite potential AC advantages in terms of experience and technology. Our goal is to determine if these potential AC advantages correspond to a difference in treatment outcome.

STUDY DESIGN

Historical cohort study.

SETTING

University of Kansas Medical Center, Kansas City, Kansas.

SUBJECTS AND METHODS

Review of records of patients with HNC cancers evaluated at the otolaryngology (ENT) department of an AC. Each patient's information and treatment characteristics were recorded, including radiotherapy treatment venue and treatment outcome.

RESULTS

Three hundred seventy‐four patients were analyzed, 263 were treated at an AC and 101 at a non‐AC. Patients treated at a non‐AC were more likely to present with earlier stage tumors, be treated with radiation alone rather than chemoradiotherapy, and be treated with adjuvant rather than primary radiotherapy. There was no difference in overall survival or recurrence rates between AC and non‐AC.

CONCLUSION

Patients treated at an AC are more likely to have advanced stage tumors and receive chemoradiotherapy as their primary treatment. In analyses of matching patient subsets, there was no significant difference in patient outcomes. Patients can be treated at a non‐AC without affecting outcome compared with treatment at an AC.
Submental Flap for Reconstructing Tongue Defect with V‐Y Advancement Flap for Repairing Submental Defect
Authors: Chen Wei‐Liang , Yang Zhao‐Hui , Li Jing‐Song , Huang Zhi‐Quan , Wang Jian‐Guang , Zhang Bin
Published: July 2009

OBJECTIVE

To assess the reliability of the facial‐submental artery island flap for reconstructing tongue defects and the aesthetic benefits of using two V‐Y islanded flaps for repairing the resulting submental defect.

STUDY DESIGN

Case series with chart review.

SETTING

Patient with tongue cancer, younger patient, cosmetic outcome.

SUBJECTS AND METHODS

Thirty‐three tongue defects were repaired with facial‐submental artery island flaps, and the submental defects were repaired with two V‐Y advancement flaps. The ages of the patients ranged from 28 to 57 years; 19 were men and 14 were women. All of the lesions were tongue squamous cell carcinoma. The size of the facial‐submental artery island flap ranged from 3.5 × 7.0 to 5.0 × 8.0 cm. The size of the V‐Y advancement flaps ranged from 3.0 × 3.0 to 4.0 × 4.0 cm. Direct closure was achieved at all donor sites.

RESULTS

The facial‐submental artery island flaps and V‐Y advancement flaps survived in 93.9 percent and 97.0 percent, respectively. The patients were followed for 12 to 26 months. The functional results in terms of speech and swallowing were good, and the aesthetic outcomes using two V‐Y advancement flaps to repair the submental defects were satisfactory. Two patients with extracapsular lymph node spread developed local recurrence: One is alive with disease and the other is dead.

CONCLUSIONS

The facial‐submental artery island flap is a simple, reliable flap that is preferred for reconstructing tongue defects. Using two V‐Y advancement flaps for repairing the donor site defect improves the cosmetic outcome in the submental region.
Partial Cricotracheal Resection in Children
Authors: George Mercy , Ikonomidis Christos , Jaquet Yves , Monnier Philippe
Published: July 2009

OBJECTIVES

To delineate the various factors contributing to failure or delay in decannulation after partial cricotracheal resection (PCTR) in children.

STUDY DESIGN

Case series.

SETTING

Academic tertiary medical center.

SUBJECTS AND METHODS

A retrospective case review of 100 children who underwent PCTR between 1978 and 2008 for severe subglottic stenosis using an ongoing database.

RESULTS

Ninety of 100 (90%) patients were decannulated. Six patients needed secondary tracheostomy. The results of the preoperative evaluation showed grade II stenosis in four patients, grade III in 64 patients, and grade IV in 32 patients. The overall decannulation rate was 100 percent in grade II, 95 percent in grade III, and 78 percent in grade IV stenosis. Fourteen (14%) patients required revision open surgery. The most common cause of revision surgery was posterior glottic stenosis. Partial anastomotic dehiscence was seen in four patients. Delayed decannulation (>1 year) occurred in nine patients. Overall mortality rate in the whole series was 6 percent. No deaths were directly related to the surgery. No iatrogenic recurrent laryngeal nerve injury was present in the entire series.

CONCLUSION

Comorbidities and associated syndromes should be addressed before PCTR is planned to improve the final postoperative outcome in terms of decannulation. Perioperative morbidity due to anastomotic dehiscence, to a certain extent, can be avoided by intraoperative judgment in the selection of double‐stage surgery when more than five tracheal rings need to be resected. Subglottic stenosis with glottic involvement continues to pose a difficult challenge to pediatric otolaryngologists, often necessitating revision procedures.
Head and Neck Squamous cell Carcinoma Targeted Chemosensitization
Authors: Figures Mindy R. , Wobb Jessie , Araki Koji , Liu Tingyan , Xu Lei , Zhu Hanjing , O'Malley Bert W. , Li Daqing
Published: July 2009

OBJECTIVE

The current treatment for advanced head and neck squamous cell carcinoma continues to result in poor outcomes. The purpose of this study is to investigate the benefit of fibroblast growth factor 2‐targeted adenovirus‐mediated mutant‐Rad50 (FGF2‐Ad‐Rad50) gene transfer in enhancing chemosensitization for head and neck squamous cell carcinoma and reducing chemotoxicity.

STUDY DESIGN

Randomized controlled laboratory study.

SETTING

University of Pennsylvania, Philadelphia, PA.

SUBJECTS AND METHODS

Human head and neck squamous cell carcinoma tumor cells and a mouse model with human head and neck squamous cell carcinoma were used for this study. There were five mice in each study group. FGF2‐fab' molecule was conjugated with an adenoviral mutant‐Rad50 construct. FGF2‐targeted transgene expression efficiency was evaluated in vitro. Tumor cytotoxicity and growth inhibition were examined after combined FGF2‐Ad‐Rad50 with cisplatin treatment in vitro and in vivo. Anti‐tumor mechanisms were investigated.

RESULTS

FGF2‐targeted gene transfer approach significantly improved transgene expression in head and neck squamous cell carcinoma tumor cells over a nontargeted approach (207.51 ± 33.62 vs 51.44 ± 8.28, respectively). FGF2‐Ad‐Rad50 with cisplatin demonstrated a superior tumor suppression effect (264.5 ± 124.1 mm3 vs 567.1 ± 267.6 mm3), increased DNA double‐strand breaks (1349 ± 51.67 vs 774 ± 28.56), and anti‐angiogenesis (%ROI: 0.76% ± 0.38% vs 2.10% ± 1.66%) in tumor cells over nontargeted adenovirus.

CONCLUSION

Combination of FGF2‐Ad‐Rad50 with cisplatin significantly improves anti‐tumor effect by targeting DNA repair systems and tumor angiogenesis. The great benefit of this strategy supports clinical trial for novel treatment of head and neck squamous cell carcinoma.
Deep Brain Stimulation Effects in Patients with Tinnitus
Authors: Shi Yongbing , Burchiel Kim J. , Anderson Valerie C. , Martin William Hal
Published: July 2009

OBJECTIVE

To report deep brain stimulation (DBS) effects in patients with tinnitus.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Seven patients implanted with DBS systems for movement disorders who also reported having tinnitus were interviewed about their tinnitus conditions. Four were available for testing in a specialized tinnitus clinic with their DBS systems turned off or on. Testing included matching of self‐rated and psychoacoustically measured tinnitus loudness to measure the impact of DBS on tinnitus.

RESULTS

Three of the seven patients reported reduced tinnitus loudness when DBS was turned on. Of the four patients tested in the clinic, results indicated that DBS of the ventralis intermedius nucleus of the thalamus caused decreases in tinnitus loudness in two patients with relatively prolonged residual inhibition.

CONCLUSION

These results suggest that DBS of nonauditory thalamus structures may provide tinnitus relief for some patients.
Perceptions of foreign threats to the regime: From Lenin to Putin
Authors: Shlapentokh Vladimir
Published: July 2009

During his second term, Putin’s foreign policy was strongly influenced by the belief that the West’s hostility could help the opposition change the current regime, as the West had done in Ukraine and Georgia. A regime change would deprive the ruling elite, mostly people from the security police and army, of their power and illegally acquired wealth. Moscow restored, in early 2000, the ideology of Russia’s “encirclement” from the 1920s, which suggested that the country was surrounded by enemies in order to legitimize the regime. At the same time, as in the past, Moscow tried to punish the Western governments for their disrespect for the regime with an aggressive and uncooperative foreign policy.
Sheep and goats differences in CLA and fatty acids milk fat content in relation with mRNA stearoyl-CoA desaturase and lipogenic genes expression in their mammary gland
Authors: Tsiplakou Eleni , Flemetakis Emmanouil , Kalloniati Chrysanthi , Papadomichelakis George , Katinakis Panagiotis , Zervas George
Published: July 2009

An experiment was conducted with 12 lactating dairy ewes and 12 goats with the objective to determine whether, under the same dietary treatments, the differences in their fatty acid (FA) profile with emphasis oncis-9 trans-11CLA milk fat content, are reflected in the transcript levels of genes involved in FA andcis-9, trans-11CLA biosynthesis. The animals were fed with two diets (A, B) in different days of milk (DIM) due to the different milk yield, body weight etc, in order to have the same food intake and to avoid dietary effects. Diet A was fed to the animals on a group basis as it is traditionally used in practice, while diet B was chosen to avoid individual feed intake variation which is usually observed in group feeding. The results showed that there are significantly lower mRNA levels of acetyl-CoA carboxylase (ACC) in sheep mammary gland compared with those of goats, independently from the diet fed. The same trend was observed with the mRNA level of FA synthase (FAS), but the results were significant only for diet A. The mRNA level of lipoprotein lipase (LPL) in the mammary gland did not differ between sheep and goats fed with diet A. In addition, the concentration ofcis-9 trans-11CLA content was significantly higher in sheep milk fat compared with those of goats. This is in accordance with the significant higher levels on mRNA of stearoyl-CoA desaturase (SCD) which were observed in their mammary adipocytes of sheep compared with those of goats, independently of the fed diet (A or B). In conclusion, these findings demonstrate that the differences between sheep and goats, concerningcis-9, trans-11CLA and FA milk fat content, under the same dietary treatments could be explained in part by the differences in mRNA of SCD and lipogenic genes in their mammary gland.
Intratympanic methylprednisolone injections for subjective tinnitus
Authors: Topak M , Sahin-Yilmaz A , Ozdoganoglu T , Yilmaz H B , Ozbay M , Kulekci M
Published: July 2009

Objectives:

This study aimed to determine whether intratympanically injected methylprednisolone is effective in treating subjective tinnitus refractory to medical treatment.

Study design:

Prospective, randomised, placebo-controlled, single-blinded study.

Methods:

Seventy adult patients with subjective tinnitus of cochlear origin were randomly assigned to receive intratympanic injection of either methylprednisolone or saline solution. The treatment protocol comprised three intratympanic injections, one per week for three weeks. Improvement in tinnitus severity was measured by a self-rated tinnitus loudness scale and by the tinnitus severity index, at baseline and two weeks after the last injection.

Results:

Data for 59 patients were available for analysis. There was no significant difference between the two treatment groups regarding age, sex, pure tone average, pretreatment tinnitus intensity, tinnitus laterality or tinnitus duration. There was a significant post-treatment improvement in self-rated tinnitus loudness scale results in both groups. No significant post-treatment changes in the tinnitus severity index individual and total scores were observed in either group. The most frequently encountered side effects were pain during injection, vertigo, a burning sensation around the ear and in the throat, and a bitter taste. A burning sensation and bitter taste were observed more often in the methylprednisolone group compared with the placebo group

Conclusion:

The results of this study indicate that intratympanic methylprednisolone has no benefit, compared with placebo, for the treatment of subjective tinnitus of cochlear origin refractory to medical treatment.
Chaperonin-mediated protein folding: using a central cavity to kinetically assist polypeptide chain folding
Authors: Horwich Arthur L. , Fenton Wayne A.
Published: July 2009

The chaperonin ring assembly GroEL provides kinetic assistance to protein folding in the cell by binding non-native protein in the hydrophobic central cavity of an open ring and subsequently, upon binding ATP and the co-chaperonin GroES to the same ring, releasing polypeptide into a now hydrophilic encapsulated cavity where productive folding occurs in isolation. The fate of polypeptide during binding, encapsulation, and folding in the chamber has been the subject of recent experimental studies and is reviewed and considered here. We conclude that GroEL, in general, behaves passively with respect to its substrate proteins during these steps. While binding appears to be able to rescue non-native polypeptides from kinetic traps, such rescue is most likely exerted at the level of maximizing hydrophobic contact, effecting alteration of the topology of weakly structured states. Encapsulation does not appear to involve ‘forced unfolding’, and if anything, polypeptide topology is compacted during this step. Finally, chamber-mediated folding appears to resemble folding in solution, except that major kinetic complications of multimolecular association are prevented.
The International Criminal Court and Participation of Victims: A Third Party to the Proceedings?
Authors: FRIMAN HÅKAN
Published: July 2009

The provisions of the ICC Statute allowing victims to participate in the criminal proceedings in their own right were a novel feature in international criminal proceedings. While representing a welcomed restorative element, victim participation has been a time and resource consuming issue for the ICC to handle. After a number of decisions concerning participation in the investigation and pre-trial phases of the process, the trial chamber in the Lubanga case and the Appeals Chamber have issued the first rulings with respect to victim participation at trial. This note addresses these decisions and controversial issues therein, such as the nexus between the victim and the crime charged and the victim's right to adduce and challenge evidence. One may now ask whether victims as ‘participants’ are in fact becoming ‘parties’ to the criminal proceedings.
The Authority of States to Use Names in International Law and the Macedonian Affair: Unilateral Entitlements, Historic Title, and Trademark Analogies
Authors: BANTEKAS ILIAS
Published: July 2009

The international legal entitlement by which a state constitutionally designates its name, or a province therein, involves a unilateral act. Where, however, another state wishes to choose the same appellation, as is the case with the former Yugoslav Republic of Macedonia (FYROM), the matter can only be resolved by reference to the first user and the maxim prior in tempore potior in jure. The first user must provide evidence of continuous use and of protest in those cases where the same appellation was appropriated by a third state. Under such circumstances the entitlement becomes exclusive, rather than concurrent, because the prior user may be said to possess a sound historic title, such that has been recognized by international judicial bodies to determine acquisition of territory, effective administration, historic bays, and so on. The exclusivity of the entitlement is further reinforced by analogy with general principles derived from the law of trademarks. At a practical level, the application of the international law of geographical indications clearly demonstrates that the designation ‘Macedonia’ cannot be used for a significant number of products originating in FYROM, since the Greek province of Macedonia has for a long time branded and registered such products. This will create insurmountable problems for producers in FYROM when they try to brand their goods under the country's constitutional name. A change of name, particularly through the compromisory use of a compound, would alleviate legal, political, and financial concerns.
Dutch Euthanasia: Background, Practice, and Present Justifications
Authors: Kimsma G. K. , Van Leeuwen E.
Published: July 2009

Dutch developments on euthanasia have drawn much attention over the years. Defenders and opponents have been telling very different stories about the practice of euthanasia and the frequency of cases, and the Dutch government has been struggling with the legal and moral problems involved. Concern about the procedures followed by physicians as well as questions on the “real” figures led the government to decide to organize an epidemiological study on the extent and the decision making. The results of the study were published in November 1991 (The End of Life in Medical Practice, 1991). Interpretation of the data may lead to a final settlement of the debate on euthanasia and has inevitably led to a revival of the moral debate of the 1970s. For the moment it has been decided that euthanasia will remain officially illegal under the Penal Code. However, in cases where euthanasia does occur, Attorneys General will continue to check the procedures followed by physicians to ensure no abuses have occurred and to safeguard physicians against prosecution. In this contribution, we discuss the development and intertwinement of legal, medical, and moral aspects of euthanasia in The Netherlands and the effects of the empirical studies of 1991, both on definitions and procedures for medical decisions at the end of life(MDEL)
Futility: Is Definition the Problem? Part I
Authors: Cotler Miriam Piven , Gregory Dorothy Rasinski
Published: July 2009

A physician recently asked how to respond in the case of an 87-year-old patient with advanced Alzheimer's disease, who was unable to swallow or tolerate a nasogastric tube, when the family insisted a gastrostomy tube be inserted but the physician believed the intervention futile. That question encompasses some of the crucial issues in the concept of futility of the treatment goals of physician, patient, and family; the rights of patients and families to demand care; physician judgment; family values; and, to the degree that it represents many similar dilemmas, justice. What are professionals saying when they pronounce treatment futile? What are patients' rights if they or their surrogates disagree?

The word “futile” implies a precision about outcome probability that we do not have, and it ignores the wide range of treatments for a given diagnosis. Is futile the same as useless or the opposite of hope? Futile for what? Cure? Restora tion of function? Prolongation of life? Relief from pain? Relief from anxiety? Com fort? Reassurance? To satisfy or placate the patient or the family? The word “futile” is so imprecise that, rather than clarifying, it confuses and clutters the discussion.
The Story of Laurens
Authors: Spreeuwenberg Cor
Published: July 2009

On 10 July 1973, Laurens, our second son, was born in the same Dutch hospital where I worked as an intensive care physician. Two weeks after we brought him. home from the hospital, my wife heard him crying at about 5:45 A.M. Rather than going to him, she decided to wait until his scheduled feeding time. At about 6:10 when she went to Laurens's room to feed him, she saw him. face down in the corner of his crib. He appeared dead. She screamed for me. I ran from upstairs to Laurens's room on the ground floor. I initiated cardio-pulmonary resuscitation and continued the CPR while my wife called our general practitioner. He arrived in about 10 minutes and the ambulance arrived a minute later.
CQ Interview with Heleen M. Dupuis: Actively Ending the Life of a Severely Handicapped Newborn: A Dutch Ethicist's Perspective
Authors: Dupuis Heleen M.
Published: July 2009

CQ: The Baby Bas Ross case stirred much public debate in The Netherlands since 1988 -a newborn infant with Down's syndrome whose parents refused to consent to a surgery that would have repaired an otherwise fatal congenital anomaly. Can you share your thoughts with us on this case?

HD: I was the first ethicist to comment on this case because I was a friend of Dr. Molenaar, who was the final surgical decision maker for Baby Bas. A physician and I supported his decision throughout the prosecution that followed. We also summarized the case in the N.T.V.G., the Dutch Magazine of Medicine. We argued In the article that parents should have the option to make nontreatment decisions. Moreover, In cases where the physician has to perform aggressive medical interventions, there certainly must be thorough and sound justification to ensure that the decision to Intervene Is in the best interest of the child.
Ethics Consultation: The Least Dangerous Profession?
Authors: Scofield Giles R. , Fletcher John C. , Jonsen Albert R. , Lilje Christian , Self Donnie J. , Ross Judith Wilson
Published: July 2009

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.
Measuring Hospital Ethics Committee Success
Authors: Scheirton Linda S.
Published: July 2009

As hospital ethics committees (HECs) become more common in American hospitals, their degree of success should be measured. Just as new technological procedures are evaluated, institutional innovations should also be evaluated. Currently, little is known about the success of HECs, and some authors have wondered whether these committees serve any useful purpose at all. This article reviews the descriptive results of a 1990 study on HEC success as they pertain to the question of how to measure committee success.
Assessing Bioethics Today
Authors: Thomasma David C.
Published: July 2009

During 1992, academic bioethicists celebrated the 30th anniversary of bioethics. Some like to date the origin of modern secular bioethics to the advent of transplant technology that began with kidney transplantation in the early 1960s in the Seattle, Washington, area. This is certainly a good candidate for a starting point. Another might be the work of Joseph Fletcher in the New York area with the Euthanasia Society of America and with clergy training. Still another candidate for the origins of secular bioethics would be the trial of physicians at the University of Virginia for transplanting a kidney at which the same Joseph Fletcher testified. At that trial, the alteration occurred in American law from a definition of death that focused on the cessation of heartbeat to one that focused on the cessation of brain function.
A Critique of Traditional Relationship Models
Authors: Loewy Roberta Springer
Published: July 2009

Today's ever-widening expert/novice gap–in technology generally but in healthcare technology especially–has been implicated as both cause and consequence of a sharp rise in fundamental misunderstandings between medical professionals and lay populace. Recently created social roles (e.g., clinical medical ethicists) and institutions (e.g., hospital ethics committees) have further prompted critics to suggest that a multiplication of “disinterested” experts not only fails to resolve such misunderstandings, it compounds them. As a result, it should come as no surprise that the problem of paternalistic expertise has emerged as an ethical issue of immense interest from both a theoretical and practical standpoint. For this reason, a critical inquiry in healthcare today centers on finding a practical model that most adequately and accurately characterizes patient–physician relationships.
Can Complex Legislation Solve Our End-of-Life Problems?
Authors: Minogue Brendan , Reagan James E.
Published: July 2009

Over a 20-year period, the United States has developed a consensus of legal opinion concerning living wills and other advance directives. At the heart of this consensus are two interconnected principles. First, the state should minimally interfere with the wishes of patients and surrogates and the decisions of physicians about foregoing life-sustaining treatments. Second, state interference is permissible for the sake of protecting a compelling state interest. The overwhelming majority of states with advance directive laws have attained this balance of minimal interference and compelling state interest in developing their laws.
Ethics Committees at Work
Authors: Marshall Patricia A. , Hartz Jay , Tan S.Y.
Published: July 2009

Mrs. A. is a 50-year-old woman, originally from Greece, who came to the United States with her family in 1973. A widow, with three grown children, she has been living near two of her sons and their families. For many years, Mrs. A. has suffered from, non-insulin-dependent diabetes, emphysema, and hypertension. On the day of a family picnic, she developed a high fever and vomiting. She was taken by her oldest son, Thomas, to the emergency department, where evidence was discovered of a severe infection of her kidneys that had spread to her blood.
The Journey of a Child and His Hear; A Decade of Transformation in the Legal, Medical, and Ethical Care of a Child with Down Syndrome
Authors: Gathman Gary E.
Published: July 2009

Much of recent medical, legal, and ethical focus has been directed toward the unborn or newly born. Guidelines and frameworks for decision making are in the early stages of evolution and are likely to shift as the politics, ethics, and economics of caregiving move beyond technologic accomplishments and debates into a more compassionate construct that may include input (when necessary and appropriate) from an institutional bioethics committee. Beyond that, the courts may continue to be the place where unresolved issues are settled, and with each passing year new and often divergent legal decisions are being generated that further complicate the physician's role as care giver and healer.
Why Doctors Hate Medical Ethics
Authors: Sheehan Myles N.
Published: July 2009

For the past 3 years, since acquiring formal training in healthcare ethics and philosophy, I have been one of those physicians who “does” ethics. I teach medical students and residents, write articles, speak at conferences, chair an ethics committee, and informally consult with colleagues on cases where they request advice related to ethical issues in the care of patients. These activities have been a rewarding and challenging part of my practice. There has also been a fair amount of frustration. Unfortunately, both in teaching and patient care, it has been a frequent experience to finish a discussion with physicians only to be told that what I said was nice but had no bearing in the real world. In the words of a medical resident: 'You know, this ethics stuff is really a lot of crap, isn't it?'
Bioethics and the Body Politic
Authors: d'Oronzio Joseph C.
Published: July 2009

Has the private body of biethics become a microcosm of the body politic? Politics is ethics writ large. Ethics is politics writ small. However we turn it, the practice of bioethics is increasingly attuned to developments in public policy. The establishment of a “Health Policy Watch” in these pages is an invitation for research and reflection on these issues.
African American Suspicion of the Healthcare System Is Justified: What Do We Do about It?
Authors: Dula Annette
Published: July 2009

A recent message on one of the e-mail bulletin boards sent by a college student read, “I believe that the AIDS virus was developed in government labs for the purpose of controlling black folks.” In September 1990, Essence, an African American magazine with a circulation of 900,000, had as a lead article “AIDS: Is It Genocide?” In 1991, the New York Times quoted Clarence Page, African American columnist and Pulitzer prize winner: “You could call conspiracy theories about AIDS and drugs fringe ideas, but they seem, to have a large following among the black intelligentsia. … [And] you find it at all levels.” In April 1992, Lorene Gary explained in Newsweek “Why it's not just paranoia.” In that same month, another New York Times article reported: “Bizarre as it may seem to most people, many black Americans believe that AIDS and the health measures used against it are part of a conspiracy to wipe out the black race.”4 In February 1992, Science quoted Peter Breggin, director of the Center for the Study of Psychiatry in Bethesda, Maryland, as saying that research on violence “cloaks the intention to identify problem black children and then … prescribe pacifying drugs.”
C-sections as Ideal Births: The Cultural Constructions of Beneficence and Patients' Rights in Brazil
Authors: Souza Cecilia De Mello E
Published: July 2009

The culture of giving birth in Brazil has changed drastically since 1970. The caesarean section, once known as a life-saving medical procedure to be used under extraordinary circumstances, is now perceived by the medical profession and their female patients as a safe, painless, modern, and ideal form of birth for any pregnant woman. Brazil has the world's highest percentage of caesarean deliveries. The widespread use of C-sections has become a cultural phenomenon whose boundaries extend far beyond the medical arena. Medical practitioners have appropriated cultural values regarding the female body and sexuality, rein-forced a blind fascination with technology, and medicalized women's fear of labor to justify their preference for surgical births. By narrowing ethical concerns to the doctor-patient relationship and drawing on the notion of the patient's best Interest, physicians defend their practice as appropriate and even desirable.
Women in Clinical Studies: A Feminist View
Authors: Sherwin Susan
Published: July 2009

There is significant evidence that the health needs of women and minorities have been neglected by a medical research community whose agendas and protocols tend to focus on more advantaged segments of society. In response, the National Institutes of Health (NIH) and Food and Drug Administration (FDA) in the United States have recently issued new policies aimed at increasing the utilization of women in clinical studies. As well, the U.S. Congress passed the NIH Revitalization Act of 1993, which specifically mandates increased inclusion of women and racial and ethnic groups in clinical studies. On the face of it, such gender and race-specific policies would appear to be morally problematic because traditionally ethics opposes the use of sex or race as legitimate criteria for distributions of benefits or burdens in social policies. Hence, these policies pose some significant moral questions. Feminist ethics provides us with a framework for evaluating such policies because of its readiness to recognize that socially and politically significant factors such as sex and race are morally relevant in setting public policy. Of course, feminist ethics does not simply endorse all appeals to sex and race but only the policies in which attention to such factors will contribute to social justice. In this essay, I Identify some of the Important ethical questions that a feminist ethics perspective raises about research policies devised to promote the Inclusion of women in clinical studies.
Reworking Autonomy: Toward a Feminist Perspective
Authors: Donchin Anne
Published: July 2009

The principled approach to theory building that has been a conspicuous mark of bioethical theory for the past generation has in recent years fallen under considerable critical scrutiny. Although some critics have confined themselves to reordering the dominant principles, others have rejected a principled approach entirely and turned to alternative paradigms. Prominent among critics are antiprin-ciplists, who want to jettison the principle-based approach altogether and adopt a casuistic (case-specific) model, and communitarians, who favor an eclectic model combining features of both the casuistic model and a modified principled approach. Particularly conspicuous in virtually all such critiques is their challenge to the preeminence of the principle of autonomy. Critical barbs have been aimed not only at theories favoring a hierarchical ordering of moral principles that give first place to autonomy, but also at those that include autonomy among a set of ostensibly coequal principles. Though these critics have performed a valued function by displacing bioethical principles from their Olympian perch beyond actual decision-making contexts, some version of the principle of autonomy may, nonetheless, be well worth defending but for very different reasons than those put forward by its supporters.
The Caduceus in court: Euthanasia and Assisted Suicide in The Netherlands
Authors: Schwartz Robert L.
Published: July 2009

As ethics committees become involved in discussing the propriety of euthanasia and assisted suicide, and as healthcare providers begin to seriously consider whether they might ever have a role in hastening the dying process, many have looked to The Netherlands as the only real example of a nation that permits (or, at least, excuses) euthanasia in limited circumstances. Unfortunately, partisans in the Dutch debate have often written about the Dutch experience as advocates rather than as neutral observers. Some have argued that euthanasia, which, they claim, is rarely actually practiced, is universally accepted within The Netherlands; others have reported that the Dutch social fabric has been rended irreparably by what they claim, is a practice far more widespread than is generally understood. The debate in the United States has also been colored by a misunderstanding of the legal regulation of euthanasia in The Netherlands.
Dementia in Our Midst: The Moral Community
Authors: Post Stephen G.
Published: July 2009

This article focuses on the elderly patient with a progressive and irreversible dementia, most often of the Alzheimer type. However dementia, the decline in mental function from a previous state, can occur in all ages. For example, if Alzheimer's disease (AD) is the dementia of the elderly, increasingly AIDS is the dementia of many who are relatively young. I will not present the major ethical issues relating to dementia care following the progression of disease from the mild to the severe stages, for I have done this elsewhere. Among the issues included are: presymptomatic testing, both psychological and genetic; responsible diag- nostic disclosure and use of support groups; restrictions on driving and other activities; preemptive assisted suicide; advance directives for research and treatment; quality of life in relation to the use of life-extending technologies; and euthanasia.
Healthcare as a Commons
Authors: Jecker Nancy S. , Jonsen Albert R.
Published: July 2009

In September 1994, theNew York Timescarried a front page article declaring healthcare reform dead in Congress. The obituary on healthcare followed a Congressional decision not to pursue the issue further in 1994. Although Congress and the President will likely revisit healthcare reform during 1995, the choices may be between various incremental steps, rather than substantive changes to bring about universal coverage.
Ethical and Policy Issues in Human Embryo Twinning
Authors: Bonnicksen Andrea L.
Published: July 2009

In 1993, investigators from George Washington University (GWU) Medical Center separated the cells of 17 human embryos and produced 48 embryos, an average of three embryos for each original. The method, variously called twinning, cloning, embryo splitting, and blastomere separation, demonstrated that human embryos could be split to create genetically identical entities during conception. When publicized, however, the experiment brought to mind a different view of cloning repeated since the beginning of the new reproductive technologies. In the early 1970s, when research onin vitrofertilization (IVF) was in its infancy, commentators worried that cloning–defined as the duplication of persons–would be next, leading to a scenario of “boys genetically exactly like the father, girls like the mother, or individuals like some true or false hero of art, science, or sports, or like some demagogue or some saint.”
Clones, Harms, and Rights
Authors: Rhodes Rosamond
Published: July 2009

As the possibility of cloning humans emerges on the horizon people are worrying about the morality of using the new technology. They are anxious about the ethical borders that might be crossed when duplicate humans can be produced by separating the cells of a newly fertilized human egg or, in the more distant future, by creating a zygote from an existing person's genetic material. They are apprehensive about eugenics, concerned about creating humans as sources of spare parts for others, uneasy about producing humans without intending to allow them to live and develop, and uncomfortable about using duplicate humans as business ventures.
Transparent Women, Visible Genes, and New Conceptions of Disease
Authors: Hubbard Ruth
Published: July 2009

Technological innovations have transformed our culture's ways of thinking about procreation and pregnancy, and about health and illness. Until not so long ago, the ongoing processes inside women's bodies as they gestated their future babies was up to conjecture. In Western industrialized countries, pregnancy was the slow process during which a woman gradually came to accept the fact that she was sharing her bodily space with another, and that now, as well as after the baby emerged, the primary responsibility for that new person's survival would be hers.
Comparing Two Euthanasia Protocols: The Free University of Amsterdam Academic Hospital and the Medical Center of Alkmaar
Authors: Kimsma Gerrit K. , Van Leeuwen Evert
Published: July 2009

Hospital ethics committees in The Netherlands have had the unique responsibility of developing euthanasia policies for their institutions. Although each policy necessarily reflects a particular facility, family resemblances necessarily remain. In the interest of ethics committees outside The Netherlands that may soon face the same challenge, two such policies are presented here accompanied by commentary high-lighting their similarities and differences.
Secrets of the Couch and the Grave: The Anne Sexton Case
Authors: Pellegrino Edmund D.
Published: July 2009

In 1991, Diane Wood Middlebrook, a professor of English at Stanford University, published a biography of the poet Anne Sexton in which, among other things, she used as source material some 300 tapes of Sexton's psychotherapeutic sessions with her psychiatrist, Dr. Martin Orne. After some years of reluctance and with the concurrence of Sexton's daughter and literary executor, Linda Gray Sexton, Orne released the tapes to Professor Middlebrook. Middlebrook's picture of Sexton drew heavily on the tapes, supplemented by scrapbooks, letters, photos, clippings, unpublished poems, and hospital records.
Determinants of Decision Making for Circumcision
Authors: Ciesielski-Carlucci Chris , Milliken Nancy , Cohen Neal H.
Published: July 2009

Research is ongoing concerning the medical risks and benefits of routine neonatal male circumcision. Interpretation of the data, however, is controversial. Circumcision presents a number of challenges in obtaining informed consent because of a variety of interesting issues. It is a nonemergent, elective procedure that allows for evaluation and discussion over time. In this respect, observation of the informed consent process for circumcision is relevant to other medical decisions, such as advance directives, discussed between primary care providers and patients. Obtaining informed consent for circumcision has its constraints. The process generally occurs over a brief hospital stay. There have been recent changes in the official position regarding the procedure by professional medical societies, and it raises considerable psychologic issues for the provider and may Impact the way in which Information is provided.
Is the Treatment Beneficial, Experimental, or Futile?
Authors: Schneiderman Lawrence J. , Jecker Nancy S.
Published: July 2009

D.T. a 35-year-old woman, was found to have breast cancer. At the time of mastectomy axillary lymph nodes were positive and the cancer was classified as adenocarcinoma, grade 4. The patient underwent conventional chemotherapy. When it became apparent the disease was metastatic, the patient's oncologist contacted a well-known cancer center regarding the possibility of treating the patient with high dose chemotherapy and autologous bone marrow transplantation (HDC/ABMT). The patient's health insurance provider informed the patient, however, that the treatment—estimated to cost in the range of $150,000–200,000—was “considered experimental or research in nature” and therefore was not included in coverage. D.T. did not pursue this further. Approximately 2 years later, cancer was detected in the patient's spine. This time she applied to another well-known cancer center for HDC/ABMT. The cancer center agreed to accept her on the condition of proof of ability to pay for the treatment. Again her insurer refused coverage on the same grounds as before. D.T. found another source for the money, underwent treatment, then sued the insurance carrier. She sought a declaratory judgment that the treatment was covered under the insurance policy. The court ruled in favor of D.T. finding the contract phrase “considered experimental” ambiguous.
Exploring the Role of Religion in Medical Ethics
Authors: Thomasma David C. , Loewy Erich H.
Published: July 2009

From time to time medical ethicists bemoan the loss of a religious perspective in medical ethics. The discipline had its origins in the thinking of explicitly religious thinkers such as Paul Ramsey and Joseph Fletcher. Furthermore, many of those who contributed to the early development of the discipline had training in theology. One thinks of Daniel Callahan, Richard McCormick, Albert Jonsen, Sam. Banks. As the discipline becomes more and more self-reflective, with attention being paid to methodological and conditional concerns, it is only natural that the roots are due for a reexamination. The time has therefore come for some reassessment. The first steps here are taken in the form of a dialogue between the coauthors to clarify authentic contributions and weed out unauthentic ones.
Incompetent Persons as Research Subjects and the Ethics of Minimal Risk
Authors: Glass Kathleen Cranley , Speyer-Ofenberg Marc
Published: July 2009

The voluntary and informed consent of subjects has been the central focus of concern in research reviews, overshadowing the importance of all other considerations. The Nuremberg Code, with its rights-based protection of the subject's autonomy above all else, made it difficult to justify research with no intended benefit when subjects are incompetent to make a valid informed choice to participate. Subsequent codes providing for research with incompetent subjects followed the lead of Nuremberg, substituting the informed authorization of a proxy for the informed consent of the subject.