A Less Perfect Union.

This is a daunting time, not only in terms of our public health and our economic health but also in terms of the health of the republic. It is an old theme that any form of popular government needs virtuous citizens if it is to survive. It also needs citizens to agree on what counts as a virtue. I fear that the pandemic has shown that "We, the people" do not agree, and this shows what we already knew, that there are profound cracks in our union.

Concepts at the Bedside: Variations on the Theme of Autonomy.

This article examines the patient/clinician conversation when there is disagreement about the values at stake in the treatment decision. To set the stage for that examination, three cases of refusal of treatment are considered, which point to three ways of understanding the content and value of autonomy. In the patient/clinician conversation, the clinician must inevitably adopt one of these conceptions of autonomy, but if he or she adopts a conception that puts significant weight on having rationally defensible values determine the treatment decision, there is still a limit to how far the clinician may challenge the patient's values. Through an appeal to John Rawls's criterion of political legitimacy, the author argues that the clinician may challenge the ordering of the values he or she shares with the patient, but that the clinician may not challenge the content of the patient's fundamental-or life-guiding-beliefs.

Changing the Question.

Jack, who is seventy-five years old, is in the hospital with a terminal condition that has undermined his cognitive faculties. He has left no advance directive and has never had a conversation in which he made his treatment wishes remotely clear. Yet now, a treatment decision must be made, and in modern American medicine, the treatment decision for Jack is supposed to be made by a surrogate decision-maker, who is supposed to use a decision-making standard known as "substituted judgment." According to the substituted judgment standard, Jack's surrogate decision-maker, his wife, is supposed to decide on his treatment by determining what Jack would do if he did have decisional capacity. That is, she is supposed to answer the question, what would the patient choose? I will argue that this is the wrong question to ask because when the question has a determinate answer, that answer is sometimes not sufficiently connected to the value that is supposed to make the question morally salient, and because sometimes, perhaps often, there is no determinate answer to the question of what the patient would choose. Jointly, these two problems suggest the need for a different question.

Practical Wisdom, Rules, and the Parent-Pediatrician Conversation.

In this article, I explore a tension between one of the aspirations of the standard algorithm for decision-making at the bedside and what will often actually happen at the bedside. The aspiration is to avoid physician paternalism, but the algorithm has had the effect of limiting the scope for the exercise of the physician's capacity for practical wisdom, and yet clinical practice often requires the exercise of that capacity. Against this background, I examine the content of shared decision-making in pediatrics. I do the following: point to a feature of the standard algorithm for patient and surrogate (and so also parental) decision-making, make an analytical point about the use of rules versus individual judgments, and examine the elements of the patient-doctor conversation or, in the pediatric realm, the parent-doctor conversation.

The Different Moral Bases of Patient and Surrogate Decision-Making.

My topic is a problem with our practice of surrogate decision-making in health care, namely, the problem of the surrogate who is not doing her job-the surrogate who cannot be reached or the surrogate who seems to refuse to understand or to be unable to understand the clinical situation. The analysis raises a question about the surrogate who simply disagrees with the medical team. One might think that such a surrogate is doing her job-the team just doesn't like how she is doing it. My analysis raises the question of whether (or perhaps when) she should be overridden. In approaching this problem, I focus not on the range of difficulties in practice but on the underlying moral conceptual issue. My concern will be to show that the moral values that underpin patient decision-making are fundamentally different from those that underpin surrogate decision-making. Identifying the distinctions will set parameters for any successful solution to the "Who should decide?" QUESTION: A patient has a specific kind of moral right to make her own medical decisions. A surrogate has no analogous moral right to decide for someone else. We want the surrogate to make the decision because we believe that she has a relevant epistemological advantage over anyone else on the scene. If and when she has no such advantage or if she refuses or is unable to use it, then there might not be sufficient reason to let her be the decision-maker.

A Justifiable Asymmetry.

It is a clinician's cliché that a physician only challenges a patient's capacity to make a treatment decision if that decision is not what the physician wants. Agreement is proof of decisional capacity; disagreement is proof or at least evidence of capacity's absence. It is assumed that this asymmetry cannot be justified, that the asymmetry must be a form of physicians' paternalism. Instead what is at issue when patient and physician disagree are usually two laudable impulses. The first is physicians' commitment to patients' well-being: physicians have a professional obligation as well as, ideally, a personal commitment to take care of patients--to do their best to bring about a positive medical outcome. The second impulse is common to much of human life, namely, the urge to find and to understand the source of our disagreements with one another. In this article we argue that, jointly, these impulses justify the asymmetry with regard to examining patients' capacity.

Whose interests count?

Whose interests should count and how should various interests be balanced at the pediatric patient's bedside? The interests of the child patient clearly count. Recently, however, many authors have argued that the family's interests also count. But how should we think about the interests of others? What does it mean to talk about "the family" in this context? Does it really just mean the interests of each individual family member? Or is the family itself a moral entity that has interests of its own independent of the interests of each of its members? Are such interests important only as they affect the patient's interest or also for their own sake? In this special supplement to Pediatrics, a group of pediatricians, philosophers, and lawyers grapple with these questions. They examine these issues from different angles and reach different conclusions. Jointly, they demonstrate the ethical importance and, above all, the ethical complexity of the family's role at the bedside.

"Pregnancy is not a disease": conscientious refusal and the argument from concepts.

In many American states, a health care worker has a legal right to immunity from employer sanction if she refuses to perform actions at odds with her conscience: she has a legal right to accommodation of her conscientious beliefs. A number of arguments have been advanced to defend or reject this right. These have tended to focus on the possibly conflicting interests of the health care worker and the patient. Recently, however, a new argument has been proposed to justify immunity from employer sanction. This argument rests on the premise that the scope of the very concepts of medicine and disease circumscribes the scope of proper medical practice. Procedures and activities that fall outside the scope of medicine and disease are not properly within the brief of health care personnel. This argument is important because, in principle, it stands outside the balancing of interests. Its central claim is nonsectarian-namely, that a person ought to do her job but need not do what is not her job. This claim avoids taking any stand in the culture wars. It is merely a claim about the logic of the concept "professional." The medical professional who refuses to perform a procedure is not asking for special treatment. On the contrary, she is asking to be treated normally-in accordance with the normal contours of her job. Of course, other arguments also seek to justify health care providers' immunity from employer sanction. Ultimately, these different arguments need to be prized apart and scrutinized one by one. This essay focuses on the argument from the concepts of medicine and disease, as a down payment on that larger project.

Responses to switching to maraviroc-based antiretroviral therapy in treated patients with suppressed plasma HIV-1-RNA load.

BACKGROUND: Maraviroc (MVC) has shown good efficacy and tolerability in treatment-naive and treatment-experienced HIV-1-infected patients with CCR5-tropic virus. Data on patients switching to MVC while on suppressive antiretroviral therapy (ART) are limited. The aim of this study was to evaluate patients on suppressive ART switching to an MVC-containing regimen (MVC-CR), and test the hypothesis that the switch may have an impact on T cell activation. METHODS: The study population comprised 20 treated adults who started MVC with a plasma HIV-1-RNA load (viral load, VL) of <50 copies/ml. Viral tropism was assessed by V3 loop sequencing using proviral DNA from peripheral blood mononuclear cells (PBMCs). Changes in clinical and laboratory parameters were evaluated at a median of 2 and 6 months of follow-up. T cell activation was determined by measuring soluble CD30 in plasma. RESULTS: Reasons for switching to a MVC-CR were drug toxicity and tolerability, low CD4 cell count and ART simplification. Over median 7.5 months of follow-up, 3/20 patients discontinued MVC due to severe headache, fatigue and VL rebound. A significant reduction in soluble CD30 levels in MVC-treated patients was observed during follow-up at both 2 (p = 0.027) and 6 months (p = 0.001). CONCLUSIONS: Switching suppressive ART to a MVC-CR based upon genotypic tropism prediction from proviral DNA improves tolerability. The observed impact on T cell activation warrants further investigation.

Temocillin use in England: clinical and microbiological efficacies in infections caused by extended-spectrum and/or derepressed AmpC ß-lactamase-producing Enterobacteriaceae.

BACKGROUND: Temocillin, a ß-lactam stable against most ß-lactamases [including extended-spectrum ß-lactamases (ESBLs) and derepressed AmpC cephalosporinases (dAmpC)], has been suggested as an alternative to carbapenems when Pseudomonas can be excluded. Aims To assess temocillin clinical and microbiological cure rates (CCR and MCR) in infection caused by ESBL/dAmpC-producing Enterobacteriaceae and the effects of different dosage regimens. METHODS: Data were collected retrospectively from patients treated for at least 3 days with temocillin for urinary tract infection (n = 42), bloodstream infection (n = 42) or hospital-acquired pneumonia (n = 8) in six centres in the UK. RESULTS: Data on 92 infection episodes were collected. Overall CCR and MCR were 86% and 84% respectively; ESBL/dAmpC status had no effect. Significantly higher CCR and MCR occurred in patients treated with temocillin at optimal dosage [2 g twice daily or renally adjusted equivalent (ORAE)] compared with those treated with a suboptimal dosage (<2 g twice daily ORAE) (CCR 91% and MCR 92% versus CCR 73% and MCR 63%). This difference was more pronounced in the ESBL/dAmpC-positive subset (CCR 97% and MCR 97% versus CCR 67% and MCR 50%). CONCLUSIONS: Clinical and microbiological efficacies of temocillin are unaffected by ESBL/dAmpC production, confirming its potential application as a carbapenem-sparing agent. Both CCR and MCR are optimized by a regimen of 2 g twice daily ORAE in ESBL/dAmpC-positive infection.

Agency and authenticity: which value grounds patient choice?

In current American medical practice, autonomy is assumed to be more valuable than human life: if a patient autonomously refuses lifesaving treatment, the doctors are supposed to let him die. In this paper we discuss two values that might be at stake in such clinical contexts. Usually, we hear only of autonomy and best interests. However, here, autonomy is ambiguous between two concepts-concepts that are tied to different values and to different philosophical traditions. In some cases, the two values (that of agency and that of authenticity) entail different outcomes. We argue that the comparative value of these values needs to be assessed.

Choosing for another: beyond autonomy and best interests.

According to bioethics orthodoxy, when we ask, "What would the patient choose?" the patient's autonomy is at stake. In fact, what underpins the moral force of that question is a value different from either autonomy or best interests. This is the value of doing things in a way that is authentic to the person.

Arrival of Klebsiella pneumoniae producing KPC carbapenemase in the United Kingdom.

BACKGROUND: KPC-type carbapenemases are increasingly prevalent in parts of the USA and Israel and are an emerging concern in South America, Europe and China. We investigated the UK's first two KPC-producing Klebsiella pneumoniae isolates. METHODS: The isolates were referred to the UK's national reference laboratory for confirmation of carbapenem resistance. Susceptibilities were determined by agar dilution, and bla(KPC) and Tn4401-like elements were sought by PCR and sequencing. Isolates were compared by PFGE of XbaI- and SpeI-digested genomic DNA. RESULTS: The isolates were from patients in different UK hospitals, with no epidemiological connection. Both were resistant to carbapenems (MICs > 16 mg/L), with imipenem MICs unchanged by EDTA, and also to all other beta-lactams (including inhibitor combinations), tobramycin, amikacin and ciprofloxacin. They were susceptible to gentamicin (MICs

Are alcoholics less deserving of liver transplants?

When does behavior trigger a lesser claim to medical resources? When does chronic drinking, for example, mean that one has a lesser claim to a liver transplant? Only when one's behavior becomes a callous indifference to others' needs--when one knows the consequences of heavy drinking and knows that by drinking one may end up depriving someone else of a liver.