The Ashley treatment: a step too far, or not far enough?

This "current controversies" contribution describes the recent case of a severely disabled six year old girl who has been subjected to a range of medical interventions at the request of her parents and with the permission of a hospital clinical ethics committee. The interventions prescribed have become known as "the Ashley treatment" and involve the performance of invasive medical procedures (eg, hysterectomy) and oestrogen treatment. A central aim of the treatment is to restrict the growth of the child and thus make it easier for her parents to care for her at home. The paper below discusses the main objections to the treatment. It concludes that the most serious concern raised by the case is that it may set a worrying precedent if the moral principle employed in justification of the treatment is applied again to endorse it in similar circumstances. Finally, it raises the possibility that that same moral principle may even be invoked to justify more radical interventions than those that were actually performed in the Ashley treatment.

The impairment/disability distinction: a response to Shakespeare.

Tom Shakespeare's important new book includes, among other topics, a persuasive critique of the social model of disability. A key component in his case against that model consists in an argument against the impairment/disability distinction as this is understood within the social model. The present paper focuses on the case Shakespeare makes against that distinction. Three arguments mounted by Shakespeare are summarised and responded to. It is argued that the responses adequately rebut Shakespeare's case on this specific issue. Moreover, as the engagement with Shakespeare's argument illustrates, his claim to employ a critical realist perspective appears to be in considerable tension with the case he offers against the impairment/disability distinction.

Suitability of electrosurgical analysers for routine maintenance testing of electrosurgery units - a technical note.

PRIMARY OBJECTIVE: To evaluate the use of electrosurgical analysers in testing power output and leakage current from an electrosurgery unit and compare this to the manufacturer recommendations for routine testing. METHOD: Two electrosurgical analysers were compared to reference measurements (carried out using non-inductive resistors, a current transformer and oscilloscope) over a range of tests described in IEC 60601-2-2: 1998 measuring power output and leakage currents in different conditions. The analysers used were Metron QA-ES and Fluke 454A. OUTCOMES: Both analysers gave similar results to the reference measurements for power output. The Metron QA-ES gave similar results to the reference measurements for leakage current testing; however the Fluke 454A gave substantially different results when used as described in the manual. CONCLUSIONS: Electrosurgical analysers can be a valuable tool in the workshop, enabling rapid, accurate testing of electrosurgery equipment without needing additional equipment and setting up times. Not all analysers can perform all the tests that may be needed and in some cases the accuracy of the results is questionable. Users must be certain of the capabilities and limitations of the analyser before making decisions based on the results.

Moral perspectives on the prevention of suicide in mental health settings.

The response to suicidal clients is a recurrent and deep ethical problem in mental health practice. Rational suicide is rarely considered in relation to psychological suffering and is generally only discussed within the literature in connection with terminal illness. Focusing on a case example derived from a composite of patient experiences, this paper considers the premise that suicidal ideation may not be an irrational belief arising from mental disorder and analyses the ethical aspects of nursing care through the competing moral frameworks of the care-based and principle-based approaches to nursing ethics. We conclude that when the client is not capable of autonomous decision making, the two approaches lead to the same response. But when the client is capable of autonomous decision making, the two approaches lead to different responses. Specifically, from the care-based perspective, intervention to prevent suicide is easier to justify and helps formulate a nursing response, which promotes hope through the engagement.

Transhumanism, medical technology and slippery slopes.

In this article, transhumanism is considered to be a quasi-medical ideology that seeks to promote a variety of therapeutic and human-enhancing aims. Moderate conceptions are distinguished from strong conceptions of transhumanism and the strong conceptions were found to be more problematic than the moderate ones. A particular critique of Boström's defence of transhumanism is presented. Various forms of slippery slope arguments that may be used for and against transhumanism are discussed and one particular criticism, moral arbitrariness, that undermines both weak and strong transhumanism is highlighted.

Ethical concerns regarding guidelines for the conduct of clinical research on children.

In this article we examine ethical aspects of the involvement of children in clinical research, specifically those who are incapable of giving informed consent to participate. The topic is, of course, not a new one in medical ethics but there are some tensions in current guidelines that, in our view, need to be made explicit and which need to be responded to by the relevant official bodies. In particular, we focus on tensions between the World Medical Association Declaration of Helsinki, and the guidance offered by the British Medical Association, the Royal College of Paediatrics and Child Health (formerly the British Paediatric Association), and the Council for International Organizations of Medical Sciences. We conclude with a call for these organisations to make their guidance explicit in relation to the World Medical Association Declaration.

Disability, identity and the "expressivist objection".

The practice of prenatal screening for disability is sometimes objected to because of the hurt and offence such practices may cause to people currently living with disabilities. This objection is commonly termed "the expressivist objection". In response to the objection it is standardly claimed that disabilities are analogous to illnesses. And just as it would be implausible to suppose reduction of the incidence of illnesses such as flu sends a negative message to ill people, so it is not plausible to suppose prevention of disability sends a negative message to disabled people. The expressivist objection hinges, however, upon a view of the relationship between disability and self identity which sees disability as part of the identity of the disabled person, in a way in which illnesses such as flu cannot be. This possibility is generally not considered in critiques of the expressivist objection. In this paper, an "identity claim" to the effect that disabilities can be identity constituting is accepted and the force of the expressivist argument is reconsidered in the light of its acceptance. It is concluded that even when such an identity claim is accepted, the expressivist objection is still not morally compelling.

Psychological well-being in South African university students.

Black university students in South Africa reported lower mean rated psychological well-being than U.S. subjects. Social and political factors may contribute to these differences.

Prenatal genetic screening for intellectual disability.

BACKGROUND: This paper argues that the main ground for the moral justification of screening and termination of foetuses on grounds of intellectual disability stems from a conception of what it is to lead a good human life. METHOD: Having established this claim, three well-known philosophical theories of a good human life are briefly presented. CONCLUSION: In the light of consideration of these theories, it is proposed that life with intellectual disability is not necessarily incompatible with the conditions necessary for leading a good human life.

Depression among university students in South Africa.

Of 129 first-year students at an historically Black university students in psychology reported significantly less depression than nonpsychology students, and younger students reported significantly lower scores on depression than older students on the Beck Depression Inventory.

Prevention of disability on grounds of suffering.

This paper examines one particular justification for the screening and termination of embryos/fetuses which possess genetic features known to cause disability. The particular case is that put forward in several places by John Harris. He argues that the obligation to prevent needless suffering justifies the prevention of the births of disabled neonates. The paper begins by rehearsing Harris's case. Then, drawing upon claims advanced in a recent paper in the Journal of Medical Ethics, it is subjected to critical scrutiny, focusing on Harris's "suffering claim" (the claim that a life with disability inevitably involves suffering on a significant scale).(1) It is argued that the suffering claim must be false if understood as an empirical claim. And, even if understood as a conceptual truth, it mistakenly assimilates the concepts of harm and suffering. Finally, again focusing on Harris's recent work in this area, his characterisation of disability as a "harmed condition" is shown not to apply in the case of at least some moderate forms of intellectual disability.

Anxiety among university students in South Africa.

Of 214 first-year students in an historically Black university, 17.8% scored in the Severe range on the Beck Anxiety Inventory. Sex and rural or urban background were not significant factors.

The 2.7 A crystal structure of the activated FERM domain of moesin: an analysis of structural changes on activation.

Moesin binds to a large range of proteins through its N terminal FERM (band 4.1, ezrin, radixin, moesin) domain. In full-length moesin isolated from cells, this binding is masked by binding to the C-terminal domain of moesin (C-ERMAD). Activation takes place by phosphorylation of Thr 558 in the C-ERMAD, which releases the C-ERMAD. A recently determined crystal structure of a noncovalent complex of the FERM and C-ERMAD domains showed for the first time that the structure of the FERM domain consists of three subdomains, each of which is similar to known structures. The structure reported here also contains a unique 47-residue helix pointing away from the FERM domain at the start of the alpha domain, in agreement with secondary structure predictions. Removal of the C-ERMAD does not result in a huge rearrangement of the FERM domain, but comparison with the activated radixin structure shows a consistent set of small changes. Not surprisingly, the exposed C-ERMAD binding area interacts in crystal contacts. More interestingly, a negatively charged peptide binds to the inositol site in a crystal contact and causes a greater conformational change in the structure than inositol.

Benner and Wrubel on caring in nursing.

AIMS: To explain the distinction between intentional and ontological care; to explain the distinction, within the category of ontological care, between deep care and identity constituting care and to show how the latter form of care is of relevance to nursing theory and practice. BACKGROUND: The idea of intentional care is familiar in much writing on care within nursing literature. Within Benner and Wrubel's book The Primacy of Caring, Stress and Coping in Health and Illness the idea of ontological care is exploited. But many interpret their claims on this topic as claims concerning intentional care. The present paper tries to clarify this misunderstanding. CONCLUSION: The notions of intentional and ontological care are each important within nursing theory and practice. But it is also important to understand how they differ. And it is equally important to appreciate how the idea of ontological care applies to nursing practice.

Biodistribution of 99Tcm-labelled 5-thio-D-glucose.

We studied the biodistribution and tumour localization of 99Tcm-labelled-5-thio-D-glucose (99Tcm-TG). 5-Thio-D-glucose was labelled with 99Tcm by direct stannous ion reduction. The biodistribution of 99Tcm-TG was investigated in normal rabbits and in mice bearing experimental tumours. In rabbits, the plasma and clearance of 99Tcm-TG was 14.5 +/- 2.0 and 11.3 +/- 3.0 ml.min-1 respectively. Urinary excretion at 1 h was 53 +/- 5%. 99Tcm-TG was injected intravenously in mice bearing MC26 colon carcinoma and tissue samples were analysed by gamma scintillation counting at various times. Uptake of 99Tcm-TG in tumour at 1 and 3 h was 1.6 +/- 0.3% and 1.2 +/- 0.3%; the tumour to muscle ratios were 2.7:1 and 4:1 respectively. The autoradiographic biodistribution of 99Tcm-TG in MX-1 human breast xenografted nude mice showed more persistent tumour uptake of 99Tcm-TG than 14C-2-deoxyglucose (14C-DG). 99Tcm-TG accumulated in the centre of the tumours; 14C-DG was decreased in this central region probably because of zones of infarction on necrosis. The discordance between the tumour uptake of 99Tcm-TG and 14C-DG indicates that 99Tcm-TG does not act like a glucose analog, suggesting 99Tcm-TG avidity for zones of infarction or necrosis. The further study of 99Tcm-TG in tumours and ischaemic injury is warranted.

The idea of nursing science.

This paper addresses the question of whether or not nursing can legitimately be considered as a science. It is proposed that an adequate answer to this question requires consideration of recent developments in philosophy of science (as urged by Paley). It is shown that such developments call into question the 'rational image' of science. However, a defence of the legitimacy of the scientific enterprise has been attempted by Laudan, an advocate of the 'historical turn'. Two conditions necessary for the applicability of this 'turn' are identified. It is shown that although they apply relatively unproblematically to science, they do not readily apply to nursing. Hence the conclusion is drawn that claims for the integrity of nursing science stand in need of much further development.

The art of nursing.

This article discusses the question of whether, as is often claimed, nursing is properly described as an art. Following critical remarks on the claims of Carper, Chinn and Watson, and Johnson, the account of art provided by RG Collingwood is described, with particular reference to his influential distinction between art and craft. The question of whether nursing is best described as an art or a craft is then discussed. The conclusion is advanced that nursing cannot properly be described as an art, given acceptance of Collingwood's influential definition of art. Moreover, it is shown that, due to difficulties inherent in specifying the 'ends' of nursing, nursing is only problematically described as a craft.

Nordenfelt's theory of disability.

This paper is an attempt to provide a critical evaluation of the theory of disability put forward by Lennart Nordenfelt. The paper is in five sections. The first sets out the main elements of Nordenfelt's theory. The second section elaborates the theory further, identifies a tension in the theory, and three kinds of problems for it. The tension derives from Nordenfelt's attempt to respect two important but conflicting constraints on a theory of health. The problems derive from characterisation of the goals of persons; the difficulty which Nordenfelt has in respecting the plausible view that there is a distinction between illness and disability; and the presence in the theory of other strongly counterintuitive implications. In section three a defence of Nordenfelt is attempted from within the resources available within his own theory. This defence seeks to exploit his distinctions between a person who is ill and one who is 'generally disabled' and that between first- and second-order disabilities. However, it is concluded that there are insufficient resources within Nordenfelt's theory to fend off the criticisms developed in section two. The fourth section of the paper attempts a defence of Nordenfelt. It is claimed that introduction of the concept of capacity helps to explain differences between problem cases in the theory. Finally, it is shown that at least two important constraints on any theory of disability emerge from the preceding discussion.

The body as object versus the body as subject: the case of disability.

This paper is prompted by the charge that the prevailing Western paradigm of medical knowledge is essentially Cartesian. Hence, illness, disease, disability, etc. are said to be conceived of in Cartesian terms. The paper attempts to make use of the critique of Cartesianism in medicine developed by certain commentators, notably Leder (1992), in order to expose Cartesian commitments in conceptions of disability. The paper also attempts to sketch an alternative conception of disability--one partly inspired by the work of Merleau-Ponty. In particular, three key Cartesian claims are identified and subjected to criticism. These are as follows: (a) The claim that the body is an object, (b) what is termed here 'the modularity thesis', and (c) the claim that the body cannot be constitutive of the self (i.e. since the soul/mind/brain is). In opposition to these claims, it is argued that the body is properly viewed as a subject; that there are neither purely mental, nor purely physical disabilities; and that selves are constituted, at least in part, by their bodies.