How Bioethics and Case Law Diverge in Assessments of Mental Capacity: An Argument for a Narrative Coherence Standard.

Clinical assessments of mental capacity have long been guided by four basic cognitive criteria (understanding, appreciation, ability to reason, communication of decision), distilled directly from widespread legal precedent in common law cases of informed consent and refusal. This article will challenge the sufficiency of these legal criteria at the bedside on the assertion that clinicians and bioethicists who evaluate decisional capacity face questions far deeper than the mere presence or absence of a patient's informed consent. It will then present an additional standard beyond the existing cognitive criteria - to be called the Narrative Coherence Standard - that may begin to bridge the gap between the existing legal standards and higher-order bioethical priorities. This standard will be treated with a philosophical argument for its use, as well as a detailed exploration of its technical components and conceptual underpinnings.

A Futile Use of Futility.

As the rates of intravenous opioid use have increased, so have its associated medical complications, such as endocarditis, and known interventions, such as heart-valve replacements. For many patients, including Jacob, whose case was brought to my psychiatric consult service and to my colleagues in the clinical ethics service, relapse increases the risk of repeat endocarditis and the need for repeat surgical interventions. Previous works have posed the bioethical quandary regarding the responsibilities of a surgeon in these repeat procedures and whether a surgeon may ethically refuse to perform a repeat intervention in a patient who has relapsed. Notions of futility are commonly used to navigate this complex terrain, and they were the focus of the ethics consideration given to Jacob's case, in which surgeons were reluctant to perform valve replacements. In this narrative essay, I interrogate the concept of futility by appealing to its history and variable meanings, and I argue against its relevance in cases like Jacob's. I propose that a more suitable bioethical approach in such cases would consider resource allocation, the sociocultural stigma of addiction, and the interpersonal and narrative factors that make each case unique.

Granulomatous mastitis: changing clinical and imaging features with image-guided biopsy correlation.

OBJECTIVES: To review clinical presentation, revisit patient demographics and imaging findings in granulomatous mastitis and determine the optimal biopsy method for diagnosis. METHODS: A retrospective study was performed to review the clinical presentation, imaging findings and biopsy methods in patients with granulomatous mastitis. Twenty-seven patients with pathology-proven granulomatous mastitis were included. RESULTS: The average age at presentation was 38.0 years (range, 21-73 years). Seven patients were between 48 and 73 years old. Twenty-four patients presented with symptoms and three patients were asymptomatic. Nineteen patients were imaged with mammography demonstrating mammographically occult lesions as the predominant finding. Twenty-six patients were imaged with ultrasound and the most common finding was a mass lesion. Pathological diagnosis was made by image-guided biopsy in 44 % of patients. The imaging features of granulomatous mastitis on mammography are infrequently described. CONCLUSIONS: Our study demonstrates that granulomatous mastitis can occur in postmenopausal or asymptomatic patients, although previously reported exclusively in young women with palpable findings. Presentation on mammography as calcifications requiring mammographically guided vacuum-assisted biopsy has not been previously described. The diagnosis of granulomatous mastitis can easily be made by image-guided biopsy and surgical excision should be reserved for definitive treatment. KEY POINTS: • Characterizes radiographic appearance of granulomatous mastitis in postmenopausal or asymptomatic patients. • Granulomatous mastitis can present exclusively as calcifications on mammography. • The diagnosis of granulomatous mastitis is made by image-guided biopsy techniques.