The physician and prison hunger strikes: reflecting on the experience in Turkey.

The medical ethics of a physician's relationship with a prisoner who is participating in a collective hunger strike has become a major public, professional, and governmental concern in The Republic of Turkey. This article examines the Turkish experience and debate about physician ethics during prison hunger strikes. It is hoped that this analysis will be of use to those formulating policy in similar situations.

Behavioural assessment for HIV prevention: a model programme design.

This paper describes a model HIV prevention programme for relief agencies working in extremely impoverished or socially disrupted areas. A detailed behavioural inventory is proposed to assess: sexual behaviours, traditional cutting procedures, midwifery practices, the availability of injectables and injection equipment in local markets, the use of intoxicants, sex workers, prisons, military behaviours, community beliefs, and the performance of the community health infrastructure. The needs of AIDS orphans and the stigmatizations of person's with AIDS are also assessed. This assessment also examines who has authority to address these issues and what measures of programme assessment could be used for each programme area. The model is currently being tested in south Sudan.

The health effects of economic sanctions and embargoes: the role of health professionals. Ethics and Human Rights Committee.

As a widely used tool of foreign policy, economic sanctions take many forms. They include mandating trade restrictions (for example, limiting imports from or exports to a sanctioned nation), freezing bank accounts, limiting international travel to and from an area, imposing additional tariffs, and exerting other pressures that are intended to slow key economic activities. Since the end of the Cold War, as the global market has expanded, many countries and the United Nations have increasingly used economic sanctions instead of military intervention to compel nations to end civil or extraterritorial war or to reduce abuse of human rights. Similarly, the United States has attempted to influence international governments' domestic policies by using other economic means, such as relating "most favored nation" trading status to a country's human rights record or prohibiting the import of goods from countries in which illegal child labor is widespread. Repercussions from these measures influence a country's economic development and, therefore, can also affect the overall welfare of a nation's population. In contrast to war's easily observable casualties, the apparently nonviolent consequences of economic intervention seem like an acceptable alternative. However, recent reports suggest that economic sanctions can seriously harm the health of persons who live in targeted nations. For this reason, the American College of Physicians-American Society of Internal Medicine has undertaken this examination of physicians' roles in addressing the health effects of economic sanctions.

Holocaust survivors' perspectives on the euthanasia debate.

The paper reports on a qualitative analysis of 15 personal interviews with holocaust survivors in Israel concerning their perceptions of similarities and differences between socially-assisted dying and the holocaust policies. The design of the study was exploratory/descriptive and asked the following questions: "Some discussions have expressed similarities between Nazi Germany and euthanasia. Do you believe the comparison is justified? In what ways are euthanasia and the holocaust similar? In what ways are they different?" Participants concluded that profound differences existed between Nazi Germany and socially assisted dying. These differences were established from four different perspectives in 10 different themes, and demonstrated by 24 different examples of the themes. Informants further cautioned philosophers about comparisons between the holocaust and other human behaviors. The survivors perceived that such a comparison has negative consequences for their own well-being, the dignity of their family members, the next generation and the Israeli society.

Deaths caused by bedrails.

OBJECTIVES: To determine how bedrails cause death in order to suggest clinical and ergonomic changes to prevent such deaths and to promote research to improve the use and design of bed systems. DESIGN: A review of reports of adult deaths and injuries from bedrails contained in the United States Consumer Product Safety Commission Death Certificate File and its Reported Incidents File and its National Injury Information Clearinghouse Accident Investigations from 1993 to 1996. Deaths involving the use of vest restraints were excluded. We reconstructed, reenacted, and have graphically depicted major patterns of deaths. A review of the literature to 1966 was also done. RESULTS: The 74 deaths described are categorized into three types: (1) 70% were entrapments between the mattress and a rail so that the face was pressed against the mattress, (2) 18% were entrapment and compression of the neck within the rails, and (3) 12% were deaths caused by being trapped by the rails after sliding partially off the bed and having the neck flexed or the chest compressed. CONCLUSIONS: Deaths from bedrails are underrecognized and preventable clinical events that can occur in any medical setting. Preventing these events will require a unified redesign of the relationships between rails, mattresses, and beds, which are now often assembled and used as separate products. Clinicians can prevent many of these deaths by using bedrails much more judiciously, confirming the proper relationships between beds, rails and mattresses, and using alarms.

Advance end-of-life treatment planning. A research review.

The year 1996 marks the fifth anniversary of the federal Patient Self-Determination Act. The Patient Self-Determination Act required hospitals, nursing homes, and health plans to ask whether patients have advance directives and to incorporate them into the medical record. A "living will" is an advance directive by which a person tells caregivers the circumstances in which life-sustaining treatment is to be provided or forgone if the patient is unable to communicate. A "durable power of attorney for health care" enables one to designate a person to speak on his or her behalf if the author loses decision-making capacity. "Advance planning" is the process of reflection, discussion, and communication of treatment preferences for end-of-life care that precedes and may lead to an advance directive.

Untying the elderly. 1989 to 1993 update.

Research and public policy pertaining to the use of physical restraints has advanced since Evans' and Strumpfs' 1989 review. Research better delineates the harms caused by restraints, although not finding benefits. Federal law sharply restricts the use of restraints. Legal liability weighs against the use of restraints in most instances. Nursing homes have published substantial experience with programs to reduce and eliminate the use of physical restraints.

Academic health centers and health care reform.

There is increasing support for the proposition that academic health centers have a duty to accept broad responsibility for the health of their communities. The Health of the Public program has proposed that centers become directly involved in the social-political process as advocates for reform of the health care system. Such engagement raises important issues about the roles and responsibilities of centers and their faculties. To address these issues, the authors draw upon the available literature and their experiences in recent health care reform efforts in Minnesota and Vermont in which academic health center faculty participated. The authors discuss (1) the problematic balance between academic objectivity and social advocacy that faculty must attempt when they engage in the health care reform process; (2) the management of the sometimes divergent interests of academic health centers, some of their faculty, and society (including giving faculty permission to engage in reform efforts and developing a tacit understanding that distinguishes faculty positions on reform issues from the center's position on such issues); and (3) the challenge for centers to develop infrastructure support for health reform activities. The authors maintain that academic health centers' participation in the process of health care reform helps them fulfill the trust of the public that they are obligated to and ultimately depend on.

Contributions of empirical research to medical ethics.

Empirical research pertaining to cardiopulmonary resuscitation (CPR), clinician behaviors related to do-not-resuscitate (DNR) orders and substituted judgment suggests potential contributions to medical ethics. Research quantifying the likelihood of surviving CPR points to the need for further philosophical analysis of the limitations of the patient autonomy in decision making, the nature and definition of medical futility, and the relationship between futility and professional standards. Research on DNR orders has identified barriers to the goal of patient involvement in these life and death discussions. The initial data on surrogate decision making also points to the need for a reexamination of the moral basis for substituted judgment, the moral authority of proxy decision making and the second-order status of the best interests standard. These examples of empirical research suggest that an interplay between empirical research, ethical analysis and policy development may represent a new form of interdisciplinary scholarship to improve clinical medicine.

Commentary: Ms. Lubell's complaint (a fictional clinical record)

Imagining a case from the viewpoint of a family member rather than of the patient redirects moral attention to issues overlooked when the patient is the focus of concern.