General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery.

In this article, we describe an extension of general anaesthesia - beyond facilitating surgery - to the relief of suffering during dying. Some refractory symptoms at the end of life (pain, delirium, distress, dyspnoea) might be managed by analgesia, but in high doses, adverse effects (e.g. respiratory depression) can hasten death. Sedation may be needed for agitation or distress and can be administered as continuous deep sedation (also referred to as terminal or palliative sedation) generally using benzodiazepines. However, for some patients these interventions are not enough, and others may express a clear desire to be completely unconscious as they die. We summarise the historical background of an established practice that we refer to as 'general anaesthesia in end-of-life care'. We discuss its contexts and some ethical and legal issues that it raises, arguing that these are largely similar issues to those already raised by continuous deep sedation. To be a valid option, general anaesthesia in end-of-life care will require a clear multidisciplinary framework and consensus practice guidelines. We see these as an impending development for which the specialty should prepare. General anaesthesia in end-of-life care raises an important debate about the possible role of anaesthesia in the relief of suffering beyond the context of surgical/diagnostic interventions.

Patient values informing medical treatment: a pilot community and advance care planning survey.

Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors. OBJECTIVES: We sought to identify priorities of care for patients attending an advance care planning (ACP) clinic and among the general population, and to identify factors associated with priorities other than prolonging life. METHODS: We used a locally developed survey tool 'What Matters Most' to identify values. Choices presented were: maintaining dignity, avoiding pain and suffering, living as long as possible, and remaining independent. Participants rated the importance of each and then selected a main priority for their doctor. Participant groups were a purposive sample of 382 lay people from the general population and 100 attendees at an ACP clinic. RESULTS: Living as long as possible was considered to be less important than other values for ACP patients and for the general population. Only 4% of ACP patients surveyed and 2.6% of our general population sample selected 'living as long as possible' as their top priority for medical treatment. CONCLUSIONS: 'Living as long as possible' was not the most important value for ACP patients, or for a younger general population. Prioritisation of other goals appeared to be independent of extreme age or illness. When end of life treatment is being discussed with patients, priorities other than merely prolonging life should be considered.

Responsibility, prudence and health promotion.

This article considers the role of responsibility in public health promotion. Efforts to tackle non-communicable diseases which focus on changing individual behaviour and reducing risk factor exposure sometimes invoke individual responsibility for adopting healthy lifestyles. We provide a critical discussion of this tendency. First, we outline some key distinctions in the philosophical literature on responsibility, and indicate how responsibility is incorporated into health promotion policies in the UK. We argue that the use of some forms of responsibility in health promotion is inappropriate. We present an alternative approach to understanding how individuals can 'take responsibility' for their health, based on the concept of prudence (i.e. acting in one's interests). In this discussion, we do not prescribe or proscribe specific health promotion policies. Rather, we encourage public health professionals to consider how underlying assumptions (in this case, relating to responsibility) can shape health promotion policy, and how alternative framings (such as a shift from encouraging individual responsibility to facilitating prudence) may justify different kinds of action, for instance, shaping environments to make healthy behaviours easier, rather than using education as a tool to encourage responsible behaviour.

Risk assessment tools in criminal justice and forensic psychiatry: The need for better data.

Violence risk assessment tools are increasingly used within criminal justice and forensic psychiatry, however there is little relevant, reliable and unbiased data regarding their predictive accuracy. We argue that such data are needed to (i) prevent excessive reliance on risk assessment scores, (ii) allow matching of different risk assessment tools to different contexts of application, (iii) protect against problematic forms of discrimination and stigmatisation, and (iv) ensure that contentious demographic variables are not prematurely removed from risk assessment tools.

The Intensive Care Lifeboat: a survey of lay attitudes to rationing dilemmas in neonatal intensive care.

BACKGROUND: Resuscitation and treatment of critically ill newborn infants is associated with relatively high mortality, morbidity and cost. Guidelines relating to resuscitation have traditionally focused on the best interests of infants. There are, however, limited resources available in the neonatal intensive care unit (NICU), meaning that difficult decisions sometimes need to be made. This study explores the intuitions of lay people (non-health professionals) regarding resource allocation decisions in the NICU. METHODS: The study design was a cross-sectional quantitative survey, consisting of 20 hypothetical rationing scenarios. There were 119 respondents who entered the questionnaire, and 109 who completed it. The respondents were adult US and Indian participants of the online crowdsourcing platform Mechanical Turk. Respondents were asked to decide which of two infants to treat in a situation of scarce resources. Demographic characteristics, personality traits and political views were recorded. Respondents were also asked to respond to a widely cited thought experiment involving rationing. RESULTS: The majority of respondents, in all except one scenario, chose the utilitarian option of directing treatment to the infant with the higher chance of survival, higher life expectancy, less severe disability, and less expensive treatment. As discrepancy between outcomes decreased, however, there was a statistically significant increase in egalitarian responses and decrease in utilitarian responses in scenarios involving chance of survival (P = 0.001), life expectancy (P = 0.0001), and cost of treatment (P = 0.01). In the classic 'lifeboat' scenario, all but two respondents were utilitarian. CONCLUSIONS: This survey suggests that in situations of scarcity and equal clinical need, non-health professionals support rationing of life-saving treatment based on probability of survival, duration of survival, cost of treatment or quality of life. However, where the difference in prognosis or cost is very small, non-health professionals preferred to give infants an equal chance of receiving treatment.

Noradrenaline effects on social behaviour, intergroup relations, and moral decisions.

Recent research has begun to elucidate the neural basis of higher order social concepts, such as the mechanisms involved in intergroup relations, and moral judgments. Most theories have concentrated on higher order emotions, such as guilt, shame, or empathy, as core mechanisms. Accordingly, psychopharmacological and neurobiological studies have investigated the effects of manipulating serotonin or oxytocin activity on moral and social decisions and attitudes. However, recently it has been determined that changes in more basic emotions, such as fear and anger, might also have a significant role in social and moral cognition. This article summarizes psychopharmacological and fMRI research on the role of noradrenaline in higher order social cognition suggesting that indeed noradrenergic mediated affective changes might play key - and probably causal - role in certain social attitudes and moral judgments. Social judgments may also be directly influenced by numerous neurotransmitter manipulations but these effects could be mediated by modulation of basic emotions which appear to play an essential role in the formation of social concepts and moral behaviour.

ß-Adrenoceptor blockade modulates fusiform gyrus activity to black versus white faces.

INTRODUCTION: The beta-adrenoceptor antagonist propranolol is known to reduce peripheral and central activity of noradrenaline. A recent study found that intervention with propranolol diminished negative implicit racial bias. MATERIALS AND METHOD: The current study used functional magnetic resonance imaging (fMRI) in order to determine the neural correlates of this effect. Healthy volunteers (N = 40) of white ethnic origin received a single oral dose (40 mg) of propranolol, in a randomised, double-blind, parallel group, placebo-controlled design, before viewing unfamiliar faces of same and other race. RESULTS AND DISCUSSION: We found significantly reduced activity in the fusiform gyrus and thalamus following propranolol to out-group faces only. Additionally, propranolol lowered the implicit attitude score, without affecting explicit prejudice measure. CONCLUSION: These findings suggest that noradrenaline pathways might modulate racial bias by acting on the processing of categorisation in the fusiform gyrus.

Perinatal management of trisomy 18: a survey of obstetricians in Australia, New Zealand and the UK.

OBJECTIVE: The objective of this study was to explore the attitudes of obstetricians in Australia, New Zealand and the UK towards prenatally diagnosed trisomy 18 (T18). METHOD: Obstetricians were contacted by email and invited to participate in an anonymous electronic survey. RESULTS: Survey responses were obtained from 1018/3717 (27%) practicing obstetricians/gynaecologists. Most (60%) had managed a case of T18 in the last 2 years. Eighty-five per cent believed that T18 was a 'lethal malformation', although 38% expected at least half of liveborn infants to survive for more than 1 week. Twenty-one per cent indicated that a vegetative existence was the best developmental outcome for surviving children. In a case of antenatally diagnosed T18, 95% of obstetricians would provide a mother with the option of termination. If requested, 99% would provide maternal-focused obstetric care (aimed at maternal wellbeing rather than fetal survival), whereas 80% would provide fetal-oriented obstetric care (to maximise fetal survival). Twenty-eight per cent would never discuss the option of caesarean; 21% would always discuss this option. Management options, attitudes and knowledge of T18 were associated with location, practice type, gender and religion of obstetricians. CONCLUSION: There is variability in obstetricians' attitudes towards T18, with significant implications for management of affected pregnancies.

Functional neuroimaging and withdrawal of life-sustaining treatment from vegetative patients.

Recent studies using functional magnetic resonance imaging of patients in a vegetative state have raised the possibility that such patients retain some degree of consciousness. In this paper, the ethical implications of such findings are outlined, in particular in relation to decisions about withdrawing life-sustaining treatment. It is sometimes assumed that if there is evidence of consciousness, treatment should not be withdrawn. But, paradoxically, the discovery of consciousness in very severely brain-damaged patients may provide more reason to let them die. Although functional neuroimaging is likely to play an increasing role in the assessment of patients in a vegetative state, caution is needed in the interpretation of neuroimaging findings.

Research ethics and lessons from Hwanggate: what can we learn from the Korean cloning fraud?

In this review of the Korean cloning scandal involving Woo-Suk Hwang, the nature of the disaster is documented and reasons why it occurred are suggested. The general problems it raises for scientific research are highlighted and six possible ways of improving practice are offered in the light of this case: (1) better education of science students; (2) independent monitoring and validation; (3) guidelines for tissue donation for research; (4) fostering of debate about ethically contentious research in science journals; (5) development of an international code of ethical research practice; (6) fostering of public involvement in ethical review and debate through the web.

Children's consent and paediatric research: is it appropriate for healthy children to be the decision-makers in clinical research?

AIM: To determine the appropriateness of asking healthy children to make a decision regarding participation in a research study. METHODS: Participants constituted a group of children taking part in a follow-up to a vaccine study which involved a blood test to look at the persistence of antibodies. Information about the study was given to each child and following venepuncture an oral questionnaire was completed to establish understanding of the vaccine study. Parental views concerning their child's ability to make a decision regarding research participation were also sought. RESULTS: 73 children participated overall. Following venepuncture 59% (n = 43) had grasped some aspect of the reasoning behind venepuncture with 33% (n = 24) unclear. The majority of parents (n = 55) and a substantial number of children (n = 28) believed that the parent should make the decision about study participation, although it is clear that a significant minority of parents thought it is right to involve the child in that process. CONCLUSION: New guidance about the requirements for informed consent involving children in research is needed, which can respect the autonomy of the child and the role of the parent, while recognising the limited capacity of some children to understand age-appropriate information.

Do oncologists discuss expensive anti-cancer drugs with their patients?

BACKGROUND: In Australia, some anti-cancer drugs are only available at significant financial cost to patients. We sought the views and practices of Australian medical oncologists regarding discussion of high cost drugs (HCDs). PARTICIPANTS AND METHODS: A postal survey was mailed to all 274 members of the Medical Oncology Group of Australia. Three clinical scenarios described HCDs associated with either improved overall survival, encouraging response rate in a treatment-refractory cancer, or a scenario with improved treatment tolerability. Participants were asked about their discussion and prescription of HCDs. RESULTS: There was a 78% response rate. Most respondents were male (71%), worked in a metropolitan practice (87%) and spent more than 50% of their working time in patient care (87%). Forty-eight percent had previously prescribed a HCD. In the three scenarios, respondents would generally prescribe the drug if it were subsidised, however, between 28% and 41% (depending on the scenario) would not mention the HCD if it were not subsidised. Major reasons for not mentioning the HCD were concerns that discussion would 'worry the patient' or that the doctor would 'feel bad'. CONCLUSIONS: Despite literature suggesting that patients wish to be well informed and active participants in decision making, the practice of a significant percentage of Australian medical oncologists may prevent this.

What should we say?

Abstract ethics mostly focuses on what we do. One form of action is a speech act. What we say can have profound effects. We can and should choose our words and how we speak wisely. When someone close to us suffers an injury or serious illness, a duty of beneficence requires that we support that person through beneficial words or actions. Though our intentions are most often benign, by what we say we often make the unfortunate person feel worse. Beginning with two personal accounts, this article explains what can go wrong in the compassionate speech of wellwishers, and uncovers some of the reasons why people say things that are hurtful or harmful. Despite a large body of clinical evidence, there is no perfect strategy for comforting a friend or relative who is ill, and sometimes even the best thing to say can still be perceived as insensitive and hurtful. In some cases, we may have good reason to knowingly say a hurtful or insensitive thing. Saying these 'wrong' things can sometimes be the best way to help a person in the long term. To complicate matters, there can be moral reasons for overriding what is good for the patient. What kind of admonishments should we make to a badly behaved patient? What is the value of authenticity in our communication with the people we love? These questions demand an ethical defence of those speech acts which are painful to hear but which need to be said, and of those which go wrong despite the best efforts of the wellwisher. We offer an ethical account, identifying permissible and impermissible justifications for the things we say to a person with a serious injury or illness.

Ethical considerations in presymptomatic testing for variant CJD.

Variant Creutzfeldt-Jakob disease (vCJD) is a fatal, transmissible, neurodegenerative disorder for which there is currently no effective treatment. vCJD arose from the zoonotic spread of bovine spongiform encephalopathy. There is now compelling evidence for human to human transmission through blood transfusions from presymptomatic carriers and experts are warning that the real epidemic may be yet to come. Imperatives exist for the development of reliable, non-invasive presymptomatic diagnostic tests. Research into such tests is well advanced. In this article the ethical implications of the availability of these tests are elaborated and comparisons drawn with predictive genetic testing for Huntington's disease and screening for HIV. Paramount to considerations is the issue of whom to test, weighing up respect for personal autonomy against obligations to benefit and protect society. A paradigm is proposed similar to that used for HIV screening but with unique features: compulsory testing of all blood/organ donors and individuals undergoing surgery or invasive procedures who have a significant risk of disease transmission.

What makes the best medical ethics journal? A North American perspective.

BACKGROUND: There currently exist no data on the factors that contribute to determining why medical ethicists choose to review for and submit articles to medical ethics journals. OBJECTIVE: To establish which factors contribute to medical ethicists reviewing articles for or submitting them to medical ethics journals by consulting those who are active in this capacity. METHODS: Medical ethicists were surveyed to determine their incentives and disincentives for reviewing articles for or submitting them to medical ethics journals. Survey participants were chosen based on a review of the academic and research record of medical ethicists working in North America in higher education institutions. RESULTS: The most frequent incentives to reviewing journal articles were: an opportunity to contribute to the field/profession, the good reputation of the journal, the high impact factor of the journal, and to keep up to date on current research. The most frequent disincentives to reviewing journal articles were: time constraints due to academic commitments, the poor reputation of the journal, and time constraints caused by other editorial commitments (for example, reviewing for other journals/publishers). The most important incentives to submitting journal articles were: the good reputation of the journal, the quality of scholarship previously published in the journal, the impact factor of the journal, and a fast turn-around from acceptance to publication. The most important disincentives to submitting journal articles were: the poor reputation of the journal, the poor quality of work previously published in the journal, and a slow turn-around from acceptance to publication. CONCLUSION: A series of factors that medical ethics journals should strive to employ to encourage reviewing and submission of articles are recommended.