Differences emerge in visceral adipose tissue accumulation after selection for innate cardiovascular fitness.

Cardiorespiratory fitness (CRF) has been reported to be inversely associated with visceral adipose tissue (VAT) accumulation, independent of body weight. However, the confounding effect of physical activity on the association between CRF and VAT remains inadequately addressed. On the basis of maximal oxygen uptake (VO(2 max)), 143 sedentary, overweight women were dichotomized into high-fit (HF) and low-fit (LF) groups. Body composition and VAT were measured using dual-energy X-ray absorptiometry and computed tomography, respectively, and activity-related energy expenditure (AEE) was calculated using the doubly labeled water technique. No differences were observed between HF and LF for body mass index (HF 28.2 ± 1.3; LF 28.3 ± 1.31 kg m(-2)), total body weight (HF 77.5 ± 6.8; LF 77.9 ± 7.3 kg), total fat mass (HF 33.5 ± 5.1; LF 33.9 ± 4.4 kg) or AEE (HF 439.9 ± 375.4; LF 517.9 ± 298.7 kcal day(-1)). Significant differences in visceral adiposity (HF 68.5 ± 30.4; LF 91.2 ± 31.8 cm(2); P<0.001) and insulin sensitivity (HF 5.1 ± 1.8; LF 3.1 ± 2.4 S(I) × 10(-4) min(-1) µIU(-1) ml(-1); P<0.01) were observed between the HF and LF groups, independent of age, race and AEE. This study affirms previous findings that CRF is an important determinant of the accumulation of VAT, and this relationship is independent of physical activity.

Children's rights to health care.

This paper will explore the application of an account of justice in health and health care to the special case of children. It is tempting to hold that children require no special treatment in an account of just health care; justice requires guaranteeing access to at least basic health care services to all persons, whatever their age group, within the constraints of a society's resources. However, I will argue that for a number of reasons we need to address what justice requires specifically for children from the health care system, even if the answer must be embedded within a general account of justice in health and health care.

Misconceived sources of opposition to physician-assisted suicide.

This article addresses 2 prominent sources of opposition to physician-assisted suicide (PAS): first, the fear of abuse and, second, common moral distinctions drawn between PAS and other forms of end-of-life decisions and care. Each is grounded in a false assumption that PAS is radically different from other forms of widely accepted end-of-life decisions and care. The experience to date in Oregon gives some reassurance that the practice there permitting PAS has not been significantly abused. Moreover, the author argues that abuse, understood as decisions not in accord with what the patient wants, or would have wanted, is greatest when someone other than the patient is the decisionmaker. On this ground, PAS should be less subject to abuse than other surrogate decisions about life support. Moreover, Oregon's law, like virtually all proposals to legalize PAS, contains numerous safeguards that are not present in decisions about life support generally. Second, it is argued that some prominent conceptualizations of accepted end-of-life decisions and care thought to distinguish them morally from PAS fail on closer analysis to do so.

Palliative options of last resort: a comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia.

Palliative care is generally agreed to be the standard of care for the dying, but there remain some patients for whom intolerable suffering persists. In the face of ethical and legal controversy about the acceptability of physician-assisted suicide and voluntary active euthanasia, voluntarily stopping eating and drinking and terminal sedation have been proposed as ethically superior responses of last resort that do not require changes in professional standards or the law. The clinical and ethical differences and similarities between these 4 practices are critically compared in light of the doctrine of double effect, the active/passive distinction, patient voluntariness, proportionality between risks and benefits, and the physician's potential conflict of duties. Terminal sedation and voluntarily stopping eating and drinking would allow clinicians to remain responsive to a wide range of patient suffering, but they are ethically and clinically more complex and closer to physician-assisted suicide and voluntary active euthanasia than is ordinarily acknowledged. Safeguards are presented for any medical action that may hasten death, including determining that palliative care is ineffective, obtaining informed consent, ensuring diagnostic and prognostic clarity, obtaining an independent second opinion, and implementing reporting and monitoring processes. Explicit public policy about which of these practices are permissible would reassure the many patients who fear a bad death in their future and allow for a predictable response for the few whose suffering becomes intolerable in spite of optimal palliative care.

What is the moral authority of family members to act as surrogates for incompetent patients?

Policy and practice regarding the proper role of family members in acting as surrogate decision makers for incompetent patients often suffer from an incomplete understanding of the diverse grounds of families' moral authority to act as surrogates. The different, sometimes conflicting, grounds of family surrogacy are explored: (1) its establishment by democratic decision processes; (2) the self-determination of the incompetent patient; (3) the fact that a family member usually acts according to the patient's wishes and interest; (4) the reality that family members are usually most affected by the patient's decisions; (5) consideration of these effects; (6) a recognition that the family is a moral unit, responsible for its members. Each of these grounds must be considered when selecting a surrogate or deciding on the proper scope of the surrogate's decision-making authority.

Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia.

BACKGROUND: In making decisions about life-sustaining medical interventions, respect for patient autonomy has been widely advocated, yet little is known about what variables may compete with a physician's ability to honor patient requests in clinical situations. We investigated physician attitudes and behaviors about end-of-life decisions by means of a questionnaire that posed five hypothetical scenarios in which an elderly, competent, terminally ill patient made a request that, if agreed to by the physician, could result in the patient's death. METHODS: We surveyed 392 physicians in Rhode Island and asked them to decide (1) whether or not they would comply with a specific patient request, (2) the justifications they used in making their decision, and (3) whether they had been approached with such a request in their clinical practices. RESULTS: Two hundred fifty-six physicians (65%) responded. Of the respondents, 98% agreed not to intubate the patient in the face of worsening respiratory failure. Eighty-six percent agreed to give the patient a dose of narcotics that could cause respiratory compromise and death to treat his pain adequately. Fifty-nine percent agreed, once the patient was intubated without hope of coming off the respirator, to turn the respirator off. Nine percent agreed to give the patient a prescription for an amount of sleeping pills that would be lethal if taken all at once. Only 1% agreed to give the patient a lethal injection. When they complied with patient requests, physicians cited patient autonomy as the principle most important to their decision making. Physicians who would not comply with patient requests also, paradoxically, often cited this principle but agreed with it less strongly; others cited concerns about the ethical nature of the request, legal questions, and the perception that they were "killing the patient." Sixty-five percent of respondents had been asked by patients to turn off a respirator, and 12% had been asked to administer lethal injections. Twenty-eight percent of respondents indicated that they would comply with requests for lethal injection more frequently if such an action were legal. CONCLUSIONS: Difficult clinical decisions regarding potentially life-prolonging measures are commonly heard in clinical practice. Physicians value the concept of patient autonomy but place it in the context of other ethical and legal concerns and do not always accept specific actions derived from this principle.

Euthanasia.

The principles of self-determination and individual well-being support the use of voluntary euthanasia by those who do not have moral or professional objections to it. Opponents of this posture cite the ethical wrongness of the act itself and the folly of any public or legal policy permitting euthanasia. Positive consequences of making euthanasia legally permissible respect the autonomy of competent patients desiring it, expand the population of patients who can choose the option, and release the dying patient from otherwise prolonged suffering and agony. Potentially bad consequences of permitting euthanasia include the undermining of the "moral center" of medicine by allowing physicians to kill, the weakening of society's commitment to provide optimal care for dying patients, and, of greatest concern, the "slippery slope" argument. The evaluation of the arguments leads to support for euthanasia, with its performance not incompatible with a physician's professional commitment.