The paper offers a critical response to the proposed “dis/analogy” between the restriction of Jehovah's Witness parental right to refuse life‐saving blood transfusions for their minor children and a “general” and “permanent” ban on “unnecessary” pediatric intersex surgery. The main argument of the analogy is “securing the patient's future autonomy.” Feinberg's theory of rights is used to demonstrate that the proposed analogy is untenable. A new category of developmental rights‐in‐trust is introduced to address specific needs of gender development (...) in DSD situations. Both premises are disputed. First, it is shown that the case of overriding Jehovah's Witness parental rights is not based on securing the patient's future autonomy, but a simple dependency right in Feinberg's theory. Second, it is demonstrated that pediatric intersex surgery is not in the same situation in all morally relevant respects as the Jehovah's Witness case because it represents a special type of developmental right‐in‐trust. In conclusion, the arguments based on the proposed analogy do not justify a “general and permanent” on pediatric intersex surgery. (shrink)

_Background:_ Weight-related stigma is reported frequently by higher body-weight patients in healthcare settings. Bariatric surgery triggers profound weight loss. This weight loss may therefore alleviate patients' experiences of weight-related stigma within healthcare settings. In non-clinical settings, weight-related stigma is associated with weight-inducing eating patterns. Dietary adherence is a major challenge after bariatric surgery. _Objectives:_ (1) Evaluate the relationship between weight-related stigma and post-surgical dietary adherence; (2) understand if weight loss reduces weight-related stigma, thereby improving post-surgical dietary adherence; and (...) (3) explore provider and patient perspectives on adherence and stigma in healthcare settings. _Design:_ This mixed methods study contrasts survey responses from 300 postoperative bariatric patients with ethnographic data based on interviews with 35 patients and extensive multi-year participant-observation within a clinic setting. The survey measured experiences of weight-related stigma, including from healthcare professionals, on the Interpersonal Sources of Weight Stigma scale and internalized stigma based on the Weight Bias Internalization Scale. Dietary adherence measures included patient self-reports, non-disordered eating patterns reported on the Disordered Eating after Bariatric Surgery scale, and food frequencies. Regression was used to assess the relationships among post-surgical stigma, dietary adherence, and weight loss. Qualitative analyses consisted of thematic analysis. _Results:_ The quantitative data show that internalized stigma and general experiences of weight-related stigma predict worse dietary adherence, even after weight is lost. The qualitative data show patients did not generally recognize this connection, and health professionals explained it as poor patient compliance. _Conclusion:_ Reducing perceptions of weight-related stigma in healthcare settings and weight bias internalization could enhance dietary adherence, regardless of time since patient's weight-loss surgery. (shrink)

The market for cosmetic surgery tourism is growing with an increase in people travelling abroad for cosmetic surgery. While the reasons for seeking cosmetic surgery abroad may vary the most common reason is financial, but does cheaper surgery abroad carry greater risks? We explore the risks of poorly regulated cosmetic surgery to society generally before discussing how harm might be magnified in the context of cosmetic tourism, where the demand for cheaper surgery drives the (...) market and makes surgery accessible for increasing numbers of people. This contributes to the normalisation of surgical enhancement, creating unhealthy cultural pressure to undergo invasive and risky procedures in the name of beauty. In addressing the harms of poorly regulated surgery, a number of organisations purport to provide a register of safe and ethical plastic surgeons, yet this arguably achieves little and in the absence of improved regulation the risks are likely to grow as the global market expands to meet demand. While the evidence suggests that global regulation is needed, the paper concludes that since a global regulatory response is unlikely, more robust domestic regulation may be the best approach. While domestic regulation may increase the drive towards foreign providers it may also have a symbolic effect which will reduce this drive by making people more aware of the dangers of surgery, both to society and individual physical wellbeing. (shrink)

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, (...) as well as the reasons provided for this. A random sample of general practitioners and orthopaedic surgeons as well as members of the general public received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a “recommendation strategy” vis-à-vis smoking cessation prior to surgery rather than a “requirement strategy”. The normative reasons speak in favour of the “recommendation strategy”. (shrink)

Society in the 21st century is in many ways different from society in the 1950s, the 1960s or the 1970s. Two of the most important changes relate to the level of education in the population and the balance between work and private life. These days a large percentage of people are highly educated. Partly as a result of economic progress in the 1950s and the 1960s and partly due to the fact that many women entered the labour force, people started (...) searching for ways to combine their career with family obligations and a private life (including hobbies, outings and holidays). Medical professional ethics, more specifically: professional attitudes towards patients and colleagues, is influenced by developments such as these, but how much and in what way? It was assumed that surgery ethics would be more robust, resistant to change and that general practitioner (GP) ethics would change more readily in response to a changing society, because surgeons perform technical work in operating theatres in hospitals whereas GPs have their offices in the midst of society. The journals of Dutch surgeons and GPs from the 1950s onwards were studied so as to detect traces of change in medical professional ethics in The Netherlands. GP ethics turned out to be malleable compared with surgery ethics. In fact, GP medicine proved to be an agent of change rather than merely responding to it, both with regard to the changing role of patients and with regard to the changing work life balance. (shrink)

In recent years, bariatric surgery has become an increasingly popular treatment of obesity. The amount of resources spent on this kind of surgery has led to a heated debate among health care professionals and the general public, as each procedure costs at minimum $14,500 and thousands of patients undergo surgery every year. So far, no substantial argument for or against giving this treatment a high priority has, however, been presented. In this article, I argue that regardless (...) which moral perspective we consider—greatest need, utility or personal responsibility—the conclusion is that we should give bariatric surgery a high priority when allocating scarce resources in health care. (shrink)

Coronary by-pass surgery has been performed in hundreds of thousands of patients in the last 15 years with a high standard of technical and surgical perfection. The indications for this kind of surgery, however, are still controversial because in spite of many retrospective and several prospective studies it cannot be proven convincingly that in a given patient this surgical procedure will prolong life or prevent myocardial infarction. The present attempt to analyze the causes for this controversy shows that (...) the main reasons for this uncertainty lie: (a) in the enigma of the underlying (ischemic heart) disease itself, which is supposed to lend itself to surgical therapy; (b) in the inadequate methods available up until now for characterizing the state of the disease, its probable course, and its pathogenesis; and (c) in the professional group interests which have a momentum of their own. (shrink)

Recent debates over the use of sham surgery as a control for studies of fetal tissue transplantation for Parkinson’s disease have focused primarily on rival interpretations of the US federal regulations governing human-subjects research. Using the core ethical and methodological considerations that underwrite the equipoise requirement, we nd strong prima facie reasons against using sham surgery as a control in studies of cellular-based therapies for Parkinson’s disease and more broadly in clinical research. Additionally, we believe that these reasons (...) can be generalized to apply to the use of other placebo controls that carry signi cant risks of positive harms in and of themselves. As a result, our arguments are centrally relevant to the emerging drive to subject therapies with a surgical component to the same rigorous standards of evaluation as those governing the approval of new pharmaceuticals. (shrink)

Clinical cases of frontal lobe lesions have been significantly associated with acquired aggressive behaviour. Restoring neuronal and cognitive faculties of aggressive individuals through invasive brain intervention raises ethical questions in general. However, more questions have to be addressed in cases where individuals refuse surgical treatment. The ethical desirability and permissibility of using intrusive surgical brain interventions for involuntary or voluntary treatment of acquired aggressiveness is highly questionable. This article engages with the description of acquired aggressiveness in general, and (...) presents a rare clinical case to illustrate the difficulties of treating this population. To expand the debate further, this article explores the ethics related to invasive brain surgery in three parts: a) it examines coercive involuntary invasive brain surgery for the benefit of protecting others on individuals suffering from acquired aggressiveness who lack decision-making capacities to consent; b) it addresses voluntary psychosurgery on individuals suffering from acquired aggressiveness who are competent to consent; and, c) it questions whether acquired aggressive individuals, who are legally competent, have a duty to consent to invasive brain surgery, in order to maintain their autonomy by reducing or even eliminate their aggressive drives. Ensuring the safety and efficacy of surgical brain interventions could increase the ethical permissibility of voluntary treatment, but it would not necessarily entail ethical justification for proceeding with invasive brain surgery for treatment of intractable acquired aggressive behaviour. (shrink)

Should face transplants be undertaken? This article examines the ethical problems involved from the perspective of the recipient, looking particularly at the question of identity, the donor and the donor’s family, and the disfigured community and society more generally. Concern is expressed that full face transplants are going ahead.

Should face transplants be undertaken? This article examines the ethical problems involved from the perspective of the recipient, looking particularly at the question of identity, the donor and the donor’s family, and the disfigured community and society more generally. Concern is expressed that full face transplants are going ahead.

This paper presents and analyzes the practice journal of a barber-surgeon in the town of Münster, in Northern Germany, in which he recorded about 950 cases he treated between 1602 and 1614. Based on this source, it examines the clientele and the fees of a German barber-surgeon in the early seventeenth century, and looks at the injuries and complaints for which patients sought his treatment.

Demands for access to experimental therapies are frequently framed in the language of rights. This article examines the justifiability of such demands in the specific context of surgical innovations, these being promising but non-validated and potentially risky departures from standard surgical practices. I argue that there is a right to access innovative surgery, drawing analogies with other generally accepted rights in medicine, such as the right not to be forcibly treated, to buy contraceptives, and to choose to have an (...) abortion, including a post-viability abortion where the mother's life or health is threatened by the pregnancy. I argue that we accept these rights because we believe that people are entitled to try to preserve their lives and health and to make choices of an important and intensely personal kind, and I suggest that a person's choice of medical treatment should be seen in the same light. However, since few rights are absolute, I also consider the circumstances in which it may be justifiable to limit the right to access innovative surgery. In discussing this question, I apply the human rights standard of proportionality, comparing the importance of the reasons for limiting the right with the severity of the invasion on liberty. (shrink)

Fundamento. La historia de la Neurocirugía en el territorio está estrechamente relacionada con la de otras especialidades como la Cirugía General y la Ortopedia. Tiene sus primeras referencias establecidas en la etapa colonial en el Hospital General, documentadas en el Boletín del Colegio Médico de Camagüey. Objetivo es resaltar la importancia que tuvieron el Hospital General y el Colegio Médico de Camagüey con su boletín en la historia de la Neurocirugía y la Ortopedia. Método. Es una investigación (...) histórica que se basa en la revisión documental y utiliza el submétodo cronológico para establecer el orden de los hechos que se describen. Desarrollo. El Hospital General a partir de su reconstrucción a finales del siglo XIX, se convirtió en el principal centro médico quirúrgico de la provincia en la época colonial. Muchos de los resultados de la actividad asistencial y científica de sus médicos apareció publicada en el Boletín del Colegio Médico de Camagüey, prestigiosa revista científica que se encargó de divulgar los resultados de la medicina camagüeyana y donde aparecen artículos que evidencian cómo cirujanos generales realizaron las primeras intervenciones neuroquirúrgicas y ortopédicas. Conclusiones. Se consideran al Hospital General y al Colegio Médico de Camagüey y su boletín, como elementos indispensables al escribir la historiografía de la Neurocirugía y la Ortopedia en el territorio. Ground: the history of Neurosurgery in this place is closely linked to other specialties like General Surgery and Orthopedics. The first documented references went back to the colonial period in the General Hospital, documented in the bulletin of the medical college in Camagüey. The objective is to highlight the importance of the General Hospital and the medical college and its bulletin in the history of Neurosurgery and Orthopedics in Camagüey. Methods: This a historical investigation that was carried out taking documented revision and using chronologic sub method to establish the order of the facts that have been described. Development: Since the reconstruction of the General hospital at the end of the XIX century, it became the main medical_ surgical center in the province during the colonial period. Many of the scientific results and medical activities were published in the bulletin of the medical college, which became a well-known scientific magazine that was in charge of publishing the medical success in Camagüey. There are articles to prove that general surgeons performed the first neurosurgical and orthopedic interventions. Conclusions: The General hospital, the medical college and its bulletin are considered crucial elements to describe the history of Neurosurgery and Orthopedics in the territory. (shrink)

Several general anesthetics produce their sedative effect by activating endogenous sleep pathways. We propose that general anesthesia is a two‐step process targeting sleep circuits at low doses, and synaptic release mechanisms across the entire brain at the higher doses required for surgery. Our hypothesis synthesizes data from a variety of model systems, some which require sleep (e.g. rodents and adult flies) and others that probably do not sleep (e.g. adult nematodes and cultured cell lines). Non‐sleeping systems can (...) be made insensitive (or hypersensitive) to some anesthetics by modifying a single pre‐synaptic protein, syntaxin1A. This suggests that the synaptic release machinery, centered on the highly conserved SNARE complex, is an important target of general anesthetics in all animals. A careful consideration of SNARE architecture uncovers a potential mechanism for general anesthesia, which may be the primary target in animals that do not sleep, but a secondary target in animals that sleep. (shrink)

Maternal fetal surgery (MFS) trials have the potential to substantially increase the survival and quality of life of fetuses with life-threatening conditions, but they also entail relevant and yet overlooked fair access challenges. In this topic piece, we will present the fair access concerns in MFS trials/practice and their ethical ramifications as well as some possible ways to address them. The most obvious challenge is cost. Although the cost of the surgery itself is generally covered, costs are high (...) for participants, including commute or housing near the hospital. This might hinder participations of parents from lower economic status. Strict eligibility criteria aimed at protecting participants further limit accessibility. These issues further affect the scientific validity of the trial. For example, the above-mentioned issues contribute to difficulties in recruitment which already lead to MFS trials delays and cancellations. They also contributed to homogeneous samples that are difficult to generalize. Hence, it is important that researcher first acknowledge the existence of fair access issues beyond those related to the cost of the surgery itself and that these issues affect participants’ right to fair access to the trial benefits as well as the scientific validity of the trial. Second, it is important that researchers actively try to foresee and reduce these issues. (shrink)

Background: The law and literature about children’s consent generally assume that patients aged under-18 cannot consent until around 12 years, and cannot refuse recommended surgery. Children deemed pre-competent do not have automatic rights to information or to protection from unwanted interventions. However, the observed practitioners tend to inform young children s, respect their consent or refusal, and help them to “want” to have the surgery. Refusal of heart transplantation by 6-year-olds is accepted. Research question: What are possible reasons (...) to explain the differences between theories and practices about the ages when children begin to be informed about elective heart surgery, and when their consent or refusal begins to be respected? Research design, participants and context: Research methods included reviews of related healthcare, law and ethics literature; observations and conversations with staff and families in two London hospitals; audio-recorded semi-structured interviews with a purposive sample of 45 healthcare professionals and related experts; interviews and a survey with parents and children aged 6- to 15-years having elective surgery (not reported in this paper); meetings with an interdisciplinary advisory group; thematic analysis of qualitative data and co-authorship of papers with participants. Ethical considerations: Approval was granted by four research ethics committees/authorities. All interviewees gave their informed written consent. Findings: Interviewees explained their views and experiences about children’s ages of competence to understand and consent or refuse, analysed by their differing emphases on informed, signified or voluntary consent. Discussion: Differing views about children’s competence to understand and consent are associated with emphases on consent as an intellectual, practical and/or emotional process. Conclusion: Greater respect for children’s practical signified, emotional voluntary and intellectual informed consent can increase respectful understanding of children’s consent. Nurses play a vital part in children's practitioner-patient relationships and physical care and therefore in all three elements of consent. (shrink)

This Special Issue on Psychedelic Ethics highlights that while psychedelic medicine may not be “exceptional” in its therapeutic value and risk (Cohen and Marks 2025), it is “distinctive” in that it...

Objectives: The aim of this study was to examine priority setting for coronary artery bypass surgery, and to provide an overview of decisions and rationales used in clinical practice.Method: Questionnaires were sent to all permanently employed cardiologists, cardiothoracic surgeons, and anaesthesiologists at nine Swedish hospitals performing adult cardiothoracic surgery.Results: A total of 208 physicians responded . There was considerable agreement concerning the criteria that should be used to set priorities for coronary artery bypass interventions . However, there was (...) a lack of accord regarding the use of national guidelines for priority setting and risk indexes.Conclusions: Basic training and the strong support of ethical principles in priority setting are lacking. The respondents indicated a need for clearer guidelines and an open dialogue or discussion. The lack of generally acknowledged plans and guidelines for priority setting may result in unequal, conditional, and unfair treatment. (shrink)

Surgical ethics have generally been framed as general medical ethics applied to surgical contexts. This model is helpful, but may miss some of the special features of the surgical process and relationship. It is suggested in this paper that there are five categories of experience and relationship which are especially important in surgery —rescue, proximity, ordeal, aftermath and presence. The sense of rescue, the feeling of relational proximity, the ordeal and the aftermath of surgery are things which (...) the patient experiences. Understanding these experiences allow surgeons to understand what may be asked of them in an ethical sense. Recognition of the reality and validity of each category in the surgical process highlights the importance of presence, the acts by which the surgeon demonstrates that he is present to the patient throughout the surgical process and its aftermath. While the teaching of communication skills may never compensate for insensitivity, the ideal of presence as virtue and duty can be taught by precept and example. (shrink)

This article examines patients’ calls to three different GP services in the United Kingdom. Using conversation analysis, combined with coding of 447 calls, we studied the role of thank you in closing sequences, focusing on their timing and order in relation to service outcome. We show first how patients withhold thank you in orientation to an absent summary or specification of service: patients are more likely to initiate thank you if the receptionist volunteers such a summary. Second, we show there (...) is variation in how appropriately participants project the termination of calls using thank you. Finally, while thank you serves a primary role in managing the termination of calls, the timing, order and design of thank you can also display patient satisfaction. We discuss our findings in terms of service encounters more generally, including implications for larger scale analysis. (shrink)

Aim: To assess, against a checklist of specific areas of required information and using standard published criteria, to what extent leaflets given before cataract surgery provided patients with enough information to give adequately informed consent.Method: Twelve ophthalmology departments in the West Midlands region were asked to submit the cataract information leaflets given to their patients at the preoperative assessment for analysis. Using criteria published by the General Medical Council, British Medical Association, and Medical Defence Union the leaflets were (...) assessed for their contribution to informed consent for patients considering cataract surgery. Leaflets were scored according to the information they provided on: diagnosis, prognosis, treatment options, costs to the patient, details about the procedure, its purpose, likely benefits, how to prepare for it, what to expect during and after the operation, and the common as well as serious complications that may occur. The readability of the information was also assessed.Results: All the units’ leaflets provided information on diagnosis, the lifestyle changes required postoperatively, and cost involved to the patient. Only five units had leaflets that mentioned the risks involved in cataract surgery. The other areas of information were covered by 50–75% of the leaflets. Fifty per cent of the leaflets included a diagram. The average SMOG readability score was high.Conclusion: Although present cataract information leaflets make some contribution to the process of informed consent, most do not address important areas outlined by the General Medical Council. Many of the areas of information that are required for informed consent could easily be covered, and should be borne in mind when designing patient information leaflets. Resources are available on the internet including toolkits, guides, and means of assessment for the production of patient information leaflets. (shrink)

Background Healthcare systems are increasingly struggling with resource constraints, given demographic changes, technological development, and citizen expectations. The aim of this article is to normatively analyze different suggestions regarding how publicly financed plastic surgery should be delineated in order to identify a well-considered, normative rationale. The scope of the article is to discuss general principles and not define specific conditions or domains of plastic surgery that should be treated within the publicly financed system. Methods This analysis uses (...) a reflective equilibrium approach, according to which considered normative judgements in one area should be logically and argumentatively coherent with considered normative judgements and background theories at large within a system. Results and conclusions In exploring functional versus non-function conditions, we argue that it is difficult to find a principled reason for an absolute priority of functional conditions over non-functional conditions. Nevertheless, functional conditions are relatively easier to establish objectively, and surgical intervention has a clear causal effect on treating a functional condition. Considering non-functional conditions that require plastic surgery [i.e., those related to appearance or symptomatic conditions ], we argue that the patient needs to experience some degree of suffering, which must be ‘validated’ in some form by the healthcare system. This validation is required for both functional and non-functional conditions. Functional conditions are validated by distinguishing between statistically normal and abnormal functioning. Similarly, for non-functional conditions, statistical normality represents a potential method for distinguishing between what should and should not be publicly funded. However, we acknowledge that such a concept requires further development. (shrink)

How should a practice, subservient to a public good, be regulated in order to guarantee fair access without encouraging improper claims? In the first place, a clear understanding of the goal of the practice is indispensable for knowing what criteria the regulation must contain. As to the purely formal aspect, the regulation of any practice must include both general rules and particular instances. Finally, to resolve conflicts, committees in which different kinds of expertise are represented should be installed. These (...) three theses are illustrated by the Dutch regulation for cosmetic surgery. (shrink)

Historians have found it difficult to give a general account of the early medical use of X‐rays in medicine. While the rays were hailed by some as a miracle technology, their early medical application was patchy, often remaining subsidiary to traditional methods of diagnosis and treatment, and was of disputed value. In this essay, I argue that the selective appropriation of the new technology needs to be understood within the wider medical practice of the period. The argument is developed (...) around the case of orthopedic surgery in Germany, probably the first example in which doctors quickly made X‐rays indispensable as a medical tool. I show that value of X‐rays in this case was contingent upon an ongoing dispute, the theory and practice of surgical intervention, and the sociology of new surgical knowledge. (shrink)

The majority of obstetrician‐gynecologists in practice operate very infrequently. Most residents graduate with strong surgical skill sets, given residency requirements. Nonetheless, their practices become dominated by obstetrics, and their gynecologic surgical skills deteriorate. While cesarean sections are surgical in nature, the skill sets needed in these surgeries differ from the skills used in general gynecologic surgery. As gynecology has taken a back seat to obstetrics in our specialty, not only surgical skills but also diagnostic and management skills have (...) deteriorated. (shrink)

Objective: Deep brain stimulation targeted to the ventral intermediate nucleus of the thalamus is effective for motor symptoms in essential tremor, but there is limited data on cognitive outcomes. We examined cognitive outcomes in a large cohort of ET DBS patients.Methods: In a retrospective analysis, we used repeated-measures ANOVA testing to examine whether the age of tremor onset, age at DBS surgery, hemisphere side implanted with lead, unilateral vs. bilateral implantations, and presence of surgical complications influenced the cognitive outcomes. (...) Neuropsychological outcomes of interest were verbal memory, executive functioning, working memory, language functioning, visuospatial functioning, and general cognitive function.Results: We identified 50 ET DBS patients; 29 males; the mean age of tremor onset was 35.84 years with a median age of 38 years. The mean age at DBS was 68.18 years. There were 37 unilateral 30 left, seven right, and 13 bilateral brain implantations. In the subgroup analysis, there was a significant interaction between assessment and age of tremor onset ; F = 4.47; p = 0.043 for working memory. The post hoc testing found improvements for younger onset ET. Similarly, there was a significant interaction between assessment and complications vs. no complications subgroups; F = 4.34; p = 0.043 for verbal memory with worsening scores seen for ET patients with complications. The remaining tests were not significant.Conclusion: In this large cohort of ET patients with, DBS was not accompanied by a significant decline in many cognitive domains. These outcomes were possibly related to the selection of patients with normal cognitive functioning before surgery, unilateral DBS implantations for the majority, and selection of patients with optimal response to DBS. (shrink)

Breast cancer is a disease that is difficult to face and that often hinders body acceptance. Body changes due to surgery can be very emotionally challenging for those who experience them. The aim of this study is to explore the differences on body image and psychological adjustment on women with breast cancer with high and low alexithymia according to the type of surgery. In this cross-sectional study, 119 women diagnosed with breast cancer were evaluated with different self-report questionnaires. (...) Afterward, patients were divided into two groups to analyze dependent variables according to the type of surgery. The results of the General Linear Model suggest that when patients show high alexithymia combined with having undergone a radical mastectomy, they show higher levels of Hopelessness. Furthermore, in patients with high alexithymia, higher scores of maladaptive coping styles and greater distortion of body image were found. Alexithymia seems to play an important role in the way in which women cope with their disease, especially in those with radical mastectomy. (shrink)

Idiopathic generalized epilepsy (IGE) is a common type of epilepsy and despite an increase in the number of available anti-seizure medications, approximately 20–30% of people with IGE continue to experience seizures despite adequate medication trials. Unlike focal epilepsy, resective surgery is not a viable treatment option for IGE; however, neuromodulation may be an effective surgical treatment for people with IGE. Thalamic stimulation through deep brain stimulation (DBS) and responsive neurostimulation (RNS) have been explored for the treatment of generalized and (...) focal epilepsies. Although the data regarding DBS and RNS in IGE is limited to case reports and case series, the results of the published studies have been promising. The current manuscript will review the published literature of DBS and RNS within the centromedian nucleus of the thalamus for the treatment of IGE, as well as highlight an illustrative case. (shrink)

IntroductionPreoperative neurocognitive disorder is a common condition affecting 14–51. 7% of the elderly population. General anesthesia has already been associated with the one-year post-operative neurocognitive disorder, specifically, a deficit in executive function, measured by the Trail Making Test B, but its long-term effects on cognitive function have not been investigated. We aimed to detect preO-NCD prevalence in patients scheduled for cardiac surgery and further investigate the possible role of previous general anesthesia in general preoperative cognitive status (...) [measured via the Montreal Cognitive Assessment ] and/or in executive functioning.MethodsIn this observational, prospective study, 151 adult patients scheduled for elective cardiac surgery underwent MoCA and TMT-B. Data on age, education, pGA, comorbidities, and laboratory results were collected.ResultsWe discovered a general cognitive function impairment of 79.5% and an executive function impairment of 22%. Aging is associated with an increased likelihood and education with a decreased likelihood of general cognitive impairment, but only education was significantly associated with a decreased likelihood of executive function impairment. While pGA did not significantly affect preO-NCD, a noteworthy interaction between aging and pGA was found, resulting in a synergistic effect, increasing the likelihood of executive function impairment.ConclusionWe found a high prevalence of preO-NCD in patients scheduled for cardiac surgery. General cognitive function impairment is highly associated with advancing age. However, older patients with at least one pGA appeared to be at an increased risk of preO-NCD, especially executive function impairment, suggesting that TMT-B should be associated with MoCA in the preoperative cognitive evaluation in this population. (shrink)

Wir diskutieren ethische Probleme der medizinischen Behandlung intersexueller Kinder. Gefragt wird nach dem Stellenwert von Elternwünschen nach eindeutiger Geschlechtszuweisung sowie nach den Konfliktfeldern, die zum einen zwischen konkurrierenden Wunschvorstellungen der Eltern und der behandelnden Ärzte, zum andern zwischen Kindeswohl und Kinderrechten entstehen können. Gegenwärtig wird Neugeborenen mit anatomisch uneindeutigem Genital trotz unsicherer Prognose über die Behandlungsergebnisse oft noch ein Geschlecht zugewiesen und operativ erstellt. Dieses Vorgehen ist von verschiedenen Seiten ethisch heftig kritisiert worden. Kipnis u. Diamond forderten 1998 im „Journal (...) of Clinical Ethics“ ein Moratorium für alle nicht vital indizierten geschlechtskorrigierenden Eingriffe. Diese Forderung orientiert sich am Interesse des zukünftigen Erwachsenen, betont dessen prospektive Autonomie und klammert den Elternwunsch aus. Dieses „Modell des antizipierten Konsenses“ kann jedoch mit Bezug auf Neugeborene und Kleinkinder bedeutsame Aspekte des Eltern-Kind-Verhältnisses nicht angemessen erfassen. Im Aufsatz werden Argumente angeführt, die es aus Sicht einer Ethik der Elternschaft rechtfertigen, ethische Entscheidungen auf der Basis eines beziehungsorientierten Modells zu treffen. In unserem Modell fallen Elternwünsche ethisch ins Gewicht. (shrink)

In the present article we consider general anesthesia as a means of exploring questions regarding unconscious influence. The primary questions addressed in the research are whether surgical patients who are under adequate general anesthesia unconsciously perceive auditory information and whether they can benefit from such information. In addition, we consider the relevance of individual hypnotic ability for perceptual processing in this context. Ninety-six adult patients, undergoing elective abdominal hysterectomy, were randomly allocated to one of four tape-recorded conditions: therapeutic (...) suggestions, melodies, suggestions-plus-melodies, or silence. Double-blind conditions were satisfied in every respect. Patients received a standardized, but typical, "balanced" anesthetic, and level of anesthesia was adequately monitored. Following surgery, all patients received their analgesic medication from a patient-controlled device. Patients who were played therapeutic suggestions used a significantly smaller dose of morphine than patients who were not played suggestions. Although hypnotic ability was not significantly associated with therapeutic outcome, high but not low hypnotizable patients accurately guessed whether they were played suggestions. No compelling evidence for memory of melodies was obtained. (shrink)

Objective To ascertain and improve the understanding and use of chaperones among the patients of an English general practice (GP). Background Doctors have long been advised to have a third party present during intimate physical examinations. Little is known about the understanding of the term in the general population in England and the consequences of this for the promotion and use of chaperones in GP. We audited the understanding and use of chaperones in an English GP. The aim (...) of the study was to increase the awareness of the availability of chaperones in our population. Methods A questionnaire was given randomly to 100 patients attending the GP surgery. Participants were asked about their awareness of and frequency of requesting a chaperone while undergoing intimate examinations. Based on the initial results, a poster was designed for the waiting room to increase awareness. Data were collected with the same questionnaire to see if the new poster altered surgery attendees understanding and likely subsequent use of chaperones. Results In the initial audit, 29% of patients were unaware of the term chaperone, and only one person (1%) had ever requested a chaperone. After the introduction of a specially designed poster, the results showed an improvement in awareness from 71% to 89%, and the likely frequency of using a chaperone increased from 1% to 4%. Conclusion There is a need to improve the understanding of the general population about chaperones if we are to see greater use of chaperones in GP. (shrink)

Background There is little dispute that the ideal moral standard for surgical informed consent calls for surgeons to carry out a disclosure dialogue with patients before they sign the informed consent form. This narrative study is the first to link patient experiences regarding the disclosure dialogue with patient-surgeon trust, central to effective recuperation and higher adherence. Methods Informants were 12 Israelis, aged 29–81, who underwent life-saving surgeries. A snowball sampling was used to locate participants in their initial recovery process upon (...) discharge. Results Our empirical evidence indicates an infringement of patients’ right to receive an adequate disclosure dialogue that respects their autonomy. More than half of the participants signed the informed consent form with no disclosure dialogue, and thus felt anxious, deceived and lost their trust in surgeons. Surgeons nullified the meaning of informed consent rather than promoted participants’ moral agency and dignity. Discussion Similarity among jarring experiences of participants led us to contend that the conduct of nullifying surgical informed consent does not stem solely from constraints of time and resources, but may reflect an underlying paradox preserving this conduct and leading to objectification of patients and persisting in paternalism. We propose a multi-phase data-driven model for informed consent that attends to patients needs and facilitates patient trust in surgeons. Conclusions Patient experiences attest to the infringement of a patient’s right to respect for autonomy. In order to meet the prima facie right of respect for autonomy, moral agency and dignity, physicians ought to respect patient’s needs. It is now time to renew efforts to avoid negligent disclosure and implement a patient-centered model of informed consent. (shrink)

Policies that determine whether someone is allowed access to reproductive healthcare or not vary widely among countries, especially in their age requirements. This raises the suspicion of arbitrariness, especially because often no underlying justification is provided. In this article, we pose the question—under which circumstances is it morally acceptable to use age for policy and legislation in the first place? We start from the notion that everyone has a _conditional positive_ right to fertility treatment. Subsequently, we set off to formulate (...) a framework that helps to determine who should be excluded from treatment nonetheless. The framework’s three core elements are: choosing and ethically justifying exclusion criteria (target), determining the actual limit between in- and exclusion (cut-off), and selecting variables that help to predict the exclusion criteria via correlation (as they are not directly measurable) (proxy). This framework allows us to show that referring to age in policy and legislation is only ethically justifiable if there is a sufficiently strong correlation with a non-directly measurable exclusion criterion. Moreover, since age is only one of many predicting variables, it should therefore not be ascribed any special status. Finally, our framework may be used as an argumentative scheme to critically assess the ethical legitimacy of policies that regulate access to (fertility) treatments in general. (shrink)

The Human Condition is neither a well-defined nor well-described concept—nevertheless, it is generally agreed that human sexuality is a fundamental and constituent part of it. For most able-bodied persons, accessing and expressing one's sexuality is a (relatively) trouble-free process. However, many disabled persons experience difficulty in accessing their sexuality, while others experience such significant barriers that they are often precluded from sexual citizenship altogether. Recognising the barriers to the sexual citizenship of disabled persons, the concept of a Welfare-Funded Sex Doula (...) Program has been advanced — a program specifically aimed at meeting the various (and often complex) sexual needs of disabled people. Below we show how that program can be justified within at least two different moral frameworks, the capabilities approach and liberal utilitarianism, and consider and repudiate arguments against it. (shrink)

Automatic control of physiological variables is one of the most active areas in biomedical engineering. This paper is centered in the prediction of the analgesic variables evolution in patients undergoing surgery. The proposal is based on the use of hybrid intelligent modelling methods. The study considers the Analgesia Nociception Index to assess the pain in the patient and remifentanil as intravenous analgesic. The model proposed is able to make a one-step-ahead prediction of the remifentanil dose corresponding to the current (...) state of the patient. The input information is the previous remifentanil dose, the ANI variable and the electromyogram signal. Modelling techniques used are Artificial Neural Networks and Support Vector machines for Regression combined with clustering methods. Both training and validation were done with a real dataset from different patients. Results obtained show the potential of this methodology to calculate the drug dose corresponding to a given analgesic state of the patient. (shrink)

Whole body gestational donation offers an alternative means of gestation for prospective parents who wish to have children but cannot, or prefer not to, gestate. It seems plausible that some people would be prepared to consider donating their whole bodies for gestational purposes just as some people donate parts of their bodies for organ donation. We already know that pregnancies can be successfully carried to term in brain-dead women. There is no obvious medical reason why initiating such pregnancies would not (...) be possible. In this paper, I explore the ethics of whole-body gestational donation. I consider a number of potential counter-arguments, including the fact that such donations are not life-saving and that they may reify the female reproductive body. I suggest if we are happy to accept organ donation in general, the issues raised by whole-body gestational donation are differences of degree rather than substantive new concerns. In addition, I identify some intriguing possibilities, including the use of male bodies–perhaps thereby circumventing some potential feminist objections. (shrink)

With few exceptions, the literature on withdrawing and withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines on this matter are even more uniform. However, while no small degree of progress has been made toward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remains with regard to withdrawing treatment. Given that the absence of clinical (...) benefit means treating patients is not only ethically questionable but also taxing on resources that could meet the needs of others, this ambivalence is troubling. Equally, the enduring ambivalence of professionals might be taken to indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understanding that withdrawing and withholding life-saving treatment are different practices, the meanings of which are fully comprehensible only through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that if one is to engage with the inappropriate protraction of life-saving treatment resulting from healthcare professionals’ disinclination to withdraw it, then the differences between these practices should be taken seriously. (shrink)

It can be assumed that value judgements, which are needed to judge what is ‘good’ or ‘better’ and what is ‘bad’ or ‘worse’, are involved in every decision-making process. The theoretical understanding and analysis of value judgements is, therefore, important in the context of bioethics, for example, to be able to ethically assess real decision-making processes in biomedical practice and make recommendations for improvements. However, real decision-making processes and the value judgements inherent in them must first be investigated empirically (‘empirical (...) bioethics’). For this to succeed, what exactly a ‘value judgement’ is and of what components it might consist must initially be theoretically clarified. A corresponding conceptual model can then support or even enable empirical data collection and analysis and, above all, subsequent ethical analysis and evaluation. This paper, therefore, presents a value judgement model with its theoretical derivation. It also illustrates its application in an interview study of decision-making between animal experimentation and alternative methods in the context of biomedical research. Though the model itself can be theoretically deepened and extended, the application of the model works in general and helps to uncover what value judgements can enter into decision-making. However, the empirical methods, for example, qualitative interviews, can also be better oriented towards eliciting value judgements (as understood according to the model). Further applications of the model to other topics or by means of other empirical methods are conceivable. (shrink)

Medicine is increasingly subject to various forms of criticism. This paper focuses on dominant forms of criticism and offers a better account of their normative character. It is argued that together, these forms of criticism are comprehensive, raising questions about both medical science and medical practice. Furthermore, it is shown that these forms of criticism mainly rely on standards of evaluation that are assumed to be internal to medicine and converge on a broader question about the aim of medicine. Further (...) work making medicine’s internal norms explicit and determining the aim of medicine would not only help to clarify to what extent the criticism is justified, but also assist an informed deliberation about the future of medicine. To illustrate some of the general difficulties associated with such a task, the paper concludes by critically engaging Edmund Pellegrino’s account of the aim of medicine as well as the Hastings Center’s consensus report. (shrink)

The aim of this paper is to enhance doctors’ awareness of implicit understandings between doctors and patients in the context of pre-operative communication of risks. This paper draws on insights from the philosophy of language – in particular pragmatic analysis tools – that make explicit the implicit understandings of the interaction. Mastering not only _what is said_ but also _what is unsaid_ allows doctors to improve their communication with their patients. I suggest that being aware of the implications of the (...) interactions is useful for improving both the doctor’s and the patient’s experience, further strengthening the therapeutic alliance. In this article I analyze actual cases involving pre-operative evaluation before cardiac surgery from a philosophy of language perspective. The paper is structured as follows: a description of the relevant philosophy of language tools that I will apply; an overview of the risk-communication context; an explanation of the link between “the implicit dimension” and trust, addressing whether the doctor needs to convey the whole truth; and the analysis of real cases. In conclusion, I re-emphasize the importance of implicit meanings during risk communication. (shrink)

In 2017, Michael Nair-Collins formulated his Transitivity Argument which claimed that brain-dead patients are alive according to a concept that defines death in terms of the loss of moral status. This article challenges Nair-Collins’ view in three steps. First, I elaborate on the concept of moral status, claiming that to understand this notion appropriately, one must grasp the distinction between direct and indirect duties. Second, I argue that his understanding of moral status implicit in the Transitivity Argument is faulty since (...) it is not based on a distinction between direct and indirect duties. Third, I show how this flaw in Nair-Collins’ argument is grounded in the more general problems between preference utilitarianism and desire fulfillment theory. Finally, I present the constructivist theory of moral status and the associated moral concept of death and explain how this concept challenges the Transitivity Argument. According to my view, brain death constitutes a valid criterion of death since brain death is incompatible with the preserved capacity to have affective attitudes and to value anything. (shrink)

Contemporary bioethics generally stipulates that public moral deliberation must avoid allowing religious beliefs to influence or justify health policy and law. Secular premises and arguments are assumed to maintain the neutral, common ground required for moral deliberation in the public square of a pluralistic society. However, a careful examination of non-theistic arguments used to justify euthanasia (regarding contested notions of human dignity, individual autonomy, and death as annihilation) reveals a dependence on metaethical and metaphysical beliefs that are not universally accepted (...) in a pluralistic society. Such beliefs function in non-theistic arguments in the same way that foundational beliefs justify moral convictions in religious frameworks of belief. This parallel is apparent when religious belief is defined broadly (_a la_ John Reeder) as ‘the search for the good in light of the limits and possibilities of the real.’ Seen through this interpretive lens, frameworks comprising Secular foundational commitments function, in ethically relevant respects, like the guiding beliefs found in the comprehensive frameworks of traditional religions. When conscientious practice in healthcare is reconsidered in light of this foundational similarity between the religious and the secular, it is clear that those who object to the foundational beliefs underpinning Secular arguments for euthanasia should not be required to provide, participate in, or refer patients for euthanasia (or other ethically controversial practices similarly dependent on contested frameworks of belief) in pluralistic societies that prize moral freedom as a primary human good. (shrink)

Defining disease and delineating its boundaries is a contested area in contemporary philosophy of medicine. The leading naturalistic theory faces a new round of difficulties related to defining a normal environment alongside normal organismic functioning and to delineating a discrete boundary between risk factors and disease. Normative theories face ongoing and seemingly intractable difficulties related to value pluralism and the problematic relation between theory and practice. In this article, I argue for an integral—as opposed to a hybrid—philosophy of health based (...) on Bernard Lonergan’s notion of generalized empirical method that provides a way to settle these difficulties dynamically and comprehensively, both in theory, by orienting functional and statistical investigation toward an explanatory ecological viewpoint, and in practice, by framing critiques in relation to the normativity intrinsic to all human inquiry. (shrink)