The overdose epidemic continues to accelerate, with deaths from overdose increasing from approximately 78,000 pre-pandemic to nearly 100,000 presently. While much of the focus in mainstream media has been on overdoses from opioids, women are overdosing on a variety of drugs. The gendered dimensions of the overdose epidemic have been largely ignored even though this crisis has been building for decades. From 1997 to 2017, the overall death rate for women ages 30–64 from overdoses has increased 260 (...) percent. The largest increases in this group were women between the ages of 55 and 64. Factors such as the sexual division of labor, greater financial insecurity, intimate partner violence, and significant burdens from... (shrink)

In this issue, Marshall et al discuss the importance of capacity and autonomy in the setting of opioid overdose, in Revise and Refuse: Capacity, Autonomy, and Refusal of Care After Opioid Overdose...

North America is in the grips of an epidemic of opioid-related poisonings. Overdose education and naloxone distribution programmes emerged as an option for structurally vulnerable populations who could not or would not access mainstream emergency medical services in the event of an overdose. These task shifting programmes utilize lay persons to deliver opioid resuscitation in the context of longstanding stigmatization and marginalization from mainstream healthcare services. OEND programmes exist at the intersection of harm reduction and emergency services. One (...) goal of OEND programmes is to help redress the health-related inequities common among people who use drugs, which include minimizing the gap between people who use drugs and the formal healthcare system. However, if this goal is not achieved these inequities may be entrenched. In this article, we consider the ethical promises and perils associated with OEND as task shifting. We argue that public health practitioners must consider the ethical aspects of task shifting programmes that may inadvertently harm already structurally vulnerable populations. We believe that even if OEND programmes reduce opioid-related deaths, we nevertheless question if, by virtue of its existence, OEND programmes might also unintentionally disenfranchise structurally vulnerable populations from comprehensive healthcare services, including mainstream emergency care. (shrink)

In August 2017, a group of activists erected in Ottawa's downtown a tent as a first overdose prevention site as a response to what the public and the activists perceived as an epidemic—a devastating wave of opioid and fentanyl overdoses in Canada. The Ontario premier was urged to declare an emergency that would provide increased funding for harm reduction and also send a message to survivors and families that the lives of their loved ones mattered. Thus, the discourses around (...) the so‐called opioid crisis used a language of moral sentiments to legitimate political action. This “new humanitarianism” is considered a priori as good, but in this article, I ask what is politically at stake if we base our actions on the logic of humanitarian reason. The new universalism of humanitarian organizations is based on the individualism of human rights and thus on a moral imperative that replaces the political. Initiatives like the OPS movement often fill the gaps in social services in the absence of the state and address social problems as emergencies and public health issues, thereby transforming them into medical problems—performing the medicalization of sociopolitical problems. This is what I call the NGOization of the opioid crisis. This form of humanitarianism is a universalism of the temporal present without any universal promise for a better future or the amelioration of human conditions—it is a humanitarianism of emergency. What characterizes new humanitarianism is that it responds to situations of suffering that are the result of increasing inequality and injustices without addressing the root causes of this suffering. Not addressing these causes means to be complicit in perpetuating the inequalities and to restrict visions of possible alternatives. (shrink)

Overdose deaths involving prescription opioids killed more than 17,000 Americans in 2017, marking a five-fold increase since 1999. High prescribing rates of opioid analgesics have been a substantial contributor to prescription opioid misuse, dependence, overdose and heroin use. There was recognition approximately ten years ago that opioid prescribing patterns were contributing to this startling increase in negative opioid-related outcomes, and federal actions, including Medicare reimbursement reform and regulatory actions, were initiated to restrict opioid prescribing. The current manuscript is (...) a description of those actions, the effect of those actions on opioid prescribing and related patient outcomes. We also describe our proposal of methods of expanding these efforts as an important piece to further reduce opioid-related misuse, dependence, and overdose death. (shrink)

1 Overview of the problem2 Situationally Specific Normal Functioning and Capacities3 Kingma’s Criticism4 How Normal Responses can be Pathological5 Too Many Pathologies?6 Conclusions.

In “Revive and Refuse: Capacity, Autonomy, and Refusal of Care After Opioid Overdose”, Marshall, Derse, Weiner, and Joseph contend that patients who may appear to satisfy the standard criteria for...

Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that (...) physicians have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation. (shrink)

Drug overdose has recently surpassed motor vehicle accidents to become the leading cause of unintentional injury death in the United States. The epidemic is largely driven by opioids such as oxycodone, hydrocodone, and methadone, which kill more Americans than heroin and cocaine combined. The demographics of overdose have changed over the past few decades as well: according to the latest data, the average overdose victim is now a non-Hispanic white man aged 45-54.These deaths — over 16,000 per (...) year — are almost entirely preventable. Opioid overdose kills by slowly depressing respiration, a process that can take several hours. It can be quickly and effectively reversed by the timely administration of naloxone, an opioid antagonist that works by displacing opioids from the brain receptors to which they attach, reversing their depressant effect. Naloxone, also known as Narcan, has many benefits and minimal risks. Although it is a prescription drug, it is not a controlled substance and has no abuse potential. (shrink)

In 2022, an estimated 110,000 people died of an opioid-related drug overdose in the United States (Ahmad et al. 2024) primarily related to illicit fentanyl. However, fatal overdoses comprise only a...

The article “Revive and Refuse: Capacity, Autonomy, and Refusal of Care After Opioid Overdose,” Marshall et al. (2024) highlights the critical issue of care after an opioid overdose. “Revive and Re...

“You almost died!” the doctor said as the patient gathered their things and prepared to leave the emergency department (ED). The rest of the care team, flanked by a group of security officers, look...

According to the Institute of Medicine, chronic pain affects at least 116 million adults in the United States, which is more than the total affected by heart disease, cancer, and diabetes combined. Pain costs the nation up to $635 billion each year in medical treatment and lost productivity. It has been conceptualized as a public health problem due to its prevalence, seriousness, disparities, vulnerable populations, the utility of population health strategies, and the importance of prevention at both the population and (...) individual levels. For many patients, treatment of pain is inadequate due to uncertain diagnoses, societal stigma, the lack of effective treatments, and inadequate patient and clinician knowledge about the best ways to manage pain. This article explores the inadequate treatment of pain in the U.S. and the subsequent rise of prescription painkiller abuse, misuse, and overdoses. This is followed by a review of the actions taken by states to regulate the prescribing of controlled substances. (shrink)

States have implemented a variety of legal and policy approaches to address the overdose epidemic. Some approaches, like increasing access to naloxone and connecting overdose survivors with evidence-based treatment, have a strong public health foundation and a compelling evidence base. Others, like increasing reliance on punitive criminal justice approaches, have neither. This article examines law and policy changes that are likely to be effective in reducing overdose-related harm as well as those that are likely to increase it.

Despite shifts in rhetoric and some positive movement, Americans with the disease of addiction are still often stigmatized, criminalized, and denied access to evidencebased care. Dramatically reducing the number of lives unnecessarily lost to overdose requires an evidence-based, equity-focused, well-funded, and coordinated response. We present in this brief article evidence-based and promising practices for improving and refocusing the response to this simmering public health crisis. Topics covered include improving clinical decision-making, improving access to non-judgmental evidence-based treatment, investing in comprehensive (...) public health approaches to problematic drug use, and changing the way law enforcement actors interact with people who use drugs. (shrink)

Bioethics has received important criticisms for its perceived privileging of biomedical authority with longstanding calls for greater recognition of the social, political, economic, historical, and...

Marshall et al. (2024) identify a potential ethical conflict between the principles of beneficence and respect for patient autonomy when patients refuse to remain in an emergency department (ED) fo...

Marshall et al. (2024) persuasively argue that some patients with opiate use disorder (OUD), who refuse observation after naloxone resuscitation in the emergency department (ED), “may be making non...

Harm reduction initiatives such as the distribution of naloxone have been crucial in saving lives during the opioid crisis in North America. Despite these efforts, today’s drug supply contaminated...

In recent years, the Minnesota Attorney General’s Office and the Minnesota Department of Health have cultivated a productive partnership to strengthen the state’s multidisciplinary response to overlapping health equity and social justice issues. This article describes shared efforts in three areas: post-conviction justice, drug overdose, and human trafficking/exploitation.

Pain policy is not drug policy. If society wants to improve the lives of people in pain and compress the terrible inequalities in its diagnosis and treatment, we have to tailor policy to the root causes driving our problems in treating pain humanely and equitably. In the United States, we do not. Instead, we have proceeded to conflate drug policy with pain policy, relying on arguably magical thinking for the conclusion that by addressing the drug overdose crisis, we are (...) simultaneously addressing the pain crisis. This is a category error, decades of commitment to which have resulted mostly in a worsening of both public health problems. Disentangling our problems in treating pain fairly and equitably from our problems with drugs and substance use is the only path to humane and ethical policy for each. (shrink)

Opioid agonist treatment, including methadone, is the safest and most effective method for treating opioid use disorders and reduces opioid overdose deaths. While access to methadone is highly regulated by federal law, a substantial portion of states impose stricter barriers.

A drug overdose epidemic in North America has sped the expansion of harm reduction services. Drawing on fieldwork in Ottawa, Ontario, we examine forms of care among people offering and accessing these resources. Notably, our interlocutors do not always characterize harm reduction as caring for oneself. Thus, we differentiate between the ethics of care through which one enters desired subject positions, and anethical careful practices. Harm reduction is sometimes anethical, enacted through minor gestures that do not constitute ethical work (...) but allow for its future realization. Une épidémie d’overdose de drogue en Amérique du Nord a accéléré l’expansion des services de réduction des risques. En s’appuyant sur un travail de terrain à Ottawa, Ontario, nous examinons les formes de souci et soin parmi les personnes qui fournissent ces ressources et qui y ont accès. Tout particulièrement, nos interlocuteurs ne caractérisent pas toujours la réduction des risques comme le souci de soi. Ainsi, nous faisons la différence entre l’éthique du souci de soi et des soins par laquelle on entre dans les positions de sujets souhaitées, et les pratiques soignantes anéthiques. La réduction des risques est parfois anéthique, mise en œuvre par des gestes mineurs qui ne constituent pas un travail éthique mais permettent sa réalisation future. (shrink)

The national opioid epidemic is severely impacting Indian Country. In this article, we draw upon data from the Centers for Disease Control and Prevention to describe the contours of this crisis among Native Americans. While these data are subject to significant limitations, we show that Native American opioid overdose mortality rates have grown substantially over the last seventeen years. We further find that this increase appears to at least parallel increases seen among non-Hispanic whites, who are often thought to (...) be uniquely affected by this crisis. We then profile tribal medical and legal responses to the opioid epidemic, ranging from tribally-operated medication-assisted therapy to drug diversion courts rooted in traditional tribal cultures. (shrink)

I will present and criticise the two theories of truthmaking David Armstrong offers us in Truth and Truthmakers (Armstrong 2004), show to what extent they are incompatible and identify troublemakers for both of them, a notorious – Factualism, the view that the world is a world of states of affairs – and a more recent one – the view that every predication is necessary. Factualism, combined with truthmaker necessitarianism – ‘truthmaking is necessitation’ – leads Armstrong to an all-embracing totality state (...) of affairs that necessitates not only everything that is the case but also everything else – that which is not the case, that which is merely possible or even impossible. All the things so dear to realists – rocks, natural properties, real persons – become mere abstractions from this ontological monster. The view that every predication is necessary does in some sense the opposite: it does away with totality states of affairs and, arguably, also with states of affairs. We have particulars and universals, partially identical and necessarily connected to everything else. Just by the existence of anything, everything is necessitated – the whole world mirrored in every monad. Faced with the choice between these two equally unappealing alternatives, I suggest returning to Armstrong’s more empiricist past: the world is not an all-inclusive One, nor necessitated by every single particular and every single universal, but a plurality of particulars and universals, interconnected by a contingent and internal relation of exemplification. While a close variant, truthmaker essentialism, can perhaps be saved, this means giving up on truthmaker necessitarianism. This, I think, what it takes to steer a clear empiricist course between the Scylla of Spinozist general factness and the Charybdis of a Leibnizian overdose of brute necessities. (shrink)

It is widely accepted in clinical ethics that removing a patient from a ventilator at the patient’s request is ethically permissible. This constitutes voluntary passive euthanasia. However, voluntary active euthanasia, such as giving a patient a lethal overdose with the intention of ending that patient’s life, is ethically proscribed, as is assisted suicide, such as providing a patient with lethal pills or a lethal infusion. Proponents of voluntary active euthanasia and assisted suicide have argued that the distinction between killing (...) and letting die is flawed and that there is no real difference between actively ending someone’s life and "merely" allowing them to die. This paper shows that, although this view is correct, there is even less of a distinction than is commonly acknowledged in the literature. It does so by suggesting a new perspective that more accurately reflects the moral features of end-of-life situations: if a patient is mentally competent and wants to die, his body itself constitutes unwarranted life support unfairly prolonging his or her mental life. (shrink)

It has recently been suggested by Shaw (2007) that the distinction between voluntary active euthanasia, such as giving a patient a lethal overdose with the intention of ending that patient's life, and voluntary passive euthanasia, such as removing a patient from a ventilator, is much less obvious than is commonly acknowledged in the literature. This is argued by suggesting a new perspective that more accurately reflects the moral features of end-of-life situations. The argument is simply that if we consider (...) the body of a mentally competent patient who wants to die, a kind of ‘unwarranted’ life support, then the distinction collapses. We argue that all Shaw has provided is a perspective that makes the conclusion that there is little distinction between voluntary active euthanasia and voluntary passive euthanasia only seemingly more palatable. In doing so he has yet to convince us that this perspective is superior to other perspectives and thus more accurately reflects the moral features of the situations pertaining to this issue. (shrink)

Mistakes and errors happen in most spheres of human life and activity, including in medicine. A mistake can be as simple and benign as the collection of an extra and unnecessary urine sample. Or a mistake can cause serious but reversible harm, such as an overdose of insulin in a patient with diabetes, resulting in hypoglycemia, seizures, and coma. Or a mistake can result in serious and permanent damage for the patient, such as the failure to consider epiglottitis in (...) an initial differential diagnosis, resulting in a chronic vegetative state for a seven-year-old boy. Or a mistake can be an error in judgment that leads to a patient's death. (shrink)

Emergency declarations are a vital legal authority that can activate funds, personnel, and material and change the legal landscape to aid in the response to a public health threat. Traditionally, declarations have been used against immediate and unforeseen threats such as hurricanes, tornadoes, wildfires, and pandemic influenza. Recently, however, states have used emergency declarations to address public health issues that have existed in communities for months and years and have risk factors such as poverty and substance misuse. Leaders in these (...) states have chosen to use emergency powers that are normally reserved for sudden catastrophes to address these enduring public health issues. This article will explore emergency declarations as a legal mechanism for response; describe recent declarations to address hepatitis A and the opioid overdose epidemic; and seek to answer the question of whether it is appropriate to use emergency powers to address public health issues that are not traditionally the basis for an emergency declaration. (shrink)

Deaths of Despair (DoD), or mortality resulting from suicide, drug overdose, and alcohol-related liver disease, have been rising steadily in the United States over the last several decades. In 2020, a record 186,763 annual despair-related deaths were documented, contributing to the longest sustained decline in US life expectancy since 1915–1918. This forum feature considers how health humanities disciplines might fruitfully engage with this era-defining public health catastrophe and help society better understand and respond to the crisis.

Different immunotherapeutic approaches are in the pipeline for the treatment of drug dependence. “Drug vaccines” aim to induce the immune system to produce antibodies that bind to drugs and prevent them from inducing rewarding effects in the brain. Drugs of abuse currently being tested using these new approaches are opioids, nicotine, cocaine, and methamphetamine. In human clinical trials, “cocaine and nicotine vaccines” have been shown to induce sufficient antibody levels while producing few side effects. Studies in humans, determining how these (...) vaccines interact in combination with their target drug, are underway. However, although vaccines can become a reasonable treatment option for drugs of abuse, there are several disadvantages that must be considered. These include i) great individual variability in the formation of antibodies, ii) the lack of protection against a structurally dissimilar drug that produces the same effects as the drug of choice, and iii) the lack of an effect on the drug desire that may predispose an addict to relapse. In addition, a comprehensive overview of several crucial ethical issues has not yet been widely discussed in order to have not only a biological approach to immunotherapy of addiction. Overall, immunotherapy offers a range of possible treatment options: the pharmacological treatment of addiction, the treatment of overdoses, the prevention of toxicity to the brain or the heart, and the protection of the fetus during pregnancy. So far, the results obtained from a small-scale experiment using vaccines against cocaine and nicotine suggest that a number of important technical challenges still need to be overcome before such vaccines can be approved for clinical use. (shrink)

In the target article, “Revive and Refuse: Capacity, Autonomy, and Refusal of Care After Opioid Overdose,” Kenneth D. Marshall and collaborators (2024) highlight important complexities in the care...

Those researching HIV prevention measures for people who inject drugs face a dilemma. Regions where baseline HIV prevalence and onward transmission via injecting is sufficiently high to power HIV prevention trials are also those where repressive laws, policies and practices raise concerns about the ethics of research subject protection. Dawson et al, outlining criteria to address ethical challenges in HIV prevention research among PWID, recommend that all trial participants be offered sterile injecting equipment and urge additional strategies to limit research (...) and background risks.1 In light of ethical questions opened by recent clinical trials involving PWID, including several the authors cite favourably, these cautions are timely. Dawson et al urge weighing of costs and benefits of PWID participation in research trials as an essential part of the ethical calculus. Overdose is a particular risk in any trial that uses abstinence from opioids as a precondition for participation or as an outcome of interest, and a risk that institutional review boards and researchers frequently ignore. Given the increased likelihood of fatal overdose for those who return to injection following a period of abstinence, provision to all trial participants of naloxone—the overdose antidote …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Navigating Hard Situations that Medical School Cannot Prepare You ForJenna BennettI imagined my first experience with grief as a medical student would be peaceful and measured, prompted by the quiet and peaceful [End Page 88] passing of an elderly individual who lived a long life, surrounded by loving family members comforting each other and reminiscing. Of course, I knew things would get harder—I just didn't expect it to be (...) during my first clinical experience as a medical student.My vision for my first experience with grief as a medical student was idealistic, but I was not unfamiliar with grief on a professional or personal basis. Prior to medical school, I was an aide at a long-term care facility. Many patients were on hospice, so end-of-life care and conversations took place daily without fear or shame. Deaths in this setting had happened as I envisioned—a natural course after a long life. Most of the time, the patients and their families were prepared and accepting. It was, of course, a somber occasion no matter how prepared everyone was, but death was almost never unexpected or met with anything other than tearful acceptance. As an aide, I felt honored to provide care at the end of one's life.In my personal life, I had similarly lost elderly family members. Although it was upsetting to have my loved ones pass away, no matter how much time we had to prepare, my family and I were never blind-sided and had time to discuss final wishes and cherish time together; however, for my family, there was one exception to this. When I was young, my father unexpectedly passed away from a heroin overdose. He was alone when he died, not even 30 years old.For a long time, I was ashamed of my father's death. I was very young, and I didn't understand the nature of addiction. I was angry, confused, and embarrassed. As a result, I created my own version that I thought was more palatable, for years telling everyone he had passed away surrounded by a loving family after a long battle with lung cancer.Over the years, I came to terms with my father's death. I learned that substance use is a disease, not a choice. I forgave my dad, along with eventually also forgiving myself for my years of denial and shame. His struggles and death ended up being a large motivation to pursue a career in the medical field, along with being a key part of my identity that I no longer hesitate to share. Despite having matured in this way long before starting medical school, I now recognize I still had some lingering rejection of the wide reality of tragedies that exist in our world.My first clinical experience as a medical student was a 3-week rotation with pediatric hospitalists. By the halfway point of this rotation, I was having a great time and was excited to finally be working with patients after months of sitting in lecture halls and late nights in the library. Of course, all the children we saw were sick, which was hard to see, but all the patients either had viral infections or chronic, but usually non-life-threatening, conditions. Therefore, everyone in our service rapidly improved with minimal interventions, and almost everyone was able to go home after just a few days. I was also encouraged by how loving and knowledgeable all of the family members of the patients were. Even when family members were upset and occasionally took frustrations out on the physicians I was working with, I was not shaken and empathized entirely, as I knew the families' reactions resulted from love and concern for their children. Overall, these initial experiences with patients and their families maintained my optimism that things wouldn't get emotionally hard for me anytime soon, but life, and subsequently medicine, do not wait for you to be ready.I was chatting with my attending one morning toward the latter half of this rotation. Another care team came into our small workroom, which was not unusual, but I could immediately tell something was different... (shrink)

The opioid epidemic has claimed the lives of more than 183,000 individuals since 1999 and is now the leading cause of accidental death in the United States. Meanwhile, rates of incarceration have quadrupled in recent decades, and drug use is the leading cause of incarceration. Medication-assisted treatment or MAT is the gold standard for treatment of opioid use disorder. Incarcerated individuals with opioid use disorder treated with methadone or buprenorphine have a lower risk of overdose, lower rates of hepatitis (...) C transmission, and lower rates of re-incarceration. Despite evidence of improved outcomes, many jails and prisons do not offer MAT to individuals with opioid use disorder. This seems partly due to a scientifically unjustified preference for an abstinence-only treatment approach. The absence of MAT in prisons and jails results in poor outcomes for individuals and poses a public health threat to communities. Furthermore, it disproportionately harms poor communities and communities of color. Health care providers in prisons and jails have an ethical obligation to offer MAT to individuals with opioid use disorder to mitigate risk of infectious diseases, opioid overdose and health disparities associated with incarceration. (shrink)

You have not opened the wrong journal!The police have a duty to protect the public and to investigate any, and all, serious crimes. The article by Lynøe and Leijonhufvud raises important issues about the interaction between hospital staff and police in cases in which suggested medical negligence crosses into the arena of serious legal offences, which range from murder and homicide to serious assault.1Although arising in Sweden, the issues raised in this case are generalisable. While our understanding is limited to (...) the journal article there seem several uncontested facts: a children's intensive care doctor was arrested, charged and acquitted of the mercy killing of an infant in a Swedish hospital. The baby had sustained severe brain injury prior to this clinician's involvement, either due to birth asphyxia or to an accidental overdose of salt. The baby died after withdrawal of life-sustaining treatment with parental agreement. At a later stage, the family asked the police to investigate the initial salt incident. Despite the team attending the baby after WLST stating that only a morphine infusion was administered, a 25-day postmortem femoral artery sample showed ‘an extremely high level of thiopentone’ , although no control sample was analysed.Healthcare staff are subject to the laws of their country. However, Lynøe and Leijonhufvud raise the issue of a conflict between what they term ‘soft law’—the rules, regulations and ethics of healthcare practice and the law of the land. …. (shrink)

OBJECTIVE: This paper addresses the question of the circumstances which lead clinicians to use legal coercion in the management of patients with severe anorexia nervosa, and explores similarities and differences between such formal coercion and other forms of 'strong persuasion' in patient management. METHOD: Logistic regression and other statistical analysis was undertaken on 75 first admissions for anorexia nervosa from a sample of 117 successive admissions to an eating disorder facility in New South Wales, Australia, where an eating disorder was (...) the primary diagnosis. Admissions with other primary diagnoses, such as bulimia nervosa (25 episodes), and entries with a co morbid diagnosis (e.g. depression or opiate overdose), were discarded, leaving 96 admissions by 75 individuals. RESULTS: Resort to measures of legal coercion into treatment was found to be associated with three main indicators: the patient's past history (number of previous admissions); the complexity of their condition (the number of other psychiatric co morbidities); and their current health risk (measured either by Body Mass Index or the risk of re-feeding syndrome). CONCLUSIONS: Our study is consistent with the few earlier studies about indicators for legal coercion in anorexia nervosa management, and suggests that clinicians use legal coercion very sparingly, distinguishing legal coercion from other forms of close clinical management of patients. (shrink)

After retirement, older people often find themselves far from their children and grandchildren, and many spend their last years isolated and alone. As traditional concepts of family and social institutions fragment, social networks weaken, leading to an epidemic of loneliness, and substance abuse and suicide in developed countries. In fact, life expectancy in the US has dropped for the past few years, in large part due to a dramatic increase in suicide and drug overdose. None of these social problems (...) is likely to be solved by metformin. They point to a crisis of identity and meaning, an existential crisis. In this context, one might wonder if we are already seeing the effects of tinkering with our lifespan. There are many more conclusions one could draw about the implications of longevity, many of which have been elegantly described in Beyond Therapy: Biotechnology and the Pursuit of Happiness, published by the President’s Council on Bioethics, which I used as a reference for this talk. I hope I have been successful in providing a 10,000-foot view of the questions of efforts to extend human longevity and its implications that will provoke thought and discussion. I would like to end these reflections by turning back to my favorite transhumans. The reason we love superheroes is not for their superior strength or intelligence, but their characters. They use their powers to protect and serve humanity rather than dominate or annihilate it. It is not their gadgetry that makes them great, but how they use it to save the vulnerable. Even as a small child I knew that if everyone acted the way they did, the world would be a better place. The moral of every story was that the “enhancement” humanity needed would not come as the fruit of technology, but of virtue. (shrink)

The Japanese Medical Act section 21 states that doctors must report unnatural deaths to the police, even though the term “unnatural death” is not defined by law. However, many doctors are reluctant to report potential therapeutic deaths . The Japanese Society of Legal Medicine has submitted guidelines for unnatural death, including PTD. These define a PTD as an unexpected death, the cause of which is unknown, but which is potentially related to medical practice. Such deaths are “reportable” to the coroner (...) in the UK. In this study, we addressed the question of whether physicians would report each of eight hypothetical PTDs. Although the clinical societies declare that doctors must report deaths due to gross negligence, 60% of the participants said that they would not report gross negligence involving an overdose in cases where they had obtained informed consent or had provided an explanation after the death occurred. This can be accounted for by the mistaken belief on the part of the participants that obtaining informed consent exempts Japanese physicians from the duty of reporting PTDs. The attitude of Japanese physicians is caused by the death investigation system, which is designed to discover whether a crime has been committed rather than focusing on the cause of death. Accordingly, the Japanese Government has decided to commission a pilot study from an independent organisation in which medical specialists will investigate PTDs in order to prevent deaths occurring as a result of gross negligence. (shrink)

Oregon is the only state in the United States where a physician may legally prescribe a lethal dose of barbiturate for a patient intending suicide. The Oregon Death with Dignity Act was passed by voters in 1994 and came into effect after much legal wrangling in October of 1997. At the same time, a cabinetmaker named Pat Matheny was struggling with progressive weakness from amyotrophic lateral sclerosis, or ALS. I met with Pat and his family for a lengthy interview in (...) October 1998 in Coos Bay, Oregon, for a television news report on his decision to get a lethal prescription. Below is an extract from that interview. On the day this introduction was written, 10 March 1999, Pat took the prescribed lethal overdose of barbiturates and died at home. His illness was taking his voice, he could not move his hands or legs, and breathing was becoming very difficult. His mother told me he knew that was for him. (shrink)

Over the last year, pundits looking for an explanation for the improbable victory of Donald Trump in the 2016 presidential election have turned to the opioid epidemic, a public health crisis qua political crisis. Since the widespread closure of steel mills and other manufacturing plants throughout middle America in the 1980s, a new so-called "Oxy electorate" has emerged, citizens who rely on painkillers to ameliorate the material realities of economic decline and loss of community. According to postelection statistics, six of (...) the nine counties in Ohio that flipped from traditionally Democratic to vote Republican in 2016 logged an overdose rate that well exceeded the national average. Historian Kathleen Frydl... (shrink)

In response to a sharp rise in opioid-involved overdose deaths in the USA, states have deployed increasingly aggressive strategies to limit the loss of life, including civil commitment—the forcible detention of individuals whose opioid use presents a clear and convincing danger to themselves or others. While civil commitment often succeeds in providing short-term protection from overdose, emerging evidence suggests that it may be associated with long-term harms, including heightened risk of severe withdrawal, relapse and opioid-involved mortality. To better (...) assess and mitigate these harms, states should collect more robust data on long-term health outcomes, decriminalise proceedings and stays, provide access to medications for opioid use disorder and strengthen post-release coordination of community-based treatment. (shrink)

A man of twenty‐two is admitted to an intensive care unit (ICU)after intentionally overdosing on Tylenol. The nurse asks the intensivist on call if someone from the local organ procurement organization should be called in to speak to the family, given a worsening clinical picture and the likelihood that the patient will progress to brain death. The patient's condition is such that multiple organs, including his heart and lungs, could be donated. The intensivist instructs the nurse not to call, as (...) he wishes to have an end‐of‐life discussion with the parents. He believes that the parents should know that death is imminent and that further interventions will not save their son. He argues that introducing the OPO at this point will cause the family more distress. He wants the parents to be able to give their son a peaceful death without additional stressors. What are the broader implications of not calling the OPO at this juncture? Does the nurse involved have an ethical obligation to override the intensivist's instructions by calling the OPO? Should the fact that multiple healthy organs could be harvested from this patient's body have any bearing on the decision to call the OPO? (shrink)

Involuntary civil commitment to treatment for opioid use disorder prevents imminent overdose, but also restricts autonomy and raises other ethical concerns. Using the Kass Public Health Ethics Framework, we identified ICC benefits and harms. Benefits include: protection of vulnerable, underserved patients; reduced legal consequences; resources for families; and “on-demand” treatment access. Harms include: stigmatizing and punitive experiences; heightened family conflict and social isolation; eroded patient self-determination; limited or no provision of OUD medications; and long-term overdose risk. To use (...) ICC ethically, it should be recognized as comprising vulnerable patients worthy of added protections; be a last resort option; utilize consensual, humanizing processes; provide medications and other evidence-based-treatment; integrate with existing healthcare systems; and demonstrate effective outcomes before diffusion. ICC to OUD treatment carries significant potential harms that, if unaddressed, may outweigh its benefits. Findings can inform innovations for ensuring that ICC is used in an ethically responsible way. (shrink)