While pain is common among seniors, it is not adequately treated or managed. In particular, pain in seniors with dementia is often undertreated and undermanaged. Although the undertreatment of pain among persons with cognitive impairments represents a serious ethical concern for pain clinicians, most writers in the area explain the undertreatment of pain by focusing on issues related to liability, fears of addiction to opioids, and erroneous beliefs that pain is a normal part of the ageing process. We argue that (...) the philosophical notion of personhood must also be given careful attention when considering the problem of pain undermanagement. In this paper, we consider the undertreatment of pain among seniors with dementia, while focusing on the ontology of relationships and on existential philosophy. Moreover, we outline a series of recommendations to help minimize the probability of pain undertreatment in this population and to encourage considerations relating to personhood when treating people with dementia. (shrink)

A comprehensive account of human kindness.

The development of ethical and practice guidelines related to mental health service on the Internet has lagged behind the movement of practitioners into this area. Even for clinicians who are not offering services on the Web, the Internet has led to confusion and concern about proper roles and responsibilities. This article discusses an actual experience we had with a self-described rationally suicidal man with multiple sclerosis. After presenting some background on MS, we report initial interactions with the man verbatim and (...) summarize subsequent correspondence in an analysis of the man's claim that his decision to die was well reasoned and that he should be allowed a physician's assistance. (shrink)

This article examines the current state of end-of-life care in internal medicine wards in Israel, through an analysis of medical practice and the existing legal framework. The authors demonstrate the processes that lead chronically ill, elderly patients to perceive death as an unexpected phenomenon that is to be avoided at all costs. This perception stems, among other things, from the lack of public debate on questions relating to the end of life and the dominant cultural expectation that physicians provide curative (...) interventions. This results in a dearth of palliative care for the elderly along with a growing number of medical interventions that are of questionable value. The authors propose an alternative approach that highlights individual well-being and that demonstrates the potential areas of intervention by which death can be transformed into an expected and acceptable occurrence for the old and infirm. This approach allows patients to avoid unnecessary interventions and to reduce the burden of responsibility on family members and physicians, who are currently being called on to make end-of-life choices under exigent circumstances. We present these dilemmas by focusing on typical cases of incompetent elderly patients when there is no clear documentation of their wishes regarding treatment, and when their families do not have a coherent perception of what they may have wanted or of the care that would be most appropriate for them. We conclude with a call to action that highlights the need for greater awareness—through public discourse and private discussions—of end-of-life medical choices before the onset of ill-health and incompetence. (shrink)

Background In Switzerland, right-to-die organisations assist their members with suicide by lethal drugs, usually barbiturates. One organisation, Dignitas, has experimented with oxygen deprivation as an alternative to sodium pentobarbital. Objective To analyse the process of assisted suicide by oxygen deprivation with helium and a common face mask and reservoir bag. Method This study examined four cases of assisted suicide by oxygen deprivation using helium delivered via a face mask. Videos of the deaths were provided by the Zurich police. Dignitas provided (...) protocol and consent information. Results One man and three women were assisted to death by oxygen deprivation. There was wide variation in the time to unconsciousness and the time to death, probably due to the poor mask fit. Swiss law prevented attendants from effectively managing the face mask apparatus. Purposeless movements of the extremities were disconcerting for Dignitas attendants, who are accustomed to assisting suicide with barbiturates. None of the dying individuals attempted self-rescue. Conclusions The dying process of oxygen deprivation with helium is potentially quick and appears painless. It also bypasses the prescribing role of physicians, effectively demedicalising assisted suicide. Oxygen deprivation with a face mask is not acceptable because leaks are difficult to control and it may not eliminate rebreathing. These factors will extend time to unconsciousness and time to death. A hood method could reduce the problem of mask fit. With a hood, a flow rate of helium sufficient to provide continuous washout of expired gases would remedy problems observed with the mask. (shrink)

Despite significant advances in medicine, death remains a certainty for every living human being. End-of-life care decision-making is not made easier in a multi-cultural and multi-religious society like Malaysia. As such, planning for one's death by making Advance Decisions can be immensely valuable as it can help healthcare providers in Malaysia to understand better the preferences and wishes of their patients. However, compared to other countries, there is currently no specific legislation on any form of Advance Decisions in Malaysia despite (...) many doctors voicing a need for them. Unlike the Mental Capacity Act 2005 in the UK, the Malaysian Mental Health Act 2001 does not cover all instances of incapacity and only applies to those who suffer from a mental disorder as defined in the Act. In the absence of legislation, one could look to ethical guidelines, especially from the Malaysian Medical Council, but find that this can sometimes be problematic. It is argued that a concerted effort involving all relevant parties is required to develop a pragmatic and viable Advance Decisions frameworkl in Malaysia. (shrink)

This article argues that the early Christian ?order of widows? provides a fruitful model for Christian ethicists struggling to address the medical and social problems of elderly women today. After outlining the precarious state of the ?almanah? - or widow - in biblical times, it describes the emergence of the order of widows in the early Church. Turning to the contemporary situation, it argues that demographics both in the United States and around the globe suggest that meeting the needs of (...) elderly women will become an enormous challenge in the years to come. The order of widows illustrates a three-fold conception of solidarity that has immediate implications today. That conception of solidarity encourages us: 1) to identify the unique medical needs of elderly women (e.g., osteoporosis); 2) to find ways of overcoming their societal isolation, which can increase their risk of medical and psychological problems; and 3) to develop strategies for enabling them to remain contributing members of the community for as long as possible. This essay is a slightly revised version of a keynote address given by the author at a conference on ?Women?s Health and Human Rights? held in Rome, Italy in February 1998 and sponsored by the Vatican, Georgetown University, and the Università Cattolica del Sacro Cuore. The proceedings of that conference were published in Italy by the Società Editrice Universo-Roma in a volume entitled Women?s Health Issues, edited by Spagnolo and Gambino (2003). (shrink)

The current ethical-legal consensus — prohibiting assisted suicide and euthanasia, but (1) allowing patients to forgo all life-saving treatment, and (2) permitting pain relief that increases the risk of death — is a means of having it both ways. This is how we often make “tragic choices.”.

I sometimes wonder whether some proponents of physician-assisted suicide or physician-assisted death think they own the copyright to such catchy phrases as “death with dignity” and “a good death” so that if you are against PAS or PAD, thenyou must be againsta dignified death or a good death. If one removes the quotation marks around phrases like “aid-in-dying” or “compassionate care for the dying,” I am not opposed to such end-of-life care either. Indeed, how couldanybodybe against this type of care?I (...) do not want to abandon dying patients anymore than Dr. Timothy Quill does. Although, unfortunately, it will not always be easy to achieve the desired result, I agree with him that it ought to be a goal of medicine “to help people die well, to help them receive a good death” — or at least “the best possible” death under the circumstances. I part company with Professor Quill, however, when he urges us to change the law in the majority of our states so that in some circumstances patients may achieve a “good death” or a “dignified” one by means of lethal drugs. (shrink)

Along with anatomical dissection, attendance at hospital autopsies has historically been seen as an essential part of medical education. While the use of the dead body for teaching purposes is losing favour in Australian medical schools, this shift is preceded by a significant decline in the rate of autopsies nationwide (and internationally). The decline of the autopsy has particular implications for pathology training where the capacity to perform an autopsy is a requirement. Rather than join the debates in medical literature (...) about the merits of these shifts, this article goes behind the scenes of a hospital mortuary to study autopsy training and practice from the perspective of those who undertake it. The article first introduces the discipline of pathology—‘the science of medicine’—which is built upon centuries of post-mortem study and establishes the fact of the disappearing autopsy. The article then draws upon data from anthropological fieldwork in a Department of Anatomical Pathology to discuss some of the ways trainees manage the work of cutting up the dead. Concepts such as detachment, immersion and disciplinary practice are covered in during this unveiling of everyday practice in a hospital mortuary. (shrink)

Against the usual paternalism, this article develops the proposition to structure the interaction between the doctor and the patient as an inter-subjective consultation. This means that the "information" of the patient prior to treatment, when "informed consent" is secured, as well as the actual medical treatment would have to be turned into an interaction between two responsible individuals. The "irresponsibility" of this patient, which is supposed to result from his "uninformedness", as is often argued in favour of keeping to paternalism, (...) does not have to lead to an interaction model of prescription and compliance. Even for the interaction with patients who are unable to understand or consent, the concept of dialogical interaction must be maintained counterfactually; it has only to be supplemented by the variant of "tutorial action". The prescriptive model of behaviour is extended by the obligation—even when the doctor is the sole decision maker—of acting in the well-understood self-interest of the patient and, if necessary, of providing evidence for this orientation of the treatment. Thus, the model of dialogical interaction is shown to be the comprehensive model, because it covers the interests of the doctor and of the patient. (shrink)

Without exaggeration, it could be said that we are entering a golden age of neuroscience. Informed by recent developments in neuroimaging that allow us to peer into the working brain at both a structural and functional level, neuroscientists are beginning to untangle mechanisms of recovery after brain injury and grapple with age-old questions about brain and mind and their correlates neural mechanisms and consciousness. Neuroimaging, coupled with new diagnostic categories and assessment scales are helping us develop a new diagnostic nosology (...) about disorders of consciousness which will likely improve prognostication and suggest therapeutic advances. Historically such diagnostic refinement has yield therapeutic advances in medicine and there is no reason to doubt that this will be the case for disorders of consciousness, perhaps bringing relief to a marginalized population now on the periphery of the therapeutic agenda. In spite of this promise, the translation of research findings into the clinical context will be difficult. As we move from descriptive categories about disorders of consciousness, like the vegetative or minimally conscious states, to ones further specified by integrating behavioral and neuroimaging findings, humility not hubris should be the virtue that guides the ethical conduct of research and practice. (shrink)

In this paper, we propose analogies between medical discourse and Edward Said's “Orientalism.” Medical discourse, like Orientalism, tends to favor institutional interests and can be similarly dehumanizing in its reductionism, textual representations, and construction of its subjects. To resist Orientalism, Said recommends that critics—“intellectuals”—adopt the perspective of exile. We apply Said's paradigm of intellectual-as-exile to better understand the work of key physician-authors who cross personal and professional boundaries, who engage with patients in mutually therapeutic relationships, and who take on the (...) public responsibility of representation and advocacy. We call these physician-authors “medical intellectuals” and encourage others to follow in their path. (shrink)