Ben Saunders claims that actual consent is not necessary for organ donation due to ‘normative consent’, a concept he borrows from David Estlund. Combining normative consent with Peter Singer's ‘greater moral evil principle’, Saunders argues that it is immoral for an individual to refuse consent to donate his or her organs. If a presumed consent policy were thus adopted, it would be morally legitimate to remove organs from individuals whose wishes concerning donation are not known. This paper disputes Saunders' arguments. (...) First, if death caused by the absence of organ transplant is the operational premise, then, there is nothing of comparable moral precedence under which a person is not obligated to donate. Saunders' use of Singer's principle produces a duty to donate in almost all circumstances. However, this premise is based on a flawed interpretation of cause and effect between organ availability and death. Second, given growing moral and scientific agreement that the organ donors in heart-beating and non-heart-beating procurement protocols are not dead when their organs are surgically removed, it is not at all clear that people have a duty to consent to their lives being taken for their organs. Third, Saunders' claim that there can be good reasons for refusing consent clashes with his claim that there is a moral obligation for everyone to donate their organs. Saunders' argument is more consistent with a conclusion of ‘mandatory consent’. Finally, it is argued that Saunders' policy, if put into place, would be totalitarian in scope and would therefore be inconsistent with the freedom required for a democratic society. (shrink)

The American Journal of Bioethics, Volume 12, Issue 6, Page 17-20, June 2012.

Recently, several articles in the scholarly literature on medical ethics proclaim the need for “responsible scholarship” in the debate over the proper criteria for death, in which “responsible scholarship” is defined in terms of support for current neurological criteria for death. In a recent article, James M. DuBois is concerned that academic critiques of current death criteria create unnecessary doubt about the moral acceptability of organ donation, which may affect the public’s willingness to donate. Thus he calls for a closing (...) of the debate on current death criteria and for journal editors to publish only critiques that “substantially engage and advance the debate.” We argue that such positions as DuBois’ are a threat to responsible scholarship in medical ethics, especially scholarship that opposes popular stances, because it erodes academic freedom and the necessity of debate on an issue that is literally a matter of life and death, no matter what side a person defends. (shrink)

There is a trend of recruiting faith leaders at mosques to overcome religious barriers to organ donation, and to increase donor registration among Muslims. Commentators have suggested that Muslims are not given enough information about organ donation in religious sermons or lectures delivered at mosques. Corrective actions have been recommended, such as funding campaigns to promote organ donation, and increasing the availability of organ donation information at mosques. These actions are recommended despite published literature expressing safety concerns (i.e., do no (...) harm) in living and end-of-life organ donation. Living donors require life-long medical follow-up and treatment for complications that can appear years later. Scientific and medical controversies persist regarding the international guidelines for death determination in end-of-life donation. The medical criteria of death lack validation and can harm donors if surgical procurement is performed without general anesthesia and before biological death. In the moral code of Islam, the prevention of harm holds precedence over beneficence. Moral precepts described in the Quran encourage Muslims to be beneficent, but also to seek knowledge prior to making practical decisions. However, the Quran also contains passages that demand honesty and truthfulness when providing information to those who are seeking knowledge. Currently, information is limited to that which encourages donor registration. Campaigning for organ donation to congregations in mosques should adhere to the moral code of complete, rather than selective, disclosure of information. We recommend as a minimal standard the disclosure of risks, uncertainties, and controversies associated with the organ donation process. (shrink)

Volume 20, Issue 6, June 2020, Page 22-24.

In early 2017, Nevada amended its Uniform Determination of Death Act, in order to clarify the neurologic criteria for the determination of death. The amendments stipulate that a determination of death is a clinical decision that does not require familial consent and that the appropriate standard for determining neurologic death is the American Academy of Neurology’s guidelines. Once a physician makes such a determination of death, the Nevada amendments require the withdrawal of life-sustaining treatment within twenty-four hours with limited exceptions. (...) Neurologists have generally supported Nevada’s amendments for clarifying the diagnostic standard and limiting the ability of family members to challenge it. However, it is more appropriate to view the Nevada amendments with concern. Even though the primary purpose of the UDDA is to ensure that all functions of a person’s entire brain have ceased, the AAN guidelines do not accurately assess this. In addition, by characterizing the determination of death as solely a clinical decision, the Nevada legislature has improperly ignored the doctrine of informed consent, as well as the beliefs of particular faiths and cultures that reject brain death. Rather than resolving controversies regarding brain death determinations, the Nevada amendments may instead instigate numerous constitutional challenges. (shrink)

The determination of death by neurological criteria remains controversial scientifically, culturally, and legally, worldwide. In the United Kingdom, although the determination of death by neurological criteria is not legally codified, the Code of Practice of the Academy of Medical Royal Colleges is customarily used for neurological death determination and treatment withdrawal. Unlike some states in the US, however, there are no provisions under the law requiring accommodation of and respect for residents' religious rights and commitments when secular conceptions of death (...) based on medical codes and practices conflict with a traditional concept well-grounded in religious and cultural values and practices. In this article, we analyse the medical, ethical, and legal issues that were generated by the recent judgement of the High Court of England and Wales in Re: A [2015] EWHC 443. Mechanical ventilation was withdrawn in this case despite parental religious objection to a determination of death based on the code of practice. We outline contemporary evidence that has refuted the reliability of tests of brainstem function to ascertain the two conjunctive clinical criteria for the determination of death that are stipulated in the code of practice: irreversible loss of capacity for consciousness and somatic integration of bodily biological functions. We argue that: the tests of brainstem function were not properly undertaken in this case; the two conjunctive clinical criteria set forth in the code of practice cannot be reliably confirmed by these tests in any event; and absent authentication of the clinical criteria of death, the code of practice wrongly invokes a secular definition of death based on the loss of personhood. Consequently, the moral obligation of a pluralistic society to honor and respect diverse religious convictions to the greatest extent possible is being violated. Re A is contrasted with the US case of Jahi McMath in which the court accommodated parental religious objection to the determination of neurological death codified in the Uniform Determination of Death Act. We conclude that the legal system in the United Kingdom should not favour a secular definition of death over a definition of death that is respectful of religious values about the inviolability and sanctity of life. We recommend the legal recognition of religious accommodation in death determination to facilitate cultural sensitivity and compassionate care to patients and families in a pluralistic society. (shrink)

_Purpose._ The main purpose of this research is to comprehend the philosophical principles in the spread and legitimation of the Self-made-man idea in the worldview transformations of the 17th century. _Theoretical basis._ Historical and comparative methods became fundamental ones for the research. The research is based on the creative heritage of R. Descartes, T. Hobbes, J. Locke, as well as the works of modern researchers. _Originality._ The analysis shows that the Self-made-man idea, which originated in the ancient world and gradually (...) spreads in the Christian Middle Ages, gained a powerful impetus in the philosophical and moral-legal metamorphoses of the 17th century. These metamorphoses theoretically substantiated and radically accelerated the transition from mystical to rational, from theocentric to the anthropocentric worldview, and, as a result, to the recognition of the intellectual autonomy of the individuals and the freedom of their own will, the emergence of the construct of natural human rights, the requirements of religious tolerance and freedom of conscience, ultimately, to the principle of reliance on one’s own strength and the individual’s personal responsibility for one’s own destiny. Exactly these ideas in interaction with the ideas of Puritanism became the theoretical basis for the formation of B. Franklin’s views and the corresponding cultural code. _Conclusions._ The philosophy of the 17th century, having laid the principles of a new – subject-centric – metaphysics, as well as the philosophical and legal foundations of liberal ideology, provided philosophical and moral-legal legitimation to the sporadic attempts of man to break out of the triple circle of fatalism, paternalism, and conformity to a rationally founded and the ever-growing orientation of the individual towards active self-determination and self-realization, self-reliance and personal responsibility for their own destiny as key principles of the Self-made-man concept. (shrink)

Takanat ha-shavim, Magen ṿa-shemesh. Ṿa-yaged Moshesh, hosafot ṿe-heʻarot ʻal sefer Takanat ha-shavim.

_The purpose_ of this study is the reflection on ways of philosophical legitimation for the "Self-made-man" idea in the worldview of the Renaissance and Reformation. _Theoretical basis._ Historical, comparative, and hermeneutic methods became the basis for this. The study is based on the works of Nicholas of Cusa, G. Pico della Mirandola, N. Machiavelli, M. Montaigne, E. Roterodamus, M. Luther, J. Calvin together with modern researchers of this period. _Originality._ The analysis allows us to come to the conclusion that casts (...) doubt on the still widespread belief according to which the emergence of the "Self-made-man" idea is localized by the process of forming the American cultural code and the ideological heritage of Benjamin Franklin. It is highlighted that the formation of this idea is the result of a long process that originated in the ancient world and gains a special impetus in the Renaissance and Reformation. Precisely in the cultural context of the latter, the ancient intention to recognize the individual’s right to self-determination and self-government, which in the depths of Christian theology acquires only a potentially universal character, becomes not only acceptable but also, in the context of Protestantism worldview, the only admissible, in fact, individual’s obligatory life guidelines. _Conclusions._ Humanistic and reformation thoughts quite naturally led to further ideological legitimation of the person’s idea of who is creating oneself. This legitimation was during the complex interaction of numerous factors of culture in the Late Middle Ages, as well as ideas and intentions inherited from Antiquity. Key among them was the gradual formation of a new social order, in essence, indifferent to paternalistic rudiments, together with the ethics of Protestantism corresponding to it. The latter does not only legalize but, de facto, sacralizes the individual’s reorientation from hopes for the synergy of God’s grace and own free will in personal salvation, toward the self-reliance and personal efforts, awareness of personal responsibility for the own fate as key principles of the "Self-made-man" concept. (shrink)

Evidence from our research on young children's temporal understanding supports Hoerl & McCormack's view that young children rely on a temporal updating system to change representations over time. We propose that the shift from temporal updating to temporal reasoning is enabled by children's expanding representations of event sequences, along with developments in language, memory, and other cognitive competencies.

We have lost one of the giants of the twentieth century physics when Yoichiro Nambu passed away in July, 2015, at the age of 94. Today's Standard Model, though still incomplete in many respects, is the culmination of the most successful theory of the Universe to date, and it is built upon foundations provided by discoveries made by Nambu in the 1960s: the mechanism of spontaneously broken symmetry in Nature (with G Jona-Lasinio) and the hidden new SU(3) symmetry of quarks (...) and gluons (with M-Y Han). In this volume honoring Nambu's memory, World Scientific Publishing presents a unique collection of papers written by his former colleagues, collaborating researchers and former students and associates, not only citing Nambu's great contributions in physics but also many personal and private reminiscences, some never told before. This book is a volume for all who benefited not only from Nambu's contributions toward understanding the Universe but also his warm and kind persona. It is a great addition to the history of contemporary physics. (shrink)

Cultural competence, a clinical skill to recognise patients' cultural and religious beliefs, is an integral element in patient‐centred medical practice. In the area of death and dying, physicians' understanding of patients' and families' values is essential for the delivery of culturally appropriate care. Dementia is a neurodegenerative condition marked by the decline of cognitive functions. When the condition progresses and deteriorates, patients with advanced dementia often have eating and swallowing problems and are at high risk of developing malnutrition. Enteral tube (...) feeding is a conventional means of providing artificial nutrition and hydration to meet nutritional needs, but its benefits to the frail population are limitedly shown in the clinical evidence. Forgoing tube feeding is ethically challenging when patients are mentally incompetent and in the absence of an advance directive. Unlike some developed countries, like the United States of America, death and dying is a sensitive issue or even a taboo in some cultures in developing countries that forgoing enteral tube feeding is clinically and ethically challenging, such as China and Malaysia. This article in three parts 1) discusses the clinical and ethical issues related to forgoing tube feeding among patients with advanced dementia, 2) describes how Hong Kong Chinese, North American, and Malaysian Islamic cultures respond differently in the decision‐making patterns of forgoing tube feeding for patients with advanced dementia, and 3) reiterates the clinical implications of cultural competence in end‐of‐life care. (shrink)

The aim of this study is to gain an understanding of why employees misuse information systems resources in the workplace. Rather than consider “intention,” as existing behavioral research commonly does, this study investigates actual behavior and employs IS resource misuse as the dependent variable. Data from a web-based survey are analyzed using the partial least squares approach. In light of the dual-process approach and the theory of planned behavior, the findings suggest that IS resource misuse may be both an intentional (...) type of behavior and an unreasoned action. Perceived behavioral control influences employees’ IS resource misuse actions via their desires or intentions, whereas attitude toward such misuse affects these actions via employees’ desires alone. Subjective norm is found not to affect employees’ IS resource misuse via either desires or intentions. In terms of its theoretical contribution, this study considers unethical behavior in information systems by incorporating a dual-process model and the theory of planned behavior. With regard to its managerial significance, the study’s results will help managers to better understand why employees commit IS resource misuse within organizations. (shrink)

Some of the environmental crises can be avoided, but others come unannounced and the adverse effects affect the communities as a whole with women, children and people with disabilities being affected the most. The world is in constant flux where climate changes are affecting the daily lives of humanity and the ecosystem as a whole. Global efforts towards environmental crises are in place including the Sustainable Development Goals (SDGs), Hyogo protocol and Sendai framework among other legislations, safeguarding the environment as (...) a whole. Women have played many roles when responding, preparing and mitigating the adverse effects of environmental crises with some of the roles visible and others invisible and unpaid. Women have been involved in identifying hazards through their indigenous knowledge systems and manoeuvring ways for the continuity of lives in their local communities. This study utilised a qualitative research methodology. A case study of Cyclone Idai in Chipinge was explored. Moser’s triple framework and the African Ecofeminist theory guided the discussions in this article.Contribution: The article concluded by recommending that concerted efforts should be made to emancipate women and pragmatically embrace gender as an essential variable in the environmental crisis. (shrink)

The historical development of the famous Einstein formula \ is briefly discussed. In this paper, on the basis of the Einstein viewpoint a new general approach is proposed for demonstrating the correctness of the formula \ . It is can be seen that the generalized approach leads to Einstein’s famous formula, too. During recent years, various papers have been published concerning the incompleteness of this famous formula. It is demonstrated that the presented claims in these articles are not mathematically legitimate. (...) It is clear that there are still some important misunderstandings concerning the interpretation of Einstein’s mass-energy equivalence formula. (shrink)

Children with autism spectrum disorder show marked difficulties in reading comprehension, a complex cognitive skill fundamental to successful daily functioning that is associated with core executive functions. However, the neurophysiological mechanisms underlying reading comprehension deficits in these children remain elusive. Twenty-one right-handed males with high-functioning ASD and 23 age-, IQ-, educational level-, sex- and handedness-matched typically developing individuals underwent a reading comprehension test and the semantic verbal fluency test that tapped core executive functions underlying reading comprehension during concurrent prefrontal functional (...) near-infrared spectroscopy measurement. Participants’ information processing efficiency was also assessed. High-functioning ASD children exhibited general reading comprehension [main effect of group: F = 7.58, p = 0.009], selective verbal fluency deficits [Group × category interaction: F = 4.90, p = 0.032] and slower processing speed. Regarding the hemodynamics of the prefrontal cortex, although ASD individuals showed comparable patterns of PFC brain activation to their healthy counterparts, lower PFC intrahemispheric [main effect of group: F = 11.36, p = 0.002] and interhemispheric [main effect of group: F = 7.79, p = 0.008] functional connectivity were evident during the semantic verbal fluency test. At the whole-group level, poorer reading comprehension performance was associated with poorer performance in the semantic verbal fluency test. Moreover, poorer semantic verbal fluency test performance was associated with slower information processing speed, which is associated with reduced left medial PFC functional connectivity. Abnormal intrahemispheric and interhemispheric prefrontal hypoconnectivity is associated with deficits in executive processes essential for reading comprehension in ASD. Our study has provided important implications for the neuropsychological and neurophysiological mechanisms underlying reading comprehension deficits in ASD. (shrink)

_The purpose _is to study that period of evolution of Gogol’s position, in which his ideas of russian messianism are most clearly outlined ("Selected Passages" and "The Author’s Confession"). To delineate the forms of determining the influence of messianism on his negative assessments of the anthropology of the Early New Age and the Enlightenment. Realization of the specified purpose presupposes, first, the analysis of his way of interpreting humanism in the European classical philosophy, and, secondly, to clarify the nature of (...) his connection with the way of substantiating the idea of the Russian messianism. _Theoretical basis._ Our view of Gogol’s heritage is based on the conceptual positions of phenomenology, existentialism, and hermeneutics. _Originality._ It is revealed, that period of evolution of Gogol’s position, which most clearly outlines his ideas of russian messianism ("Selected Passages" and "The Author’s Confession"), his position on human nature and its calling is fundamentally different from the position of philosophy of Early New Age and the Enlightenment. If in the first case, it is a question of service to the russian empire, in the last one, it is a question of self-development of the person. Gogol’s dehumanization of those perceptions about the man that have occurred in European classical philosophy is a precondition in justification of russian messianism for him. One of its key factors is a narrow understanding of insight the ideas concerning the spiritual foundation of the world, namely – its reduction to the russian empire. _Conclusions._ Gogol’s philosophical doctrine of man is only partially described as belonging to the "philosophy of the heart". The disadvantage of this qualification is the impossibility of explaining the question of the origins in Gogol’s attempt to substantiate russian messianism. The article demonstrates that the deformation of the basic idea about the connectivity of man with the spiritual arche of the world is its substantive precondition for the philosophy of the Early New Age and the Enlightenment. Gogol narrows it down to the Russian Empire, which makes it impossible to positively delineate the orientations of the russian people. Therefore, his oeuvre during the work on "Selected Passages" and "The Author’s Confession" for future generations is a warning about the futility of a single russian path of development, isolated from European civilization. As the further development of russian thought and history proves, Gogol’s warning as a Ukrainian thinker really has not been heard. A vivid manifestation of this is the cave nationalism that we see today during the russian-Ukrainian war. (shrink)

Background Moral sensitivity and academic integrity discernment hold paramount importance for healthcare professionals. Owing to distinct undergraduate educational backgrounds, nurses and physicians may exhibit divergent moral perspectives, academic integrity cognisance, and moral sensitivity within clinical environments. A limited number of studies have investigated the disparities and congruencies pertaining to moral sensitivity and academic ethical awareness among nursing and medical students. Objective The study compares moral sensitivity and academic ethical awareness of undergraduate nursing and medical students with and without clinical exposure. (...) Research design A self-administered cross-sectional survey conducted from January to February 2022 was used to collect data from a medical school in Hong Kong. Participants and research context A total of 545 respondents, including 137 nursing students and 408 medical students, completed the questionnaire. Ethical consideration Ethics approval of the study was obtained. Written consent was waived to maintain anonymity because completing the questionnaire was considered implied consent. Findings Both groups of undergraduates demonstrated a high level of bioethics knowledge. In terms of academic integrity, medical students were found to have a less concerned attitude towards punctuality, attendance, and skipping classes. Regarding moral sensitivity, senior medical students with clinical experience put less emphasis on decision-making involving patient participation, while senior nursing students were more hesitant in withholding treatment for incompetent patients who refused treatment. Both nursing and medical students showed decreased moral sensitivity in the ‘conflicts’ domain with increased clinical exposure. Conclusion Study findings contribute to the discussion comparing the ethical attitudes of nursing and medical students. More effort should be made in nursing and medical education to promote practices in line with high academic integrity and to develop the ability to be morally sensitive in professional settings. (shrink)

Background Psychiatric electroceutical interventions (PEIs) use electrical or magnetic stimulation to treat mental disorders and may raise different ethical concerns than other therapies such as medications or talk therapy. Yet little is known about stakeholders’ perceptions of, and ethical concerns related to, these interventions. We aimed to better understand the ethical concerns of a variety of stakeholder groups (patients with depression, caregivers of patients, members of the public, and psychiatrists) regarding four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), (...) deep brain stimulation (DBS), and adaptive brain implants (ABI).Methods We conducted a national survey of these four stakeholder groups, using an embedded video vignette experiment depicting a patient with treatment-resistant depression and her psychiatrist discussing the possibility of treatment with one of the four PEIs.Results Participants’ ethical concerns varied by stakeholder group, by PEI, and by the interaction of the two. The three non-clinician groups tended to have similar ethical concerns, but to differ from psychiatrists. Similar concerns were raised with regard to the two implantable technologies, DBS and ABI. Overall, there was relatively little concern about the involuntary use of PEIs, though some expressed concern about the adequacy of information provided during the consent process. There was also significant concern that patients may not receive helpful therapies.Conclusions To our knowledge, this is the first national survey that includes multiple stakeholder groups and multiple PEI modalities. A better understanding of the ethical concerns of stakeholders can help to shape clinical practice and health care policy regarding PEIs. (shrink)

Producing content-related gestures has been found to impact students’ learning, whether such gestures are spontaneously generated by the learner in the course of problem-solving, or participants are instructed to pose based on experimenter instructions during problem-solving and word learning. Few studies, however, have investigated the effect of (a) performing instructed gestures while learning concepts or (b) producing gestures without there being an implied connection between the gestures and the concepts being learned. The two studies reported here investigate the impact of (...) instructed hand movements on students’ subsequent understanding of a concept. Students were asked to watch an instructional video—focused on the concept of statistical model—three times. Two experimental groups were given a secondary task to perform while watching the video, which involved moving their hands to mimic the placement and orientation of red rectangular bars overlaid on the video. Students were told that the focus of the study was multitasking, and that the instructed hand movements were unrelated to the material being learned. In the content-match group the placement of the hands reinforced the concept being explained, and in the content-mismatch group it did not. A control group was not asked to perform a secondary task. In both studies, findings indicate that students in the content-match group performed better on the posttest, and showed less variation in performance, than did students in the content-mismatch group, with control students falling in between. Instructed hand movement—even when presented as an unrelated, secondary task—can affect students’ learning of a complex concept. (shrink)

Organ donation after cardiac or circulatory death (DCD) has been introduced to increase the supply of transplantable organs. In this paper, we argue that the recovery of viable organs useful for transplantation in DCD is not compatible with the dead donor rule and we explain the consequential ethical and legal ramifications. We also outline serious deficiencies in the current consent process for DCD with respect to disclosure of necessary elements for voluntary informed decision making and respect for the donor's autonomy. (...) We compare two alternative proposals for increasing organ donation consent in society: presumed consent and mandated choice. We conclude that proceeding with the recovery of transplantable organs from decedents requires a paradigm change in the ethics of organ donation. The paradigm change to ensure the legitimacy of DCD practice must include: (1) societal agreement on abandonment of the dead donor rule, (2) legislative revisions reflecting abandonment of the dead donor rule, and (3) requirement of mandated choice to facilitate individual participation in organ donation and to ensure that decisions to participate are made in compliance with the societal values of respect for autonomy and self-determination. (shrink)

Contemporary bioethics education has been developed predominately within Euro-American contexts, and now, other global regions are increasingly joining the field, leading to a richer global understanding. Nevertheless, many standard bioethics curriculum materials retain a narrow geographic focus. The purpose of this article is to use local cases from the Asia-Pacific region as examples for exploring questions such as ‘what makes a case or example truly local, and why?’, ‘what topics have we found to be best explained through local cases or (...) examples?’, and ‘how does one identify a relevant local case?’ Furthermore, we consider the global application of local cases to help extend the possible scope of the discussion, opening new avenues for the development of practical bioethics educational materials. We begin with a background description and discussion of why local cases enhance bioethics education, move to an overview of what is currently available and what is not for the region, and then outline a discussion of what it means to be local using example cases drawn from Hong Kong, Australia, Pakistan, and Malaysia. We are not creating a casebook but rather constructing by example a toolbox for designing active and dynamic learning cases using regional diversity as contextualised cases with generalised principles. (shrink)

End-of-life organ donation is controversial in Islam. The controversy stems from: scientifically flawed medical criteria of death determination; invasive perimortem procedures for preserving transplantable organs; and incomplete disclosure of information to consenting donors and families. Data from a survey of Muslims residing in Western countries have shown that the interpretation of religious scriptures and advice of faith leaders were major barriers to willingness for organ donation. Transplant advocates have proposed corrective interventions: reinterpreting religious scriptures, reeducating faith leaders, and utilizing media (...) campaigns to overcome religious barriers in Muslim communities. This proposal disregards the intensifying scientific, legal, and ethical controversies in Western societies about the medical criteria of death determination in donors. It would also violate the dignity and inviolability of human life which are pertinent values incorporated in the Islamic moral code. Reinterpreting religious scriptures to serve the utilitarian objectives of a controversial end-of-life practice, perceived to be socially desirable, transgresses the Islamic moral code. It may also have deleterious practical consequences, as donors can suffer harm before death. The negative normative consequences of utilitarian secular moral reasoning reset the Islamic moral code upholding the sanctity and dignity of human life. (shrink)

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration . This withdrawal is deemed necessary because patients in PDOC can (...) survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession. (shrink)

We respond to Morgan and Feeley’s critique on our article “Mass Media in Organ Donation: Managing Conflicting Messages and Interests.” We noted that Morgan and Feeley agree with the position that the primary aims of media campaigns are: “to educate the general public about organ donation process” and “help individuals make informed decisions” about organ donation. For those reasons, the educational messages in media campaigns should not be restricted to “information from pilot work or focus groups” but should include evidence-based (...) facts resulting from a comprehensive literature research. We consider the controversial aspects about organ donation to be relevant, if not necessary, educational materials that must be disclosed in media campaigns to comply with the legal and moral requirements of informed consent. With that perspective in mind, we address the validity of Morgan and Feeley’s claim that media campaigns have no need for informing the public about the controversial nature of death determination in organ donation. Scientific evidence has proven that the criteria for death determination are inconsistent with the Uniform Determination of Death Act and therefore potentially harmful to donors. The decision by campaign designers to use the statutory definition of death without disclosing the current controversies surrounding that definition does not contribute to improved informed decision making. We argue that if Morgan and Feeley accept the important role of media campaigns to enhance informed decision making, then critical controversies should be disclosed. In support of that premise, we will outline: (1) the wide-spread scientific challenges to brain death as a concept of death; (2) the influence of the donor registry and team-huddling on the medical care of potential donors; (3) the use of authorization rather than informed consent for donor registration; (4) the contemporary religious controversy; and (5) the effects of training desk clerks as organ requestors at the Department of Motor Vehicles offices. We conclude that organ donation is a medical procedure subject to all the ethical obligations that the medical profession must uphold including that of transparency and truthfulness. (shrink)

The determination of death by neurological criteria remains controversial scientifically, culturally, and legally, worldwide. In the United Kingdom, although the determination of death by neurological criteria is not legally codified, the Code of Practice of the Academy of Medical Royal Colleges is customarily used for neurological death determination and treatment withdrawal. Unlike some states in the US, however, there are no provisions under the law requiring accommodation of and respect for residents' religious rights and commitments when secular conceptions of death (...) based on medical codes and practices conflict with a traditional concept well-grounded in religious and cultural values and practices. In this article, we analyse the medical, ethical, and legal issues that were generated by the recent judgement of the High Court of England and Wales in Re: A [2015] EWHC 443. Mechanical ventilation was withdrawn in this case despite parental religious objection to a determination of death based on the code of practice. We outline contemporary evidence that has refuted the reliability of tests of brainstem function to ascertain the two conjunctive clinical criteria for the determination of death that are stipulated in the code of practice: irreversible loss of capacity for consciousness and somatic integration of bodily biological functions. We argue that: the tests of brainstem function were not properly undertaken in this case; the two conjunctive clinical criteria set forth in the code of practice cannot be reliably confirmed by these tests in any event; and absent authentication of the clinical criteria of death, the code of practice wrongly invokes a secular definition of death based on the loss of personhood. Consequently, the moral obligation of a pluralistic society to honor and respect diverse religious convictions to the greatest extent possible is being violated. Re A is contrasted with the US case of Jahi McMath in which the court accommodated parental religious objection to the determination of neurological death codified in the Uniform Determination of Death Act. We conclude that the legal system in the United Kingdom should not favour a secular definition of death over a definition of death that is respectful of religious values about the inviolability and sanctity of life. We recommend the legal recognition of religious accommodation in death determination to facilitate cultural sensitivity and compassionate care to patients and families in a pluralistic society. (shrink)

Advance health care directives and informed consent remain the cornerstones of patients' right to self-determination regarding medical care and preferences at the end-of-life. However, the effectiveness and clinical applicability of advance health care directives to decision-making on the use of life support systems at the end-of-life is questionable. The Uniform Anatomical Gift Act (UAGA) has been revised in 2006 to permit the use of life support systems at or near death for the purpose of maximizing procurement opportunities of organs medically (...) suitable for transplantation. Some states have enacted the Revised UAGA (2006) and a few of those have included amendments while attempting to preserve the uniformity of the revised Act. Other states have introduced the Revised UAGA (2006) for legislation and remaining states are likely to follow soon. (shrink)

The required professional and ethical pronouncements of accountants mean that auditors need to be competent and exercise due care and skill in the performance of their audits. In this study, we examine what happens when auditors take on more clients than they should, thus raising doubts about their ability to maintain competence and audit quality. Using 2803 observations of Malaysian companies from 2010 to 2013, we find that auditors with multiple clients are associated with lower earnings quality, proxied by total (...) accruals and discretionary accruals. Our results demonstrate that associating client firms’ reported discretionary accruals with individual auditors, rather than their firms or offices, is important in determining audit quality. Moreover, we demonstrate that the disclosure of auditors’ signatures on their reports is useful for assessing auditor quality at the individual level, thus contributing to the debate on the usefulness of having auditor identities on reports. (shrink)

In assisted dying, the end-of-life trajectory is shortened to relieve unbearable suffering. Unbearable suffering is defined broadly enough to include cognitive (early dementia), psychosocial or existential distress. It can include old-age afflictions that are neither life-threatening nor fatal in the “vulnerable elderly”. The voluntary refusal of food and fluids (VRFF) combined with continuous deep sedation (CDS) for assisted dying is legal. Scientific understanding of awareness of internal and external nociceptive stimuli under CDS is rudimentary. CDS may blunt the wakefulness component (...) of human consciousness without eradicating internal affective awareness of thirst and hunger. Patients may suffer because of the slow dying process following dehydration and starvation. The difficulty to adequately control distress, without bringing the dying process to a rapid conclusion by lethal pharmacological interventions, can cause feelings of guilt among hospice and medical staff. Furthermore, the double-effect principle is not applicable in these situations because the primary objective of VRFF is to hasten death. Legal and societal debate should focus on sharpening the boundaries between assisted dying and palliative care. This separation is necessary to: 1) uphold trust in the patient-phyician relationship, and 2) preserve integrity and ethics of the medical profession. (shrink)