Commentator: Mark Purvis Commentator: Sheena McMain Commentator: Clare Connolly Commentator: Maggie Eisner Commentator: Shirley Brierley Commentator: Becky Ship.

The US FDA currently encourages the addition of vitamin D to milk and cereals, with the aim of reducing rickets in children and osteoporosis in adults. However, vitamin D not only regulates the expression of genes associated with calcium homeostasis, but also genes associated with cancers, autoimmune disease, and infection. It does this by controlling the activation of the vitamin D receptor (VDR), a type 1 nuclear receptor and DNA transcription factor. Molecular biology is rapidly coming to an understanding of (...) the multiplicity of roles played by the VDR, but clinical medicine is having difficulty keeping up with the pace of change. For example, the FDA recently proposed a rule change that will encourage high levels of vitamin D to be added to even more foods, so that the manufacturers can claim those foods “reduce the risk of osteoporosis”. The FDA docket does not review one single paper detailing the transcriptional activity of vitamin D, even though, on average, one new paper a day is being published on that topic. Nor do they review whether widespread supplementation with vitamin D, an immunomodulatory secosteroid, might predispose the population to immune dysfunction. This BioEssay explores how lifelong supplementation of the food chain with vitamin D might well be contributing to the current epidemics of obesity and chronic disease. BioEssays 30:173–182, 2008. © 2008 Wiley Periodicals, Inc. (shrink)

_Peter Greenaway's Postmodern/Poststructuralist Cinema_ Edited by Paula Willoquet-Maricondi and Mary Alemany-Galway Lanham, MD: The Scarecrow Press, 2001 ISBN 0-8108-3892-3 xxviii + 360 pp.

invited commentary on David Oderberg's call for conscientious objection in medicine to be permitted in the UK.

Interest in the neural processes underlying decision making has led to a flurry of recent research in the fields of both moral psychology and neuroeconomics. In this paper, we first review some important findings from both disciplines, and then argue that the two fields can mutually benefit each other. A more explicit recognition of the role of values and norms will likely lead to more accurate models of decision making for neuroeconomists, whereas the tasks, insights into neural mechanisms, and mathematical (...) modeling common in neuroeconomic research offer moral psychologists the opportunity to expand their field and move beyond methodological limitations that may have hindered the field’s progress to this point. We conclude by highlighting an exciting group of recent studies that illustrate the potential of research that embraces the integrated moral/neuroeconomic approach that we suggest here. (shrink)

In this article I will discuss how clinicians might best treat adolescents who may die. I initially discuss these patients’ cognition, emotional tendencies, and sensitivity to interpersonal cues. I next discuss their parents’ feelings of loss and guilt and their clinicians’ risk of imposing their own moral views without knowing this. I then address the practical concerns of helping these patients gain or regain resilience and to identify strengths they have had in the past. I finally explore who, among staff, (...) might be best able to do this. I highlight as the main goal that patients, their parents, and ideally also their clinicians are able to come to agree on the best course the patients should take. (shrink)

I suggest that we may want to strive, over time, to change our present professional-cultural view, from one that sees an expression of moral distress as a threat, to a professional-cultural view that welcomes these challenges. Such an effort to better medicine would not only include dissenting clinicians, but patients (and their loved ones) as well.

As we go to press, the threat of biological or chemical warfare in the Persian Gulf is no longer imminent. Yet the questions raised by the proposed use of “investigational drugs,” without informed consent, to protect U.S. troops remain. The article by Edmund G. Howe and Edward D. Martin presents the arguments that informed the Pentagon's thinking on the subject. It and the commentaries, by George J. Annas and Michael A. Grodin, and Robert J. Levine, explore, among others, issues (...) of informed consent, of distinguishing ‘research’ and ‘treatment,’ and of the nature and extent of the autonomy of military personnel.—B‐JC, HLN. (shrink)

In recent years, a dramatic increase in the study of infrastructure has occurred in the social sciences and humanities, following upon foundational work in the physical sciences, architecture, planning, information science, and engineering. This article, authored by a multidisciplinary group of scholars, probes the generative potential of infrastructure at this historical juncture. Accounting for the conceptual and material capacities of infrastructure, the article argues for the importance of paradox in understanding infrastructure. Thematically the article is organized around three key points (...) that speak to the study of infrastructure: ruin, retrofit, and risk. The first paradox of infrastructure, ruin, suggests that even as infrastructure is generative, it degenerates. A second paradox is found in retrofit, an apparent ontological oxymoron that attempts to bridge temporality from the present to the future and yet ultimately reveals that infrastructural solidity, in material and symbolic terms, is more apparent than actual. Finally, a third paradox of infrastructure, risk, demonstrates that while a key purpose of infrastructure is to mitigate risk, it also involves new risks as it comes to fruition. The article concludes with a series of suggestions and provocations to view the study of infrastructure in more contingent and paradoxical forms. (shrink)

Physicians who are impaired, engage in unprofessional behavior, or violate laws may be barred from further practice. Likewise, medical students may be dismissed from medical school for many infractions, large and small. The welfare of patients and the general public must be our first priority, but when we assess physicians and students who have erred, we should seek to respond as caringly and fairly as possible. This piece will explore how we may do this at all stages of the proceedings (...) physicians and students may encounter. This may include helping them to resume their medical careers if and when this would be sufficiently safe and beneficial for patients. (shrink)

In this special issue of The Journal of Clinical Ethics, different views on both the ethical desirability of women delivering in hospitals or at home with midwives are discussed. What careproviders, including midwives, should recommend to mothers in regard to the place of giving birth is considered. Emotional concerns likely to be of importance to mothers, fathers, midwives, and doctors are also presented. Finally, possible optimal approaches at the levels of both policy and the bedside are suggested.

Shared decision making (SDM) is the state of the art for clinicians’ communication with patients and surrogate decision makers. SDM involves give and take, in which all parties interact to maximize the autonomy of patients. In this article I summarize the core steps of SDM and explore ways to use it to benefit patients to the greatest extent. I review three articles included in this issue of The Journal of Clinical Ethics that highlight additional approaches we can use to help (...) patients and parents to see what may be in their own or their child’s best interest. I describe how these approaches can be used in most other medical fields. I explore ways to share information with patients that are outside the usual scope of SDM. Finally, I discuss how we might look, together with patients, at what all parties are feeling before we begin the process of SDM. (shrink)

The author, editor-in-chief of The Journal of Clinical Ethics, recalls the contributions of Albert R. Jonsen, PhD, one of the founding members of the editorial board of the journal.

Clinical ethics consultants (CECs) must know key moral principles and have adequate psychosocial skills. This is, though, not enough. They must also have and hone “between-the-lines” skills that will change over time. This article discusses seven of these skills that CECs need before, during, and after consultations. They have in common the unusual primary goal of maximizing CECs’ ability to bond with the patients and families with whom they consult. A focus on relationships, rather than on ethical outcomes, may paradoxically (...) enhance the possibility of achieving an ethical outcome. (shrink)

Stress can make the comprehension of complex information more difficult, yet patients and their family members often must receive, process, and make decisions based on new, complex information presented in unfamiliar and stressful clinical environments such as the intensive care unit. Families may be asked to make decisions regarding the donation of organs and genetic tissue soon after the death of a loved one, based on new, complex information, under tight time limits. How can we assist patients and families to (...) better process complex information while under stress, and make better decisions for themselves or a loved one? (shrink)

A recently enacted law permits patients to see their electronic medical record (EMR) immediately after their careprovider writes in it. In this article I discuss a proposal that authors make in this issue of The Journal of Clinical Ethics, that ethics consultants (ECs) keep their notes in a separate section of the EMR that patients cannot access when their ethics notes may be troubling to patients, to avoid unduly harming them.I discuss this concern and three more widely applicable clinical goals: (...) to help patients feel safe; to gain patients’ trust; and to provide hope to patients, when possible. These goals apply to careproviders and ECs who seek to help patients and families resolve ethical conflicts. I explain why these goals are singularly important and how careproviders may pursue them, using as an example informing patients about temporal framing to help them find hope. (shrink)

In this issue of The Journal of Clinical Ethics, Emily Bell and Eric Racine are guest editors of a special section focusing on the use of deep brain stimulation (DBS) to treat Parkinson’s disease. In “Deep Brain Stimulation, Ethics, and Society,” Bell and Racine report that DBS already has been used to treat more than 50,000 patients. The ethical issues raised in this special section are important not only in regard to Parkinson’s disease and DBS, but in many areas of (...) medicine.The articles discuss sound, state-of-the-art ethical approaches. This introduction to the issue presents approaches that are adjunctive and intended to increase careproviders’ options, that should increase careproviders’ ability to individualize the care that they provide to their patients. (shrink)

This article focuses on three different ways that we may demean people by seeing them as less than they are, and describes ways we may best avoid doing this. More specifically, I explain how we may not see the physical and emotional issues that plague patients and others. This may be because they choose not to disclose their difficulties to us. We may also err when we see only one aspect of who and how others are. These challenges pose ethical (...) quandaries that involve equity, improved communication with patients, and subjecting ethical principles to empirical study before we adopt them. I explore the means to do these. (shrink)

Alzheimer’s disease is singularly tragic in that it may rob patients of much or all of their personal identity. Some persons fear this outcome so much that they talk of wanting to find the “sweet spot,” a time midway in the course of everincreasing dementia, during which they are able to foresee a possible loss of identity in sufficient time to end their life before they lose the capacity to choose to do so, and before further devastation occurs. This article (...) presents the belief of some experts that patients always retain a basic, core underlying awareness. Practical approaches that careproviders and caregivers can take to maximize patients’ quality of life are discussed. The possibility that patients and loved ones can find meaning in last months and years of life is emphasized. (shrink)

In the documentary Boston Med, patients, their family members, and their careproviders agree to be filmed in real medical situations. Why would they do this? The possible answers to this question may help us to make sense of the paradoxical results of a recent study, in which patients with terminal illness ranked their careproviders highly for communication, even though the patients had failed to learn that they had a fatal illness. Based on this analysis, I offer careproviders a practical approach (...) they can use to improve communication with patients, particularly to help patients to feel less alone. This same approach can also be applied in bioethics consultation. (shrink)

Lainie Friedman Ross suggests that clinicians increase our efforts to meet children’s most basic needs in several ways. These include prioritizing, to a greater extent, children’s present and future feelings; placing greater decisional weight on other family members’ needs; spotting earlier threats from surrogate decision makers so that we can better prevent these threatened harms; and finding ways to intervene earlier so that we can allow parental surrogate decision makers to remain in this role. I offer some practical ways in (...) which Ross’s ideas might be applied. (shrink)

The author suggests that a “first generation” task in bioethics is to give patients the information they need; a “second generation” task is to do this in the most effective way; and a “third generation” task is to avoid harming patients by imposing value biases. The author discusses ways to pursue this third generation task.