A critical review of five articles that appeared in the special issue of Acta Asiatica, i.e. • Saitō, Akira. “Avalokiteśvara in the Prajñāpāramitāhṛdaya.” • Watanabe, Shōgo. “The Lineage of the Prajñāpāramitāhṛdaya: With a Focus on Its Introduction and Expressions of Emptiness.” • Horiuchi, Toshio. “Revisiting the ‘Indian’ Commentaries on the Prajñāpāramitāhṛdaya: Vimalamitra’s Interpretation of the Eight Aspects.” • Ishii, Kōsei. “The Chinese Texts and Sanskrit Text of the Prajñāpāramitāhṛdaya Seen by Wŏnch’ŭk 円測.” • Silk, Jonathan A. “The Heart Sūtra as (...) Dhāraṇī.” -/- My overall impression of Frontier is that the authors are committed to a hermeneutic dictated by the Buddhist religion itself, that the Heart Sutra is an Indian text, composed in Sanskrit. The articles in Frontier seem to suggest that no counterfactual evidence exists, or could exist, that would change this conclusion. (shrink)

This article illustrates the importance of research methods in Buddhist Studies using the recent article on the Heart Sutra by Ng and Ānando (2019) as a case study. The authors make a novel conjecture about the Heart Sutra to explain a difference between the Xīnjīng (T 251) and the Dàmíngzhòujīng (T 250) but in doing so they neglect the relevant research methods and critical thinking. Their selection of literary resources is somewhat erratic and their evaluation of them appears to contain (...) bias. The authors did not consult relevant Sanskrit texts (including the Sanskrit Heart Sutra). The logic applied to their source materials appears to be faulty at times and this causes them to arrive at an unconvincing conclusion. By going over the same ground, using more appropriate methods and materials, a far better explanation of the problem emerges. (shrink)

A comprehensive comparison of the Chinese and Sanskrit texts of the Heart Sutra shows that, even after correcting transmission errors, there are substantial differences between them. Most of the differences appear to arise from the process of translating the text from Chinese to Sanskrit in isolation from Sanskrit Prajñaparamita literary traditions. Some differences appear to reflect the differing doctrinal commitments of those involved in creating/transmitting the texts. Following a suggestion by Huifeng (2014), I take a phenomenological approach when reading the (...) Heart Sutra, effectively creating a new kind of commentary that eschews the usual references to metaphysics, mysticism, and magic. The focus here is on the phenomenology of sensory experience and especially the cessation of sensory experience in meditation. (shrink)

Received traditions of Prajñāpāramitā interpretation embrace a hermeneutic in which truth and falsehood are one and the same. This philosophy has deep roots in Indian Buddhism, and it gained prominence in Europe and her colonies through the writings of D. T. Suzuki and his devotee, Edward Conze. It is relatively easy to show that the “contradictions” that form the main axiom of their reading are the result of misunderstanding the texts they relied on. Having done this I discuss a new (...) way of understanding Prajñāpāramitā which shifts the emphasis towards an epistemological reading along the lines of Sue Hamilton’s epistemic approach to Pāli texts. I show how Prajñāpāramitā makes sense in relation to a particular type of meditation practice that aimed to bring about the cessation of sensory experience leaving the meditator in a state of contentless awareness which early Buddhists called suññatāvihāra, “dwelling in [the] absence [of sensory experience].”. (shrink)

Connections between Pañcaviṃśatisāhasrikā-prajñāpāramitā-sūtra and Aṣṭasāhasrikā-prajñāpāramitā-sūtra suggest a new interpretation of an important passage in the Prajñāpāramitā-hṛdaya or Heart Sutra. I am able to show that the four phrases exemplified by “form is emptiness” were once a reference to the well-known simile, “Form is like an illusion” (rūpam māyopamam). As the Prajñāpāramitā corpus expanded, the simile became a metaphor, “form is illusion”. It was then deliberately altered by exchanging “illusion” for “emptiness”, leading to the familiar phrases. This connection opens the door (...) to reading the Heart Sutra, and the early Prajñāpāramitā sutras more generally, along the lines of Sue Hamilton’s (2000) epistemological approach to the Pāḷi suttas; i.e. as focussed on experience and particularly the meditative experience known in the Pāḷi suttas as dwelling in emptiness (suññatā-vihāra). In this view, the Heart Sutra makes sense on its own terms without having to invoke paradox or mysticism. (shrink)

This article offers an introductory overview of the attribution and dating of the versions of the extended Heart Sutra preserved in the Chinese Tripiṭaka and some preliminary assessments of the reliability of these sources. It includes some observations about the interesting features of each version and a stemma showing how they relate to the wider world of Heart Sutra versions. Finally, a conjecture is made about the language in which the extension was made. The Heart Sutra appears to have been (...) extended twice in the early eighth century, leaving us with two different versions of the extended text. It appears that the first extended text, like the standard Heart Sutra, may have been composed in Chinese, while the second extended text appears to have been composed in Sanskrit. (shrink)

The Chinese Heart Sutra was traditionally considered a translation of an Indian Sanskrit text. In the late 20th century scholars began to question this tradition. The Heart Sutra reuses passages from other texts, principally the Large Prajñāpāramitā Sutra. The reused passages are extant in Sanskrit and Chinese source texts and this enables us to perform a unique form of comparative analysis to confirm what language the Heart Sutra was composed in. Jan Nattier examined about half of the text – the (...) 'core section' – and concluded it was composed in Chinese and 'back-translated' into Sanskrit. Nattier’s method has been extended to other parts of the text with the same result. This article details an exhaustive application of Nattier’s method to the Heart Sutra. Considering 22 points of comparison, many of them new, we find a pervasive pattern of features and bugs that definitively point to Chinese origins. (shrink)

Edward Conze still dominates the field of Prajñāpāramitā Studies, such as it is, forty years after his death in 1979. He continues to draw the highest praise from some quarters for his “meticulous” scholarship and his “pioneering” work on Prajñāpāramitā. Does he deserve this praise? As a person, he could be extremely unpleasant shading into something more like malevolence. He was a self-confessed elitist, who hated “blacks” and thought of women as “servants”. As a scholar, Conze was erratic, eccentric, and (...) obscurantist with a conscious commitment to magical thinking. His editions, translations, and exegesis of Prajñāpāramitā are all unreliable. The argument here, however, is not for summary judgement; rather, I present evidence to establish the case for a thorough reassessment of Conze’ s oeuvre. (shrink)

The paper reports a study that investigated the relationship between students? self-predicted and actual General Certificate of Secondary Education results in order to establish the extent of over- and under-prediction and whether this varies by subject and across genders and socio-economic groupings. It also considered the relationship between actual and predicted attainment and attitudes towards going to university. The sample consisted of 109 young people in two schools being followed up from an earlier study. Just over 50% of predictions were (...) accurate and students were much more likely to over-predict than to under-predict. Most errors of prediction were only one grade out and may reflect examination unreliability as well as student misperceptions. Girls were slightly less likely than boys to over-predict but there were no differences associated with social background. Higher levels of attainment, both actual and predicted, were strongly associated with positive attitudes to university. Differences between predictions and results are likely to reflect examination errors as well as pupil errors. There is no evidence that students from more advantaged social backgrounds over-estimate themselves compared with other students, although boys over-estimate themselves compared with girls. (shrink)

This book theorizes aesthetic classroom management through a hermeneutical approach with three fields of literature: history and philosophical foundations of chivalry, chivalry’s promulgation through the Victorian Age, and parallel issues of identity in twenty-first century teacher education. The aim of the book is to examine the relationship between chivalric ethos and education. The presented case study addresses more specifically the following question: how can chivalry be re-imagined or theorized in an educational setting? Few studies address the concept of aesthetics and (...) hermeneutical context in American classroom management and classroom life, and Attwood pinpoints and traces the medieval social concept of chivalry through the centuries and argues it has manifested itself in classroom social construction in the twenty-first century. (shrink)

This article examines the construction of woman's voice, gaze and desire in Jane Campion's Oscar-winning film The Piano, 1993, with particular reference to the film's central character, Ada, and to the traditional female figures which her character suggests – siren, mermaid, Little Red Riding Hood, Bluebeard's wife. It investigates the ways in which The Piano interrogates and disturbs traditional patriarchal narratives, ways of speaking and seeing, and patriarchal constructions of bodily pleasure and desire; revealing these as partial, hard of hearing, (...) short sighted and incapable of pleasure. It argues that while the film succeeds in this interrogation, it goes further in its attempt to envisage forms of speech, sight and pleasure which do not conform to traditional models based on the notion of rigid oppositions between self and other, masculine and feminine, active and passive. Instead, by focusing on mutual pleasure, sensuality, communication and the ability to be moved, it sets in motion ‘other’ ways of experiencing and understanding women's voices, looks, desires. It concludes that The Piano articulates a demand for an encounter with men, in which women are neither marginalized as ‘the feminine’ nor re-incorporated into a patriarchal order; and imagines the possibility of both autonomy and connection, power and pleasure. (shrink)

ABSTRACT The recent report of the Milburn Review into Social Mobility highlights the under-representation of young people from lower socio-economic groups in higher education and encourages universities and others to act to remedy this situation as a contribution to greater social mobility. The paper uses data from the Longitudinal Study of Young People in England to examine the relationship between social background, attainment and university participation. The results show that differences in school-level attainment associated with social background are by far (...) the most important explanation for social background differences in university attendance. However, there remains a small proportion of the participation gap that is not accounted for by attainment. It is also the case that early intentions for higher education participation are highly predictive of actual participation. The results suggest that although there may be some scope for universities to act to improve participation by people from less advantaged backgrounds, a much more important focus of action is on improving the school-level achievement of these students. (shrink)

The concept of rational suicide argues that suicide could be a rational choice, in certain circumstances. Such an argument faces criticism when there is an accompanying mental illness, as many view suicide as a symptom of mental illness rather than as a rational choice about one's life. More specifically, the rational suicide debate has mostly excluded individuals with schizophrenia, as it is widely seen as a disorder that impairs rational decision making. This paper aims to examine the concept of rational (...) suicide in schizophrenia: Could it be possible that some acts of suicide are driven from a rational choice by patients suffering from schizophrenia? This paper does not include discussions related to physician-assisted dying in schizophrenia. (shrink)

Change blindness is a phenomenon of visual perception that occurs when a stimulus undergoes a change without this being noticed by its observer. Since it was first described in the 1990s, change blindness has provided a unique means to investigate the role of attention in visual processing. To date, the effect has been produced by changing images displayed on screen as well as changing people and objects in an individual’s environment. In this study, we combine these two approaches to directly (...) compare the levels of change blindness produced in real-world and on-screen scenarios. We use a single series of museum artefacts and two groups of participants to simultaneously produce saccade-contingent change blindness in a real-world scenario, and camera pan-contingent change blindness in an on-screen scenario. We present the results in two parts. First, we find no significant difference between the mean levels of change blindness produced in on-screen and real-world scenarios by the same visual stimuli. Second, we identify a group of artefacts that were associated with a high level of change blindness in both scenarios and a group that were associated with a low level of change blindness in both scenarios. We suggest that the difference in change blindness levels results from bottom-up influences including the visible area and contrast of changes. We discuss the relation of these findings to our understanding of change detection as a part of visual processing, as well as the insights they offer to our understanding of the experience of viewing objects within a museum setting. (shrink)

Articles by Bain Attwood, Tim Murray, Gillian Cowlishaw, Stephen Muecke, Andrew Lattas, Philip Jones, Barry Morris, Tim Rowse, Heather Goodall, Jan Pettman and Colin Pardoe annotated separately.

The media are inextricable from controversy yet "controversy" is an under-theorized term in studies of the media, even though controversies over specific images, from "video nasties" to snapshots from Abu Ghraib, have structured our understanding of the media's power, seductiveness and dangers. This collection offers a series of case studies of recent media controversies and draws on new perspectives in cultural studies to consider a wide variety of types of image, including newspaper cartoons, advertising and fashion photography, music videos, photojournalism, (...) news media, art works, hardcore porn film, anime, horror and exploitation movies, video games, and YouTube reaction videos. In the current climate when images appear to be increasingly controversial, it is important that media controversies are not made the excuse for greater censorship and the demonization of "dangerous" images and the audiences that consume them. The case studies in this book suggest how we might achieve a more subtle understanding of controversial images and negotiate the difficult terrain of the new media landscape. (shrink)

'. . . this is a good book that will well serve both students who are new to Ramsey and those who might not be better acquainted with his work . . .'-THE JOURNAL OF RELIGION.

The paper reports a study of children's attitudes to school based on a questionnaire survey of 845 pupils in their first year of secondary school in England, together with interviews with a sample of the children. A clearly structured set of attitudes emerged from a factor analysis which showed a distinction between instrumental and affective aspects of attitudes but also dimensions within these, including a sense of teacher commitment and school as a difficult environment. Virtually all children had a strong (...) sense of the importance of doing well at school. However, a substantial minority were not sure that they would stay on after 16. There were few differences between boys and girls or between children from different socio-economic backgrounds but children planning to leave at 16 enjoyed school less and were less sure that it had anything to offer them. There was an almost universal commitment to the value of education but, for a minority, an ambivalence about the experience and relevance of schooling for them. (shrink)

This book explains how an understanding of creation and convent love can give firm foundations for moral truth, confident to withstand moral confusion and cynicism.

Pornography has always been central to debates about sex and emerging new media technologies. Today, debate is increasingly focused on online pornographies. This collection examines pornography's significance as a focus of definition, debate, and myth; its development as a mainstream entertainment industry; and the emergence of the new economy of Porn 2.0, and of new types of porn labor and professionalism. It looks at porn style behind the scenes of straight hardcore, in gay, lesbian, and queer pornographies, in shock sites, (...) and in amateur erotica, and investigates the rise of the online porn fan community, the sex blogger, the erotic rate-me site and the visual cultures of swingers. Treating these developments as part of a broader set of economic and cultural transformations, this book argues that new porn practices reveal much about contemporary and competing views of sex and the self, the real and the body, culture, and commerce. (shrink)

The Routledge Companion to Media, Sex and Sexuality is a vibrant and authoritative exploration of the ways in which sex and sexualities are mediated in modern media and everyday life. The 40 chapters in this volume offer a snapshot of the remarkable diversification of approaches and research within the field, bringing together a diverse mix of scholars and researchers from around the world and from different disciplinary backgrounds including cultural studies, education, history, media studies, sexuality studies and sociology. The volume (...) includes research from around the world to give readers a broad array of global and transnational issues and intersectional perspectives as authors address a series of important questions that have consequences for current and future thinking in the field. Topics explored include postfeminism, masculinities, media industries, queer identities, video games, media activism, music video, sexualization, celebrities, sport, sex advice books, pornography and erotica, and social and mobile media. The Routledge Companion to Media, Sex and Sexuality is an essential guide to the central ideas, concepts and debates currently shaping research in mediated sexualities and the connections between conceptions of sexual identity, bodies and media technologies. (shrink)

The belief that damaging an object may harm the individual to which the object relates is common among adults. We explored whether arousal following the destruction of a photograph of a loved partner is greater than that following the destruction of a photograph of a stranger, and whether this response is greater than when a photograph representing a non-person sentimental attachment is destroyed, using a measure of skin conductance response. Long-term supporters of a football team, who were also in a (...) long-term relationship, showed increased arousal when asked to destroy a photograph of their partner, but not a photograph of their team, even though both elicited equivalent ratings of emotional attachment. This may be because football teams are conceptualized differently from individuals. Future studies should address whether destruction of symbols that represent the enduring nature of the team elicit more emotional distress than photograph. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:“Destined to Fail”: Carl Seashore’s World of Eugenics, Psychology, Education, and Music by Julia Eklund KozaJune Boyce-TillmanJulia Eklund Koza, “Destined to Fail”: Carl Seashore’s World of Eugenics, Psychology, Education, and Music (Ann Arbor, MI: University of Michigan Press, 2021)This is a difficult book to read not only because of its length but also its content. While reading the history of eugenics and how it played out in the (...) invention of the holocaust, I found myself feeling the nausea that I similarly feel when embarking on Margaret Attwood’s Handmaid’s Tale. I also remembered how I had used the Seashore tests of musical ability in my time teaching in London primary schools. I was faced with a common problem in UK State schools–three places for violin tuition and twenty children seeking them. The Seashore tests appeared to be the answer to the problem. The claims made for them were that they would tell me which children were likely to succeed because they had more musical ability than others. It was only in the process of using them that I realized that this was an unjustified claim. Conversations with John Sloboda revealed two other aspects that might play out in musical success. One was a moment/event which made a person fall in love with a particular instrument and want to learn it. The other was the amount of time a person would put in to practice the instrument, which in many London contexts with high-rise flats and no soundproofing [End Page 83] was extremely difficult. All that the Seashore tests showed was the third aspect involved in engagement with music, which was the ability to recognize the musical patterns of a particular culture. But what this book shows us so clearly is the danger of rating this ability to grasp the musical patterns of the Western classical musical traditions as the totality of musical ability. Beneath this is the belief that some people are innately musical but, more significantly, others are not. In my experience, musicality is a difficult area in our UK culture; people are more likely to say that they are not musical in a way that they would not in relation to any other academic discipline such as English, geography or history. In many educational contexts, I have pointed out that, if a teacher believes that some students are musical and some are not, then it is unethical to have class music lessons for everyone in the curriculum. Helpfully, in the final chapter of the book, some of these shades from the past, that still color contemporary thinking about music education, are clearly set out.To turn to the book itself, the first chapter sets out Seashore’s life as a “Mendelian hereditarian who believed that musical talent is biologically inheritable, differently bestowed, and immutable.”1 The author contextualizes the belief system in which this is rooted, discussing the American Eugenics Society, the best baby contests, and the “great man” narratives of the early to mid-twentieth century (first set out in Galton’s idea of genius). Seashore’s legacy figures in a number of academic fields, including audiology, aesthetics, educational reform, the American Psychological Society, and the National Academy of Sciences. She hopes to initiate a debate about how eugenics has, and still does have, a part in stories of both music education and education generally. She situates her work in a view of “‘the past’ as a dynamic construct created and recreated in the present.”2 She sets up a different way of remembering the past by acknowledging that past, present, and future are culturally constructed and bounded, in which she uses Foucault’s concept of power.3 She considers the role of “solid” science in supporting both eugenics and its responsibility for the Holocaust. I would recommend that anyone embarking on historical musicology read this chapter to understand the complex mechanisms which need to underpin such study.My own academic research has been about deconstructing the patriarchal values that filled my own miseducation in music history. The legacy of Galton’s construction of genius dominated my music education and when I took my professorial... (shrink)

Imagining Dewey' features productive (re)interpretations of 21st century experience using the lens of John Dewey's 'Art as Experience', through the doubled task of putting an array of international philosophers, educators, and artists-researchers in transactional dialogue and on equal footing in an academic text. This book is a pragmatic attempt to encourage application of aesthetic learning and living, ekphrasic interpretation, critical art and agonist pluralism.0There are two foci: (a) Deweyan philosophy and educational themes with (b) analysis and examples of how educators, (...) artists, and researchers envision and enact artful meaning making. This structure meets the needs of university and high school audiences, who are accustomed to learning about challenging ideas through multimedia and aesthetic experience.00Contributors are: James M. Albrecht, Adam I. Attwood, John Baldacchino, Carolyn L. Berenato, M. Cristina Di Gregori, Holly Fairbank, Jim Garrison, Amanda Gulla, Bethany Henning, Jessica Heybach, David L. Hildebrand, Ellyn Lyle, Livio Mattarollo, Christy McConnell Moroye, Maria-Isabel Moreno-Montoro, Maria Martinez Morales, Stephen M. Noonan, Louise G. Phillips, Scott L. Pratt, Joaquin Roldan, Leopoldo Rueda, Tadd Ruetenik, Leisa Sasso, Bruce Uhrmacher, David Vessey, Ricardo Marin Viadel, Sean Wiebe, Li Xu and Martha Patricia Espiritu Zavalza. (shrink)

This thesis explores relationships between music produced around 1800 for domestic consumption and the fictional genre of romance – a genre of fantastic atmospheres, settings and characters, quest plots with dramatic events, and a sense of antiquity and desire that represents remoteness and addresses the cultural periphery. What this fiction says about music offers a new view of romanticism in British print culture, making this thesis serve as counterhistory to studies of nineteenth-century European operatic and orchestral canons and their links (...) with later fiction. I survey the use of music in romance novels by Ann Radcliffe, Matthew Lewis, Sir Walter Scott and James Hogg in the period 1790-1830, interrogating the ways that music served to create mood and atmosphere, enlivened social scenes and contributed to plot developments. I explore the connections between musical scenes in romance fiction and the domestic song literature – short accompanied songs, both sacred and secular, by composers such as Thomas Attwood, John Wall Callcott, Matthew Cooke, John Baptist Cramer, John Barnett, François Hippolyte Barthélemon, Charles Dibdin, William Hawes, Thomas Moore, John Parry, William Reeve, Reginald Spofforth, and Sir John Stevenson. My intersectional reading revolves around a series of imaginative figures – including the minstrel, fairies, ghosts, witches, and other supernatural figures, and Christians engaged both in virtue and vice – the identities of which remained generally consistent as influence passed between the art forms. While authors quoted song lyrics and included musical descriptions and characters, their novels recorded and modelled the performance of songs by the middle and upper classes, influencing the work of composers and the actions of contemporary performers who read romance fiction. My thesis shows how the intersection of romances with vocal music recorded a society on the cusp of modernisation, with a printing industry emerging to serve people’s growing appetites for entertainment amidst their changing views of religion and the occult. No mere diversion, fiction was integral to musical culture and together both art forms reveal key intellectual currents that circulated in the early nineteenth-century British home. (shrink)

Rigorous oversight has achieved great success in ensuring fully informed consent from patients when choosing to take prescription drugs. As concerns about the influence of pharmaceutical gifts on physicians have increased, state legislatures have adopted statutes intended to reduce the influence of such gifts; “sunshine laws” require pharmaceutical companies to disclose gifts to doctors. The Department of Health and Human Services Office of the Inspector General has issued industry guidance that delineates marketing that is not permissible.[1] The Patient Protection and (...) Affordable Care Act requires drug companies to disclose payments made to physicians for consulting, speaking and travel.[2] Full disclosure and transparent reporting enable patients to discern financial motive or any other incentive a physician may have in prescribing drugs, but when patients seek a new procedure or innovative surgery, achieving informed consent is challenging without a regulating body’s control. BACKGROUND Informed consent constitutes a process in which a fully informed patient can take part in decisions about his or her health care.[3] Informed consent is based on the principle that people are the best guardians of their own interests. Elements of informed consent include disclosure, cognition and a process of consent, refusal or choice. This paper shall focus on the current gap in disclosure requirements in doctor-patient dialogue regarding surgeries or other procedures and the impacts of that gap. While state and federal oversight have enhanced informed consent among patients in regards to pharmaceuticals, safeguarding informed consent is more challenging when providing care dependent on the skill of a surgeon or when seeking a new procedure without the control of a regulating body. This difficulty can be remedied through increased oversight, with the burden upon both the physician and health care facility to pursue objective evidence of benefit and risks and then disclose such data to the patient. CYTOREDUCTIVE SURGERY WITH HYPERTHERMIC CHEMOTHERAPY (HIPEC) HIPEC is a complex surgical procedure now offered to patients with advanced cancers of the gastrointestinal tract without definitive evidence of benefit. HIPEC involves surgical removal of all visible metastatic cancer within the abdominal cavity and the instillation of heated chemotherapy in the cavity to penetrate the surfaces; the goal is to eradicate all metastatic disease.[4] HIPEC was popularized by Paul Sugarbaker, MD, to treat the rare condition of pseudomyxoma peritonei, a complication of appendix cancer. Appendix cancer affects 1,500 Americans annually, while pseudomyxoma peritonei occurs in one to two per million per year.[5] The success of HIPEC to eradicate disease in this rare condition led to the extrapolation of the approach to other cancers of the gastrointestinal tract that have spread within the abdominal cavity, mainly colon cancer. Due to the complexities of randomized studies of surgical procedures, scant evidence exists showing HIPEC works for metastatic colon cancer. One randomized study showed that patients undergoing HIPEC lived an average of 22.4 months post-surgery, while those who pursued traditional chemotherapy lived only 12.6 months.[6] However, the study’s flaws were rampant. Those who pursued chemotherapy alone received a now outdated regimen; average current survival for chemotherapy alone is more than 22 months.[7] Second, the extent of disease was known only in those patients who underwent surgery; a wide variation in survival existed dependent on those with small volume as compared to large volume disease (29 months and 5 months, respectively). The extent of disease for the control group, those receiving chemotherapy alone, is not known. Third, 8 percent of surgical patients died in the post-operative period. A recent retrospective review of the experience at the Roswell Park Cancer Institute, in Buffalo, New York, over an eight-year period supports a benefit of HIPEC for colon cancer with intra-abdominal spread.[8] Of 38 patients treated in this manner, the five-year overall survival rate was 38 percent. Using standard chemotherapy regimens for advanced colon cancer during this time period, the expected five-year survival rate would be less than 10 percent. The limitations of this study are its retrospective and nonrandomized design. It is important to note that in this series, the five-year overall survival rate for appendix cancer treated with HIPEC, its original intent, was greater than 66 percent. Despite scant evidence of efficacy, patients—anecdotally younger, healthier and wealthier—seek out this treatment, and the number of physicians offering it has increased. David Ryan, MD, a gastrointestinal oncologist at Massachusetts General Hospital, has noted that HIPEC’s use has been growing due to the inability of surgeons to make a living performing it only on appendix cancer patients, its original intent.[9] Because such an innovative surgery involves a departure from standard practice, greater caution and regulation is needed for a number of reasons. When that innovation is in the surgeon’s self interest, the surgeon’s judgment about the patient’s best interest may be clouded. Surgeons may hold an economic interest in promoting the procedure, they may fear being left behind the curve of medical advancement, or they may be influenced by a desire for rewards.[10] LESSONS LEARNED By the late 1980s, nearly every American academic medical center had established bone marrow transplantation programs for the treatment of breast cancer after several small, uncontrolled phase 1 and 2 studies suggested that high-dose chemotherapy with autologous bone marrow transplantation resulted in better outcomes than would have been expected with standard chemotherapy alone. A single randomized study, in 1995, supported this hypothesis.[11] As a result of this single study, an estimated 30,000 breast cancer patients in the U.S. received bone marrow transplants between 1985 and 1998. Despite scant data, the presumption of benefit was widespread.[12] In an attempt to ensure objective evidence of efficacy, multiple academic institutions pursued rigorous randomized clinical trials comparing high-dose chemotherapy with autologous bone marrow transplant to standard chemotherapy for all stages of breast cancer. In 1999, results of five randomized trials were presented at the American Society of Clinical Oncology meeting, only one of which supported the therapy’s use. That study was conducted by the same investigators who presented the first data in 1995. An on-site investigation and review of records of the institution revealed scientific misconduct, including no signed informed consent and no institutional review board approval. The results of both studies were retracted.[13] Medical centers moved to shutter their programs.[14] The same conflicts at play in the decision to perform HIPEC are evidenced in this historical lesson. Academic medical centers opened programs as others did, maintaining competitiveness in the fast-moving field of cancer care. Doctors performed transplants on little data; if they did not, these women—often desperate—would go elsewhere in search of a doctor willing to perform the procedure. There was little regulation over tens of thousands of treatments that were later deemed to have no proven benefit. CONCLUSION Conflicting values and interests among physicians and patients are inescapable. When disclosure is required in cases in which an outside commercial entity may profit, such as pharmaceutical companies, patients are made better aware of any reason outside of his or her best medical interest for which he or she may be prescribed a drug. In the absence of a regulatory body, patients are at risk of incomplete disclosure. Such incomplete disclosure impedes informed consent in these medical instances of pursuing surgeries or other procedures. Outside interests, such as prestige sought by a physician, financial gain, or support of a burgeoning academic program may induce medical providers to encourage or perform a surgery or procedure absent data regarding efficacy. Patients may be unaware of the need of the physician or hospital to justify the expense of these programs, such as those currently opening for HIPEC treatment, or those that performed bone marrow transplants on breast cancer patients. In such cases in which statutory framework is nonexistent and in which no federal agency governs medical care with clear rules, it is the responsibility of physicians to both ensure that true informed consent is secured and expose their motivation, in the absence of objective data, to this vulnerable population. PDF REFERENCE NOTES 1. D. Grande, “Limiting the influence of pharmaceutical industry gifts on physicians: Self regulation or government intervention?,” Journal of General Internal Medicine, 2010, 25:79-83. 2. P.C. Hebert, N. MacDonald, K. Flegel et al., “Competing interests and undergraduate medical education: Time for transparency,” Canadian Medical Association Journal, 2010, 182:1279. 3. S.N. Whitney, A.L. McGuire, L.B. McCullough, “A typology of shared decision making, informed consent, and simple consent,” Annals of Internal Medicine, 2004, 140:54-9. 4. D. Bartlett, “HIPEC: The complexities of clinical trials,” Annals of Surgical Oncology, 2008, 15:1277-79. 5. P.H. Sugarbaker, “New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome?,” Lancet Oncology, 2006, 7:69-76. 6. V.J. Verwaal, S. van Ruth, E. de Bree, et al., “Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer,” Journal of Clinical Oncology, 2003, 21:3737-43. 7. E. Jullumstrø, A. Wibe, S. Lydersen, et al., “Colon cancer incidence, presentation, treatment and outcomes over 25 years,” Colorectal Disease, 2011, 13:512-8. 8. M. Halslinger, V. Faancescutti, K. Attwood, et al., “A contemporary analysis of morbidity and outcomes in cytoreduction/hyperthermic intraperitoneal chemoperfusion,” Cancer Medicine, 2013, 2:334-342. 9. D. Ryan, “Cytoreductive surgery and hyperthermic intraperitonal chemotherapy: History repeating itself or a new standard?,” American Society of Clinical Oncology, 2011, 127-8. 10. D. Meyerson, “Innovative surgery and the precautionary principle” Journal of Medicine and Philosophy, originally published online Oct. 24, 2013. 11. W.R. Bezwoda, L. Seymour, R.D. Dansey, “High-dose chemotherapy with hematopoietic rescue as primary treatment for metastatic breast cancer: A randomized trial,” Journal of Clinical Oncology, 1995, 13:2483-2489. 12. R.A. Rettiq, P.D. Jacobson,, C.M. Farquhar, et al., in False hope: bone marrow transplantation for breast cancer (New York: Oxford University Press, 2007), p. 1-355. 13. “Special Departments: Retraction,” Journal of Clinical Oncology, 2001, 19:2973. 14. H.G. Welch, J. Mogielnicki, “Presumed benefit: lessons from the American experience with marrow transplantation for breast cancer,” British Medical Journal, 2002, 324:1088-92. (shrink)