Tieu, Matthew Review of: Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy, by Theodore Dalrymple, Encounter Books, 2006.

Medical and nursing personnel have an obligation to provide the medication necessary for every patient’s pain relief. This includes patients whose life-supporting mechanical ventilation is being removed, who may not exhibit traditional signs of pain or dyspnea. The purpose of this paper is not to argue a position on withdrawing life support. Rather, it argues that nurses and physicians have an obligation to provide pain-relieving medication, such as opiates, when life support is removed, to ensure that those entrusted to their (...) care do not experience pain or significant distress. This is based on the principle of double effect, by which two actions, one intended and one unintended, may be permissible if there is a proportionate reason. The goal in these situations is never to hasten death intentionally but to make patients’ pain and suffering tolerable as a matter of compassionate and loving care. (shrink)

In addition to endogenously produced opiates, which are part of normal affiliative neurocircuitry and attachment formation, exogenous opiates – such as drugs of addiction and abuse – may affect affiliation. We consider possible modulatory effects of such exogenous opiates on the development of early parent–infant attachment from both parents' and infants' perspectives.

The problem of divine hiddenness has become one of the most prominent arguments for atheism in the current philosophy of religion literature. Schellenberg (Divine hiddenness and human reason 1993), one of the problem’s prominent advocates, holds that the only way to prevent completely the occurrence of nonresistant nonbelief would be for God to have granted all of us a constant awareness of Him (or at least a constant availability of such awareness) from the moment we achieved the age of reason. (...) Now, if that were the case, we might be faced with a difficult obstacle to the development of a proper, meaningful relationship with God: namely, since the experience of God would be so unutterably wonderful (at least for some), we could be at risk of coming to commune with God not from love of Him but for the amazing experience that that communion involves. In other words, given that mystical union with infinite perfection is, qua experience, inconceivably better than that of any drug, we might come to treat God as something analogous to a powerful narcotic, seeking the experience for the pleasure of the experience more than from any devotion. Since God wants to foster genuinely meaningful relationship with Him, He rightly delays granting us such awareness of Himself, even though that leaves open the risk that nonresistant nonbelief could arise. (shrink)

In this article, we discuss the ethical dimensions for the prescribing behaviours of opioids for a chronic pain patient, a scenario commonly witnessed by many physicians. The opioid epidemic in the USA and Canada is well known, existing since the late 1990s, and individuals are suffering and dying as a result of the easy availability of prescription opioids. More recently, this problem has been seen outside of North America affecting individuals at similar rates in Australia and Europe. We argue that (...) physicians are also confronted with an ethical crisis where a capitalist-consumerist society is contributing to this opioid crisis in which societal, legal and business interests push physicians to overprescribe opioids. Individual physicians often find themselves unequipped and unsupported in attempts to curb the prescribing of opioid medications and balance competing goals of alleviating pain against the judicious use of pain medications. Physicians, individually and as a community, must reclaim the ethical mantle of our profession, through a more nuanced understanding of autonomy and beneficence. Furthermore, physicians and the medical community at large have a fiduciary duty to patients and society to play a more active role in curbing the widespread distribution of opioids in our communities. (shrink)

Talk of 'spirituality' and 'individual religion' is proliferating both in popular discourse and scholarly works. Increasingly people claim to be 'spiritual but not religious,' or to prefer 'individual religion' to 'organized religion.' Scholars have for decades noted the phenomenon - primarily within the middle class - of individuals picking and choosing elements from among various religious traditions, forming their own religion or spirituality for themselves. While the topics of 'spirituality' and 'individual religion' are regularly treated as self-evident by the media (...) and even some scholars of religion, Capitalizing Religion provides one of the first critical analyses of the phenomenon, arguing that these recent forms of spirituality are in many cases linked to capitalist ideology and consumer practices. Examining cases such as Eckhart Tolle's The Power of Now, and Karen Berg's God Wears Lipstick, Craig Martin ultimately argues that so-called 'individual religion' is a religion of the status quo or, more critically, 'an opiate of the bourgeoisie.' Capitalizing Religion: Ideology and Opiate of the Bourgeoisie is a landmark publication in critical religious studies. (shrink)

In this journal, Dr Daniel Daly, an American bioethicist, uses a principlist approach (respect for autonomy, non-maleficence, beneficence and justice) to argue that intravenous opiate users should not be denied repeat heart valve replacements if these are medically indicated, ‘unless the valve replacement significantly violates another’s autonomy or one or more of the three remaining principles’.1 In brief outline, the paper seeks to use a widely accepted ethical theory—‘principlism’ as developed by Beauchamp and Childress over the last 40 plus (...) years and eight editions of their ground-breaking book Principles of Biomedical Ethics2—to resolve clinical disagreement about the ethics of denying medically indicated life-prolonging treatment to patients who continue or resume intravenous opiate use. The argument Dr Daly's argument in very brief summary is that in the context of contemporary American medical practice, such treatment is ethically justified—perhaps even ethically required—if requested or accepted by an adequately autonomous patient and thus respects the patient’s autonomy, if it is not harmful to the patient, if it is beneficial to the patient, and if it is fair and just in terms of Aristotle’s formal theory of justice according to which equals should be treated equally while unequals should be treated unequally in proportion to the morally relevant inequality or inequalities. Dr Daly focuses his argument around a typical case description where these conditions are met and therefore where, he concludes, repeat heart valve replacements ought to be provided. As Dr Daly notes, principlism ‘is not without its problems; nonetheless it does provide a viable set of principles that are widely held by medical ethicists and inform the work of ethics committees at many secular medical facilities’. DOI (declaration of interest): The writer of this editorial is a career-long supporter and defender of the use of ‘principlism’ or ‘the four principles …. (shrink)

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Background: There is a significant discourse in the literature that opines that people who use illicit opiates are unable to provide informed consent due to withdrawal symptoms and cognitive impairment as a result of opiate use. Aims: This paper discusses the issues related to informed consent for this population. Ethical considerations: Ethical approval was obtained from both the local REB and the university. Written informed consent was obtained from all participants. Method: This was a qualitative interpretive descriptive study. 22 (...) participants were interviewed, including 18 nurses, 2 social workers and 2 clinic support workers. The findings were analyzed using thematic analysis, which is a way of systematically reducing the complexity of the information to arrive at generalized explanations. Results: The staff at the clinic were overwhelming clear in their judgment that people who use opiates can and should be able to participate in research and that their drug use is not a barrier to informed consent. Conclusions: It is important to involve people who use opiates in research. Protectionist concerns about this population may be overstated. Such concerns do not promote the interests of research participants. People who use heroin need to be able to tell their story. (shrink)

Obwohl die Substitutionsbehandlung nachweislich den Gesundheitszustand opiatabhängiger Patienten verbessern und die Beschaffungskriminalität reduzieren kann, bestehen enge gesetzliche Regelungen, die die Therapiefreiheit der behandelnden Ärzte stark begrenzen: So werden durch das Betäubungsmittelgesetz und die zugehörigen Verordnungen nicht nur das Behandlungsziel (Abstinenz) sondern auch notwendige Therapiebausteine definiert, die darauf ausgerichtet sind, die Therapietreue des Patienten zu kontrollieren. Deutsche Ärzte, die die strengen Auflagen nicht strikt befolgten, wurden zu Gefängnisstrafen verurteilt. Wie der Artikel zeigt, fördern die bestehenden Gesetze eine „kontrollierende“ statt einer motivierenden (...) ärztlichen Behandlung, ohne wichtige Ziele, wie den Schutz der Allgemeinheit vor einer illegalen Verbreitung illegaler Opioide, vollständig zu erreichen. Zusammenfassend zeigt der Artikel, dass eine stärker am Wohl der Patienten ausgerichtete Substitutionsbehandlung (einschließlich notwendiger Kontrolluntersuchungen) mit hoher Wahrscheinlichkeit auch die Öffentlichkeit wirksamer vor den potenziellen Gefahren einer illegalen Verbreitung von gefährlichen Opioiden schützt als die Befolgung abstrakter, restriktiver gesetzlichen Normen. (shrink)

Throughout the 20th century, many doctors did not view pain management as an important aspect of their practice. Because pain cannot be objectively measured by the doctor, many doctors found it dif...

Because little is known about the human trait of affiliation, we provide a novel neurobehavioral model of affiliative bonding. Discussion is organized around processes of reward and memory formation that occur during approach and consummatory phases of affiliation. Appetitive and consummatory reward processes are mediated independently by the activity of the ventral tegmental area (VTA) dopamine (DA)–nucleus accumbens shell (NAS) pathway and the central corticolimbic projections of the u-opiate system of the medial basal arcuate nucleus, respectively, although these two (...) projection systems functionally interact across time. We next explicate the manner in which DA and glutamate interact in both the VTA and NAS to form incentive-encoded contextual memory ensembles that are predictive of reward derived from affiliative objects. Affiliative stimuli, in particular, are incorporated within contextual ensembles predictive of affiliative reward via: (a) the binding of affiliative stimuli in the rostral circuit of the medial extended amygdala and subsequent transmission to the NAS shell; (b) affiliative stimulus-induced opiate potentiation of DA processes in the VTA and NAS; and (c) permissive or facilitatory effects of gonadal steroids, oxytocin (in interaction with DA), and vasopressin on (i) sensory, perceptual, and attentional processing of affiliative stimuli and (ii) formation of social memories. Among these various processes, we propose that the capacity to experience affiliative reward via opiate functioning has a disproportionate weight in determining individual differences in affiliation. We delineate sources of these individual differences, and provide the first human data that support an association between opiate functioning and variation in trait affiliation. Key Words: affiliation corticolimbic-striatal networks; appetitive and consummatory reward; dopamine; oxytocin; personality; social bonds; social memory; u-opiates. (shrink)

The Iowa Gambling Task (IGT) and the Soochow Gambling Task (SGT) are two experience-based risky decision-making tasks for examining decision-making deficits in clinical populations. Several cognitive models, including the expectancy-valence learning model (EVL) and the prospect valence learning model (PVL), have been developed to disentangle the motivational, cognitive, and response processes underlying the explicit choices in these tasks. The purpose of the current study was to develop an improved model that can fit empirical data better than the EVL and PVL (...) models and, in addition, produce more consistent parameter estimates across the IGT and SGT. Twenty-six opiate users (mean age 34.23; SD 8.79) and 27 control participants (mean age 35; SD 10.44) completed both tasks. Eighteen cognitive models varying in evaluation, updating, and choice rules were fit to individual data and their performances were compared to that of a statistical baseline model to find a best fitting model. The results showed that the model combining the prospect utility function treating gains and losses separately, the decay-reinforcement updating rule, and the trial-independent choice rule performed the best in both tasks. Furthermore, the winning model produced more consistent individual parameter estimates across the two tasks than any of the other models. (shrink)

Patient and public involvement is widely thought to be important in the improvement of health care delivery and in health equity. Purpose: The article examines the role of experiential knowledge in service co-production in order to develop opiate substitution treatment services (OST) for high-risk opioid users. Method: Drawing on social representations theory and the concept of social identity, we explore how experts’ by experience and registered nurses’ understandings of OST contain discourses about the social representations, identity, and citizenship of (...) the participants and the effects these may have on developing or hindering inclusive and bottom-up forms of patient and public involvement. Results: The meeting sessions that potentially offer room for creativity and problem-solving fail to provide any new propositions for fixing the system. The health care professionals primarily identify themselves as regulators who protect the correctness of their actions and show little interest in considering experiential knowledge on opioid addiction. Conclusion: The participation of patients has been one of the prominent reforms implemented in health care. The goal of client-centered thinking is often emphasised; however, the implementation is not simple due to the strongly institutionalised knowledge and related working patterns and practices in health care. (shrink)

In this study, we investigate the use of narrative in online conversations among persons suffering from chronic opiate addiction and evaluate both its positive and negative uses. Illness narratives, as argued by sociologist Arthur Frank and psychiatrist/medical anthropologist Arthur Kleinman, enable patients to give order to life experiences and receive support from others. We wished to explore under what circumstances online support coalesces and breaks apart. The narratives we examined exemplify two topics frequently discussed on the message board: the (...) recovery process and what it means to be ‘clean’. To better understand these narratives from a theoretically based approach, we used the work of rhetorical theorist Kenneth Burke. Burke's description of two human motives, suffering and perfection, led us to an understanding of how unification and division happened within the online community. We found that the recovery narrative primarily embodied the author's suffering and, consequently, received support from other members of the message board. The second narrative centered on what it means to be ‘clean’ through a discussion of the author's desire to court temptation, revealing what Burke calls the rotten nature of perfection. As a result, the author of the narrative provoked disagreements and did not receive support. (shrink)

The authors regard opiates as the primary neural substrate for social attachment, and peptide hormones as subsidiary. One may instead conclude from their evidence that oxytocin, vasopressin, and opiates play complementary roles in attachment. Oxytocin and vasopressin relate to different aspects of emotional experience, and opiates to quiescence from long-term attachment. This is related to intimacy versus affiliation.

Adoption, from the Latin opiate, “to choose,” means “to take into a relationship, especially another's child as one's own”. The word implies a permanent taking of responsibility. While the assumption that biological parents should rear their children is vital to society, adoption provides an alternative that is sometimes necessary.

In recent years, the publication of the studies on the transmissibility in mammals of the H5N1 influenza virus and synthetic genomes has triggered heated and concerned debate within the community of scientists on biological dual-use research; these papers have raised the awareness that, in some cases, fundamental research could be directed to harmful experiments, with the purpose of developing a weapon that could be used by a bioterrorist. Here is presented an overview regarding the dual-use concept and its related international (...) agreements which underlines the work of the Australia Group Export Control Regime. It is hoped that the principles and activities of the AG, that focuses on export control of chemical and biological dual-use materials, will spread and become well known to academic researchers in different countries, as they exchange biological materials and scientific papers. To this extent, and with the aim of drawing the attention of the scientific community that works with yeast to the so called Dual-Use Research of Concern, this article reports case studies on biological dual-use research and discusses a synthetic biology applied to the yeast Saccharomyces cerevisiae, namely the construction of the first eukaryotic synthetic chromosome of yeast and the use of yeast cells as a factory to produce opiates. Since this organism is considered harmless and is not included in any list of biological agents, yeast researchers should take simple actions in the future to avoid the sharing of strains and advanced technology with suspicious individuals. (shrink)

Are there sex differences in pain? For experimentally delivered somatic stimuli, females have lower thresholds, greater ability to discriminate, higher pain ratings, and less tolerance of noxious stimuli than males. These differences, however, are small, exist only for certain forms of stimulation and are affected by many situational variables such as presence of disease, experimental setting, and even nutritive status. For endogenous pains, women report more multiple pains in more body regions than men. With no obvious underlying rationale, some painful (...) diseases are more prevalent among females, others among males and, for many diseases, symptoms differ between females and males. Sex differences in attitudes exist that affect not only reporting, coping, and responses to treatment, but also measurement and treatment. So many variables are operative, however, that the most striking feature of sex differences in reported pain experience is the apparent overall lack of them. On the other hand, deduction from known biological sex differences suggests that these are powerful sex differences in the operation of pain mechanisms. First, the vaginal canal provides an additional route in women for internal trauma and invasion by pathological agents that puts them at greater risk for developing hyperalgesia in multiple body regions. Second, sex differences in temporal patterns are likely to give rise to sex differences in how pain is and stimuli are interpreted, a situation that could lead to a greater variability and wider range of pains without obvious peripheral pathology among females. Third, sex differences in the actions of sex hormones suggest pain-relevant differences in the operation of many neuroactive agents, opiate and nonopiate systems, nerve growth factor, and the sympathetic system. Thus, while inductive analysis of existing data demonstrate more similarities than differences in pain experience between females and males, deductive analysis suggests important operational sex differences in its production. (shrink)

The concept of the “End of History” was originally developed by G. W. F. Hegel in the Phenomenology of the spirit in 1806 (Hegel, 2018). The concept can be closely related to a utopia, the completion of the work of philosophers, and the creation of a perfect framework of the finished system of ideas. Hegel had a lot of influence on Western philosophy with the development of this idea and on Marx, who obviously thought of history in dialectic terms. However, (...) he developed the idea of “communism”, which would have been a state of humankind very similar to the concept of Hegel, with no class differences and no opiates of the people—and no place for further development (Marx & Engels, 2002). The “End of History” is based on this theoretical viewpoint that mankind has reached the final and most advanced form of societal development. However, the theorists and their intellectual followers both have to realize a painful way that the phenomenon can only be attained preliminarily. It proves to be a utopia. (shrink)

Although Karl Marx and Søren Kierkegaard are both major figures in nineteenth-century Western thought, they are rarely considered in the same conversation. Marx is the great radical economic theorist, the prophet of communist revolution who famously claimed religion was the "opiate of the masses." Kierkegaard is the renowned defender of Christian piety, a forerunner of existentialism, and a critic of mass politics who challenged us to become "the single individual." But by drawing out important themes bequeathed them by their (...) shared predecessor G. W. F. Hegel, Jamie Aroosi shows how they were engaged in parallel projects of making sense of the modern, "dialectical" self, as it realizes itself through a process of social, economic, political, and religious emancipation. In The Dialectical Self, Aroosi illustrates that what is traditionally viewed as opposition is actually a complementary one-sidedness, born of the fact that Marx and Kierkegaard differently imagined the impediments to the self's appropriation of freedom. Specifically, Kierkegaard's concern with the psychological and spiritual nature of the self reflected his belief that the primary impediments to freedom reside in subjectivity, such as in our willing conformity to social norms. Conversely, Marx's concern with the sociopolitical nature of the self reflected his belief that the primary impediments to freedom reside in the objective world, such as in the exploitation of the economic system. However, according to Aroosi, each thinker represents one half of a larger picture of freedom and selfhood, because the subjective and objective impediments to freedom serve to reinforce one another. By synthesizing the writing of these two diametrically opposed figures, Aroosi demonstrates the importance of envisioning emancipation as a subjective, psychological, and spiritual process as well as an objective, sociopolitical, and economic one. The Dialectical Self attests to the importance and continued relevance of Marx and Kierkegaard for the modern imagination. (shrink)

This paper is addressed to recent theoretical discussions of the Anthropocene, in particular Bernard Stiegler’s Neganthropocene (Open Universities Press, 2018), which argues: “As we drift past tipping points that put future biota at risk, while a post-truth regime institutes the denial of ‘climate change’ (as fake news), and as Silicon Valley assistants snatch decision and memory, and as gene-editing and a financially-engineered bifurcation advances over the rising hum of extinction events and the innumerable toxins and conceptual opiates that Anthropocene Talk (...) fascinated itself with—in short, as ‘the Anthropocene’ discloses itself as a dead-end trap…”. The objective of this paper is therefore twofold: (1) to discuss how the Anthropocene is appropriated to certain ideological discourses (paradoxically) to maintain the hegemony of precisely those systems of production that have most accelerated climate change etc.; (2) to consider how the factography of the Anthropocene is exploited in this process to mask the ideological character of industry-aligned “technocratic” environmental management. The paper is not concerned with specific case studies in terms of government and industry policy, or climate science, but rather with the ways in which the discourse of the Anthropocene has been inflected within the humanities and the broader cultural field—that is to say, ideologically, as a system or logic of meaning. How the Anthropocene “means” is, in this respect, a question of some importance. This paper does not attempt to address all the facets of this question, but focuses upon a central “apocalyptic” strain in the discourse of the Anthropocene drawn particularly from Francis Fukuyama’s millennial posthumanism and centred in the question of “sustainability” as catastrophe management—with the risk that real environmental degradation will become an alibi for a revived neoliberalism. In other words, that the critical Earth system transformations that characterise the Anthropocene are themselves commodities, and that the project of their amelioration is in process of defining a future (opportunistic) “crisis” rhetoric with a global political franchise. The ideological import of the Anthropocene stems precisely from the fact that it is planetary and, while catalysed by human agency, independent in its specific behaviour from it. The Anthropocene objectively presents as the contemporary counterpart of the Cold War doctrine of Mutually Assured Destruction and the most compelling argument for a new kind of technological “arms race.” But it also presents as the condition of an emerging ideological discourse which will determine how this race is run. From the discourse on “energy security” to the widespread “security crackdown” on environmental activists across the so-called developed & developing world, the Anthropocene has come to represent the co-option of a scientific factography for the thinly disguised resurgence of “ideological science” of the Fukuyamaesque variety (post-history, post-human). For Fukuyama, the true meaning of “posthuman” is thus the accomplishment of humanity’s historical mission. As the “End of History” designates an end of ideological struggle, so too the dénouement of the Anthropocene and the “ends of man” represent the accomplished purpose of species warfare: dominion, not simply over the world, but over all possible worlds. According to this narrative, science—like technology—must be uniquely at the service of the maintenance of the global order, organised around a universal appeal to “crisis management.” It is precisely for this reason that what calls itself post-human masks the return of an ever-more-apocalyptic Humanism. (shrink)

Thinkers like Slavoj Žižek and Tim Morton have heralded the end of our ideological constructions of nature, warning that popular “ecology” or the “natural” is just the latest opiate of the masses. Attempting to think what I call Nature after Nature, I turn to the Kamakura period Zen master Dōgen Eihei (1200–1253) to explore the possibilities of thinking Nature in its non-ideological self-presentation or what Dōgen called “mountains and rivers (sansui).” I bring Dōgen into dialogue with his great champion, (...) the American poet Gary Snyder (who understands the process of sansui as “the wild”), as well as with thinkers as diverse as Schelling, Kundera, Žižek, Agamben, and Muir. Beyond Nature being any one thing, what Badiou derides as the “cosmological one,” I argue for the reawakening and sobering up to multiple Nature, beyond its appearance as an object to a discerning subject, as the bioregions which give us our interdependent and dynamic being. (shrink)

Activity anorexia illustrates selection of behavior at the biological, behavioral, and neural levels. Based on evolutionary history, food depletion increases the reinforcement value of physical activity that, in turn, decreases the reinforcement effectiveness of eating – resulting in activity anorexia. Neural opiates participate in the selection of physical activity during periods of food depletion.

We review three possible theoretical mechanisms for the placebo effect: conditioning, expectancy and endogenous opiates and consider the implications of the first two for clinical research and practice in the area of pain management. Methodological issues in the use of placebos as controls are discussed and include subtractive versus additive expectancy effects, no treatment controls, active placebo controls, the balanced placebo design, between- versus within-group designs, triple blind methodology and the double expectancy design. Therapeutically, the possibility of shaping negative placebo (...) responses through placebo sag, overservicing and the use of placebos on their own are explored. Suggestions for using conditioned placebos strategically in conjunction with nonplacebos are made and ways of maximizing the placebo component of nonplacebo treatments are examined. Finally, the importance of investigating the placebo effect in its own right is advocated in order to better understand the long-neglected psychological aspects of the therapeutic transaction. (shrink)

Activity anorexia illustrates selection of behavior at the biological, behavioral, and neural levels. Based on evolutionary history, food depletion increases the reinforcement value of physical activity that, in turn, decreases the reinforcement effectiveness of eating – resulting in activity anorexia. Neural opiates participate in the selection of physical activity during periods of food depletion.

In lieu of an abstract, here is a brief excerpt of the content:“Please Help Me”Rebecca L. VolpeTwo–year–old Jay was born prematurely at 26 weeks gestation, addicted to opiates. After several months in the Neonatal ICU, he was sent home, ventilator–dependent but with a high likelihood of survival and a low chance of severe, lasting disability. When Jay was 1½, he had a cardiopulmonary arrest at home. The parents of children who are on ventilators at home receive extensive education and training (...) about how to respond to something like an arrest. They are taught that a quick response is often critical to their child’s long–term prognosis. And yet, Jay’s parents took such a long time to respond to his code that Jay now has severe hypoxic ischemic encephalopathy: his brain was deprived of oxygen for so long that he has no higher cortical function, and will never think, speak, walk, or play.Currently, Jay is ventilator–dependent and has a very poor prognosis. Jay goes back and forth between a nursing home and the hospital. During one of his many hospitalizations, the ICU team decided to call an ethics consultation, because they felt that continued aggressive intervention was no longer in Jay’s best interests. I was the person on the other end of the line when the medical team called. After having a brief conversation with the attending physician, I left my office and walked to the Pediatric ICU to visit Jay. I arrived at the bedside—really just a large crib—and saw a baby with dark hair lying flat on his back. His tongue was swollen and protruding from his mouth, his eyes were puffy and closed, and his limbs were limp. On his belly was a piece of paper with the words, “BECKY PLEASE HELP ME” typed in huge, bold font. I looked up, into the eyes of the attending physician and said, “Did you type that?” The physician nodded yes. Much could be said about this physician’s behavior. But the bottom line—from a clinical perspective, at least—is that this ICU team was desperate, and that they had significant expectations that I would be able to help them.I began the work of the consultation. I reviewed the medical record, spoke with members of the treating team, and set up a time to talk to the family. During the family meeting, I learned that Jay’s parents wanted to continue to treat aggressively, and that they believed it was not their place to decide when it was their son’s time to die. That was [End Page 122] God’s decision. They could not fathom removing interventions that were maintaining their son’s life. They acknowledged that his quality of life was not high, but, still, it was life.The preferences of the treating team were in stark contrast to the parents’ preferences. The neurologists believed Jay did not have the capacity to experience physical pain, but the ICU team believed that continuing to treat Jay was cruel. Although the ICU team acknowledged that Jay was probably not suffering, they noted that we could not know for sure, and that sometimes Jay grimaced and withdrew—signs that are often interpreted as suffering. The ICU team also argued that given all the sick children in the world, and the scarcity of healthcare resources, it didn’t make sense to invest hundreds of thousands of dollars into prolonging Jay’s life. Additionally, they discovered that Jay had osteopenia (weak, brittle bones)—which was causing multiple bone fractures. The ICU team anguished over the thought of Jay’s small, soft bones continuing to break despite their best efforts.The bioethicist in me knows that, as long as the patient isn’t suffering and the parents aren’t demanding futile interventions (they weren’t), our role as providers was not to judge the parents’ value system. I told the ICU team over and over that different people place different value on Jay’s type of life, and that it wasn’t for us to tell them that their value structure was wrong. I talked with other members of the clinical ethics consultation service. Then I brought the case to the entire institutional... (shrink)

Injury to the central or peripheral nervous system is often associated with persistent pain. After ischemic injury to the spinal cord, rats develop severe mechanical allodynia-like symptoms, expressed as a pain-like response to innocuous stimuli. In its short-lasting phase the allodynia can be relieved with the [gamma]-aminobutyric acid (GABA)-B receptor agonist baclofen, which also reverses the hyperexcitability of dorsal horn interneurons to mechanical stimuli. Furthermore, there is a reduction in GABA immunoreactivity in the dorsal horn of allodynic rats. Clinical neuropathic (...) pain of peripheral and central origin often cannot be relieved by opiates at doses that do not cause side effects. The loss of sensitivity to opiates may be associated with the up-regulation of endogenous antiopioid substances, such as the neuropeptide cholecystokinin (CCK). CCK and its receptor (CCK-R) protein is normally not detectable in rat dorsal root ganglion cells. After peripheral nerve section, both CCK and CCK-R are up-regulated in the dorsal root ganglia. Furthermore, CI 988, an antagonist of the CCK-B receptor, chronically coadministered with morphine, reduces autotomy, a behavior that may be a sign of neuropathic pain following peripheral nerve section. Thus, opiate insensitivity may be due to the release of CCK from injured primary afferents. Similarly, in the chronic phase of the spinal ischemic model of central pain, the allodynia-like symptom is not relieved by systemic morphine, but is significantly reversed by the CCK-B antagonist. Consequently, up-regulation of CCK and CCK-R in the CNS may also underlie opiate drug insensitivity following CNS injury. Thus, dysfunction of central inhibition involving GABA and endogenous opioids may be a factor underlying the development of sensory abnormalities and/or pain following injury to neural tissue. (shrink)

RESUMO: Não há, no pensamento de Marx, uma elaboração sistemática acerca da religião, embora haja uma crítica a ela enquanto crítica social das condições materiais de existência, que é o fundamento dela. Para Marx, a religião, entendida especificamente como superstição, idolatria, “ópio”, a qual conforma o homem e embaraça a sua consciência, deve ser negada, mas não se trata pura e simplesmente de um desprezo, de uma proibição ou perseguição à religião, nem tampouco de uma negação em geral a ela, (...) uma vez que ela é uma questão privada e deve ser respeitada, mas de desvelar o véu religioso presente na sociedade e no seu ordenamento político, no Estado, que oculta a exploração e a opressão humana. A crítica à religião como crítica da realidade social, da qual ela nasce e é expressão ideal, contribui, de certa forma, para a emancipação social do homem. ABSTRACT: it is not to be found in Marx’s thought a systematic elaboration concerning religion, although there is indeed a critical appraisal of it as a result from his social critique of material conditions of human existence which is its foundation. In Marx’s perception, religion is understood specifically as superstition, idolatry, “opiate”, something that pushes man to accommodation and twists his conscience, and as such should be dismissed, this act being not, however, a mere refusal, prohibition or persecution, or a wide negation of it, considering that it is a private issue and as such should be respected, but as an effort to cast off the religious veil covering society and its political ordainment commanded by the State, and hides exploitation and oppression of human beings. Critique of religion as an evaluation of social reality, from which religion derives, is an ideal proposition that to a certain extension contributes to the social emancipation of men. (shrink)

In many countries around the world, people who inject drugs remain at high risk of HIV acquisition not because effective forms of prevention are unknown, nor because they find effective prevention undesirable, but because those in charge, mainly politicians but also bureaucrats, find evidence-based practice politically unacceptable. The evidence for preventive efficacy of harm reduction strategies, most prominently needle and syringe programmes but also treatment programmes such as opiate substitution, is irrefutable.1 However, political responses to drug use issues are (...) varied and complex, so the will to implement appropriate harm reduction programmes in the interests of public health remains lacking in too many jurisdictions. As a consequence, the discussion of how best, in the context of research, to reduce HIV incidence in populations of people who inject drugs but are not offered comprehensive access to known prevention strategies is—tragically—an important one. Dawson et al 2 focus on access to sterile injecting equipment and recognise that this should remain the ‘default’ standard of prevention for HIV prevention trials involving people for whom injecting drug use is the primary risk factor for HIV acquisition. ‘Standard of prevention’ means the background or minimal HIV risk reduction interventions offered to all participants in a trial, regardless of what other investigational interventions they are assigned to receive. The standard of prevention concept is grounded in the ethical principle of beneficence—that researchers and sponsors are obliged to maximise benefits and minimise risks to participants in research studies.3 …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt with pain medications that might (...) have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

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

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt with pain medications that might (...) have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

Two days following her arrest, a forty-four-year-old woman died in jail from aspiration pneumonia secondary to Untreated opiate withdrawal. The New York State Commission of Corrections concluded in its final report that had adequate medical evaluation and treatment been afforded, her death would have been prevented. A forty-six-year-old male with a history of alcohol dependence was arrested for trespassing and held in the county jail. Three days later he became agitated and aggressive. Following physician orders, deputies placed him in (...) restraints. He subsequently vomited and seized. Fifteen minutes later, he experienced respiratory arrest and died.These cases highlight a serious, but neglected problem in jails across the country: inadequate assessment and treatment of drug and alcohol withdrawal among arrestees. In this article, we show that untreated drug or alcohol withdrawal is associated with adverse outcomes including needless pain and suffering, medical morbidity, and in some instances, death. (shrink)

Two days following her arrest, a forty-four-year-old woman died in jail from aspiration pneumonia secondary to Untreated opiate withdrawal. The New York State Commission of Corrections concluded in its final report that had adequate medical evaluation and treatment been afforded, her death would have been prevented. A forty-six-year-old male with a history of alcohol dependence was arrested for trespassing and held in the county jail. Three days later he became agitated and aggressive. Following physician orders, deputies placed him in (...) restraints. He subsequently vomited and seized. Fifteen minutes later, he experienced respiratory arrest and died.These cases highlight a serious, but neglected problem in jails across the country: inadequate assessment and treatment of drug and alcohol withdrawal among arrestees. In this article, we show that untreated drug or alcohol withdrawal is associated with adverse outcomes including needless pain and suffering, medical morbidity, and in some instances, death. (shrink)