ETHICAL ISSUES IN FORENSIC PSYCHIATRIC RESEARCH ON MENTALLY DISORDERED OFFENDERS

This paper analyses ethical issues in forensic psychiatric research on mentally disordered offenders, especially those detained in the psychiatric treatment system. The idea of a 'dual role' dilemma afflicting forensic psychiatry is more complicated than acknowledged. Our suggestion acknowledges the good of criminal law and crime prevention as a part that should be balanced against familiar research ethical considerations. Research aiming at improvements of criminal justice and treatment is a societal priority, and the total benefit of studies has to be balanced against the risks for research subjects inferred by almost all systematic studies. Direct substantial risks must be balanced by health benefits, and normal informed consent requirements apply. When direct risks are slight, as in register-based epidemiology, lack of consent may be counter-balanced by special measures to protect integrity and the general benefit of better understanding of susceptibility, treatment and prevention. Special requirements on consent procedures in the forensic psychiatric context are suggested, and the issue of the relation between decision competence and legal accountability is found to be in need of further study. The major ethical hazard in forensic psychiatric research connects to the role of researchers as assessors and consultants in a society entertaining strong prejudices against mentally disordered offenders.     

BRAIN DEATH IN ISLAMIC ETHICO‐LEGAL DELIBERATION: CHALLENGES FOR APPLIED ISLAMIC BIOETHICS

Since the 1980s, Islamic scholars and medical experts have used the tools of Islamic law to formulate ethico‐legal opinions on brain death. These assessments have varied in their determinations and remain controversial. Some juridical councils such as the Organization of Islamic Conferences' Islamic Fiqh Academy (OIC‐IFA) equate brain death with cardiopulmonary death, while others such as the Islamic Organization of Medical Sciences (IOMS) analogize brain death to an intermediate state between life and death. Still other councils have repudiated the notion entirely. Similarly, the ethico‐legal assessments are not uniform in their acceptance of brain‐stem or whole‐brain criteria for death, and consequently their conceptualizations of, brain death. Within the medical literature, and in the statements of Muslim medical professional societies, brain death has been viewed as sanctioned by Islamic law with experts citing the aforementioned rulings. Furthermore, health policies around organ transplantation and end‐of‐life care within the Muslim world have been crafted with consideration of these representative religious determinations made by transnational, legally‐inclusive, and multidisciplinary councils. The determinations of these councils also have bearing upon Muslim clinicians and patients who encounter the challenges of brain death at the bedside. For those searching for ‘Islamically‐sanctioned’ responses that can inform their practice, both the OIC‐IFA and IOMS verdicts have palpable gaps in their assessments and remain clinically ambiguous. In this paper we analyze these verdicts from the perspective of applied Islamic bioethics and raise several questions that, if answered by future juridical councils, will better meet the needs of clinicians and bioethicists.     

WASHING THE CITIZEN: WASHING, CLEANLINESS AND CITIZENSHIP IN MENTAL HEALTH CARE

Participation in the community and citizenship for patients are common ideals that inspire improvements in mental health care. But what is meant by citizenship? Here an analysis is made of washing practices in psychiatric nursing in long-term mental health institutions. Four repertoires of washing are described, each oriented towards a specific notion of citizenship. In the first repertoire, washing is part of individual privacy; the patient is “enacted” as an individual whose authenticity should be respected in order to equip him or her for participation in the community. In the second repertoire, washing is a basic skill; the patient must learn to take care of her body in order to become an independent citizen. In the third repertoire washing is a precondition to citizenship; patients are to be helped to develop their potentials so that they can find their way in the community. In the fourth repertoire, washing is one opportunity among others to develop social relations; the extent and quality of these relations define a citizen. This analysis opens up not the question if, but which type of citizenship should be promoted.     

STEM CELL TREATMENTS IN CHINA: RETHINKING THE PATIENT ROLE IN THE GLOBAL BIO‐ECONOMY

The paper looks in detail at patients that were treated at one of the most discussed companies operating in the field of untried stem cell treatments, Beike Biotech of Shenzhen, China. Our data show that patients who had been treated at Beike Biotech view themselves as proactively pursuing treatment choices that are not available in their home countries. These patients typically come from a broad variety of countries: China, the United Kingdom, the United States, South Africa and Australia. Among the patients we interviewed there seemed to be both an awareness of the general risks involved in such experimental treatments and a readiness to accept those risks weighed against the possible benefits. We interpret this evidence as possibly reflecting the emergence of risk‐taking patients as ‘consumers’ of medical options as well as the drive of patients to seek treatment options in the global arena, rather than being hindered by the ethical and regulatory constraints of their home countries. Further, we found that these patients tend to operate in more or less stable networks and groups in which they interact and cooperate closely and develop opinions and assessments of available treatment options for their ailments. These patients also perform a multiple role as patients, research subjects, and research funders because they are required to pay their way into treatment and research activities. This new social dynamics of patienthood has important implications for the ethical governance of stem cell treatments.     

ETHICAL DEBATE OVER ORGAN DONATION IN THE CONTEXT OF BRAIN DEATH

This study investigated what information about brain death was available from Google searches for five major religions. A substantial body of supporting research examining online behaviors shows that information seekers use Google as their preferred search engine and usually limit their search to entries on the first page. For each of the five religions in this study, Google listings reveal ethical controversy about organ donation in the context of brain death. These results suggest that family members who go online to find information about organ donation in the context of brain death would find information about ethical controversy in the first page of Google listings. Organ procurement agencies claim that all major world religions approve of organ donation and do not address the ethical controversy about organ donation in the context of brain death that is readily available online.     

评价狗心肌缺血性室性心律失常的电生理学方法

用冠状动脉Harris二期结扎并部分再灌注法及心肌梗塞恢复期的心脏程控刺激技术(PES),进行心电生理检查并诱发与终止室性心动过速(VT)和心室纤颤(VF),建立了狗心肌缺血/再灌注后VT/VF的在体心脏电生理学研究方法,对该方法的可靠性、实用性及其临床相关性进行了探讨。结果表明,狗心肌缺血/再灌注5～8d后用PES能可靠地、重复地诱发出VT/VF,再灌注的梗塞心肌是其电生理异常的病理基础,该方法具有较好的重复性,是一种有价值的电生理学研究方法。     

DISPUTING THE ETHICS OF RESEARCH: THE CHALLENGE FROM BIOETHICS AND PATIENT ACTIVISM TO THE INTERPRETATION OF THE DECLARATION OF HELSINKI IN CLINICAL TRIALS

In this paper we argue that the consensus around normative standards for the ethics of research in clinical trials, strongly influenced by the Declaration of Helsinki, is perceived from various quarters as too conservative and potentially restrictive of research that is seen as urgent and necessary. We examine this problem from the perspective of various challengers who argue for alternative approaches to what ought or ought not to be permitted. Key themes within this analysis will examine these claims and argue they have implications for the interests of the research subject, research governance and regulation. Using our work with TREAT‐NMD, the neuromuscular clinical trials network, we posit that there is a place for advancing the discourse of moral rights and moral duties in the context of research, especially from the perspective of patients and their families, and for including the politics of patient activism and empowerment. At the same time we remain vigilant to the danger that the therapeutic misconception and other serious vulnerabilities for the patient population in clinical trials, are at risk of being overlooked.     

THE CONSEQUENCES OF DIOECY FOR SEED DISPERSAL: MODELING THE SEED-SHADOW HANDICAP

Abstract.— Recent evidence has suggested that clades of dioecious angiosperms have fewer extant species on average than those of cosexual (hermaphroditic and monoecious) relatives. Reasons for the decrease in speciation rates and/or increase in extinction rates are only beginning to be investigated. One possibility is that dioecious species suffer a competitive disadvantage with cosexuals because only half of the individuals in a dioecious population are seed bearing. When only females produce seed, offspring will be more spatially clumped and will experience more local resource competition than when every individual produces seed. We examine two spatially explicit models to determine the effect of a reduction in seed dispersers on the invasibility and persistence of dioecious populations. Even though dioecious females were allowed to produce twice as many seeds as cosexuals, our results show that a reduction in the number of seed dispersers causes a decrease in the ability of dioecious progeny to find uninhabited sites, thus reducing persistence times. These results suggest that the maintenance of dioecy in the presence of hermaphroditic competitors requires a substantial increase in relative fitness and/or a large dispersal advantage of dioecious seeds.     

ADVANCE DIRECTIVES IN TURKEY'S CULTURAL CONTEXT: EXAMINING THE POTENTIAL BENEFITS FOR THE IMPLEMENTATION OF PATIENT RIGHTS

Advance directives are not a part of the healthcare service in Turkey. This may be related with the fact that paternalism is common among the healthcare professionals in the country, and patients are not yet integrated in the decision‐making process adequately. However, starting from the enactment of the Regulation of Patient Rights in 1998, this situation started to change. While the paternalist tradition still appears to be strong in Turkey, the Ministry of Health has been taking concrete measures in the recent years to ensure that patient rights are implemented in healthcare practice. Therefore, Turkey now seems to be in a transitional period where a move towards a more patient‐autonomy centred approach is being supported by the regulatory authorities, as well as the academic circles and the public at large. In the light of this background, this paper aims to examine the potential benefits of advance directives, particularly with regard to their possible effect in the clinical decision‐making process of Turkey's context. It will be argued that advance directives, if correctly understood and implemented in the right settings, may be beneficial, particularly for improving communication between patients and healthcare professionals and for implementing of the right to refuse treatment.     

CURRICULUM GUIDE FOR RESEARCH ETHICS WORKSHOPS FOR COUNTRIES IN THE MIDDLE EAST

To help ensure the ethical conduct of research, many have recommended educational efforts in research ethics to investigators and members of research ethics committees (RECs). One type of education activity involves multi‐day workshops in research ethics. To be effective, such workshops should contain the appropriate content and teaching techniques geared towards the learning styles of the targeted audiences. To ensure consistency in content and quality, we describe the development of a curriculum guide, core competencies and associated learning objectives and activities to help educators organize research ethics workshops in their respective institutions. The curriculum guide is divided into modular units to enable planners to develop workshops of different lengths and choose content materials that match the needs, abilities, and prior experiences of the target audiences. The content material in the curriculum guide is relevant for audiences in the Middle East, because individuals from the Middle East who participated in a Certificate Program in research ethics selected and developed the training materials (e.g., articles, powerpoint slides, case studies, protocols). Also, many of the activities incorporate active‐learning methods, consisting of group work activities analyzing case studies and reviewing protocols. The development of such a workshop training curriculum guide represents a sustainable educational resource to enhance research ethics capacity in the Middle East.     

BRAIN,MIND AND MACHINE: WHAT ARE THE IMPLICATIONS OF DEEP BRAIN STIMULATION FOR PERCEPTIONS OF PERSONAL IDENTITY,AGENCY AND FREE WILL?

Brain implants, such as Deep Brain Stimulation (DBS), which are designed to improve motor, mood and behavioural pathology, present unique challenges to our understanding of identity, agency and free will. This is because these devices can have visible effects on persons' physical and psychological properties yet are essentially undetectable when operating correctly. They can supplement and compensate for one's inherent abilities and faculties when they are compromised by neuropsychiatric disorders. Further, unlike talk therapy or pharmacological treatments, patients need not ‘do’ anything for the treatment to take effect. If one accepts, as we argue here, that brain implants are unique among implantable types of devices, then this can have significant implications for what it means to persist as the same person and be the source of one's thoughts and actions. By examining two of the most common indications for DBS in current use, namely in the motor (Parkinson's Disease) and psychiatric (Major Depression) domains, we further argue that although DBS, as it is currently applied, does not necessarily represent a unique threat to personal identity and agency per se, it introduces an unprecedented ‘third party’ into the debate on these concepts. In this way, DBS can be used as a tool to begin probing, both conceptually and empirically, some of philosophy's most perennial metaphysical questions.     

PROVISION OF COMMUNITY‐WIDE BENEFITS IN PUBLIC HEALTH INTERVENTION RESEARCH: THE EXPERIENCE OF INVESTIGATORS CONDUCTING RESEARCH IN THE COMMUNITY SETTING IN SOUTH ASIA

Background: This article describes the types of community‐wide benefits provided by investigators conducting public health research in South Asia as well as their self‐reported reasons for providing such benefits. Methods: We conducted 52 in‐depth interviews to explore how public health investigators in low‐resource settings make decisions about the delivery of ancillary care to research subjects. In 39 of the interviews respondents described providing benefits to members of the community in which they conducted their study. We returned to our narrative dataset to find answers to two questions: What types of community‐wide benefits do researchers provide when conducting public health intervention studies in the community setting, and what reasons do researchers give when asked why they provided community‐wide benefits? Findings: The types of community‐wide benefits delivered were directed to the health and well‐being of the population. The most common types of benefits delivered were the facilitation of access to health care for individuals in acute medical need and emergency response to natural disasters. Respondents' self‐reported reasons when asked why they provided such benefits fell into 2 general categories: intrinsic importance and instrumental importance.     

DETAINED AND DRUGGED: A BRIEF OVERVIEW OF THE USE OF PHARMACEUTICALS FOR THE INTERROGATION OF SUSPECTS, PRISONERS, PATIENTS, AND POWS IN THE US

Using medical literature citations, Congressional hearings, and declassified documents this paper examines the uses of pharmaceuticals in the interrogation of vulnerable populations. From the use of IV relaxants on criminal suspects during the 1920s to the Global War on Terror, the nexus of drugs, testing, and interrogations will be explored in both the domestic and international contexts.     

FROM MEDICAL RATIONING TO RATIONALIZING THE USE OF HUMAN RESOURCES FOR AIDS CARE AND TREATMENT IN AFRICA: A CASE FOR TASK SHIFTING

With a global commitment to scaling up AIDS care and treatment in resource‐poor settings for some of the most HIV‐affected countries in Africa, availability of antiretroviral treatment is no longer the principal obstacle to expanding access to treatment. A shortage of trained healthcare personnel to initiate treatment and manage patients represents a more challenging barrier to offering life‐saving treatment to all patients in need. Physician‐centered treatment policies accentuate this challenge. Despite evidence that task shifting for nurse‐centered AIDS patient care is effective and can alleviate severe physician shortages that currently obstruct treatment scale‐up, political commitment and policy action to support task shifting models of care has been slow to absent. In this paper we review the evidence in support of task shifting for AIDS treatment in Africa and argue that continued policy inaction amounts to unwarranted healthcare rationing and as such is ethically untenable.     

TRANSIENT AMMONIUM UPTAKE IN THE MACROALGA ULVA LACTUCA (CHLOROPHYTA): NATURE,REGULATION, AND THE CONSEQUENCES FOR CHOICE OF MEASURING TECHNIQUE1

The nature of transient ammonium uptake by the macroalga Ulva lactuca L. was studied from the depletion of ammonium after single additions of ammonium to batch cultures. The experiments were carried out by the application of two different experimental setups: the “multiple flask” and the “perturbation” techniques. Uptake rate was nonlinear with time, and three distinct, succeeding phases of uptake were identified: 1) “surge” uptake, i.e. transiently enhanced uptake that lasted for a few hours only, followed by 2) “internally” controlled uptake, a relatively constant phase occurring at high substrate concentrations, and finally 3) the “externally” controlled uptake phase, which was substrate-dependent and occurred at low substrate concentrations. Surge uptake occurred over a broad range of substrate concentrations but was concentration-dependent and, so, equalled externally controlled uptake rates at substrate concentrations below 3–10 μM. The transient nature of ammonium uptake rate seemed related to rapid changes in small intracellular pools of inorganic nitrogen or amino acids rather than to changes in total N content of the algae. The transient nature of ammonium uptake has important implications for the measurement of uptake rates when either of the two standard methods, the multiple flask and the perturbation technique, are used, and I recommend that a combination of the two methods be used for future uptake experiments.     

SYNTHESIS OF MYCOSPORINE-LIKE AMINO ACIDS IN CHONDRUS CRISPUS (FLORIDEOPHYCEAE) AND THE CONSEQUENCES FOR SENSITIVITY TO ULTRAVIOLET B RADIATION

The induction and protective role of the UV-absorbing compounds known as mycosporine-like amino acids (MAAs) were examined in sublittoral Chondrus crispus Stackh. transplanted for 2 weeks in the spring and summer to shallow water under three irradiance conditions: PAR (photosynthetically active radiation; 400–700 nm), PAR + UVA (PAR + 320– 400 nm), PAR + UVA + UVB (PAR + UVA + 280– 320 nm). Sublittoral thalli collected around Helgoland, North Sea, Germany, from 6 m below the mean low water of spring tides contained less than 0.1 mg·g⁻¹ dry weight (DW) total MAAs, whereas eulittoral samples contained over 1 mg·g⁻¹ DW. Transplantation to shallow water led to the immediate synthesis of three MAAs in the following temporal order: shinorine (λ_max 334 nm), asterina (λ_max 330 nm), and palythine (λ_max 320 nm), with the shinorine content peaking and then declining after 2 days (exposure to 100 mol photons·m⁻²). Maximum total MAA content (2 mg·g⁻¹ DW) also occurred after 2 days of induction, exceeding the content normally found in eulittoral samples. Furthermore, the relative proportion of the different MAAs at this time was different than that in eulittoral samples. After 2 days the total content declined to the eulittoral value, with palythine as the principal MAA. Similar data were obtained for all treatments, indicating that MAA synthesis in C. crispus was induced by PAR and not especially stimulated by UV radiation. The ability of photosystem II (PSII) to resist damage by UVB was tested periodically during the acclimation period by exposing samples to a defined UVB dose in the lab. Changes in chlorophyll fluorescence (F_v/F_m and effective quantum yield, φ_II) indicated that PSII function was inhibited during the initial stage of acclimation but gradually improved with time. No difference among screening treatments was detected except in spring for the samples acclimating to PAR + UVA + UVB. In this treatment F_v/F_m and φ_II were significantly lower than in the other treatments. During the first week of each experiment, growth rates were also significantly reduced by UVB. The reductions occurred despite maximum MAA content, indicating an incomplete protection of photosynthetic and growth-related processes.     

BIPARENTAL INBREEDING AND INTERREMNANT MATING IN A PERENNIAL PRAIRIE PLANT: FITNESS CONSEQUENCES FOR PROGENY IN THEIR FIRST EIGHT YEARS

Despite fundamental importance to population dynamics, mating system evolution, and conservation management, the fitness consequences of breeding patterns in natural settings are rarely directly and rigorously evaluated. We experimentally crossed Echinacea angustifolia, a widespread, perennial prairie plant undergoing radical changes in distribution and abundance due to habitat fragmentation. We quantified the effects of both biparental inbreeding and crossing between remnant populations on progeny survival and reproduction in the field over the first eight years. Lifetime fitness is notoriously difficult to assess particularly for iteroparous species because of the long sequence and episodic nature of selection events. Even with fitness data in hand, analysis is typically plagued by nonnormal distributions of overall fitness that violate the assumptions of the usual parametric statistical approaches. We applied aster modeling, which integrates the measurements of separate, sequential, nonnormally distributed annual fitness components, and estimated current biparental inbreeding depression at 68% in progeny of sibling‐mating. The effect of between‐remnant crossing on fitness was negligible. Given that relatedness among individuals in remnant populations is already high and dispersal very limited, inbreeding depression may profoundly affect future dynamics and persistence of these populations, as well as their genetic composition.     

THE CONDITION DEPENDENCY OF FITNESS IN MALES AND FEMALES: THE FITNESS CONSEQUENCES OF JUVENILE DIET ASSESSED IN ENVIRONMENTS DIFFERING IN KEY ADULT RESOURCES

Variation in environmental or genetic quality leads to phenotypic variation in condition, but how much variation in fitness is created by this variation in condition? Using Drosophila melanogaster, we manipulated condition via alternative larval diets and then tested several key factors predicted to influence how much variation in fitness results from differences in condition. Specifically, we were interested in whether male and female fitness are affected equally by condition and whether the strength of selection on condition depends on the abundance of key resources limiting the reproductive output of each sex. We measured selection on condition in alternative assay contexts that varied in the abundance of adult food (a key resource for females) or in the abundance of females (a key resource for males). Overall, selection tended to be stronger on males than females. However, selection on males was weakened when the abundance of their key resource (females) was elevated. Increasing the abundance of the key resource for females (live yeast) elevated their reproductive output as expected but did not change the strength of selection in this sex. Instead, this manipulation increased selection on males, suggesting that this environmental factor indirectly affects selection on males via their interaction with females.