‘Alive by default’: An exploration of Velleman’s unfair burdens argument against state sanctioned euthanasia

In this article we critically evaluate an argument against state-sanctioned euthanasia made by David Velleman in his 1992 paper ‘Against the right to die’. In that article, Velleman argues that legalizing euthanasia is morally problematic as it will deprive eligible patients of the opportunity of staying ‘alive by default’. That is to say, those patients who are rendered eligible for euthanasia as a result of legislative reform will face the burden of having to justify their continued existence to their epistemic peers if they are to be perceived as ‘reasonable’. We discuss potential criticisms that could be made of the argument, and consider how a defender of the view might respond. Velleman’s argument is particularly interesting as it is a consequentialist argument against state-sanctioned euthanasia, challenging the many consequentialist arguments that have been made in favour of legalizing the procedure. We conclude by suggesting that further research on the question of unfair burdens is important to adequately evaluating the potential harms of legalizing euthanasia for patients at the end of life.     

Cyanobacteria and seasonal death: A new taphonomic model for the Eocene Messel lake

Two new observations lead us to reconsider the taphonomy of Messel. First, several horses as well as turtles indicate death at a specific season although they come from different horizons. Second, specific structures in the Sediments are very similar to those found in Neumark-Nord. There they could be related to Cyanobacteria. Blooms of Cyanobacteria may poison die surface water. From actual observations it is known that animals drinking such poison water collapse immediately and die mostly near or within the water soon. This model might explain why birds and bats are so frequent throughout the entire profile of Messel. Both drink from the water surface during flight. In contrast to volcanic exhalations, assumed so far, such algae blooms occur repeatedly and always during early summer and autumn. An erratum to this article is available at .     

Do Patients Want to Die at Home? A Systematic Review of the UK Literature,Focused on Missing Preferences for Place of Death

Background

End-of-life care policy has a focus on enabling patients to die in their preferred place; this is believed for most to be home. This review assesses patient preferences for place of death examining: the extent of unreported preferences, the importance of patient factors (place of care and health diagnosis) and who reports preferences.

Methods and Findings

Systematic literature review of 7 electronic databases, grey literature, backwards citations from included studies and Palliative Medicine hand search. Included studies published between 2000–2015, reporting original, quantifiable results of adult UK preferences for place of death. Of 10826 articles reviewed, 61 met the inclusion criteria. Summary charts present preferences for place of death by health diagnosis, where patients were asked and who reported the preference. These charts are recalculated to include ‘missing data,’ the views of those whose preferences were not asked, expressed or reported or absent in studies. Missing data were common. Across all health conditions when missing data were excluded the majority preference was for home: when missing data were included, it was not known what proportion of patients with cancer, non-cancer or multiple conditions preferred home. Patients, family proxies and public all expressed a majority preference for home when missing data were excluded: when included, it was not known what proportion of patients or family proxies preferred home. Where patients wished to die was related to where they were asked their preference. Missing data calculations are limited to ‘reported’ data.

Conclusions

It is unknown what proportion of patients prefers to die at home or elsewhere. Reported preferences for place of death often exclude the views of those with no preference or not asked: when ‘missing data’ are included, they supress the proportion of preferences for all locations. Caution should be exercised if asserting that most patients prefer to die at home.     

Debate: Do all patients with heart failure require automatic implantable defibrillators for the prevention of sudden death?

Recent clinical trials indicate that approximately two-thirds of patients in New York Heart Association (NYHA) class II and III, who comprise almost 90% of patients with heart failure, die suddenly. Patients in NYHA class IV usually die of progressive heart failure. Implantation of implantable cardioverters defibrillators (ICDs) in this population would represent a huge logistic problem and economic expense. Clinical trials have recently demonstrated that β-blocker therapy with carvedilol, bisoprolol, and toprol XL decrease the sudden death rate by almost 50%, in addition to impacting significantly on death due to worsening heart failure. This medical approach is beneficial to all patients, and should be our major therapy. However, it is reasonable to attempt to identify that subpopulations of heart failure patients who could benefit from an ICD.     

Effect of food deprivation on dominance status in blue-footed booby (Sula nebouxii) broods

A pecking hierarchy is normally established in the usual two-chickbrood of the blue-footed booby (Sula nebouxii). The senior (first-hatched)chick dominates its smaller sibling and receives a greater shareof parentally provided food. Experimental broods were createdby putting together two unrelated junior chicks of die sameage in a vacated foster nest The state of the chicks was manipulatedby a period of controlled artificial feeding so that each chickunderwent a different level of food deprivation. The resultingdominance relationship depended on the relative food deprivationlevel of the chicks: the hungrier chick normally became dominant.However, die effect of hunger was occasionally overruled bysize difference: when die hungrier chick was much smaller thanits foster sibling, it was unable to gain dominance over itslarger companion. Dominance status is likely to have greatervalue for die hungrier chick, while die cost of fighting shouldbe lower for die larger chick. These results conform to dieevolutionarily stable strategy predicted for games widi asymmetricpayoff and differences in resource holding power.     

Modification of responses to sex pheromone in the male Mediterranean flour moth, Ephestia kuehniella, by additional substances

Fourteen substances were tested as vapour for the ability to modify the wing vibration response of male Ephestia kuehniella to sex pheromone from the female over a period of 30 sec. Eleven substances had little or no effect on behaviour when tested alone, but six of the eleven decreased the response to pheromone, one increased it, and four had no effect. Two substances were tested in a wind tunnel for their effect as background vapour on the number of male E. kuehniella present at a source of female sex pheromone over a period of 18 min. The effects of these substances in the wind tunnel were the inverse of their effects in the experiments on wing vibration, that is, the short-term measurements of wing vibration gave no indication of the influence of these substances on the accumulation of males at a source of female sex pheromone.

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Zusammenfassung In einer Zeitspanne von je 30 sec wurden 14 Stoffe in Dampfform auf ihre Fähigkeit geprüft, die Flügelschwirr-Reaktion der männlichen Ephestia kuehniella in Gegenwart des weiblichen Geschlechtspheromons zu verändern.Wenn 11 dieser Stoffe ohne Beigabe des weiblichen Geschlechtspheromons untersucht wurden, ergab sich wenig oder gar keine Wirkung auf das Verhalten der männlichen Tiere; in Gegenwart von weiblichem Geschlechtspheromon verminderten dagegen 6 dieser Stoffe das Verhalten der Männchen gegenüber diesem Pheromon, ein Stoff erhöhte die Reaktion und 4 Stoffe hatten keine Wirkung.In einer Zeitspanne von je 18 min wurden 2 Stoffe als Hintergrunddampf in einen Windkanal gebracht und untersucht, ob sie die Zahl der Männchen von E. kuehniella beeinflussen können, die sich an der Quelle des weiblichen Geschlechtspheromons sammeln.Die Wirkung dieser Stoffe im Windkanal stand in umgekehrtem Verhältnis zu ihrer Wirkung im Flügelschwirr-Experiment, das heißt, die kurzfristigen Messungen des Flügelschwirrens ergeben keinen Hinweis auf die Einwirkung dieser Stoffe auf die an der Quelle des weiblichen Geschlechtspheromons angesammelte Zahl der Männchen.

     

Retinopathy at Diagnosis of Diabetes,with Special Reference to Patients under 40 Years of Age

Diabetic retinopathy was present in 7·5% of 5,157 newly diagnosed patients seen at the Birmingham General Hospital Diabetic Clinic between 1960 and 1967. Although die condition becomes commoner with increasing age it is found in 1·5% of patients aged 20 to 39 years. The aetiology is discussed, the conclusion being that in young as in elderly diabetics asymptomatic diabetes of long duration is the main factor.     

Terminal cancer care and patients' preference for place of death: a prospective study.

OBJECTIVE--To assess the preference of terminally ill patients with cancer for their place of final care. DESIGN--Prospective study of randomly selected patients with cancer from hospital and the community who were expected to die within a year. Patients expected to live less than two months were interviewed at two week intervals; otherwise patients were interviewed monthly. Their main carer was interviewed three months after the patient''s death. SETTING--District general hospital, hospices, and patients'' homes. MAIN OUTCOME MEASURE--Stated preferred place of final care; actual place of death; reason for final hospital admission for those in hospital; community care provision required for home care. RESULTS--Of 98 patients approached, 84 (86%) agreed to be interviewed, of whom 70 (83%) died during the study and 59 (84%) stated a preferred place of final care: 34 (58%) wished to die at home given existing circumstances, 12 (20%) in hospital, 12 (20%) in a hospice, and one (2%) elsewhere. Their own home was the preferred place of care for 17 (94%) of the patients who died there, whereas of the 32 patients who died in hospital 22 (69%) had stated a preference to die elsewhere. Had circumstances been more favourable 67% (41) of patients would have preferred to die at home, 16% (10) in hospital, and 15% (9) in hospice. CONCLUSION--With a limited increase in community care 50% more patients with cancer could be supported to die at home, as they and their carers would prefer.     

On estimation of the survivor average causal effect in observational studies when important confounders are missing due to death

Summary .  We focus on estimation of the causal effect of treatment on the functional status of individuals at a fixed point in time t * after they have experienced a catastrophic event, from observational data with the following features: (i) treatment is imposed shortly after the event and is nonrandomized, (ii) individuals who survive to t * are scheduled to be interviewed, (iii) there is interview nonresponse, (iv) individuals who die prior to t * are missing information on preevent confounders, and (v) medical records are abstracted on all individuals to obtain information on postevent, pretreatment confounding factors. To address the issue of survivor bias, we seek to estimate the survivor average causal effect (SACE), the effect of treatment on functional status among the cohort of individuals who would survive to t * regardless of whether or not assigned to treatment. To estimate this effect from observational data, we need to impose untestable assumptions, which depend on the collection of all confounding factors. Because preevent information is missing on those who die prior to t *, it is unlikely that these data are missing at random. We introduce a sensitivity analysis methodology to evaluate the robustness of SACE inferences to deviations from the missing at random assumption. We apply our methodology to the evaluation of the effect of trauma center care on vitality outcomes using data from the National Study on Costs and Outcomes of Trauma Care.     

Does hospital at home for palliative care facilitate death at home? Randomised controlled trial

ObjectiveTo evaluate the impact on place of death of a hospital at home service for palliative care.DesignPragmatic randomised controlled trial.SettingFormer Cambridge health district.Participants229 patients referred to the hospital at home service; 43 randomised to control group (standard care), 186 randomised to hospital at home.InterventionHospital at home versus standard care.ResultsTwenty five (58%) control patients died at home compared with 124 (67%) patients allocated to hospital at home. This difference was not significant; intention to treat analysis did not show that hospital at home increased the number of deaths at home. Seventy three patients randomised to hospital at home were not admitted to the service. Patients admitted to hospital at home were significantly more likely to die at home (88/113; 78%) than control patients. It is not possible to determine whether this was due to hospital at home itself or other characteristics of the patients admitted to the service. The study attained less statistical power than initially planned.ConclusionIn a locality with good provision of standard community care we could not show that hospital at home allowed more patients to die at home, although neither does the study refute this. Problems relating to recruitment, attrition, and the vulnerability of the patient group make randomised controlled trials in palliative care difficult. While these difficulties have to be recognised they are not insurmountable with the appropriate resourcing and setting.

Key messages

• Terminally ill patients allocated to hospital at home were no more likely to die at home than patients receiving standard care
• Although the subsample of patients actually admitted to hospital at home did show a significant increase in likelihood of dying at home, whether this was due to the service itself or the characteristics of patients admitted to hospital at home could not be determined
• The need to balance ideal research design against the realities of evaluation of palliative care had the effect that the trial achieved less statistical power than originally planned
• Particular problems were that many patients failed to receive the allocated intervention because of the unpredictable nature of terminal illness, inclusion of other service input alongside hospital at home, and the wide range of standard care available
• The trial illustrated problems associated with randomised controlled trials in palliative care, none of which are insurmountable but which require careful consideration and resourcing before future trials are planned

     

Localization of the deleted segment in the cri-du-chat syndrome

Summary Fluorescence studies in 17 cri-du-chat patients made it possible to locate the pathogenetic segment to a specific section at the short arm of chromosome No. 5.

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Zusammenfassung Fluorescenzuntersuchungen an 17 Cri du Chat-Patienten ermöglichten die Lokalisation des pathogenetischen Segmentes auf einem spezifischen Abschnitt des kurzen Arms von Chromosom 5.

     

Effect of high dose cytosine arabinoside on quantitative EEG in patients with acute myeloid leukemia

Background EEG activity is considered an index of functional state of brain. Chemotherapy (CT), used for non-central nervous system (CNS) cancer, can cross the blood brain barrier and contribute to changes in the functional state of brain that can alter background EEG activity. Quantitative EEG (qEEG) is superior to conventional EEG in the detection of subtle alterations of EEG background activity and for this reason, the use of qEEG might assist the clinician in evaluating the possible effect of CT on the CNS. The nucleoside analog cytosine arabinoside (Ara-C) is one of the milestone chemotherapeutic agents used for treatment of acute myeloid leukemia (AML). Our observational study evaluates the possible effect of Ara-C on the qEEG of patients with AML, without CNS involvement. We conducted an observational study on newly diagnosed AML patients without CNS involvement, undergoing treatment with Ara-C to analyze the possible effect of Ara-C high doses on EEG background activity using qEEG analyses. A total of nine AML patients, 5 with Ara-C i.v. high dose (≥3 g/m² die), 4 with standard dose (100 mg/m² die) underwent qEEG (at rest, during hyperpnoea, mental arithmetic task and blocking reaction). We compared the EEG background activity of the two groups at baseline and after 6 months. Statistical analysis showed no significant differences between the two groups in mean relative power for all frequency bands, at rest and during hyperpnoea, mental arithmetic task and blocking reaction. Our data indicate that high dose Ara-C i.v. did not induce significant changes on EEG background activity in our patients. Future research in this area could include prospective studies that would combine qEEG and neuropsychological testing to assess the impact of CT on brain functions.     

THE DUTY TO DIE AND THE BURDENSOMENESS OF LIVING

This article addresses the question of whether the arguments for a duty to die given by John Hardwig, the most prominent philosophical advocate of such a duty, are sound. Hardwig believes that the duty to die is relatively widespread among those with burdensome illnesses, dependencies, or medical conditions. I argue that although there are rare circumstances in which individuals have a duty to die, the situations Hardwig describes are not among these. After reconstructing Hardwig's argument for such a duty, highlighting his central premise that ill, dependent, or aged individuals can impose unfair burdens upon others by continuing to live, I clarify precisely what Hardwig intends by his thesis that many of us have a duty to die. I then show that an important disanalogy exists between an uncontroversial example in which an individual has a duty to die and the situations in which Hardwig proposes individuals have a duty to die. More specifically, in situations where a duty to die exists, an individual's having a duty to die logically implies that those she burdens have a right to kill that individual in self‐defense. I then suggest that the burdens that ill, dependent, or aged individuals impose on their families, loved ones, or caregivers do not constitute the kind of threat that warrants the latter killing the former in self‐defense. Hence, the duty to die is much rarer than Hardwig supposes.     

Histoplasmosis in India

The article gives a critical review of the available publications pertaining to Histoplasmosis in India. Evidence on hand indicates that this fungus infection is not endemic in India.

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Zusammenfassung Der Artikel gibt einen kritischen Überblick über die verfügbaren Veröffentlichungen, die die Histoplasmose in Indien betreffen. Daraus geht hervor, daß diese Pilzerkrankung in Indien nicht endemisch ist.

     

新疆小浆果植物资源及其开发利用

新疆北疆山区具有非常丰富的小浆果资源,但开发利用尚处初级阶段。对新疆北疆小浆果的分布现状及保护、合理开发利用和人工栽培状况进行了初步探讨,提出了在山区发展小浆果类经济树种的初步建议。     

N-Acetylcysteine promotes long-term survival of cones in a model of retinitis pigmentosa

Retinitis pigmentosa (RP) is a major source of blindness caused by a large variety of mutations that lead to the death of rod photoreceptors. After rods die, cones gradually die from progressive oxidative damage. Several types of antioxidant formulations have been shown to reduce cone cell death over a relatively short-time frame, but in order for this strategy to be translated into a new treatment for patients with RP, prolonged effects will be needed. In this study, we determined that orally administered N-acetylcysteine (NAC) reduced cone cell death and preserved cone function by reducing oxidative damage in two models of RP, rd1(+/+) and rd10(+/+) mice. In rd10(+/+) mice, supplementation of drinking water with NAC promoted partial maintenance of cone structure and function for at least 6 months. Topical application of NAC to the cornea also reduced superoxide radicals in the retina and promoted survival and functioning of cones. Since oral and/or topical administration of NAC is feasible for long-term treatment in humans, and NAC has a good safety profile, it is reasonable to consider clinical trials to evaluate the effects of prolonged treatment with NAC in patients with RP.     

How palliative care patients’ feelings of being a burden to others can motivate a wish to die. Moral challenges in clinics and families

The article explores the underlying reasons for patients’ self‐perception of being a burden (SPB) in family settings, including its impact on relationships when wishes to die (WTD) are expressed. In a prospective, interview‐based study of WTD in patients with advanced cancer and non‐cancer disease (organ failure, degenerative neurological disease, and frailty) SPB was an important emerging theme. In a sub‐analysis we examined (a) the facets of SPB, (b) correlations between SPB and WTD, and (c) SPB as a relational phenomenon. We analyzed 248 interviews with 62 patients, their family caregivers, and professionals using grounded theory and interpretive phenomenological analysis. SPB appeared as important empathic concern in care situations. Patients expressed many sorts of concerns for others, but also perceived an altered self‐understanding that did not meet mutual expectations within relationships. In SPB associated with WTD three constellations were found: (a) WTD to unburden others; (b) patients decided against hastening death to prevent being a further burden to others (in these cases, the SPB counteracted the wish to die); and (c) both wishes for and against dying were sustained by SPB. These patients often felt paralyzed and suffered deeply. Family caregivers felt emotionally touched by SPB and tried to unburden patients by caring and compassion. We concluded that the impact of SPB on a WTD and the various meanings the facets of SPB have in balancing relationships need to be worked out individually. An early palliative and narrative approach is warranted.     

On Ancestral Self-Fashioning: Photography in the Time of AIDS

This article looks at a series of photographic practices that emerged in Southwestern Uganda in the 1990s, in response to an emergent AIDS epidemic. In particular, it looks at the albums AIDS patients made in the final months of their lives. The article argues that these albums are an outcome both of a modernist, realist register and of an alternative set of locally meaningful dispositions toward the photograph. It is by keeping both of these frames in view that we are able to understand the extraordinary ongoing power these albums continue to have, long after the deaths of their producers, the AIDS patients themselves.     

Aspects of Plastic Surgery: Other Congenital Abnormalities

The plastic surgeon is not a miracle worker, as so many of his patients believe. Nevertheless, he can do much to minimize the functional and cosmetic effect of many congenital deformities. If a moral can be drawn from this article it must be that the plastic surgeon should be given an early opportunity to see and assess the patients described here, if only to ease the anxiety in the minds of their parents by appropriate reassurance and discussion.     

Der Einfluß von Tannin auf die Dehnbarkeit der Zellwand

Zusammenfassung Das Ziel vorliegender Arbeit war, die Wirkung von Tannin auf die Zellwanddehnbarkeit zu untersuchen. Sämtliche Versuche wurden mit 35 mm langen Hypokotylspalthälften 6 Tage alter Sonnenblumenkeimlinge ausgeführt. Die Zellwanddehnbarkeit solcher Spalthälften, die mit Glycerinlösung infiltriert waren, erfolgte mit einer Streckwaage. Nach einer 24stündigen Vorbehandlung in Tanninlösungen (5·10^–4 molar) wurde die Dehnbarkeit der Zellwände um 26% erniedrigt. Die tanninbedingte Abnahme der Wanddehnbarkeit war pH-abhängig. Sie war am stärksten bei pH 6 und sank mit zunehmender Säure des Inkubations-mediums. Bei pH 7 war die Dehnbarkeit tanninbehandelter Hypokotyle sogar stärker als die entsprechender Pufferkontrollen. Die Erniedrigung der Zellwanddehnbarkeit durch Tannin lief parallel zu einer Wachstumshemmung. Offensichtlich wirkt der Gerbstoff Tannin nicht direkt auf die Zellwand, da die Dehnbarkeit von Hypokotylgewebe nicht verändert wurde, wenn diese ohne Vorbehandlung mit einer tanninhaltigen Glycerinlösung infiltriert und plasmolysiert wurden. Die Wirkung auf die Zellwand scheint sekundärer Natur zu sein und über den Stoffwechsel abzulaufen. Mögliche Reaktionsmechanismen wurden ausführlich besprochen.

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Summary The aim of this paper was to investigate the effect of tannin on the extensibility of cell walls. All experiments were done with 35 mm hypocotyl sections of six days old sunflower-seedlings which were split longitudinally into two identical halves. The wall extensibility of those split halves which were plasmolysed by infiltration with glycerin was measured by using a special stretching apparatus. It was found that after a 24 hours preincubation period in tannin solutions (5·10^–4 molar) the extensibility of cell walls became reduced by 26 per cent. The rate of the tannin-caused decrease of cell wall extensibility was dependent on the acidity of the incubation fluid. It was highest at pH 6 and sank with increasing acidity of incubation medium. The extensibility of hypocotyls treated with tannin was at pH 7 even higher than that of corresponding buffer controls. The reduction of cell wall extensibility by tannin ran fairly parallel with a growth inhibition. It has been shown that there is obviously no direct action on the cell wall by tannin, since the extensibility of hypocotyl tissue was not affected if it was infiltrated and plasmolysed by a tannin containing glycerin solution without any pretreatment. The effect on the cell wall seems of secondary nature and acts probably via metabolic factors. Possible mechanisms are extensively discussed.