Cruel choices: autonomy and critical care decision-making

Although autonomy is clearly still the paradigm in bioethics, there is increasing concern over its value and feasibility. In agreeing with those concerns, I argue that autonomy is not just a status, but a skill, one that must be developed and maintained. I also argue that nearly all health-care interactions do anything but promote such decisional skills, since they rely upon assent, rather than upon genuinely autonomous consent. Thus, throughout most of their medical lives, patients are socialised to be heteronomous, rather than autonomous. Yet, at the worst possible time--critical care decision-making--when life and death consequences are attached to the choices, the paradigm shifts and real consent is sought, even demanded, thereby making an often traumatic situation even harder. I go on, though, to also reject paternalistic models of beneficence as an alternative. Rather, I conclude that the problem is so fundamental in healthcare that a genuine solution would require a radical restructuring. I recommend steps that can be taken in the interim to improve the situation and to move toward such a restructuring.     

A social ethological perspective applied to care of and research on songbirds

The interrelationships among individuals in gregarious species can have profound effects on the animals' behavior, physiology, and even health. Captive housing should address the social needs of such species because failure to do so can result in the development and expression of abnormal behavior. But determining what social stimuli to provide for any given species poses many challenges. I review recent work on brown-headed cowbirds (Molothrus ater) that was designed to identify the social stimuli critical for effective development and breeding. The work demonstrates the importance of social experiences in organizing reproductive physiology and behavior, so much so that inattention to these experiences can lead to misinterpretation of the function and mechanisms of the birds' behavior. There are no general rules applicable to all social species, however. Determining the social conditions needed for members of any species requires an ethological approach that evaluates the sensory, cognitive, and ecological characteristics of the species and considers those characteristics in the design of captive housing and research.     

Relational autonomy,care, and Jehovah's Witnesses in Germany

Drawing from an ethics of care, relational approaches to autonomy have recently emerged in bioethics. Unlike individual autonomy with its emphasis on patients’ rights, choice, and self‐determination which has been the hallmark of bioethics consistent with the ideology of individualism in neoliberal democracies in Western countries, relational autonomy highlights the relatedness, interdependency, and social embeddedness of patients. By examining the mediating role that male Hospital Liaison Committee members in Germany play in facilitating care that supports Jehovah's Witnesses’ refusal of blood transfusions, this article moves beyond ‘dyadic relations’ and contexts of caregiving. It also contributes to a deeper understanding of care and relational conceptualizations of Witness patients’ autonomy globally.     

A test of the mate deprivation hypothesis of sexual coercion

According to the mate deprivation hypothesis of sexual coercion, males are more likely to use sexually coercive tactics if they are disadvantaged in gaining access to desirable mates. This hypothesis was tested in a sample of 156 young, heterosexual, mostly single men enrolled in a Canadian university. Differential access to mates was indexed by self-perceived mating success, self-reported sexual history, and relative earning potential. Sexual coercion was assessed using the Koss's sexual experiences survey. Results did not support the hypothesis: men who identified themselves as sexually coercive tended to have higher self-perceived mating success, had significantly more extensive sexual histories, and did not report lower relative earning potential. Coercive men reported a greater preference for partner variety and casual sex. Sexual strategy theory is used to propose two alternative models of sexual coercion.     

Surrogacy and autonomy

Surrogacy contracts pose a sufficiently great number of serious risks to personal autonomy to justify their impermissability. These risks, such as the surrogate mother's loss of control over her body and daily activities during the pregnancy, the powerlessness of having to give up a child to whom one may have formed a deep attachment, and the normal dangers of pregnancy, seriously undercut the ability to make a fully informed and free choice to become a surrogate mother. The social circumstances of surrogate mothers and the prerequisites of dispositional autonomy are analyzed, as is the attitude toward women fostered by such contracts, their effect on the child involved, and their harmful view of children as property.     

AIDS, gays, and state coercion

Mohr argues that coercive government policies in response to the AIDS crisis are unjustified and pose a serious threat to the rights of homosexuals. AIDS presently can be transmitted only to those whose actions place them at risk. Paternalistic state coercion is warranted only when a person has diminished capacity or when necessary to prevent someone from ceasing to be an independent agent. Furthermore, an individual may regard sex as a central value. Finally, using public health as a rationale for closing bathhouses or otherwise regulating sexual behavior is a step toward totalitarianism, because coercion is unwarranted when protection from a disease can be achieved by individual action and because the public good served by reducing the size of the pool of AIDS-exposed people is outweighed by the unjust discrimination involved in using coercive measures that affect only certain individuals.     

A perspective on Q-cycles

An examination is made of both the Q-cycle andb-cycle formulations of electron transfer and energy conservation in the cytochromebc ₁ complex. A working hypothesis for the complex is presented, based upon the Q-cycle notion of vectorial reaction sites, but incorporating theb-cycle feature of semiquinone movement between these sites.     

A perspective on inversin

Over the past 5 years, there has been increasing evidence for the role of primary (9+0) cilia in renal physiology and in establishing the left-right axis. The cilia in the renal tract are immotile and thought to have a sensory function. Cilia at the murine embryonic node have a vortical movement that sets up a leftward flow. Inversin, the protein defective in the inv mouse and in patients with type-2 nephronophthisis, localizes to both renal and node primary cilia. However, we present evidence that it is also expressed before the node forms and that its subcellular localization in renal tubular cells is not confined to the cilia. Its role in both the pathway determining left-right axis and renal function remains to be elucidated.     

Health care costs and financing in world perspective.

Expenditures for health services, as a percentage of national wealth (gross national product, or GNP), have been rising throughout the world. Data to quantify this trend are available for many industrialized countries. The share of health spending derived from governmental sources has also been increasing. Mandatory or social insurance has developed to support health services in 70 nations. While widely used for paying doctors on a fee basis or by capitation, in Latin America doctors are organized in polyclinics and paid by salaries. General revenues are used to support Ministry of Health programs. Among health expenditures, the largest share goes to hospitalization. Cost sharing by patients is widely used to control rising costs. World trends have promoted equity in health care delivery.