No, pregnancy is not a disease.

Anna Smajdor and Joona Räsänen argue that we have good reason to classify pregnancy as a disease. They discuss five accounts of disease and argue that each account either implies that pregnancy is a disease or if it does not, it faces problems. This strategy allows Smajdor and Räsänen to avoid articulating their own account of disease. Consequently, they cannot establish that pregnancy is a disease, only that plausible accounts of disease suggest this. Some readers will dismiss Smajdor and Räsänen's claims as counterintuitive. By analogy, if a mathematical proof concludes '2+2=5', readers will know-without investigation-that an error occurred. Rather than dismiss Smajdor and Räsänen's work, however, the easiest way to undermine their argument is to describe at least one plausible account of disease that (1) excludes pregnancy and (2) avoids the problems they raise for it. This is our strategy. We focus on dysfunction accounts of disease. After outlining Smajdor and Räsänen's main arguments against dysfunction accounts, we explain why pregnancy is not a disease on these accounts. Next, we defend dysfunction accounts against the three problems that Smajdor and Räsänen raise. If successful, then contra Smajdor and Räsänen, at least one plausible account of disease does not imply that pregnancy is a disease. We suspect that defenders of other accounts can respond similarly. Yet, we note that insofar as dysfunction accounts align with the commonsense intuition that pregnancy is not a disease, this, all else being equal, seems like a point in their favour.

Exploring attitudes toward xenotransplantation: A scoping review of healthcare workers, healthcare students, and kidney patients.

BACKGROUND: Recent advances mean that formal clinical trials of solid organ xenotransplantation are increasingly likely to begin and patients requiring a kidney transplant could be the first participants. Healthcare workers and healthcare students constitute the current and future workforce that will influence public opinion of xenotransplantation. The attitudes of these populations are important to consider before recruitment for formal clinical trials begins. METHODS: This scoping review was reported according to the PRISMA extensions for scoping reviews checklist and the Joanna Briggs Institute methodology for scoping reviews. The Scopus, PubMed, and ScienceDirect databases were searched to identify articles that studied the attitudes of healthcare workers, healthcare students, or kidney patients toward xenotransplantation. RESULTS: The search generated 816 articles, of which 27 met the eligibility criteria. The studies were conducted in 14 different countries on five different continents. Participants from the 27 studies totaled 29,836-this was constituted of 6,223 (21%) healthcare workers, 21,067 (71%) healthcare students, and 2,546 (8%) kidney patients. All three groups had an overall positive attitude toward xenotransplantation. However, in studies where participants were asked to consider xenotransplantation when the risks and results were not equal to allotransplantation-the overall attitude switched from positive to negative. The results also found that Spanish-speaking populations expressed more favorable views toward xenotransplantation compared to English-speaking populations. CONCLUSION: The results of this review suggest that while attitudes of the three groups toward xenotransplantation are-on the face of it-positive, this positivity deteriorates when the risks and outcomes are framed in more clinically realistic terms. Only formal clinical trials can determine how the risks and outcomes of xenotransplantation compare to allotransplantation.

Close contacts of xenograft recipients: Ethical considerations due to risk of xenozoonosis.

With decades of pre-clinical studies culminating in the recent clinical application of xenotransplantation, it would appear timely to provide recommendations for operationalizing oversight of xenotransplantation clinical trials. Ethical issues with clinical xenotransplantation have been described for decades, largely centering on animal welfare, the risks posed to the recipient, and public health risks posed by potential spread of xenozoonosis. Much less attention has been given to considerations relating to potentially elevated risks faced by those who may care for or otherwise have close contact with xenograft recipients. This paper examines the ethical and logistical issues raised by the potential exposure to xenozoonotic disease faced by close contacts of xenotransplant recipients-defined herein as including but not limited to caregivers, household contacts, and sexual partners-which warrants special attention given their increased risk of exposure to infection compared to the general public. We discuss implications of assent or consent by these close contacts to potentially undergo, along with the recipient, procedures for infection screening and possible quarantine. We then propose several options and recommendations for operationalizing oversight of xenotransplantation clinical trials that could account for and address close contacts' education on and agency regarding the risk of xenozoonosis.

Genetic disenhancement and xenotransplantation: diminishing pigs' capacity to experience suffering through genetic engineering.

One objection to xenotransplantation is that it will require the large-scale breeding, raising and killing of genetically modified pigs. The pigs will need to be raised in designated pathogen-free facilities and undergo a range of medical tests before having their organs removed and being euthanised. As a result, they will have significantly shortened life expectancies, will experience pain and suffering and be subject to a degree of social and environmental deprivation. To minimise the impact of these factors, we propose the following option for consideration-ethically defensible xenotransplantation should entail the use of genetic disenhancement if it becomes possible to do so and if that pain and suffering cannot be eliminated by other means. Despite not being a morally ideal 'solution', it is morally better to prevent unavoidable pain until a viable non-animal alternative becomes available.

Infection Prevention and the Protective Effects of Unidirectional Displacement Flow Ventilation in the Turbulent Spaces of the Operating Room.

BACKGROUND: Unidirectional displacement flow (UDF) ventilation systems in operating rooms are characterized by a uniformity of velocity ≥80% and protect patients and operating room personnel against exposure to hazardous substances. However, the air below the surgical lights and in the surrounding zone is turbulent, which impairs the ventilation system's effect. AIM: We first used the recovery time (RT) as specified in International Organization for Standardization 14644 to determine the particle reduction capacity in the turbulent spaces of an operating room with a UDF system. METHODS: The uniformity of velocity was analyzed by comfort-level probe grid measurements in the protected area below a hemispherical closed-shaped and a semi-open column-shaped surgical light (tilt angles: 0°/15°/30°) and in the surrounding zone of a research operating room. Thereafter, RTs were calculated. RESULTS: At a supply air volume of 10,500 m3/h, the velocity, reported as average uniformity ± standard deviation, was uniform in the protected area without lights (95.8% ± 1.7%), but locally turbulent below the hemispherical closed-shaped (69.3% ± 14.6%), the semi-open column-shaped light (66.9% ± 10.9%), and in the surrounding zone (51.5% ± 17.6%). The RTs ranged between 1.1 and 1.7 min below the lights and 3.5 ± 0.28 min in the surrounding zone and depended exponentially on the volume flow rate. CONCLUSIONS: Compared to an RT of ≤20 min as required for operating rooms with mixed dilution flow, particles here were eliminated 12-18 times more quickly from below the surgical lights and 5.7 times from the surrounding zone. Thus, the effect of the lights was negligible and the UDF's retained its strong protective effect.

Pediatric Cardiac Xenotransplantation: Recommendations for the Ethical Design of Clinical Trials.

For children with complex congenital heart problems, cardiac allotransplantation is sometimes the best therapeutic option. However, availability of hearts for pediatric patients is limited, resulting in a long and growing waitlist, and a high mortality rate while waiting. Cardiac xenotransplantation has been proposed as one therapeutic alternative for neonates and infants, either in lieu of allotransplantation or as a bridge until an allograft becomes available. Scientific and clinical developments in xenotransplantation appear likely to permit cardiac xenotransplantation clinical trials in adults in the coming years. The ethical issues around xenotransplantation of the heart and other organs and tissues have recently been examined, but to date, only limited literature is available on the ethical issues that are attendant with pediatric heart xenotransplantation. Here, we summarize the ethical issues, focusing on (1) whether cardiac xenotransplantation should proceed in adults or children first, (2) pediatric recipient selection for initial xenotransplantation trials, (3) special problems regarding informed consent in this context, and (4) related psychosocial and public perception considerations. We conclude with specific recommendations regarding ethically informed design of pediatric heart xenotransplantation trials.

Xenograft recipients and the right to withdraw from a clinical trial.

Preclinical xenotransplantation research using genetically engineered pigs has begun to show some promising results and could one day offer a scalable means of addressing organ shortage. While it is a fundamental tenet of ethical human subject research that participants have a right to withdraw from research once enrolled, several scholars have argued that the right to withdraw from xenotransplant research should be suspended because of the public health risks posed by xenozoonotic transmission. Here, we present a comprehensive critical evaluation of the claim that xenotransplant recipients should be required to waive their right to withdraw from lifelong biosurveillance. We conclude that if xenotransplantation requires participants to waive their right to withdraw, then clinical trials may not be justifiable, given the ethical and legal obstacles involved with doing so. Consequently, if clinical trials are permitted with a right to withdraw, then they may pose a significant public health risk.

Xenotransplantation Clinical Trials and Equitable Patient Selection.

Xenotransplant patient selection recommendations restrict clinical trial participation to seriously ill patients for whom alternative therapies are unavailable or who will likely die while waiting for an allotransplant. Despite a scholarly consensus that this is advisable, we propose to examine this restriction. We offer three lines of criticism: (1) The risk-benefit calculation may well be unfavorable for seriously ill patients and society; (2) the guidelines conflict with criteria for equitable patient selection; and (3) the selection of seriously ill patients may compromise informed consent. We conclude by highlighting how the current guidance reveals a tension between the societal values of justice and beneficence.

A fair exchange: why living kidney donors in England should be financially compensated.

Every year, hundreds of patients in England die whilst waiting for a kidney transplant, and this is evidence that the current system of altruistic-based donation is not sufficient to address the shortage of kidneys available for transplant. To address this problem, we propose a monopsony system whereby kidney donors can opt-in to receive financial compensation, whilst still preserving the right of individuals to donate without receiving any compensation. A monopsony system describes a market structure where there is only one 'buyer'-in this case the National Health Service. By doing so, several hundred lives could be saved each year in England, wait times for a kidney transplant could be significantly reduced, and it would lessen the burden on dialysis services. Furthermore, compensation would help alleviate the common disincentives to living kidney donation, such as its potential associated health and psychological costs, and it would also help to increase awareness of living kidney donation. The proposed system would also result in significant cost savings that could then be redirected towards preventing kidney disease and reducing health disparities. While concerns about exploitation, coercion, and the 'crowding out' of altruistic donors exist, we believe that careful implementation can mitigate these issues. Therefore, we recommend piloting financial compensation for living kidney donors at a transplant centre in England.

Xenotransplantation: A historical-ethical account of viewpoints.

Formal clinical trials of pig-to-human organ transplant-known asxenotransplantation-may begin this decade, with the first trials likely to consist of either adult renal transplants or pediatric cardiac transplant patients. Xenotransplantation as a systematic scientific study only reaches back to the latter half of the 20th century, with episodic xenotransplantation events occurring prior to that. As the science of xenotransplantation has progressed in the 20th and 21st centuries, the public's knowledge of the potential therapy has also increased. With this, there have been shifting ethical stances toward xenotransplantation in key areas, such as religious and public viewpoints towards xenotransplantation, animal rights, and public health concerns. This review provides a historical-ethical account of xenotransplantation and details if or how viewpoints have shifted over time.

The Problem with 'Suction Only' Methods to Reduce Surgical Smoke Exposure.

Surgical staff and patients are frequently exposed to surgical smoke and there is mounting evidence that this may be harmful. Borsetti et al. have devised a novel approach to minimising intraoperative exposure to surgical smoke. Here, I briefly outline my concerns with the 'suction only' approach to addressing this problem. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Kidney xenotransplantation: Future clinical reality or science fiction?

There is a global shortage of organs for transplantation and despite many governments making significant changes to their organ donation systems, there are not enough kidneys available to meet the demand. This has led scientists and clinicians to explore alternative means of meeting this organ shortfall. One of the alternatives to human organ transplantation is xenotransplantation, which is the transplantation of organs, tissues, or cells between different species. The resurgence of interest in xenotransplantation and recent scientific breakthroughs suggest that genetically engineered pigs may soon present a realistic alternative as sources of kidneys for clinical transplantation. It is therefore important for healthcare professionals to understand what is involved in xenotransplantation and its future implications for their clinical practices. First, we explore the insufficiency of different organ donation systems to meet the kidney shortage. Second, we provide a background and a summary of the progress made so far in xenotransplantation research. Third, we discuss some of the scientific, technological, ethical, and public health issues associated with xenotransplantation. Finally, we summarize the literature on the attitudes of healthcare professionals toward xenotransplantation.

In defense of xenotransplantation research: Because of, not in spite of, animal welfare concerns.

It is envisioned that one day xenotransplantation will bring about a future where transplantable organs can be safely and efficiently grown in transgenic pigs to help meet the global organ shortage. While recent advances have brought this future closer, worries remain about whether it will be beneficial overall. The unique challenges and risks posed to humans that arise from transplanting across the species barrier, in addition to the costs borne by non-human animals, has led some to question the value of xenotransplantation altogether. In response, we defend the value of xenotransplantation research, because it can satisfy stringent welfare conditions on the permissibility of animal research and use. Along the way, we respond to the alleged concerns, and conclude that they do not currently warrant a cessation or a curtailing of xenotransplantation research.

Mathieu Jaboulay's (1860-1913) contribution to xenotransplantation.

Mathieu Jaboulay (1860-1913) was a professor of clinical surgery in Lyon, France who is best known for his development of vascular anastomosis and for conducting the first reported renal xenotransplantation experiments on humans, using pig and goat kidneys to treat end-stage renal failure in 1906. His insights and pioneering techniques contributed significantly to allotransplantation and contemporary attempts at xenotransplantation. He is also credited with inventing several surgical instruments and novel surgical techniques that continue to influence vascular, general, and urological surgery to this day. However, this article will focus specifically on his notable contributions to xenotransplantation research and surgery.

Why inconsistency arguments fail: a response to Shaw.

Opponents of abortion are commonly said to be inconsistent in their beliefs or actions, and to fail in their obligations to prevent the deaths of embryos and fetuses from causes other than induced abortion. We have argued that these 'inconsistency arguments' conform to a pattern which is susceptible to a number of objections, and that consequently they fail en masse. In response, Joshua Shaw argues that we misrepresent inconsistency arguments, and that we underestimate the extent to which our opponents have anticipated and addressed counterarguments. In this essay we draw on aspects of Shaw's alternative formulation of inconsistency arguments to present an improved inconsistency argument structure. While we agree with Shaw that inconsistency arguments must each be examined on their merits, we reject Shaw's assertion that our objections are dependent on misrepresentations. Our initial objections remain largely successful, therefore, in dealing with the inconsistency arguments of which we are aware.