Kaci Hickox: public health and the politics of fear.

Kaci Hickox was a nurse who worked with persons who were infected with Ebola in West Africa. When she returned to the United States, the governors of New Jersey and Maine intervened to confine her to inpatient quarantine despite the fact that she was asymptomatic and had no serological evidence of infection. She defied the quarantine which resulted in enormous public attention and discussion of quarantine and public fear. This article summarizes the case discussing the history of the case, the government actions, and the final legal rulings.

The new military medical ethics: legacies of the Gulf Wars and the War on Terror.

United States military medical ethics evolved during its involvement in two recent wars, Gulf War I (1990-1991) and the War on Terror (2001-). Norms of conduct for military clinicians with regard to the treatment of prisoners of war and the administration of non-therapeutic bioactive agents to soldiers were set aside because of the sense of being in a 'new kind of war'. Concurrently, the use of radioactive metal in weaponry and the ability to measure the health consequences of trade embargos on vulnerable civilians occasioned new concerns about the health effects of war on soldiers, their offspring, and civilians living on battlefields. Civilian medical societies and medical ethicists fitfully engaged the evolving nature of the medical ethics issues and policy changes during these wars. Medical codes of professionalism have not been substantively updated and procedures for accountability for new kinds of abuses of medical ethics are not established. Looking to the future, medicine and medical ethics have not articulated a vision for an ongoing military-civilian dialogue to ensure that standards of medical ethics do not evolve simply in accord with military exigency.

Autopsy findings in asphyxia in medical bed rails.

Lethal asphyxial entrapment between bedrails and mattresses is a well-recognized clinical event although there are few descriptions of autopsy findings. This convenience sample series of 29 deaths shows the infrequency of petechiae and laryngeal crush injuries and subtlety of soft-tissue trauma findings in such cases. Petechiae, plethora, and venous congestion may be noted in extremities that are pinned by rails in a manner that obstructs venous return. Medical examiners must mainly rely on eyewitness descriptions of the how the person was found and try to correlate this position with scanty signs of trauma.

Profane research versus researching the profane: commentary on Basoglu (2009).

Torture survivors, therapists, and society look to behavioral science for help understanding the traumatization, needs, and treatment of torture survivors. Any research of torture can and possibly will be used by torturers to refine their abuse of prisoners. It is difficult but necessary to discern profane research from therapeutic research of a profane activity. M. Basoglu's (2009) study of the traumatization of torture survivors is enormously helpful to clinicians who must heal and to policymakers who must understand the psychological toll of torture.

Medical ethics and the interrogation of Guantanamo 063.

The controversy over abusive interrogations of prisoners during the war against terrorism spotlights the need for clear ethics norms requiring physicians and other clinicians to prevent the mistreatment of prisoners. Although policies and general descriptions pertaining to clinical oversight of interrogations in United States' war on terror prisons have come to light, there are few public records detailing the clinical oversight of an interrogation. A complaint by the Federal Bureau of Investigation (FBI) led to an Army investigation of an interrogation at the United States prison at Guantanamo Bay. The declassified Army investigation and the corresponding interrogation log show clinical supervision, monitoring and treatment during an interrogation that employed dogs, prolonged sleep deprivation, humiliation, restraint, hypothermia and compulsory intravenous infusions. The interrogation and the involvement of a psychologist, physician and medics violate international and medical norms for the treatment of prisoners.

Hospice benefits and phase I cancer trials.

Medicare denies hospice coverage to patients with terminal illnesses who enroll as participants in phase I studies, which assess the toxicity and dosing of potential treatments for incurable diseases. Federal regulations require patients to forgo curative therapies, and they interpret phase I agents as treatment for the terminal condition for which hospice care was elected. Thus, by enrolling as a participant in a phase I trial, a patient otherwise eligible for hospice is rendered ineligible. Private insurers have similar provisions for children and adults younger than 65 years of age. Such exclusions are not defensible on ethical or clinical grounds. Policymakers, insurers, and institutional review boards all have a role in resolving this problem.

Deaths between bedrails and air pressure mattresses.

OBJECTIVES: To describe how patients die by becoming trapped between therapeutic air pressure mattresses and bed rails. DESIGN: A retrospective review of all voluntary reports deaths in beds with air mattresses that can be found in the Food and Drug Administration's on-line databases of adverse medical events that cover 1994 to 2001. SETTING: Death reports come from manufacturers, medical staff, and coroners and describe deaths in hospitals, nursing homes, and home care, although type of care site is often not given. MEASUREMENTS: Event descriptions were reviewed to determine how the person became entrapped in the rail and how responsibility for the event was allocated. RESULTS: There were 35 deaths involving many product lines. Twenty-one deaths involved overlay air mattresses placed on top of a regular mattress. Thirteen patients died in beds with built-in air mattresses. Compression of the mattress allowed an off-center person to slide against the rail where reexpansion of the mattress kept the person compressed against the rail. Two patterns were seen. In one, the mattress bunched up behind a person who was lying on the side of the bed, pushing the neck against a bedrail. In the second type, a patient died after sliding off the bed and having the neck or chest compressed between the rail and bed. Manufacturers attributed the deaths to poor clinical decision-making or inadequate monitoring. CONCLUSIONS: Lethal asphyxiation in beds with air pressure mattresses is a variant of bedrail-mattress entrapment that requires redesign by bed manufacturers and risk awareness by clinicians.

HIV in insurgency forces in sub-Saharan Africa - a personal view of policies.

The special requirements for HIV-prevention programmes by armed forces or insurgency groups in very poor countries that are in active conflict have not been well described. Customary military programme components include: education on sexually transmitted diseases, condom distribution, and HIV testing. Programmes for these armed forces must address: a command structure that may not prioritize this activity, severe resource and logistical constraints, weak health systems for treating sexually transmitted illness, beliefs in traditional medicines for symptoms of sexually transmitted illness, illiteracy that diminishes the utility of educational pamphlets, rape and sexual bartering by soldiers, battlefield transfusions, tattooing and the co-epidemic of tuberculosis.

Traditional surgeons in sub-Saharan Africa: images from south Sudan.

Itinerant traditional surgeons work throughout sub-Saharan Africa and perform many procedures including: tooth extraction, abortion, injections, incising and draining abscesses, uvulectomy, circumcision, inguinal hernia surgery, non-invasive cataract luxation, and surgery on closed and open fractures. Cutting and injection equipment are not cleaned and are used on a rapid succession of up to 10 patients in a single clinic session. These procedures cause haemorrhage, septicaemia, tetanus, gangrene, contractures, abscesses, airway obstruction, keloids, iatrogenic fistulae, lacerations of vital organs, loss of limbs, and death. Recent work suggesting that many cases of HIV infection may be caused by medical exposure lend a new urgency to researching the work of traditional surgeons. Collaborative programmes for re-training and re-shaping the work of these practitioners is more likely to be effective in reducing the morbidity than attempts to suppress their work.

Medical ethicists, human curiosities, and the new media midway.

Medical ethicists have assumed a role in justifying public voyeurism of human "curiosities." This role has precedent in how scientists and natural philosophers once legitimized the marketing of museums of "human curiosities." At the beginning of the twentieth century, physicians dissociated themselves from entrepreneurial displays of persons with anomalies, and such commercial exhibits went into decline. Today, news media, principally on television, promote news features about persons that closely resemble the nineteenth century exhibits of human curiosities. Reporters solicit medical ethicists for soundbites to affirm the newsworthiness and propriety of public voyeurism of these medical stories. Ethicists' soundbites are usually ambiguous or self-evident and rarely enable viewers to morally engage the issues. The precedent of early twentieth century physicians disengaging from such exploitive public shows is a useful example for medical ethics.

Confronting depression and suicide in physicians: a consensus statement.

OBJECTIVE: To encourage treatment of depression and prevention of suicide in physicians by calling for a shift in professional attitudes and institutional policies to support physicians seeking help. PARTICIPANTS: An American Foundation for Suicide Prevention planning group invited 15 experts on the subject to evaluate the state of knowledge about physician depression and suicide and barriers to treatment. The group assembled for a workshop held October 6-7, 2002, in Philadelphia, Pa. EVIDENCE: The planning group worked with each participant on a preworkshop literature review in an assigned area. Abstracts of presentations and key publications were distributed to participants before the workshop. After workshop presentations, participants were assigned to 1 of 2 breakout groups: (1) physicians in their role as patients and (2) medical institutions and professional organizations. The groups identified areas that required further research, barriers to treatment, and recommendations for reform. CONSENSUS PROCESS: This consensus statement emerged from a plenary session during which each work group presented its recommendations. The consensus statement was circulated to and approved by all participants. CONCLUSIONS: The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians' seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement. This consensus statement recommends transforming professional attitudes and changing institutional policies to encourage physicians to seek help. As barriers are removed and physicians confront depression and suicidality in their peers, they are more likely to recognize and treat these conditions in patients, including colleagues and medical students.

Legal procedures in Wanglie: a two-step, not a sidestep.

Hospital policies...have a very limited role in addressing the substantive issue of authority with regard to nonbeneficial therapies. First, they could not be limited, as Mishkin suggests, to persons in a persistent vegetative state. Nonbeneficial therapies encompass many other scenarios including ineffective cancer chemotherapy or open-heart surgery on profoundly demented persons. Second, I am not convinced that families or patients could be meaningfully informed of the specific relevance of such policies to their care in advance of a dispute. Most importantly, the view that such policies are required as a foundation to withhold nonbeneficial therapy implies that patients otherwise have a new right to command the provision of nonbeneficial therapies.... It may well be judicially preferable to ask directly for declarative relief from a duty to provide a treatment, as Mishkin suggests. I am not convinced that such an approach would be "ethically" superior....Third, the novel, declarative approach directly risks a precedent that would affirm the family's right to demand futile therapy....Ultimately, when public policy on this kind of dispute is clearer, a declarative strategy may well be preferable. For now, the Wanglie case has outlined the fundamental issues of this novel legal question and has generated a fruitful discussion of a complex issue in patient care and public policy.