Reconsidering counselling and consent.

In the current era patient autonomy is enormously important. However, recently there has also been some movement back to ensure that trust in the doctor's skill, knowledge and virtue is not excluded in the process. These new nuances of informed consent have been referred to by terms such as beneficent paternalism, experience-based paternalism and we would add virtuous paternalism. The purpose of this paper is to consider the history and current problematic nature of counselling and consent. Starting with the tradition founded by Hippocrates we trace and seek to understand how relevant aspects of the patient-doctor relationship have evolved under the influences of subsequent moral theories. Finally we tentatively endorse certain modes of counselling in the current era in order to promote morally sound, good clinical practice.

Healing Without Waging War: Beyond Military Metaphors in Medicine and HIV Cure Research.

Military metaphors are pervasive in biomedicine, including HIV research. Rooted in the mind set that regards pathogens as enemies to be defeated, terms such as "shock and kill" have become widely accepted idioms within HIV cure research. Such language and symbolism must be critically examined as they may be especially problematic when used to express scientific ideas within emerging health-related fields. In this article, philosophical analysis and an interdisciplinary literature review utilizing key texts from sociology, anthropology, history, and Chinese and African studies were conducted to investigate the current proliferation of military metaphors. We found the use of these metaphors to be ironic, unfortunate, and unnecessary. To overcome military metaphors we propose to (1) give them less aggressive meanings, and/or (2) replace them with more peaceful metaphors. Building on previous authors' work, we argue for the increased use of "journey" (and related) metaphors as meaningful, cross-culturally appropriate alternatives to military metaphors.

Increased hospital costs associated with red blood cell transfusion.

BACKGROUND: Red blood cell (RBC) transfusion is independently associated in a dose-dependent manner with increased intensive care unit stay, total hospital length of stay, and hospital-acquired complications. Since little is known of the cost of these transfusion-associated adverse outcomes our aim was to determine the total hospital cost associated with RBC transfusion and to assess any dose-dependent relationship. STUDY DESIGN AND METHODS: A retrospective cohort study of all multiday acute care inpatients discharged from a five hospital health service in Western Australia between July 2011 and June 2012 was conducted. Main outcome measures were incidence of RBC transfusion and mean inpatient hospital costs. RESULTS: Of 89,996 multiday, acute care inpatient discharges, 4805 (5.3%) were transfused at least 1 unit of RBCs. After potential confounders were adjusted for, the mean inpatient cost was 1.83 times higher in the transfused group compared with the nontransfused group (95% confidence interval, 1.78-1.89; p < 0.001). The estimated total hospital-associated cost of RBC transfusion in this study was AUD $77 million (US $72 million), representing 7.8% of total hospital expenditure on acute care inpatients. There was a significant dose-dependent association between the number of RBC units transfused and increased costs after adjusting for confounders. CONCLUSION: RBC transfusions were independently associated with significantly higher hospital costs. The financial implication to hospital budgets will assist in prioritizing areas to reduce the rate of RBC transfusions and in implementing patient blood management programs.

Universality of abrupt holographic quenches.

We make an analytic investigation of rapid quenches of relevant operators in d-dimensional holographic conformal field theories, which admit a dual gravity description. We uncover a universal scaling behavior in the response of the system, which depends only on the conformal dimension of the quenched operator in the vicinity of the ultraviolet fixed point of the theory. Unless the amplitude of the quench is scaled appropriately, the work done on a system during the quench diverges in the limit of abrupt quenches for operators with dimension (d/2)≤Δ

Moral perspectives on stimulant use by healthy students.

The quest for enhancement has been part of human culture for thousands of years. Progress in scientific developments and especially in medical science has enabled previously unimaginable advances to be employed in endeavours to improve human functioning in its various forms. Previously enhancement focused on aspects such as prolonging life, improving the immune system or cosmetic enhancements. Cognitive enhancement is currently receiving substantial attention. The use of stimulants such as methylphenidate, especially among students at tertiary institutions aiming to enhance their cognitive abilities, has raised concerns, ranging from safety issues and the risk of drug abuse to moral issues relating to the broader context of enhancement. We consider arguments used to debate both the promotion of enhancement therapies and the restriction and possibly even prevention of their use.

Deliberating about race as a variable in biomedical research.

Race as a variable in research ethics is investigated: to what extent is it morally appropriate to regard the race of research subjects as pivotal for research outcomes? The challenges it poses to deliberation in research ethics committees are considered, and it is concluded that race sometimes must be considered, subject to clearly stated qualifications.

Moral and social complexities of AIDS in Africa.

In this article, the main complexities of understanding and curbing the HIV/AIDS pandemic in (South) Africa, are discussed. These are: 1. Poverty as niche or social context of the pandemic, 2. Denial, lack of leadership and the politicization of the public discourse on AIDS, 3. Problems related to accomplishing behavior changes under conditions of deprivation and illiteracy, 4. Women's vulnerability, and 5. The disenchantment of intimacy brought about by the pandemic. In each case, some solutions are suggested, although the notion of complexity does not allow for definitive solutions. Concluding remarks deal with the possible philosophical and moral sense that we might make of the pandemic.

AIDS and Africa. Introduction.

Sub-Saharan Africa is the epicenter of the HIV/AIDS epidemic, and in this issue of the Journal, seven authors discuss the moral, social and medical implications of having 70% of those stricken living in this area. Anton A. van Niekerk considers complexities of plague in this region (poverty, denial, poor leadership, illiteracy, women's vulnerability, and disenchantment of intimacy) and the importance of finding responses that empower its people. Solomon Benatar reinforces these issues, but also discusses the role of global politics in sub-Saharan Africa, especially discrimination, imperialism and its exploitation by first world countries. Given the public health crisis, Udo Schüklenk and Richard E. Ashcroft defend compulsory licensing of essential HIV/AIDS medications on consequentialist grounds. Keymanthri Moodley discusses the importance of conducting research and the need to understand a moderate form of communitarianism, also referred to as "ubuntu" or "communalism", to help some Africans understand research as an altruistic endeavour. Godfrey B. Tangwa also defends traditional African values of empathy and ubuntu, discussing how they should be enlisted to fight this pandemic. Loretta M. Kopelman criticizes the tendency among those outside Africa to dismiss the HIV/AIDS pandemic, attributing one source to the ubiquitous and misguided punishment theory of disease. The authors conclude that good solutions must be cooperative ventures among countries within and outside of sub-Saharan Africa with far more support from wealthy countries.

Through a glass, darkly: data and uncertainty in the AIDS debate.

The HIV/AIDS epidemic is the greatest threat to development in much of Africa. It is already the main cause of death in many countries, especially those in Southern Africa. However there is an absence of solid data on the scale and scope of the disease and how it is evolving. In this article we discuss the data on the epidemic--where it comes from and how it is presented. We note the limitations of the use of antenatal clinic surveys--which provide the bulk of our information. We then turn to the evidence of impact. The paper shows that the long incubation period between infection and illness means that it takes time for HIV infections to turn into AIDS cases, and AIDS cases to translate into deaths with all the consequences of orphaning, poverty and changing population structures. Furthermore it means that once the HIV prevalence has peaked, AIDS impact will take years to work through--this epidemic is a 'long-wave' event. The paper is premised on the view that HIV causes AIDS and AIDS causes death. It notes that insufficient and/or unreliable data have allowed leaderships to deny the scope and scale of the problem and that this is unacceptable. However it is incumbent on all to accept the moral responsibility for and the moral consequences of their work, and this includes those who gather, interpret and use the data.