Vulnerability in practice: Peeling back the layers, avoiding triggers, and preventing cascading effects.

The concept of vulnerability is widely used in bioethics, particularly in research ethics and public health ethics. The traditional approach construes vulnerability as inherent in individuals or the groups to which they belong and views vulnerability as requiring special protections. Florencia Luna and other bioethicists continue to challenge traditional ways of conceptualizing and applying the term. Luna began proposing a layered approach to this concept and recently extended this proposal to offer two new concepts to analyze the concept of vulnerability, namely understanding external conditions that trigger vulnerability and layers of vulnerability with cascading effects. Luna's conception of vulnerability is useful, which we demonstrate by applying her layered view and the new analyses in multiple contexts. We begin by outlining Luna's view and we use vignettes from healthcare involving transgender patients, the care of patients in psychiatric contexts, and research involving prisoners to illustrate how each part of Luna's concept elucidates important moral issues.

Covert administration of medication in food: a worthwhile moral gamble?

The covert administration of medication occurs with incapacitated patients without their knowledge, involving some form of deliberate deception in disguising or hiding the medication. Covert medication in food is a relatively common practice globally, including in institutional and homecare contexts. Until recently, it has received little attention in the bioethics literature, and there are few laws or rules governing the practice. In this paper, we discuss significant, but often overlooked, ethical issues related to covert medication in food. We emphasise the variety of ways in which eating has ethical importance, highlighting what is at risk if covert administration of medication in food is discovered. For example, losing trust in feeders and food due to covert medication may risk important opportunities for identity maintenance in contexts where identity is already unstable. Since therapeutic relationships may be jeopardised by a patient's discovery that caregivers had secretly put medications in their food, this practice can result in an ongoing deception loop. While there may be circumstances in which covert medication is ethically justified, given a lack of suitable alternatives, we argue that in any particular case this practice should be continually re-evaluated in light of the building moral costs to the relational agent over time.

Motivational Interviewing Training Outcomes Among Providers in a Children's Hospital.

Motivational interviewing (MI) has proven a well-established psychotherapeutic intervention designed to enhance motivation for behavior change. While the benefits of MI have been established, little research has systematically evaluated dissemination of MI efforts to healthcare providers, especially among pediatric providers. The present pilot study evaluated whether healthcare providers gained valuable knowledge, confidence and desire to utilize MI, and skills in MI techniques and if these outcomes varied based on provider characteristics or duration and intensity of MI training. Twenty pediatric healthcare professionals in a large academic pediatric hospital completed an advanced 20-h MI training and 103 pediatric healthcare professionals completed a basic 4-h MI workshop. The study demonstrated no significant differences in post-workshop MI knowledge, confidence, or desire based on trainee demographics. We also found no significant change from post-basic workshop to post-advanced workshop for advanced MI trainees. However, the advanced training workshop participants evidenced significant growth in utilizing MI skills (via MITI coding) and self-reported confidence in using MI skills. We therefore conclude that while the basic workshop allows participants to gain valuable MI knowledge and confidence and desire to utilize MI, it is through the advanced training that providers have the opportunity to practice these skills, receive feedback, and ultimately gain the expertise necessary to be effective MI providers. Overall, results from this pilot study suggest MI training in pediatric hospitals represents an important area of opportunity for multidisciplinary training, dissemination, and practice.

Relational autonomy in action: Rethinking dementia and sexuality in care facilities.

BACKGROUND: Caregivers and administrators in long-term facilities have fragile moral work in caring for residents with dementia. Residents are susceptible to barriers and vulnerabilities associated with the most intimate aspects of their lives, including how they express themselves sexually. The conditions for sexual agency are directly affected by caregivers' perceptions and attitudes, as well as facility policies. OBJECTIVE: This article aims to clarify how to approach capacity determinations as it relates to sexual activity, propose how to theorize about patient autonomy in this context, and suggest some considerations for finding an ethically responsible and practically feasible way to respect the sexual rights of this population. RESEARCH DESIGN: The focus is on residents with early to moderate dementia in states of daily dependency on professional caregivers. The article critically examines existing empirical research on sexuality among persons with dementia, caregivers' attitudes, and institutional roadblocks to enabling residents' sexuality. A relational lens and insights from disability studies are used in the philosophical analysis. PARTICIPANTS AND RESEARCH CONTEXT: No research participants were part of this analysis. ETHICAL CONSIDERATIONS: This article offers a conceptual analysis and normative framework only. FINDINGS: The analysis highlights the delicate balance that capacity assessments for sexual activity have to strike; while caregivers should protect those who cannot give adequate consent, the denial of sexuality among residents can cause deep, long-ranging harms. Sexual agency features into an ongoing sense of self for many individuals with dementia, and the imposition of inappropriate standards and expectations for sexual autonomy can lead to unwarranted obstacles to sexual activity. DISCUSSION: Recommendations include developing clear and inclusive institutional policies and practices of care, providing education for caregivers on how to discuss and document residents' sexual preferences over time, and taking advantage of ethics consultation services. CONCLUSION: This analysis establishes the need for more research and discussion on this sensitive topic. Future research should investigate the specific responsibilities of caregivers in furthering the sexual interests of residents, how exactly to modify existing capacity instruments, and how best to support historically marginalized patients in their sexual identities.

Differential patterns of amygdala and ventral striatum activation predict gender-specific changes in sexual risk behavior.

Although the initiation of sexual behavior is common among adolescents and young adults, some individuals express this behavior in a manner that significantly increases their risk for negative outcomes including sexually transmitted infections. Based on accumulating evidence, we have hypothesized that increased sexual risk behavior reflects, in part, an imbalance between neural circuits mediating approach and avoidance in particular as manifest by relatively increased ventral striatum (VS) activity and relatively decreased amygdala activity. Here, we test our hypothesis using data from seventy 18- to 22-year-old university students participating in the Duke Neurogenetics Study. We found a significant three-way interaction between amygdala activation, VS activation, and gender predicting changes in the number of sexual partners over time. Although relatively increased VS activation predicted greater increases in sexual partners for both men and women, the effect in men was contingent on the presence of relatively decreased amygdala activation and the effect in women was contingent on the presence of relatively increased amygdala activation. These findings suggest unique gender differences in how complex interactions between neural circuit function contributing to approach and avoidance may be expressed as sexual risk behavior in young adults. As such, our findings have the potential to inform the development of novel, gender-specific strategies that may be more effective at curtailing sexual risk behavior.

A neuroscience perspective on sexual risk behavior in adolescence and emerging adulthood.

Late adolescence and emerging adulthood (specifically ages 15-24) represent a period of heightened sexual risk taking resulting in the greatest annual rates of sexually transmitted infections and unplanned pregnancies in the US population. Ongoing efforts to prevent such negative consequences are likely to benefit from a deepening of our understanding of biological mechanisms through which sexual risk taking emerges and biases decision making during this critical window. Here we present a neuroscience framework from which a mechanistic examination of sexual risk taking can be advanced. Specifically, we adapt the neurodevelopmental triadic model, which outlines how motivated behavior is governed by three systems: approach, avoidance, and regulation, to sexual decision making and subsequent risk behavior. We further propose a testable hypothesis of the triadic model, wherein relatively decreased threat-related amygdala reactivity and increased reward-related ventral striatum reactivity leads to sexual risk taking, which is particularly exaggerated during adolescence and young adulthood when there is an overexpression of dopaminergic neurons coupled with immature top-down prefrontal cortex regulation. We conclude by discussing how future research based on our adapted triadic model can inform ongoing efforts to improve intervention and prevention efforts.

Ethical Bargaining and Parental Exclusion: A Clinical Case Analysis.

Although there has been significant attention in clinical ethics to when physicians should follow a parent's wishes, there has been much less discussion of the obligation to solicit viewpoints and decisions from all caregivers who have equal moral and legal standing in relation to a pediatric patient. How should healthcare professionals respond when one caregiver dominates decision making? We present a case that highlights how these problems played out in an ethical bargain. Ethical bargaining occurs when the parties involved choose not to pursue a morally preferable option for the sake of coming to a resolution. This case is not one of parental disagreement; rather, the medical team agreed to exclude the patient's mother from decision making if the patient's father promised to bring their son back to the hospital for necessary medical tests. We argue that there is an obligation to notice and acknowledge power asymmetries in the family unit, which, in this case, was manifested as the marginalization of the female decision maker by the male decision maker. In these scenarios, clinicians should be careful to avoid treating parents as one homogenous unit, and they should take action to enable caregivers' autonomy and voice. While there are moral and practical limits to how and when physicians should intervene in family dynamics, we discuss the steps that the medical team should have taken in this case to avoid undermining the parental authority of the mother. We conclude by offering recommendations to address and enable caregivers' autonomy at an institutional level, and we discuss the importance of tracking and responding to damaging family dynamics to prevent ethically impermissible bargaining.

Scientific research and human rights: a response to Kitcher on the limitations of inquiry.

In his recent work exploring the role of science in democratic societies Kitcher (Science in a democratic society. Prometheus Books, New York, 2011) claims that scientists ought to have a prominent role in setting the agenda for and limits to research. Against the backdrop of the claim that the proper limits of scientific inquiry is John Stuart Mill's Harm Principle (Kitcher in Science, truth, and democracy. Oxford University Press, New York, 2001), he identifies the limits of inquiry as the point where the outcomes of research could cause harm to already vulnerable populations. Nonetheless, Kitcher argues against explicit limitations on unscrupulous research on the grounds that restrictions would exacerbate underlying social problems. I show that Kitcher's argument in favor of dissuading inquiry through conventional standards is problematic and falls prey to the same critique he offers in opposition to official bans. I expand the conversation of limiting scientific research by recognizing that the actions that count as 'science' are located in the space between 'thinking' and 'doing'. In this space, we often attempt to balance freedom of research, as scientific speech, against the disparate impact citizens might experience in light of such research. I end by exploring if such disparate impact justifies limiting research, within the context of the United States, under Title VII of the Civil Rights Act of 1964 or under international human rights standards more generally.

Cues to urinary urgency and urge incontinence: how those diagnosed with overactive bladder syndrome differ from undiagnosed persons.

PURPOSE: To investigate the extent to which cues are reported to be associated with urinary urgency incontinence and urinary urgency. DESIGN: Descriptive and correlational study comparing 2 groups. METHODS: An online questionnaire assessing the extent to which 19 environmental, 3 mood, 3 cognitive, 3 stress incontinence, 1 bladder volume cue, and 3 unlikely cues were associated with episodes of urinary urgency incontinence and urgency was administered. PARTICIPANTS: Three hundred six participants were randomly drawn from a panel of respondents maintained by Zoomerang, Inc. Approximately half (n = 150) had self-reported diagnoses of overactive bladder syndrome (OAB) and half did not. Cue ratings were compared between persons with and without OAB and between likely and unlikely cues. RESULTS: The most frequently reported environmental cues were "On the way to the bathroom" and "Arrival at home/opening front door"; these cues were reported by both groups. Respondents with and without OAB showed significant differences in the mean number of cues associated with urinary urgency incontinence and with urinary urgency; persons with OAB were always higher. Significant differences between persons with and without OAB were found for 28 of 32 cues associated with incontinence and 25 of 32 cues associated with urinary urgency. To investigate response bias, within-subjects analyses compared mean responses to the 3 unlikely cues to means of all other cues. Analyses revealed that scores for unlikely cues were significantly lower than scores for likely cues. CONCLUSION: Cues associated with urgency incontinence and urgency were frequently reported by both groups. However, responding to cues was significantly more frequent among those who had been diagnosed with OAB. These findings may have implications for the diagnosis and treatment of urinary urgency incontinence.

Environmental cues to urgency and leakage episodes in patients with overactive bladder syndrome: a pilot study.

PURPOSE: To assess the frequency with which environmental cues, which might constitute Pavlovian-conditioned stimuli, occur with urgency and leakage symptoms associated with overactive bladder syndrome (OAB). SUBJECTS AND SETTINGS: The sample group comprised 17 adults (13 women and 4 men); their median age was 74.71 years. METHODS: A semistructured interview was conducted with a convenience sample of 17 patients diagnosed with OAB. Patients were interviewed about interoceptive and environmental cues they related to instances of urinary urgency and leakage. Interviews persisted for 6.11 to 59.38 minutes (M = 21.86 minutes) and were conducted by an interviewer who was trained to administer the interview guide. RESULTS: Most respondents associated at least 1 environmental cue with urgency and leakage, respectively. A mean of 6.1 urgency-related and 4.0 leak-related environmental cues were reported. The most commonly reported environmental cues were "on my way to the bathroom" reported by 88% and "opening the front door of my home" reported by 71%. CONCLUSION: These findings support the hypothesis that Pavlovian conditioning plays a role in OAB symptoms and suggest that treatment might be enhanced by inclusion of Pavlovian extinction procedures.

How Substance Users With ADHD Perceive the Relationship Between Substance Use and Emotional Functioning.

OBJECTIVE: Although substance use (SU) is elevated in ADHD and both are associated with disrupted emotional functioning, little is known about how emotions and SU interact in ADHD. We used a mixed qualitative-quantitative approach to explore this relationship. METHOD: Narrative comments were coded for 67 persistent (50 ADHD, 17 local normative comparison group [LNCG]) and 25 desistent (20 ADHD, 5 LNCG) substance users from the Multimodal Treatment Study of Children with ADHD (MTA) adult follow-up (21.7-26.7 years-old). RESULTS: SU persisters perceived SU positively affects emotional states and positive emotional effects outweigh negative effects. No ADHD group effects emerged. Qualitative analysis identified perceptions that cannabis enhanced positive mood for ADHD and LNCG SU persisters, and improved negative mood and ADHD for ADHD SU persisters. CONCLUSION: Perceptions about SU broadly and mood do not differentiate ADHD and non-ADHD SU persisters. However, perceptions that cannabis is therapeutic may inform ADHD-related risk for cannabis use.

Inhospitable Healthcare Spaces: Why Diversity Training on LGBTQIA Issues Is Not Enough.

In an effort to address healthcare disparities in lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations, many hospitals and clinics institute diversity training meant to increase providers' awareness of and sensitivity to this patient population. Despite these efforts, many healthcare spaces remain inhospitable to LGBTQ patients and their loved ones. Even in the absence of overt forms of discrimination, LGBTQ patients report feeling anxious, unwelcome, ashamed, and distrustful in healthcare encounters. We argue that these negative experiences are produced by a variety of subtle, ostensibly insignificant features of healthcare spaces and interpersonal interactions called microaggressions. Healthcare spaces and providers often convey heteronormative microaggressions, which communicate to LGBTQ-and, we suggest, intersex and asexual (IA)-people that their identities, experiences, and relationships are abnormal, pathological, unexpected, unwelcome, or shameful. We identify heteronormative microaggressions common to healthcare settings and specify how they negatively impact LGBTQIA patients. We argue that standard diversity training cannot sufficiently address heteronormative microaggressions. Despite these challenges, healthcare institutions and providers must take responsibility for heteronormative microaggressions and take steps to reduce their frequency and mitigate their effects on LGBTQIA care. We conclude by offering strategies for problem-solving at the level of medical education, institutional culture and policy, and individual awareness.

Identifying Adolescent Patients at Risk for Sexually Transmitted Infections: Development of a Brief Sexual Health Screening Survey.

This study examined the association between survey responses to health behaviors, personality/psychosocial factors, and self-reported sexually transmitted infections (STIs) to create a brief survey to identify youth at risk for contracting STIs. Participants included 200 racially diverse 14- to 18-year-old patients from a pediatric primary care clinic. Two sexual behavior variables and one peer norm variable were used to differentiate subgroups of individuals at risk of contracting a STI based on reported history of STIs using probability (decision tree) analyses. These items, as well as sexual orientation and having ever had oral sex, were used to create a brief sexual health screening (BSHS) survey. Each point increase in total BSHS score was associated with exponential growth in the percentage of sexually active adolescents reporting STIs. Findings suggest that the BSHS could serve as a useful tool for clinicians to quickly and accurately detect sexual risk among adolescent patients.

Development of a measure of college students' adherence to religious doctrine concerning sexual behavior.

OBJECTIVE: The authors developed a 14-item measure of adherence to religious doctrine concerning sexual behavior (ARDSB). The ARDSB psychometric properties were investigated to better understand religious motivations associated with changes in sexual behavior that may provide support for sexual health promotion and prevention programs. PARTICIPANTS: Four hundred eighty-three undergraduates aged 18 to 26. METHODS: Data were collected from an online survey during the 2012-2013 academic school year. RESULTS: Principle components factor analysis identified 2 factors: reasons to break religious doctrine and reasons to adhere to religious doctrine concerning sexual behavior. The subscales had good internal consistency. Correlations, t tests, and analyses of variance of the subscales with measures of intrinsic and extrinsic religiosity and self-reported sexual behavior and risk provide support for concurrent validity. CONCLUSIONS: The ARDSB could be employed as a measure to better understand sexual behavior; it is inexpensive and relatively easy to employ in both research and campus ministry settings.