Home Intravenous Antibiotic Treatment for a Patient with Opioid Use Disorder.

Intravenous drug abusers may incur bloodstream infections, in particular those involving the heart valves, that often require extended courses of antibiotics, commonly on the order of six weeks. Conventional wisdom has dictated that even when patients are sufficiently well to not need ongoing hospitalization, it is unsafe to complete their antibiotic course in any setting other than in a closely supervised facility, even if this is contrary to their wishes. The assumption has been that such patients would be at risk of using their indwelling intravenous catheter for illicit purposes. Recent advances in the care of patients who suffer from addiction disorders suggest that when patients receive state-of-the-art addiction treatment, many may be able to continue their intravenous antibiotic course unsupervised, at home. This represents a departure from the parentalistic model of care of impaired patients who are prone to self-harm, moving towards a model that respects autonomy and trusts patients who are in recovery to continue their care in a manner that is self-beneficial.

Should patients who use illicit drugs be offered a second heart-valve replacement?

Intravenous drug users (IVDUs) have an elevated risk of contracting infectious endocarditis. Most of them have good effect from medical treatment, but some will need valve replacement. Until a few years ago, our hospital withheld valve surgery if patients with intravenous drug dependency and infectious endocarditis came to need a second valve replacement. However, there are no consensus guidelines for treatment of this group of patients, and a dearth of data on the effects and benefits of interventions. Using a method of ethical analysis, we here discuss whether it is appropriate to offer valve surgery to drug users for a second time.

Pain as a fact and heuristic: how pain neuroimaging illuminates moral dimensions of law.

In legal domains ranging from tort to torture, pain and its degree do important definitional work by delimiting boundaries of lawfulness and of entitlements. Yet, for all the work done by pain as a term in legal texts and practice, it has a confounding lack of external verifiability. Now, neuroimaging is rendering pain and myriad other subjective states at least partly ascertainable. This emerging ability to ascertain and quantify subjective states is prompting a "hedonic" or a "subjectivist" turn in legal scholarship, which has sparked a vigorous debate as to whether the quantification of subjective states might affect legal theory and practice. Subjectivists contend that much values-talk in law has been a necessary but poor substitute for quantitative determinations of subjective states--determinations that will be possible in the law's "experiential future." This Article argues the converse: that pain discourse in law frequently is a heuristic for values. Drawing on interviews and laboratory visits with neuroimaging researchers, this Article shows current and in-principle limitations of pain quantification through neuroimaging. It then presents case studies on torture-murder, torture, the death penalty, and abortion to show the largely heuristic role of pain discourse in law. Introducing the theory of "embodied morality," the Article describes how moral conceptions of rights and duties are informed by human physicality and constrained by the limits of empathic identification. Pain neuroimaging helps reveal this dual factual and heuristic nature of pain in the law, and thus itself points to the translational work required for neuroimaging to influence, much less transform, legal practice and doctrine.

Off-pump coronary artery bypass graft without systemic heparin in a Jehovah Witness patient.

A Jehovah Witness patient with renal failure on dialysis, with low hemoglobin, underwent urgent off-pump coronary artery bypass grafting without systemic heparinization. The pros, cons, and details of the technique used are discussed.

Issues surrounding lethal injection as a means of capital punishment.

Lethal injection as a method of state-sanctioned capital punishment was initially proposed in the United States in 1977 and used for the first time in 1982. Most lethal injection protocols use a sequential drug combination of sodium thiopental, pancuronium bromide, and potassium chloride. Lethal injection was originally introduced as a more humane form of execution compared with existing mechanical methods such as electrocution, toxic gassing, hanging, or firing squad. Lethal injection has not, however, been without controversy. Several states are considering whether lethal injection meets constitutional scrutiny forbidding cruel and unusual punishment. Recently in the case of Ralph Baze and Thomas C. Bowling, Petitioners, v John D. Rees, Commissioner, Kentucky Department of Corrections et al, the United States Supreme Court upheld the constitutionality of the lethal injection protocol as carried out in the Commonwealth of Kentucky. Most of the debate has surrounded the dosing and procedures used in lethal injection and whether the drug combinations and measures for administering the drugs truly produce a timely, pain-free, and fail-safe death. Many have also raised issues regarding the "medicalization" of execution and the ethics of health care professionals' participation in any part of the lethal injection process. As a result of all these issues, the future of lethal injection as a means of execution in the United States is under significant scrutiny. Outcomes of ongoing legislative and judicial reviews might result in cessation of lethal injection in totality or in alterations involving specific drug combinations or administration procedures.

The ethical "elephant" in the death penalty "room".

The United States Supreme Court recently ruled that execution by a commonly used protocol of drug administration does not represent cruel or unusual punishment. Various medical journals have editorialized on this drug protocol, the death penalty in general and the role that physicians play. Many physicians, and societies of physicians, express the opinion that it is unethical for doctors to participate in executions. This Target Article explores the harm that occurs to murder victims' relatives when an execution is delayed or indefinitely postponed. By using established principles in psychiatry and the science of the brain, it is shown that victims' relatives can suffer brain damage when justice is not done. Conversely, adequate justice can reverse some of those changes in the brain. Thus, physician opposition to capital punishment may be contributing to significant harm. In this context, the ethics of physician involvement in lethal injection is complex.

Lethal injection, autonomy and the proper ends of medicine.

Gerald Dworkin has argued that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection. He does this by proposing a principle by which we are to judge whether an action is consistent with the proper ends of medicine. I argue: (a) that this principle, if valid, does not show that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection; and (b) that this principle is not valid, and this is because it mistakenly views the promotion of patient autonomy as one of the proper ends of medicine. Rather, I propose, we should view respect for a patient's autonomy as a constraint on the pursuit of the proper ends of medicine, rather than as one of the proper ends itself. With this revised understanding of the proper ends of medicine, we can conclude that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection.