Four mesothelioma cases from a single automotive dealership: A case series.

BACKGROUND: Four cases of mesothelioma were noted in a workplace of some 110 persons at a tractor dealership between 2006 and 2023. Each worker had a different job title. METHODS: Medical-legal case material was reviewed and abstracted from four cases from the same dealership, all supplied via one law firm. RESULTS: Four mesotheliomas are reported from this single facility that used chrysotile asbestos automotive products. Two of the four cases had no other known exposures to asbestos. DISCUSSION: Automotive products containing chrysotile do appear capable of causing mesothelioma. Job category is not a good surrogate for exposure.

Moral Distress in Deciding How Others Die.

This essay discusses how Susan Shapiro's Speaking for the Dying (2019) contributes to understanding surrogate decision-making in intensive care. Shapiro's ethnography is based on over two years of observing day-to-day decision-making by surrogates and family members who found themselves having to speak for loved ones who were no longer capable of expressing their own wishes for treatment or its termination. After summarizing Shapiro's specific findings-in particular what made no observable difference in decision-making, including advance directives-greater attention is given to how she acts as a witness to the emotional burden and distress that these decisions cause for both family members and professional staff. Shapiro allows us to hear the voices of people forced to make high-stakes decisions in the most stressful conditions with little guidance. We hear the contradictions inherent in surrogate decision-making and gain insight into how the institutional organization of intensive care produces moral distress.

The Twin Crises of Principles and Stories.

This symposium contribution argues that politicized responses to the COVID-19 pandemic mark the fracturing of the consensus that bioethics has been built upon. This consensus involved the mutual dependence of principles and stories: principles need stories to become applicable in clinical action, and stories need to reflect principles if they are to make generalized claims. Two mid-20th-century theorists, Erving Goffman and Walter Benjamin, each predicted the thinness of appeals to principles and to stories, respectively; their skepticism describes our moment. Anti-public health responses to COVID restrictions show that principles now have radically different meanings within different factional groups, so appealing to them perpetuates divisions. Complementary to that, stories are told more as displays of group membership than as testimony of individual experience. The predictable future is that bioethics controversies will become more fraught.

Ethical thinking in occupational and environmental medicine: Commentaries from the Selikoff Fund for Occupational and Environmental Cancer Research.

A tribute to Dr. Irving J. Selikoff MD, the founder of this journal, is indeed welcome now more than two decades after his passing. He was known during his lifetime as the US Father of Environmental Medicine which at the time encompassed occupational medicine and much more as industry also polluted the general environment. The 1970s were a busy time as OSHA and the EPA were newly formed and high exposures to workers were no exception. Dr. Selikoff was a brave pioneer examining workers throughout the country and Canada, publicizing their exposures, and writing and presenting the scientific results. Industry was not always receptive and controlled an astounding amount of narrative, with the creation of the American Journal of Industrial Medicine filling a void of scientific need. We four authors write about the ethics of occupational health, the plight of nuclear energy workers, the climate crisis and opportunity for unions to engage workers, and the global march toward educating medical students on workers' health and safety. All four of us interacted with Dr. Selikoff during his tenure at Mount Sinai, and over the years joined each other in promoting his legacy. Toward that end we have written articles honoring his memory.

Case-fatality study of workers and residents with radiographic asbestos disease in Libby, Montana.

BACKGROUND: Vermiculite ore from Libby, Montana contains on average 24% of a mixture of toxic and carcinogenic amphibole asbestiform fibers. These comprise primarily winchite (84%), with smaller quantities of richterite (11%) and tremolite (6%), which are together referred to as Libby amphibole (LA). METHODS: A total of 1883 individuals who were occupationally and/or environmentally exposed to LA and were diagnosed with asbestos-related pleuropulmonary disease (ARPPD) following participation in communitywide screening programs supported by the Agency for Toxic Substances and Disease Registry (ATSDR) and followed up at the Center for Asbestos Related Disease (CARD) between 2000 and 2010. There were 203 deaths of patients with sufficient records and radiographs. Best clinical and radiologic evidence was used to determine the cause of death, which was compared with death certificates. RESULTS: Asbestos-related mortality was 55% (n = 112) in this series of 203 patients. Of the 203 deaths, 34 (17%) were from asbestos-related malignancy, 75 (37%) were from parenchymal asbestosis, often with pleural fibrosis, and 3 (1.5%) were from respiratory failure secondary to pleural thickening. CONCLUSIONS: Asbestos is the leading cause of mortality following both occupational and nonoccupational exposure to LA in those with asbestos-related disease.

Malignant mesothelioma: Ongoing controversies about its etiology in females.

Malignant mesothelioma (MM) is one of the most aggressive cancers with the poorest of outcomes. There is no doubt that mesothelioma in males is related to asbestos exposure, but some authors suggest that most of the cases diagnosed in females are "idiopathic." In our assessment of the science, the "low risk" of mesothelioma in females is because of the nonsystematic recording of exposure histories among females. Indeed, asbestos exposure is mentioned in only some of the studies that include females. We estimate the risk of MM among females to be close to that in males. The absence of detailed exposure histories should be rectified in future studies involving ​women. As a matter of social justice, the ongoing failure to recognize asbestos as the cause of a majority of cases of MM in females does them, and their kin, a profound disservice.

Tragic Realism: Reading Simon Critchley for Bioethics.

The essay explores how Simon Critchley's critique of philosophy and understanding of tragedy might affect bioethics and health-care practice. What I playfully call the Critchley Doctrine begins with a rejection of philosophy's aspiration to a non-contradictory life and its premise that humans act on rational deliberation. This rejection opens us to a recognition of the uncontainable that is expressed in tragedy, and that speaks to what is inexplicable about the suffering of illness. Critchley advocates an ethics of heteronomy or hetero-affectivity rather than autonomy, but his version is distinguished by its recognition of how crushing the demands of the other can be. Tragedy and humor offer what he calls aesthetic reparation. A tragic medicine balances grieving with humor and seeks above all honesty in communication.

Suffering, Medicine, and What Is Pointless.

Beginning with Eric Cassell's much-cited definition of suffering, this essay engages with Scott Samuelson's Seven Ways of Looking at Pointless Suffering (2018). How each of Samuelson's seven ways is relevant to health care and bioethics is suggested through various examples. The discussion underscores the crucial choice for health-care professionals between being an expert technician who provides treatment or being a healer, in an expansive sense first described by Cassell and elaborated by extending Samuelson's useful typology. Also at issue is Samuelson's title word pointless. Samuelson's seven ways each attempt to make suffering seem to have a point. The essay questions whose needs are met, either by declaring suffering pointless, or by asserting what its point is. Examples relate these issues to clinical practice.

Asbestos in commercial indian talc.

BACKGROUND: Easily available commercial Indian talc products widely used in Southeast Asia were examined for the presence of asbestos. Asbestos in talc products carry all risks of asbestos-related disease. METHODS: Using polarizing light microscopy, transmission electron microscopy (TEM), electron diffraction, and X-ray analysis, multiple over-the-counter Indian talc products were examined for the presence of asbestos. RESULTS: Results In an initial group of five Indian talc products, one was found to contain tremolite asbestos. The second group of eight products was tested and six of eight contained tremolite asbestos as well. No other regulated amphibole was found. CONCLUSION: Large quantities of body talc products containing asbestos are used throughout Southeast Asia and are likely to pose a public health risk for asbestos-related diseases, especially for the cancers related to asbestos exposure. The country of origin in which the talc examined was sourced for production is unknown to the authors, and further investigation to measure associated public health risk is needed.

"Who's There?": A Vulnerable Reading of Hamlet.

Vulnerable reading asks how literary works can be useful as companions to people who suffer; its focus is literature as solace. Questions of why we should turn to Shakespeare to express suffering, and why to poetic literature, are considered. An exemplary reading of Hamlet discusses three levels of vulnerable reading: the play as mirror in which readers can see reflections of their own troubles and gain new expressive possibilities for themselves; the play as training in acquiring a new voice to resist these troubles; and the play as a pedagogy of engagement in dialogue with others in relations of care. Hamlet proclaims that the "readiness is all." How does the play mentor that readiness?

Virtue Ethics in Monetized Medicine.

This review essay situates Abraham Nussbaum's The Finest Traditions of Our Calling (2016) within the contemporary genre of physician memoirs that shade into critiques of institutional medicine. Nussbaum's primary concern is the demoralization of medicine as it becomes increasingly monetized; patients are reduced to body parts and reimbursement schedules. He argues that physicians continue to have considerable choice in how they practice, despite institutional constraints. For bioethics, Nussbaum's advocacy of virtue ethics is notable. His book is a moving testimonial to contemporary problems, but also a manifesto for possibilities of change at the individual level.

Truth Telling, Companionship, and Witness: An Agenda for Narrative Ethics.

Narrative ethics holds that if you ask someone what goodness is, as a basis of action, most people will first appeal to various abstractions, each of which can be defined only by other abstractions that in turn require further definition. If you persist in asking what each of these abstractions actually means, eventually that person will have to tell you a story and expect you to recognize goodness in the story. Goodness and badness need stories to make them thinkable and to translate them into individual and collective actions. Yet after more than two decades of considering the issue, I do not believe that a collection of stories can by itself guide actions in ways that are sufficient to respond to ethical troubles in institutional settings. The question will always remain open for me, but my present belief is that narrative bioethics is always hyphenated, in the sense that guidance from stories needs to be allied with other ethical guidance. Each side of the hyphen qualifies the other side. The hyphenation I will argue for in this essay is "narrative-deontology."

Working environment and myeloproliferative neoplasm: A population-based case-control study following a cluster investigation.

BACKGROUND: Occupational exposures, including those to polycyclic aromatic hydrocarbons (PAH), are suspected risk factors for myeloproliferative neoplasms (MPN). METHODS: We investigated occupational exposures and MPN risk (54 cases and 472 controls) in a population-based case-control study in three rural Pennsylvania counties. Occupational histories, coded to SIC/SOC 1980, were linked to a previously created PAH job-exposure matrix. Odds ratios for industry (17 categories), occupation (26 categories), and PAH exposure were adjusted using logistic regression. RESULTS: No industries or occupations were strongly or consistently associated with increased MPN risk. Analysis of employment duration found that being employed for 5 or more years in transportation, communications, and other public utilities was associated with MPN risk. There was no indication of an association with cumulative PAH exposure. CONCLUSIONS: These few associations did not appear to have a common exposure. This exploratory study does not support the hypothesis that occupational exposure, including PAH, are strong risk factors for MPNs.

Trap-free transport in ordered and disordered TiO2 nanostructures.

Understanding the influence of different film structures on electron diffusion in nanoporous metal oxide films has been challenging. Because of the rate-limiting role that traps play in controlling the transport properties, the structural effects of different film architectures are largely obscured or reduced. We describe a general approach to probe the impact of structural order and disorder on the charge-carrier dynamics without the interference of transport-limiting traps. As an illustration of this approach, we explore the consequences of trap-free diffusion in vertically aligned nanotube structures and random nanoparticle networks in sensitized titanium dioxide solar cells. Values of the electron diffusion coefficients in the nanotubes approached those observed for the single crystal and were up to 2 orders of magnitude greater than those measured for nanoparticle films with various average crystallites sizes. Transport measurements together with modeling show that electron scattering at grain boundaries in particle networks limits trap-free diffusion. In presence of traps, transport was 10(3)-10(5) times slower in nanoparticle films than in the single crystal. Understanding the link between structure and carrier dynamics is important for systematically altering and eventually controlling the electronic properties of nanoscaled materials.

Narrative ethics as dialogical story-telling.

The narrative ethicist imagines life as multiple points of view, each reflecting a distinct imagination and each more or less capable of comprehending other points of view and how they imagine. Each point of view is constantly being acted out and then modified in response to how others respond. People generally have good intentions, but they get stuck realizing those intentions. Stories stall when dialogue breaks down. People stop hearing others' stories, maybe because those others have quit telling their stories. The narrative ethicist's job is to help people generate new imaginations that can restart dialogues.

Asbestos history and use.

All six fiber types called asbestos can cause all the diseases related to exposure, including lung cancer. Known to the ancients, the modern history of asbestos hazards started in the 1890s with more and more data accumulating over time. Use increased exponentially in the middle of the 20th century with major use coming in construction and ship building. The recognition of asbestos as causing lung cancer dates to the early 1940s.

Asbestos-Related lung Cancer: An underappreciated oncological issue.

Asbestos, a group of class I (WHO) carcinogenic fibers, is the main cause of mesothelioma. Asbestos inhalation also increases the risk to develop other solid tumours with lung cancer as the most prominent example [91]. The incidence of asbestos-related lung cancer (ARLC) is estimated to be to six times larger than the mesothelioma incidence thereby becoming an important health issue [86]. Although the pivotal role of asbestos in inducing lung cancer is well established, the precise causal relationships between exposures to asbestos, tobacco smoke, radon and 'particulate' (PM2.5) air pollution remain obscure and new knowledge is needed to establish appropriate preventive measures and to tailor existing screening practices[22,61,65]. We hypothesize that a part of the increasing numbers of lung cancer diagnoses in never-smokers can be explained by (historic and current) exposures to asbestos as well as combinations of different forms of air pollution (PM2.5, asbestos and silica).