Mike Green

The twenty‐six‐year‐old patient requested a prophylactic bilateral mastectomy with reconstruction because of an extensive family history of cancer. She reported that she had developed melanoma at twenty‐five; that her mother, sister, aunts, and a cousin all had breast cancer; that a cousin had ovarian cancer at nineteen; and that a brother was treated for esophageal cancer at fifteen. The treating team was skeptical about this history, and they could find no documentation of the patient's reported melanoma. The surgeon wrote the patient's primary care physician, explaining that he had seen the patient and planned to proceed with the bilateral mastectomy and reconstruction. The primary care physician responded that he was unable to substantiate several of the patient's claims; some of his colleagues believed the family history to be fabricated. Trying to make sense of the discrepancies, the genetic counselor called a counselor colleague who had met with this patient. The colleague suggested that the in‐house genetic counselor “google” the patient. The search revealed two Facebook pages linked to the patient. In one, apparently a personal profile, the patient stated that in addition to battling stage four melanoma, she had recently been diagnosed with breast cancer. She provided a link to a site where she solicited donations to attend a summit for young cancer patients. The other Facebook page featured numerous pictures of her with a bald head, as though she has been through chemotherapy. The genetic counselor showed the Facebook pages to the surgeon, who then decided not to operate. Should health care professionals “google” their patients?

This article answers questions about the consistency, coherence, and motivation of Hobbes's account of the right to punish. First, it develops a novel account of authorization that explains how Hobbes could have consistently held both that the subjects do not give the sovereign the right to punish and also that they authorize the sovereign to punish. Second, it shows that, despite appearances, the natural and artificial elements of Hobbes's account form a coherent whole. Finally, it explains why Hobbes thought it was important to establish the sovereign's right to punish apart from the sovereign's power to punish.

The Paleolithic paintings and drawings found on cave walls at sites in France and Spain, such as Lascaux, Altamira and Vallon-Pont-D'Arc, have profound effects on those who see them. In addition to their historical interest, they are prized for their aesthetic and spiritual qualities, which have had an important influence on modern art. But the caves are small and the paintings are fragile. Access to them has been sharply limited: some caves have been closed to protect the paintings from the damage caused by human respiration; access to others is limited to those who negotiate a daunting reservation scheme. Despite being the heritage of humanity as a whole, the cave paintings are, and must be, restricted to a very few. Not everyone who wants to see the paintings can do so if they are to survive.

Background: Prior research has explored reasons why health care providers may or may not choose to seek an ethics consultation. Although low-quality communication is evident in many ethics consultations, it is unknown whether poor communication in clinical settings is related to health care providers' requests for ethics involvement. Objective: To assess the relationship between self-reported ratings of health care providers' inter- and intraprofessional communication and ethics consultation requests. Method: This cross-sectional survey was conducted using a self-administered questionnaire of physicians and nurses in six intensive care units at one academic medical center in the United States. The questionnaire assessed perceptions about requesting ethics consultations and how health care providers perceive communication. Results: Two hundred sixty-two participants (228 nurses and 34 physicians) responded to the survey (response rate 55%; 59% for nurses and 41% for physicians). Requests for an ethics consult were positively associated with perceived quality of interprofessional communication (r =.13, p

Mr. Galanas, an eighty‐six‐year‐old man, intentionally shot himself in the chest and abdomen. Surprisingly, the bullet damaged only his distal pancreas and part of his colon, requiring a diverting colostomy to prevent leakage of bowel fluids into his abdomen. After being admitted, he lies intubated in the intensive care unit awaiting surgery to repair his colon. He is responsive but does not demonstrate clear decision‐making capacity. He grudgingly accepts pain medications but refuses antibiotics and antidepressants. He has a living will that gives his wife durable power of attorney and also explicitly states a desire to refuse all medical interventions if he is permanently unconscious or in an end‐stage condition. Mrs. Galanas reports frequent conversations in which her husband said he would not want to be sustained on life support. She also says that he often mentioned he would not want an ostomy bag—a likely, albeit temporary, outcome of the proposed surgery. His physicians are nervous about withholding medical interventions when Mr. Galanas's injury is the result of a suicide attempt and his prognosis is good. Should the care team surgically repair his injured colon, regardless of the patient's capacity, his advance directive, and his wife's statement that he would not want surgery or other life‐sustaining treatment?

This paper poses the question, “what are providers’ obligations to patients who lie?” This question is explored through the lens of a specific case: a 26–year–old woman who requests prophylactic bilateral mastectomy with reconstruction reports a significant and dramatic family history, but does not want to undergo genetic testing. Using a conversational–style discussion, the case is explored by a breast surgeon, genetic counselor/medical geneticist, clinical psychologist, chair of a hospital ethics committee and director of a clinical ethics consultation service.

In the face of mounting criticism against advance directives, we describe how a novel, computer-based decision aid addresses some of these important concerns. This decision aid, Making Your Wishes Known: Planning Your Medical Future , translates an individual's values and goals into a meaningful advance directive that explicitly reflects their healthcare wishes and outlines a plan for how they wish to be treated. It does this by (1) educating users about advance care planning; (2) helping individuals identify, clarify, and prioritize factors that influence their decision-making about future medical conditions; (3) explaining common end-of-life medical conditions and life-sustaining treatment; (4) helping users articulate a coherent set of wishes with regard to advance care planning—in the form of an advance directive readily interpretable by physicians; and (5) helping individuals both choose a spokesperson, and prepare to engage family, friends, and health care providers in discussions about advance care planning.

PurposeAdvance directives have been criticized for failing to help physicians make decisions consistent with patients’ wishes. This pilot study sought to determine if an interactive, computer-based decision aid that generates an advance directive can help physicians accurately translate patients’ wishes into treatment decisions.MethodsWe recruited 19 patient-participants who had each previously created an advance directive using a computer-based decision aid, and 14 physicians who had no prior knowledge of the patient-participants. For each advance directive, three physicians were randomly assigned to review the advance directive and make five to six treatment decisions for each of six (potentially) end-of-life clinical scenarios.From the three individual physicians’ responses, a “consensus physician response” was generated for each treatment decision (total decisions = 32). This consensus response was shared with the patient whose advance directive had been reviewed, and she/he was then asked to indicate how well the physician translated his/her wishes into clinical decisions.ResultsPatient-participants agreed with the consensus physician responses 84 percent (508/608) of the time, including 82 percent agreement on whether to provide mechanical ventilation, and 75 percent on decisions about cardiopulmonary resuscitation (CPR).Across the six vignettes, patient-participants’ rating of how well physicians translated their advance directive into medical decisions was 8.4 (range = 6.5-10, where 1 = extremely poorly, and 10 = extremely well). Physicians’ overall rating of their confidence at accurately translating patients’ wishes into clinical decisions was 7.8 (range = 6.1-9.3, 1 = not at all confident, 10 = extremely confident).ConclusionFor simulated cases, a computer-based decision aid for advance care planning can help physicians more confidently make end-of-life decisions that patients will endorse.

Though graphic narratives (or comics) now permeate popular culture, address every conceivable topic including illness and dying, and are used in educational settings from grade school through university, they have not typically been integrated into the medical school curriculum. This paper describes a popular and innovative course on comics and medicine for 4th-year medical students. In this course, students learn to critically read book length comics as well as create their own stories using the comics format. The rationale for the course, its general content and format, and methods for teaching are described. Finally, the author offers some reflections on why this medium resonates so powerfully with medical student learners

Thomas Hobbes's theory of the laws of nature covers only a subset of these rules, namely, those that “concern the doctrine of Civill Society”. There are many interpretations that attribute more ambitious aims to Hobbes, such as reconciling the claims of morality and interest, defending a version of divine command theory, showing that some aims are supremely rational, or using a theory of reciprocity to unite reason and morality. This chapter argues that Hobbes can accomplish his most important goals with the minimalist theory. Hobbes describes the behavior of societies in the state of nature whose members support themselves by raiding other cities. Hobbes's moral theory makes the case for the state because it holds that social life governed by the laws of nature is available only within the state. In addition to supporting Hobbes's political theory, the minimalist theory presents an alternative to Aristotle's theory of justice.

The adage “an ounce of prevention is worth a pound of cure” is widely used in healthcare settings and can be applied to the work of institutional clinical ethics committees. The model of clinical ethics consultation, however, is inherently reactive: a crisis or question emerges, and ethics experts are called to help. In an effort to employ a proactive component to the model of clinical ethics consultation (as well as to standardize our educational interventions), we developed ethics pocket cards. The purpose of this article is to: (1) describe the rationale for using ethics pocket cards, (2) provide examples of our cards, and (3) begin a dialogue about the potential uses of ethics pocket cards. In doing so, we hope to explore how such portable, economical devices can advance the goals of ethics consultation as well as the educational aims of ethics committees.

What is the value of having medical students engage in creative production as part of their learning? Creating something new requires medical students to take risks and even to fail--something they tend to be neither accustomed to nor comfortable with doing. “Making stuff” can help students prepare for such failures in a controlled environment that doesn’t threaten their professional identities. Furthermore, doing so can facilitate students becoming resilient and creative problem-solvers who strive to find new ways to address vexing questions. Though creating something new can be fun, this is not the main outcome of interest. Rather, the principle reason we recommend devoting precious curricular time to creative endeavors is because it helps medical students become better doctors.

The view that social justice takes priority over both global justice and the demands of sub-groups faces two critics. Particularist critics ask why societies should have fundamental significance compared with other groups as far as justice is concerned. Cosmopolitan critics ask why any social unit short of humanity as a whole should have fundamental significance as far as justice is concerned. One way of trying to answer these critics is to show that members of societies have special obligations to one another. This paper considers voluntarist and liberal nationalist accounts of such special obligations. It is especially concerned with developing a strong, sympathetic case for the less familiar nationalist position. Nonetheless, in each case the best arguments against the cosmopolitan critic require important concessions to the particularist critic. This suggests that there is a general problem with defending social justice against both critics at the same time.