Medical treatment and the good death: an ethical analysis of euthanasia, physician assisted suicide, and the right to die

Frequent advances in medical technologies have brought fonh many innovative treatments that allow medical teams to treal many patients with grave illness and serious trauma who would have died only a few years earlier. These changes have given some patients a second chance at life, but for others. these new treatments have merely prolonged their dying. Instead of dying relatively painlessly, these unfortunate patients often suffer from painful tenninal illnesses or exist in a comatose state that robs them of their dignity, since they cannot survive without advanced and often dehumanizing forms of treatment. Due to many of these concerns, euthanasia has become a central issue in medical ethics. Additionally, the debate is impacted by those who believe that patients have the right make choices about the method and timing of their deaths. Euthanasia is defined as a deliberate act by a physician to hasten the death of a patient, whether through active methods such as an injection of morphine, or through the withdrawal of advanced forms of medical care, for reasons of mercy because of a medical condition that they have. This study explores the question of whether euthanasia is an ethical practice and, as determined by ethical theories and professional codes of ethics, whether the physician is allowed to provide the means to give the patient a path to a "good death," rather than one filled with physical and mental suffering. The paper also asks if there is a relevant moral difference between the active and passive forms of euthanasia and seeks to define requirements to ensure fully voluntary decision making through an evaluation of the factors necessary to produce fully informed consent. Additionally, the proper treatments for patients who suffer from painful terminal illnesses, those who exist in persistent vegetative states and infants born with many diverse medical problems are examined. The ultimate conclusions that are reached in the paper are that euthanasia is an ethical practice in certain specific circumstances for patients who have a very low quality of life due to pain, illness or serious mental deficits as a result of irreversible coma, persistent vegetative state or end-stage clinical dementia. This is defended by the fact that the rights of the patient to determine his or her own fate and to autonomously decide the way that he or she dies are paramount to all other factors in decisions of life and death. There are also circumstances where decisions can be made by health care teams in conjunction with the family to hasten the deaths of incompetent patients when continued existence is clearly not in their best interest, as is the case of infants who are born with serious physical anomalies, who are either 'born dying' or have no prospect for a life that is of a reasonable quality. I have rejected the distinction between active and passive methods of euthanasia and have instead chosen to focus on the intentions of the treating physician and the voluntary nature of the patient's request. When applied in equivalent circumstances, active and passive methods of euthanasia produce the same effects, and if the choice to hasten the death of the patient is ethical, then the use of either method can be accepted. The use of active methods of euthanasia and active forms of withdrawal of life support, such as the removal of a respirator are both conscious decisions to end the life of the patient and both bring death within a short period of time. It is false to maintain a distinction that believes that one is active killing. whereas the other form only allows nature to take it's course. Both are conscious choices to hasten the patient's death and should be evaluated as such. Additionally, through an examination of the Hippocratic Oath, and statements made by the American Medical Association and the American College of physicians, it can be shown that the ideals that the medical profession maintains and the respect for the interests of the patient that it holds allows the physician to give aid to patients who wish to choose death as an alternative to continued suffering. The physician is also allowed to and in some circumstances, is morally required, to help dying patients whether through active or passive forms of euthanasia or through assisted suicide. Euthanasia is a difficult topic to think about, but in the end, we should support the choice that respects the patient's autonomous choice or clear best interest and the respect that we have for their dignity and personal worth.

Controle social e controle externo podem interagir? : avaliação as práticas do TCE-TO no estímulo à participação cidadã

O tema "controle social" nunca esteve tão em voga quanto atualmente. Trata-se de mais uma inovação produzida pelo estado democrático de direito, e que consiste, entre outros objetivos, na busca da legitimidade e da eficiência dos atos da administração pública, na redução das distâncias entre esta e a sociedade, na vinculação das demandas sociais às políticas públicas, e, é claro, no fortalecimento dos controles e da fiscalização. A premissa básica deste trabalho é a suposição de que há sinergia entre o controle social e o controle externo exercido pelos tribunais de contas, valendo-se para tal afirmação da avaliação das práticas do Tribunal de Contas do Estado do Tocantins no estímulo à participação cidadã. Assim, o objetivo deste trabalho de pesquisa é mostrar como o exercício do controle social, exercido pelo cidadão mediante mecanismos adequados criados pelos tribunais de contas, pode interagir com o controle externo de sua responsabilidade, com ganhos significativos para os controles da administração pública. Entre esses mecanismos, as ouvidorias dessas instituições estão entre as ações mais fortes que promovem o controle social. As ouvidorias nos tribunais de contas representam canais de controle da sociedade sobre a gestão pública, e abrem importante espaço para o debate e o consenso em tomo do objetivo comum dos tribunais e da sociedade: a correta aplicação dos recursos públicos que garanta eficiência, eficácia e efetividade. Para atingir seus objetivos, os tribunais de contas necessitam identificar e coibir as práticas contrárias ao interesse público presentes na formação social brasileira, tais como: a má gestão, a corrupção e a ineficiência. Assim, com vistas a identificá-Ias e coibi-Ias, é fundamental a participação da sociedade, que pode, deve e precisa contribuir neste sentido. Desta forma, apresentamos as práticas dos TCs do Brasil quanto ao tema, e, ainda, em detalhe, a ouvidoria do TCE-TO, e destacamos outras ações de estímulo ao controle social e à participação cidadã executadas por aquela Corte de Contas.

Too difficult to manage, too big to ignore: party choice in multiparty presidential systems

In consensual (proportional) highly fragmented multiparty settings, political parties have two historical choices to make or pathways to follow: i) playing a majoritarian role by offering credible candidates to the head of the executive; or ii) playing the median legislator game. Each of those choices will have important consequences not only for the party system but also for the government. The purpose of this paper is to investigate the role played by median legislator parties on coalition management strategies of presidents in a comparative perspective. We analyze in depth the Brazilian case where the Partido do Movimento Democrático Brasileiro (PMDB) has basically functioned as the median legislator party in Congress by avoiding the approval of extreme policies, both on the left and on the right. Based on an expert survey in Latin America, we built an index of Pmdbismo and identified that there is a positive correlation between partisan fragmentation and median legislator parties. In addition, we investigate the effect of having a median legislator party in the governing coalition. We found that it is cheaper and less difficult for the government to manage the coalition having the median legislative party on board.

Selecting appropriate bedding to reduce locomotion problems in broilers

Two experiments were carried out at the Poultry Sector of the School of Agrarian Sciences of the Federal University of Grande Dourados to evaluate the incidence of leg problems in broilers reared on two distinct types of bedding material: rice husks or wood shavings, both new and reused. In both trials, a randomized experimental design was applied in factorial arrangement (2 x 2 x 2) using two genetic strains (Cobb® or Ross®); two sexes (male or female), and two litter materials (rice husks or wood shavings). In each trial 1080 one day pullets were reared equally divided in the treatments. The birds were placed in 4.5 m² boxes at a density of 10 birds m-2. All birds were fed diets with equal nutritional density, and water was offered ad libitum. Feeds were divided in three phases: starter diet (1 - 21 days), grower diet (22 - 35 days), and finisher diet (36 - 45 days). on day 45, fifty birds were randomly selected in each experiment to evaluate flock leg problems. The following parameters were analyzed: gait score, incidence of valgus and varus disorder, footpad dermatitis, femoral degeneration, tibial dyschondroplasia, and spondylolisthesis. Ambient temperature during rearing and litter caking and moisture content were recorded in four boxes per treatment. The analytical hierarchy process was used to organize the data into specific criteria. Several criteria, related to the attributes that were determinant according to the statistical analysis, were chosen in order to provide the best input to the process. Results indicated that new wood-shavings bedding was the most appropriate bedding to prevent locomotion problems, followed by new rice husks, reused wood shavings, and reused rice husks. However, when leg problems were associated to sex and genetic strain, male Ross birds strain presented less problems when reared on new rice husks, followed by new wood shavings

Artificial neural networks: A novel approach to analysing the nutritional ecology of a blowfly species, Chrysomya megacephala

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Alkaline ribonuclease activity in maternal serum and in serum of newborns from birth up to thirty days of age. A study made with full-term appropriate-, full-term small- and preterm appropriate-for-gestational-age infants

We have studied the alkaline ribonuclease (RNase) activity in maternal serum and serum of full-term small- (T-SGA), full-term appropriate- (T-AGA) and preterm appropriate-for-gestational age (PT-AGA) newborns. A significantly lower level of RNase was observed in T-AGA and T-SGA newborns on the 30th day of age and in PT-AGA newborns on the 15th and 30th days of age, as compared to other T-AGA, T-SGA and PT-AGA groups of infants at birth. RNase activity was significantly higher in cord blood than in the maternal blood in all categories studied. Moreover, in preterm newborns, RNase activity in cord blood was significantly higher in those presenting a lower gestational age. We did not observe any significant difference in RNase levels in the cord blood of newborns from the 3 categories studied. The same results were observed concerning maternal blood. We, therefore, conclude that RNase activity in cord blood or in maternal blood is not a very statisfactory indicator of fetal malnutrition.

Evaluation of motivation methods used to obtain appropriate oral hygiene levels in schoolchildren.

The aim of the present study is to assess the behaviour of different motivation methods on levels of oral hygiene among schoolchildren aged from 7 to 9 years in Araraquara, SP, Brazil. The methods tested were: indirect instruction using 'The Smiling Robot' (group I), indirect instruction through class presentation (group II) and direct instruction with macromodels (group III). A control group was also constituted, which received no kind of motivation (group IV). The O'Leary Plaque Index was used as the evaluation method, applied before the instruction and 30 days after application of the different methods. It was noted that the plaque index had not decreased in group IV only. In conclusion, all the motivation methods promoted significant decrease of plaque index and among these methods, the 'The Smiling Robot' was the one that provided the best results.

Women's contribution to equality in Latin America and the Caribbean

Includes bibliography

Response to Chemotherapy in Overweight/Obese Patients With Low-Risk Gestational Trophoblastic Neoplasia

Objective Despite rising global obesity rates, the impact of obesity on gestational trophoblastic neoplasia (GTN) remains uninvestigated. This study aimed at investigating whether overweight/obesity relates to response to chemotherapy in low-risk GTN patients.Methods This nonconcurrent cohort study included 300 patients with International Federation of Gynecology and Obstetrics-defined postmolar low-risk GTN treated with a single-agent chemotherapymethotrexate or actinomycin-D (actD)between 1973 and 2012 at the New England Trophoblastic Disease Center. Chemotherapy dosing was based on actual body weight regardless of obesity status, except for 5-day courses or pulse regimens of actD. Patients were classified as overweight/obese (body mass index [BMI] 25 kg/m(2)) or non-overweight/obese (BMI <25 kg/m(2)). Information on patient characteristics and response to chemotherapy (need for second-line chemotherapy, reason for changing to an alternative chemotherapy, number of cycles, need for combination chemotherapy, and time to human chorionic gonadotropin remission) was obtained.Results Of 300 low-risk GTN patients, 81 (27%) were overweight/obese. Overweight/obese patients were older than the non-overweight/obese patients (median age: 30 vs 28 years, P = 0.004). First-line therapy using actD was more frequent in overweight/obese patients (6.2% vs 1.4%, P = 0.036). Resistance and toxicity were similar between groups. No significant difference in the number of chemotherapy cycles needed for remission or time required to achieve remission was found between groups.Conclusions No association between overweight/obesity and low-risk GTN outcomes was found. Current chemotherapy dosing using BMI seems to be appropriate for overweight/obese patients with low-risk GTN.

Multiobjective Genetic Algorithm applied to dengue control

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Student Reactions to Professor Use of Facebook

Mazer, Murphy and Simonds (2007) recently demonstrated that high self-disclosure, compared to low self-disclosure, on a fictitious professor's Facebook profile was related to students' expectations of a positive classroom environment and high levels of motivation. These findings raise the question of whether all types of self-disclosure would have the same effect. This study examined college students' perceptions of specific ways that professors might use Facebook. We created six Facebook profiles for a fictitious male professor, each with a specific emphasis: Republican, Democrat, religious, family- oriented, socially oriented, or professional only. While viewing a printed version of one of the randomly distributed profiles, participants responded to questions that assessed their perceptions of the professors' teaching ability, classroom demeanor and appropriateness of self-disclosure, as well as their own Facebook use. Students responded most negatively, but sometimes with greatest interest, to professors' posting of social and political information. Appropriate use of Facebook, including professional and family information, increased students' respect for the professor and his classroom. These findings could be very helpful in guiding professor Facebook use.

Creating Meaningful Homework and Implementing Homework Presentations to Aid in Mathematics Instruction

In this action research study of sixth grade mathematics, I investigated the use of meaningful homework and the implementation of presentations and its effect on students’ comprehension of mathematical concepts. I collected data to determine whether the creating of meaningful homework and the implementation of homework presentations would have a positive impact on the students’ understanding of the concepts being taught in class and the reasoning behind assigning homework. The homework was based on the lesson taught during class time. It was grade-level appropriate and contained problems similar to those students completed in class. A pre-research and post-research survey based on homework perceptions and my teaching practices was given, student interviews were conducted throughout the research period, weekly teacher journals were kept that pertained to my teaching practices and the involvement of the students that particular week, and homework assignments were collected to gauge the students’ understanding of the mathematics lessons. Most students’ perceptions on homework were positive and most understood the reasoning for homework assignments.

A dog at the keyboard: using arbitrary signs to communicate requests

As a consequence of domestication, dogs have a special readiness for communication with humans. We here investigate whether a dog might be able to acquire and consistently produce a set of arbitrary signs in her communication with humans, as was demonstrated in ""linguistic"" individuals of several species. A female mongrel dog was submitted to a training schedule in which, after basic command training and after acquiring the verbal labels of rewarding objects or activities, she learned to ask for such objects or activities by selecting lexigrams and pressing keys on a keyboard. Systematic records taken during spontaneous interaction with one of the experimenters showed that lexigrams were used in an appropriate, intentional way, in accordance with the immediate motivational context. The dog only utilized the keyboard in the experimenter`s presence and gazed to him more frequently after key pressing than before, an indication that lexigram use did have communicative content. Results suggest that dogs may be able to learn a conventional system of signs associated to specific objects and activities, functionally analogous to spontaneous soliciting behaviors and point to the potential fruitfulness of the keyboard/lexigram procedure for studying dog communication and cognition. This is the first report to systematically analyze the learning of arbitrary sign production in dogs.

Using the National Institute of Health Stroke Scale to Predict Dysphagia in Acute Ischemic Stroke

Background and Purpose: Oropharyngeal dysphagia is a common manifestation in acute stroke. Aspiration resulting from difficulties in swallowing is a symptom that should be considered due to the frequent occurrence of aspiration pneumonia that could influence the patient's recovery as it causes clinical complications and could even lead to the patient's death. The early clinical evaluation of swallowing disorders can help define approaches and avoid oral feeding, which may be detrimental to the patient. This study aimed to create an algorithm to identify patients at risk of developing dysphagia following acute ischemic stroke in order to be able to decide on the safest way of feeding and minimize the complications of stroke using the National Institutes of Health Stroke Scale (NHISS). Methods: Clinical assessment of swallowing was performed in 50 patients admitted to the emergency unit of the University Hospital, Faculty of Medicine of Ribeirao Preto, Sao Paulo, Brazil, with a diagnosis of ischemic stroke, within 48 h after the beginning of symptoms. Patients, 25 females and 25 males with a mean age of 64.90 years (range 26-91 years), were evaluated consecutively. An anamnesis was taken before the patient's participation in the study in order to exclude a prior history of deglutition difficulties. For the functional assessment of swallowing, three food consistencies were used, i.e. pasty, liquid and solid. After clinical evaluation, we concluded whether there was dysphagia. For statistical analysis we used the Fisher exact test, verifying the association between the variables. To assess whether the NIHSS score characterizes a risk factor for dysphagia, a receiver operational characteristics curve was constructed to obtain characteristics for sensitivity and specificity. Results: Dysphagia was present in 32% of the patients. The clinical evaluation is a reliable method of detection of swallowing difficulties. However, the predictors of risk for the swallowing function must be balanced, and the level of consciousness and the presence of preexisting comorbidities should be considered. Gender, age and cerebral hemisphere involved were not significantly associated with the presence of dysphagia. NIHSS, Glasgow Coma Scale, and speech and language changes had a statistically significant predictive value for the presence of dysphagia. Conclusions: The NIHSS is highly sensitive (88%) and specific (85%) in detecting dysphagia; a score of 12 may be considered as the cutoff value. The creation of an algorithm to detect dysphagia in acute ischemic stroke appears to be useful in selecting the optimal feeding route while awaiting a specialized evaluation. Copyright (C) 2012 S. Karger AG, Basel