Monday, December 31, 2018

In Rehab, ‘Two Warring Factions’: Abstinence vs. Medication

Lead story on p.1 of Sunday's New York Times:

A reluctant evolution is taking place in residential drug treatment for opioid addiction. Here’s a look at one center’s wary shift.

MURFREESBORO, Tenn. — Just past a cemetery along a country road, an addiction treatment center called JourneyPure at the River draws hundreds of patients a month who are addicted to opioids and other drugs. They divide their days between therapy sessions, songwriting, communing with horses and climbing through a treetop ropes course. After dinner, they’re driven into town in white vans for 12-step meetings.

It is a common regimen at residential treatment programs, but as the opioid epidemic persists, JourneyPure is evolving. Though its glossy website doesn’t mention it, the company is ramping up its use of medications to blunt the torturous withdrawal symptoms and cravings that compel many with opioid addiction to keep using. There is substantial evidence backing this approach, which is supposed to be used in tandem with therapy. But because two of the three federally approved medicines are opioids themselves, it is spurned by people who believe taking drugs to quit drugs is not real recovery.

Addiction experts say such resistance is obstructing efforts to reduce overdose deaths and help addicted Americans get their lives back on track, even as many drain their savings or go into debt paying for repeated stints in residential rehab. Two-thirds of the patients admitted to JourneyPure’s program here over the last three months said it wasn’t their first time in treatment.

“I’m watching the dominoes fall on our industry,” said David Perez, JourneyPure at the River’s new chief executive, who has helped lead the push toward using more medication-assisted treatment. “People are dying, and we are feeling more and more impotent to stop it. That is what’s shifting beliefs, more than anything.” (continues)
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Reader responses

Thursday, December 27, 2018

Training the Next Generation of Doctors and Nurses

For decades, medical education has followed a timeworn path — heaps of book learning and lectures, then clinical rotations exposing students to patients.

But as technology explodes into patient care (surgeons can preview operations using virtual 3-D images built from a patient’s scans), the gap between medical education and real-world care has “become a chasm,” said Marc Triola, director of N.Y.U. Langone’s Institute for Innovations in Medical Education, created in 2013 to address the issue.

“The health care delivery system is changing every day,” he said, “and our medical education system has been lagging.”

In what looks like an urgent game of catch-up, medical and nursing schools across the country are retooling how and what they teach. This is also getting a boost from concern about the looming shortage of primary caregivers.

While “the national narrative is that we need more” doctors and nurses, said Erin Fraher, director of the Carolina Health Workforce Research Center, “that is precisely the wrong way to frame this. The question has to be: Where are the places in the U.S. where patients cannot get access to diabetes care, access to prenatal care?”

Those questions are redesigning health care education, with more community-based clinic rotations, special programs (and scholarships) for rural and underserved students, and a greater role for nurses and nurse practitioners. As schools seek to make learning more efficient, technology — including virtual reality, augmented-reality software and high-fidelity simulations (mannequins “breathe,” cry, sweat and respond to medication) — is a big part of that.

And it must be, given that students have to learn more information, faster. Much of medicine is slow; you can’t shortcut taking a medical history. But visiting the pathology lab to study a colon sample?

This is where Greg Dorsainville, a multimedia developer and one of 28 full-time staff members in the N.Y.U. institute, steps in, using a 360-degree camera to film a 45-minute session with a pathologist. He cut the lesson to 5:46, time that a medical student can spare to don goggles, zoom in and see what a polyp actually looks like, making it something to be remembered as “a visual in their mind. It’s not just a concept.”

Thursday, December 20, 2018

Aging


  1. Undoing Aging 2019 announces Program and Speakers! Undoing Aging is focused on the cellular and molecular repair of age-related damage as the basis of therapies to bring aging under full medical control. It brings together scientists and...

  • Every Third Thought: On Life, Death, and the Endgame (McCrum) "This is a deeply personal book of reflection and conversation – with brain surgeons, psychologists, hospice workers and patients, writers and poets, and it confronts an existential question: in a world where we have learnt to live well at ..."

Monday, December 17, 2018

Image result for new yorker healthcare cartoons
More...

Dr. Google Is a Liar

Fake news threatens our democracy. Fake medical news threatens our lives.
It started during yoga class. She felt a strange pull on her neck, a sensation completely foreign to her. Her friend suggested she rush to the emergency room. It turned out that she was having a heart attack.

She didn’t fit the stereotype of someone likely to have a heart attack. She exercised, did not smoke, watched her plate. But on reviewing her medical history, I found that her cholesterol level was sky high. She had been prescribed a cholesterol-lowering statin medication, but she never picked up the prescription because of the scary things she had read about statins on the internet. She was the victim of a malady fast gearing up to be a modern pandemic — fake medical news.

While misinformation has been the object of great attention in politics, medical misinformation might have an even greater body count. As is true with fake news in general, medical lies tend to spread further than truths on the internet — and they have very real repercussions.

Numerous studies have shown that the benefits of statins far outweigh the risks, especially for people at high risk of heart disease. But they have been targeted online by a disparate group that includes paranoid zealots, people selling alternative therapies and those who just want clicks. Innumerable web pages and social media posts exaggerate rare risks and drum up unfounded claims, from asserting that statins cause cancer to suggesting that low cholesterol is actually bad for health. Even stories simply weighing the risks versus benefits of statins, a2016 study found, were associated with patients’ stopping the cholesterol-lowering drugs — which is associated with a spike in heart attacks... (continues)

Thursday, December 6, 2018

Why Scientists Are So Upset About the First Crispr Babies

A rogue researcher defied myriad scientific and ethical norms and guidelines...


A Chinese scientist recently claimed he had produced the world’s first gene-edited babies, setting off a global firestorm. If true — the scientist has not yet published data that would confirm it — his actions would be a sensational breach of international scientific conventions. Although gene editing holds promise to potentially correct dangerous disease-causing mutations and treat some medical conditions, there are many safety and ethical concerns about editing human embryos.

Here are answers to some of the numerous questions swirling around this development.
What happened?

The scientist, He Jiankui, said he used Crispr, a gene-editing technique, to alter a gene in human embryos — and then implanted the embryos in the womb of a woman, who gave birth to twin girls in November.

That is illegal in many countries, including the United States. China has halted Dr. He’s research and is investigating whether he broke any laws there. Among the concerns are whether the couples involved in Dr. He’s research were adequately informed about the embryo editing and the potential risks involved.

Dr. He says he has submitted his research to a scientific journal. But nothing has been published yet, and he announced the births of the twins before his research could be peer-reviewed by fellow scientists. He also appears to have taken other secretive steps that defy scientific standards... (continues)

Saturday, October 13, 2018

Bioethics, Spring 2019

Returning to MTSU, January 2019-
PHIL 3345,
Dr. Phil Oliver-Office hours TTh 11:15-12:45 & by appt.
TTh 4:20-5:45 pm, James Union Building (JUB) 202
Supporting the philosophical study of bioethics, biomedical ethics, biotechnology, and the future of life, at Middle Tennessee State University and beyond... "Keep your health, your splendid health. It is better than all the truths under the firmament." William James
===

Our anchoring theme: the psychological and social dimensions of medicine and the life sciences from birth to death, with a special emphasis this semester on the “biopolitics” of new and emerging biotechnologies such as assisted reproduction, human genetic modification, and DNA forensics.”

Texts 2019. We’ll begin with these texts:

  • Bioethics: The Basics (Campbell) ”...the word ‘bioethics’ just means the ethics of life…” 
  • Beyond Bioethics (Obasogie) “Bioethics’ traditional emphasis on individual interests such as doctor-patient relationships, informed consent, and personal autonomy is minimally helpful in confronting the social and political challenges posed by new human biotechnologies…” 
Each student will also choose and report on an additional relevant text, thus enabling us to extend our study of the field by “crowd-sourcing” many more of the crucial issues it raises.

For more info contact phil.oliver@mtsu.edu, or visit http://bioethjpo.blogspot.com/

Saturday, October 6, 2018

The Comforting Fictions of Dementia Care

Many facilities are using nostalgic environments as a means of soothing the misery, panic, and rage their residents experience. [But is it okay to further deceive dementia patients about reality?]

The large central room of the memory-care unit was designed to look like an old-fashioned American town square. There was a small fountain, surrounded by plants and a low stone wall; there were a couple of lampposts, and benches, tables, and chairs set about. The carpet was mottled with darker and lighter shades of green, to resemble grass growing and bending in different directions. Along the walls were the façades of what looked like clapboard houses, with wooden shutters and shingled pitched roofs and porches that extended into the room. Two long hallways, which led off from opposite sides of the central room, looked like streets in the same town, with more clapboard façades and porches on either side. These façades were not altogether fake: each front door opened onto a suite of small rooms—living room, bedroom, bathroom—that was a resident’s home.

Some of the porches had rocking chairs that you could sit in and watch people go by. Many of the residents were quite restless, and there was nowhere else to go, so people did walk by fairly often. Daylight came in through high windows just below the ceiling, and the ceiling itself consisted of bright light panels painted to look like a blue sky dotted with clouds. In the evening, as it began to grow dark outside, lights on the porches came on. Sometime later, the street lamps were lit; and finally, around eight o’clock, the ceiling sky was switched off, so that the unit came to look like a small-town street at night.

The illusion was surprisingly effective. While the central area didn’t feel like outdoors, exactly, it didn’t feel like a room, either—it was halfway between the two, at once enclosed and public. People who spent time there found themselves referring to the hallways as streets, and the suites as houses. And although the unit was conceived as a kind of nostalgic stage set, a harkening back to an America of eighty or ninety years ago, when many of its residents were children, in fact it looked much like the town outside: Chagrin Falls, Ohio, in the Chagrin Valley just east of Cleveland, a town of clapboard houses with wooden shutters and shingled pitched roofs and rocking chairs on the porches.

The impression that the unit was outdoors and public was all the stronger because the people who gathered each day in the central room had no common purpose or shared understanding of what they were doing there. Some knew that they had come to live in the memory-care unit because they could no longer manage living on their own: they could no longer drive, or they tended to forget their medication or leave the stove on, or if they went for a walk they might get lost. Some knew that they were in a memory-care unit but didn’t believe they needed to be there and tried to get out. Others did not know where they were, or knew sometimes but not at other times, or else seemed to have reached a point at which the question of where they were was no longer important.

The staff tried to keep the residents busy. They played hangman and trivia and bingo and beanbag toss. They performed stretching exercises and cognitive exercises every morning. There was Bible study and crafts and manicures each week. They watched Indians games on TV in the summer, and Cavaliers and Browns games in the fall. Elsewhere in the facility, there was an artificial main street, with a library, a gift shop, a beauty salon, a chapel in which services were held on Sundays, and a couple of faux storefronts—an oil company, a hardware store. Sometimes the residents were taken on outings—picnics or fishing at a nearby lake—and sometimes relatives came to take them to lunch, but most of the time the clapboard streetscape of the memory-care unit was their world.

The streetscape at the Lantern, the home at Chagrin Valley, is particularly encompassing and detailed, but comforting fictions—scenery, props, and other simulations—are employed in many homes for people with dementia. Some nursing homes offer their residents realistic vinyl baby dolls, along with diapers, bottles, and clothes. Some residents grow so attached to the dolls that it seems they believe they are real babies, although it is difficult to tell. Many people become visibly calmer when they are holding the dolls; but some relatives and staff find the dolls demeaning, and wonder whether it’s possible not to infantilize a person who is cuddling a toy baby.

People with dementia often ask to go home. Some ask even if they’re still in the house they’ve lived in for years; but people in institutions can ask many times a day. Telling a person in an institution that they live here now, that this is their permanent home, is usually neither comforting nor convincing, so, to address this problem, many nursing homes and hospitals have installed fake bus stops. When a person asks to go home, an aide takes them to the bus stop, where they sit and wait for a bus that never comes. At some point, when they are tired, and have forgotten what they are doing there, they are persuaded to go back.

Some years ago, a company in Boston began marketing Simulated Presence Therapy, which involved making a prerecorded audiotape to simulate one side of a phone conversation. A relative or someone close to the patient would put together an “asset inventory” of the patient’s cherished memories, anecdotes, and subjects of special interest; a chatty script was developed from the inventory, and a tape was recorded according to the script, with pauses every now and then to allow time for replies. When the tape was ready, the patient was given headphones to listen to it and told that they were talking to the person over the phone. Because patients’ memories were short, they could listen to the same tape over and over, even daily, and find it newly comforting each time. There was a séance-like quality to these sessions: they were designed to simulate the presence of someone who was merely not there, but they could, in principle, continue even after that person was dead... (continues)

Larissa MacFarquhar, New Yorker


Monday, October 1, 2018

First I Met My Children, Then My Girlfriend

A former sperm donor, searching online, finds both offspring and love.

I didn’t meet my girlfriend, Jessica, until 12 years after our daughter, Alice, was born.

Let me explain. Nearly 25 years ago, I returned from a year of teaching English abroad, moved in with my mother and, lacking prospects, began driving a cab. One day I saw a newspaper ad seeking healthy men, 18 to 35, to participate in a semen donation program.

“Donors” is the standard industry word, yet virtually all of us are paid. Forty dollars a pop was what I received in 1994.

I applied to sell my sperm and sold twice weekly for a year. At the time I was in a long-distance relationship, so this seemed like a good outlet. When I told my mother, she presciently wondered aloud if this was the only way she was going to have grandchildren.

Today, sperm buyers view detailed profiles for potential vendors, whereas I wasn’t asked to provide much beyond college major, hobbies and family health history. Jessica and her partner at the time chose me primarily because I was a writer and musician... (continues)

Monday, September 10, 2018

"I am about to kill my mother"

Sarah Lyall:


I am looking for a way to put this off as long as possible, and so I start watching one of the final episodes of the TV drama “The Americans.” Today, Keri Russell, playing a Russian agent, is spying on a State Department official by posing as a nurse for his terminally ill wife.
The agent is a stone-cold murderer, but she feels desperately sorry for the official, whose attempts to help his wife kill herself with morphine have left her in a gasping, not-dead limbo. So Keri Russell finishes the job by shoving a paintbrush down the woman’s throat and holding a plastic bag over her head.

This is not a good time to be watching this particular scene.

Right now my mother is in bed across the hall, in the endgame of Stage 4 lung cancer. She is nearly 83, she has had enough, and she is ready to die. More specifically, she is ready to have me help her die.

I can see her point.

An unsentimental, practical person, she has for many years been preparing for the moment when death would become more alluring than life. We have talked about it nonstop since she received her diagnosis about three months ago and, like Gloria Swanson going up in a blaze of grand pronouncements, declared that she intended to forgo chemotherapy... (continues)

Sunday, September 9, 2018

Vaccines and Immunity

BETWEEN HOPE AND FEAR 
A History of Vaccines and Human Immunity 
By Michael Kinch
334 pp. Pegasus Books. $27.95.

As Michael Kinch tells us in “Between Hope and Fear: A History of Vaccines and Human Immunity,” vaccinations have saved millions, possibly billions, of lives. Along with antisepsis and anesthesia, they rank as one of the greatest achievements of scientific medicine. It is therefore deeply disturbing that in recent decades a significant minority of people in the world’s wealthier countries has become opposed to them. This anti-vaccination movement has even been given the nod by Donald Trump. To be effective, a vaccine requires that at least 95 percent of a population receive it — a phenomenon known as “herd immunity.” If even a small number of parents decide not to have their child vaccinated because of an alleged (and usually spurious) risk from the vaccine, they are putting enormous numbers of children at risk of contracting the disease the vaccine protects against.

Until the 19th century, human life was dominated by infectious illness. Up to 50 percent of children died before the age of 5, almost all from infections. Long exposure over centuries to some of these pathogens yielded some resistance, but the devastating potential of infectious diseases was demonstrated when Europeans arrived in the so-called New World. In Cuba and its surrounding islands, it is estimated that one-third of the population was killed by smallpox beginning in 1518, and two-thirds of the survivors by measles in 1529.




(continues)

Natural solace

Robert Macfarlane (@RobGMacfarlane)
"In the hospice where I work, I am often struck by the intense solace some patients find in the natural world": take a few minutes to read ⁦‪@doctor_oxford‬⁩'s beautiful & moving essay the power of nature & living joyfully, right to the end of one's time.
nytimes.com/2018/09/08/opi…

Monday, August 20, 2018

Uninsured and underinsured

Atul Gawande (@Atul_Gawande)
Nearly half of all Americans in fair or poor health — 46.4% — are uninsured or have affordability problems despite having coverage. ⁦‪@DrewAltman‬⁩ axios.com/not-just-unins…

Monday, August 13, 2018

“Dopesick: Dealers, Doctors, and the Drug Company That Addicted America”

Fewer than 50 pages into Beth Macy’s “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America,” one of the many opioid users she talks to — this one a mother in Virginia — explains how her addiction started in the early 2000s, after routine gallbladder surgery. “The doctor didn’t force me to take them,” she said of OxyContin and Percocet, two powerful painkillers she was instructed to take concurrently. But her doctor, she assumed, was a “high-standard person, someone you’re supposed to trust and believe in.”

If you want a glimpse into how the opioid crisis began, the woman’s words are a good place to start. She was aware of her own choice in the matter, but her physician instructed her to double up on highly addictive narcotics. An expert, someone supposed to know better, had betrayed her trust.

Books like “Pain Killer,” by Barry Meier, a reporter for The New York Times, and “Dreamland,” by the journalist Sam Quinones, have covered the opioid crisis in detail, but they appeared before the 2016 election, when the places in the country most affected by the epidemic went for Drumpf. With “Dopesick,” her third book after “Factory Man” and “Truevine,”Macy has waded into a public health morass that has also become a political minefield. Commentators on the left have pointed out the gaping discrepancy between the sympathy extended to today’s opioid users, who are mainly white, and the brutal, racist handling of the war on crack.

“Dopesick” touches on these political developments, but its emphasis lies elsewhere. Macy’s strengths as a reporter are on full display when she talks to people, gaining the trust of chastened users, grieving families, exhausted medical workers and even a convicted heroin dealer, whose scheduled two-hour interview with the author ended up stretching to more than six hours. (continues)

How to Quantify a Nurse’s ‘Gut Feelings’

"I had a nagging sense that something was wrong, but I couldn’t articulate it."
By Theresa Brown (Ms. Brown is a hospice nurse.)

At the start of my shift, at 7 a.m., my patient, newly admitted a few days before for a blood cancer, was talking and acting normally. By the end of my shift, 12 hours later, she had grown confused and her speech was garbled. A CT scan revealed bleeding in her brain. She was sent to intensive care and died the next day.

This was years ago, but the case still haunts me. I believe that moving faster on her treatment might have prevented her sharp decline. But the medical team didn’t share my sense of urgency, and no obvious red flags signaled a coming emergency. Without a worrisome clinical value or test result to point to, my concern alone wasn’t persuasive.

Every nurse likely knows the feeling. The patient’s vital signs are just a little off, she seems not quite herself, her breathing is slightly more labored. But on paper she looks stable, so it’s hard to get a doctor to listen, much less act.

In such situations nurses invoke “gut feelings,” but they actually aren’t feelings at all — they are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment. The idea is that working at the bedside has honed nurses’ perceptions to be especially alert to brewing trouble. (continues)

Monday, August 6, 2018

Why Doctors Should Read Fiction

Last week, Sam Kean wrote about a new paper in Literature and Medicine. The paper, he explained, argues that “certain literary exercises can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.”


As a physician who teaches both ethics and creative writing to medical students and house officers, I appreciate the value of using fiction and narrative to enhance the training of future physicians. These tools are certainly helpful in cultivating humanistic and compassionate doctors. However, medical school is rather late in the game to introduce these techniques. Ideally, admissions committees at medical schools should be looking for students who are imaginative and who are already reading literature, including literature about illness and physician-patient relationships. One might argue for altering medical school admissions requirements accordingly—for instance, replacing required courses in Newtonian physics with those that foster creativity and emotional understanding. As a physician, I am often asked to listen to my patients’ stories with empathy; in contrast, not once have I ever had to calculate the trajectory of a patient to be shot out of a cannon.




Jacob M. Appel, M.D., J.D., M.P.H.
Assistant Professor of Psychiatry and Medical Education
Director of Ethics Education in Psychiatry
Mount Sinai School of Medicine 

New York, N.Y.
==


The Atlantic (@TheAtlantic)
Letter: Literature should be a medical school admissions requirement on.theatln.tc/ooFciqp
The annals of literature are packed with writers who also practiced medicine: Anton Chekhov, Arthur Conan Doyle, William Carlos Williams, John Keats, William Somerset Maugham, and on and on. As doctors, they saw patients at their most vulnerable, and their medical training gave them a keen eye for observing people and what makes them tick.
But if studying medicine is good training for literature, could studying literature also be good training for medicine? A new paper in Literature and Medicine, “Showing That Medical Ethics Cases Can Miss the Point,” argues yes. In particular, it proposes that certain literary exercises, like rewriting short stories that involve ethical dilemmas, can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.

Thursday, May 3, 2018

Installment 2 - Selwa Kanakrieh

Jehovah’s Witnesses Refusal to Accept Blood Transfusions.
The firm belief by the Jehovah's witnesses to entirely refuse to acknowledge blood transfusion; despite the seriousness of a particular situation including an emergency case, is because they are taught according to their teachings that transfusion of blood is sacred standpoint that is not up to negotiation and that if anyone has value and esteem that their life is a God-given gift they shall in no way accept blood transfusion in order to maintain their lives (Hoffman, 2016).
The Jehovah's witnesses stand with their Bible teachings which claim that blood incorporation, blood transfusions as well as blood donations and storing of their blood for transfusion at a later date, may it arise, is forbidden. This entire belief of the Jehovah’s witnesses is derived from a scripture that is different from other Christian values; thus reason as to why Jehovah's Witnesses are well known across the globe.
Jehovah’s witnesses further explain that the reason as to why they would instead not accept blood transfusions is because it is their way of showing great respect to God. This is elaborated by the fact that they are allowed to eat meat regardless of the fact that it may contain some blood. The Jehovah's witnesses, therefore, claim that the problem is not with the blood itself. Nonetheless, it is the respect and value they give to God that brought up there making this decision.  
 Organ Transplant and Judaism
At one moment opposed, Jewish practice and law on organ donation have altered dramatically, which some perceive as the beauty of Judaism as a living and evolving religion. Because organ transplantation is a very successful approach to save a life, the donation of organs has been perceived a compulsory act, a mitzvah chiyuvit, by every significant branch of Judaism. 
All the same, it is worth mentioning that some Orthodox leaders differ on the manner in which time of the death of a donor, and prefer a point later than the death of the brain. Death of the brain which results in some organs being deemed unusable but even in such an instance the kidneys, barring the disease of the kidney, remain transplantable after the demise of the donor. For that reason, not to bequeath at least a number of an individual's organs has become a sin of the mitzvah of pikuakh nefesh, i.e. saving a life.
Pikuakh nefesh which is ‘saving a life' in the English language, is a fundamental value of the Jews, and at any given time 40,000 individuals appear on the waiting list of The United network for the sharing of organs. As such, there is a question of whether to conduct a body organ while alive is a mitzvah (Messina, 2015). The answer is that as long as it beneficial and will not bring risk to an individual’s donor’s life, the removal of organs surgically and their subsequent donations such as kidneys or lungs through an alive donor is a mitzvah kiyumit, a mitzvah that should be deemed as praise-worthy but never in any way an obligatory mitzvah, because with all surgery there exists some great fear and some risk. 
In summary three verses from the Old Testament Torah (the first five books of the Bible) frame the idea of organ donation: “Thou shalt not stand by the blood of your neighbor” [Leviticus 19:16], ‘Thou shalt surely heal” [Exodus 21: 19] and “You shall restore” (an object that is lost, which is inclusive of someone’s health )[Exodus 23: 4]. The part of Judaism that refuses organ donation is against a live person donating an organ such as a kidney to another while they are both alive and is based on Leviticus 19:16. As such, there is no problem if the donor is dead.

Wednesday, May 2, 2018

Human Experimentation 2nd installment- Zach Nix


In my first installment , I posed several questions about human experimentation. However, I tried to stay fair to both sides of the argument. In installment 2 I will be stating my opinions and reasoning.
            Concerning the use of undeniably unethical research results I believe that it should be treated in a case by case manner. Much like any scientific paper the research should be reviewed for inaccuracies or bias. Simply because an individual is amoral does not mean that the results they produce are skewed, though it does warrant scrutiny. If data obtained by slaughter can save lives then it does indeed produce a “unique opportunity” that otherwise would never have occurred. As was discussed in class the use of such data can even be seen as a way to honor the dead. If the lives taken provided data that saved lives then perhaps their deaths meant more than just a war crime.
            Concerning informed consent, I agree for the most part with common practices. Although the way in which researchers attempt to convey information to subjects needs to increase to ensure that the subjects understand the study and risks more fully. Of more interest is the ethics of terminal subjects in research. If a person is desperate due to a terminal diagnosis then it is more likely they may participate in a type of test that may be more likely to end in death. Most trails on gene therapy have been targeted to genes that cause dearth early in life and many of the tests have cause the premature death of the subject. These tests understandably make one uneasy and need to be carefully monitored, but if the patient understands that they are risking a slightly longer life in return for furthering the research that may one day prevent their situation in the first place, then it is easy to see the appeal. Tests outside of the body can only tell us so much when concerning a system as complex as the human body, therefore, research such as cancer studies need willing cancer patients or the disease will never be cured. Tests such as these are the reason that any progress in medicine has been made. Small pocks or polio would never have been cured if it was not for the pioneers who risked their lives in a study or procedure that could have ended their lives.
            A more nuanced issue concerning consent is the ability of the cognitively impaired to give consent in the first place. In the case of children, it is obvious that they do not fully understand the concept of death, not to mention the difficulty explaining a procedure or test. While I generally advocate against the ability of parents to declare the desires, such as religion, of their child, children represent a huge demographic with unique traits that require their participation in tests that outweighs the issues inherent in allowing a parent to make life and death choices for a child. In the case of mentally impaired children and adults the ability to understand their own situation may not be easily determined. In these cases the specific impairment often has legal structures already in place for decision making of these individual that should be used. But if not I believe that the ethical action is to only allow for these individuals to be research subjects if, despite impairment, they are consenting when the nature of the research is explained to the best of the researchers ability and that the research requires the specific participation of the impaired demographic for proper results.

I commented on Jonathan and Joseph's 2nd installments.