Asylum seeker’s ‘brain death’ shows failure of care and of democracy

The news that Hamid Kehazaei, a 24-year-old Iranian asylum seeker detained on Manus Island, has been diagnosed as brain dead following his transfer to the Mater Hospital in Brisbane is a tragedy. That it is a tragedy for this young man and his family is unquestionable – but the extent of this tragedy may be much more pervasive than we realise. If the emerging details of his case are correct, Kehazaei developed septicaemia as a complication of cellulitis (skin and soft-tissue infection) arising from a cut in his foot. This, in itself, is disturbing. Severe infection can result in brain death – either from infection of the brain itself (meningitis, encephalitis or brain abscess), or from brain injury due to a lack of oxygen resulting from cardiac arrest (as appears to be the case here), or from reduced blood supply to the brain. Yet it is very uncommon, especially in a young, previously healthy man. Such a case could occur in Australia and has been described in 2012 in young Indigenous adults in Central Australia. Nevertheless, severe sepsis resulting from a foot infection is preventable. And a case like this occurring in an Australian national would raise serious questions about the appropriateness of the antibiotics used and the timeliness of care. Most cases of brain death result from traumatic brain injury, stroke or lack of oxygen to the brain following asphyxia, near-drowning, or prolonged cardiopulmonary resuscitation. What happened to Hamid Kehazaei raises concerns about the adequacy of care provided to him during initial treatment, including wound care and antibiotics, and how soon he was transferred to expert medical care, first to Port Moresby and subsequently to Brisbane. If this young man became ill and had his brain die while seeking asylum in Australia and while in our care, then we must examine the details of his case and ask ourselves not only whether it was preventable but whether our policies and processes actually contributed to his death

The Validity and Timing of the ABR Core Exam

The American Board of Radiology's (ABR) new Core Exam is not working, at least not as well as it needs to. Having helped to prepare candidates (RG), studied for and taken the exam (WK), and talked with hundreds of candidates who have taken the exam (RG and WK), we believe that that one aspect of the exam, its validity, can be significantly enhanced. Just as we expect candidates for board certification and practicing radiologists to measure up to the high standards, so we should subject the board exam to continuous scrutiny, seeking opportunities to rectify errors and enhance the exam's overall quality, with a view to better promoting excellence in radiology practice and the care of patients. Here we focus on two exam parameters: validity and timing

Destigmatizing the placebo effect

Alfano’s reframing of the operationalization of the placebo effect (PE) in the context of informed consent (IC) has broader implications for clinical practice, particularly with regard to the employment of the concept of authorized libertarian paternalism (Alfano 2015). Stigmatization of people refers to the development of a value judgment declaring that a person with certain attributes is in some way of lesser status, diminished, or invalid, with resultant negative consequences for such individuals. Concepts may also be stigmatized, particularly those that are easily falsifiable, including, apropos of the subject of PEs, mesmerism, sugar pills, and sham procedures, and hence PEs have historically been regarded with great skepticism, exemplifying something dishonest, misleading, “unscientific,” or invalid (Gold and Lichtenberg 2014). While recent studies have revealed extraordinary insights into the placebo and nocebo effect (PNE), in many ways these insights have had only limited impact upon the practice of medicine or upon (negative) views of the PNE. There may be many reasons why this is so. It may be because of the inherent conservatism of medicine, the need for medicine to distinguish itself from nonconventional practices through its (scientific) method and its capacity to provide an account of mechanism, or the intransigence of firmly held views in any field of practice. Indeed, investigators have “long recognized that individuals tend to maintain rather than change their stereotypes, despite receiving evidence that counters them” (Lyons and Kashima 2003, 989). Enculturation in medicine, in particular, systematically reinforces that certain concepts and actions are “foreign” to valid practice through a process of stereotype maintenance. Conscious, deliberate, or incidental/unwitting utilization of the placebo effect is characterized as deceptive, unethical, unscientific, and unprofessional and hence an action that separates physicians from nonphysicians. However, as distinct from a modern correlate of mesmerism or purely charismatic practice, there is an extensive, well-validated evidence base demonstrating specific psychological and biological processes underpinning PNEs (Hall, Loscalzo, and Kaptchuk 2015). This emergent evidence base is not simply of passing interest but poses significant challenges to traditionally held beliefs about both the role of PNEs in medical practice and about medical practice more generally

Double meanings will not save the principle of double effect

In an article somewhat ironically entitled “Disambiguating Clinical Intentions,” Lynn Jansen promotes an idea that should be bewildering to anyone familiar with the literature on the intention/foresight distinction. According to Jansen, “intention” has two commonsense meanings, one of which is equivalent to “foresight.” Consequently, questions about intention are “infected” with ambiguity—people cannot tell what they mean and do not know how to answer them. This hypothesis is unsupported by evidence, but Jansen states it as if it were accepted fact. In this reply, we make explicit the multiple misrepresentations she has employed to make her hypothesis seem plausible. We also point out the ways in which it defies common sense. In particular, Jansen applies her thesis only to recent empirical research on the intentions of doctors, totally ignoring the widespread confusion that her assertion would imply in everyday life, in law, and indeed in religious and philosophical writings concerning the intention/foresight distinction and the Principle of Double Effect. Key words: double effect, end-of-life, foresight, intention, sedatio

Echinocandin inhibition of 1,3-β-D-glucan synthase from Candida albicans

AbstractThe cyclic peptide antibiotic echinocandin was found to inhibit 1,3-β-D-glucan synthase activity present in a mixed membrane fraction from Candida albicans. Addition of antibiotic reduced the Vmax of the enzyme, but the Km was unaffected. GTP stimulated enzyme activity ~ 4-fold, but did not affect the percentage inhibition of the enzyme by echinocandin. Treatment of the reaction products with α-amylase and β-glucanase confirmed that the polymer synthesised was 1,3-β-D-glucan, not glycogen

The management of children with Spinal Muscular Atrophy Type 1 in Australia

Aims: To (1) estimate the prevalence of Spinal Muscular Atrophy Type 1 (SMA 1); (2) describe what practices characterise end-of-life care of patients with SMA 1; (3) ascertain whether a consistent approach to the management of these patients exists in Australia. Methods: An audit of the Australasian pathology laboratories offering the diagnostic SMN1 deletion test was conducted for patients diagnosed with SMA in Australia for 2010 and 2011. In addition, a retrospective clinical audit was conducted in eight major Australian paediatric hospitals of the end-of-life care provided to children with confirmed SMA 1 from 2005 to 2010. Results: 35 children were included in the clinical audit, accounting for an estimated 61% of children diagnosed with SMA 1 from 2005-2010. 26% were ventilated invasively, only two of whom were intubated after the diagnosis was confirmed. No children were ventilated long-term (>90 days) or had a tracheostomy performed. Nasogastric tube feeding was a common measure to support adequate nutritional intake. Total parenteral nutrition, gastrostomy and fundoplication were not provided for any children. Conflict over end-of-life care decisions was documented in one instance, without the involvement of a guardianship tribunal. Conclusion: There appears to be a consistent approach in the management of children with SMA 1 in Australia, which can be characterised as ‘actively managed dying.’ This study could contribute to the development of Australian consensus guidelines for the management of these children. These results also highlight a number of ethical issues related to the management of children with SMA 1

Rethinking pediatric ethics consultations

Johnson and colleagues (2015) report a retrospective review of the experience of an ethics consultation service at a single, highly specialized children's hospital over an 11-year period. Despite its methodologic limitations, the results of this study are worthy of note. The St. Jude Children's Research Hospital ethics consultation service consulted on a range of complex cases, including the management of conflict between parents and physicians, futility, parental demands, treatment nonadherence, and, less commonly, end-of-life issues. The number of case consultations was small, fewer than five per year, and did not increase over time. The retrospective nature of the study prevented eliciting how often consultations altered treatment or other decisions. No record was kept of clinical staff, parent, or patient perception of the value of the ethics consultation, nor of the frequency or value of informal (curb side) ethics consultations. The St. Jude ethics consultation process is consistent with “standard” models in the field. An ethics team comprising two to five staff members, including an ethicist, performs the initial ward consultation, which is then discussed with the formal clinical ethics committee of 21 people. Other involved services participate via interdisciplinary meetings. The types of consultation are consistent with many other services, including both formal and informal consultations using a range of methods to assist resolution of cases, including mediation and arbitration. Despite open access to requesting consultations, including anonymous enquiries, almost all requests came from physicians, often the same ones. Only a few came from nurses and none from parents or patients. Importantly, nurses appeared to be subject to repercussions from physicians if they requested consultations, an important issue that requires further attention but goes beyond the scope of our commentary. We suggest that the experience of the St. Jude service illustrates both the limitations of ethics consultation and the need to evaluate the importance and impact of an ethics service using metrics other than simply the number of case consultations

In reply to: Questioning the ethics of ethicists

Hamor questions ‘the ethics of the ethicists’ without addressing the substantive points made in our paper.1 While our empirical findings were that physicians and members of the public consider that some gifts are appropriate, we go further and explore the implications of those findings.2 Just as a public survey finding support for capital punishment would not be sufficient to convince us that it was right, we argue that pharmaceutical industry largesse should not be accepted simply because it enjoys popular or professional support. Data are important, but are not the only consideration. Values, including the independence of clinical decision making and the primacy of patient welfare, should also be considered. These are accepted ethical commitments within the profession. For these reasons, we question pharmaceutical marketing and the use of ‘gifts’ to influence doctors' prescribing. There is concern in the literature about the potential for this strategy to bias doctors' judgments. The giving of ‘gifts’ to doctors has the intended outcome that doctors prescribe from loyalty to the ‘gift’ giver rather than prescribing on the basis of evidence of drug efficacy and safety. Even a small gift like ‘post-it’ notes can have this effect. Hamor, however, appears to argue that acceptance of gifts from industry is not morally problematic without addressing the primary concern that this may undermine the independence of clinical decision making and potentially put patients at risk