Social Determinants of Health and Slippery Slopes in Assisted Dying Debates: Lessons From Canada

The question of whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying has recently come to the fore in debates about the legalization of assisted dying. For example, it was central to critiques of the 2021 amendments made to Canada’s assisted dying law. The question of whether changes to a country’s assisted dying legislation lead to descents down slippery slopes has also come to the fore—as it does any time a jurisdiction changes its laws. We explore these two questions through the lens of Canada’s experience both to inform Canada’s ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law. Canada’s Medical Assistance in Dying (MAiD) law has evolved through a journey from the courts to Parliament, back to the courts, and then back to Parliament. Along this journey the eligibility criteria, the procedural safeguards, and the monitoring regime have changed. In this article, we focus on the eligibility criteria. First, we explain the evolution of the law and what the eligibility criteria were at the various stops along the way. We then explore the ethical justifications for Canada’s new criteria by looking at two elements of the often-corrosive debate. First, we ask whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying of decisionally capable people with mental illnesses and people with disabilities as their sole underlying medical conditions. Second, we ask whether Canada’s journey supports slippery slope arguments against permitting assisted dying

Bioethics met its COVID‐19 Waterloo: The doctor knows best again

The late Robert Veatch, one of the United States’ founders of bioethics, never tired of reminding us that the paradigm-shifting contribution that bioethics made to patient care was to liberate patients out of the hands of doctors, who were traditionally seen to know best, even when they decidedly did not know best. It seems to us that with the advent of COVID-19, health policy has come full-circle on this. COVID-19 gave rise to a large number of purportedly “ethical” guidance documents aiming to assist health care providers and practitioners with responding to the ethical challenges that might arise in their response to the pandemic. Ethics has two primary functions: provide clear action guidance, and provide clear action justification. The documents in question arguably reflect the ultimate policy triumph of bioethical “principlism”, and, perhaps surprisingly, as a corollary, the ultimate triumph of “doctor-knows-best”

How special is medical conscience?

The vigorous legal and ethical debates over conscientious objection have taken place largely within the domain of health care. Is this because conscience in medicine is of a special kind, or are there other reasons why it tends to dominate these debates? Beginning with an analysis of the analogy between medical conscience and conscientious objection in wartime, I go on to examine various possible grounds for distinguishing between medicine and other professional contexts (taking law and accountancy as examples). The conclusion is that no principled difference exists between the military and medical cases, nor between the health professions and other professions. Nevertheless, there are practical reasons why medical conscience has distinctive importance, mainly concerning the rapid advance of medical technology. Medical conscience will, for these reasons, continue to drive the debate over conscientious objection, even though legal protection should in principle extend to all professions

Clinical and histologic comparison of two different composite grafts for sinus augmentation: a pilot clinical trial

Background and objectives : Sinus augmentation is a procedure used for augmenting insufficient bone height that is often observed in the maxillary posterior areas. Many different techniques as well as bone graft regimens have been suggested for performing this procedure. It was the goal of this study to compare, clinically and histologically, two different composite grafting regimens used for sinus augmentation. Material and methods : Five patients, needing a bilateral sinus augmentation to allow implant placement, were recruited for this study. Right sinuses were grafted with cortical bone (collected from overlying the sinus membrane) and bovine hydroxyapatite (HA), while the left side sinuses were grafted with overlying autologous bone plus a bioglass (BG) material. Bone core biopsies were taken at 6 months after sinus graft or at the time of implant insertion. A waiting period of 6 additional months was granted to allow healing, before prosthetic restoration and functional loading. The level of peri-implant bone was evaluated 12 months after loading. A comparative histomorphometric analysis was conducted and a statistical analysis was performed. Results : All implants in both groups were functional after a 12-month loading period. No bone loss was observed radiographically or clinically in both groups. Histologic analysis revealed that both composite grafts had a high biocompatibility. In the bovine HA-containing group, minimal xenogenic graft absorption was noted. In contrast, BG group samples presented a high absorption rate with some remaining particles imbedded in new normal bone. Conclusions : Sinus augmentation using a combination of autogenous bone plus either bovine HA or BG is a predictable technique. To cite this article: Galindo-Moreno P, Ávila G, FernÁndez-Barbero JE, Mesa F, O'Valle-Ravassa F, Wang H-L. Clinical and histologic comparison of two different composite grafts for sinus augmentation: a pilot clinical trial. Clin. Oral Impl. Res . 19 , 2008; 755–759 doi: 10.1111/j.1600-0501.2008.01536.xPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73800/1/j.1600-0501.2008.01536.x.pd

An argument for physician-assisted suicide and against euthanasia

The article opens with the hypothesis that the default position that should guide healthcare providers when treating patients at the end-of-life is that patients opt for life. In the absence of an explicit request to die, we may assume that patients wish to continue living. Thus, the role of the medical profession is to provide patients with the best possible conditions for continued living. The article makes a case for physician-assisted suicide legislation. It examines the 'quality-of-life' argument, and the issue of the patient's autonomy and competence. It is argued that (1) quality-of-life is a subjective concept. Only the patient can conclude for herself that her quality-of-life is so low to warrant ending it, and that (2) only competent patients may request ending their lives. Patients' lives should not be actively terminated by the medical team without the explicit consent of patients. The article then probes the role of physicians at the end-of-life, arguing that medicine should strive to cater to the wishes of all patients, not only the majority of them. Physicians should not turn their backs to justified requests by their patients. Physicians are best equipped to come to the help of patients at all stages of their illness, including their end-of-life. At the same time, in ending life, the final control mechanism should be with the patient. Thus, physician-assisted suicide is preferred to euthanasia in order to lower the possibility of abuse and of ending the lives of patients without their consent and against their wishes. As matters of life and death are grave, they should be taken with utmost seriousness, requiring the instalment of ample checks against abuse and facilitating mechanisms designed to serve the patient's best interests. The article concludes with 19 careful and detailed guidelines for physician-assisted suicide. These are necessary measures designed to ensure that the best interests of the patients are served as they wished.RésuméL’article commence par l’hypothèse que la position par défaut qui doit guider les fournisseurs de soins de santé lors du traitement de patients à la fin de la vie est que les patients optent pour la vie. En l’absence d’une demande explicite de mourir, nous pouvons supposer que les patients souhaitent continuer à vivre. Ainsi, le rôle de la profession médicale est de fournir aux patients les meilleures conditions possibles pour poursuivre la vie. L’article fait un cas pour la législation du suicide assisté par un médecin. Il examine l’argument « qualité de vie », et la question de l’autonomie et de la compétence du patient. On fait valoir que (1) la qualité de vie est un concept subjectif. Seul le patient peut conclure pour lui-même que sa qualité de vie est si faible pour justifier y mettre fin, et (2) que les seul le patient compétent peut demander de mettre fin à sa vie. Il ne devrait pas être mis fin activement à la vie des patients par l’équipe médicale sans le consentement explicite des patients. L’article explore ensuite le rôle des médecins à la fin de la vie, en faisant valoir que la médecine doit s’efforcer de répondre à toutes les attentes des patients, pas seulement à la majorité d’entre elles. Les médecins ne devraient pas tourner le dos aux demandes motivées de leurs patients. Les médecins sont les mieux équipés pour venir en aide à leurs patients à tous les stades de leur maladie, y compris en fin de vie. Dans le même temps, en fin de vie, le mécanisme de réglage final doit se faire avec le patient. Ainsi le suicide médicalement assisté est préférable à l’euthanasie pour réduire les abus comme mettre fin à la vie des patients sans leur consentement ou contre leur volonté. Comme les questions de la vie et de la mort sont graves, elles doivent être prises avec le plus grand sérieux. L’article conclut sur 19 directives précises et détaillées concernant le suicide médicalement assisté. Ces mesures nécessaires visent à assurer le meilleur intérêt des patients

Histomorphometric comparison of maxillary pristine bone and composite bone graft biopsies obtained after sinus augmentation

Sinus grafting is a technique oriented to facilitate implant placement in posterior atrophic maxillae. Several modifications of the original technique and a wide variety of materials have been proposed; most of them associated with implant survival rates. However, the quality of the bone obtained after the application of certain grafting materials has not been fully elucidated yet. The aims of this multicenter study were to analyse histomorphometrical samples obtained 6 months after sinus grafting using a composite graft consisting of anorganic bovine bone (ABB)+ autologous bone (AB), and to compare these samples with maxillary pristine bone biopsies.Ninety maxillary sinus augmentations were performed for delayed implant placement ( N =90) in 45 consecutive patients (test group). Bone cores were harvested 6 months after grafting for histomorphometric and ultrastructural study. Control pristine bone biopsies were taken from the posterior maxilla of 10 patients (control). Bone radiographic changes were assessed up to 24 months after implant loading.The total mean values after analysis of test cores revealed a proportion of 46.08±16.6% of vital bone, 42.27±15.1% of non-mineralized connective tissue, and 37.02±25.1% of the remaining ABB particles. Significant bone remodeling activities were noticed in sinus grafting samples when compared with pristine bone. A statistically significant difference was observed in the number of osteoid lines between two groups, with higher values in the test one (15.1±11.48% vs. 2.5±2.2%, P =0.0005). Ultrastructural study showed that vital trabecular bone was in intimal contact with ABB particles. Radiographic analysis revealed that the higher the proportion of remaining ABB, the lower the total vertical resorption of the graft.Sinus grafting constitutes an excellent model for the study of de novo bone formation patterns and graft consolidation, when a combination of different bone substitutes is applied. The combination of ABB+AB yields highly satisfactory outcomes from both a clinical and a histologic perspective. To cite this article: Galindo-Moreno P, Moreno-Riestra I, Ávila G, Fernández-Barbero JE, Mesa F, Aguilar M, Wang H-L, O'Valle F. Histomorphometric comparison of maxillary pristine bone and composite bone graft biopsies obtained after sinus augmentation. Clin. Oral Impl. Res . 21 , 2009; 122–128.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78644/1/j.1600-0501.2009.01814.x.pd

The challenges and opportunities of conducting a clinical trial in a low resource setting: The case of the Cameroon mobile phone SMS (CAMPS) trial, an investigator initiated trial

Conducting clinical trials in developing countries often presents significant ethical, organisational, cultural and infrastructural challenges to researchers, pharmaceutical companies, sponsors and regulatory bodies. Globally, these regions are under-represented in research, yet this population stands to gain more from research in these settings as the burdens on health are greater than those in developed resourceful countries. However, developing countries also offer an attractive setting for clinical trials because they often have larger treatment naive populations with higher incidence rates of disease and more advanced stages. These factors can present a reduction in costs and time required to recruit patients. So, balance needs to be found where research can be encouraged and supported in order to bring maximum public health benefits to these communities. The difficulties with such trials arise from problems with obtaining valid informed consent, ethical compensation mechanisms for extremely poor populations, poor health infrastructure and considerable socio-economic and cultural divides. Ethical concerns with trials in developing countries have received attention, even though many other non-ethical issues may arise. Local investigator initiated trials also face a variety of difficulties that have not been adequately reported in literature. This paper uses the example of the Cameroon Mobile Phone SMS trial to describe in detail, the specific difficulties encountered in an investigator-initiated trial in a developing country. It highlights administrative, ethical, financial and staff related issues, proposes solutions and gives a list of additional documentation to ease the organisational process

Effect of anorganic bovine bone to autogenous cortical bone ratio upon bone remodeling patterns following maxillary sinus augmentation

Introduction: Maxillary sinus augmentation is a predictable implant site development technique, although several local and systemic factors may influence outcomes. The aim of this study was to evaluate healing patterns and bone remodeling activity following the use of two different graft mixtures for maxillary sinus augmentation. Materials and methods: Patients in need of maxillary sinus augmentation were randomly assigned to two different groups. A graft mixture using a 50% autologous bone (AB) to 50% anorganic bovine bone (ABB) ratio was used in group 1, while a 20% AB to 80% ABB ratio was utilized for group 2. After a 6‐month healing period, bone core biopsies were harvested for histological, histomorphometrical, and immunohistochemical analyses. Results: Twenty‐eight subjects participated in this study. No statistically significant differences were found between groups in regards to vital bone and non‐mineralized tissue proportions. Higher number of osteoid lines (18.05 ± 10.06 in group 1 vs. 9.01 ± 7.53 in group 2; P =0.023) and higher cellularity, particularly regarding the number of osteocytes (631.85 ± 607.98 in group 1 vs. 219.08 ± 103.26 in group 2; P =0.002), were observed in specimens from group 1. Differences in expression patterns of osteopontin and tartrate‐resistant acid phosphatase were also detected between groups. Conclusion: AB to ABB ratio appears to influence bone remodeling patterns and cell content following maxillary sinus augmentation procedures. Similar proportion of vital bone was found in specimens obtained from both groups. More cellular presence was observed in samples containing higher proportions of AB. To cite this article: Galindo‐Moreno P, Moreno‐Riestra I, Avila G, Padial‐Molina M, Paya JA, Wang H‐L, O'Valle F. Effect of anorganic bovine bone to autogenous cortical bone ratio upon bone remodeling patterns following maxillary sinus augmentation. Clin. Oral Impl. Res . 22 , 2011; 857–864. doi: 10.1111/j.1600‐0501.2010.02073.xPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/86802/1/j.1600-0501.2010.02073.x.pd