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1.  Deprivations, futures and the wrongness of killing 
Journal of Medical Ethics  2001;27(6):363-369.
In my essay, Why abortion is immoral, I criticised discussions of the morality of abortion in which the crucial issue is whether fetuses are human beings or whether fetuses are persons. Both argument strategies are inadequate because they rely on indefensible assumptions. Why should being a human being or being a person make a moral difference? I argued that the correct account of the morality of abortion should be based upon a defensible account of why killing children and adults is wrong. I claimed that what makes killing us wrong is that our premature deaths deprive us of our futures of value, that is, the goods of life we would have experienced had we survived. This account of the wrongness of killing explains why killing is one of the worst of crimes and how killing greatly harms the victim. It coheres with the attitudes of those with cancer or HIV facing premature death. It explains why we believe it is wrong to kill infants (as personhood theories do not). It does not entail that it wrongs a human being to end her life if she is in persistent vegetative state or if her future must consist only of unbearable physical suffering and she wants to die (as sanctity of human life theories do not). This account of the wrongness of killing implies (with some defensible additional assumptions) that abortion is immoral because we were fetuses once and we know those fetuses had futures of value.
Mark Brown claims that this potential future of value account is unsound because it implies that we have welfare rights to what we need to stay alive that most people would reject. I argue that Brown is incorrect in two ways: a welfare right to what we need to stay alive is not directly implied by my account and, in addition, most of us do believe that dependent human beings have substantial welfare rights to what they need to stay alive. Brown argues that depriving us of a future of value of which we have mental representations both is a better explanation of the wrongness of killing and does not imply that abortion is immoral. I reply that (a) if Brown's arguments against my view were sound, those arguments could be easily adapted to show that his view is unsound as well and (b) Brown's view is both ambiguous and unsound on any interpretation.
The most popular class of pro-choice argument strategies appeals to the view that some or all fetuses lack either a mental state or function or a capacity for a mental state or function necessary for possession of the right to life. Desires, interests, sentience, various concepts, moral agency, and rationality have all been suggested as candidates for this crucial mental role. Brown's analysis is one member of this class of strategies. I believe that it is possible to show that none of these strategies is reasonable. However, there are so many of these strategies that the required argument demands something more like a book and less like a short essay. The argument of the following essay is a piece of this larger argument.
Key Words: Abortion • future of value • Mark Brown • Don Marquis • the right to life • welfare rights
PMCID: PMC1733477  PMID: 11731597
Surgical confusions have been rarely studied, especially in ophthalmology. The author hypothesized that such confusions occur rarely but are unacceptable in the public, legal, and regulatory arenas; often occur in circumstances presenting predictable risk; more often involve wrong lens implant than wrong eye, procedure, or patient; and can be prevented by following the Universal Protocol.
A retrospective series of 106 cases occurring between 1982 and 2005 included 42 closed files from the Ophthalmic Mutual Insurance Company and 64 cases reported to the New York State Health Department. Records were grouped by procedure planned and analyzed to answer these questions: How did the error occur? By whom and when was the error recognized? Who was responsible? Was the patient informed? What was done to the patient? What was the outcome? What liability payments were made? What policy changes or sanctions resulted? Was the error preventable by following the Universal Protocol?
The most common confusion was wrong lens implant, accounting for 67 (63%) of the 106 cases. Wrong eye surgery occurred in 15 cases, wrong eye blocks in 14, wrong patient/procedure in 8, and wrong corneal transplant in 2. In 16 cases, the Universal Protocol would have been unlikely to prevent the confusion.
Surgical confusions occur infrequently and usually cause little or no permanent injury, but they may be devastating to the patient, the physician, and the profession. Measures to prevent such confusions, including the Universal Protocol and related checklists, deserve the acceptance, support, and active participation of ophthalmologists.
PMCID: PMC2258113  PMID: 18427628
3.  Towards evidence based medicine for paediatricians 
In order to give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence‐based” answers to common questions which are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format which has been successfully developed by Kevin Macaway‐Jones and the group at the Emergency Medicine Journal—“BestBets”.
A word of warning. The topic summaries are not systematic reviews, though they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor search the grey, unpublished literature. What Archimedes offers are practical, best evidence‐based answers to practical, clinical questions.
The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching2 and gaining answers.3) A brief report of the search used follows—this has been performed in a hierarchical way, to search for the best‐quality evidence to answer the question. ( A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as number needed to treat), books by Sackett et al4 and Moyer et al5 may help. To pull the information together, a commentary is provided. But to make it all much more accessible, a box provides the clinical bottom lines.
Electronic‐only topics that have been published on the BestBets site ( and may be of interest to paediatricians include:
When is a second course of indomethacin effective for PDA in neonates?
Does delayed cord clamping prevent sepsis?
Readers wishing to submit their own questions—with best evidence answers—are encouraged to review those already proposed at If your question still hasn't been answered, feel free to submit your summary according to the Instructions for Authors at Three topics are covered in this issue of the journal:
In children aged <3 years does procalcitonin help exclude serious bacterial infection in fever without focus?
Does avoidance of breast feeding reduce mother‐to‐infant transmission of hepatitis C virus infection?
Should children under treatment for juvenile idiopathic arthritis receive flu vaccination?
CAN gambling with other people's children
When we use tests to “rule out” a condition, we generally accept that we are left with a small risk of being wrong. (I think we have all discharged a child with an “upper respiratory tract infection” on a Friday to be greeted with them on antibiotics for pneumonia the following Monday.) How much faith we place in a test result is a product of two things: our initial assumption about the likelihood of the diagnosis (pretest probability) and our opinion as to how effective the test is (accuracy), but our actions do not just reflect these factors.
For instance, a well, afebrile child with a scattering of petechiae over its wrist 8 hours before, is unlikely to have meningococcal disease. If you perform a couple of tests, you can find that it has a low C‐reactive protein and a normal full blood count. What we do with this varies widely; some people would treat this with 48 h of antibiotics, others would discharge the patient home.
It is interesting to reflect on two things: first, what chance of meningococcal disease would you put on this clinical picture (before the test), and what about with the test results? What about your colleagues? You may be surprised by how widely this varies. Second, even those who have the same estimates of risk of disease may have different preferred actions (depending on their attitude to risk).
In looking at the diagnostic test for the ruling out of a disease, we can make our arguments more useful by having some data on the assumptions we make, and then transparently discussing our attitudes to risk. It is only after doing this that we can really decide if a test is good enough for us, regardless of how accurate it might be.
1Moyer VA, Ellior EJ. Preface. In: Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health, Issue 1. London: BMJ Books, 2000.
2Richardson WS, Wilson MC, Nishikawa J, et al. The well‐built clinical question: a key to evidence‐based decisions. ACP J Club 1995;123:A12–13.
3Bergus GR, Randall CS, Sinift SD, et al. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med 2000;9:541–7.
4Sackett DL, Starus S, Richardson WS, et al. Evidence‐based medicine. How to practice and teach EBM. San Diego: Harcourt‐Brace, 2000.
5Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health. Issue 1. London: BMJ Books, 2000.
PMCID: PMC2083694  PMID: 17376947
4.  Physicians’ Beliefs About Conscience in Medicine: A National Survey 
To explore physicians’ beliefs about whether physicians sometimes have a professional obligation to provide medical services even if doing so goes against their conscience, and to examine associations between physicians’ opinions and their religious and ethical commitments.
A survey was mailed in 2007 to a stratified random sample of 1,000 U.S. primary care physicians, selected from the American Medical Association Physician Masterfile. Participants were classified into three groups according to agreement or disagreement with two statements: “A physician should never do what he or she believes is morally wrong, no matter what experts say,” and “Sometimes physicians have a professional ethical obligation to provide medical services even if they personally believe it would be morally wrong to do so.”
The response rate was 51% (446/879 delivered questionnaires). Forty-two percent and 22% believed they are never and sometimes, respectively, obligated to do what they personally believe is wrong, and 36% agreed with both statements. Physicians who are more religious are more likely to believe that physicians are never obligated to do what they believe is wrong (58% and 31% of those with high and low intrinsic religiosity, respectively; multivariate odds ratio, 2.9; 95% CI, 1.2–7.2). Those with moral objections to any of three controversial practices were more likely to hold that physicians should never do what they believe is wrong.
A substantial minority of physicians do not believe there is ever a professional obligation to do something they personally believe is wrong.
PMCID: PMC2859045  PMID: 19707071
5.  Cause of Androgenic Alopecia: Crux of the Matter 
What is wrong with the current understanding of etiopatho genesis of androgenic alopecia (AGA)? What is the most important question to ask to understand AGA? Why is that question skimped? Which findings are interpreted incorrectly? Is there anything that has not been discerned about AGA until today? What are the deceptive factors for investigators? Is it possible to snap the whole view uninterruptedly in one clear picture? Answers and an overview with fresh perspectives are provided.
PMCID: PMC4174066  PMID: 25289259
6.  Respectful encounters and return to work: empirical study of long-term sick-listed patients' experiences of Swedish healthcare 
BMJ Open  2011;1(2):e000246.
To study long-term sick-listed patients' self-estimated ability to return to work after experiences of healthcare encounters that made them feel either respected or wronged.
A cross-sectional and questionnaire-based survey was used to study a sample of long-term sick-listed patients (n=5802 respondents). The survey included questions about positive and negative encounters as well as reactions to these encounters, such as ‘feeling respected’ and ‘feeling wronged’. The questionnaire also included questions about the effects of these encounters on the patients' ability to return to work.
Among patients who had experienced positive encounters, those who also felt respected (n=3327) demonstrated significantly improved self-estimated ability to return to work compared to those who did not feel respected (n=79) (62% (95% CI 60% to 64%) vs 34% (95% CI 28% to 40%)). Among patients with experiences of negative encounters, those who in addition felt wronged (n=993) claimed to be significantly more impeded from returning to work compared to those who did not feel wronged (n=410) (50% (95% CI 47% to 53%) vs 31% (95% CI 27% to 35%)).
The study indicates that positive encounters in healthcare combined with feeling respected significantly facilitate sickness absentees' self-estimated ability to return to work, while negative encounters combined with feeling wronged significantly impair it.
Article summary
Article focus
To what extent can positive and perceived respectful healthcare encounters influence long-term sick-listed patients' ability to return to work?
To what extent can negative and perceived unfair healthcare encounters influence long-term sick-listed patients' ability to return to work?
Key messages
Long-term sick-listed patients' self-estimated ability to return to work is significantly facilitated if healthcare encounters are perceived as respectful.
Long-term sick-listed patients' self-estimated ability to return to work is significantly impeded if healthcare encounters are perceived as unfair.
The net effect of feeling respected was highest among patients with somatic disorders, while the net effect of feeling wronged was highest among patients with psychiatric disorders.
Strengths and limitation of this study
The study sample was large and we obtained quite a high response rate.
The outcome measure was the respondents' self-estimated ability to return to work, not their actual ability.
The findings are based on the views of long-term sick-listed patients and so generalisation may not be possible.
PMCID: PMC3211048  PMID: 22021890
7.  Patient Perceptions of Mistakes in Ambulatory Care 
Archives of internal medicine  2010;170(16):1480-1487.
Little information exists about current patient perceptions of medical mistakes in ambulatory care within a diverse population.
To learn about adults’ perceptions of mistakes in ambulatory care, what factors were associated with perceived mistakes, and whether or not the respondents changed physicians because of these perceived mistakes
Cross-sectional survey conducted in 2008
Seven primary care medical practices in North Carolina
One thousand six hundred ninety-seven English or Spanish speaking adults, aged 18 and older, who presented to a medical provider during the data collection period.
1) Has a doctor in a doctor’s office ever made a mistake in your care? 2) In the past 10 years, has a doctor in a doctor’s office made a wrong diagnosis or misdiagnosed you? (If yes, how much harm did this cause you?) 3) In the last 10 years, has a doctor in a doctor’s office given you the wrong medical treatment or delayed treatment? (If yes, how much harm did this cause you?) 4) Have you ever changed doctors because of either a wrong diagnosis or a wrong treatment of a medical condition?
Two hundred sixty-five participants (15.6%) responded that a doctor had ever made a mistake, 13.4% reported a wrong diagnosis, 12.4% reported a wrong treatment, and 14.1% reported having changed doctors because of a mistake. Participants perceived mistakes and harm in both diagnostic care and medical treatment. Patients with chronic low back pain, higher levels of education, and poor physical health were at increased odds of perceiving harm, whereas African-Americans were less likely to perceive mistakes.
Patients perceived mistakes in their diagnostic and treatment care in the ambulatory setting. These perceptions had a concrete impact on the patient-physician relationship, often leading patients to seek another health care provider.
PMCID: PMC3070906  PMID: 20837835
8.  Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study 
PLoS Medicine  2012;9(1):e1001164.
In a before-and-after study, Johanna Westbrook and colleagues evaluate the change in prescribing error rates after the introduction of two commercial electronic prescribing systems in two Australian hospitals.
Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries. Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use. This study evaluated the effectiveness of two commercial e-prescribing systems in reducing prescribing error rates and their propensities for introducing new types of error.
Methods and Results
We conducted a before and after study involving medication chart audit of 3,291 admissions (1,923 at baseline and 1,368 post e-prescribing system) at two Australian teaching hospitals. In Hospital A, the Cerner Millennium e-prescribing system was implemented on one ward, and three wards, which did not receive the e-prescribing system, acted as controls. In Hospital B, the iSoft MedChart system was implemented on two wards and we compared before and after error rates. Procedural (e.g., unclear and incomplete prescribing orders) and clinical (e.g., wrong dose, wrong drug) errors were identified. Prescribing error rates per admission and per 100 patient days; rates of serious errors (5-point severity scale, those ≥3 were categorised as serious) by hospital and study period; and rates and categories of postintervention “system-related” errors (where system functionality or design contributed to the error) were calculated. Use of an e-prescribing system was associated with a statistically significant reduction in error rates in all three intervention wards (respectively reductions of 66.1% [95% CI 53.9%–78.3%]; 57.5% [33.8%–81.2%]; and 60.5% [48.5%–72.4%]). The use of the system resulted in a decline in errors at Hospital A from 6.25 per admission (95% CI 5.23–7.28) to 2.12 (95% CI 1.71–2.54; p<0.0001) and at Hospital B from 3.62 (95% CI 3.30–3.93) to 1.46 (95% CI 1.20–1.73; p<0.0001). This decrease was driven by a large reduction in unclear, illegal, and incomplete orders. The Hospital A control wards experienced no significant change (respectively −12.8% [95% CI −41.1% to 15.5%]; −11.3% [−40.1% to 17.5%]; −20.1% [−52.2% to 12.4%]). There was limited change in clinical error rates, but serious errors decreased by 44% (0.25 per admission to 0.14; p = 0.0002) across the intervention wards compared to the control wards (17% reduction; 0.30–0.25; p = 0.40). Both hospitals experienced system-related errors (0.73 and 0.51 per admission), which accounted for 35% of postsystem errors in the intervention wards; each system was associated with different types of system-related errors.
Implementation of these commercial e-prescribing systems resulted in statistically significant reductions in prescribing error rates. Reductions in clinical errors were limited in the absence of substantial decision support, but a statistically significant decline in serious errors was observed. System-related errors require close attention as they are frequent, but are potentially remediable by system redesign and user training. Limitations included a lack of control wards at Hospital B and an inability to randomize wards to the intervention.
Please see later in the article for the Editors' Summary
Editors' Summary
Medication errors—for example, prescribing the wrong drug or giving a drug by the wrong route—frequently occur in health care settings and are responsible for thousands of deaths every year. Until recently, medicines were prescribed and dispensed using systems based on hand-written scripts. In hospitals, for example, physicians wrote orders for medications directly onto a medication chart, which was then used by the nursing staff to give drugs to their patients. However, drugs are now increasingly being prescribed using electronic prescribing (e-prescribing) systems. With these systems, prescribers use a computer and order medications for their patients with the help of a drug information database and menu items, free text boxes, and prewritten orders for specific conditions (so-called passive decision support). The system reviews the patient's medication and known allergy list and alerts the physician to any potential problems, including drug interactions (active decision support). Then after the physician has responded to these alerts, the order is transmitted electronically to the pharmacy and/or the nursing staff who administer the prescription.
Why Was This Study Done?
By avoiding the need for physicians to write out prescriptions and by providing active and passive decision support, e-prescribing has the potential to reduce medication errors. But, even though many countries are investing in expensive commercial e-prescribing systems, few studies have evaluated the effects of these systems on prescribing error rates. Moreover, little is known about the interactions between system design and errors despite fears that e-prescribing might introduce new errors. In this study, the researchers analyze prescribing error rates in hospital in-patients before and after the implementation of two commercial e-prescribing systems.
What Did the Researchers Do and Find?
The researchers examined medication charts for procedural errors (unclear, incomplete, or illegal orders) and for clinical errors (for example, wrong drug or dose) at two Australian hospitals before and after the introduction of commercial e-prescribing systems. At Hospital A, the Cerner Millennium e-prescribing system was introduced on one ward; three other wards acted as controls. At Hospital B, the researchers compared the error rates on two wards before and after the introduction of the iSoft MedChart e-prescribing system. The introduction of an e-prescribing system was associated with a substantial reduction in error rates in the three intervention wards; error rates on the control wards did not change significantly during the study. At Hospital A, medication errors declined from 6.25 to 2.12 per admission after the introduction of e-prescribing whereas at Hospital B, they declined from 3.62 to 1.46 per admission. This reduction in error rates was mainly driven by a reduction in procedural error rates and there was only a limited change in overall clinical error rates. Notably, however, the rate of serious errors decreased across the intervention wards from 0.25 to 0.14 per admission (a 44% reduction), whereas the serious error rate only decreased by 17% in the control wards during the study. Finally, system-related errors (for example, selection of an inappropriate drug located on a drop-down menu next to a likely drug selection) accounted for 35% of errors in the intervention wards after the implementation of e-prescribing.
What Do These Findings Mean?
These findings show that the implementation of these two e-prescribing systems markedly reduced hospital in-patient prescribing error rates, mainly by reducing the number of incomplete, illegal, or unclear medication orders. The limited decision support built into both the e-prescribing systems used here may explain the limited reduction in clinical error rates but, importantly, both e-prescribing systems reduced serious medication errors. Finally, the high rate of system-related errors recorded in this study is worrying but is potentially remediable by system redesign and user training. Because this was a “real-world” study, it was not possible to choose the intervention wards randomly. Moreover, there was no control ward at Hospital B, and the wards included in the study had very different specialties. These and other aspects of the study design may limit the generalizability of these findings, which need to be confirmed and extended in additional studies. Even so, these findings provide persuasive evidence of the current and potential ability of commercial e-prescribing systems to reduce prescribing errors in hospital in-patients provided these systems are continually monitored and refined to improve their performance.
Additional Information
Please access these Web sites via the online version of this summary at
ClinfoWiki has pages on medication errors and on electronic prescribing (note: the Clinical Informatics Wiki is a free online resource that anyone can add to or edit)
Electronic prescribing in hospitals challenges and lessons learned describes the implementation of e-prescribing in UK hospitals; more information about e-prescribing in the UK is available on the NHS Connecting for Health Website
The Clinicians Guide to e-Prescribing provides up-to-date information about e-prescribing in the USA
Information about e-prescribing in Australia is also available
Information about electronic health records in Australia
PMCID: PMC3269428  PMID: 22303286
9.  Utility of Diagnostic Ultrasound in Evaluating Fracture Healing 
With increase in population, modes of transportation and a fast pace of life, an individual’s chances of accident and thereby chances of getting fractured have increased significantly. Fracture has thus become a significant factor contributing to morbidity and mortality. To resume a normal life, after one suffers from a fracture is also an ordeal. The transition appears smooth if the fracture healing goes on in a smooth manner as is expected through its routine stages of reactive phase, reparative phase and remodeling phase. But if in this chain something goes wrong or some factors are not optimum upto the mark, then the process becomes unsuccessful and the repair is either partial or directionless. It is therefore very vital to confirm whether or not the callus which bridges the fractured fragments is healthy or not. Here in lies the role of imaging as it can show the status of callus without disturbing it. What complicates the picture is that a callus might not be well demonstratable unless it mineralizes or calcifies. An imaging modality like ultrasound therefore stands out as it can show the state of callus in its different stages. This article aims at demonstrating how ultrasound- a non invasive diagnostic imaging modality can give precise information about the progress of fracture healing and thereby aid in management of fractures, so that an individual can return back to normal productive lifestyle. This preliminary study highlights the spectrum of fracture healing as seen on ultrasound.
PMCID: PMC4003633  PMID: 24783128
Fracture; Healing; Ultrasound; Callus; Mineralization; Vascularization
10.  What should we say? 
Journal of Medical Ethics  2006;32(1):7-12.
Abstract ethics mostly focuses on what we do. One form of action is a speech act. What we say can have profound effects. We can and should choose our words and how we speak wisely. When someone close to us suffers an injury or serious illness, a duty of beneficence requires that we support that person through beneficial words or actions. Though our intentions are most often benign, by what we say we often make the unfortunate person feel worse. Beginning with two personal accounts, this article explains what can go wrong in the compassionate speech of wellwishers, and uncovers some of the reasons why people say things that are hurtful or harmful. Despite a large body of clinical evidence, there is no perfect strategy for comforting a friend or relative who is ill, and sometimes even the best thing to say can still be perceived as insensitive and hurtful. In some cases, we may have good reason to knowingly say a hurtful or insensitive thing. Saying these 'wrong' things can sometimes be the best way to help a person in the long term. To complicate matters, there can be moral reasons for overriding what is good for the patient. What kind of admonishments should we make to a badly behaved patient? What is the value of authenticity in our communication with the people we love? These questions demand an ethical defence of those speech acts which are painful to hear but which need to be said, and of those which go wrong despite the best efforts of the wellwisher. We offer an ethical account, identifying permissible and impermissible justifications for the things we say to a person with a serious injury or illness.
PMCID: PMC2563280  PMID: 16373515
compassion; equity; misfortune; moral luck
11.  Neural basis of moral verdict and moral deliberation 
Social neuroscience  2011;6(4):398-413.
How people judge something to be morally right or wrong is a fundamental question of both the sciences and the humanities. Here we aim to identify the neural processes that underlie the specific conclusion that something is morally wrong. To do this, we introduce a novel distinction between “moral deliberation,” or the weighing of moral considerations, and the formation of a “moral verdict,” or the commitment to one moral conclusion. We predict and identify hemodynamic activity in the bilateral anterior insula and basal ganglia that correlates with committing to the moral verdict “this is morally wrong” as opposed to “this is morally not wrong,” a finding that is consistent with research from economic decision-making. Using comparisons of deliberation-locked vs. verdict-locked analyses, we also demonstrate that hemodynamic activity in high-level cortical regions previously implicated in morality—including the ventromedial prefrontal cortex, posterior cingulate, and temporoparietal junction—correlates primarily with moral deliberation as opposed to moral verdicts. These findings provide new insights into what types of processes comprise the enterprise of moral judgment, and in doing so point to a framework for resolving why some clinical patients, including psychopaths, may have intact moral judgment but impaired moral behavior.
PMCID: PMC3176943  PMID: 21590588
Morality; Judgment; Anterior insula; Ventromedial prefrontal cortex
12.  Present self-represented futures of value are a reason for the wrongness of killing 
Journal of Medical Ethics  2002;28(3):196-197.
In Marquis's recent paper he has not satisfactorily shown that killing does not adversely affect the victim's present self-represented desires for their future. Marquis is correct in believing life and death are distinct, but living and dying are not. In fact, to use a well-known saying, "the second we are born we start to die". During the process of dying, whether it be long as in over our lifetime or short as in as we are being killed, there comes a point when the present realistic desires we have we know will never be satisfied. This is why killing can be wrong. This would imply killing an unconscious person, infant, or fetus cannot be wrong. But such killing can be wrong, despite the person killed not experiencing the desire not to be killed as he was dying. Killing can be wrong because others can have a present self-represented desire for that person not to be killed to have been killed. If this line of reasoning is correct, then the "best interests" principle often applied to life and death considerations regarding unconscious persons, infants, and fetuses, is invalid, as such human beings do not have present desires. All that matters is what relevant others rationally desire, after being informed of the facts and the consequences, for that unconscious person, infant or fetus.
PMCID: PMC1733587  PMID: 12042409
13.  A future like ours revisited 
Journal of Medical Ethics  2002;28(3):192-195.
It is claimed by the future like ours anti-abortion argument that since killing adult humans is wrong because it deprives them of a future of value and the fetus has a future of value, killing fetuses is wrong in the same way that killing adult human beings is wrong. In The morality of abortion and the deprivation of futures (this journal, April 2000) I argued that the persuasive power of this argument rests upon an equivocation on the term "future of value". If the expression means "a potential future of value" then the moral claim is implausible because people do not in general have rights to what they need to fulfill their potential; if the expression means "self-represented future of value" then the argument fails because the fetus does not represent its future. Under no interpretation is the argument sound. In Deprivations, futures and the wrongness of killing (this journal, December 2001) Donald Marquis, author of the future like ours argument, responds at length to this objection. In the present essay the focus of the debate shifts to the proper interpretation of the right not to be killed. Donald Marquis argues that this liberty right entails the welfare right to the means necessary to sustain life; I argue that the right not to be killed does not entail unlimited welfare rights. On Marquis's view, the right not to be killed confers upon the fetus the right to whatever it takes to sustain life; on the view I defend, the right not to be killed does not confer upon the fetus or anyone else the right to another person's body. On Marquis's view, abortion is almost never permissible; on my view abortion is almost always permissible.
PMCID: PMC1733571  PMID: 12042408
14.  Expectations and experience of people who consult in a training practice 
All the patients (348) seen in one week in a training practice in Exeter were asked to complete a pair of questionnaires, one before and one after consulting, about the content of that consultation. Seventy-one per cent responded. Ninety-two per cent of respondents expected to be told what was wrong with them, although 72 per cent had a “pretty good idea” of what was wrong beforehand. In the event, 76 per cent felt they had actually been told what was wrong. Sixty-one per cent sought advice or suggestions for self-help. Fifty-four per cent expected to receive, and 57 per cent received a prescription, including 14 per cent who had not expected one. Ninety-three per cent were satisfied with what took place.
The nine patients who were dissatisfied had expectations which differed little from those of the rest, but their experience in the consultation differed significantly, particularly in relation to discussion, comprehension and the exchange of information. It is concluded that the need for explanatory information greatly exceeded the need for medication in this sample of people.
Some special problems and differences were identified among people who consulted the trainee: in particular, their consultations were less likely to be relaxed and they expected to be, and were, followed up less often than those who saw a principal.
PMCID: PMC1972118  PMID: 7320987
15.  Image Retake Analysis in Digital Radiography Using DICOM Header Information 
A methodology to automatically detect potential retakes in digital imaging, using the Digital Imaging and Communications in Medicine (DICOM) header information, is presented. In our hospital, neither the computed radiography workstations nor the picture archiving and communication system itself are designed to support reject analysis. A system called QCOnline, initially developed to help in the management of images and patient doses in a digital radiology department, has been used to identify those images with the same patient identification number, same modality, description, projection, date, cassette orientation, and image comments. The pilot experience lead to 6.6% and 1.9% repetition rates for abdomen and chest images. A thorough analysis has shown that the real repetitions were 3.3% and 0.9% for abdomen and chest images being the main cause of the discrepancy being the wrong image identification. The presented methodology to automatically detect potential retakes in digital imaging using DICOM header information is feasible and allows to detect deficiencies in the department performance like wrong identifications, positioning errors, wrong radiographic technique, bad image processing, equipment malfunctions, artefacts, etc. In addition, retake images automatically collected can be used for continuous training of the staff.
PMCID: PMC3043704  PMID: 18592314
Diagnostic image quality; Digital Imaging and Communications in Medicine (DICOM); image analysis
16.  On the morality of deception--does method matter? A reply to David Bakhurst. 
Journal of Medical Ethics  1993;19(3):183-187.
Does it signify morally whether a deception is achieved by a lie or some other way? David Bakhurst has challenged my view that it can signify. Here I counter his criticisms--firstly, by clarifying the terminology: What counts as a lie? Secondly, by exploring further what makes lying wrong. Bakhurst maintains that lying is wrong in that it infringes autonomy--and other deceiving stratagems, he says, do so equally. I maintain that lying is wrong in that it endangers trust--and other types of deceiving stratagems do not do so equally. Lying to patients, I contend, is an abuse of their trust. Other forms of their intentional deception need not be so, although, in our autonomy-minded culture, they are likely to be so.
PMCID: PMC1376288  PMID: 8230152
17.  Gist-based conceptual processing of pictures remains intact in patients with amnestic mild cognitive impairment 
Neuropsychology  2012;26(2):202-208.
The picture superiority effect, better memory for pictures compared to words, has been found in young adults, healthy older adults, and, most recently, in patients with Alzheimer’s disease and mild cognitive impairment. Although the picture superiority effect is widely found, there is still debate over what drives this effect. One main question is whether it is enhanced perceptual or conceptual information that leads to the advantage for pictures over words. In this experiment, we examined the picture superiority effect in healthy older adults and patients with amnestic mild cognitive impairment (MCI) to better understand the role of gist-based conceptual processing.
We had participants study three exemplars of categories as either words or pictures. In the test phase, participants were again shown pictures or words and were asked to determine whether the item was in the same category as something they had studied earlier or whether it was from a new category.
We found that all participants demonstrated a robust picture superiority effect, better performance for pictures than for words.
These results suggest that the gist-based conceptual processing of pictures is preserved in patients with MCI. While in healthy older adults preserved recollection for pictures could lead to the picture superiority effect, in patients with MCI it is most likely that the picture superiority effect is a result of spared conceptually-based familiarity for pictures, perhaps combined with their intact ability to extract and use gist information.
PMCID: PMC3295863  PMID: 22229341
picture superiority effect; mild cognitive impairment; Alzheimer’s disease; familiarity; recollection
18.  Can Psychopathic Offenders Discern Moral Wrongs? A New Look at the Moral/Conventional Distinction 
Journal of Abnormal Psychology  2011;121(2):484-497.
A prominent view of psychopathic moral reasoning suggests that psychopathic individuals cannot properly distinguish between moral wrongs and other types of wrongs. The present study evaluated this view by examining the extent to which 109 incarcerated offenders with varying degrees of psychopathy could distinguish between moral and conventional transgressions relative to each other and to non-incarcerated healthy controls. Using a modified version of the classic Moral/Conventional Transgressions task (Nucci & Turiel, 1978) that employs a forced-choice format to minimize strategic responding, the present study found that total psychopathy score did not predict performance on the task. Task performance was explained by some individual sub-facets of psychopathy and by other variables unrelated to psychopathy, such as IQ. The authors conclude that, contrary to earlier claims, insufficient data exist to infer that psychopathic individuals cannot know what is morally wrong.
PMCID: PMC3397660  PMID: 21842959
moral reasoning; moral/conventional transgressions distinction; psychopathy; insanity
19.  Implementation of patient safety strategies in European hospitals 
Quality & Safety in Health Care  2009;18(Suppl_1):i57-i61.
This study is part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on cross-border care, investigating quality improvement strategies in healthcare systems across the European Union (EU).
To explore to what extent a sample of acute care European hospitals have implemented patient safety strategies and mechanisms and whether the implementation is related to the type of hospital.
Data were collected on patient safety structures and mechanisms in 389 acute care hospitals in eight EU countries using a web-based questionnaire. Subsequently, an on-site audit was carried out by independent surveyors in 89 of these hospitals to assess patient safety outputs. This paper presents univariate and bivariate statistics on the implementation and explores the associations between implementation of patient safety strategies and hospital type using the χ2 test and Fisher exact test.
Structures and plans for safety (including responsibilities regarding patient safety management) are well developed in most of the hospitals that participated in this study. The study found greater variation regarding the implementation of mechanisms or activities to promote patient safety, such as electronic drug prescription systems, guidelines for prevention of wrong patient, wrong site and wrong surgical procedure, and adverse events reporting systems. In the sample of hospitals that underwent audit, a considerable proportion do not comply with basic patient safety strategies—for example, using bracelets for adult patient identification and correct labelling of medication.
PMCID: PMC2629924  PMID: 19188463
20.  Experience of wrong-site tooth extraction among Nigerian dentists 
The Saudi Dental Journal  2011;23(3):153-156.
To report the experience of wrong-site tooth extraction among Nigerian dentists.
Study design
A self-administered questionnaire was distributed among a cross-section of Nigerian dentists. Information requested included personal experience on wrong-site tooth/teeth extraction and its after-effect, possible reasons for wrong-site tooth extraction and documentation of the event in patients’ case. Respondents were also asked if they were aware of any colleagues who had previously experienced wrong-site tooth extraction and possible legal implication of the event, and if they aware of the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery.
Twenty-two (13%) of the respondents reported having extracted a wrong tooth. The event occurred within 5 years after graduation in most cases. Most respondents (53.6%) informed the patient immediately after the event. Only 68% of the respondents documented the event in patient’s case record. Most common reasons for wrong-site tooth extraction were heavy workload, presence of multiple condemned teeth and miscommunication between dentists. Fifty-five percent of respondents were aware of a colleague who had extracted a wrong tooth. The most probable legal implication of wrong-site tooth extraction according to the respondents was litigation by the patient. Only 25% of dentists were aware of a universal protocol for preventing wrong-site surgery.
Wrong tooth/teeth extraction is not an uncommon event in the studied environment. The need to be familiar with universal protocol on wrong-site surgery and its legal implications are highlighted.
PMCID: PMC3723253  PMID: 23960510
Wrong-site; Tooth; Extraction; Dentists
21.  A Collaborative Epidemiological Investigation into the Criminal Fake Artesunate Trade in South East Asia  
PLoS Medicine  2008;5(2):e32.
Since 1998 the serious public health problem in South East Asia of counterfeit artesunate, containing no or subtherapeutic amounts of the active antimalarial ingredient, has led to deaths from untreated malaria, reduced confidence in this vital drug, large economic losses for the legitimate manufacturers, and concerns that artemisinin resistance might be engendered.
Methods and Findings
With evidence of a deteriorating situation, a group of police, criminal analysts, chemists, palynologists, and health workers collaborated to determine the source of these counterfeits under the auspices of the International Criminal Police Organization (INTERPOL) and the Western Pacific World Health Organization Regional Office. A total of 391 samples of genuine and counterfeit artesunate collected in Vietnam (75), Cambodia (48), Lao PDR (115), Myanmar (Burma) (137) and the Thai/Myanmar border (16), were available for analysis. Sixteen different fake hologram types were identified. High-performance liquid chromatography and/or mass spectrometry confirmed that all specimens thought to be counterfeit (195/391, 49.9%) on the basis of packaging contained no or small quantities of artesunate (up to 12 mg per tablet as opposed to ∼ 50 mg per genuine tablet). Chemical analysis demonstrated a wide diversity of wrong active ingredients, including banned pharmaceuticals, such as metamizole, and safrole, a carcinogen, and raw material for manufacture of methylenedioxymethamphetamine (‘ecstasy'). Evidence from chemical, mineralogical, biological, and packaging analysis suggested that at least some of the counterfeits were manufactured in southeast People's Republic of China. This evidence prompted the Chinese Government to act quickly against the criminal traders with arrests and seizures.
An international multi-disciplinary group obtained evidence that some of the counterfeit artesunate was manufactured in China, and this prompted a criminal investigation. International cross-disciplinary collaborations may be appropriate in the investigation of other serious counterfeit medicine public health problems elsewhere, but strengthening of international collaborations and forensic and drug regulatory authority capacity will be required.
Paul Newton and colleagues' international, collaborative study found evidence that counterfeit artesunate was being manufactured in China, which prompted a criminal investigation.
Editors' Summary
Malaria is one of the world's largest public health problems, causing around 500 million cases of illness and at least one million deaths per year (the estimates vary widely). The most serious form of malaria is caused by the parasite Plasmodium falciparum, which has become resistant to multiple drugs that had previously been the cornerstones of antimalarial regimens. One group of drugs for treating malaria, the artemisinin therapies including artesunate, are based upon a Chinese herb called qinghaosu; these have now become vital to the treatment of P. falciparum malaria. But counterfeit artesunate, containing none or too little (“subtherapeutic levels”) of the active ingredient, is a growing problem especially in South and East Asia. Fake artesunate is devastating for malaria control: it causes avoidable death, reduces confidence in the drug, and takes away profit from legitimate manufacturers. Of major concern also is the potential for subtherapeutic counterfeit artesunate to fuel the parasite's resistance to the artemisinin group of drugs.
Previous estimates have suggested that between 33% and 53% of artesunate tablets in mainland South East Asia are counterfeit. In this paper the authors report on an unprecedented international collaboration and criminal investigation that attempted to quantify and source counterfeit artesunate among some of the most malarious countries in Asia.
Why Was This Study Done?
Previous reports have identified the problem of fake artesunate, but as of yet there have been few reports on the potential solutions. Concerned health workers and scientists, the regional World Health Organization (WHO) office and the International Criminal Police Organization (INTERPOL) got together to discuss what could be done in May 2005 when it became clear the counterfeit artesunate situation was worsening in the Greater Mekong Sub-Region of South East Asia (comprising Cambodia, Lao People's Democratic Republic, Myanmar, Thailand, Vietnam, and Yunnan Province in the People's Republic of China). Their subsequent investigation combined the goals and methods of a range of concerned parties—police, scientists, and health workers—to identify the source of counterfeit artesunate in South East Asia and to supply the evidence to help arrest and prosecute the perpetrators.
What Did the Researchers Do and Find?
The researchers conducted forensic analyses of samples of genuine and counterfeit artesunate. They selected these samples from larger surveys and investigations that had been conducted in the region beginning in the year 2000. Genuine samples were supplied by a manufacturer to provide a comparator. The authors examined the physical appearance of the packages and subjected the tablets to a wide range of chemical and biological tests that allowed an analysis of the components contained in the tablets.
When comparing the collected packages and tablets against the genuine samples, the researchers found considerable diversity of fake artesunate in SE Asia. Sixteen different fake hologram types (the stickers contained on packages meant to identify them as genuine) were found. Chemical analysis revealed that all tablets thought to be fake contained no or very small quantities of artesunate. Other ingredients found in the artesunate counterfeit tablets included paracetamol, antibiotics, older antimalarial drugs, and a range of minerals, and there were a variety of gases surrounding the tablets inside the packaging. Biological analyses of pollen grains inside the packaging suggested that the packages originated in the parts of South East Asia along the Chinese border.
What Do these Findings Mean?
The results were crucial in helping the authorities establish the origin of the fake artesunate. For example, the authors identified two regional clusters where the counterfeit tablets appeared to be coming from, thus flagging a potential manufacturing site or distribution network. The presence of wrong active pharmaceutical ingredients (such as the older antimalarial drugs) suggested the counterfeiters had access to a variety of active pharmaceutical ingredients. The presence of safrole, a precursor to the illicit drug ecstasy, suggested the counterfeits may be coming from factories that manufacture ecstasy. And the identification of minerals indigenous to certain regions also helped identify the counterfeits' origin. The researchers concluded that at least some of the counterfeit artesunate was coming from southern China. The Secretary General of INTERPOL presented the findings to the Chinese government, which then carried out a criminal investigation and arrested individuals alleged to have produced and distributed the counterfeit artesunate.
The collaboration between police, public health workers and scientists on combating fake artesunate is unique, and provides a model for others to follow. However, the authors note that substantial capacity in forensic analysis and the infrastructure to support collaborations between these different disciplines are needed.
Additional Information.
Please access these Web sites via the online version of this summary at
The World Health Organization in 2006 created IMPACT—International Medical Products Anti-Counterfeiting Taskforce—with the aim of forging international collaboration to seek global solutions to this global challenge and in raising awareness of the dangers of counterfeit medical products. The task force membership includes international organizations, nongovernmental organizations, enforcement agencies, pharmaceutical manufacturers' associations, and drug and regulatory authorities. IMPACT's Web site notes that trade in counterfeit medicines is widespread and affects both developed and developing countries but is more prevalent in countries that have weak drug regulatory systems, poor supply of basic medicines, unregulated markets, high drug prices and/or significant price differentials. IMPACT holds international conferences and maintains a rapid alert system for counterfeit drugs.
The drug industry's anticounterfeit organization, Pharmaceutical Security Institute, works to develop improved systems to identify the extent of the counterfeiting problem and to assist in coordinating international inquiries. Its membership includes 21 large pharmaceutical companies.
The Web site of David Pizzanelli, a world expert on security holography, contains a PowerPoint presentation co-authored by Paul Newton that illustrates the different types of fake holograms found on fake artesunate packages, and their implications for artemisinin resistance (
PMCID: PMC2235893  PMID: 18271620
22.  Persons and their copies. 
Journal of Medical Ethics  1999;25(2):98-104.
Is cloning human beings morally wrong? The basis for the one serious objection to cloning is that, because of what a clone is, clones would have much worse lives than non-clones. I sketch a fragment of moral theory to make sense of the objection. I then outline several ways in which it might be claimed that, because of what a clone is, clones would have much worse lives than non-clones. In particular, I look at various ideas connected with autonomy. I conclude that there is no basis to the claim that, because of what a clone is, clones would have much worse lives than non-clones. I therefore reject the claim that cloning human beings is morally wrong.
PMCID: PMC479190  PMID: 10226912
23.  Still feeling it: the time course of emotional recovery from an attentional perspective 
Emotional reactivity and the time taken to recover, particularly from negative, stressful, events, are inextricably linked, and both are crucial for maintaining well-being. It is unclear, however, to what extent emotional reactivity during stimulus onset predicts the time course of recovery after stimulus offset. To address this question, 25 participants viewed arousing (negative and positive) and neutral pictures from the International Affective Picture System (IAPS) followed by task-relevant face targets, which were to be gender categorized. Faces were presented early (400–1500 ms) or late (2400–3500 ms) after picture offset to capture the time course of recovery from emotional stimuli. Measures of reaction time (RT), as well as face-locked N170 and P3 components were taken as indicators of the impact of lingering emotion on attentional facilitation or interference. Electrophysiological effects revealed negative and positive images to facilitate face-target processing on the P3 component, regardless of temporal interval. At the individual level, increased reactivity to: (1) negative pictures, quantified as the IAPS picture-locked Late Positive Potential (LPP), predicted larger attentional interference on the face-locked P3 component to faces presented in the late time window after picture offset. (2) Positive pictures, denoted by the LPP, predicted larger facilitation on the face-locked P3 component to faces presented in the earlier time window after picture offset. These results suggest that subsequent processing is still impacted up to 3500 ms after the offset of negative pictures and 1500 ms after the offset of positive pictures for individuals reacting more strongly to these pictures, respectively. Such findings emphasize the importance of individual differences in reactivity when predicting the temporality of emotional recovery. The current experimental model provides a novel basis for future research aiming to identify profiles of adaptive and maladaptive recovery.
PMCID: PMC3659338  PMID: 23734116
emotion; attention; reactivity; recovery; face; late positive potential; P3; N170
24.  Angelika Amon: Conquering the divide 
The Journal of Cell Biology  2011;193(2):254-255.
Amon studies how cells segregate their chromosomes and what happens when they get it wrong.
Amon studies how cells segregate their chromosomes and what happens when they get it wrong.
PMCID: PMC3080264  PMID: 21502356
25.  What do family physicians consider an error? A comparison of definitions and physician perception 
BMC Family Practice  2006;7:73.
Physicians are being asked to report errors from primary care, but little is known about how they apply the term "error." This study qualitatively assesses the relationship between the variety of error definitions found in the medical literature and physicians' assessments of whether an error occurred in a series of clinical scenarios.
A systematic literature review and pilot survey results were analyzed qualitatively to search for insights into what may affect the use of the term error. The National Library of Medicine was systematically searched for medical error definitions. Survey participants were a random sample of active members of the American Academy of Family Physicians (AAFP) and a selected sample of family physician patient safety "experts." A survey consisting of 5 clinical scenarios with problems (wrong test performed, abnormal result not followed-up, abnormal result overlooked, blood tube broken and missing scan results) was sent by mail to AAFP members and by e-mail to the experts. Physicians were asked to judge if an error occurred. A qualitative analysis was performed via "immersion and crystallization" of emergent insights from the collected data.
While one definition, that originated by James Reason, predominated the literature search, we found 25 different definitions for error in the medical literature. Surveys were returned by 28.5% of 1000 AAFP members and 92% of 25 experts. Of the 5 scenarios, 100% felt overlooking an abnormal result was an error. For other scenarios there was less agreement (experts and AAFP members, respectively agreeing an error occurred): 100 and 87% when the wrong test was performed, 96 and 87% when an abnormal test was not followed up, 74 and 62% when scan results were not available during a patient visit, and 57 and 47% when a blood tube was broken. Through qualitative analysis, we found that three areas may affect how physicians make decisions about error: the process that occurred vs. the outcome that occurred, rare vs. common occurrences and system vs. individual responsibility
There is a lack of consensus about what constitutes an error both in the medical literature and in decision making by family physicians. These potential areas of confusion need further study.
PMCID: PMC1702358  PMID: 17156447

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