Disruptive technologies, engineered concepts, and normative guidance

John Edwards is the clinical administrator for Gift of Life Donor Program in Philadelphia, Pa, overseeing all clinical aspects of organ and tissue recovery, and a faculty member for the Gift of Life Institute, Philadelphia, providing training and mentoring for healthcare organizations nationally. Patti Mulvania oversees the clinical education program for the Gift of Life Donor Program in Philadelphia and is a faculty member of the Gift of Life Institute, specializing in consent and clinical communication. Virginia Robertson is the associate director of the Gift of Life Institute in Philadelphia. Formerly, she was the director of hospital services for the Gift of Life Donor Program. Gweneth George is the director of hospital services for the Gift of Life Donor Program in Philadelphia. She directs a team of nearly 20 hospital development staff accountable for donation performance in 150 acute care hospitals. Richard Hasz is vice president of clinical services for the Gift of Life Donor Program in Philadelphia. He oversees the day-to-day clinical operations, including transplant coordination, hospital development, organ preservation, and tissue recovery. Howard Nathan is president and chief executive officer of the Gift of Life Donor Program in Philadelphia. The program has been involved in coordinating more than 22 000 organ transplantations and tens of thousands of tissue transplantations since 1974.

Objective To summarize the clinical features and technical key points on brain death during decision-made process in children with suspected brain death. Methods Twenty-four coma children with Glasgow coma scale score 3 and no spontaneous respiration were collected from May 2015 to February 2017 in Beijing Children′s Hospital, Capital Medical University to make the brain death determination.All children received at least one confirmatory test.According to the Chinese standards for determining brain death (pediatric), all patients were divided into brain death group and non-compliance group.The clinical features were analyzed.The sensitivity, specificity, false positive rate and false negative rate of electroencephalogram (EEG), short latency somatosensory evoked potential (SLSEP) and transcranial Doppler sonography (TCD) were calculated. Results Among these 24 cases, there were 16 males and 8 females, aged 5.6 (2.0, 8.8) years old.Ten cases met the criteria of brain death.Twelve (50%, 12/24 cases) cases received autonomic breathing test.A total of 25 tests were conducted, of which 21 were successful.The completion rates of EEG, TCD and SLSEP were 100.0% (24/24 cases), 83.3% (20/24 cases) and 54.2% (13/24 cases), respectively.EEG had the highest sensitivity (100%) and specificity (79%). SLSEP had good sensitivity (100%), but the specificity was only 40%.The combination of EEG with SLSEP had the highest specificity and sensitivity, both of which were 100%, and the false positive rate and false negative rate were 0. Conclusions The key to determine brain death successfully is to make adequate preparations, to receive formal training and to apply standard operation.In the determination of brain death in children, EEG has a good sensitivity and specificity in single confirmation test, which is the priority item.The combination of EEG with SLSEP is the most advantageous. Key words: Glasgow coma scale; Coma; Child; Brain death

The article is an attempt to clarify the distinctive normativity of law, as it is reflected in the legal systems of constitutional democracies. It explores the ability of interpretive theories to capture the conceptual characteristics of the normativity of law. The normative guidance the law provides is characterised in terms of normative claims. Normative claims are construed as being based upon linking up expectations with practical reasons. The analysis lays out the conditions of providing normative guidance with the help of drawing a distinction between the success and efficacy of normative claims. The article addresses the issue of the distinctiveness of the normativity of law. It argues that it is its institutional character that makes the normativity of law distinctive. It is manifested in the claim of law to a kind of priority over all other normative mechanisms. The ability of the law to provide successful and efficacious normative guidance is explained in terms of three types of reasons: moral reasons, compliance reasons and response reasons. An implication of this insight is the moral legitimacy is constitutive of the normativity of law. The article concludes with an exploration of the dimensions of moral legitimacy and the way they make the normativity of law associated with the ideals of democracy and the rule of law.

The article is the first part of an analysis that seeks to clarify the distinctive normativity of law, as it is reflected in the legal systems of constitutional democracies. It explores the ability of interpretive theories to capture the conceptual characteristics of the normativity of law. The normative guidance the law provides is characterised in terms of normative claims. Normative claims are construed as being based upon linking up expectations with practical reasons. The analysis lays out the conditions of providing normative guidance with the help of drawing a distinction between the success and efficacy of normative claims. The success of normative claims is explained in terms of their substantive justificatory background and the competence of those making them. The characterisation of the efficacy of normative claims is based on the distinction between instrumental and non-instrumental reasons.

Selected Abstracts From the 2013 International Neuroethics Society Annual Meeting

In a 1968 Report, the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death promulgated influential criteria for the idea and practice known as "brain death." Before and since the Committee met, brain death has been a focal point of visions and nightmares of medical progress, purpose, and moral authority. Critics of the Committee felt it was deaf to apparently central moral considerations and focused on the self-serving purpose of expanding transplantation. Historical characterizations of the uses and meanings of brain death and the work of the Committee have tended to echo these themes, which means also generally repeating a widely held bioethical self-understanding of how the field appeared-that is, as a necessary antidote of moral expertise. This paper looks at the Committee and finds that historical depictions of it have been skewed by such a bioethical agenda. Entertaining different possibilities as to the motives and historical circumstances behind the Report it famously produced may point to not only different histories of the Committee, but also different perspectives on the historical legacy and role of bioethics as a discourse for addressing anxieties about medicine.

Determination of brain death in children--a medicial center experience.

Non confirmatory electroencephalography in patients meeting clinical criteria for brain death: Scenario and impact on organ donation

Apnea testing is mandatory to confirm brain death; however, it is unsafe for patients who have substantial hypoxemia without ventilator support. We used a new modified apnea test without the need to disconnect the patient from the ventilator in the present study and compared the outcomes and complications of the new method to the widely used old method. The current study was conducted on people suspected of having brain death. Both the old and new apnea tests were carried out on the same individual. In the new modified method, instead of hyperventilating and then separating the brain death from the ventilator, the induced hypercapnia method was used, and instead of performing repeated arterial blood gas (ABG), the target ETCO2 was obtained, and at the time of the target ETCO2, ABG was also checked followed by comparing ETCO2 with PaCO2. Thirty patients, including 25 (83.3%) males and 5 (16.75%) females, were included in the study. The results showed significant improvement in terms of O2 saturation and heart rate (HR) using the new modified apnea test compared to the common test. Systolic blood pressure, diastolic blood pressure, and the frequency of complications were improved in the new modified test. The modified apnea test produced better results in terms of O2 saturation, HR, and other clinical factors, while it does not require disconnection from the ventilator and repeated ABG assessment. Therefore, it can be used to successfully diagnose brain death in high-risk individuals suffering from severe hypoxia.

Imaging tests in determination of brain death

237 ISSN 1741-0541 10.2217/PME.12.5 © 2012 Future Medicine Ltd Personalized Medicine (2012) 9(3), 237–239 “...genomic pathology [is] founded on the premise that sequencing the human genome is rapidly becoming so routine and inexpensive that it will inevitably find its way into fundamental aspects of healthcare – not only in disease diagnosis and management, but also disease prevention, risk mitigation and health maintenance.”

Safety and Outcomes in 100 Consecutive Donation After Circulatory Death Liver Transplants Using a Protocol That Includes Thrombolytic Therapy.

In an attempt to provide some clarification in the abortion issue it has recently been proposed that since 'brain death' is used to define the end of life, 'brain life' would be a logical demarcation for life's beginning. This paper argues in support of this position, not on empirical grounds, but because of what it reflects of what is valuable about the term 'life'. It is pointed out that 'life' is an ambiguous concept as it is used in English, obscuring the differences between being alive and having a life, a crucial distinction for bioethical questions. The implications of this distinction for the moral debate about abortion are discussed.

Organ transplantation is impossible without donation which is performed both intra vitam and posthumously. Each case of multi-organ collection provides help to 4 to 6 patients. We believe that presentation of modern algorithms for diagnosing brain death is quite feasible, and such information can be useful not only for anesthesiologists, but also for doctors of other specialties. This paper presents materials related to organ donation. Diagnostic criteria for human brain death, as well as the procedure for ascertaining human brain death and the actions of doctors of healthcare institutions in relation to persons who are in these institutions and who have clinical indications for the diagnosis of brain death, are determined by "The procedure for cancellation of active measures to maintain the patient's life…". Active measures (ventilation, infusion therapy and vasopressor support, etc.) to support the patient's life are cancelled after the patient's brain death is ascertained, except for cases where the deceased person is considered a potential donor. Verification of the human brain death is carried out by the case management team of the healthcare institution involving, if necessary, members of consultative and diagnostic mobile team, specialists of other healthcare institutions. The head of the healthcare institution is responsible for timely and proper engagement and work of the case management team. The responsible person determines the membership of the case management team by making an appropriate entry in the case record and is responsible for its work.
 An anesthesiologist and a neurologist (neurosurgeon) who have at least 5 years of practical experience in the specialty are engaged in the case management team to ascertain brain death in persons over 18 years of age.
 Physicians involved in the removal of human anatomical materials and transplantation thereof, as well as transplant coordinator, may not be included in the case management team.

Case example On April 15, 1975, 21-year-old Karen Ann Quinlan attended a friend's birthday party at a bar near her home in New Jersey. Karen was on a strict diet at the time, and she was also taking the anti-anxiety drug diazepam (Valium ® ). After several drinks at the party, Karen felt faint, and friends took her home and put her to bed. When they checked on her fifteen minutes later, she had stopped breathing. They attempted to revive her and called for assistance. Emergency medical technicians arrived, continued cardio-pulmonary resuscitation efforts, and transported Karen to a nearby hospital, where she was placed on a mechanical ventilator . Karen remained hospitalized, on ventilator support, for the next several months, but she did not regain consciousness. Neurologists diagnosed her condition as a “persistent vegetative state,” a form of irreversible unconsciousness caused by lack of oxygen to her brain during the time when she was not breathing. Karen did, however, retain some brain activity. She did not meet established brain-oriented legal and medical criteria for death (sometimes called “brain death”), since those criteria require a finding of “irreversible cessation of total brain function.” Her physicians were convinced that Karen could not survive without ongoing ventilator support . Karen's parents, Joseph and Julia Quinlan, had consented to all recommended life-sustaining treatments for their daughter during the first three months of her hospitalization. By the end of July 1975, however, they reached the conclusion that Karen would not want continuing life-sustaining treatment in a state of permanent unconsciousness. The Quinlans were devout Roman Catholics; after consultation with their parish priest, they requested that Karen's ventilator support be discontinued and that she be allowed to die. Karen's physicians responded that they could not honor this request, on the grounds that removing Karen's ventilator support would be a form of euthanasia that would be immoral, illegal, and contrary to medical standards of care. Karen was a patient at St. Claire's Hospital, and the hospital supported the physicians’ decision to continue ventilator support. What should have been done to resolve this disagreement? With the rapid expansion of health care services in the United States in the decades immediately following World War II, patients, health care professionals, and the American public at large confronted new and challenging moral questions about what treatments should be offered and provided, especially near the beginning and the end of human life.