Decisions In Clinical Medicine Research Articles

Medical Ethics: A Very Short Introduction

Medical Ethics: A Very Short IntroductionMichael Dunn and Tony HopeOxford University Press, 2018Let me begin by saying as a long-term advocate of more conscientious, deliberate, and compelling education in the ethical aspects of medical practice, this book is a most welcome contribution.Medical Ethics, a volume in the Oxford University Press series of Very Short Introductions is compact (fits in a jacket pocket), brief (10 chapters, 122 pages), brilliant (passim), and affordable ($11.95). Hence, efficacy in several dimensions.This book, now in its second edition, is the best elementary introduction to medical ethics we have. By “best” I mean the most successful combination of clear writing, accessible analytic acuity of central concepts and issues, pedagogical design, useful guidance to more advanced material, and brevity.Other introductory works in this area are sometimes better in one or more of these categories. One that comes to mind (also recommended for more depth) is Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine by Albert R. Johnson, Mark Siegler, and William J. Linslade. However, none is as successful as a combination of all these criteria.If I were still teaching medical ethics to residents, when time efficiency is essential, I would certainly use Medical Ethics as a principal resource.The authors present a mix of philosophical insight, grounded in close study of foundational texts, and clinical observation, grounded in reflection on years of experience. The mix is at once intellectually elevating and clinically useful.The book opens with an explication of eight “tools of ethical reasoning” used by philosophers, which are then on display in consideration of a range of topics that challenge medical practitioners.These tools are: 1) Distinguishing facts from values; 2) Reasoning from principles; 3) Defining terms; 4) Elucidating concepts; 5) Case comparison; 6) Thought experiments; 7) Logic; 8) Spotting and avoiding fallacies in reasoning.While using these tools as guidelines, the authors advise it is important to remember: Ethical reasoning cannot be reduced to algorithms. Situations are complex and doing the right thing will often require flexibility. Rationality, if practiced in isolation from other virtues, can, like bureaucracy, become rigid and inhuman. Humane medicine will require in addition to rationality: wisdom, imagination, and creativity.This statement reflects the authors’ general and long-term approach to ethical problems, an approach that is a disciplined attempt to achieve clarity, rather than an opportunity to invoke a commitment to any sort of abstraction (theory, law, ideology, secular or religious tradition, and so on). Readers are encouraged to get rid of the fuzz and goo of careless thought, to achieve clarity about the issue or case at hand, before committing to a treatment plan. (As an aside—in many years of consulting with patients, their families, and attending caregivers, I found that most disagreements could be resolved simply by clarifying the language each party was using. Clarity alone often generated agreement; when it did not, at least differences were better defined and more amenable to resolution.)A variety of cases, laws concerning medical decisions, and “customs of practice,” are presented then followed by an evaluation employing all or some of the tools mentioned above, which discussion is in turn followed by an inquiry of the reader: “Would you use the explicated techniques differently, and perhaps reach a different judgment?” The approach, throughout the presentation of issues, is, again: What is the best way, all things considered, to reach a good judgment about the right thing to do? Reaching such judgment on solid, defensible grounds, all things considered, in a shared language, is the essence of applied medical ethics.The range of cases, laws, and customs considered includes, but is not limited to: assisted dying, people who don’t exist yet, inconsistencies about responses to mental illness, fair procedures for allocating medical resources, the myth of evidence-based value-free policy-making, the role of rescue according to statistics versus to known individuals, modern genetics testing and traditional confidentiality, cultural mores and consent, and the various support roles of medical ethics.The best summary of the book’s message I can offer is this: Attending to the particulars of individuals-in-context is always appropriate, if not mandatory while evaluating ethical aspects of clinical practice. After rational consideration of the kind outlined by the authors, forming different judgments in similar (but not identical) cases ought to be considered an achievement rather than an inconsistency to be avoided. The consistency to be most valued in clinical decision-making is not found in identical results, but rather in the application of rational processes, tempered with empathy and imagination. The particular elements of individual contexts matter and rational judgments will be, and ought to be affected by them.The Further Reading addendum is excellent, offering books, articles, journals, and institutions that have contributed to our—so far—only moderately successful effort in providing essential and continuing medical ethics education.

Special Report: Ethical Decision-Making in Contemporary Psychiatric Practice—An Evolving Challenge

Special Report: Ethical Decision-Making in Contemporary Psychiatric Practice—An Evolving Challenge

Международный опыт нормативно-правового регулирования права врача на свободу совести

This study provides an overview of international regulation of legal practices associated with conscientious objection in medicine. It explores the junctures of judgment in procedures for legal and ethical decisions in clinical medicine. The article presents an exploratory account of how health professionals adapt to new ethical practices and how these practices may become a challenge, raising ethical concerns and resistance from those involved, leading to broader debate about ethical principles in medicine. The concept of decision-making concerning conscientious objection in medicine was analyzed within the context of international and national laws in such countries as the USA, Poland, Germany, Italy, Sweden and Russia. In addition, the researchers provide an analytical review of secondary data from large surveys and studies in the field of bioethics and medical ethics.

There is Only One Valid Definition of Clearance: Critical Examination of Clearance Concepts Reveals the Potential for Errors in Clinical Drug Dosing Decisions

Drug dosing decisions in clinical medicine and in introducing a drug to market for the past 60 years are based on the pharmacokinetic/clinical pharmacology concept of clearance. We used chemical reaction engineering models to demonstrate the limitations of presently employed clearance measurements based upon systemic blood concentration in reflecting organ clearance. The belief for the last 49 years that in vivo clearance is independent of the mechanistic model for organ clearance is incorrect. There is only one valid definition of clearance. Defining organ clearance solely on the basis of systemic blood concentrations can lead to drug dosing errors when drug effect sites reside either in an eliminating organ exhibiting incremental clearance or in a non-eliminating organ where intraorgan concentration is governed by transporter actions. Attempts to predict clearance are presently hampered by the lack of recognition that what we are trying to predict is a well-stirred model clearance.

Speech is a Sensitive Marker of Neuropsychiatric and Neurodegenerative Conditions (in the Right Context)

The speech, language and voice of a speaker can inform clinical diagnosis, disease progression or treatment response. Here we discuss example use cases from studies in Parkinson’s disease (PD), depression and schizophrenia where speech has proven effective in informing decisions in clinical medicine and clinical trials.

Understanding and improving decisions in clinical medicine (V): Jekyll and Hyde, the two faces of clinical reasoning.

Understanding and improving decisions in clinical medicine (V): Jekyll and Hyde, the two faces of clinical reasoning.

Ethical case interventions for adult patients.

Decisions in clinical medicine can be associated with ethical challenges. Ethical case interventions (e.g. ethics committee, moral case deliberation) identify and analyse ethical conflicts which occur within the context of care for patients. Ethical case interventions involve ethical experts, different health professionals as well as the patient and his/her family. The aim is to support decision-making in clinical practice. This systematic review gathered and critically appraised the available evidence of controlled studies on the effectiveness of ethical case interventions. To determine whether ethical case interventions result in reduced decisional conflict or moral distress of those affected by an ethical conflict in clinical practice; improved patient involvement in decision-making and a higher quality of life in adult patients. To determine the most effective models of ethical case interventions and to analyse the use and appropriateness of the outcomes in experimental studies. We searched the following electronic databases for primary studies to September 2018: CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched CDSR and DARE for related reviews. Furthermore, we searched Clinicaltrials.gov, International Clinical Trials Registry Platform Search Portal and conducted a cited reference search for all included studies in ISI WEB of Science. We also searched the references of the included studies. We included randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies which compared ethical case interventions with usual care or an active control in any language. The included population were adult patients. However, studies with mixed populations consisting of adults and children were included, if a subgroup or sensitivity analysis (or both) was performed for the adult population. We used standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care review group. We used meta-analysis based on a random-effects model for treatment costs and structured analysis for the remaining outcomes, because these were heterogeneously reported. We used the GRADE approach to assess the certainty of the evidence. We included four randomised trials published in six articles. The publication dates ranged from 2000 to 2014. Three studies were conducted in the USA, and one study in Taiwan. All studies were conducted on intensive care units and included 1165 patients. We judged the included studies to be of moderate or high risk of bias. It was not possible to compare different models of the intervention regarding effectiveness due to the diverse character of the interventions and the small number of studies. Included studies did not directly measure the main outcomes. All studies received public funding and one received additional funding from private sources.We identified two models of ethical case interventions: proactive and request-based ethics consultation. Three studies evaluated proactive ethics consultation (n = 1103) of which one study reported findings on one key outcome criterion. The studies did not report data on decisional conflict, moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life or ethical competency for proactive ethics consultation. One study assessed satisfaction with care on a 5-point Likert scale (1 = lowest rating, 5 = highest rating). The healthcare providers (nurses and physicians, n = 365) scored a value of 4 or 5 for 81.4% in the control group and 86.1% in the intervention group (P > 0.05). The patients or their surrogates (n = 275) scored a value of 4 or 5 for 83.6% in the control group and for 74.8% in the intervention group (P > 0.05). It was uncertain whether proactive ethics consultation led to high satisfaction with care, because the certainty of evidence was very low.One study evaluated request-based ethics consultation (n = 62). The study indirectly measured decisional conflict by assessing consensus regarding patient care. The risk (increase in consensus, reduction in decisional conflict) increased by 80% as a result of the intervention. The risk ratio was 0.20 (95% confidence interval 0.09 to 0.46; P < 0.01). It was uncertain whether request-based ethics consultation reduced decisional conflict, because the certainty of evidence was very low. The study did not report data on moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life, or ethical competency or satisfaction with care for request-based ethics consultation. It is not possible to determine the effectiveness of ethical case interventions with certainty due to the low certainty of the evidence of included studies in this review. The effectiveness of ethical case interventions should be investigated in light of the outcomes reported in this systematic review. In addition, there is need for further research to identify and measure outcomes which reflect the goals of different types of ethical case intervention.

Understanding and improving decisions in clinical medicine (IV): prospects and challenges of nudging in healthcare.

Understanding and improving decisions in clinical medicine (IV): prospects and challenges of nudging in healthcare.

Understanding and improving decisions in clinical medicine (III): towards cognitively informed clinical thinking.

Understanding and improving decisions in clinical medicine (III): towards cognitively informed clinical thinking.

O33-1 - The Problem between Clinical Ethics and Medical Therapy

Background: The problem of clinical ethics is not a special case. In daily clinical practice, with considering and analyzing various problems among patients, their families, and surround medical stuffs, to search for the best solution with respect is an important attitude. In recent 2 years we have experienced 9 times for 6 cases of discussion at clinical ethics committee (CEC) (42 to 85 year-old) in our hospital. We have reported with scientific investigation. Four cases were discussed about extubation on the assumption without performing intubation in case of worsening respiratory failure. In the remaining 2 cases, the discussion point was about removal their percutaneous cardiopulmonary (PCPS) support without introducing PCPS again in case of assuming hemodynamic breakdown. The members of the CEC were our hospital executives consisting of each section chief appointed by the director of our hospital. After introducing patient's medical history from the attending physician, discussion was done on whether substition for advanced invasive medical therapy was possible or not, because continuing current treatment may give a great distress to the patients and violation of fundamental human rights. Based on the practical approach to ethical decisions in clinical medicine, 1. medical indication, 2. Patient preferences, 3. patient's QOL and 4. contextual features surrounding patient had been figure out. In our cases after precise discussion, we have withhold treatment.

Understanding and improving decisions in clinical medicine (II): making sense of reasoning in practice.

Understanding and improving decisions in clinical medicine (II): making sense of reasoning in practice.

Understanding and improving decisions in clinical medicine (I): Reasoning, heuristics, and error.

Understanding and improving decisions in clinical medicine (I): Reasoning, heuristics, and error.

Ethical case interventions for adult patients

BACKGROUND Decisions in clinical medicine can be associated with ethical challenges. Ethical case interventions (e.g. ethics committee, moral case deliberation) identify and analyse ethical conflicts which occur within the context of care for patients. Ethical case interventions involve ethical experts, different health professionals as well as the patient and his/her family. The aim is to support decision-making in clinical practice. This systematic review gathered and critically appraised the available evidence of controlled studies on the effectiveness of ethical case interventions. OBJECTIVES To determine whether ethical case interventions result in reduced decisional conflict or moral distress of those affected by an ethical conflict in clinical practice; improved patient involvement in decision-making and a higher quality of life in adult patients. To determine the most effective models of ethical case interventions and to analyse the use and appropriateness of the outcomes in experimental studies. SEARCH METHODS We searched the following electronic databases for primary studies to September 2018: CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched CDSR and DARE for related reviews. Furthermore, we searched Clinicaltrials.gov, International Clinical Trials Registry Platform Search Portal and conducted a cited reference search for all included studies in ISI WEB of Science. We also searched the references of the included studies. SELECTION CRITERIA We included randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies which compared ethical case interventions with usual care or an active control in any language. The included population were adult patients. However, studies with mixed populations consisting of adults and children were included, if a subgroup or sensitivity analysis (or both) was performed for the adult population. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care review group. We used meta-analysis based on a random-effects model for treatment costs and structured analysis for the remaining outcomes, because these were heterogeneously reported. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included four randomised trials published in six articles. The publication dates ranged from 2000 to 2014. Three studies were conducted in the USA, and one study in Taiwan. All studies were conducted on intensive care units and included 1165 patients. We judged the included studies to be of moderate or high risk of bias. It was not possible to compare different models of the intervention regarding effectiveness due to the diverse character of the interventions and the small number of studies. Included studies did not directly measure the main outcomes. All studies received public funding and one received additional funding from private sources.We identified two models of ethical case interventions: proactive and request-based ethics consultation. Three studies evaluated proactive ethics consultation (n = 1103) of which one study reported findings on one key outcome criterion. The studies did not report data on decisional conflict, moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life or ethical competency for proactive ethics consultation. One study assessed satisfaction with care on a 5-point Likert scale (1 = lowest rating, 5 = highest rating). The healthcare providers (nurses and physicians, n = 365) scored a value of 4 or 5 for 81.4% in the control group and 86.1% in the intervention group (P > 0.05). The patients or their surrogates (n = 275) scored a value of 4 or 5 for 83.6% in the control group and for 74.8% in the intervention group (P > 0.05). It was uncertain whether proactive ethics consultation led to high satisfaction with care, because the certainty of evidence was very low.One study evaluated request-based ethics consultation (n = 62). The study indirectly measured decisional conflict by assessing consensus regarding patient care. The risk (increase in consensus, reduction in decisional conflict) increased by 80% as a result of the intervention. The risk ratio was 0.20 (95% confidence interval 0.09 to 0.46; P < 0.01). It was uncertain whether request-based ethics consultation reduced decisional conflict, because the certainty of evidence was very low. The study did not report data on moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life, or ethical competency or satisfaction with care for request-based ethics consultation. AUTHORS' CONCLUSIONS It is not possible to determine the effectiveness of ethical case interventions with certainty due to the low certainty of the evidence of included studies in this review. The effectiveness of ethical case interventions should be investigated in light of the outcomes reported in this systematic review. In addition, there is need for further research to identify and measure outcomes which reflect the goals of different types of ethical case intervention.

Blink or think: can further reflection improve initial diagnostic impressions?

Experienced clinicians derive many diagnoses intuitively, because most new problems they see closely resemble problems they've seen before. The majority of these diagnoses, but not all, will be correct. This study determined whether further reflection regarding initial diagnoses improves diagnostic accuracy during a high-stakes board exam, a model for studying clinical decision making. Keystroke response data were used from 500 residents who took the 2010 American Board of Internal Medicine (ABIM) Internal Medicine Certification Examination. Data included time to initial response on each question, whether the answer was correct, and whether or not the resident changed her or his initial response. The focus was on 80 diagnosis questions that comprised realistic clinical vignettes with multiple-choice single-best answers. Cognitive skill (ability) was measured using overall exam scores. Case complexity was determined using item difficulty (proportion of examinees that correctly answered the question). A hierarchical generalized linear model was used to assess the relationship between time spent on initial responses and the probability of correctly answering the questions. On average, residents changed their responses on 12% of all diagnosis questions (or 9.6 questions out of 80). Changing an answer from incorrect to correct was almost twice as likely as changing an answer from correct to incorrect. The relationship between response time and accuracy was complex. Further reflection appears to be beneficial to diagnostic accuracy, especially for more complex cases.

Deciding About Fast and Slow Decisions

Two reports in this issue address the important topic of clinical decision making. Dual process theory has emerged as the dominant model for understanding the complex processes that underlie human decision making. This theory distinguishes between the reflexive, autonomous processes that characterize intuitive decision making and the deliberate reasoning of an analytical approach. In this commentary, the authors address the polarization of viewpoints that has developed around the relative merits of the two systems. Although intuitive processes are typically fast and analytical processes slow, speed alone does not distinguish them. In any event, the majority of decisions in clinical medicine are not dependent on very short response times. What does appear relevant to diagnostic ease and accuracy is the degree to which the symptoms of the disease being diagnosed are characteristic ones. There are also concerns around some methodological issues related to research design in this area of enquiry. Reductionist approaches that attempt to isolate dependent variables may create such artificial experimental conditions that both external and ecological validity are sacrificed. Clinical decision making is a complex process with many independent (and interdependent) variables that need to be separated out in a discrete fashion and then reflected on in real time to preserve the fidelity of clinical practice. With these caveats in mind, the authors believe that research in this area should promote a better understanding of clinical practice and teaching by focusing less on the deficiencies of intuitive and analytical systems and more on their adaptive strengths.

Saving lives is more important than abstract moral concerns: financial incentives should be used to increase organ donation.

Ever since organ donation became clinically feasible, there have not been enough organs to go around. Figure 1 shows the rate of change from a base value in 1995 through 2008, of three variables: (1) the number of deceased donors, (2) the number of patients with end-stage organ failure who are waiting for an organ, and (3) the number of waiting list patients who either die before an organ becomes available (ie, death on the waiting list or after removal from the waiting list as “too sick to transplant”) [1]. The number of potential recipients on transplant waiting lists has more than doubled, and now stands at over 100,000, whereas the number of deceased donors has increased by only half. Meanwhile, the numbers of deaths related to the organ shortage, which is now greater than 9,000 a year, has grown in parallel with the waiting list. Thus, the gap between supply and demand has grown every year for the past 15 years. Fig 1 Relative change (from 1988 baseline data) in the number of patients on organ waiting lists, deaths on the waiting list, and number of donors each year, 1988–2008. Graph derived from Organ Procurement and Transplantation Network data [1]. Approximately two thirds of the waiting list patients suffer from end-stage renal disease. Because the kidney is a paired organ, living individuals can donate one kidney, and several thousand donate every year, mostly to relatives with whom they have an emotional bond. The problem underlying the organ gap is not a lack of medically suitable organs from patients dying from severe brain damage; if all such patients became donors, the waiting list would shrink rapidly, yet only half of potential deceased donors actually donate, and many potential living donors are medically unsuitable or are unwilling to donate, so not enough organs are donated to satisfy the need for them. How can we increase the number of donors? When a difficult or dangerous job has to be done, such as working on high-rise construction projects, we give workers an added incentive to take these jobs by offering them more benefits, such as salary supplements. Perhaps offering a financial incentive for organ donation would increase the number of willing donors. But if offering people financial incentives could increase the supply of organs, should we do it? Would it be morally appropriate? Kidneys are by far the most common transplants and can come from either a deceased donor (two kidneys) or from a living donor (one kidney). Making the case for providing financial incentives to living donors is much more difficult than for deceased donors, so if that case can be made, the arguments can cover virtually all donations, from both living and deceased donors. Although this is a cardiothoracic surgery journal, the current debate centers on living donors of kidneys. This is more appropriate than might be obvious at first, because the arguments for and against financial incentives for organ donation can be generalized easily to both living and deceased donors, and therefore these can apply to the therapies of most immediate concern to cardiothoracic surgeons (ie, heart and lung transplantations). The debate is rendered more concrete by focusing on the case of a United States senator who has a decision to make.

Book Review: Clinical ethics: a practical approach to ethical decisions in clinical medicine, fifth edition

Book Review: Clinical ethics: a practical approach to ethical decisions in clinical medicine, fifth edition

Supporting decisions in clinical medicine: neural networks in lower gastrointestinal haemorrhage

Aids for making health-care decisions have been much researched over the past decade. The attraction is that such aids could be used to supplement human decisions when there are multiple factors to consider in arriving at a decision and when experience may be limited. 1 Hunt DL Haynes RB Hanna SE Smith K Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA. 1998; 280: 1339-1346 Crossref PubMed Scopus (1254) Google Scholar , 2 Sintchenko V Coiera EW Which clinical decisions benefit from automation? A task complexity approach. Int J Med Inf. 2003; 70: 309-316 Crossref PubMed Scopus (44) Google Scholar In today's Lancet, Ananya Das and colleagues provide a good example of a situation ripe for decision support: patients with lower gastrointestinal haemorrhage present to emergency healthcare services where they are initially likely to be triaged by support staff, and the outcomes range from a small self-limiting bleed to death from massive haemorrhage. The prognosis in upper gastrointestinal haemorrhage can be predicted by several well-validated scores, 3 Sanders DS Carter MJ Goodchap RJ Cross SS Gleeson DC Lobo AJ Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers. Am J Gastroenterol. 2002; 97: 630-635 Crossref PubMed Google Scholar but there is less information on bleeding from the lower gastrointestinal tract. Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive modelANN can accurately predict the outcome for patients presenting with acute lower-gastrointestinal haemorrhage and may be generally useful for the risk stratification of these patients. Full-Text PDF

Menopausal hormone therapy informed consent

A little over a year ago now, the large hormone therapy clinical trial of the Women’s Health Initiative came to an abrupt halt. The publication of the results rocked the medical community and our patients because a class of drugs once thought to be associated overwhelmingly with benefit was found to cause more harm than good. Now doctors have the dilemma of how to inform patients of the results of the Women’s Health Initiative in a way that will help them make the best decision for themselves of whether they should use of these agents for hot flashes, night sweats, vaginal dryness, or prevention of osteoporosis. In the thousands of daily conversations on this topic, the scenario used to look like this: The patient came to the office asking questions about menopause. When the practitioner determined the patient was going through the menopausal transition, the doctor wrote a prescription for hormone pills or patches, saying they would address her concerns by replacing the hormones her body used to make. They would abolish her hot flashes, slow her bone loss, and reduce her risk of a heart attack. The patient asked if the pills caused breast cancer. Probably in some women, the doctor would acknowledge, but argued that the benefits to the heart and bones were worth taking the chance. Now the patient comes to the office and asks about the confusing information she has been reading on the increased risk of heart attack, strokes, blood clots, and dementia with hormone use. The doctor acknowledges the information has changed and is very important, but the decision to use or not to use hormones is up to her. She has menopausal symptoms and wants a solution. However, she is looking for something safe that does not cause more problems than it solves.

RETRACTED: Ethical issues in surgical treatment and research

This article has been retracted at the request of the Editor-in-Chief and Author. Please see http://www.elsevier.com/locate/withdrawalpolicy . Reason: There are problems with this monograph. Multiple passages from the sections entitled, “Ethics and End-of-Life Issues” (pp. 357–379) and “Ethics and Research in Surgery” (pp. 379–398), authored by Rene Lafreniere were taken from the following sources without appropriate attribution given the original authors: (1) Jonsen AR, Siegler M, Winslade WD. Clinical ethics: a practical approach to ethical decisions in clinical medicine. New York: McGraw Hill, 1992. (2) Troidl H, McKneally MF, Towards a definition of clinical research, In: Troidl H, McKeally MF, Mulder DS, Wechsler AS, McPeek B, Spitzer WO, editors. Surgical Research, Basic Principles and Clinical Practice, 3rd Edition, New York: Springer-Verlag; 1998, pp. 3–7. (3) Macklin R. The ethical problems with sham surgery in clinical research. New Eng J Med 1999; 341: 992–996). (4) Medical Futility in End-of-Life Care: Report of the Council on Ethical and Judicial Affairs, American Medical Association. JAMA. 1999; 281:937–941. (5) Younger SJ and Shuck JM, Advanced directives and determination of death, in Surgical Ethics. Eds. McCollough LB, Jones JW and Brody BA. 1st Edition. New York, Oxford University Press, 1998, pp. 57–77. (6) Frader JE and Caniano DA, Research and Innovation in Surgery, in Surgical Ethics, Eds. McCollough LB, Jones JW and Brody BA. 1st Edition. New York, Oxford University Press, 1998, pp. 216–241. (7) Margo CE, Towards an Operational Definition of Human Research. J Med Ethics. 2001; 27: 40–43 This monograph is thus retracted with apologies to the authors of the unattributed works. Sincerely, Peter Angelos, MD, PhD; Rene Lafreniere, MD; Timothy F. Murphy, PhD; Wayne Rosen, MD; November 15, 2006