Number Of Harms Research Articles

COVID-related stress as a driver of unusual medical presentations

Amid the COVID-19 (SARS-COV2) global pandemic, children and families faced a number of stresses. This practice insight case study describes a presentation of a child with a rash at the height of the pandemic shutdowns with the realization that the stress of closing school led to her presentation for medical care for a factitious disorder. This case shows that, while staff may initially suspect parents, children can also report factitious illness without the knowledge of their parents, and these reports were affected by the COVID-19 pandemic. While it is unclear whether actual child abuse and neglect increased during the pandemic, there is no question that the stresses placed on families resulted in a number of harms. This highlights the need for dedicated child protection teams and preexisting procedures to objectively and sensitively look beyond physical injury to best support children and families, especially during times of monumental community stress.

Enhancing Strategic Learning Through the Implementation of Robust Process Improvement in a Specialized Tertiary Care Hospital.

Performance improvement (PI) in healthcare is essential to improve health, patient experience, and reduce costs. PI projects became low, inconsistent and weakly-sustained in our hospital. The low number and low sustainability were scarcely in alignment with our strategic goal to become a high reliability organization (HRO). This was due to lack of standardized knowledge and ability to initiate and sustain PI projects. Therefore, a structured framework was developed, followed by the building of capacity and capability in the use of robust process improvement (RPI) amidst the COVID-19 pandemic. A team of healthcare quality professionals collaborated with Hospital Performance Improvement-Press Ganey for hospital-wide quality improvement project. The team received training on RPI from Press Ganey and created the framework to use . This framework is based on the Institute for Healthcare Improvement Model for Improvement, Lean, Six Sigma, and FOCUS-PDSA (Find-Organize-Clarify-Understand-Select-Plan-Do-Study-Act). Thereafter, the team of internal coaches organized an RPI training course that consisted of 6 sessions, for clinical and nonclinical staff , using classroom and virtual sessions during the pandemic. This course was increased to eight sessions to avoid information overload. Process measures were collected using a survey to obtain feedback, whereas outcome measures were from the number of completed projects and their effects related to costs, access to care, waiting time, number of harms, and compliance. Participation and submission improved after three PDSA (Plan-Do-Study-Act) cycles. This resulted in an increased number of completed and sustained projects from 50 in 2019 to 94 in 2020 and continued to rise to 109 in 2021. There were 140 and 122 certified RPI coaches in 2020 and 2021, respectively. Although there was a decrease in the number of certified coaches in 2021, the number of completed projects was higher than in 2020. The overall effect of these completed projects by the third quarter of 2021 showed improvement in access to care by 39%, compliance to standards of care by 48%, satisfaction by 8%, and reduction in costs by 47,010 SAR, in waiting time of 170 hours, and in the number of harms by 89. This quality improvement project led to enhanced capacity of staff as seen in the increased number of certified RPI coaches, thereby increasing the submission and completion of projects in 1 year. Its sustainability during the 2 succeeding years continued to enhance project completion and maintenance, bringing quality improvement benefits to the organization and the patients.

Key considerations for the implementation of clinically focused Prescription Drug Monitoring Programs to avoid unintended consequences.

Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, including opioid analgesics and benzodiazepines. PDMP have been widely implemented throughout North America and are currently being introduced in Australia and some parts of Europe. PDMP were originally developed by and for law enforcement, however many jurisdictions have now shifted use toward clinical care and harm reduction through early identification of prescription dependence and extra-medical use, and to ensure appropriate supply of controlled substances to the community through monitoring health care provider prescribing and dispensing patterns (Deloitte, 2018; Picco etal., 2021a; CDC,2021a, U.S Department of Justice, 2018). Clinically-motivated PDMP highlight medication-related risk, based on the patient's prescribing and dispensing history. Health care professionals can use this information to aid or inform clinical decision-making and provide opportunities for intervention and treatment (Deloitte, 2018) . However, a number of harms have been associated with the use of PDMP, including increased stigma and discrimination, untreated pain and mental illness, and denial of appropriate health care for those identified as 'high risk'. In this article we examine these harms and potential mitigating factors. We conclude with some suggestions and future directions for research to address some of the current uncertainties regarding PDMP use. We highlight the need for mixed methods research to better understand the personal impacts of PDMP policy on the populations they were designed to aid.

Adult retrospective report of child abuse and prospective indicators of childhood harm: a population birth cohort study

BackgroundWe aim to determine whether adult retrospective report of child abuse is associated with greater risk of prospectively assessed harmful environments in childhood. We assessed possible recall basis by adult depression status.MethodsAt 45 years, participants of the 1958 British birth cohort (N = 9308) reported a range of abuse types (by 16 years). Prospective data, ages 7–16 years, were obtained for impoverished upbringing, hazardous conditions, anti-social behaviours and 16 years poor parent-child relationships. We estimated associations between retrospective report of child abuse and prospectively measured harm using (i) odds ratios (ORs, 95% confidence intervals) and (ii) positive predictive values (PPVs). PPVs were calculated stratified by adult depression status.ResultsPrevalence of retrospectively reported abuse ranged from 10.7% (psychological) to 1.60% (sexual) and 14.8% reported ≥ 1 type; prospectively recorded harm ranged from 10% (hazardous conditions/poor parent-child relationships) to 20% (anti-social behaviours). Adults retrospectively reporting abuse were more likely to have had harmful childhood environments: 52.4% had ≥ 1 indicator of harm (vs. 35.6% among others); ORsex-adjusted for poor relationships with parents was 2.98 (2.50, 3.54). For retrospectively reported (vs. none) abuse, there was a trend of increasing relative risk ratio with number of harms, from 1.75 (1.50, 2.03) for 1 to 4.68 (3.39, 6.45) for 3/4 childhood harms. The PPV of ≥ 1 prospectively recorded harm did not differ between depressed (0.58 (0.52, 0.64)) and non-depressed (0.58 (0.55, 0.61)) groups.ConclusionsIn a population cohort, adult retrospective report of child abuse was associated with several harms, prospectively measured from childhood to adolescence, providing support for the validity of retrospective report-based research. Findings suggest retrospectively reported child abuse is not biased by depression in adulthood.

Environmental Displacement and Mental Well-Being in Banjarnegara, Indonesia.

Background:Residential moves (displacement) owing to climate- and weather-related disasters may significantly impact mental health. Despite the growing risk from climate change, health impacts of environmental-mobility remain understudied.Objectives:We assessed the effects of displacement on the association between landslides and changes in perceived mental well-being in Banjarnegara, Indonesia. We also investigated whether sociodemographics (age, sex, level of education, household-level income, or employment in agriculture) and landslide characteristics (number and severity of landslides) were associated with differing odds of relocation after experiencing landslides.Methods:In this cross-sectional study, we surveyed 420 individuals who experienced landslides between 2014 and 2018 to assess perceived changes in mental well-being, comparing after landslide exposure to before landslide exposure. We used a novel six-item measure that was created in collaboration with the local community to compare perceived changes between those who were displaced by landslides and those who were not displaced, using logistic and multinomial regressions adjusted for sociodemographic characteristics. We then assessed whether the odds of displacement differed based on sociodemographic characteristics and landslide exposure characteristics, using logistic regressions.Results:Those who were displaced were more likely than those who were not displaced to report perceived increases in economic stability [; 95% confidence interval (CI): 1.45, 6.46], optimism (; 95% CI: 1.87, 8.61), safety (; 95% CI: 1.44, 5.10), religiosity (; 95% CI: 1.03, 3.65), and closeness with community (; 95% CI: 1.10, 3.33) after landslides compared with before their first landslide during the study period. More frequent landslide exposures were associated with reduced odds of relocation, but more severe landslides were associated with increased odds of relocation.Discussion:These findings suggest that landslides affect the mental well-being not only of those who are displaced but also of those who are left behind. Further, this work supports the need for community-based participatory research to fully capture the health impacts of environmental mobility. https://doi.org/10.1289/EHP9391

The Relationship Between the U.S. State Alcohol Policy Environment and Individuals' Experience of Secondhand Effects: Alcohol Harms Due to Others' Drinking.

Although restrictive state alcohol policy environments are protective for individuals' binge drinking, research is sparse on the effect of alcohol policies on alcohol's harms to others (AHTO). We examined the lagged associations between efficacy of U.S. state alcohol policies and number of harms from others' drinking 1year later. Individuals with AHTO data in a nationally representative sample of U.S. adults (analytic sample n=26,744) that pooled the 2000, 2005, 2010, and 2015 National Alcohol Surveys and a 2015 National Alcohol's Harm to Others Survey were linked with prior-year state policy measures. We used 2 measures from the Alcohol Policy Scale (APS)-effectiveness in reducing (i) binge drinking and (ii) impaired driving, based on experts' efficacy judgments regarding 29 state alcohol policies. Three 12-month AHTO measures (due to another drinker) were experiencing: (i) either family/marriage difficulties or financial troubles; (ii) being assaulted or vandalized; and (iii) passenger with drunk driver or traffic accident. Multilevel models accounting for clustering within states and stratified by age-groups (<40 vs. ≥40) examined associations between the APS and AHTO measures, controlling for individual covariates (gender, race, education, employment and marital status, family problem-drinking history) of the victim. Only for those aged <40, the lagged APS-Binge drinking and APS-Impaired driving scores were each inversely associated with aggression-related harms and, separately, with drunk driving-related harm from someone else's drinking (ps<0.05 to<0.01). Family/financial harms were not associated with APS scores for either age-group. Composite AHTO measures (any of 3 harm-types) also were inversely associated with stronger state alcohol policy environments (ps<0.05 to <0.01). State alcohol policies may be effective in reducing, to a meaningful degree, aggression-related harms and vehicular hazards due to other drinkers, but mainly in those under 40.

Is there an association between trends in alcohol consumption and cancer mortality? Findings from a multicountry analysis.

The aim of this analysis is to examine long-term trends in alcohol consumption and associations with lagged data on specific types of cancer mortality, and indicate policy implications. Data on per capita annual sales of pure alcohol; mortality for three alcohol-related cancers - larynx, esophageal, and lip, oral cavity, and pharynx; and per capita consumption of tobacco products were extracted at the country level. The Unobservable Components Model was used for this time-series analysis to examine the temporal association between alcohol consumption and cancer mortality, using lagged data, from 17 countries. Statistically significant associations were observed between alcohol sales and cancer mortality, in the majority of countries examined, which remained after controlling for tobacco use (P<0.05). Significant associations were observed in countries with increasing, decreasing, or stable trends in alcohol consumption and corresponding lagged trends in alcohol-related cancer mortality. Curtailing overall consumption has potential benefits in reducing a number of harms from alcohol, including cancer mortality. Future research and surveillance are needed to investigate, monitor, and quantify the impact of alcohol control policies on trends in cancer mortality.

Brief of Electronic Frontier Foundation and R Street Institute As Amici Curiae, in WesternGeco, LLC v. ION Geophysical Corp., No. 16-1011

The Court’s ruling in this case could vastly expand the reach of U.S. patent law. Although the dispute before the Court involves a claim brought under 35 U.S.C. § 271(f), the theory of damages advanced by the Solicitor General and others could allow extraterritorial damages in all patent cases. Expanding patent damages in this way would effectively transform every U.S. patent into a worldwide patent. That result cannot be justified as a matter of doctrine or policy. Damages for patent infringement are limited to acts within the United States—to hold otherwise would contradict the plain text of the Patent Act, which has a clear domestic focus. Section 271(a), which limits infringement to acts “within the United States” and importation “into the United States,” is expressly limited to domestic conduct. And although § 271(f) was enacted in response to an extraterritoriality decision of this Court, that statutory provision does not provide for extraterritorial damages; rather, it remains firmly rooted in conduct “in or from the United States.” The legislative history makes clear that Congress’ sole intention with § 271(f) was narrowly to abrogate that decision of this Court and no more, contradicting the notion that § 271(f) expands patent remedies to overseas use. Thus, contrary to the arguments of Petitioner and some amici, the Patent Act explicitly renders foreign injuries inactionable, an observation sufficient to reject Petitioner’s arguments and dispose of this case. The long-standing assumption of international patent policy is that an innovator who wishes to recover damages for sales or uses in a jurisdiction must apply for a patent in that nation. Disrupting that arrangement will cause a number of harms, many of which would be felt particularly by companies operating in the United States. Extraterritorial damages, especially if imposed under a theory that would apply even to infringement under § 271(a), could expose companies that conduct research and development in the United States to worldwide damages. This would discourage companies from innovating here. International damages could also undermine other nations’ sovereignty. Both the scope of patent law and available remedies differ around the world. This means that allowing damages in U.S. courts for sales and uses overseas could undermine the autonomy of nations that have chosen not to extend patent law to certain fields. Moreover, allowing extraterritorial damages might encourage other nations’ courts to impose damages for sales and use in the United States, thereby undermining U.S. sovereignty.

Validation of the Short Gambling Harm Screen (SGHS): A Tool for Assessment of Harms from Gambling.

It is common for jurisdictions tasked with minimising gambling-related harm to conduct problem gambling prevalence studies for the purpose of monitoring the impact of gambling on the community. However, given that both public health theory and empirical findings suggest that harms can occur without individuals satisfying clinical criteria of addiction, there is a recognized conceptual disconnect between the prevalence of clinical problem gamblers, and aggregate harm to the community. Starting with an initial item pool of 72 specific harms caused by problematic gambling, our aim was to develop a short gambling harms scale (SGHS) to screen for the presence and degree of harm caused by gambling. An Internet panel of 1524 individuals who had gambled in the last year completed a 72-item checklist, along with the Personal Wellbeing Index, the PGSI, and other measures. We selected 10 items for the SGHS, with the goals of maximising sensitivity and construct coverage. Psychometric analysis suggests very strong reliability, homogeneity and unidimensionality. Non-zero responses on the SGHS were associated with a large decrease in personal wellbeing, with wellbeing decreasing linearly with the number of harms indicated. We conclude that weighted SGHS scores can be aggregated at the population level to yield a sensitive and valid measure of gambling harm.

Distress and alcohol-related harms from intimates, friends, and strangers

Alcohol’s harms to others (AHTO) has gained increased research and policy attention, yet little information is available on different social relationships involved in such harms or consequences of harms perpetrated by various types of drinkers. Using data from the 2014 to 2015 US National Alcohol Survey (N = 5,922), we present analyses comparing frequency and impacts of eight past-year harms from other drinkers. In this sample (53% female; 66% White/Caucasian, 13% Black/African American, and 15% other race; 15% Hispanic/Latino of any race; mean age = 47 years), 19% reported at least one harm in the prior 12 months, 8% reported more than one harm, 4.9% reported a family perpetrator, 3.5% a spouse perpetrator, 6.1% a friend perpetrator, and 8.1% a stranger perpetrator. Controlling for basic demographics, the number of harms in the past year and harms perpetrated by known others (but not strangers) were significantly associated with recent distress. When comparing specific harms, financial problems due to a family member’s or a spouse/partner’s drinking each were associated with significantly greater distress, as were feeling threatened or afraid of family members, spouses/partners, or friends who had been drinking. These new data shed light on possible intervention points to reduce negative impacts of AHTO in the United States.

Erratum to: Long-Term Health and Psychosocial Status of Youth who Received Substance Abuse Treatment in Adolescence

Alcohol and substance abuse in the adolescent population is a major health concern with a number of harms known to be associated with high levels of use. Few studies report on long-term health status of youth who have received treatment for a substance abuse problem during adolescence. This study aimed to describe the long-term status of a cohort of adolescents who received treatment in an intensive day treatment program situated in a tertiary care paediatric hospital. Youth participated in an interview that collected data using both standardized screening tools (GAIN-SS, AUDIT, CUDIT, DUI) as well as closed and open ended questions about education, employment, and physical and mental health status. Young adults in this sample continue to use alcohol and cannabis, with a proportion reporting problematic use. Their academic achievement is close to expected for their age group. They report concurrent mental health disorders; and as a cohort, access the health care system for both acute and chronic health conditions more than their contemporaries. These findings support the inclusion of academic, mental health and medical components in programs for adolescents with substance abuse, in order to address a broad range of determinants of health outcomes.

Time-Related Changes in Yield and Harms of Screening Breast Magnetic Resonance Imaging

PurposeBreast magnetic resonance imaging (MRI) is accepted as a useful adjunct to screening mammography for women at high risk for breast cancer. Nevertheless, concerns about false-positive findings remain, and data about MRI harms and yields are limited. The aim of this study was to quantify harms and yields of breast MRI over time in a large series of patients. MethodsA retrospective review was performed of patients at increased risk for breast cancer who underwent annual screening digital mammography and MRI from 2007 to 2013. Harms were defined as events not producing a breast cancer diagnosis (ultrasonography [US], imaging-guided core or surgical biopsy procedure, recommendation for short-term follow-up, or a combination). ResultsOf 350 high-risk patients offered MRI screening, 320 underwent 757 screening MRI procedures over time. The median age at the first MRI was 48 years. All patients met American Cancer Society criteria for annual screening breast MRI. Total harms were highest with the first MRI procedure and decreased with subsequent MRI screening. Of 75 biopsy procedures performed, including 58 US- or MRI-guided core biopsy procedures and 17 surgical biopsy procedures, 6 specimens were found to be malignant, including 2 resulting from biopsy procedures performed based on findings from the first MRI scan, 0 from the second MRI scan, 3 from the third MRI scan, and 1 from the fourth MRI scan. ConclusionAmong women followed with screening MRI, the number of harms was shown to decrease over time. Breast cancer continued to be detected in MRI studies performed over time. This study demonstrates the utility of MRI screening performed over time in high-risk women.

Just War Theory and the Last of Last Resort

The last resort criterion has a hallowed place in the just war theory tradition. Many leading just war theory scholars accept it as a jus ad bellum requirement and some powerful politicians reference it. While there are several versions of last resort, many take it to mean that peaceful options that have a reasonable chance of achieving a just cause must be exhausted before the use of force is permissible. Its justification is straightforward and commonsensical: war is terrible, inevitably results in the deaths of numerous innocents and destruction of their property, and thus should be avoided whenever possible. I argue that last resort should be dropped from the just war tradition because its inclusion in the just war tradition can result in a greater number of harms to innocents than if the precept did not exist. What should matter morally is the severity and numbers of harms inflicted on innocents, not whether those harms are inflicted violently or nonviolently. I suggest that in the context of achieving a just cause, the only actions that are permissible are those that are likely to inflict the fewest morally weighted harms and that meet the other just war theory precepts (excluding last resort). Three accounts of last resort do not permit this, whereas while a fourth does, it is redundant with an important account of the jus ad bellum proportionality precept. Thus violent policies may be preferable in some rare circumstances to nonviolent alternatives such as non-targeted sanctions and negotiations because nonviolent policies sometimes are more likely to foreseeably and avoidably result in far greater harms to innocents than violent options.

Second-hand drinking may increase support for alcohol policies: new results from the 2010 National Alcohol Survey.

The harms of second-hand smoke motivated tobacco control legislation. Documenting the effects of harms from others' drinking might increase popular and political will for enacting alcohol policies. We investigated the individual-level relationship between having experienced such harms and favouring alcohol policy measures, adjusting for other influences. We used the landline sample (n = 6957) of the 2010 National Alcohol Survey, a computer-assisted telephone interview survey based on a random household sample in the USA. Multivariable regression models adjusted for personal characteristics, including drinking pattern (volume and heavy drinking), were used to investigate the ability of six harms from others' drinking to predict a three-item measure of favour for stronger alcohol policies. Adjusting for demographics and drinking pattern, number of harms from others' drinking predicted support for alcohol policies (P < 0.001). In a similar model, family- and aggression-related harms, riding with a drink driver and being concerned about another's drinking all significantly influenced favour for stronger alcohol policy. Although cross-sectional data cannot prove a causal influence or directionality, the association found is consistent with the hypothesis that experiencing harms from others' drinking (experienced by a majority) makes one more likely to favour alcohol policies. Other things equal, women, racial/ethnic minorities, lower-income individuals and lighter drinkers tend to be more supportive of alcohol controls and policies. Studies that estimate the impact of harms from other drinkers on those victimised are important and now beginning. Next we need to learn how such information could affect decision makers and legislators.

Methadone maintenance therapy as evidence based drug abuse planning in developed countries: Can developing countries afford and learn from this experience?

Use of illicit substances of abuse is a major public health problem in developed countries like the US. However, this problem of illicit substance use has spread like a tumor to include currently developing countries where most of its youths and adolescents are actively engaged in this illegal practice. This problem is even more worse in poor resource countries, as use of these substances is accompanied with a lot of HIV- risk behaviours, and for cocaine and heroin drug injectors often share injecting equipments hence increasing the chances of contracting and spreading HIV infection. Apart from HIV infection, other infections include hepatitis B, C, abscesses and other ill-health problems such as drug dependence manifested with complex set of behaviours related to mental illnesses. For non-drug injectors, the chances of contracting and spreading HIV through their unsafe/unprotected sexual behaviours especially those having multiple partners is there. Use of these illicit substances have other consequences like compromising the dosing schedule or adherence / poor compliance to ARTs/ARVs among those enrolled. Furthermore, use of illicit substances may be accompanied with domestic sexual violence which is done without using any protective (condoms) measures) leading to HIV/AIDS and unplanned pregnancies. However, various studies and preventive approaches have been tried in the US on drug abusers in order to prevent the associated adverse health outcomes. There are many reasons why people use drugs. In many situations, drugs are being used as artificial problem-solvers such as frustrations, stress or tiredness. Drugs can often make a problem disappear for a short time but not usually the answer for solving the problem. They just help to remove it temporarily. Other people choose to use drugs to enjoy the feelings or for recreational purposes which many drugs produce. For example, many people, especially young people, experiment with using drugs to find out more about the sensations they produce. Drug use is a problem to users when it begins to cause some damage to their physical health, mental health and social well-being. These include mental illness, diseases caused by or related to use of drugs e.g. practice of sharing needles or syringes among drug injectors and also non-drug injectors may acquire HIV/AIDS and Hepatitis, crimes and violence. However, the number of harm associated with the use of drugs is increasing in Tanzania and other developing countries in Sub-Saharan Africa and globally in developed nations like the US and many others.

P.6.013 Polysubstance use among HIV-infected drinkers in Russia

During puberty, when young people are completing their education, transitioning into employment, and forming longer-term intimate relationships, a shift in emotional regulation and an increase in risky behaviour, including substance use, is seen. This Series paper considers the potential effects of alcohol, tobacco, and illicit drug use during this period on: social, psychological, and health outcomes in adolescence and young adulthood; role transitions, and later health and social outcomes of regular substance use initiated in adolescence; and the offspring of young people who use substances. We sourced consistent support for causal relations between substance use and outcomes and evidence of biological plausibility from different but complementary research designs. Many adverse health and social outcomes have been associated with different types of substance use. The major challenge lies in deciding which are causal. Furthermore, qualitatively different harms are associated with different substances, differences in life stage when these harms occur, and the quality of evidence for different substances and health outcomes varies substantially. The preponderance of evidence comes from a few high-income countries, thus whether the same social and health outcomes would occur in other countries and cultures is unclear. Nonetheless, the number of harms that are causally related to substance use in young people warrant high-quality research design interventions to prevent or ameliorate these harms.

WAITING TIME AS A PRICE FOR DECEASED DONOR KIDNEYS*

I. INTRODUCTION Kidneys for transplantation are supplied by deceased and living organ donors. Candidates for kidney transplantation face the choice of joining the waiting list for deceased donor kidneys, where many wait over 3 years before receiving an organ, or finding a living donor. Patients with living donors are transplanted immediately. In this study, I estimate the impact of waiting time on the demand for deceased versus living donor kidneys. I hypothesize that waiting time acts like a price for deceased donor organs. As waiting time increases, new transplant candidates will substitute away from the deceased donor waiting list toward living donor transplantation. This study follows extensive work on the impact of waiting times for surgery and other procedures in the British National Health Service (see, e.g., Cullis, Jones, and Propper 2000; Martin et al. 2007; Windmeijer, Gravelle, and Hoonhout 2005). In this setting, private treatment or no care form the outside option. A difficulty faced by researchers in estimating the impact of waiting time on demand is reverse causation: there is a mechanistic pathway leading from demand to waiting time and a behavioral pathway leading from waiting time to demand. I use a structural model of the wailing list to construct a predicted waiting time measure that isolates variation in waiting time due to regional differences in the demand for and supply of deceased donor kidneys. I find that use of living donor transplantation is moderately responsive to the supply of deceased donors. II. BACKGROUND Patients with end stage renal disease who are suitable candidates for kidney transplantation are referred to transplant centers for evaluation. During the initial appointment, patients are encouraged to consider living donor transplantation and to solicit possible donors from among family and friends. Living donor transplantation offers a number of advantages. There is no waiting list, and living donor transplant recipients experience better posttransplant outcomes. The only disadvantage is that it subjects healthy living donors to a medical procedure from which they derive no direct benefit, in apparent violation of the first, do no harm precept of medical ethics. Although the short-term mortality risks are extremely small (Ibrahim et al. 2009; Ingelfinger 2005; Segev et al. 2010), all donors suffer from the discomfort associated with undergoing an invasive operation. Potential living donors are subjected to an extensive physical and psychological evaluation. Traditionally, donors who were not immunologically compatible with the recipient were ruled out. Now it is increasingly common to perform transplants where donor and recipient do not match on any of the six human leukocyte antigens used to assess compatibility. This trend reflects improvements in immunosuppressive drugs and possibly, consistent with the study hypothesis, longer wait times for deceased donor kidneys. (1), (2) Patients unable to find a living donor must wait for a kidney from a deceased donor. (3) Deceased donor kidneys are allocated to patients on the waiting list based on organ procurement organization (OPO) region, waiting time, and immunologic compatibility. (4) OPOs are the 58 regional entities that oversee the consent and organ removal process. A kidney from a deceased donor is first offered to wait-listed patients in the same OPO region. If the kidney is not used by any of the local transplant centers, then it is offered to patients in other regions. (5) In 2005, 60% of kidneys were transplanted locally. The remainder were allocated to patients outside the local region based on accumulated waiting time and compatibility. There are a number of harms and risks associated with waiting for a deceased donor transplant. The longer the wait, the greater is the likelihood the patient will die before receiving a transplant. Longer waiting times are associated with worse posttransplant outcomes (Meier-Kriesche et al. …

The Ethics of Creating and Responding to Doubts about Death Criteria

Expressing doubts about death criteria can serve healthy purposes, but can also cause a number of harms, including decreased organ donation rates and distress for donor families and health care staff. This paper explores the various causes of doubts about death criteria-including religious beliefs, misinformation, mistrust, and intellectual questions-and recommends responses to each of these. Some recommended responses are relatively simple and noncontroversial, such as providing accurate information. However, other responses would require significant changes to the way we currently do business. Policymakers should establish minimum national standards for determining death to foster a trustworthy system; academics and publishers have a duty to publish only materials that substantially engage and advance the debate to minimize the harm caused by divided expert opinion; and opposition to the dead donor rule should be conceptually separated from doubts about death criteria.