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The past decade has seen a burgeoning of scholarly interest in conscientious objection in healthcare. While the literature to date has focused primarily on individual healthcare practitioners who object to participation in morally controversial procedures, in this article we consider a different albeit related issue, namely, whether publicly funded healthcare institutions should be required to provide morally controversial services such as abortions, emergency contraception, voluntary sterilizations, and voluntary euthanasia. Substantive debates about institutional responsibility have remained largely at the level of first-order ethical debate over medical practices which institutions have refused to offer; in this article, we argue that more fundamental questions about the metaphysics of institutions provide a neglected avenue for understanding the basis of institutional conscientious objection. To do so, we articulate a metaphysical model of institutional conscience, and consider three well-known arguments for undermining institutional conscientious objection in light of this model. We show how our metaphysical analysis of institutions creates difficulties for justifying sanctions on institutions that conscientiously object. Thus, we argue, questions about the metaphysics of institutions are deserving of serious attention from both critics and defenders of institutional conscientious objection. [ABSTRACT FROM AUTHOR]

The controversy over the equivalence of continuous sedation until death (CSD) and physician-assisted suicide/euthanasia (PAS/E) provides an opportunity to focus on a significant extended use of CSD. This extension, suggested by the equivalence of PAS/E and CSD, is designed to promote additional patient autonomy at the end-of-life. Samuel LiPuma, in his article, "Continuous Sedation Until Death as Physician-Assisted Suicide/Euthanasia: A Conceptual Analysis" claims equivalence between CSD and death; his paper is seminal in the equivalency debate. Critics contend that sedation follows proportionality protocols for which LiPuma's thesis does not adequately account. Furthermore, sedation may not eliminate consciousness, and as such LiPuma's contention that CSD is equivalent to neocortical death is suspect. We not only defend the equivalence thesis, but also expand it to include additional moral considerations. First, we explain the equivalence thesis. This is followed by a defense of the thesis against five criticisms. The third section critiques the current use of CSD. Finally, we offer two proposals that, if adopted, would broaden the use of PAS/E and CSD and thereby expand options at the end-of-life. [ABSTRACT FROM AUTHOR]

Existing studies of policy diffusion rely on quantitative or qualitative methods depending on the number of cases and the policy at hand. Studies of diffusion in Canada, for instance, almost exclusively use qualitative techniques due to the limited number of subnational units. In this article, we explore whether machine learning techniques can complement qualitative approaches in these contexts. In 2015, the Canadian federal government decided to impose the legalization of cannabis and gave the provinces and territories a short time frame to develop and implement legislation. Previous qualitative research on this case found that within-province policy development was more salient than interprovincial diffusion. Using a plagiarism detection software, we find limited evidence of exact matches between provincial legislation, but a cosine score approach reveals significant similarities across provinces. These results suggest that computational and qualitative techniques together should be used where possible to identify and analyze policy diffusion in certain contexts. [ABSTRACT FROM AUTHOR]

This article examines whether political parties reward the parliamentary activity of members of parliament (MPs) through candidate selection processes. Previous research on this question provides mixed evidence. Moreover, studies often disregard potentially unequal effects among different kinds of MPs. Using new data on all members of the Belgian Chamber of Representatives between 1995 and 2019 (N = 1108), this contribution shows that several types of parliamentary activity indeed matter both for MPs' general renomination as well as for their claim to realistic list positions. Furthermore, our study provides evidence that parliamentary activity matters more for the reselection of newcomers than for experienced MPs. [ABSTRACT FROM AUTHOR]

The article discusses the European Court of Human Rights case Mortier v. Belgium which relates to assisted dying. Topics discussed include the legal framework for euthanasia in Belgium, a patient's request for assisted dying after suffering from chronic depression, and the compatibility of a permissive framework for assisted dying against rights under the European Convention on Human Rights (ECHR).

Palliative sedation is a medical intervention to manage distress in dying patients, by reducing consciousness when symptom-directed therapies fail. Continuous deep sedation is ethically sensitive because it may shorten life and completely prevents communication. But sedation short of this is also common. There has been a steady increase in the use of sedation over recent decades. Sedation may have become a means to die while sleeping, rather than a method of last resort to alleviate suffering. Sedation may be requested or expected by patients, families or staff. The need for sedation may be being interpreted more loosely. The acceptance of a 'tolerable amount of discomfort' may have lost ground to a desire to get the final phase over with quickly. Sedation is not always a bad thing. Medical care is otherwise unable to completely control all distressing symptoms in every patient. Sedation may result from other necessary symptom control drugs. Dying when sedated can be seen by as 'peaceful'. We feel it is necessary, however, to highlight three caveats: the need to manage expectations, the cost in terms of loss of communication, and the grey area between continuous deep sedation and euthanasia. We conclude that there may be good grounds for sedation in palliative care, and in some cases, continuous deep sedation may be used as a last resort. But the criteria of necessary and proportionate drug treatment should remain. The normalisation of sedation into dying while sleeping should be resisted. [ABSTRACT FROM AUTHOR]

How can we definitively determine which biomedical choices are morally correct and which engage in seriously wrongful acts? Depending on whom one asks, one is informed that choices such as abortion, euthanasia, and significant body modification involve real moral harm (either as forms of murder or as denying the goodness of the body that God has provided), or that disallowing such "medical care" violates the basic rights of persons (where abortion, active euthanasia, and body modification are appreciated as positive expressions of personal autonomy). Secular bioethics appears no longer able to appreciate what could possibly be wrong with such activities, provided that the individuals involved consent in some fashion. Indeed, many actions that were once openly and easily recognized as sinful have become so commonplace, as well as politically desirable, as to appear as if they were obviously good. As the authors in this issue of Christian Bioethics explore, fully to appreciate the serious moral issues raised by modern medicine requires a foundational orientation to the Christian God. [ABSTRACT FROM AUTHOR]

Objectives In the Netherlands, a case of euthanasia of an incompetent patient with dementia and an advance euthanasia directive (AED) caused great societal unrest and led to a petition signed by more than 450 physicians. In this paper, we investigate these physicians' reasons and underlying motives for supporting the 'no sneaky euthanasia' petition, with the aim of gaining insight into the dilemmas experienced and to map out topics in need of further guidance. Methods Twelve in-depth interviews were conducted with physicians recruited via the webpage 'no sneaky euthanasia'. General topics discussed were: reasons for signing the petition, the possibilities of euthanasia in incompetent patients and views on good end-of-life care. Data were interpreted using thematic content analysis and the framework method. Results Reasons for supporting the petition are dilemmas concerning 'sneaky euthanasia', the over-simplified societal debate, physicians' personal moral boundaries and the growing pressure on physicians. Analysis revealed three underlying motives: aspects of handling a euthanasia request based on an AED, good end-of-life care and the doctor as a human being. Conclusions Although one of the main reasons for participants to support the petition was the opposition to 'sneaky euthanasia', our results show a broader scope of reasons. This includes their experience of growing pressure to comply with AEDs, forcing them to cross personal boundaries. The underlying motives are related to moral dilemmas around patient autonomy emerging in cases of decision-making disabilities in advanced dementia. To avoid uncertainty regarding patients' wishes, physicians express their need for reciprocal communication. [ABSTRACT FROM AUTHOR]

Recent works on the concept of dignity have opened up the otherwise quite deadlocked debate about assisted death (AD). Rather than just reinforcing already fixed positions, it seems to me that these conceptions of dignity make room for a moderate and normatively richer position on the moral permissibility of AD. I do not think that we have seen the full potential of the said conceptions and interpretations. I try in this article to contribute my part. First, I briefly recapitulate some of the paradoxical ways in which dignity is typically invoked in the debate and try to clear up some of the obvious confusions. Then, I go on to explore a particular Kantian line of thought in some recent works on dignity and AD that seems to pave the way for a moderate position with a more principled foundation than the usual compromise positions. [ABSTRACT FROM AUTHOR]

The past decade has seen a burgeoning of scholarly interest in conscientious objection in health care. Specifically, several commentators have discussed the implications that conscientious objection has for the delivery of timely, efficient, and nondiscriminatory medical care. In this paper, I discuss the main argument put forward by the most prominent critics of conscientious objection-what I call the Professional Duty Argument or PDA. According to proponents of PDA, doctors should place patients' well-being and rights at the center of their professional practice. Doctors should be prepared to set their personal moral or religious beliefs aside where these beliefs conflict with what is legal and considered good medical practice by relevant professional associations. Conscientious objection, on this account, should be heavily restricted, if even allowed at all. I discuss two powerful objections against PDA. The first objection, which I call the fallibility objection, notes that law and professional codes of conduct are fallible guides for ethical conduct and that conscientious objection has in the past and continues today to provide a check on aberrations in law and professional convention. The second, which I call the professional discretion objection, states that restrictions on conscientious objection undermine one of the cornerstones of good medical practice, namely, a practitioner's right to independent professional judgment. I argue that these two objections give us reason to retain conscience clauses in professional codes of conduct. [ABSTRACT FROM AUTHOR]

When two Christian prelates as internationally prominent as Desmond Tutu and George Carey call for the legalization of euthanasia and physician-assisted suicide, their arguments merit close consideration. This article sets out and evaluates their arguments. It concludes that the prelates rehearse the superficial case regularly advanced by euthanasia campaigners and fail adequately to engage with the arguments, both principled and practical, against legalization. [ABSTRACT FROM AUTHOR]

One major argument against prohibiting euthanasia and physician-assisted suicide (PAS) is that there is no rational basis for distinguishing between killing and allowing to die: if we permit patients to die by forgoing life-sustaining treatments, then we also ought to permit euthanasia and PAS. In this paper, the author argues, contra this claim, that it is in fact coherent to differentiate between killing and allowing to die. To develop this argument, the author provides an analysis of Saint Augustine's distinction between martyrdom and suicide, highlighting the relevance of intention in the assessment of an agent's actions. As a general matter of ethics, the intentions of agents, not just the outcomes of their actions, matter enormously for drawing distinctions between what is permissible and what is impermissible. Constructing an Augustinian account of this distinction between killing and allowing to die, the author argues that it is coherent to hold that assisted suicide is wrong, while also accepting that it is permissible to withhold or withdraw life-sustaining treatments. [ABSTRACT FROM AUTHOR]

Euthanasia and rational suicide were acceptable practices in some quarters in antiquity. These practices all but disappeared as Hippocratic, Jewish, Christian, and Muslim beliefs took hold in Europe and the Near East. By the late nineteenth century, however, a political movement to legalize euthanasia and physician-assisted suicide (PAS) began in Europe and the United States. Initially, the path to legalization was filled with obstacles, especially in the United States. In the last few decades, however, several Western nations have legalized euthanasia, and several US jurisdictions have now legalized PAS, giving state sanction to these once forbidden practices. With increasing social and political pressure to accept PAS, Christians need to understand how to think about this issue from an explicitly Christian perspective. Independent of the question of legalization, there are significant theological and ethical questions. This special issue aims to address those concerns, including: how does the practice of PAS or euthanasia impact our attitudes toward death, and what does it mean to "die well?" Should physicians, as healers, be involved in assisting patients who wish to bring about their own death? Are these methods significantly distinguished from other ethically justified practices in end-of-life care that also lead to a person's death? Can Christians, both as patients and practitioners, justify the use of these methods to relieve suffering in this manner as compatible with the faith? Although these questions are not new to the debate, it is increasingly important that these controversies are addressed as the practice of PAS is popularized. [ABSTRACT FROM AUTHOR]

Three penetrating captive bolt (PCB) placements were tested on cadaver heads from swine with estimated body weight (BW) >200 kg (sows = 232.9 ± 4.1 kg; boars = 229.3 ± 2.6 kg). The objectives were to determine tissue depth, cross-sectional brain area, visible brain damage (BD), regions of BD, and bolt–brain contact; and determine relationships between external head dimensions and tissue depth at each placement. A Jarvis PAS-Type P 0.25R PCB with a Long Stunning Rod Nosepiece Assembly and 3.5 g power loads was used at the following placements on heads from 111 sows and 46 boars after storage at 2 to 4 °C for ~62 h before treatment: FRONTAL (F)—3.5 cm superior to the optic orbits at midline, TEMPORAL (T)—at the depression posterior to the lateral canthus of the eye within the plane between the lateral canthus and the base of the ear, or BEHIND EAR (BE)—directly caudal to the pinna of the ear on the same plane as the eyes and targeting the middle of the opposite eye. For sows, the bolt path was in the plane of the brain for 42/42 (100%, 95% confidence interval [CI]: 91.6% to 100.0%) F heads, 39/40 (97.5%, 95% CI: 86.8% to 99.9%) T heads, and 34/39 (87.5%, 95% CI: 72.6% to 95.7%) BE heads; for the heads that could reliably be assessed for BD damage was detected in 25/26 (96.2%, 95% CI: 80.4% to 99.9%) F heads, 24/35 (68.6%, 95% CI: 50.7% to 83.2%) T heads, and 5/40 (12.5%, 95% CI: 4.2% to 26.8%) BE heads. For boars, the bolt path was in the plane of the brain for 17/17 (100.0%, 95% CI: 80.5% to 100.0%) F heads, 18/18 (100.0%, 95% CI: 81.5% to 100.0%) T heads, and 14/14 (100.0%, 95% CI: 76.8% to 100.0%) BE heads; damage was detected in 11/12 (91.7%, 95% CI: 61.5% to 99.8%) F heads, 2/15 (13.3%, 95% CI: 1.7% to 40.5%) T heads, and 7/14 (50.0%, 95% CI: 23.0% to 77.0%) BE heads. Tissue depth was reported as mean ± standard error followed by 95% one-sided upper reference limit (URL). For sows, total tissue thickness was different (P < 0.05) between placements (F: 52.7 ± 1.0 mm, URL: 64.1 mm; T: 69.8 ± 1.4 mm, URL: 83.9 mm; BE: 89.3 ± 1.5 mm, URL: 103.4 mm). In boars, total tissue thickness was different (P < 0.05) between placements (F: 41.2 ± 2.1 mm, URL: 56.3 mm; T: 73.2 ± 1.5 mm, URL: 83.4 mm; BE: 90.9 ± 3.5 mm, URL: 113.5 mm). For swine > 200 kg BW, F placement may be more effective than T or BE due to less soft tissue thickness, which may reduce concussive force. The brain was within the plane of bolt travel for 100% of F heads with BD for 96.2% and 91.7% of F sow and boar heads, respectively. [ABSTRACT FROM AUTHOR]

In the polarized debates about abortion and voluntary euthanasia, disability advocates, who normally align with left-wing social forces, have tended to side with conservative and religious voices in expressing concerns about the impact of technological and sociopolitical developments on disabled futures. This paper draws on the social model of disability and the virtue ethics tradition to explain the alignment between the religious and disability perspectives, and the theory of transformative choice to highlight the limits and biases of the pro-choice logic. Yet, it also recognizes the inherent contradiction of disabled advocates taking a paternalistic position against the personal agency of women and people facing terminal illnesses. A disability perspective serves the discussion of abortion and euthanasia as an encouragement to work together for the building of a society that enables people with diverse disabilities to exist and flourish, and helps pregnant women, people facing disabling and terminal illnesses, and politicians and social influencers to make informed choices. [ABSTRACT FROM AUTHOR]

The social stigmatization, persecution and murder of tuberculosis patients in Nazi Germany is a topic that has long been overshadowed by euthanasia crimes. Based on extensive archival research, this article shows that over 30,000 patients, labelled as deviant, became victims of forced detention. In so-called 'special institutions', which were part of the regime's terror apparatus, these people suffered severe physical abuse. An estimated 4,000 were deliberately starved to death or murdered by overdoses of medication. As the article argues, a long road led to the Nazi murder of tuberculosis patients and began with medical experience gathered during the First World War and in the 1920s. When the regime's handling of the disease and of tuberculosis patients is located within this much wider time frame, the notion that the exigencies of the Second World War caused the regime's radicalization falters. [ABSTRACT FROM AUTHOR]

Doctors, nurses, and pharmacists who refuse on grounds of conscience to participate in certain legal, expected, and standard practices have been accused of unprofessionally introducing their personal views into medicine. My first response is that they often are not engaging in conscientious objection because that involves invoking convictions external to those of the medical community. I contend that medicine, properly construed, is pathocentric, and so refusing to induce a pathology via abortion, contraception, euthanasia, etc. is actually being loyal to the internal morality of medicine. My second response is that even if such refusals are best considered conscientious objection, there is still no personal hijacking of medicine. Doctors refusing to induce pathologies need not refuse qua Christian, but can do so qua doctor. A pathocentric account of medicine provides a principled way of distinguishing conscientious objection from religious, idiosyncratic, and bigoted refusals. Patients' refused pathology-inducing procedures are not medically harmed. [ABSTRACT FROM AUTHOR]

Euthanasia of mature swine is challenging. Temporal and behind-the-ear locations are two sites that have been identified as alternatives to the more commonly used frontal placement. In stage one, the effectiveness of two penetrating captive bolt gun styles (cylinder or pistol) was evaluated using frontal, temporal, and behind-the-ear placement in anesthetized mature swine (n = 36; weight: 267 ± 41 kg). For stage one, when evaluating treatment efficacy by sex, the cylinder-style equipment was 100% effective in achieving death when applied to all cranial locations (frontal, temporal, and behind-the-ear) for sows; however, the pistol-style equipment was only 100% effective when applied at the behind-the-ear location for sows. For boars, the cylinder-style equipment was 100% effective when applied to the frontal and behind-the-ear location, but the pistol-style equipment was not effective for any cranial location in boars. Therefore, the pistol–frontal, pistol–temporal, pistol–behind-the-ear, and cylinder–temporal were not included for boars, and pistol–frontal and pistol–temporal were not included for sows in stage two. In stage two, commercial, mixed-breed, mature swine (n = 42; weight: 292 +/− 56 kg) were randomly assigned to one of four treatments based on the inclusion criteria described in stage one. A three-point traumatic brain injury (TBI) score (0 = normal; 1 = some abnormalities; 2 = grossly abnormal, unrecognizable) was used to evaluate six neuroanatomical structures (cerebral cortex, cerebellum, hypothalamus, thalamus, pons, and brain stem), and the presence of hemorrhage was also noted. All treatments were 100% effective in stage two. A significant interaction between gun style and placement was determined on predicting total TBI as the cylinder style produced a higher total TBI score compared with the pistol type of the magnitude of +2.8 (P < 0.01). The cylinder style tended to produce a greater TBI score than the pistol in the temporal location (+1.2; P = 0.08). No difference was noted for TBI score behind-the-ear between the cylinder- and pistol-style gun (P > 0.05). TBI tended to be less in boars compared with sows (−0.6; P = 0.08). Hemorrhage was observed in frontal, parietal, occipital, and temporal lobes. This study demonstrated that the cylinder-style captive bolt gun more effectively resulted in brain trauma and death compared with a pistol-style gun and the behind-the-ear and temporal placement showed promise as an alternative placement site for euthanizing mature pigs on-farm. [ABSTRACT FROM AUTHOR]

Clear and careful thinking is an indispensable aid in the pursuit of answers to the difficult ethical question faced by clinicians, patients, and families. In this issue of The Journal of Medicine and Philosophy devoted to issues in clinical ethics, the authors engage in this enterprise by reflecting on morally good medical decision making, conscientious objection, presumed consent in organ donation, the permissibility of surrogate decision making, and the failure of legislative limits on the scope of euthanasia in Belgium. [ABSTRACT FROM AUTHOR]

In 2002 with the passing of the Euthanasia Law, Belgium became one of the few countries worldwide to legalize euthanasia. In the 18 years since the passing of the law, much has changed. We argue that in Belgium a widening of the use of euthanasia is occurring and that this can be ethically and legally problematic. This is in part related to the fact that several legal requirements intended to operate as safeguards and procedural guarantees in reality often fail to operate as such. We focus on three kinds of safeguards or procedural guarantees: (1) the legally defined due care criteria for eligibility for euthanasia; (2) the consultation of a second (and sometimes third) physician; and (3) the reporting of euthanasia cases to the Federal Control and Evaluation Commission for Euthanasia. We will show how each of these three safeguards can exhibit shortcomings in theory and practice. [ABSTRACT FROM AUTHOR]

In 2002, the Belgian Act on euthanasia came into effect, regulating the intentional ending of life by a physician at the patient's explicit request. Subsequently, the number of reported euthanasia deaths increased every year. Specifically, the proportion of euthanasia deaths in older persons has risen significantly in the last few years. Since the conception of the Euthanasia Act, Belgian physicians have been confronted with challenges concerning euthanasia requests in older persons with polypathology, tiredness of life or dementia. By exploring these issues, this commentary highlights the importance of a meticulous and team-based assessment of the (i) seriousness of the underlying condition, (ii) voluntariness of the request and (iii) decisional capacity of the older person requesting euthanasia. [ABSTRACT FROM AUTHOR]

Most representative democracies seem to experience dwindling levels of legitimacy in the eyes of citizens. Nevertheless, it remains unclear what people want from parliamentary decision-making. In this study, we test the impact of outcome favourability, actor involvement and justifications on the perceived legitimacy of a parliamentary decision-making process on euthanasia in Finland. We do so with the help of a survey experiment (n = 1243), where respondents were exposed to a vignette where the treatments varied randomly. The results suggest that outcome favourability is of primary importance, but the involvement of experts and citizens also boost legitimacy in the eyes of citizens. Justifications, or presenting arguments for the decisions, does not enhance legitimacy and may even cause a backfire mechanism where the difference between getting and not getting the preferred outcome is amplified. [ABSTRACT FROM AUTHOR]

Background: Euthanasia and assisted suicide laws in the Netherlands require physicians meet clinical guidelines when performing the practice to ensure death is peaceful and painless. Despite oversight by the regional review committees over each case, little research exists into the frequency of guideline deviation and the reasons for nonadherence.Methods: Cases reported and reviewed between 2012 and 2017 that did not meet due medical care were analysed for thematic content. Semistructured interviews were conducted with 11 Dutch physicians on their experience with the clinical and pharmacological elements of euthanasia and assisted suicide, their interaction and comportment with the recommended guidelines, and reasons why guideline deviation might occur. Reported case reviews and interviews were used to obtain themes and subthemes to understand how and why deviations from clinical guidelines happened.Results: Violations of due medical care were found in 42 (0.07%) of reported cases. The regional review committees found physicians in violation of due medical care mostly for inadequate confirmation of coma-induction and deviations from recommended drug dosages. Physicians reported that they rarely deviated from the guidelines, with the most common reasons being concern for the patient's family, concern over the drug efficacy, mistrust in the provided guidelines, or relying on the poor advice of pharmacists or hospital administrators.Conclusions: Deviations from the guidelines and violations of due medical care are rare, but should nonetheless be monitored and prevented. A few areas for improvement include skills training for physicians, consistency between review committee rulings, and further clarity on dosage recommendations. [ABSTRACT FROM AUTHOR]

Christopher Boorse is very skeptical of there being a pathocentric internal morality of medicine. Boorse argues that doctors have always engaged in activities other than healing, and so no internal morality of medicine can provide objections to euthanasia, contraception, sterilization, and other practices not aimed at fighting pathologies. Objections to these activities have to come from outside of medicine. I first argue that Boorse fails to appreciate that such widespread practices are compatible with medicine being essentially pathocentric. Then I contend that the pathocentric essence, properly understood, does not prohibit physicians from engaging in actions that are not aimed at combating pathologies, but rather supports an internal morality of medicine that allows medical providers to refuse without penalty to engage in practices that promote pathologies. [ABSTRACT FROM AUTHOR]

Introduction: Rapid aeromedical evacuation (AE) is standard of care in current conflicts. However, not much is known about possible effects of hypobaric conditions. We investigated possible effects of hypobaria on organ damage in a swine model of acute lung injury.Methods: Lung injury was induced in anesthetized swine via intravenous oleic acid infusion. After a stabilization phase, animals were subjected to a 4 hour simulated AE at 8000 feet (HYPO). Control animals were kept at normobaria. After euthanasia and necropsy, organ damage was assessed by combined scores for hemorrhage, inflammation, edema, necrosis, and microatelectasis.Results: Hemodynamic, neurological, or hematologic measurements were similar prior to transport. Hemodynamic instability became apparent during the last 2 hours of transport in the HYPO group. Histological injury scores in the HYPO group were higher for all organs (lung, kidney, liver, pancreas, and adrenal glands) except the brain, with the largest difference in the lungs (P < 0.001).Conclusions: Swine with mild acute lung injury subjected to a 4 hour simulated AE showed more injury to most organs and, in particular, to the lungs compared with ground transport. This may exacerbate otherwise subclinical pathology and, eventually, manifest as abnormalities in gas exchange or possibly end-organ function. [ABSTRACT FROM AUTHOR]

Introduction: To establish a rabbit model of posterior penetrating eye injury as a platform to test potential therapeutics.Materials and Methods: Anesthetized rabbits received posterior penetrating eye injury in one eye, whereas contralateral eyes were maintained as uninjured controls. Rabbits were randomized into two experimental groups. Group A was euthanized on Day 14 postinjury to determine retinal fibrosis at an early phase of disease progression. Group B was euthanized on Day 28 postinjury to examine retinal fibrosis at a late phase of disease progression. We examined animals on postinjury Days 7, 14, 21, and 28 with indirect ophthalmoscope and fundus photography. After euthanasia, eyes were processed for histology and immunofluorescence labeling of fibrotic proteins α-smooth muscle actin and collagen I.Results: Early fibrosis was detected by Day 14, as indicated by indirect ophthalmoscopy and fundus imaging. Fibrotic membranes were visible at sites of injury. Immunofluorescence analysis detected α-smooth muscle actin and collagen I within the fibrotic membranes.Conclusions: These data show that ocular fibrosis can be detected within 14 days after initial injury, with more severe fibrosis detected at 28 days postinjury. These results will be used to determine the optimal time points for later studies designed to test treatment strategies. [ABSTRACT FROM AUTHOR]

Edmund Pellegrino and David Thomasma's writings have had a worldwide impact on discourse about the philosophy of medicine, professionalism, bioethics, healthcare ethics, and patients' rights. Given their works' importance, it is surprising that commentators have ignored their admission of an unresolved and troubling dilemma and inconsistency in their theory. The purpose of this article is to identify and state what problems worried them and to consider possible solutions. It is argued that their dilemma stems from their concerns about how to justify professional rules restricting colleagues from performing acts they view as direct, active, and formal (intentional) killings, such as physician-assisted suicide, mercy killing, and abortion. It is further argued that their inconsistency is that they both assert and deny that professional colleagues should not use their moral or theological values to impose professional restrictions on other colleagues without adequate philosophical grounds. At risk are their arguments about the nature of an internal morality for medicine, a secular and multicultural basis for medical ethics, and a nonarbitrary way to determine what acts fall outside the ends of medicine. These are arguments they claim also apply to other healthcare professions. The article begins with a brief overview of their key positions to provide the context in which they make their admission. [ABSTRACT FROM AUTHOR]

Canadians are looking to expand their Medical Assistance in Dying (MAID) program to include mature minors. Yet, little evidence exists to support this expansion. The Council of Canadian Academies released a report in December 2018 indicating that little is known about how mature minors make meaning of end of life care. To address this knowledge gap, research is needed to understand how mature minors make meaning of the dying process in the first place. Since social perceptions drive Canadian health care, practice, and end of life mentalities, the question that needs to be asked is: What is the Canadian perception of a good death for mature minors? To answer this question it is first necessary to examine the meaning that death and dying hold for mature minors, as voiced by mature minors themselves. [ABSTRACT FROM AUTHOR]

The article analyzes the provisions of the Belgian Euthanasia Law which allows minors with capacity for discernment to obtain euthanasia. Topics discussed include the capability of minors to exercise their rights as patients, the conflict of the Euthanasia Law with human rights, and the provisions of the Belgian Civil Code about non-emancipated minors.

Debates on morally acceptable and lawful end-of-life (EOL) practices in pediatrics were reignited by the recent amendment in Belgian law to allow euthanasia for minors of any age who meet the criteria for capacity. Euthanasia and its legalization in pediatrics are often opposed based on the availability of aggressive palliative sedation. For terminally ill patients, this type of sedation is often identified as continuous and deep sedation until death (CDS). We demonstrate that this reasoning is based on flawed assumptions: (1) CDS is a morally preferable alternative to euthanasia; (2) CDS can meet the same patient needs as euthanasia; (3) children lack the capacity and experience to make EOL decisions; (4) unlike euthanasia, CDS does not raise capacity issues. Our aim is not to reject CDS as a valid option at the EOL, nor to offer a clear-cut defense of euthanasia for minors, but to emphasize the ethical issues with both practices. [ABSTRACT FROM AUTHOR]

We revisit the evidence attributing sentience-pain-suffering to aquatic animals. The objective is to inform readers of the current state of affairs, to direct attention to where research is needed, and to identify "wicked" questions that are difficult to resolve unequivocally. By separating the ethical from the scientific debate, applying organized skepticism to the latter, and taking a pragmatic approach that does not depend on resolving the "wicked" questions, we hope to focus and strengthen research on aquatic animal welfare. A second but closely-related objective is to briefly summarize the research used to support the regulations governing the welfare of aquatic animals, particularly its limitations. If you interact with aquatic animals, these regulations already affect you. If the regulatory environment continues on its current trajectory (adding more aquatic animal taxa to those already regulated), activity in some sectors could be severely restricted, even banned. There are surely some lively debates and tough choices ahead. In the end, extending legal protection to aquatic animals is a societal choice, but that choice should not be ascribed to strong support from a body of research that does not yet exist, and may never exist, and the consequences of making that decision must be carefully weighed. [ABSTRACT FROM AUTHOR]

Paul Ramsey's ethics have been notable for the way he draws on the covenantal theology of Karl Barth for his own ethics. Specifically, Ramsey makes use of the concept of covenant in his landmark work on medical ethics, The Patient as Person. Covenant and the accompanying grammars of "care" and "faithfulness" are suffused throughout the book, but the theological foundations are mostly implicit with only a few indirect allusions in the preface. This paper aims to uncover and make explicit Ramsey's covenantal casuistry in The Patient as Person, with particular focus on the moral debate surrounding euthanasia. It is argued that Ramsey's normative claim that a Christian ethics grounded in covenantal theology "ought only to care for the dying" provides a persuasive moral paradigm for addressing the question of euthanasia in contradistinction to the current rights-based paradigms that encourage and justify the practice. Although Ramsey's account faces considerable cultural headwinds, his covenant paradigm provides a coherent and theologically robust account of fundamental Christian norms and could better situate and explain Christian moral commitments in the practice of medicine and other questions of public moral concern. [ABSTRACT FROM AUTHOR]

The articles in this issue serve as a commemoration of the fiftieth anniversary of Paul Ramsey's groundbreaking text Patient as Person: Explorations in Medical Ethics. Each seeks in its own way to examine the work of Paul Ramsey and to illustrate the enduring relevance of his work today, almost fifty years after the publication of Patient as Person. In this issue, Melissa Moschella relies on Ramsey's discussion of death and organ donation to reflect on current issues of public trust in bioethical matters; Patrick Smith engages Ramsey on euthanasia; Daniel Strand mines that concept so central to Ramsey's work, covenant, and applies it to current considerations of euthanasia; Bryan Pilkington places Ramsey's arguments against the selling of organs in dialogue with new arguments in favor of that practice; and, most helpfully, Gilbert Meilaender frames the issue with a short, reflective, intellectual biography of the man. [ABSTRACT FROM AUTHOR]

Ramsey sees life as a gift and a trust given to people by God. This theological understanding of human life frames his judgment of the immorality of euthanasia in its many forms. Assuming Ramsey's theological insights and framing of this issue, I highlight a particular way of thinking about euthanasia that both seems to capture the essence of the debate and does not necessarily build the moral evaluation into its description. I aim to identify and unpack the description most consistent with the claims made by Ramsey of how other end-of-life (EOL) care options are seen as life choices in order to die well enough. If this project is rightheaded, it can be used as a backdrop for assessing how many of the currently accepted and perhaps developing options in EOL and palliative care may or may not be morally distinct from euthanasia. Therefore, those who oppose euthanasia while wanting also to maintain the appropriateness of many of other EOL care options in certain situations are not acting inconsistently. This primarily conceptual work is done in service to those who take Ramsey's theological framework seriously. [ABSTRACT FROM AUTHOR]

Proper methods for euthanasia are critical for research with birds. Training in these methods is generally required by institutional animal care and use committees for any research that involves handling of birds, even if the intent is for birds to be released into the wild. Rapid cardiac compression (RCC) remains a preferred method for quick euthanasia in field settings but has not been described adequately in the literature. We describe proper application of RCC for euthanasia of small birds. We also provide external cues for a bird as it progresses toward death as well as other considerations when using RCC. Note that RCC is also known as "thoracic compression," but that term is not biologically accurate and should be abandoned. [ABSTRACT FROM AUTHOR]

La décision de la Cour suprême dans Carter c. Canada (2015) a suscité des modifications au Code criminel du Canada, de sorte que « l'aide du médecin pour mourir » est désormais une possibilité légale pour les patients adultes et consentants « affecté[s] de problèmes de santé graves et irrémédiables » qui se caractérisent par des souffrances « persistantes » et « intolérables ». En juin 2016, le projet de loi C-14 était adopté, autorisant la prestation de l'aide médicale à mourir (AMM) aux adultes admissibles dont le décès est « raisonnablement prévisible ». Cette loi fédérale prévoit un rapport sur le statut des « mineurs matures » (actuellement exclus de la loi fédérale), portant sur leur admissibilité potentielle à l'AMM. Ce rapport devrait être présenté au Parlement d'ici décembre 2018. Les médecins et les autres professionnels de la santé ont le privilège et la responsabilité de garantir les meilleures normes de soins aux nouveau-nés, aux enfants et aux adolescents en fin de vie. Parmi leurs obligations de diligence essentielles et en constante évolution, ils doivent aborder chaque situation de fin de vie de manière réfléchie, respectueuse et individuelle, dans le respect des besoins sociaux, culturels et spirituels de chaque patient (et de sa famille). Le présent document de principes décrit le contexte juridique et médical de l'AMM au Canada. On y présente le point de vue de la pédiatrie, issu d'un vaste processus de consultation structuré mené au Canada et ailleurs. Même si les « mineurs matures » sont les seuls jeunes devant faire l'objet d'un examen législatif au Canada, il est capital d'examiner les demandes d'AMM et les attitudes entourant l'AMM à l'égard des mineurs de tout âge, et ce, pour deux grandes raisons : • De plus en plus de parents de nourrissons et d'enfants ayant toujours été inaptes à consentir, y compris ceux qui sont trop jeunes pour prendre une décision raisonnée, et de jeunes parlent de questions liées à l'AMM aux professionnels de la santé canadiens. D'après les résultats d'un sondage réalisé par le Programme canadien de surveillance pédiatrique (PCSP), les parents soulèvent davantage ces questions avec les pédiatres que les mineurs. • Au Canada, les discussions sur les politiques en matière d'AMM ont relevé autant de la question et du contexte de la souffrance que des considérations d'autonomie. La loi actuelle interdit explicitement l'AMM pour les personnes inaptes lorsque la demande provient d'un tiers, mais les parents peuvent demander l'AMM au nom de leur enfant mourant. [ABSTRACT FROM AUTHOR]

The Supreme Court decision in Carter v. Canada (2015) has led to changes to the Canadian Criminal Code, such that physician-assisted death is now a legal option for consenting adult patients who have a 'grievous and irremediable medical condition' that causes 'enduring' and 'intolerable' suffering. In June 2016, Bill C-14 was enacted, allowing medical assistance in dying (MAID) for an eligible adult whose death is 'reasonably foreseeable'. An independent report on the status of 'mature minors' (who are currently excluded under federal legislation), with focus on their potential eligibility for MAID, was required by the 2016 Act and is expected to be presented to Parliament by December 2018. Ensuring that newborns, children and youth receive the highest possible standard of care as they are dying is a privilege and a responsibility for physicians and allied professionals. Bringing a thoughtful, respectful and personal approach to every end-of-life situation is an essential and evolving duty of care, and the process should meet each patient's (and family's) unique social, cultural and spiritual needs. This statement describes the current Canadian legal and medical context of MAID and articulates a paediatric perspective that has emerged from-and been informed by-the broad, structured consultation process unfolding in Canada and elsewhere. Although 'mature minors' are the only youth currently mandated for further legislative consideration in Canada, the need to examine requests for and attitudes around MAID for minors of all ages remains compelling for two main reasons: • Canadian health care professionals are increasingly being approached by the parents of 'never-competent' infants and children, including those too young to make a reasoned decision, and by youth themselves, to discuss MAID-related issues. Results from a Canadian Paediatric Surveillance Program (CPSP) survey, discussed below, indicate that parents raise such questions with paediatricians more often than do minors. • The discussion of MAID policy in Canada has been framed as much by the issue and context of suffering as by considerations of autonomy. While current legislation clearly prohibits MAID for incapable persons at the request of any other person, it is possible that parents may request MAID on behalf of their dying child. [ABSTRACT FROM AUTHOR]

Christianity's opposition to euthanasia and assisted suicide is grounded in its recognition of such actions as serious violations of the prohibition against murder and self-murder, even in cases where those individuals consent or otherwise signal their willingness to die as in cases of voluntary euthanasia. Fully to appreciate the implications of assimilating assisted death into medical practice, one must recognize the spiritual significance of killing on the physicians who euthanize patients or who aid and abet patients in killing themselves. One will also need to appreciate the spiritual importance of such actions on the patients killed. Physician-assisted suicide and voluntary euthanasia are not neutral actions. Moreover, that the patient desired or requested the killing does not change the moral character of the act or its spiritual significance. This issue of Christian Bioethics explores the implications for medicine and society as physician-assisted suicide and voluntary euthanasia are assimilated into contemporary healthcare practice. [ABSTRACT FROM AUTHOR]

According to the Standard View, a doctor who withdraws life-sustaining treatment does not kill the patient but rather allows the patient to die-an important distinction, according to some. I argue that killing (and causing death) can be understood in either of two ways, and given the relevant understanding, the Standard View is insulated from typical criticisms. I conclude by noting several problems for the Standard View that remain to be fully addressed. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, euthanasia or assisted suicide (EAS) is neither a right of the patient nor a duty of the physician. Beside the legal requirements, physicians can weigh their own considerations when they decide on a request for EAS.Objective: We aim at a better understanding of the considerations that play a role when physicians decide on a request for EAS.Methods: This was a qualitative study. We analysed 33 interviews held with general practitioners (GPs) from various regions in the Netherlands.Results: The considerations found can be divided in three main types. (i) Perceived legal criteria, (ii) individual interpretations of the legal criteria and (iii) considerations unrelated to the legal criteria. Considerations of this 3rd type have not been mentioned so far in the literature and the debate on EAS. Examples are: the family should agree to EAS, the patient's attitude must reflect resignation, or conflicts must be resolved.Conclusions: Our study feeds the ethical discussion on the tension that can arise between a physician's own views on death and dying, and the views and preferences of his patients. When considerations like 'no unresolved conflicts' or 'enough resignation' influence the decision to grant a request for EAS this poses questions from an ethical and professional point of view. We hypothesise that these considerations reflect GPs' views on what 'good dying' entails and we advocate further research on this topic. [ABSTRACT FROM AUTHOR]

Handling, weaning, and euthanasia are some of the most stressful practices performed on cow-calf operations. Although strategies to minimize stress exist, their use on western Canadian cow-calf operations is unknown. The objectives were to describe current stress-associated practices on western Canadian cow-calf operations, describe producer and operation demographics associated with the use of nonabrupt weaning methods, and explore producer perceptions toward these practices. A questionnaire focusing on stressful management practices was delivered to 109 cow-calf producers in western Canada. Fifteen respondents were purposively selected for individual interviews. The majority of producers reported calves less than 1 wk of age were handled by manual restraint (87%) and those older than 1 wk of age were handled using a cattle squeeze or table. Most producers performed abrupt weaning (70%). Interviewees often mentioned that cost and logistics were major factors in deciding on a weaning strategy. Pasture availability and facilities were viewed as constraints toward the adoption of a nonabrupt weaning method. Animal stress was considered, as producers expressed concern that nonabrupt weaning methods may cause increased stress because of the additional handling required. Producers conveyed that animal age was a major factor that impacted weaning stress and that improved animal performance might motivate them to adopt a nonabrupt weaning strategy. Producers also expressed reluctance to change previously successful traditional approaches. Of respondents, 13% did not euthanize cattle on farm and 8% did not confirm death. Producers interviewed reported that the decision to euthanize cattle on farm was difficult and that veterinary advice was often considered. Factors that influenced their decision to euthanize included the animal's likelihood of recovery and degree of pain and distress. Finally, producers explained that they considered whether the animal was salvageable and able to be transported. Identification of common methods of handling provides focus for future research to determine optimal handling strategies. Identified barriers to nonabrupt weaning may be addressed through research, extension, or policy to encourage the adoption of weaning methods that could improve animal welfare. Confirmation of death after euthanasia was identified as an area that needs to be addressed by producer education to minimize animal stress during on-farm euthanasia. [ABSTRACT FROM AUTHOR]

The Common Swine Industry Audit (CSIA) was developed and scientifically evaluated through the combined efforts of a task force consisting of university scientists, veterinarians, pork producers, packers, processers, and retail and food service personnel to provide stakeholders throughout the pork chain with a consistent, reliable, and verifiable system to ensure on-farm swine welfare and food safety. The CSIA tool was built from the framework of the Pork Quality Assurance Plus (PQA Plus) site assessment program with the purpose of developing a single, common audit platform for the U.S. swine industry. Twenty-seven key aspects of swine care are captured and evaluated in CSIA and cover the specific focal areas of animal records, animal observations, facilities, and caretakers. Animal-based measures represent approximately 50% of CSIA evaluation criteria and encompass critical failure criteria, including observation of willful acts of abuse and determination of timely euthanasia. Objective, science-based measures of animal well-being parameters (e.g., BCS, lameness, lesions, hernias) are assessed within CSIA using statistically validated sample sizes providing a detection ability of 1% with 95% confidence. The common CSIA platform is used to identify care issues and facilitate continuous improvement in animal care through a validated, repeatable, and feasible animal-based audit process. Task force members provide continual updates to the CSIA tool with a specific focus toward 1) identification and interpretation of appropriate animal-based measures that provide inherent value to pig welfare, 2) establishment of acceptability thresholds for animal-based measures, and 3) interpretation of CSIA data for use and improvement of welfare within the U.S. swine industry. [ABSTRACT FROM AUTHOR]

Euthanasia is a necessary act for any facility keeping live animals. Nevertheless, the crucial role and responsibility of the stockperson in deciding and conducting on-farm euthanasia has been overlooked. Stockperson characteristics and knowledge that lead to appropriate decision-making and the skills to competently perform the procedure remain to be identified. An important component of the stockperson's characteristics that predict behavior is the stockperson's attitudes. This preliminary study investigated the factors that influence stockperson attitudes toward the practice of on-farm euthanasia in the pork industry. A total of 120 stockpeople from 10 Australian pig farms (ranging in size from 50 to 4,754 sows and from 2 to 32 employees) completed a questionnaire based on focus group input to assess their attitudes toward euthanasia and decision processes. Factors identified included stockperson attitudes and attributes (empathy affect, empathy attribution, feeling bad about euthanizing, and negative attitudes to pigs), beliefs about the working environment (perceived time constraints and relying on others), and factors related to decision-making (comfortable with euthanasia, trouble deciding and avoid if possible, confidence, insufficient knowledge, seeking knowledge, and using sources to get advice). Numerous significant correlations were found between these variables. Furthermore, regression analyses showed confidence as the only significant predictor of being comfortable with euthanasia (12.5% of the variance; P < 0.001); insufficient knowledge and empathy attribution both as predictors of trouble deciding and avoid if possible (15.1% of the variance; P = 0.001 and P = 0.032, respectively); and empathy affect, insufficient knowledge, and perceived time constraints as predictors of feeling bad about euthanizing (23.2% of the variance; P < 0.001, P = 0.006, and P = 0.022, respectively). Stockpeople reported seeking more knowledge if they had not euthanized an animal before working with pigs (P = 0.05), and women reported greater difficulty than men in conducting euthanasia (P < 0.01). The findings indicate that euthanasia, which comprises both a decision-making process and the act itself, can adversely affect stockpeople. This preliminary study offers insights for implementation of successful practical and humane pig euthanasia protocols on farm. This will benefit stockperson well-being and animal well-being alike. [ABSTRACT FROM AUTHOR]

Current research guidelines for ectothermic tetrapod vertebrates prohibit the use of cold as an adjunct to gaseous anesthesia, and they prohibit freezing as a means of euthanasia of these same animals. Here, we argue that those guidelines merit re-evaluation. Under natural conditions, numerous amphibians and reptiles experience large variations of body temperature, and life at low temperatures is natural. In tropical species less tolerant of cold, nociception is likely to be extinguished at low temperatures because of the anesthetizing actions of cold on membranes and cold block of nerve conduction. Physical principles and physiological data suggest that smaller ectothermic vertebrates do not experience pain attributable to ice crystals that form during freezing. Therefore, whole-body cooling, followed by freezing, should be a humane form of euthanasia for numerous smaller ectothermic species. In addition, we believe that cooling offers a humane and useful means of supplementing currently acceptable methods of anesthesia. [ABSTRACT FROM AUTHOR]

Many proponents of euthanasia eschew appeals to religious premises as good reasons for thinking that human life has intrinsic worth. The reasons offered are that religious reasons do not meet some theory-neutral epistemic standard. My first argument is to show that pro-euthanasia arguments fail to meet those same standards. In order to avoid this incoherence, the rejection of religious reasons is a function of thinking that such reasons are simply false. Arguing against religious belief has typically fallen to the evidential argument from evil. My second argument is to show that the argument from evil must hold to a basic goods account of human life. Such an account is contrary to the view of human life held by most euthanasia proponents. So, euthanasia proponents who reject religious belief on the basis of an argument from evil must hold to a contradictory view of human worth. One cannot both be a euthanasia proponent and reject arguments against euthanasia (that are based in part on religious premises). I explore ways to resolve this tension, but none save pro-euthanasia arguments. [ABSTRACT FROM AUTHOR]

Christian bioethics starts with different metaphysical, epistemological, and teleological assumptions. It starts with God as Creator and Sustainer of the universe who as the second person of the Godhead became incarnate as our Redeemer and Lord. Morality reflects God's nature and is known through reason and intuition guided by revelation. The end of a Christian bioethics is to discover the way our God intends for us to live and to discover the type of person He intends for us to be in order to live a holy and sanctified life. Christian bioethicists will seek integration among their core beliefs and between their beliefs and actions, and they will bear witness to their beliefs in a world that is not yet redeemed. Each contribution in this issue represents an example of these types of Christian integration. Each bears witness to the fact that a Christian bioethics is different. [ABSTRACT FROM AUTHOR]

Purpose of the Study: This study aims to contribute an alternative understanding of the position of older people in the euthanasia and assisted suicide (EU/AS) debate. Design and Methods: Seven interviews were analyzed using Foucauldian discourse analysis, to explore concepts like knowledge, power, subjectifkation and surveillance. Results: The participants presented a "confused and conflicted" discourse, expressing the view that EU/AS is a family affair, whilst also articulating a strong sense of self-determination. Although a discourse of the medicalization of dying through medical control and surveillance was endorsed, an alternative discourse of "dying outside the medical gaze" emerged. Participants, who were in favor of EU/AS, felt "voiceless," as apparent double standards were applied in the debate, and powerful others, for example, physicians and politicians, seemed reluctant to engage. Within an "aged death" discourse, the anticipated dependency on poor care from (professional) others, made participants consider EU/AS as ways of avoiding this stage of life and the associated loss of dignity. Implications: By using Foucauldian discourse analysis, alternative power relationships were revealed which might give a different interpretation to the concept of the "slippery slope." Societal discourses and related behaviors, which devalue the dependent and old, might become internalized by older people, leading them to consider EU/AS as preferable end-of-life options. [ABSTRACT FROM AUTHOR]

On-farm euthanasia of pigs considers aspects of welfare and economics, but few comprehensive guidelines are available for swine producers and further, do not consider cultural barriers. The Hispanic workforce largely represents the bulk of agricultural workers. Euthanasia requires the ability to identify compromised pigs, technical skills, and willingness to euthanize pigs. In addition, timely euthanasia is part of the Common Swine Industry Audit (CSIA) and thus, can lead to failed audits. The U.S. swine industry employs a large percentage of Latin American workers through NAFTA visas. These workers vary in their degree of education and pig experience. Proper training of this workforce and identification of the barriers to performing timely euthanasia is critical. The objectives of this study were to: 1) develop and validate surveys (including demographic information, swine management, moral injury events scale, impact of event scale and the professional quality of life scale) in Spanish to determine Hispanic caretaker attitudes towards timely euthanasia and 2) to assess Hispanic caretakers using the validated surveys to determine the barriers associated to timely euthanasia. A total of 163 workers were surveyed and data were analyzed using Chi-Square. The results indicated that employees with less time working in the company presented less CSIA knowledge and a reduced capacity to identify pigs that needed to be euthanizing (P< 0.001). Spearman's rankorder correlations indicated that stress was the most frequently correlated scale, related with burnout, transgressions, betrayals, and worker satisfaction (P=0.022). A Mann-Whitney U test determined that there was a gender difference, presenting a high level of stress and a low level of satisfaction in females and the opposite results in males (P=0.026). It is important to identify the factors that decrease or negatively affect the ability of employees to perform euthanasia in order to provide efficient training that improves good practices in the swine industry. [ABSTRACT FROM AUTHOR]