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In the continuing debate about the role of the Clinical Ethics Consultant in performing clinical ethics consultations, it is often assumed that consultants should operate within ethical and legal standards. Recent scholarship has focused primarily on clarifying the consultant's role with respect to the ethical standards that serve as parameters of consulting. In the following, however, I wish to address the question of how the ethics consultant should weigh legal standards and, more broadly, how consultants might weigh authoritative directives, whether legal, institutional, or professional, against other normative considerations. I argue that consultants should reject the view that authoritative directives carry exclusionary reason for actions and, further, ethicists should interpret directives as lacking any moral weight qua authoritative directive. I then identify both implications and limitations of this view with respect to the evolving role of the ethics consultant in an institutional setting, and in doing so propose the kinds of considerations the ethicist should weigh when presented with an authoritative directive.

Pavarini et al. (2021) argue for the potential benefits of using games and other technologies to collect empirical data to enhance bioethics research. They propose a methodology called “design bioe...

In exploring possible justifications for the allocation of resources to patients with DoC, the authors argue that relevant frameworks ought to focus on potential morally important prospective benef...

In “Cognitive Transformation, Dementia, and the Moral Weight of Advance Directives,” (ADs) Emily Walsh argues that we should be cautious when weighting an AD over the current preferences of a demen...

The use of decision-making capacity assessments (DMCA) in clinical medicine is an underdeveloped yet quickly growing practice. Despite the ethical and clinical importance of these assessments as a means of protecting patient autonomy, clinicians, philosophers, and ethicists have identified a number of practical and theoretical hurdles which remain unresolved. One ethically important yet largely unaddressed issue is whether, and to what extent physicians ought to inform and obtain consent from patients prior to initiating a capacity assessment. In what follows, I address the following question: Must, or should, physicians obtain consent for capacity assessments? I argue that physicians have an ethical obligation to obtain express patient consent for capacity assessments, and in doing so, I challenge the predominant view which requires physicians to merely inform patients without obtaining consent. I then identify an underlying philosophical paradox that complicates the clinician's duty to obtain consent: in short, consent is needed for an assessment of one's ability to consent. Finally, I recommend a practical solution to this paradox of consent for capacity assessments by proposing a model of double consent from both the patient and health care representative.

In patients with inflammatory bowel disease (IBD), restless legs syndrome (RLS) may occur as an extraintestinal disease manifestation. Iron deficiency (ID) or folate deficiency/vitamin B12 deficiency (FD/VB12D) has previously been described to cause RLS. Here, we determined the prevalence and severity of RLS in IBD patients and evaluated the effect of iron and/or folic acid/vitamin B12 supplementation. Patients were screened for ID and RLS by a gastroenterologist. If RLS was suspected, a neurologist was consulted for definitive diagnosis and severity. Patients with RLS and ID, FD, or VB12D received supplementation and were followed-up at weeks 4 and 11 after starting supplementation. A total of 353 IBD patients were included. Prevalence for RLS was 9.4% in Crohn’s disease (CD) and 8% in ulcerative colitis (UC). Prevalence for the subgroup of clinically relevant RLS (symptoms ≥ twice/week with at least moderate distress) was 7.1% (n = 16) for CD and 4.8% (n = 6) for UC. 38.7% of RLS patients presented with ID, FD, and/or VB12D. Most frequently ID was seen (25.8%; n = 8). Iron supplementation resulted in RLS improvement (p = 0.029) at week 4 in seven out of eight patients. Although the overall prevalence of RLS in IBD did not differ to the general population, clinically relevant RLS was more frequent in IBD patients and, therefore, it is important for clinicians to be aware of RLS symptoms. Though for definite diagnosis and proper treatment of RLS, a neurologist must be consulted. Additionally, iron supplementation of IBD patients with ID can improve RLS symptoms. ClinicalTrials.gov No. NCT03457571

In “An argument for a narrative coherence standard”, Goldberg (2020) raises an important issue in identifying the gap between legal and clinical criteria for decision making capacity (DMC), arguing...

While the study by Lawrence and colleagues (Lawrence, Kaufmann, DeSilva, and Appelbaum 2019) offers several important insights into the ethical issues related to the use of DBS for depression, a no...

Background and Purpose— We compared outcome and complications in patients with stroke treated with intravenous thrombolysis (IVT) who could not live alone without help of another person before stroke (dependent patients) versus independent ones. Methods— In a multicenter IVT-register–based cohort study, we compared previously dependent (prestroke modified Rankin Scale score, 3–5) versus independent (prestroke modified Rankin Scale score, 0–2) patients. Outcome measures were poor 3-month outcome (not reaching at least prestroke modified Rankin Scale [dependent patients]; modified Rankin Scale score of 3–6 [independent patients]), death, and symptomatic intracranial hemorrhage. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (OR [95% confidence interval]) were calculated. Results— Among 7430 IVT-treated patients, 489 (6.6%) were dependent and 6941 (93.4%) were independent. Previous stroke, dementia, heart, and bone diseases were the most common causes of preexisting dependency. Dependent patients were more likely to die (OR unadjusted , 4.55 [3.74–5.53]; OR adjusted , 2.19 [1.70–2.84]). Symptomatic intracranial hemorrhage occurred equally frequent (4.8% versus 4.5%). Poor outcome was more frequent in dependent (60.5%) than in independent (39.6%) patients, but the adjusted ORs were similar (OR adjusted , 0.95 [0.75–1.21]). Among survivors, the proportion of patients with poor outcome did not differ (35.7% versus 31.3%). After adjustment for age and stroke severity, the odds of poor outcome were lower in dependent patients (OR adjusted , 0.64 [0.49–0.84]). Conclusions— IVT-treated stroke patients who were dependent on the daily help of others before stroke carry a higher mortality risk than previously independent patients. The risk of symptomatic intracranial hemorrhage and the likelihood of poor outcome were not independently influenced by previous dependency. Among survivors, poor outcome was avoided at least as effectively in previously dependent patients. Thus, withholding IVT in previously dependent patients might not be justified.

Fischer and Truog propose deemphasizing questions pertaining to consciousness in the care of patients with disorders of consciousness (DoC) (Fischer and Truog 2017). They critique the conceptual ba...

This is the case of a mother, 24 weeks pregnant, delivering a baby prematurely. She worries that the neonate will be impaired and, adding to her distress, that as a migrant worker with an 8-year-ol...

Background and Purpose— Copeptin levels are increased in patients diagnosed with stroke and other vascular diseases. Copeptin elevation is associated with adverse outcome, predicts re-events in patients with transient ischemic attack and is used in ruling-out acute myocardial infarction. We evaluated whether copeptin can also be used as a diagnostic marker in the prehospital stroke setting. Methods— We prospectively examined patients with suspected stroke on the Stroke Emergency Mobile—an ambulance that is equipped with computed tomography and point-of-care laboratory. A blood sample was taken from patients immediately after arrival. We analyzed copeptin levels in patients with final hospital-based diagnosis of stroke or stroke mimics as well as in vascular or nonvascular patients. In addition, we examined the associations of symptom onset with copeptin levels and the prognostic value of copeptin in patients with stroke. Results— Blood samples of 561 patients were analyzed. No significant differences were seen neither between cerebrovascular (n=383) and other neurological (stroke mimic; n=90) patients ( P =0.15) nor between vascular (n=391) and nonvascular patients (n=170; P =0.57). We could not detect a relationship between copeptin levels and time from onset to blood draw. Three-month survival status was available in 159 patients with ischemic stroke. Copeptin levels in nonsurviving patients (n=8: median [interquartile range], 27.4 [20.2–54.7] pmol/L) were significantly higher than in surviving patients (n=151: median [interquartile range], 11.7 [5.2–30.9] pmol/L; P =0.024). Conclusions— In the prehospital setting, copeptin is neither appropriate to discriminate between stroke and stroke mimic patients nor between vascular and nonvascular patients. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01382862. The Pre-Hospital Acute Neurological Therapy and Optimization of Medical Care in Stroke Patients study (PHANTOM-S) was registered (NCT01382862). This sub-study was observational and not registered separately, therefore.

Background and Purpose— Specialized management of patients with stroke is not available in all hospitals. We evaluated whether prehospital management in the Stroke Emergency Mobile (STEMO) improves the triage of patients with stroke. Methods— STEMO is an ambulance staffed with a specialized stroke team and equipped with a computed tomographic scanner and point-of-care laboratory. We compared the prehospital triage of patients with suspected stroke at dispatcher level who either received STEMO care or conventional care. We assessed transport destination in patients with different diagnoses. Status at hospital discharge was used as short-term outcome. Results— From May 2011 to January 2013, 1804 of 6182 (29%) patients received STEMO care and 4378 of 6182 (71%) patients conventional care. Two hundred forty-five of 2110 (11.6%) patients with cerebrovascular events were sent to hospitals without Stroke Unit in conventional care when compared with 48 of 866 (5.5%; P P P P =0.096). Conclusions— The triage of patients with cerebrovascular events to specialized hospitals can be improved by STEMO ambulances. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01382862.

In “Fetal Risks, Relative Risks, and Relatives' Risks”, Minkoff and Marshall (2016) argue against the claim that pregnant women may never put their fetuses at risk, concluding that such a principle...

In “Comfort measures for severe diffuse axonal injury: A patient's last wish,” Baek (2016) argues that the previously expressed wishes of the patient—relayed by the patient's health care proxy thou...

Joseph Vukov (2018) argues that clinicians ought to recognize the moral salience of both potential and actual consciousness in minimally conscious state (MCS) patients. While the recognition of pot...

Inflammatory bowel disease has been associated with neurological symptoms including restless legs syndrome. Here, we investigated the impact of restless legs syndrome in patients with inflammatory bowel disease on sleep, fatigue, mood, cognition, and quality of life. Two groups of inflammatory bowel disease patients, with and without restless legs syndrome, were prospectively evaluated for sleep disorders, fatigue, daytime sleepiness, depression, anxiety, and health-related quality of life. Furthermore, global cognitive function, executive function, attention, and concentration were assessed in both groups. Disease activity and duration of inflammatory bowel disease as well as current medication were assessed by interview. Inflammatory bowel disease patients with and without restless legs syndrome were matched for age, education, severity, and duration of their inflammatory bowel disease. Patients with inflammatory bowel disease and clinically relevant restless leg syndrome suffered significantly more frequent from sleep disturbances including sleep latency and duration, more fatigue, and worse health-related quality of life as compared to inflammatory bowel disease patients without restless legs syndrome. Affect and cognitive function including cognitive flexibility, attention, and concentration showed no significant differences among groups, indicating to be not related to restless legs syndrome. Sleep disorders including longer sleep latency, shorter sleep duration, and fatigue are characteristic symptoms of restless legs syndrome in inflammatory bowel disease patients, resulting in worse health-related quality of life. Therefore, clinicians treating patients with inflammatory bowel disease should be alert for restless legs syndrome.

Background and Purpose— Specialized computed tomography–equipped stroke ambulances shorten time to intravenous thrombolysis in acute ischemic stroke by starting treatment before hospital arrival. Because of longer travel-time-to-scene, time benefits of this concept are expected to diminish with longer distances from base station to scene. Methods— We used data from the Prehospital Acute Neurological Treatment and Optimization of Medical Cares in Stroke (PHANTOM-S) trial comparing time intervals between patients for whom a specialized stroke ambulance (stroke emergency mobile) was deployed and patients with conventional emergency medical service. Expected times from base station to scene had been calculated beforehand using computer algorithms informed by emergency medical service routine data. Four different deployment zones with–75% probability–expected arrival within 4, 8, 12, and 16 minutes and total population coverage of ≈1.3 million inhabitants were categorized for stroke emergency mobile deployment. We analyzed times from alarm-to-arrival at scene, to start of intravenous thrombolysis and from onset-to-intravenous thrombolysis. Results— Corresponding to the size of the respective catchment zone, the number of patients cared increased with distance (zone 1: n=30, zone 2: n=127, zone 3: n=156, and zone 4: n=217). Although time to stroke emergency mobile arrival increased with distance (mean: 8.0, 12.5, 15.4, and 18.4 minutes in zones 1–4), time from alarm-to-intravenous thrombolysis (mean: 41.8 versus 76.5; 50.2 versus 79.1; 54.5 versus 76.6; and 59.3 versus 78.0 minutes, respectively; all P Conclusions— In a metropolitan area such as Berlin, time benefits justify a specialized stroke ambulance service up to a mean travel time of 18 minutes from base station. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01382862.

We use tetrahedral microwave networks consisting of coaxial cables and attenuators connected by T-joints to make an experimental study of Wigner's reaction K matrix for irregular graphs in the presence of absorption. From measurements of the scattering matrix S for each realization of the microwave network we obtain distributions of the imaginary and real parts of K. Our experimental results are in good agreement with theoretical predictions., 12 pages, 6 figures

In “The Curious Case of the De-ICD,” Pullman and Hodgkinson (2016) provide a cogent and insightful practical analysis of a clinical case in which the patient's expressed interests appear to conflic...

We report the first combined experimental-theoretical study to realize and control the behavior of common resonances in a periodically driven system. Experimental data for the ionization of H(n=51) atoms by a bichromatic (6 and 18 GHz), linearly polarized electric field pulse show how the relative field phase can be used to control the ionization. 1D classical calculations show how this results from the phase control of the pendulumlike, common resonances, whose existence requires, at lowest order, two commensurate frequencies.

A sodium atomic beam with density ${10}^{13}$ ${\mathrm{cm}}^{\ensuremath{-}3}$ was illuminated by cw dye laser radiation (a few watts per square centimeter) tuned to the ${D}_{2}$ resonance line. In the energy spectrum of the emitted electrons, several lines were observed between 4 and 7 eV. Their positions and intensities indicate that seed electrons are produced either via associative ionization or via collisional ionization from excited states populated by energy-pooling collisions. These electrons are then heated through successive superelastic collisions with excited $3p$ atoms.

We have measured the electron-loss cross section for collisions between protons and highly excited hydrogen atoms having principal quantum numbers in the nominal $n$ band $44\ensuremath{\lesssim}n\ensuremath{\lesssim}50$. The c.m. collision energy range was $0.4 \mathrm{eV}l~Wl~61 \mathrm{eV}$. Theoretical ionization-cross-section results are compared with the data and are then used to unfold from the data the approximate electron-transfer cross section. Classical scaling calculations are found to be in reasonable agreement with the unfolded data while quantal predictions are not.

The results of the first measurements of the velocity dependence of the total ionization sigma/sub I/ and the total destruction sigma/sub d/ (ionization + excitation + deexcitation) cross sections for fast Rydberg-atom-neutral-molecule collisions are presented. The observed resonant structure in and the absolute magnitudes of sigma/sub I/ and sigma/sub d/ unambiguously confirm the prediction that the Rydberg electron bound to a fast atom scatters quasifreely. The data also strongly hint that the ionic core does the same.

The multiphoton ionization of highly excited hydrogen (45 < or = n < or = 57) for frequencies 9.4 < or = v < or = 11.6 GHz is of such high order 88 < or = k/sub 0/ < or = 173 that quantal tunneling may compete. Nevertheless, we observe resonances in the frequency dependence of the ionization rate caused by strong multiphoton transitions of order 3 < or = k' < or = 7 between adjacent energy levels. We show that these multiphoton transition proceed at rates comparable to the overall ionization rate. These results rule out tunneling as the dominant intense-field ionization mechanism.

We report the first precise measurements of the ionization rate ${\ensuremath{\Gamma}}_{I}(F)$ in the tunneling regime for resolved $n=30,40$ Stark substates of hydrogen. Excellent agreement is obtained with nonrelativistic numerical calculations. No effects of wave function mixing induced by relativistic or other interactions were observed. We consider and give an experimental upper limit for the magnitude of the H-D isotopic shift in ${\ensuremath{\Gamma}}_{I}(F)$.

An optical method is described that uses the Doppler shift to measure the velocity of a fast particle beam merged with a photon beam from a laser. The Doppler-tuned resonance signal is used in a feedback loop to regulate directly the velocity of the beam. The method is demonstrated using a beam of 4 He atoms pumped by CO 2 laser photons into high Rydberg pure quantum states. Applications to other areas of fast beam physical research are discussed.

We present a mechanism for the separation of strangeness from antistrangeness in the deconfinement transition. For a net strangeness of zero in the total system, the population of s quarks is greatly enriched in the quark-gluon plasma, while the s\ifmmode\bar\else\textasciimacron\fi{} quarks drift into the hadronic phase. This separation could result in ``strangelet'' formation, i.e., metastable blobs of strange-quark matter, which could serve as a unique signature for quark-gluon plasma formation in heavy-ion collisions.

This (occasionally speculative) paper considers the range of “hybrid experiments” in atomic physics that are now or may soon be possible with combined use of two rather different photon sources, monochromatized synchrotron radiation (SR) in the vacuum ultraviolet (VUV) below about 300 eV and lasers below about 5–10 eV. A wide range of experiments will employ one or more continuous lasers to create an appreciable stationary fraction of valence‐excited target atoms in a beam and will draw heavily on the techniques previously developed to create aligned or oriented targets for electron scattering experiments. The very low duty factor of most pulsed lasers mitigates against their use with SR, but it should be possible to develop specialized, mode‐locked, pulsed dye lasers whose pulse train is synchronized to that of the SR source. The development of “free‐electron” lasers at SR facilities will provide an ideal tunable laser source in the same laboratories, certainly in the infrared and perhaps into the UV. SR...

Recently developed fast-beam, laser-spectroscopic methods have made possible the production of useful beams of highly excited hydrogen atoms in individual Stark states labeled with parabolic quantum numbers {n, n1, n2, |m|}, including those with large, values of the magnetic quantum number |m|. Their use in recently completed and currently underway precise measurements of the intense electric field dependence of energy shifts, ionization rates, and other properties is reviewed in the light both of previous low-resolution experimental studies and of the large body of recent theoretical work on the hydrogen Stark problem. It is also described how these techniques will be useful for future atomic collision studies involving individual Stark states.