Living wills and substituted judgments: a critical analysis

In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate (who may or may not hold the “power of attorney”), and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The evermore common aversion of best interest judgments entails a risk that health care providers withdraw from the decision-making process, abandoning patients (or their family members) to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit. This revised version was published online in July 2006 with corrections to the Cover Date.     

Ring substituted 3-phenyl-1-(2-pyrazinyl)-2-propen-1-ones as potential photosynthesis-inhibiting, antifungal and antimycobacterial agents

Four series of ring substituted (E)-3-phenyl-1-(2-pyrazinyl)-2-propen-1-ones were prepared by means of modified Claisen-Schmidt condensation of acetylpyrazines with aromatic aldehydes. The structures were confirmed by elemental analysis, IR, 1H NMR and 13C NMR spectra. The compounds were tested for specific biological properties and some derivatives exhibited photosynthesis-inhibiting, antifungal and antimycobacterial properties. The most pronounced effects were observed with compounds substituted with phenolic groups. Ortho-hydroxyl substituted derivatives were more potent than the corresponding para-hydroxyl substituted analogues.     

MTT比色法评价掺锶羟磷灰石固溶体细胞毒性

利用MTT比色法评价掺锶羟磷灰石固溶体（简称锶磷灰石）的细胞毒性。对自行合成含锶量克分子数比例分别为1％、5％、10％、100％的掺锶羟磷灰石用MTT比色法进行细胞毒性测试。结果表明不同含锶量锶磷灰石的细胞毒性评级均为1级,提示锶磷灰石无明显细胞毒性,掺锶量的多少对细胞相对增殖影响不明显。     

以基团为基准借电负性修正的分子距边矢量对N，N-二甲基-2-溴苯乙胺类衍生物进行结构表征和活性预测

以基团为基准并借助电负性修正分子距边矢量 (VMDE) ,对N ,N 二甲基 2 溴苯乙胺类衍生物的结构进行表征 ,然后用多元线性回归技术 (MLR)建立新分子距边矢量与其生物活性的相关关系 ,结果表明 :新分子距边矢量与生物活性之间有良好的线性关系 ,复相关系数高达R =0 96 75 ,均方根误差RMS =0 140 ,解释方差EV =0 96 19,统计量F =87 8,优于文献使用常规取代基参数获得的结果 :R =0 917,S =0 2 38,F =5 0 1.为检查模型的稳定性和预测能力 ,还作了随机抽样检验和交互校验 ,结果优良     

Synthesis and Hydrolytic Degradation of Substituted Poly(DL-Lactic Acid)s

Non-substituted racemic poly(DL-lactic acid) (PLA) and substituted racemic poly(DL-lactic acid)s or poly(DL-2-hydroxyalkanoic acid)s with different side-chain lengths, i.e., poly(DL-2-hydroxybutanoic acid) (PBA), poly(DL-2-hydroxyhexanoic acid) (PHA), and poly(DL-2-hydroxydecanoic acid) (PDA) were synthesized by acid-catalyzed polycondensation of DL-lactic acid (LA), DL-2-hydroxybutanoic acid (BA), DL-2-hydroxyhexanoic acid (HA), and DL-2-hydroxydecanoic acid (DA), respectively. The hydrolytic degradation behavior was investigated in phosphate-buffered solution at 80 and 37 °C by gravimetry and gel permeation chromatography. It was found that the reactivity of monomers during polycondensation as monitored by the degree of polymerization (DP) decreased in the following order: LA > DA > BA > HA. The hydrolytic degradation rate traced by DP and weight loss at 80 °C decreased in the following order: PLA > PDA > PHA > PBA and that monitored by DP at 37 °C decreased in the following order: PLA > PDA > PBA > PHA. LA and PLA had the highest reactivity during polymerization and hydrolytic degradation rate, respectively, and were followed by DA and PDA. BA, HA, PBA, and PHA had the lowest reactivity during polymerization and hydrolytic degradation rate. The findings of the present study strongly suggest that inter-chain interactions play a major role in the reactivity of non-substituted and substituted LA monomers and degradation rate of the non-substituted and substituted PLA, along with steric hindrance of the side chains as can be expected.     

The Rate of Healing of Duodenal Ulcers during Omeprazole Treatment

We have studied the rate of healing of duodenal ulcers in 44 patients treated with omeprazole, 40 mg once daily for 4 weeks, with or without an 80-mg loading dose on day 1. Fourteen patients (32%) had healed by the end of the 1st week's treatment and a further 27 after a further week (giving a cumulative total of 93%). All patients (100%) had healed by the end of the treatment period. There was no significant difference in healing rate between the two treatment groups. Ulcer symptoms were relieved rapidly, and the drug was well tolerated.     

Comparison of the effect of substituted benzamides on midbrain dopamine neurones after treatment of rats for 21 days

We have tested five different substituted benzamides (nemonapride, D,L-sulpiride, remoxipride, raclopride and zacopride) for their potential to decrease the number of spontaneously active dopamine neurones in the rat midbrain after treatment for 21 days. Nemonapride, D,L-sulpiride, and remoxipride significantly reduced the number of spontaneously active dopamine neurones in the ventral tegmental area, indicating an antipsychotic potential, while raclopride and zacopride induced but minor effects. The number of active dopamine neurones in the substantia nigra pars compacta was reduced by nemonapride at higher doses which should indicate the propensity for developing extrapyramidal side-effects. In conclusion, several of the substituted benzamides showed an antipsychotic profile in this test model. In addition, some of the benzamides also showed a propensity for extrapyramidal side-effects and these results are in accordance with the profile reported from clinical trials. However, the results obtained with this model indicate that raclopride neither has antipsychotic potential nor induces extrapyramidal side-effects. The reason for this discrepancy is at present not known.     

Carbohydrate tolerance during beta-adrenergic blockade in hypertension

Summary Glucose tolerance tests were done in hypertensive patients before and after treatment for several months with the beta-blocking compound pindolol, Visken. The mean blood sugar and serum insulin levels did not alter significantly during the treatment.     

Agreement between prostate cancer patients and their clinicians about utilities and attribute importance

PURPOSE: To examine the agreement between prostate cancer patients' utilities for selected health states and their rankings of the importance of six attributes of the health states and the clinicians' judgements of what would be in the patients' best interests. METHOD: Patients with newly diagnosed localized prostate cancer individually completed a time trade-off utility assessment shortly after being diagnosed. The health states evaluated were constructed from a multi-attribute utility model that incorporated six aspects of living with the disease and outcomes of treatment. Each patient assessed his current health state and three hypothetical states that might occur in the future, and provided rankings of the importance of the six attributes. The clinicians caring for each patient independently provided their views of what utilities and importance rankings would be in the patient's best interest. RESULTS: The across-participant correlations between patients' and clinicians' utilities were very low and not statistically significant. Across-participant correlations between patient and clinician importance rankings for the six attributes were also low. Across-health state and across-attribute correlations between utilities or importance rankings were highly variable across patient-clinician pairs. CONCLUSION: In the clinical settings studied, there is not a strong relationship between valuations of current and possible future health states by patients with newly diagnosed prostate cancer and their clinicians. Implications of these results for substituted judgement, when clinicians advise their patients or recommend a treatment strategy, are discussed.