Withdrawing and withholding medical treatment: a comparative study between the Malaysian, English and Islamic law

The permissibility and lawfulness of withdrawing and withholding medical treatment has attracted considerable debates and criticisms, as the legal issues are drawn into entering the slippery slope of euthanasia. Proponents of "sanctity of life" views that withdrawing and withholding medical treatment with knowledge that death would result is still within the sphere of euthanasia, whereas proponents of "quality of life" argue that it is not, as death is not intended. Their arguments maintain that for patients who are totally dependant on machines to ensure the work of some bodily functions, living may amount to little more than survival as dying is prolonged. Furthermore, the prolonging of life of the dying patient has profound implications on patients themselves, their relatives, dependants and medical providers. Thus, withdrawing and withholding medical treatment would not only respect a patient's right to self-determination, by allowing them to die in their underlying condition, but will ensure that medical providers are able to concentrate on more worthwhile treatments. This paper discusses the intractable difficulties with the moral distinction between withholding and withdrawing treatment and euthanasia, as well as makes a comparative study between the present state of law in Malaysia and England on this issue. The paper further highlights the differences between civil law and Islamic law in this controversial area.     

Nuclear medicine at the crossroads

Many nuclear medicine procedures, originally developed more than 20 years ago, are now performed with new radiopharmaceuticals or instruments; it is therefore apposite to reappraise what we are doing and why we are doing it. The clinical utility of nuclear medicine is discussed with reference, by way of example, to gated blood pools scans and myocardial perfusion imaging; the importance of the referred population for the outcome of studies is stressed. Attention is drawn to the likelihood that the detection of ischemia would be enhanced by the administration of nitroglycerin prior to rest thallium injection. Emphasis is also placed on the increasing acceptance of dual-tracer studies. The significance of expression of p-glycoprotein by some tumors for sestamibi imaging is discussed, and advances in respect of fluorodeoxyglucose imaging are reviewed. The final section covers issues relating to the development of new procedures, such as the value of nuclear medicine in the detection and characterization of tissue oxygen levels and the possible future role of nuclear medicine in the management of sleeping and eating disorders.     

The issue of surrogacy in Czech law

Surrogacy is thought to be one of the most controversial methods of assisted reproduction. It involves cases where a commissioning couple asks a surrogate mother to give birth to a child that will be conceived from their egg and sperm because the woman from the commissioning couple is not able to bear the child to full term herself. They conclude an agreement where the surrogate mother binds herself to terminate all her parental rights to the child immediately after the child's birth and to delegate them together with the child to the commissioning couple. Ethical dilemmas concerning the issue of surrogacy together with all the possibilities of today's globalised world that enable infertile couples to find surrogate mothers abroad in case the legal regulations of their country put a ban on it create a space for a legislator to try to find a solution that will avoid all the risks and highlight a number of positives on the other hand. A Czech legislator is currently trying to find this solution and even though there are few children demonstrably born to surrogate mothers in the Czech Republic, the whole process of surrogacy still proceeds in a legal vacuum at the moment. We can only find the legal definition of a mother of a child as a woman that gives him or her birth and a provision of law that makes all the legal acts that evade the law void. Some practical consequences of this situation will be described in the text together with possibilities and the inspiration that comes from foreign legal regulations and cases.     

Terminal sedation: between pain relief, withholding treatment and euthanasia

In the last five to ten years there has been increasing debate on terminal sedation, a medical practice that is difficult to place between other decisions at the end of life, like alleviating pain, withholding treatment, and (in jurisdictions where this is allowed) euthanasia or physician-assisted suicide. Terminal sedation is the administration of sedative drugs with the aim to reduce the consciousness of a terminal patient in order to relieve distress. It is frequently accompanied by the withdrawal (or withholding) of life-sustaining interventions, such as hydration and nutrition. It is typically a measure of the last resort, to be considered in situations where all other measures to reduce pain and suffering have failed. While similar to palliative measures as far as the sedation itself is concerned, withholding of hydration and nutrition brings terminal sedation into the realm of non treatment decisions. At the same time, to the extent that the combination of these two measures may shorten the patient's life, the practice may be easily associated with euthanasia. It is no surprise therefore, that terminal sedation has been called (and has been disqualified as) 'slow euthanasia' or 'backdoor euthanasia'. This paper addresses the question how terminal sedation may be looked upon from a legal point of view. Is it indeed a disguised form of euthanasia, or should it be considered as a practice in its own right? In the latter case, what does it imply in legal terms, and under which conditions and safeguards could it be legally justified? To answer these questions, I will look first at the different clinical realities that may be brought under the heading 'terminal sedation'. Then I will deal with its two components--sedation on the one hand, and withholding artificial feeding on the other--in a legal perspective. The paper ends with conclusions on terminal sedation as a whole.     

网络成瘾的戒治

《第27次中国互联网络发展状况统计报告》显示,截至2010年12月底,我国网民规模达到4．57亿,互联网普及率攀升至34．3％。2010全球瓦联网发展报告发布：网民数近20亿。《中国青少年网瘾报告（2009）》显示,我同城市青少年网民中网瘾青少年约占14．1％,人数约为2404．2万。网瘾现象正在成为严重的社会问题,如何解决网瘾问题,正在成为全社会关注的焦点。     

Cerebral intraarterial fibrinolysis at the crossroads: is a phase III trial advisable at this time?

PURPOSETo describe the rationale for fibrinolysis, review the state of the art in cerebral fibrinolysis, and discuss whether it is time for phase III studies of cerebral intraarterial fibrinolysis.METHODSCritical review of the literature with statistical reevaluation of significant clinical data.RESULTSThere are abundant phase III data supporting the use of thrombolysis in the cardiovascular system. However, there are no published phase III trials of intraarterial fibrinolysis in stroke. All reports of cerebral intraarterial fibrinolysis are case series. The studies are typically small with variable treatment protocols and designs that are susceptible to bias. The only analysis comparing cerebral intraarterial fibrinolysis with conventional therapy is based on nonconcurrent controls.CONCLUSIONSStroke is common and costly. Acute stroke intervention with fibrinolytic drugs is theoretically justified. Studies done to date have significant, inferential limitations. The data suggest an association between thrombolysis, recanalization, and prognosis. However, imprecision and inadequate control of systematic error preclude conclusions regarding clinical outcomes. Randomized, controlled trials are needed to establish the clinical value of cerebral local intraarterial fibrinolysis. However, cerebral local intraarterial fibrinolysis availability, the cerebral local intraarterial arterial fibrinolysis learning curve, anticipated technological advances, unresolved procedural controversies, and ethical and fiscal considerations make a large phase III trial impractical and ill-advised at the present time. Additional basic research is needed to set the stage for a successful clinical trial.