The ambiguity about death in Japan: an ethical implication for organ procurement.

In the latter half of the twentieth century, developed countries of the world have made tremendous strides in organ donation and transplantation. However, in this area of medicine, Japan has been slow to follow. Japanese ethics, deeply rooted in religion and tradition, have affected their outlook on life and death. Because the Japanese have only recently started to acknowledge the concept of brain death, transplantation of major organs has been hindered in that country. Currently, there is a dual definition of death in Japan, intended to satisfy both sides of the issue. This interesting paradox, which still stands to be fully resolved, illustrates the contentious conflict between medical ethics and medical progress in Japan.     

What people close to death say about euthanasia and assisted suicide: a qualitative study

OBJECTIVE: To explore the experiences of people with a "terminal illness", focusing on the patients' perspective of euthanasia and assisted suicide. METHOD: A qualitative study using narrative interviews was conducted throughout the UK. The views of the 18 people who discussed euthanasia and assisted suicide were explored. These were drawn from a maximum variation sample, who said that they had a "terminal" illness, malignant or non-malignant. RESULTS: That UK law should be changed to allow assisted suicide or voluntary euthanasia was felt strongly by most people. Those who had seen others die were particularly convinced that this should be a right. Some had multiple reasons, including pain and anticipated pain, fear of indignity, loss of control and cognitive impairment. Those who did not want to be a burden also had other reasons for wanting euthanasia. Suicide was contemplated by a few, who would have preferred a change in the law to allow them to end their lives with medical help and in the company of family or friends. The few who opposed a change in UK law, or who felt ambivalent, focused on involuntary euthanasia, cited religious reasons or worried that new legislation might be open to abuse. CONCLUSION: Qualitative research conducted on people who know they are nearing death is an important addition to the international debate on euthanasia and assisted suicide. Those who had seen others die were particularly convinced that the law should be changed to allow assisted death.     

南京市老年公寓入住者家庭功能及其相关因素调查

目的　了解南京市入住老年公寓的老人家庭功能及相关因素。方法　应用整群随机抽样法 ,对南京市1 8家老年公寓的入住老人进行APGAR问卷及相关因素调查。结果　有 56 1 %的老人家庭功能良好 ,有 2 1 5 %的老人家庭功能中度障碍 ,有 2 2 4%的老人家庭功能严重障碍。在选择子女照顾自己及选择社会照顾自己方面 ,APGAR得分高的老人与APGAR得分低的老人相比 ,差异有显著性意义 ,老人与子女联系方式不同对家庭功能的影响之间差异有显著性意义。结论　老人与子女联系的方式影响家庭功能。     

Danish ethics council rejects brain death as the criterion of death -- commentary 1: wanting it both ways

In this commentary on the recommendations of the Danish Council of Ethics (DCE) concerning criteria for death it is argued that whilst the DCE is correct in stressing the cultural aspects of death, its adoption of cardiac-oriented criteria raises several problems. There are problems with its notion of a 'death process', which purportedly begins with brain death and ends with cessation of cardiac function, and there are serious problems regarding its commitment to a cardiac-oriented definition whilst permitting transplantation when the heart is still beating.     

Transplantation

In this paper Professor Calne pleads for a more informed approach to the problem of donor transplants, particularly in cases of kidney disease. He is concerned to inform both the medical profession and lay people. Establishing a computerized register of names and addresses of those who do not wish to have their organs used for transplantation after death would allow enquiries to be made immediately after death.

The second point of emphasis is that death of the brain is the death of the individual. A code of practice is suggested which should be followed in all transplantation centres and would allay the fears of the public and encourage the cooperation of doctors.

     

Brain death--an opposing viewpoint.

Recent and proposed legislation to establish "brain-related" criteria of death has uniformly confounded irreversible cessation of total brain function with the death of the human person. Much of the confusion comes from widespread misunderstanding of how the word "death" is used and what it means. Cessation of total brain function, whether irreversible or not, is not necessarily linked to total destruction of the brain or to the death of the person. Further, to take vital organs or to otherwise treat people as though they were dead already on the basis of these recent criteria is morally unacceptable to most Orthodox Jews and Christians.     

Whole-brain death reconsidered.

The author, a philosopher, suggests that the concept of death should be left as it is 'in its present indeterminate state', and that we ought to reject attempts to define death in terms of whole-brain death or any other type of brain death, including cerebral death and 'irreversible coma'. Instead of 'fiddling with the definition of death' clear rules should be established specifying 'what can be appropriately done to whom when'.     

葡萄糖转运体1研究进展

葡萄糖转运体（glucose transporter,GLUT）家族是葡萄糖转运的主要媒介，目前发现有13个成员。其中GLUT1以异构体的形式广泛表达于多种细胞，是介导葡萄糖经过血脑屏障的主要转运体。疾病可以改变GLUT1介导的葡萄糖转运过程，糖转运受到干扰能使脑功能受损，甚至导致脑死亡。近来研究显示，GLUT1能介导一些神经活性药物的转运，如糖基化的神经肽、低分子量肝素及D-葡萄糖衍生物等。因此，依赖于葡萄糖转运体的葡萄糖运载方法有可能是一个选择性药物运输系统，通过此高效转运系统，可调节药物进入大脑。     

More fiddling with the definition of death?

Stanley contends that G.R. Gillett, in the last paragraph of an otherwise excellent article, "Why let people die?" (Journal of Medical Ethics 1986 Jun; 12(2): 83-86), is "fiddling about" with the definition of death when he argues that the patient in a persistent vegetative state is, in an ethical sense, no longer alive as a person; that what remains is a body in which the former patient has no futher interest. Stanley maintains that the determination of the nonreversibility of decortication is uncertain while brain stem death is not reversible. Furthermore, decorticate patients are still biologically alive and decisions concerning their treatment and who makes the decisions are important questions for the medical profession and for society to address. The author concludes that these problems should not be solved by extending the definition of death to include neocortical death.     

家庭干预对医患关系的影响及评价

运用SPSS软件对“家庭干预对医患关系的影响”的调查结果处理分析发现，我国传统的家庭文化观念对医患关系有着极其显著的影响。多数人有病就医、选择医疗机构、处理医患关系时需要家属陪伴或参考家属意见；家属对医务人员的信任程度直接影响着患者的心理，部分患者在疗效不理想时更相信家属的解释。积极的家庭干预有助于增强患者对医务人员的信任、稳定患者的情绪，消极的家庭干预可能诱发患者对医务人员的不满和怀疑。和谐医患关系的构建需要积极的家庭干预。     

Should individuals choose their definition of death?

Alireza Bagheri supports a policy on organ procurement where individuals could choose their own definition of death between two or more socially accepted alternatives. First, we claim that such a policy, without any criterion to distinguish accepted from acceptable definitions, easily leads to the slippery slope that Bagheri tries to avoid. Second, we suggest that a public discussion about the circumstances under which the dead donor rule could be violated is more productive of social trust than constantly moving the line between life and death.     

将脑死亡患者作为移植器官供体的伦理学研究

脑死亡患者作为器官移植供体来源的提法逐渐引起人们的高度关注,但也遇到了诸多困境和问题,如脑死亡患者的死亡判定、脑死亡患者的意志遵循、脑死亡患者供体器官的管理、脑死亡患者供体器官的经济补偿等,结合我国社会实际情况和医疗环境,提出解决问题的建议：借鉴国外器官移植相关法律,严格遵守《人体器官移植条例》,完善立法和人体器官移植质量监控。     

Medical decisions concerning the end of life: a discussion with Japanese physicians.

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.     

The diagnosis of brain death

No apologies are needed for returning to the subject of brain death and its definition. There has been so much public discussion that it is important for public confidence that the issues should be clarified. In the following two contributions - one from a professor of neurosurgery and the other from a lawyer - an attempt is made to convince doctors (if that is needed) and lay people alike that what appears to be a new bogy is not one at all but a confusion of thought arising from the use of new technology to treat brain-damaged patients. This, however, might not be the view of Mr Skegg (Journal of medical ethics, 2, 190) who, fearful of the situation, has argued for a statutory definition of death.

Professor Jennett discusses the findings of a conference of the Royal Colleges of the United Kingdom which met to try and remove uncertainty surrounding the diagnosis of brain death. In his view the Colleges' document is to be welcomed for `its authority and its practicality' and `should lead to more humane medical practice'. Mr Kennedy, from a legal position, comes to the same conclusion, that with a good code of practice, as advocated by the Royal Colleges, no legislation is called for.

     

The problematic symmetry between brain birth and brain death.

The possible symmetry between the concepts of brain death and brain birth (life) is explored. Since the symmetry argument has tended to overlook the most appropriate definition of brain death, the fundamental concepts of whole brain death and higher brain death are assessed. In this way, a context is provided for a discussion of brain birth. Different writers have placed brain birth at numerous points: 25-40 days, eight weeks, 22-24 weeks, and 32-36 weeks gestation. For others, the concept itself is open to question. Apart from this, it needs to be asked whether a unitary concept is an oversimplification. The merits of defining two stages of brain birth, to parallel the two definitions of brain death, are discussed. An attempt is then made to map these various stages of brain birth and brain death onto a developmental continuum. Although the results hold biological interest, their ethical significance is less evident. Development and degeneration are not interchangeable, and definitions of death apply specifically to those who are dying, not those who are developing. I conclude that while a dual concept of brain death has proved helpful, a dual concept of brain birth still has problems, and the underlying concept of brain birth itself continues to be elusive.     

The hospitalisation of death: should more people die at home?

With the increase in the proportion of hospital deaths there is increasing debate about appropriateness of place of death. Death should be a family affair but is increasingly hidden from public view. In contrast to those who die at home, most of those who die in hospital die alone with no relatives or friends with them. Husbands and wives are less likely to have the opportunity to say 'goodbye' to their dying spouses. As people become less familiar with death they may increasingly assume that the terminally ill are better cared for in hospital. However, this need not be the case. Most people want to die at home, most do not for social rather than medical reasons. It is not the illness itself which leads to hospital admission in many cases but its duration and nature--and the type of burden it places on relatives. Although home care should be encouraged where possible, no amount of exhortation to the family or to the dying person of the advantages of home care can disguise the fact that demand for domiciliary services is greater than is now being provided. The paper is based on one read to a London Medical Group Symposium.     

Gardner; re BWV: Victorian Supreme Court makes landmark Australian ruling on tube feeding

The Victorian Supreme Court has decided that artificial nutrition and hydration provided through a percutaneous gastrostomy tube to a woman in a persistent vegetative state may be withdrawn. The judge ruled, in line with a substantial body of international medical, ethical and legal opinion, that any form of artificial nutrition and hydration is a medical procedure, not part of palliative care, and that it is a procedure to sustain life, not to manage the dying process. Thus, the law does not impose a rigid obligation to administer artificial nutrition or hydration to people who are dying, without due regard to their clinical condition. The definition of key terms such as "medical treatment", "palliative care", and "reasonable provision of food and water" in this case will serve as guidance for end-of-life decisions in other states and territories. The case also reiterates the right of patients, and, when incompetent, their validly appointed agents or guardians, to refuse medical treatment. Where an incompetent patient has not executed a binding advance directive and no agent or guardian has been appointed, physicians, in consultation with the family, may decide to withdraw medical treatment, including artificial nutrition or hydration, on the basis that continuation of treatment is inappropriate and not in the patient's best interests. However, Victoria and other jurisdictions would benefit from clarification of this area of the law.     

脑囊尾蚴病81例磁共振分析

目的: 探讨脑囊尾蚴病的临床及磁共振(MRI)特点。方法: 对81例脑囊尾蚴病患者的临床资料和头颅MRI进行回顾性分析。结果: 81例脑囊尾蚴病头颅MRI表现分为脑实质型73例、脑室型5例和混合型3例;活虫期、退变死亡期、非活动期及混杂期四期,以脑实质型和退变死亡期最常见。杀虫治疗一般需要3~5个疗程。结论: 头颅MRI可以对脑囊尾蚴病进行准确分型、分期,为用药及疗程的确定提供依据,还可用于CT检查阴性的脑囊尾蚴病的确诊。     

电子病案与纸质病案功能等同的可行性探讨

目的探讨纸质病案信息形成合法性的基础及特性,以明确电子病案的合法性。方法对纸质病案和电子病案功能等同相关因素进行对比分析,找出共性与特性。结果依据现行法律、法规,同时通过对电子病案信息形成过程进行严格控制和管理,可有效夯实电子病案应用的合法性基础。结论实现无纸化的电子病案是完全有可能的。