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Fins JJ, Shulman KS. Neuroethics, Covert Consciousness, and Disability Rights: What Happens When Artificial Intelligence Meets Cognitive Motor Dissociation? J Cogn Neurosci 2024:1-8. [PMID: 38579252 DOI: 10.1162/jocn_a_02157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
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Fins JJ. Baseball and Bioethics Revisited: The Pitch Clock and Age Discrimination in a Timeless Pastime. Camb Q Healthc Ethics 2024; 33:267-270. [PMID: 37767653 DOI: 10.1017/s096318012300049x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
In this essay, the author reflects on a decade's old essay on baseball and bioethics inspired by a conversation with the late David Thomasma. In a reprise of his earlier paper, Fins worries that modernity has come to baseball with the advent of the pitch clock and that this innovation brings age discrimination to a timeless pastime.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT, USA
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3
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Fins JJ, Knitter J, Mukherjee D, Conti K, Donleavy-Hiller B, Gerber LM, Hersh JE, Kotorac-Erlbaum R, Milch B, Klein SM. A Descriptive Analysis of Access to Assistive Technology in Children With Acquired Brain Injury: The Right to Assistive Devices. J Head Trauma Rehabil 2024; 39:152-159. [PMID: 37492972 PMCID: PMC10811270 DOI: 10.1097/htr.0000000000000876] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVE Pediatric clinicians caring for children with acquired brain injury have noted that many individuals requiring assistive technology (AT) go unserved or face delays until devices are obtained, with potential adverse implications for recovery and development. In this article we map the pathways by which AT is prescribed and assess delays and barriers to access. METHODS We conducted a retrospective chart review of patients with moderate to severe brain injury admitted to Blythedale Children's Hospital over a 2-year period using a database drawn from the medical record. RESULTS We identified 72 children diagnosed with brain injury requiring at least 1 device. Devices were used to improve mobility and positioning, self-care, safety, and communication, and enable access to other technologies and foster social integration. We found that 55% of devices were delivered, with most deliveries to home or the hospital's outpatient department for fitting, training, and instruction. Time to delivery ranged from 12 to 250 days with an average of 69.4 days. Twenty percent of nondeliveries were attributable to change in medical status, transfer to a skilled nursing facility, or continued inpatient status, while 31% were canceled by the family. Other nondeliveries were attributed to insurance coverage. We also found that the medical record is not designed for the longitudinal tracking of devices, indicating the need for a prospective process to document the AT trajectory. CONCLUSION Instead of tolerating delays and denials, there should be a normative expectation that children have a right to medically necessary devices, consistent with disability law. This analysis was undertaken as a step toward formulating a prospective means of tracking AT recommendations, approvals, denials, and/or deliveries. Our findings should be understood as a promissory note toward structural reforms that are reflective of society's responsibility to better meet the needs of vulnerable children and their families.
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Affiliation(s)
- Joseph J Fins
- Author Affiliations: Division of Medical Ethics (Drs Fins and Mukherjee and Ms Hersh) and Department of Population Health Science (Dr Gerber), Weill Cornell Medical College, New York, New York; Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut (Dr Fins); and Blythedale Children's Hospital, Valhalla, New York (Mss Knitter, Donleavy-Hiller, Kotorac-Erlbaum, and Milch and Drs Conti and Klein)
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4
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Claassen J, Kondziella D, Alkhachroum A, Diringer M, Edlow BL, Fins JJ, Gosseries O, Hannawi Y, Rohaut B, Schnakers C, Stevens RD, Thibaut A, Monti M. Cognitive Motor Dissociation: Gap Analysis and Future Directions. Neurocrit Care 2024; 40:81-98. [PMID: 37349602 DOI: 10.1007/s12028-023-01769-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/26/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Patients with disorders of consciousness who are behaviorally unresponsive may demonstrate volitional brain responses to motor imagery or motor commands detectable on functional magnetic resonance imaging or electroencephalography. This state of cognitive motor dissociation (CMD) may have prognostic significance. METHODS The Neurocritical Care Society's Curing Coma Campaign identified an international group of experts who convened in a series of monthly online meetings between September 2021 and April 2023 to examine the science of CMD and identify key knowledge gaps and unmet needs. RESULTS The group identified major knowledge gaps in CMD research: (1) lack of information about patient experiences and caregiver accounts of CMD, (2) limited epidemiological data on CMD, (3) uncertainty about underlying mechanisms of CMD, (4) methodological variability that limits testing of CMD as a biomarker for prognostication and treatment trials, (5) educational gaps for health care personnel about the incidence and potential prognostic relevance of CMD, and (6) challenges related to identification of patients with CMD who may be able to communicate using brain-computer interfaces. CONCLUSIONS To improve the management of patients with disorders of consciousness, research efforts should address these mechanistic, epidemiological, bioengineering, and educational gaps to enable large-scale implementation of CMD assessment in clinical practice.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University Irving Medical Center, NewYork Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Michael Diringer
- Department of Neurology, Washington University, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medical College, NewYork Presbyterian Hospital, New York, NY, 10032, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Benjamin Rohaut
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP) - Pitié Salpêtrière, Paris, France
| | | | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Neurology, and Radiology, School of Medicine, Secondary Appointment in Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Martin Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
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Abstract
Patient narratives from two investigational deep brain stimulation trials for traumatic brain injury and obsessive-compulsive disorder reveal that injury and illness rob individuals of personal identity and that neuromodulation can restore it. The early success of these interventions makes a compelling case for continued post-trial access to these technologies. Given the centrality of personal identity to respect for persons, a failure to provide continued access can be understood to represent a metaphorical identity theft. Such a loss recapitulates the pain of an individual's initial injury or illness and becomes especially tragic because it could be prevented by robust policy. A failure to fulfill this normative obligation constitutes a breach of disability law, which would view post-trial access as a means to achieve social reintegration through this neurotechnological accommodation.
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Fins JJ, Shulman KS, Wright MS, Shapiro ZE. Brain injury, medical progress, and the disability paradox: Towards an Americans with Abilities Act. NeuroRehabilitation 2024; 54:141-147. [PMID: 38217618 DOI: 10.3233/nre-230118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
It is helpful to think about the needs of patients with moderate to severe brain injury through the lens of disability law. However, there are limitations to current disability law that contribute to ongoing segregation and marginalization of individuals with severe brain injury. Indeed, one of the paradoxes of American jurisprudence is that more clear constitutional protections accrue to those who have definitively immutable conditions. Thus, as neuroscience brings new therapies to those with brain injury, they may become less protected by the constitutional elements of disability law because their conditions have changed and become mutable. This is the clinical progress that brain injury professionals all seek to achieve, but ironically these advances could potentially degrade the legal protections of patients who benefit from emerging treatments. In this paper, we will critically examine this paradox at the interface of medicine and the law and suggest that the Americans with Disabilities Act (ADA) could be nicely complemented by legislation we have named the Americans with Abilities Act (AWAA). Instead of focusing on disabilities that need protection, the AWAA seeks to sustain and foster newfound abilities made possible by the fruits of medicine and neuroscience.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT, USA
- Consortium for the Advanced Study of Brain Injury (CASBI), Weill Cornell Medicine, Rockefeller University, New York, NY, USA
| | - Kaiulani S Shulman
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
| | - Megan S Wright
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- School of Law and Medicine, Pennsylvania State University, State College, PA, USA
| | - Zachary E Shapiro
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT, USA
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Abstract
Recent global events demonstrate that analytical frameworks to aid professionals in healthcare ethics must consider the pervasive role of social structures in the emergence of bioethical issues. To address this, the authors propose a new sociologically informed approach to healthcare ethics that they term "social bioethics." Their approach is animated by the interpretive social sciences to highlight how social structures operate vis-à-vis the everyday practices and moral reasoning of individuals, a phenomenon known as social discourse. As an exemplar, the authors use social bioethics to reframe common ethical issues in psychiatric services and discuss potential implications. Lastly, the authors discuss how social bioethics illuminates the ways healthcare ethics consultants in both policy and clinical decision-making participate in and shape broader social, political, and economic systems, which then cyclically informs the design and delivery of healthcare.
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Affiliation(s)
- Ryan J Dougherty
- Baylor College of Medicine, Center for Medical Ethics and Health Policy, Houston, TX, USA
| | - Joseph J Fins
- Weill Cornell Medicine, Division of Medical Ethics, New York, NY, USA
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Shapiro ZE, Deb C, Lawrence C, Golden AR, Wright MS, Kraschel KL, Fins JJ. The Scholarly and Pedagogical Benefits of the Legal Laboratory: Lessons from the Consortium for the Advanced Study of Brain Injury at Yale Law School. J Law Med Ethics 2023; 51:672-683. [PMID: 38088597 DOI: 10.1017/jme.2023.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
In our article, we share the lessons we have learned after creating and running a successful legal laboratory over the past seven years at Yale Law School. Our legal laboratory, which focuses on the intersection of law and severe brain injury, represents a unique pedagogical model for legal academia, and is closely influenced by the biomedical laboratory.
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Schiff ND, Giacino JT, Butson CR, Choi EY, Baker JL, O'Sullivan KP, Janson AP, Bergin M, Bronte-Stewart HM, Chua J, DeGeorge L, Dikmen S, Fogarty A, Gerber LM, Krel M, Maldonado J, Radovan M, Shah SA, Su J, Temkin N, Tourdias T, Victor JD, Waters A, Kolakowsky-Hayner SA, Fins JJ, Machado AG, Rutt BK, Henderson JM. Thalamic deep brain stimulation in traumatic brain injury: a phase 1, randomized feasibility study. Nat Med 2023; 29:3162-3174. [PMID: 38049620 PMCID: PMC11087147 DOI: 10.1038/s41591-023-02638-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/10/2023] [Indexed: 12/06/2023]
Abstract
Converging evidence indicates that impairments in executive function and information-processing speed limit quality of life and social reentry after moderate-to-severe traumatic brain injury (msTBI). These deficits reflect dysfunction of frontostriatal networks for which the central lateral (CL) nucleus of the thalamus is a critical node. The primary objective of this feasibility study was to test the safety and efficacy of deep brain stimulation within the CL and the associated medial dorsal tegmental (CL/DTTm) tract.Six participants with msTBI, who were between 3 and 18 years post-injury, underwent surgery with electrode placement guided by imaging and subject-specific biophysical modeling to predict activation of the CL/DTTm tract. The primary efficacy measure was improvement in executive control indexed by processing speed on part B of the trail-making test.All six participants were safely implanted. Five participants completed the study and one was withdrawn for protocol non-compliance. Processing speed on part B of the trail-making test improved 15% to 52% from baseline, exceeding the 10% benchmark for improvement in all five cases.CL/DTTm deep brain stimulation can be safely applied and may improve executive control in patients with msTBI who are in the chronic phase of recovery.ClinicalTrials.gov identifier: NCT02881151 .
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Affiliation(s)
- Nicholas D Schiff
- Feil Family Brain Mind Institute, Weill Cornell Medicine, New York, NY, USA.
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA.
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Christopher R Butson
- Scientific Computing and Imaging Institute Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
- Norman Fixel Institute for Neurological Diseases Departments of Neurology and Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Eun Young Choi
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Jonathan L Baker
- Feil Family Brain Mind Institute, Weill Cornell Medicine, New York, NY, USA
| | - Kyle P O'Sullivan
- Scientific Computing and Imaging Institute Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Andrew P Janson
- Scientific Computing and Imaging Institute Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
- Radiology and Radiological Sciences, Vanderbilt University, Nashville, TN, USA
| | - Michael Bergin
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | | | - Jason Chua
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Laurel DeGeorge
- Feil Family Brain Mind Institute, Weill Cornell Medicine, New York, NY, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Adam Fogarty
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Linda M Gerber
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Mark Krel
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Jose Maldonado
- Department of Psychiatry, Stanford University, Stanford, CA, USA
| | - Matthew Radovan
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Sudhin A Shah
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Jason Su
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA
| | - Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Thomas Tourdias
- Department of Neuroimaging, University of Bordeaux, Nouvelle-Aquitaine, France
| | - Jonathan D Victor
- Feil Family Brain Mind Institute, Weill Cornell Medicine, New York, NY, USA
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Abigail Waters
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | | | - Joseph J Fins
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Andre G Machado
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brian K Rutt
- Department of Radiology, Stanford University, Stanford, CA, USA
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA
- Bio-X Program, Stanford University, Stanford, CA, USA
| | - Jaimie M Henderson
- Department of Neurosurgery, Stanford University, Stanford, CA, USA.
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA.
- Bio-X Program, Stanford University, Stanford, CA, USA.
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10
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Fins JJ. Physician attitudes about disorders of consciousness: Good facts make for good ethics. Dev Med Child Neurol 2023; 65:1549-1550. [PMID: 37058590 PMCID: PMC10576007 DOI: 10.1111/dmcn.15619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/16/2023]
Abstract
This commentary is on the original article by Schembs et al. on pages1646–1655of this issue.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
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11
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Lewis A, Young MJ, Rohaut B, Jox RJ, Claassen J, Creutzfeldt CJ, Illes J, Kirschen M, Trevick S, Fins JJ. Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2023; 39:565-577. [PMID: 36977963 PMCID: PMC11023737 DOI: 10.1007/s12028-023-01708-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Rohaut
- Inserm, CNRS, APHP - Hôpital de la Pitié Salpêtrière, Paris Brain Institute - ICM, DMU Neuroscience, Sorbonne University, Paris, France
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
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Fins JJ, Wright MS, Shulman KS, Henderson JM, Schiff ND. Subject and Family Perspectives from the Central Thalamic Deep Brain Stimulation Trial for Traumatic Brain Injury: Part II. Camb Q Healthc Ethics 2023:1-24. [PMID: 37850455 DOI: 10.1017/s0963180123000518] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
This is the second paper in a two-part series describing subject and family perspectives from the CENTURY-S (CENtral Thalamic Deep Brain Stimulation for the Treatment of Traumatic Brain InjURY-Safety) first-in-human invasive neurological device trial to achieve cognitive restoration in moderate to severe traumatic brain injury (msTBI). To participate, subjects were independently assessed to formally establish decision-making capacity to provide voluntary informed consent. Here, we report on post-operative interviews conducted after a successful trial of thalamic stimulation. All five msTBI subjects met a pre-selected primary endpoint of at least a 10% improvement in completion time on Trail-Making-Test Part B, a marker of executive function. We describe narrative responses of subjects and family members, refracted against that success. Interviews following surgery and the stimulation trial revealed the challenge of adaptation to improvements in cognitive function and emotional regulation as well as altered (and restored) relationships and family dynamics. These improvements exposed barriers to social reintegration made relevant by recoveries once thought inconceivable. The study's success sparked concerns about post-trial access to implanted devices, financing of device maintenance, battery replacement, and on-going care. Most subjects and families identified the need for supportive counseling to adapt to the new trajectory of their lives.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT, USA
| | - Megan S Wright
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- School of Law, Pennsylvania State University, State College, PA, USA
| | - Kaiulani S Shulman
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
| | - Jaimie M Henderson
- Department of Neurosurgery, Stanford School of Medicine, Palo Alto, CA, USA
| | - Nicholas D Schiff
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
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Fins JJ, Vernaglia JS. José Manuel Rodríguez Delgado, Walter Freeman, and Psychosurgery: A Study in Contrasts. Neuroscientist 2023; 29:518-531. [PMID: 35414307 DOI: 10.1177/10738584221086603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
History has conflated the legacies of José Manuel Rodríguez Delgado and Walter Freeman, midcentury proponents of somatic therapies for neuropsychiatric conditions. Both gained notoriety: Delgado after he appeared on the front page of the New York Times having used his stimoceiver to stop a charging bull in Spain; Freeman as the proponent of lobotomy. Both were the object of critique by the antipsychiatry movement and those who felt that their methods and objectives posed a threat to personal liberty. Using archival sources, we demonstrate that this conflation is a misrepresentation of the historical record and that their methods, objectives, ethics, and philosophical commitments differed widely. Accurate knowledge about historical antecedents is a predicate for ethical analysis and becomes especially relevant information as neuroscience develops circuit-based treatments for conditions such as Parkinson disease, depression, and brain injury. Part of that corrective is to counter the conflation of Delgado's and Freeman's life and work. Appreciating their distinctive legacies can help guide neuropsychiatric research done today that might yet haunt future generations.
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Affiliation(s)
- Joseph J Fins
- Weill Medical College of Cornell University, New York, NY, USA
- The Consortium for the Advanced Study of Brain Injury, Weill Cornell Medical College and The Rockefeller University, New York, NY, USA
- Solomon Center Distinguished Scholar in Medicine, Bioethics and the Law, Yale Law School, New Haven, CT, USA
| | - John S Vernaglia
- The College of Social Studies, Wesleyan University, Middletown, CT, USA
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Ligthart S, Ienca M, Meynen G, Molnar-Gabor F, Andorno R, Bublitz C, Catley P, Claydon L, Douglas T, Farahany N, Fins JJ, Goering S, Haselager P, Jotterand F, Lavazza A, McCay A, Wajnerman Paz A, Rainey S, Ryberg J, Kellmeyer P. Minding Rights: Mapping Ethical and Legal Foundations of 'Neurorights'. Camb Q Healthc Ethics 2023:1-21. [PMID: 37183686 DOI: 10.1017/s0963180123000245] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The rise of neurotechnologies, especially in combination with artificial intelligence (AI)-based methods for brain data analytics, has given rise to concerns around the protection of mental privacy, mental integrity and cognitive liberty - often framed as "neurorights" in ethical, legal, and policy discussions. Several states are now looking at including neurorights into their constitutional legal frameworks, and international institutions and organizations, such as UNESCO and the Council of Europe, are taking an active interest in developing international policy and governance guidelines on this issue. However, in many discussions of neurorights the philosophical assumptions, ethical frames of reference and legal interpretation are either not made explicit or conflict with each other. The aim of this multidisciplinary work is to provide conceptual, ethical, and legal foundations that allow for facilitating a common minimalist conceptual understanding of mental privacy, mental integrity, and cognitive liberty to facilitate scholarly, legal, and policy discussions.
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Affiliation(s)
- Sjors Ligthart
- Willem Pompe Institute for Criminal Law and Criminology, Utrecht University, Utrecht, Denmark; Department of Criminal Law, Tilburg University, Tilberg, The Netherlands
| | - Marcello Ienca
- School of Medicine, Technical University of Munich (TUM), Germany & College of Humanities, Swiss Federal Institute of Technology in Lausanne (EPFL), Lausanne, Switzerland
| | - Gerben Meynen
- Willem Pompe Institute for Criminal Law and Criminology, Utrecht University, Utrecht, Denmark; Department of Philosophy, Faculty of Humanities, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Roberto Andorno
- Institute for Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | | | - Paul Catley
- School of Law, The Open University, Milton Keynes, UK
| | - Lisa Claydon
- School of Law, The Open University, Milton Keynes, UK
| | | | | | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
| | - Sara Goering
- Department of Philosophy, University of Washington, Seattle, WA, USA
| | - Pim Haselager
- Donders Institute for Brain, Cognition, and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Fabrice Jotterand
- Center for Bioethics and Medical Humanities, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Allan McCay
- The University of Sydney Law School, Sydney, NSW, Australia
| | - Abel Wajnerman Paz
- Instituto de Éticas Aplicadas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Stephen Rainey
- Ethics and Philosophy of Technology Section, Delft University, Delft, The Netherlands
| | - Jesper Ryberg
- Department of Philosophy, Roskilde University, Roskilde, Denmark
| | - Philipp Kellmeyer
- Department of Neurosurgery, University of Freiburg - Medical Center, Freiburg im Breisgau, Germany
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DeCamp M, Fins JJ, Sulmasy LS. Response. Chest 2023; 163:e249-e250. [PMID: 37164594 DOI: 10.1016/j.chest.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 05/12/2023] Open
Affiliation(s)
- Matthew DeCamp
- Center for Bioethics and Humanities & Division of General Internal Medicine, University of Colorado, Aurora, CO.
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY; Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT
| | - Lois Snyder Sulmasy
- Center for Ethics and Professionalism, American College of Physicians, Philadelphia, PA
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Kreitzer N, Murtaugh B, Creutzfeldt C, Fins JJ, Manley G, Sarwal A, Dangayach N. Prognostic humility and ethical dilemmas after severe brain injury: Summary, recommendations, and qualitative analysis of Curing Coma Campaign virtual event proceedings. Front Hum Neurosci 2023; 17:1128656. [PMID: 37063099 PMCID: PMC10102639 DOI: 10.3389/fnhum.2023.1128656] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundPatients with severe acute brain injuries (SABI) are at risk of living with long-term disability, frequent medical complications and high rates of mortality. Determining an individual patient’s prognosis and conveying this to family members/caregivers can be challenging. We conducted a webinar with experts in neurosurgery, neurocritical care, neuro-palliative care, neuro-ethics, and rehabilitation as part of the Curing Coma Campaign, which is supported by the Neurocritical Care Society. The webinar discussed topics focused on prognostic uncertainty, communicating prognosis to family members/caregivers, gaps within healthcare systems, and research infrastructure as it relates to patients experiencing SABI. The purpose of this manuscript is to describe the themes that emerged from this virtual discussion.MethodsA qualitative analysis of a webinar “Prognostic Humility and Ethical Dilemmas in Acute Brain Injury” was organized as part of the Neurocritical Care Society’s Curing Coma Campaign. A multidisciplinary group of experts was invited as speakers and moderators of the webinar. The content of the webinar was transcribed verbatim. Two qualitative researchers (NK and BM) read and re-read the transcription, and familiarized themselves with the text. The two coders developed and agreed on a code book, independently coded the transcript, and discussed any discrepancies. The transcript was analyzed using inductive thematic analysis of codes and themes that emerged within the expert discussion.ResultsWe coded 168 qualitative excerpts within the transcript. Two main themes were discussed: (1) the concept of prognostic uncertainty in the acute setting, and (2) lack of access to and evidence for quality rehabilitation and specialized continuum of care efforts specific to coma research. Within these two main themes, we found 5 sub-themes, which were broken down into 23 unique codes. The most frequently described code was the need for clinicians to acknowledge our own uncertainties when we discuss prognosis with families, which was mentioned 13 times during the webinar. Several strategies were described for speaking with surrogates of patients who have had a severe brain injury resulting in SABI. We also identified important gaps in the United States health system and in research to improve the care of patients with severe brain injuries.ConclusionAs a result of this webinar and expert discussion, authors identified and analyzed themes related to prognostic uncertainty with SABI. Recommendations were outlined for clinicians who engage with surrogates of patients with SABI to foster informed decisions for their loved one. Finally, recommendations for changes in healthcare systems and research support are provided in order to continue to propel SABI science forward to improve future prognostic certainty.
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Affiliation(s)
- Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, United States
- *Correspondence: Natalie Kreitzer,
| | - Brooke Murtaugh
- Brain Injury Program Manager, Department of Rehabilitation Programs, Madonna Rehabilitation Hospital, Lincoln, NE, United States
| | | | - Joseph J. Fins
- Division of Medical Ethics, Weill Cornell Medicine, New York, NY, United States
- Yale Law School, New Haven, CT, United States
| | - Geoff Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Aarti Sarwal
- Department of Neurology, Wake Forest University, Winston-Salem, NC, United States
| | - Neha Dangayach
- Departments of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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17
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Shulman KS, Fins JJ. Daniel Callahan's Decade of Doubt. Perspect Biol Med 2023; 66:249-266. [PMID: 37755715 DOI: 10.1353/pbm.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
Daniel Callahan died on July 16, 2019, just short of his 89th birthday. In the years since, we have seen the overturning of abortion rights, a concern central to his scholarship and musings about the place of religion in American civic life. Callahan's journey from lay Catholic journalist and commentator at Commonweal to a co-founder of the Hastings Center, during his decade of doubt, is especially relevant today as America revisits established precedent governing a woman's right to choose. His life-long struggle with faith and the secularization of bioethics is a story worth telling, as it may foster dialogue across a divide between religious and laical thinkers that has fractured our political discourse. We recall Callahan's misgivings about the marginalization of religious perspectives in public life; he sought not the denial of complexity nor of difference in views, but rather the importance of free and honest debate around deeply held beliefs, contextualized in the realities of the contemporary world. Callahan's ambivalence about his faith remains a part of the fabric of American life, a story that Callahan chronicled to our collective benefit for over a half-century.
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18
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Altisent R, Fins JJ. Ethical consultancy. Towards an applicable and sustainable Spanish model. Rev Clin Esp 2023; 223:58-59. [PMID: 36635024 DOI: 10.1016/j.rceng.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 01/12/2023]
Affiliation(s)
- R Altisent
- Cátedra de Profesionalismo y Ética Clínica, Facultad de Medicina de la Universidad de Zaragoza, Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain.
| | - J J Fins
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medical College, New York, NY, USA; Solomon Center for Health Law and Policy, Yale Law School, New Haven, CT, USA
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19
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Fins JJ, Giordano J. Minding Brain Injury, Consciousness, and Ethics: Discourse and Deliberations. Kennedy Inst Ethics J 2023; 33:227-248. [PMID: 38588134 DOI: 10.1353/ken.2023.a917928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
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20
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Bloch AM, Gabbay E, Gerber LM, Dickerman AL, Knowlton S, Fins JJ. Challenges and strategies in the psychiatric care of the ultra-Orthodox Jewish population: A thematic analysis of 18 psychiatrist interviews. Transcult Psychiatry 2022:13634615221126052. [PMID: 36222017 DOI: 10.1177/13634615221126052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the importance of accessible psychiatric care for the ultra-Orthodox Jewish community, prior research has characterized how stigma and suspicion of secular institutions limit mental healthcare utilization by this population. No study, however, has interviewed a cohort of psychiatrists to identify commonly encountered challenges or successfully employed strategies in the care of ultra-Orthodox Jewish psychiatric patients who have overcome these barriers to present for care. We recruited by snowball sampling from a sample of convenience 18 psychiatrists affiliated with the Weill Cornell Department of Psychiatry, experienced in the care of ultra-Orthodox Jewish patients. Each participant was engaged in a 20-45-min, semi-structured interview, which was subsequently transcribed, de-identified, and analyzed with combined deductive and inductive thematic analysis. We identified 12 challenges and 11 strategies as particularly significant in psychiatric work with ultra-Orthodox Jewish patients at every phase of treatment, including rapport-building, history-taking, diagnostic formulation, and achieving concordance with patient and family. These challenges and strategies revolved around themes of community stigma, an extended family-patient-community team, cross-cultural communication, culture-related diagnostic complexity, transference/countertransference, and conflicts between Jewish law /community norms and treatment protocol. Psychiatrists caring for ultra-Orthodox Jewish patients face a range of complex challenges stemming from factors unique to ultra-Orthodox Jewish religion, culture, and family/community structure. However, they have also identified strategies to manage these challenges and provide culturally sensitive care. Further research is necessary to directly elicit perspectives from within the ultra-Orthodox Jewish community and validate our initial findings.
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Affiliation(s)
| | - Ezra Gabbay
- Divisions of Medical Ethics, Department of Medicine, 12295Weill Cornell Medicine, New York, NY, USA
- General Internal Medicine, Department of Medicine, 12295Weill Cornell Medicine, New York, NY, USA
| | - Linda M Gerber
- Department of Population Health Sciences, 12295Weill Cornell Medicine, New York, NY, USA
| | | | - Samantha Knowlton
- Divisions of Medical Ethics, Department of Medicine, 12295Weill Cornell Medicine, New York, NY, USA
| | - Joseph J Fins
- Divisions of Medical Ethics, Department of Medicine, 12295Weill Cornell Medicine, New York, NY, USA
- Department of Psychiatry, 12295Weill Cornell Medicine, New York, NY, USA
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21
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Kolbe L, Fins JJ. Health Equity, History, and a New Presidential Bioethics Commission: Lessons from the "Lost" Reports. J Gen Intern Med 2022; 37:3471-3474. [PMID: 35882708 PMCID: PMC9321266 DOI: 10.1007/s11606-022-07733-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022]
Abstract
Convening a national bioethics commission has historically been one of the most powerful bioethical legacies a US presidential administration can undertake. The Biden Administration has not yet created such a commission; here we argue that centering health equity and healthcare access would provide a vital framework for a new commission's legacy. Moreover, we demonstrate two crucial historical episodes when American presidents appointed commissions to examine the practical and ethical implications of these very issues. We turn first to the 1952 President's Commission report on "Building America's Health," a lofty vision of universal healthcare access stymied by both political conflict and unaddressed problems of racism in the era's legislation. Its rich yet incomplete account of American health inequities serves as a valuable forerunner to questions of justice in bioethics. We then explore the President's Commission's 1983 report "Securing Access to Healthcare: A Report on the Ethical Implications of Differences in the Availability of Health Services." This report took up the mantle of equity in healthcare access, again with mixed results. Only by understanding the checkered history of these overlooked, practically "lost" reports can a new era in American bioethics successfully re-center the goal of equitable health for all.
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Affiliation(s)
- Laura Kolbe
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medical College, 435 E. 70th Street, 29JK, New York, NY, 10065, USA. .,Hospital Medicine, Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medical College, 435 E. 70th Street, 29JK, New York, NY, 10065, USA.,Solomon Center for Health Law and Policy, Yale Law School, New Haven, CT, USA.,Rockefeller University, New York, NY, USA
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22
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Mainali S, Aiyagari V, Alexander S, Bodien Y, Boerwinkle V, Boly M, Brown E, Brown J, Claassen J, Edlow BL, Fink EL, Fins JJ, Foreman B, Frontera J, Geocadin RG, Giacino J, Gilmore EJ, Gosseries O, Hammond F, Helbok R, Claude Hemphill J, Hirsch K, Kim K, Laureys S, Lewis A, Ling G, Livesay SL, McCredie V, McNett M, Menon D, Molteni E, Olson D, O'Phelan K, Park S, Polizzotto L, Javier Provencio J, Puybasset L, Venkatasubba Rao CP, Robertson C, Rohaut B, Rubin M, Sharshar T, Shutter L, Sampaio Silva G, Smith W, Stevens RD, Thibaut A, Vespa P, Wagner AK, Ziai WC, Zink E, Suarez JI. Correction to: Proceedings of the Second Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2022; 37:608-609. [PMID: 35715614 PMCID: PMC9519697 DOI: 10.1007/s12028-022-01536-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
| | - Venkatesh Aiyagari
- Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Varina Boerwinkle
- Division of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Melanie Boly
- Departments of Neurology and Psychiatry, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin, Madison, WI, USA
| | - Emery Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer Frontera
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Romergryko G Geocadin
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph Giacino
- Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Flora Hammond
- Indiana University Department of Physical Medicine and Rehabilitation, University of Indiana School of Medicine, Indianapolis, IN, USA
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Karen Hirsch
- Division of Neurocritical Care, Department of Neurology, Stanford University, Stanford, CA, USA
| | - Keri Kim
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Center, University of Liege, Liege, Belgium
- Department of Neurology, Centre Hospitalier Universitaire Sart Tilman, University of Liege, Liege, Belgium
| | - Ariane Lewis
- Department of Neurology and Neurosurgery, New York University Langone Health, New York, NY, USA
| | - Geoffrey Ling
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly McNett
- College of Nursing, Ohio State University, Columbus, OH, USA
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - DaiWai Olson
- Neuroscience Intensive Care Unit, O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristine O'Phelan
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Soojin Park
- Department of Neurology and Neurocritical Care, Columbia University, New York, NY, USA
| | - Len Polizzotto
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Jose Javier Provencio
- Department of Neurology and Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Louis Puybasset
- Department of Neuroradiology, University of Paris VI, Pierre et Marie Curie, Pitié-Salpêtrière Hospital, Paris, France
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Courtney Robertson
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins Children's Center, The Johns Hopkins University School of Medcine, Baltimore, MD, USA
| | - Benjamin Rohaut
- Neuroscience Intensive Care Unit, Department of Neurology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Michael Rubin
- Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | | | - Gisele Sampaio Silva
- Hospital Israelita Albert Einstein, Academic Research Organization and Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Wade Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Paul Vespa
- Ronald Reagan UCLA Medical Center, UCLA Santa Monica Medical Center, Santa Monica, CA, USA
| | - Amy K Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Zink
- Department of Neuroscience Nursing, The Johns Hopkins Hospital, The Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Fins JJ. The Unintended Consequences of Chile’s Neurorights Constitutional Reform: Moving beyond Negative Rights to Capabilities. NEUROETHICS-NETH 2022. [DOI: 10.1007/s12152-022-09504-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Merner AR, Fins JJ, Lázaro-Muñoz G. Brain Device Research and the Underappreciated Role of Care Partners before, during, and Post-Trial. AJOB Neurosci 2022; 13:236-239. [PMID: 36272159 PMCID: PMC9639607 DOI: 10.1080/21507740.2022.2126548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Joseph J. Fins
- Weill Medical College of Cornell University
- Yale Law School
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25
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Lewis A, Claassen J, Illes J, Jox RJ, Kirschen M, Rohaut B, Trevick S, Young MJ, Fins JJ. Ethics Priorities of the Curing Coma Campaign: An Empirical Survey. Neurocrit Care 2022; 37:12-21. [PMID: 35505222 PMCID: PMC10034145 DOI: 10.1007/s12028-022-01506-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/31/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Curing Coma Campaign (CCC) is a multidisciplinary global initiative focused on evaluation, diagnosis, treatment, research, and prognostication for patients who are comatose due to any etiology. To support this mission, the CCC Ethics Working Group conducted a survey of CCC collaborators to identify the ethics priorities of the CCC and the variability in priorities based on country of practice. METHODS An electronic survey on the ethics priorities for the CCC was developed using rank-choice questions and distributed between May and July 2021 to a listserv of the 164 collaborators of the CCC. The median rank for each topic and subtopic was determined. Comparisons were made on the basis of country of practice. RESULTS The survey was completed by 93 respondents (57% response rate); 67% practiced in the United States. On the basis of respondent ranking of each topic, the prioritization of ethics topics across respondents was as follows: (1) clinical care, (2) diagnostic definitions, (3) clinical research, (4) implementation/innovation, (5) family, (6) data management, (7) public engagement/perceptions, and (8) equity. Respondents who practiced in the United States were particularly concerned about public engagement, the distinction between clinical care and research, disclosure of results from clinical research to families, the definition of "personhood," and the distinction between the self-fulfilling prophecy/nihilism and medical futility. Respondents who practiced in other countries were particularly concerned about diagnostic modalities for clinical care, investigational drugs/devices for clinical research, translation of research into practice, and the definition of "minimally conscious state." CONCLUSIONS Collaborators of the CCC considered clinical care, diagnostic definitions, and clinical research the top ethics priorities of the CCC. These priorities should be considered as the CCC explores ways to improve evaluation, diagnosis, treatment, research, and prognostication of patients with coma and associated disorders of consciousness. There is some variability in ethics priorities based on country of practice.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, New York University Langone Medical Center, 530 First Avenue, Skirball-7R , New York, NY, 10016, USA.
| | - Jan Claassen
- Columbia University and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Benjamin Rohaut
- Sorbonne University, Paris Brain Institute - ICM, Inserm, CNRS, APHP - Hôpital de La Pitié Salpêtrière, DMU Neurosciences, Paris, France
| | | | - Michael J Young
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
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DeCamp M, Snyder Sulmasy L, Fins JJ. POINT: Does Normothermic Regional Perfusion Violate the Ethical Principles Underlying Organ Procurement? Yes. Chest 2022; 162:288-290. [PMID: 35940651 DOI: 10.1016/j.chest.2022.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/08/2022] [Indexed: 10/16/2022] Open
Affiliation(s)
- Matthew DeCamp
- Center for Bioethics and Humanities & Division of General Internal Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO.
| | - Lois Snyder Sulmasy
- Center for Ethics and Professionalism, American College of Physicians, Philadelphia, PA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY; Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT
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27
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DeCamp M, Fins JJ, Snyder Sulmasy L. Rebuttal From Dr DeCamp et al. Chest 2022; 162:292-293. [PMID: 35940653 DOI: 10.1016/j.chest.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 10/16/2022] Open
Affiliation(s)
- Matthew DeCamp
- Center for Bioethics and Humanities & Division of General Internal Medicine, Fulginiti Pavilion, University of Colorado-Anschutz Medical Campus, Aurora, CO.
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY; Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT
| | - Lois Snyder Sulmasy
- Center for Ethics and Professionalism, American College of Physicians, Philadelphia, PA
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Mainali S, Aiyagari V, Alexander S, Bodien Y, Boerwinkle V, Boly M, Brown E, Brown J, Claassen J, Edlow BL, Fink EL, Fins JJ, Foreman B, Frontera J, Geocadin RG, Giacino J, Gilmore EJ, Gosseries O, Hammond F, Helbok R, Claude Hemphill J, Hirsch K, Kim K, Laureys S, Lewis A, Ling G, Livesay SL, McCredie V, McNett M, Menon D, Molteni E, Olson D, O'Phelan K, Park S, Polizzotto L, Javier Provencio J, Puybasset L, Venkatasubba Rao CP, Robertson C, Rohaut B, Rubin M, Sharshar T, Shutter L, Sampaio Silva G, Smith W, Stevens RD, Thibaut A, Vespa P, Wagner AK, Ziai WC, Zink E, I Suarez J. Proceedings of the Second Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2022; 37:326-350. [PMID: 35534661 PMCID: PMC9283342 DOI: 10.1007/s12028-022-01505-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/29/2022] [Indexed: 12/21/2022]
Abstract
This proceedings article presents actionable research targets on the basis of the presentations and discussions at the 2nd Curing Coma National Institutes of Health (NIH) symposium held from May 3 to May 5, 2021. Here, we summarize the background, research priorities, panel discussions, and deliverables discussed during the symposium across six major domains related to disorders of consciousness. The six domains include (1) Biology of Coma, (2) Coma Database, (3) Neuroprognostication, (4) Care of Comatose Patients, (5) Early Clinical Trials, and (6) Long-term Recovery. Following the 1st Curing Coma NIH virtual symposium held on September 9 to September 10, 2020, six workgroups, each consisting of field experts in respective domains, were formed and tasked with identifying gaps and developing key priorities and deliverables to advance the mission of the Curing Coma Campaign. The highly interactive and inspiring presentations and panel discussions during the 3-day virtual NIH symposium identified several action items for the Curing Coma Campaign mission, which we summarize in this article.
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Affiliation(s)
- Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
| | - Venkatesh Aiyagari
- Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yelena Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Varina Boerwinkle
- Division of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Melanie Boly
- Departments of Neurology and Psychiatry, Wisconsin Institute for Sleep and Consciousness, University of Wisconsin, Madison, WI, USA
| | - Emery Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer Frontera
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Romergryko G Geocadin
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph Giacino
- Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Flora Hammond
- Indiana University Department of Physical Medicine and Rehabilitation, University of Indiana School of Medicine, Indianapolis, IN, USA
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Karen Hirsch
- Division of Neurocritical Care, Department of Neurology, Stanford University, Stanford, CA, USA
| | - Keri Kim
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Center, University of Liege, Liege, Belgium
- Department of Neurology, Centre Hospitalier Universitaire Sart Tilman, University of Liege, Liege, Belgium
| | - Ariane Lewis
- Department of Neurology and Neurosurgery, New York University Langone Health, New York, NY, USA
| | - Geoffrey Ling
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly McNett
- College of Nursing, Ohio State University, Columbus, OH, USA
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - DaiWai Olson
- Neuroscience Intensive Care Unit, O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristine O'Phelan
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Soojin Park
- Department of Neurology and Neurocritical Care, Columbia University, New York, NY, USA
| | - Len Polizzotto
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Jose Javier Provencio
- Department of Neurology and Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - Louis Puybasset
- Department of Neuroradiology, University of Paris VI, Pierre et Marie Curie, Pitié-Salpêtrière Hospital, Paris, France
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Courtney Robertson
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins Children's Center, The Johns Hopkins University School of Medcine, Baltimore, MD, USA
| | - Benjamin Rohaut
- Neuroscience Intensive Care Unit, Department of Neurology, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Michael Rubin
- Neurological Surgery and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | | | - Gisele Sampaio Silva
- Hospital Israelita Albert Einstein, Academic Research Organization and Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Wade Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aurore Thibaut
- Coma Science Group, GIGA Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Paul Vespa
- Ronald Reagan UCLA Medical Center, UCLA Santa Monica Medical Center, Santa Monica, CA, USA
| | - Amy K Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Zink
- Department of Neuroscience Nursing, The Johns Hopkins Hospital, The Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ienca M, Fins JJ, Jox RJ, Jotterand F, Voeneky S, Andorno R, Ball T, Castelluccia C, Chavarriaga R, Chneiweiss H, Ferretti A, Friedrich O, Hurst S, Merkel G, Molnár-Gábor F, Rickli JM, Scheibner J, Vayena E, Yuste R, Kellmeyer P. Towards a Governance Framework for Brain Data. NEUROETHICS-NETH 2022. [DOI: 10.1007/s12152-022-09498-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AbstractThe increasing availability of brain data within and outside the biomedical field, combined with the application of artificial intelligence (AI) to brain data analysis, poses a challenge for ethics and governance. We identify distinctive ethical implications of brain data acquisition and processing, and outline a multi-level governance framework. This framework is aimed at maximizing the benefits of facilitated brain data collection and further processing for science and medicine whilst minimizing risks and preventing harmful use. The framework consists of four primary areas of regulatory intervention: binding regulation, ethics and soft law, responsible innovation, and human rights.
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Real de Asua D, Fins JJ. Should healthcare workers be prioritised during the COVID-19 pandemic? A view from Madrid and New York. J Med Ethics 2022; 48:397-400. [PMID: 33910974 PMCID: PMC8103555 DOI: 10.1136/medethics-2020-107050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/09/2021] [Accepted: 04/01/2021] [Indexed: 05/30/2023]
Abstract
While COVID-19 has generated a massive burden of illness worldwide, healthcare workers (HCWs) have been disproportionately exposed to SARS-CoV-2 coronavirus infection. During the so-called 'first wave', infection rates among this population group have ranged between 10% and 20%, raising as high as one in every four COVID-19 patients in Spain at the peak of the crisis. Now that many countries are already dealing with new waves of COVID-19 cases, a potential competition between HCW and non-HCW patients for scarce resources can still be a likely clinical scenario. In this paper, we address the question of whether HCW who become ill with COVID-19 should be prioritised in diagnostic, treatment or resource allocation protocols. We will evaluate some of the proposed arguments both in favour and against the prioritisation of HCW and also consider which clinical circumstances might warrant prioritising HCW and why could it be ethically appropriate to do so. We conclude that prioritising HCW's access to protective equipment, diagnostic tests or even prophylactic or therapeutic drug regimes and vaccines might be ethically defensible. However, prioritising HCWs to receive intensive care unit (ICU) beds or ventilators is a much more nuanced decision, in which arguments such as instrumental value or reciprocity might not be enough, and economic and systemic values will need to be considered.
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Affiliation(s)
- Diego Real de Asua
- Department of Internal Medicine, Hospital Universitario de la Princesa, Madrid, Spain
- Division of Medical Ethics, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Joseph J Fins
- Division of Medical Ethics, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- CASBI, Consortium for the Advanced Study of Brain Injury, Weill Cornell Medicine and Rockefeller University, New York, New York, USA
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Waldrop G, Safavynia SA, Barra ME, Agarwal S, Berlin DA, Boehme AK, Brodie D, Choi JM, Doyle K, Fins JJ, Ganglberger W, Hoffman K, Mittel AM, Roh D, Mukerji SS, Der Nigoghossian C, Park S, Schenck EJ, Salazar‐Schicchi J, Shen Q, Sholle E, Velazquez AG, Walline MC, Westover MB, Brown EN, Victor J, Edlow BL, Schiff ND, Claassen J. Prolonged Unconsciousness is Common in COVID-19 and Associated with Hypoxemia. Ann Neurol 2022; 91:740-755. [PMID: 35254675 PMCID: PMC9082460 DOI: 10.1002/ana.26342] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/20/2022] [Accepted: 02/28/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this study was to estimate the time to recovery of command-following and associations between hypoxemia with time to recovery of command-following. METHODS In this multicenter, retrospective, cohort study during the initial surge of the United States' pandemic (March-July 2020) we estimate the time from intubation to recovery of command-following, using Kaplan Meier cumulative-incidence curves and Cox proportional hazard models. Patients were included if they were admitted to 1 of 3 hospitals because of severe coronavirus disease 2019 (COVID-19), required endotracheal intubation for at least 7 days, and experienced impairment of consciousness (Glasgow Coma Scale motor score <6). RESULTS Five hundred seventy-one patients of the 795 patients recovered command-following. The median time to recovery of command-following was 30 days (95% confidence interval [CI] = 27-32 days). Median time to recovery of command-following increased by 16 days for patients with at least one episode of an arterial partial pressure of oxygen (PaO2 ) value ≤55 mmHg (p < 0.001), and 25% recovered ≥10 days after cessation of mechanical ventilation. The time to recovery of command-following was associated with hypoxemia (PaO2 ≤55 mmHg hazard ratio [HR] = 0.56, 95% CI = 0.46-0.68; PaO2 ≤70 HR = 0.88, 95% CI = 0.85-0.91), and each additional day of hypoxemia decreased the likelihood of recovery, accounting for confounders including sedation. These findings were confirmed among patients without any imagining evidence of structural brain injury (n = 199), and in a non-overlapping second surge cohort (N = 427, October 2020 to April 2021). INTERPRETATION Survivors of severe COVID-19 commonly recover consciousness weeks after cessation of mechanical ventilation. Long recovery periods are associated with more severe hypoxemia. This relationship is not explained by sedation or brain injury identified on clinical imaging and should inform decisions about life-sustaining therapies. ANN NEUROL 2022;91:740-755.
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Affiliation(s)
- Greer Waldrop
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Seyed A. Safavynia
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Megan E. Barra
- Department of PharmacyMassachusetts General HospitalBostonMAUSA
- Center for Neurotechnology and NeurorecoveryMassachusetts General HospitalBostonMAUSA
| | - Sachin Agarwal
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - David A. Berlin
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - Amelia K Boehme
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Daniel Brodie
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Jacky M. Choi
- Division of Biostatistics, Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNYUSA
| | - Kevin Doyle
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Joseph J. Fins
- New York Presbyterian HospitalNew YorkNYUSA
- Division of Medical Ethics, Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - Wolfgang Ganglberger
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Katherine Hoffman
- Division of Biostatistics, Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNYUSA
| | - Aaron M. Mittel
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiaColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - David Roh
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Shibani S. Mukerji
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Caroline Der Nigoghossian
- New York Presbyterian HospitalNew YorkNYUSA
- Department of PharmacyNew York Presbyterian HospitalNew YorkNYUSA
| | - Soojin Park
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Edward J. Schenck
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - John Salazar‐Schicchi
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Qi Shen
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Evan Sholle
- Information Technologies & Services DepartmentWeill Cornell MedicineNew YorkNYUSA
| | - Angela G. Velazquez
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Maria C. Walline
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - M. Brandon Westover
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Emery N. Brown
- Department of Brain and Cognitive ScienceInstitute of Medical Engineering and Sciences, the Picower Institute for Learning and Memory, and the Institute for Data Systems and Society, Massachusetts Institute of TechnologyBostonMAUSA
- Department of AnesthesiaCritical Care and Pain Medicine, Massachusetts General HospitalBostonMAUSA
| | - Jonathan Victor
- New York Presbyterian HospitalNew YorkNYUSA
- Department of NeurologyWeill Cornell Medical CollegeNew YorkNYUSA
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical CenterNew YorkNYUSA
| | - Brian L. Edlow
- Center for Neurotechnology and NeurorecoveryMassachusetts General HospitalBostonMAUSA
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Nicholas D. Schiff
- New York Presbyterian HospitalNew YorkNYUSA
- Department of NeurologyWeill Cornell Medical CollegeNew YorkNYUSA
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical CenterNew YorkNYUSA
| | - Jan Claassen
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
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Shulman KS, Fins JJ. Before The Birth of Bioethics: James M. Gustafson at Yale. Hastings Cent Rep 2022; 52:21-31. [PMID: 35476357 DOI: 10.1002/hast.1352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the 1960s, tucked away at Yale Divinity School, there was a remarkable confluence of bioethics scholars under the tutelage of James M. Gustafson. His students were Jim Childress, Albert R. Jonsen, Tom Beauchamp, LeRoy Walters, Jim Drane, and Stanley Hauerwas, among others. Jonsen later recalled, "That little group was really the beginning of scholarly bioethics." Yet despite Gustafson's influence on the founding generation of bioethics scholars and his prominence as a leading mid-century Christian theologian, his legacy in bioethics is unsecured. This is an unfortunate omission, as Gustafson's contributions to bioethics were not limited to the classroom. In 1969, he brought Paul Ramsey to Yale to deliver the Lyman Beecher Lectures, a collection of talks that would coalesce into Ramsey's The Patient as Person. Gustafson also advised Daniel Callahan as Callahan and Willard Gaylin founded The Hastings Center, on whose founding board of directors Gustafson later served. Through archival research and interviews with Gustafson's former students and colleagues, we recount his biography, consider his pedagogy, and examine the theological pragmatism that informed his engagement with his students and his intellectual commitments before the birth of bioethics. By reviewing Gustafson's contributions to the nascent field of bioethics, we seek to understand why his legacy has been forgotten and to introduce him to a new generation of bioethics scholars.
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Kim N, O'Sullivan J, Olafson E, Caliendo E, Nowak S, Voss HU, Lowder R, Watson WD, Ivanidze J, Fins JJ, Schiff ND, Hill NJ, Shah SA. Cognitive-Motor Dissociation Following Pediatric Brain Injury: What About the Children? Neurol Clin Pract 2022; 12:248-257. [PMID: 35733619 PMCID: PMC9208423 DOI: 10.1212/cpj.0000000000001169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/07/2022] [Indexed: 11/27/2022]
Abstract
Background and Objectives Following severe brain injury, up to 16% of adults showing no clinical signs of cognitive function nonetheless have preserved cognitive capacities detectable via neuroimaging and neurophysiology; this has been designated cognitive-motor dissociation (CMD). Pediatric medicine lacks both practice guidelines for identifying covert cognition and epidemiologic data regarding CMD prevalence. Methods We applied a diverse battery of neuroimaging and neurophysiologic tests to evaluate 2 adolescents (aged 15 and 18 years) who had shown no clinical evidence of preserved cognitive function following brain injury at age 9 and 13 years, respectively. Clinical evaluations were consistent with minimally conscious state (minus) and vegetative state, respectively. Results Both participants' EEG, and 1 participant's fMRI, provided evidence that they could understand commands and make consistent voluntary decisions to follow them. Both participants' EEG demonstrated larger-than-expected responses to auditory stimuli and intact semantic processing of words in context. Discussion These converging lines of evidence lead us to conclude that both participants had preserved cognitive function dissociated from their motor output. Throughout the 5+ years since injury, communication attempts and therapy had remained uninformed by such objective evidence of their cognitive abilities. Proper diagnosis of CMD is an ethical imperative. Children with covert cognition reflect a vulnerable and isolated population; the methods outlined here provide a first step in identifying such persons to advance efforts to alleviate their condition.
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Affiliation(s)
- Nayoung Kim
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - James O'Sullivan
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Emily Olafson
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Eric Caliendo
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Sophie Nowak
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Henning U Voss
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Ryan Lowder
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - William D Watson
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Jana Ivanidze
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Joseph J Fins
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Nicholas D Schiff
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - N Jeremy Hill
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
| | - Sudhin A Shah
- Department of Radiology (NK, JOS, EO, HUV, JI, SAS) and Department of Rehabilitation Medicine (EC, RL), Weill Cornell Medicine, New York; Blythedale Children's Hospital (SN, WDW), Valhalla, NY; Division of Medical Ethics (JJF), Weill Cornell Medicine and New York Presbyterian Weill Cornell Medical Center; Department of Neurology and BMRI (NDS), Weill Cornell Medicine, New York; National Center for Adaptive Neurotechnologies (NJH), Stratton VA Medical Center; and Department of Electrical and Computer Engineering (NJH), State University of New York at Albany, NY
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Peterson A, Young MJ, Fins JJ. Ethics and the 2018 Practice Guideline on Disorders of Consciousness: A Framework for Responsible Implementation. Neurology 2022; 98:712-718. [PMID: 35277446 PMCID: PMC9071367 DOI: 10.1212/wnl.0000000000200301] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/16/2022] [Indexed: 11/15/2022] Open
Abstract
The 2018 practice guideline on disorders of consciousness marks an important turning point in the care of patients with severe brain injury. As clinicians and health systems implement the guideline in practice, several ethical challenges will arise in assessing the benefits, harms, feasibility, and cost of recommended interventions. We provide guidance for clinicians when interpreting these recommendations and call on professional societies to develop an ethical framework to complement the guideline as it is implemented in clinical practice.
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Affiliation(s)
- Andrew Peterson
- Institute for Philosophy and Public Policy, George Mason University, Virginia.,Penn Program on Precision Medicine for the Brain, University of Pennsylvania, Pennsylvania
| | - Michael J Young
- Department of Neurology and Edmond J. Safra Center for Ethics, Harvard University, Massachusetts
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, Cornell University, New York.,Solomon Center for Health Law & Policy, Yale Law School, Connecticut
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35
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Fins JJ, Wright MS. Dignity of Risk, Reemergent Agency, and the Central Thalamic Stimulation Trial for Moderate to Severe Brain Injury. Perspect Biol Med 2022; 65:307-315. [PMID: 35938438 DOI: 10.1353/pbm.2022.0026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This article discusses the utility of Perske's "dignity of risk" as a useful heuristic to explain the consent process for a study to evaluate central thalamic deep brain stimulation as a means to restore cognitive function in moderate to severe brain injury. Narratives of interviews with subjects and their families from a related BRAIN Initiative study reveal discordant views on risk, with subjects being more risk-tolerant than their loved ones. This is a challenge for families who remain protective of subjects who have recovered to the point that they are capable of independent decision-making. While the legal threshold for consent has been met, normative and psychological challenges remain as families accommodate themselves to the reemergent agency of the subject. Dignity of risk is a constructive framework to apprehend how families come to appreciate the primacy of the subject's voice and affirm their reemergent agency following a devastating brain injury.
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36
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Fins JJ. Consciousness, Conflations, and Disability Rights: Denials of Care for Children in the "Minimally Conscious State". J Law Med Ethics 2022; 50:181-183. [PMID: 35243988 DOI: 10.1017/jme.2022.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This essay critiques the fiercely utilitarian allocation scheme of Cameron et al. Children have no hope of recovery if their lives are cut short based on administrative protocols that misrepresent the nature of their conditions. Unilateral futility judgements - especially those based on a false predicate - are discriminatory. When considering the best interests of children, we should see possibility in disability and not advance ill-informed utilitarianism.
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37
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Fins JJ. Is deliberative democracy possible during a pandemic? Reflections of a bioethicist. Journal of Theoretical and Philosophical Psychology 2021. [DOI: 10.1037/teo0000191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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38
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Nurok M, Gusmano MK, Fins JJ. When pandemic biology meets market forces - managing excessive demand for care during a national health emergency. J Crit Care 2021; 67:193-194. [PMID: 34649745 PMCID: PMC8506348 DOI: 10.1016/j.jcrc.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/09/2021] [Accepted: 09/27/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Michael Nurok
- Director, Cardiac Surgery ICU, Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd,. Suite 3100, Los Angeles, CA 90048, United States of America.
| | - Michael K Gusmano
- Professor and Dean of Academic Programs, College of Health, Lehigh University, HST Building, 124 East Morton Street, Bethlehem, PA 18015, United States of America.
| | - Joseph J Fins
- The E. William Davis, Jr, MD Professor of, Medical Ethics & Professor of Medicine, Chief, Division of Medical Ethics, Weill Cornell Medical College, Visiting Professor of Law & Solomon Center Distinguished Scholar in Medicine, Bioethics and the Law, Yale Law School, Division of Medical Ethics, Weill Cornell Medical College, 435 East 70th St. Suite 4-J, NY, NY 10021, United States of America.
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39
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Affiliation(s)
- Kimberly S Resnick
- New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA.
| | - Joseph J Fins
- New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
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40
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Young MJ, Bodien YG, Giacino JT, Fins JJ, Truog RD, Hochberg LR, Edlow BL. The neuroethics of disorders of consciousness: a brief history of evolving ideas. Brain 2021; 144:3291-3310. [PMID: 34347037 DOI: 10.1093/brain/awab290] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 11/12/2022] Open
Abstract
Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant, and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically-responsible care in this domain are especially timely given recent surges in critically ill patients with unusually prolonged disorders of consciousness associated with coronavirus disease 2019 (COVID-19) around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness, and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and up until the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery, and ethical issues that arise within the context of caring for persons with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA 02138, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | | | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY 10021, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, MA 02115, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,School of Engineering and Carney Institute for Brain Science, Brown University, Providence, RI 02906, USA.,VA RR&D Center for Neurorestoration and Neurotechnology, Department of Veterans Affairs Medical Center, Providence, RI 02908, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA 02129, USA
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Giacino JT, Bodien YG, Zuckerman D, Henderson J, Schiff ND, Fins JJ. Empiricism and Rights Justify the Allocation of Health Care Resources to Persons with Disorders of Consciousness. AJOB Neurosci 2021; 12:169-171. [PMID: 33960891 DOI: 10.1080/21507740.2021.1904055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Yelena G Bodien
- Harvard Medical School.,Spaulding Rehabilitation Hospital.,Massachusetts General Hospital
| | | | | | | | - Joseph J Fins
- Weill Cornell Medical College.,The Rockefeller University.,Yale Law School
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42
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Fins JJ, Wright MS, Giacino JT, Henderson J, Schiff ND. In Pursuit of Agency Ex Machina: Expanding the Map in Severe Brain Injury. AJOB Neurosci 2021; 12:200-202. [PMID: 33960894 DOI: 10.1080/21507740.2021.1904050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Joseph J Fins
- Weill Cornell Medical College.,Yale Law School.,The Rockefeller University
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Abstract
Cultural historians and historians of medicine are a rarity in bioethics. Even those who write histories of bioethics are philosophers, sociologists, or theologians. Where have all the historians gone? If bioethics is to contribute to the urgent work of addressing social justice, structural racism, and health inequity, we bioethicists need to embrace history as a fully constituent part of our field. Historians can help us apprehend the ideas that shaped bioethics, and health policy more broadly, and discover the dissenting arguments that might inspire us now. Given our annus horribilis, history has become an instrumental necessity. It is only through the study of history that we can understand the past so as to reimagine how bioethics can influence health policy and work toward health equity.
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44
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Gabbay E, Fins JJ, Banja J, Evans T. Congee for the Soul. Hastings Cent Rep 2021; 51:10-12. [PMID: 33630323 DOI: 10.1002/hast.1212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Provision of adequate nutrition to elderly patients who develop dysphagia after a stroke can be quite challenging, often leading to the placement of a percutaneous entero-gastrostomy (PEG) tube for nutritional support. This hypothetical case describes the additional challenge of cross-cultural belief that leads a daughter to provide oral feeding to her mother, an act that the medical team believes is dangerous and the daughter sees as salubrious. In this case, what is the proper balance between patient safety and deference to cultural traditions and norms? Where are the limits? Two commentaries offer insights for conflict resolution, including recommending that the medical team seek to understand the cultural motivations of the family, balancing safety and respect for cultural norms. The second commentary also disagrees with the team's presumption that the daughter's feeding of her mother is a greater threat to the patient than the PEG tube feeding is.
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45
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Chandler JA, Cabrera LY, Doshi P, Fecteau S, Fins JJ, Guinjoan S, Hamani C, Herrera-Ferrá K, Honey CM, Illes J, Kopell BH, Lipsman N, McDonald PJ, Mayberg HS, Nadler R, Nuttin B, Oliveira-Maia AJ, Rangel C, Ribeiro R, Salles A, Wu H. International Legal Approaches to Neurosurgery for Psychiatric Disorders. Front Hum Neurosci 2021; 14:588458. [PMID: 33519399 PMCID: PMC7838635 DOI: 10.3389/fnhum.2020.588458] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022] Open
Abstract
Neurosurgery for psychiatric disorders (NPD), also sometimes referred to as psychosurgery, is rapidly evolving, with new techniques and indications being investigated actively. Many within the field have suggested that some form of guidelines or regulations are needed to help ensure that a promising field develops safely. Multiple countries have enacted specific laws regulating NPD. This article reviews NPD-specific laws drawn from North and South America, Asia and Europe, in order to identify the typical form and contents of these laws and to set the groundwork for the design of an optimal regulation for the field. Key challenges for this design that are revealed by the review are how to define the scope of the law (what should be regulated), what types of regulations are required (eligibility criteria, approval procedures, data collection, and oversight mechanisms), and how to approach international harmonization given the potential migration of researchers and patients.
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Affiliation(s)
| | - Laura Y. Cabrera
- Center for Ethics & Humanities in the Life Sciences and Dept. Translational Neuroscience, Michigan State University, East Lansing, MI, United States
| | - Paresh Doshi
- Department of Neurosurgery, Jaslok Hospital and Research Center, Mumbai, India
| | - Shirley Fecteau
- Department of Psychiatry and Neurosciences, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- CERVO Brain Research Center, Center Intégré Universitaire en Santé et Services Sociaux de la Capitale-Nationale, Quebec City, QC, Canada
| | - Joseph J. Fins
- Weill Cornell Medical College, Consortium for the Advanced Study of Brain Injury, Weill Cornell and the Rockefeller University, New York, NY, United States
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT, United States
| | | | - Clement Hamani
- Harquail Center for Neuromodulation, Sunnybrook Research Institute, Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | | | - C. Michael Honey
- Section of Neurosurgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brian H. Kopell
- Departments of Neurosurgery, Neurology, Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nir Lipsman
- Division of Neurosurgery, Harquail Center for Neuromodulation, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Patrick J. McDonald
- Division of Neurosurgery, Faculty of Medicine, BC Children's Hospital, University of British Columbia, Head, Vancouver, BC, Canada
| | - Helen S. Mayberg
- Departments of Neurology, Neurosurgery, Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Roland Nadler
- Peter A. Allard School of Law, University of British Columbia, Vancouver, BC, Canada
| | - Bart Nuttin
- Neurosurgeon, Katholieke Universiteit (KU) Leuven, Universitair Ziekenhuis (UZ) Leuven, Leuven, Belgium
| | - Albino J. Oliveira-Maia
- Champalimaud Research and Clinical Center, Champalimaud Center for the Unknown, Lisbon, Portugal
- NOVA Medical School, NMS, Universidade Nova De Lisboa, Lisbon, Portugal
| | - Cristian Rangel
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Arleen Salles
- Center for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
| | - Hemmings Wu
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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46
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY; Solomon Center for Health Law and Policy, Yale Law School, New Haven, Conn.
| | - Franklin G Miller
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY
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Abstract
On January 5, 2019, the Associated Press reported that a woman thought to have been in the vegetative state for over a decade gave birth at a Hacienda HealthCare facility. Until she delivered, the staff at the Phoenix center had not noticed that their patient was pregnant. The patient was also misdiagnosed. Misdiagnosis of patients with disorders of consciousness in institutional settings is more the norm than the exception. Misdiagnosis is also connected to a broad and extremely significant change in the understanding of the vegetative state-a change that the field of bioethics has not yet fully taken into account. In September 2018, the American Academy of Neurology, the American College of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research issued a comprehensive evidence-based review on disorders of consciousness and an associated practice guideline on the care of these patients. These landmark publications update the 1994 Multi-Society Task Force Report on the Vegetative State, which subcategorized the persistent vegetative state as either persistent (once the vegetative state lasted one month) or permanent (once the vegetative state lasted three months after anoxic injury or twelve months after traumatic injury). Noting that 20 percent of patients thought to be permanently unconscious might regain some level of consciousness, the new guideline has eliminated the permanent vegetative state as a diagnostic category, replacing it with the chronic vegetative state.
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48
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Fins JJ, Prager KM. The COVID-19 Crisis and Clinical Ethics in New York City. The Journal of Clinical Ethics 2020. [DOI: 10.1086/jce2020313228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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49
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Huberman BJ, Mukherjee D, Gabbay E, Knowlton SF, Green DS, Pandya N, Meredyth N, Walker JM, Shapiro ZE, Hersh JE, Chisholm MF, Waldman SA, MacKenzie CR, de Melo-Martín I, Fins JJ. Phases of a Pandemic Surge: The Experience of an Ethics Service in New York City during COVID-19. The Journal of Clinical Ethics 2020. [DOI: 10.1086/jce2020313219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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50
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Prager KM, Fins JJ. Meeting the Challenge of COVID-19: The Response of Two Ethics Consultation Services in New York City. The Journal of Clinical Ethics 2020. [DOI: 10.1086/jce2020313209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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