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Blog Posts (1435)

December 15, 2014


Dear Readers,   bioethicsscreenreflections has supported the development of the film GOING THE DISTANCE in an advisory capacity. It is a film about Traumatic Brain Injury recovery. I have the honor of co-hosting a fundraising screening&...
December 15, 2014


Bioethical issues in Traumatic Brain Injury 

GOING THE DISTANCE: JOURNEYS OF RECOVERY is a documentary film about the lives of survivors of Traumatic Brain Injury. Directed by multi-Emmy Award winning filmmaker David L. Brown, the project is seeking funding for its finishing phase. This film has had multiple previews in collaboration with brain injury advocates.  It has also been used in therapeutic TBI groups to gauge the communities' take on their depiction. An earlier film by the same director, SURFING FOR LIFE, reinforces that Brown, like any good film auteur, finds different ways of telling stories whose elements are significant to him. 

SURFING FOR LIFE deals with optimizing life from childhood through aging. It explores our relationship with water or what evolutionary biologists J. W. Nichols calls the ‘Blue Mind.’  GOING THE DISTANCE also deals with maximizing people's potential, after the have acquired brain injury. Not surprisingly, some of the films protagonists also have a restorative relationship with water. 

David L. Brown’s films have a solid optimism to them. That’s right, GOING THE DISTANCE is an optimistic film about TBI. The project follows four people through a narrative spanning roughly eight years. The work has the weight of longevity, diversity and the drama of living on the edges between life, death and rebirth. With four main characters, instead of one, the film is racial, gender, and age cohort inclusive. Permutations and combinations leave every viewer identifying with some part of the story. 

Why is Traumatic Brain Injury of particular bioethical concern?  There are tensions between beneficence, autonomy and justice manifest in issues around the epidemic incidence of TBI. The principle of beneficence, doing good with our science, services medical indications.  We now have plenty of neuroscience to support how these injuries occur at the cellular level and the best ways to prevent and deal with the sequelae. Yet, there are organizational and geopolitical barriers to clinicians and survivors accessing, or utilizing that information. Justice is facilitated by equipoise. Equipoise is the equitable distribution of burdens and benefits. Organizational and geopolitical factors often impede equipoise in the prevention and management of TBI. 

Among the important new science is a better understanding of ‘neuroplasticity,’ Dr. Albert Ray considers neuroplasticity the operating system for the nervous system.  It is the mechanism whereby the physical anatomy and physiological workings of our nervous system happen, both in normal and pathological conditions. It is what makes the brain programmable and re-programmable. 

After a period of intense neurological rest, recruitment and retraining of undamaged brain tissue improves functional capacity.  That recruitment process results from neuroplasticity, or reshaping parts of the brain, to assume tasks abandoned in the aftermath of the traumatic injury. Neuroplasticity fuels the work of occupational, physical and speech therapist and those acting in their stead. When forced to prognosticate, professionals do so within the parameters of the resource stressed systems in which they work. For instance they might cautiously say," A person with this initial assessment, receiving therapy weekly, can expect 'X' amount of functionality in one a year." GOING THE DISTANCE is a story about best chances to exceed those expectations.

Other manifestations of conflicts between beneficence and justice affect veterans returning from war zones with undiagnosed TBI as well as Post Traumatic Stress Disorder, car accidents, repetitive concussions from sports, violent assaults and motor vehicle accidents.  All of these disproportionately affect the young, very old,  poor, and people of color.  Adequate activities of known therapeutic benefit and prevention are often unattainable because of cost and lack of trained resources. Though brilliant acute trauma and neurosurgical care occurs in most urban centers in the USA, the follow up care is lacking. TBI, is a health and healthcare disparity issue. 

Traumatic Brain Injury also results in bioethical tensions between beneficence and the principal of autonomy, or the right to do what is in one’s own enlightened self-interest.  Most agree parents are appropriate surrogate decision makers for their children. Substituted judgment in adults, particularly young adults, with brain injury is wrought with uncertainty regarding extent of damage to a person’s decisional capacity. In this way TBI, like dementia, is a moving target. Dementia and TBI are related in other ways as well.

There is compelling data that negative cognitive effects are among the most disabling of post-concussion symptoms following moderate and severe TBI. These effects unfold slowly, sometimes over years and lead to high incidences of dementia. Deficits occur in attention, memory and "executive function," These deficits show up as impulsiveness, mental fatigue, frustration, depression, pain, self-medication, substance abuse and loss of employment. Justice suggest,” those with the most burden should have the most benefit.” In the most developed nations, minds which operate “like steel traps,” are adored. TBI survivors rarely have those kinds of minds and are often not well accommodated by legislative measures, including the application of the American Disability Act. 

The film CRASH REEL gives a good example of autonomy conflicting with beneficence. An extraordinary athlete, champion snow boarder, struggles with his late stage cognitive and physical limits. The recently completed film, STATES OF GRACE (reviewed elsewhere on this blog) like CRASH REEL, is about another person with uncommon capacity facing extraordinary adversity. There is much to learn from these films but it is not the story of GTD. 
GOING THE DISTANCE is about ordinary people riding waves of adversity, while attempting the boring things of daily life. They use “what they’ve got."  What they have is family, friends and advocates.  By example, GTD gently makes the point that those without support have rougher rides and may drown in the surf. GOING THE DISTANCE is a documentary about quiet heroes focused not on what they cannot do in TBI recovery, but what they can.  
GONG THE DISTANCE (Digital) directed by David L. Brown ( 2014) pending release USA.  62 mins
SURFING FOR LIFE  (Video) directed by David L. Brown (1999) USA  68 min. 
THE CRASH REEL (2013) directed by Lucy Walker  HBO Films  USA 108 mins
STATES OF GRACE ( 2014) directed by Helen Cohen and Mark Lipman (USA) distribution pending 71 mins.
Nichols, W. J. Blue Mind. Little, Brown and Company, 2014.
Ray, A. Neuroplasticity, Sensitization, and Pain. in Comprehensive Treatment of Chronic Pain by Medical, Interventional and Behavioral Approaches. ed. Deer, T.R.;Leong,M.S; Ray, A.L. et. al. ; American Acad- emy of Pain Medicine. Springer Inc. 2013.p 759-768,
Shively S1, Scher AI, Perl DP, Diaz-Arrastia R. Arch Neurol. Dementia resulting from traumatic brain injury: what is the pathology? 2012 Oct;69(10):1245-51 accessed December 12, 2014
Carmichael, S. (2010). Translating the frontiers of brain repair to treatments: Starting not to break the rules. Neurobiology of Disease, 37(2), pp. 1-10.

December 15, 2014

Tracey v. Cambridge University Hospital - Duty to Consult

The December 2014 issue of Clinical Medicine (Royal College of Physicians) includes a nice summary of the impact and implications of the UK Court of Appeal's judgment in Tracey v. Cambridge University Hospital.  Under prior UK cases like Aintree a...
December 15, 2014

Is Homo Economicus a Psychopath?

In what academics call neoclassical economics, human beings are largely rational, self-interested decision-makers. This stereotypical human, often referred to as Homo economicus, is a creature of coldly calculated selfishness, dispassionately maximizing its best interests even if that comes at the … Continue reading
December 15, 2014

Ontario Medical Board Seeks Input on Draft End-of-Life Policy

The College of Physicians and Surgeons of Ontario has just posted ’s a revised draft policy for external consultation: "Planning for and Providing Quality End-of-Life Care."  

The draft policy sets out professional expectations of physicians and provides guidance on a range of issues relating to quality end-of-life care, including futility and aid in dying.

The CPSO is inviting feedback from all stakeholders, including members of the medical profession, the public, health system organizations and other health professionals on the draft policy. Comments received by February 2015 will assist in developing a final policy which will be considered for final approval by Council.  Several good comments already appear on the online discussion board.

December 14, 2014

Patients Abandoned—Who is to blame?

<p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">The vast majority of developed nations in the world provide universal healthcare coverage for its citizens. The only developed nations that do not are “…<a href="">a few still-troubled Balkan states, the Soviet-style autocracy of Belarus, and the U.S. of A., the richest nation in the world</a>.” </span></p> <p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">Yet the United States (US) has the most expensive healthcare system in the world, by far—there really isn’t a close second—spending just under 18% of GPD and around $8,500.00 per person on healthcare. One might assume that given that type of expense, we would be getting a lot more than other countries in return for our investment. According to the research provided by <a href="">Mirror, Mirror</a>, from the Commonwealth Fund, the US sadly underperforms and often fails relative to other developed countries on major measures of performance. </span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></p>
December 14, 2014

Mass General - Futility Policy Experience

Andrew Courtwright and colleagues at the Massachusetts General Hospital have published "Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial" in the Journal of Critical Care. This w...
December 13, 2014

Communicating about Prognosis and End-of-Life Care in Patients with Advanced Cancer (video)

On November 19, 2014, Jennifer Temel presented "Communicating about Prognosis and End-of-Life Care in Patients with Advanced Cancer" at the MacLean Center for Clinical Medical Ethics.
December 12, 2014

Brain Death - Abandoned in British Labor Case?

Rowan Atkinson plays a union negotiator, arguing that brain death is not death.
December 12, 2014

The Ulysses Strategy

As the University of Chicago economist Richard Thaler tells the story, a group of fellow-graduate students in economics were at his house one night in the late nineteen-seventies, socializing before the dinner hour. Thaler saw how much they were snacking, and … Continue reading