These limitations can be overcome by reconstituting a macroaggregate kit with saline and observing non-radioactive particles generic super p-force oral jelly 160mg with visa impotence of organic organ. Colloidal particles cannot be visualized by normal light microscopy and generic super p-force oral jelly 160 mg on line erectile dysfunction drugs stendra, in situations where it is important to know the particle size distribution best super p-force oral jelly 160mg erectile dysfunction pills cheap, more elaborate techniques such as light scattering or membrane filtration will have to be used buy super p-force oral jelly 160 mg fast delivery erectile dysfunction etiology. The use of clean glassware, kits, reagents and equipment is the best way to minimize contamination. However, on occasions, particles can be present in the final solution as a result of coring of the rubber 504 7. Control can be exercised by visual inspection of the final radiopharmaceutical, while ensuring that adequate measures are taken to protect the eyes. The required level of protection can be achieved by viewing through lead glass screens or by using mirrors to view vials placed behind lead shields. It should be pointed out that such techniques may not detect small amounts of particulate contamination and are not suitable for radiopharmaceuticals which themselves are particulate. If the pH rises, the material becomes colloidal and unsuitable for labelling reactions. The easiest method of determining pH is to use narrow range pH papers, since only small samples are needed. Assessment of pH is subjective and such papers are normally only accurate to about 0. For the majority of radiopharmaceuticals these limitations are not normally detrimental. Although these objectives can be achieved by the use of a suitable sterilization technique during preparation of the radiopharmaceutical, it is often necessary to use an aseptic technique to prepare the final radiopharma- ceutical, having started with sterile materials (e. Sterility testing of radiopharmaceuticals presents difficulties and it is often impracticable to apply tests described in pharmacopoeias; this is not only because of the radioactive nature of the material but also, as is the case with Tc radiopharmaceuticals, because the batch may consist of a single container. This introduces serious problems with sample sizes and makes the test statistically unsatisfactory. In addition, there is evidence that micro- organisms do not survive in Tc radiopharmaceuticals and hence allowing them to decay in order to make testing easier can reduce the value of the test. Alternatively, for Tc radiopharmaceuticals, the culture medium can be added to the remnants of the kit vial at the end of the working day. Inevitably this means that the result of the test is only obtained retrospectively. In view of these limitations, a more satisfactory technique to ensure sterility of aseptically prepared radio- pharmaceuticals involves staff simulating exactly the preparation techniques using culture media. Such tests have the advantages of being more sensitive and of using non-radioactive materials, and can be performed earlier. Determination of the apyrogenicity of injections is currently only required when the volume administered exceeds 15 mL. This rarely occurs with radiopharmaceuticals and hence the test is not usually performed in hospital radiopharmacies. If a hospital is involved in the development of new agents, it may be prudent to assess the apyrogenicity, particularly if materials of animal origin are used in the preparation. The use of the limulus lysate test for pyrogens is now becoming widely accepted in preference to the rabbit test, but rigorous controls must be used to validate the test. Commercial manufacturers frequently use the limulus lysate test in the control of their materials. If such observations are made regularly, confidence in the quality of the materials being administered to patients is gained. When nuclear medicine images are reported, unexpected biodistribu- tions are sometimes observed and may result from problems with the radio- pharmaceutical, or alternatively may be due to the patient’s condition or even the medication the patient may be taking. If the problem has occurred with all patients who received that particular batch of radiopharmaceutical, the problem is likely to lie with the product. An example is the visualization of the stomach in patients undergoing bone imaging with a technetium phosphonate complex. This indicates the presence of pertechnetate in the radiopharmaceutical and may have arisen as a result of an incomplete reaction when preparing the kit or of instability after preparation. If this occurs on a regular basis with different batches of the same radiopharmaceutical, action is necessary to eradicate the problem. However, it is not acceptable merely to rely on the biodistribution in patients as the only quality control testing to be performed. In situations where an unexpected biodistribution is seen in one patient but not in others who received the same product, a patient related cause might be responsible. If this can be identified, it can provide useful information for future reference and to prevent misdiagnosis occurring. On rare occasions, an adverse reaction may occur in a patient to whom a radiopharmaceutical has been administered. The prevalence of such reactions has been estimated as 3 per 105 administrations and, as such, departments might not encounter a similar situation for many years. Fortunately, adverse reactions that do occur are generally mild and self-limiting and do not require extensive treatment. The adverse reaction most commonly encountered involves the development of skin rashes a few hours after administration of 99mTc bone imaging agents. Histamine release in the patient is frequently implicated as the cause of the problem, and hence symptomatic treatment with an antihistamine is sometimes beneficial. There are occasions when a severe anaphylactic reaction can occur immediately after administration and prompt action, including administration of adrenalin, may be necessary. Since the occurrence of such events is so low, they should be reported to the manufacturer of the product and, as necessary, to national authorities. In this way a database on the possible reactions that can occur is developed and information can be dissemi- nated. Departments can then be prepared to deal with such events if they occur, thereby enhancing the quality of patient care. This requires the development of appropriate documentation systems, record keeping and quality control testing protocols. These will be influenced by the range of products prepared, the source of the starting materials (e. In addition, it is important that the results obtained are reviewed and acted upon where necessary in order to maintain the quality of the products. One vital component in the assurance of quality of products is to have well trained competent staff who have the necessary skills and knowledge to deal with radioactive pharmaceutical products. This section will concentrate on procedures that have not been covered elsewhere in this manual, and also deal with monitoring. These may include: —General: departmental radiation safety rules; —Radiopharmacy: housekeeping, dose dispensing, record keeping, waste management, contamination control and accident procedures; —Patient studies: activity administration and accident procedures; —Therapy: administration, waste management, patient advice, discharge and accident procedures (Section 6. While each department should decide on its own procedures and rules, the following may serve as an example. Except for very small activities, containers are not to be handled directly and, if possible, tongs or forceps for vials and syringe shields should be used. Gloves should be removed in the proper surgical manner (with one glove held inside the other) and disposed of correctly as radioactive waste after use. Good housekeeping is important — all work areas should be kept clean and tidy, all radionuclide containers must be safely stored and readily available, adequate supplies of consumables must be available within easy reach of staff performing radio- pharmacy work, unnecessary visits to the radiopharmacy should be discouraged and contaminated sharp items such as needles must be safely stored behind shielding. Records should be kept of: —Receipt and disposal of radioactive materials; —All individual preparations for patient administration, including the patient’s name, radiopharmaceutical used, activity and date; —Quality control testing of the radionuclide calibrator. In addition: —Regular surveys (preferably weekly) of contamination must be performed. Diagnostic studies In general there are no hazards from patients who have received diagnostic doses. Use of disposable gloves (universal precautions) will provide sufficient protection from excreted radioactive material. Therapy procedures Staff caring for or working with patients who have received therapy with radionuclides may be required to follow safe working practices, according to the type of therapy. Accidental contamination procedures There are three major causes of spillage of liquid radioactive material: —From a source container; —Leakage during an injection procedure; —From patient excretions such as urine, faeces, sweat, saliva and vomitus. Spills of radioactive material are not to be regarded as an unavoidable hazard in the day to day operation of the department. Any spill has a level of danger, and acceptance of minor spills will lead to a casual approach to major spills. A kit of materials used for decontamination should be prepared and kept in an easily accessible location in the department. The contents of a decontamination kit can be decided locally, according to the materials available and the nature of the potential contamination hazards. All kits can be kept inside plastic containers (with a lid), and at a contamination site the container can be emptied and then used to place materials used in the decontamination as well as contaminated items such as clothing. A suggested list of contents for a decontamination kit is: —Disposable gloves, gowns and overshoes; —Bottles and/or spray canes of decontaminant (water with detergent and sodium thiosulphate added, at least); —Small scrubbing brushes; —Disposable and absorbent towels; —Felt tip marking pens (water soluble ink) for marking the contaminated area; —Plastic bags of different sizes; —Alcohol wipes; —Radiation warning signs, adhesive tape and labels; —Absorbent and plastic covered sheets (incontinence sheets); —Disposable forceps; —Disposable surgical masks. The following procedure should be followed on discovery of a contami- nation problem: (a) All persons involved in the incident are to vacate the immediate vicinity but are not to move freely around the department, as this involves a danger of spreading contamination. If the problem is due to a leaky syringe or other container, place the suspect item in a plastic bag and remove this to a suitable storage area. The following actions should be performed by a physicist or a senior technologist: (e) Define the area of contamination using an appropriate survey meter and, if appropriate, mark areas of hot spots with a felt tip pen. If there is any radioactive material on the skin, flush, in the first instance thoroughly with water. Decontamination of any contaminated area cannot be performed by a fixed set of rules, but must have regard for the radioisotope form and type of contamination. The following general information can be used in most cases: (1) In cases of spillage during drawing up or administering a patient injection, a suitably clad (gown, gloves and overshoes) person shall soak up any obvious liquid contamination with absorbent paper, placing such paper into a plastic bag for storage.
Reconsidering the evaluation of addiction treatment: From retrospective follow-up to concurrent recovery monitoring buy 160mg super p-force oral jelly fast delivery erectile dysfunction venous leak treatment. Psychiatric emergency service use and homelessness cost of super p-force oral jelly impotence urinary, mental disorder buy super p-force oral jelly in united states online erectile dysfunction university of maryland, and violence cheap super p-force oral jelly 160mg mastercard erectile dysfunction treatment options exercise. Counselor turnover in substance abuse treatment centers: An organizational-level analysis. Telephonic screening and brief intervention for alcohol misuse among workers contacting the employee assistance program: A feasibility study. Alcohol screening and brief intervention in the workplace: Opportunities for early identification and intervention. A comparison of methadone, buprenorphine and alpha(2) adrenergic agonists for opioid detoxification: A mixed treatment comparison meta-analysis. Environmental regulation of the development of mesolimbic dopamine systems: A neurobiological mechanism for vulnerability to drug abuse? Effects of alcohol and combined marijuana and alcohol use during adolescence on hippocampal volume and asymmetry. Improving substance abuse treatment access and retention using a case management approach. Prescription opioid abuse and dependence among physicians: Hypotheses and treatment. Quality measurement and accountability for substance abuse and mental health services in managed care organizations. Weight status continuity and change from adolescence to young adulthood: Examining disease and health risk conditions. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Case-control study of attention- deficit hyperactivity disorder and maternal smoking, alcohol use and drug use during pregnancy. The association between exposure to environmental tobacco smoke and breast cancer: A review by the California Environmental Protection Agency. The integration of pharmacological and nonpharmacological treatments in drug/alcohol addiction. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Family relationships and adolescent cigarette smoking: Results from a national longitudinal survey. Disseminating evidence-based practices in substance abuse treatment: A review with suggestions. Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (Vols. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Screening and counseling for adolescent alcohol use among primary care physicians in the United States. Impaired insight in cocaine addiction: Laboratory evidence and effects on cocaine-seeking behaviour. Dual diagnosis patients in substance abuse treatment: Relationship of general coping and substance-specific coping to 1-year outcomes. Motivational interviewing versus feedback only in emergency care for young adult problem drinking. Naltrexone and cue exposure with coping and communication skills training for alcoholics: Treatment process and 1-year outcomes. The Fagerstrom Test for Nicotine Dependence and the Diagnostic Interview Schedule. Safety and efficacy of the nicotine patch and gum for the treatment of adolescent tobacco addiction. Primary care-based intervention to reduce at-risk drinking in older adults: A randomized controlled trial. Cigarette smoking, low birth weight, and preterm births in low- income African American women. Cannabis use and risk of psychotic or affective mental health outcomes: A systematic review. Impact of distinct chemical structures for the development of a methamphetamine vaccine. Effectiveness of intensive case management for substance-dependent women receiving temporary assistance for needy families. Examining mechanisms of action in 12-step treatment: The role of 12-step cognitions. Affiliation with Alcoholics Anonymous after treatment: A study of its therapeutic effects and mechanisms of action. Smoking cessation for persons with mental illness: A toolkit for mental health providers. An experimental comparison of three types of case management for homeless mentally ill persons. Comorbid disruptive behavior disorder symptoms and their relationship to adolescent alcohol use disorders. The role of self-image in the relationship between family functioning and substance use among Hispanic adolescents. Brief interventions for alcohol problems: A meta-analytic review of controlled investigations in treatment-seeking and non- treatment-seeking populations. Pharmacogenetics: A tool for identifying genetic factors in drug dependence and response to treatment. A double-blind, placebo-controlled pilot study of carbamazepine for the treatment of alcohol dependence. Effects of progression to cigarette smoking on depressed mood in adolescents: Evidence from the National Longitudinal Study of Adolescent Health. Binge drinking in the preconception period and the risk of unintended pregnancy: Implications for women and their children. State policy report #34: Health center reimbursement for behavioral health services in Medicaid. Identification and description of multiple alcohol and other drug treatment systems: Final report. Quarterly report potency monitoring project: Report 104: December 16, 2008 thru March 15, 2009. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. An improved diagnostic instrument for substance abuse patients: The Addiction Severity Index. Integrating behavioral therapies with medication in the treatment of drug dependence. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Imaging studies expand understanding of how methamphetamine affects the human brain. S Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Preventing drug abuse among children and adolescents: Chapter 1: Risk factors and protective factors. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse. Developmental neural mechanisms of cognitive control: Implications for drug abuse interventions. Research report series: Heroin abuse and addiction: What are the treatments for heroin addiction? National voluntary consensus standards for the treatment of substance use conditions: Evidence- based treatment practices. Cost- effectiveness of a motivational intervention for alcohol-involved youth in a hospital emergency department. Bupropion reduces methamphetamine-induced subjective effects and cue-induced craving. Using qualitative research to inform survey development on nicotine dependence among adolescents. Brief alcohol intervention to prevent drinking during pregnancy: An overview of research findings. Retail tobacco outlet density and youth cigarette smoking: A propensity-modeling approach.
The risk of developing stomach cancer is thought to be increased with long-term infection with H purchase super p-force oral jelly online from canada erectile dysfunction emotional. It consists of the duo- denum best super p-force oral jelly 160mg erectile dysfunction caused by high blood pressure medication, a short section that receives secretions from the pancreas and liver via the pancreatic and common bile ducts buy 160mg super p-force oral jelly with amex erectile dysfunction doctors in brooklyn, the jejunum and the ileum buy cheap super p-force oral jelly line impotence at 17. Two other major cell types are present: enteroendocrine cells, which secrete hormones such as cholecystokinin and gastrin into blood, and goblet cells, which secrete lubri- cating mucus. Crypts (of Lieberkuhn) are moat-like invaginations of the epithelium around the villi, and are lined largely with younger epithelial cells, which are involved primarily in secretion. Toward the base of the crypts are stem cells, which continually divide and provide the source of all the epithelial cells in the crypts and on the villi. Gastric parietal cells and chief cells have Reduces shear stress on the epithelium. Cells have rapid turnover rates, usually a Abundant carbohydrates in mucin bind bacteria, few days. Stem cells, in the middle of gastric pits and The effects of toxins are minimised by their crypts, provide continual replenishment. Gastric and duodenal epithelial cells secrete bicarbonate to their apical faces to maintain a neutral pH along the epithelial plasma membrane. Their location, adjacent to crypt stem cells, suggests they have a role in defending epithelial cell renewal. The gastrointestinal tract is the largest endocrine organ in the body and the endocrine cells within it are referred to collectively as the enteric endocrine system. Three of the best-studied enteric hormones are gastrin, secreted from the stomach, which plays an important role in control of gastric acid secretion, cholecystokinin, which stimulates secretion of pancreatic enzymes and bile, and secretin, which stimulates secretion of bicarbonate-rich ﬂuids from the pancreas and liver. Normal proliferation of gastric and intestinal epithelial cells, as well as proliferation in response to such injury as ulceration, is known to be affected by a large number of endocrine and paracrine factors. Prostaglandins, particularly prostaglandin E2 and prostacyclin, have ‘cytoprotective’ effects on the gastrointestinal epithelium. Prostaglandins are synthesised within the mucosa from arachidonic acid through the action of cyclooxygenases. Their cytoprotective effect appears to result from stimulation of mucosal mucus and bicarbonate secretion, increasing mucosal blood ﬂow and, particularly in the stomach, limiting back-diffusion of acid into the epithelium. Both peptides bind to a common receptor and stimulate epithelial cell proliferation. Cytokines, such as ﬁbroblast growth factor and hepatocyte growth factor, have been shown to enhance healing of gastrointestinal ulcers in experimental models. Trefoil proteins are a family of small peptides that are secreted by goblet cells in the gastric and intestinal mucosa, and coat the apical face of the epithelial cells. Their distinctive molecular structure appears to render them resistant to proteolytic destruction. They appear to play an important role in mucosal integrity, repair of lesions and limiting epithelial cell proliferation, as well as in protecting the epithelium from a broad range of toxic chemicals and drugs. Trefoil proteins also appear to be central players in the restitution phase of epithelial damage repair, where epithelial cells ﬂatten and migrate from the wound edge to cover denuded areas. Mice with targeted deletions in trefoil genes showed exaggerated responses to mild chemical injury and delayed mucosal healing. An important part of barrier function is to prevent transit of bacteria from the lumen through the epithelium. Paneth cells are epithelial granulocytes located in small intestinal crypts of many mammals. They synthesise and secrete several antimicrobial peptides, chief among them isoforms of alpha-defensins, also known as cryptdins (‘crypt defensin’). These peptides have antimicrobial activity against a number of potential pathogens, including several genera of bacteria, some yeasts and Giardia trophozoites. Their mechanism of action is likely similar to neutrophilic alpha-defensins, which permeabilise target cell membranes. Barrier function is also supported by the gastrointestinal immune system; much of the epithe- lium is bathed in immunoglobulin A (IgA), which is secreted from sub-epithelial plasma cells and transcytosed across the epithelium into the lumen. IgA provides an antigenic barrier by binding bacteria and other antigens, although this barrier function is speciﬁc for particular antigens and requires previous exposure for development of the response. Pancreatic secretions are secreted into the lumen of the acinus and accumulate in intralobular ducts that drain to the main pancreatic duct, then directly into the duodenum. Control of the exocrine function of the pancreas is via the hormones gastrin, cholecystokinin and secretin. Pancreatic secretions from ductal cells contain bicarbonate ions that neutralise the acidic chyme from the stomach and are important in protecting the pancreas from recurrent acute and chronic pancreatitis by quickly sweeping zymogens out of it. To remain viable, all cells of the body are required to maintain a low intracellular concen- tration of sodium. The sodium–potassium pump is a highly conserved integral membrane protein, expressed in virtually all animal cells. The transport of sodium creates both an electrical and a chemical gradient across the plasma membrane. In turn this provides: • a cell’s resting membrane potential, the gradient of which is the basis for excitability in nerve and muscle cells • export of sodium from the cell, providing the driving force for several facilitated transporters, which import glucose, amino acids and other nutrients into the cell • translocation of sodium from one side of an epithelium to the other, creating an osmotic gradient that drives absorption of water. A beta glycoprotein subunit appears critical in facilitating plasma membrane localisation and activation of the alpha subunit. There are 8–10 transmembrane domains; alpha and beta subunits exist in several isoforms. Different isoforms of the alpha subunit have different afﬁnities for such glycosides. Binding of these widely-used drugs to sodium pumps speciﬁcally inhibits their activity. Inhibition of sodium pump activity in cardiac myocytes results in an increase in intracellular sodium concentration; in turn this leads to an increase in intracellular calcium concentration by sodium–calcium exchange, which appears to be the proximal mechanism for enhancing cardiac contractility. The major hormonal controls over pump activity can be summarised as follows: • Thyroid hormones appear to stimulate subunit gene transcription. Within minutes of elevated insulin secretion, pumps containing alpha-1 and 2 isoforms have increased afﬁnity for sodium and increased turnover rate. In skeletal muscle, insulin may also recruit pumps stored in the cytoplasm or activate latent pumps already present in the membrane. Some molecules, water for instance, are transported by both routes, but the tight junctions are impermeable to large organic molecules from the diet (e. Such molecules are transported exclusively by the transcellular route, by absorptive enterocytes equipped with speciﬁc transporter molecules that facilitate their entry into and out of the cells. Within the intestine, there is a proximal-to-distal gradient in osmotic permeability. The observed differences in permeability to water across the epithelium are due almost entirely to differences in conductivity across the paracellular path; tight junctions vary considerably in ‘tightness’ along the length of the gut. In the case of secretion, two distinct processes establish an osmotic gradient that pulls water into the lumen of the intestine: • Increases in lumen osmotic pressure resulting from inﬂux and digestion of foodstuffs. The chyme that passes into the intestine from the stomach typically is not hyperosmotic, but as its macromolecular components are digested, the osmolarity of that solution increases (e. Chloride ions enter the crypt epithelial cell by co-transport with sodium and potassium; sodium is pumped back out via sodium pumps and potassium is exported via a number of channels on the basolateral surface. Accumulation of negatively charged chloride anions in the crypt creates an electric potential that attracts sodium ions, pulled into the lumen apparently across tight junctions; the net result is secretion of NaCl. Secretion of NaCl into the crypt creates an osmotic gradient across the tight junction and water is drawn into the lumen by the paracellular route. It is one of the most common clinical signs of gastrointestinal disease, but can also reﬂect primary disorders outside of the digestive system. There are numerous causes of diarrhoea, but in almost all cases this disorder is a manifestation of one of the following four basic mechanisms: • Osmotic diarrhoea. Occurs if osmotically active solutes are retained in the intestinal lumen; water will not be absorbed and diarrhoea will result. For example, a failure to digest lactose (lactose intolerance) means that lactose remains in the intestinal lumen and osmotically ‘holds’ water. This change results in prolonged opening of the chloride channels, leading to uncontrolled secretion of water. Secretory diarrhoea can also result from laxatives, hormones secreted by certain types of tumour (e. Examples of pathogens frequently associated with infectious diarrhoea include bacteria, Salmonella, E. The immune response to inﬂammatory conditions in the bowel contributes substantively to development of diarrhoea. In order for nutrients and water to be efﬁ- ciently absorbed, the intestinal contents must be adequately exposed to the mucosal epithelium and retained long enough to allow absorption. Disorders in motility that accelerate transit time can decrease absorption, resulting in diarrhoea. Alterations in intestinal motility (usually increased propulsion) are observed in many types of diarrhoea. What is not usually clear, and is very difﬁcult to demonstrate, is whether primary alterations in motility are the cause of diarrhoea or simply an effect. It has saved millions of children from diarrhoea, still a leading cause of death, particularly in the developing world. The transport of glucose must be accompanied by Na+ (symport) and is the basis of rehydration therapy (see Section 4. Symporters transport substances in the same direction; antiporters transport substances in opposite directions. The junctions have a dual function: preventing solutes from crossing the epithelium between cells and allowing a concentration gradient of glucose to be maintained across the cell sheet; and acting as diffusion barriers within the plasma membrane, which help conﬁne the various carrier proteins to their respective membrane domains.
When we attempt to answer this question effective 160 mg super p-force oral jelly erectile dysfunction rap lyrics, we see that there are four main possibilities: (1) The prioritization is considered to hold whenever the values in question conXict buy super p-force oral jelly on line amex protein shakes erectile dysfunction. An example of this approach is an ordering put forward by Robert Veatch (1981) buy super p-force oral jelly 160mg low price erectile dysfunction condom, in which a group of noncon- sequentialist principles always takes priority over the principle of beneW- cence purchase 160mg super p-force oral jelly mastercard erectile dysfunction drugs with the least side effects. For any given value or set of values that suppos- edly is ranked Wrst, we can always think of a situation in which that value or set of values is overridden by other values. With regard to Veatch’s ordering, for example, there are situations in which the principle of beneWcence – and more speciWcally, the principle that we should prevent harm to others – takes priority over the nonconsequentialist principle of autonomy. To illustrate, consider the issue of whether to carry out requests by single women for artiWcial insemination, in which a central conXict is between the reproductive freedom of the woman requesting artiWcial insemination and, arguably, prevention of harm to the child who would be brought into being. The view that this issue should be resolved by always giving priority to prevention of supposed harms to the child – and that requests for artiWcial insemination by single women should never be honour- ed – is an example of the type of prioritization in question. Moreover, for every issue, the approach in question identiWes a preferable value (or set of values) and assigns priority to the chosen value(s) in every case in which the issue arises. Even when we focus on a particular issue, the view that a certain ethical value, or set of values, should always have priority often reXects an oversimpliWcation of the moral situation. For a given value or set of values that supposedly is given priority for a certain issue, often we can think of a case of the type in question in which that value or set of values is overridden by other moral considerations. This involves giving priority to one value (or group of values) in some cases but assigning priority to a diVerent value (or group of values) in other cases of the type in question. For a given type of ethical conXict, there usually are a number of morally relevant ways in which it can vary from one case to the next, and these variations can make a diVerence in the decisions that ought to be made. On the other hand, although this approach is more Xexible than the Wrst two, it falls short of the degree of Xexibility that is needed to deal adequately with the complexities of bioethics. For example, based on broad concerns about positive eugenics, it might be argued that physicians should refuse all requests for prenatal genetic testing for nondisease charac- teristics, such as intelligence, height or body build, rather than deciding on a case-by-case basis. Strong The fourth approach is preferable to the third because, although it recog- nizes the validity of case-by-case decision-making generally, it also acknowl- edges that for some issues there can be broad social considerations that provide reasons for adopting a uniform policy across all cases. It holds that there is a presumption in favour of ranking values in the context of individual cases, but that this presumption might sometimes be overridden. Thus, the fourth approach allows us to grapple with the ‘big picture’ – to ask where we are going and where we should be going in regard to human reproduction – and to formulate policies that take into account the big picture. One of the reasons these cases cause consternation for the health professionals involved in them is that doctors perceive the fetus as having a relatively high moral status. They are dissimilar to the paradigm in so many morally relevant ways that it is implausible to maintain that they ought to be treated as ends in themselves. To say that they have some moral standing implies that they should be treated with some degree of respect, although the amount of respect called for is far less than that owed to descriptive persons. Even though they have only a small degree of moral standing, it might be asked whether respect for them requires that they not be created solely for research purposes. In deciding whether certain actions should be carried out (or not carried out) in order to be adequately respectful toward pre-embryos, we therefore should consider the consequences of performing and not performing those actions. When we apply this approach to the question of creating pre-embryos solely for research purposes, our examination of consequences includes consideration of the advancement of scientiWc knowledge. Research on this question would require fertilizing thawed oocytes in vitro, allowing them to develop, and testing the pre-embryos genetically (Trounsen, 1990). Strong In these and other areas of research, there are potential medical beneWts that appear to outweigh any adverse consequences that might reasonably be expected to result from creating pre-embryos solely for research purposes. Thus, it can be argued that respect for pre-embryos does not require that we refrain from creating them for research purposes, provided the research has sound scientiWc design, is conducted with the informed consent of those donating the gametes and promises to give valuable information. First, it has been argued that there is an increased probability that one or both parents would die before the child is raised, and thus there is a risk that ovum donation to an older woman will be harmful to the child. Therefore, the claim that ovum donation to postmenopausal women risks harming the child amounts to saying that the children whose parents die are worse oV than they would have been if they had not been conceived. The latter claim is based on the view that sometimes it can make sense to say that a child is worse oV than she/he would have been if she/he had not been created, namely, when the life is Wlled with suVering to such a degree as to overshadow any pleasurable or other positive experiences the child might have. The view in question goes on to point out that having a parent die is not equivalent to having a life so terrible that one would have been better oV never having been born. Although there would be psychological trauma associated with par- ental death, one would expect the children’s lives also to contain positive experiences, so that they would regard their lives as worth living. Although there are conXicting reports within this literature, overall it supports the view that advanced maternal age (P35) is associated with an increased incidence Overview 33 of complications of pregnancy, including diabetes, hypertension, abruptio placenta, placenta previa and Caesarean section (Berkowitz et al. First, maternal risks can be reduced by screening potential ovum recipients for health problems, including diabetes and cardiovascular problems, and by closely monitoring the mother’s health status during pregnancy (Sauer et al. Second, patients should be permitted to assume at least some degree of risk, if that is their choice, provided they are mentally competent and adequately informed of the risks. In this context, being adequately informed would include being told that the degree of risk is unknown for older women who are free of prenatal health problems. In addition, positive arguments can be given supporting ovum donation for older women, based on the reasons for valuing freedom to procreate discussed in the framework. A relatively older couple might value procreation because it involves participation in the creation of a person, because it can aYrm mutual love, or because it provides a link to future persons. Let us consider the extent to which these reasons have implications for ovum donation, where the recipient will be the gestational but not the genetic mother. First, the recipient’s male partner would be the genetic father of any children who are created by the oocyte donation, and the reasons identiWed could be important to him. Also, although his partner is not the genetic mother, he might regard their mutual desire for her to gestate his genetic oVspring to be an aYrmation of each other’s love. All things considered, ovum donation for older women can satisfy reasonable desires, the fulWllment of which can promote the self-identity and self-fulWllment of the individuals involved. The framework’s exploration of reasons for valuing freedom to procreate is useful whenever new issues arise in which freedom to procreate is implicated, including ovum donation for older women. The exploration of reasons for valuing freedom not to procreate and the framework’s approach to assigning priorities to conXicting values are also useful in dealing with the variety of issues that arise. Endnotes 1 The term ‘pre-embryo’ refers to the product of gametic union from fertilization until the appearance of the embryonic axis (the primitive streak) at approximately 14 days after fertilization (Ethics Committee, 1990). The debate between universalism and relativism is particularly central in the Weld of maternal–fetal medicine, because the universal protection of individ- ual’s rights and such values as equality and personal autonomy are usually the very basis for the improvement of women’s and children’s health around the world. Nevertheless, in many cultures, particularly in many traditional (sometimes also called communitarian) communities, these values are rejec- ted and individual rights are systematically denied to women and children – often in the name of cultural integrity, customary values and the defence of collective rights, all within the same human rights discourse. This chapter attempts to give a theoretical background that can help health care profes- sionals make diYcult ethical choices in multicultural environments. Most of the practical examples mentioned in this article are from Tanzania, for the simple reason that during my visiting lectureship at the University of Dar es Salaam these local customs, the problems involved in them and attempts to solve these problems are the ones that have become most familiar to me. On the one hand, it is evident that the promotion of women’s and children’s health and well-being not only means Wnding the best possible medical cure avail- able, but also indicates commitment to the promotion of the individual’s social status in families, communities and in social order in general. On the other hand, sometimes promoting individuals’ rights and autonomy, par- ticularly women’s and children’s rights and autonomy, can lead into cul- turally based ethical disagreement and value clashes which, for their part, may turn the patients as well as their whole communities away from the help and cure they need the most. To deal with these multicultural issues and their relation to human rights in medical care, we need agreement on ethical norms that can be applied across national and cultural borders. After all, a global set of ethical norms not only needs to be applicable everywhere, it also has to be sensitive to diVerences in cultural traditions as well as diVerences in needs between individuals (and between groups of individuals) in their social contexts. In other words, global bio- ethics needs to try to get away from the misguided polarization between universalism and relativism, on the one hand, and between individualism and collectivism, on the other hand. Sometimes this same debate is discussed within the framework of liberalism and communitarianism, that is, between the protection of individual rights and the promotion of the common good (Kuczewski, 1998; Etzioni, 1999). If we are to Wnd any globally acceptable set of norms, we need to take recent feminist bioethical challenges seriously and try to Wnd a way to promote universal values in a manner that takes the particularity of cultures as well as the special needs of individuals in diVerent situations seriously. Even liberal pluralism based on the universal respect for individual rights can easily turn into relativist subjectivism, which exaggerates an individual’s autonomy, giving the illusion of free choice in a situation in which social pressure directly aVects one’s decisions and actions. Instead, the demand for the respect of collectivist values is usually set within international human rights standards and thus, must gain its plausi- bility by universalization of collective rights. In other words, the culturally relativist demand that we treat the ethical views of diVerent cultures as equals is based on contradictory arguments – the relativity of cultural values and ethical norms is defended by appealing to universal respect for tolerance, equality and collective rights. Finally, in order to Wnd a way to agree on the values that can be universally promoted, we need to make a distinction between the prescriptive and descriptive uses of terms that we use to denote particular cultural features. In other words, when we talk about ‘collectivist’ culture we have to diVerentiate between its universally acceptable, positive elements and its negative features and practices. Thus, we cannot automatically presume a collective culture to be ‘oppressive’ towards its individual members; it can as well be democrati- cally supportive of them. Alternatively, when we talk about ‘individualist’ culture, we cannot presume support for individuals’ self-development and realization of their moral autonomy. All in all, I claim that the main problem in Wnding global bioethical norms is not incompatibility between universalist and relativist reasoning or be- tween individualist and collective ethical positions per se. First, within Multicultural issues in maternal–fetal medicine 41 individualist societies, human rights lack universal protection; in particular, women’s rights are easily ignored. Second, even if we can Wnd a set of values and norms based on these values that can be globally accepted, we do not pay enough attention to their promotion in practice – what are the most accept- able means to promote the shared values and norms in particular cultural contexts? Liberalism and conflicting interests in medical decision-making When we talk about multicultural issues in maternal–fetal medicine, we often start by setting up a polarization between two quite diVerent bioethical frameworks. These approaches are, on the one hand, universalism, which focuses on universal human rights, and on the other hand, relativism, which emphasizes the relativity of cultural belief and value systems. As long as these polarizations remain, there is a tendency to create two opposite bioethical positions – that is, universalist liberal individualism and relativist com- munitarian collectivism. Bioethical thinking in Western pluralist and multicultural democracies is typically based on liberal concepts of justice, demanding the universalization of such individualist values as respect for individual autonomy, protection of individual rights and the promotion of equality and tolerance. On the other hand, this means that we need to let individuals decide on the way they want to live their lives and what kind of cultural identity to maintain. In other words, neither the state nor another individual is allowed to tell somebody what kind of life is ‘the good life’ (Rawls, 1971, 1993; Hellsten, 1999: pp.
By D. Norris. New Mexico State University.