Planned Parenthood v. Casey
Terri Schiavo Case
Human Embryonic Stem Cells
First Heart Transplant
Thomson's "A Defense of Abortion"
Karen Ann Quinlan Case
Defining Death, 1981
Nuremberg Trial and Code
Larry McAfee Case, 1985
Larry McAfee Case, 1985 – Further Reading
http://www.nytimes.com/1990/02/07/us/an-angry-man-fights-to-die-then-tests-life.html?pagewanted=all&src=pm
- July 1981: report issued by 1978-83 Presidential Commission for the Study of Ethical Problems in Medicine and Bioethical and Behavioral Research
- “Defining Death: A Report on the Medical, Legal, and Ethical Issues in the Determination of Death”
- Favors “whole brain” approach instead of “higher brain”
- Defines death as “the irreversible cessation of cardio-respiratory functions or the irreversible cessation of all functions of the brain including the brain stem”
- Basis for 1981 Uniform Determination of Death Act, now law in most states
- Link to report
- http://bioethics.georgetown.edu/pcbe/reports/past_commissions/defining_death.pdf
- 1990 NYT article on Larry and implications for right to die, care of disabled
- 2004 Theor Med Bioeth article – “Depression in the Context of Disability and ‘Right to Die’”
- 2003 J Health Polit Policy Law article about how those with disability view assisted suicide
- May 5, 1985, Georgia: Larry McAfee, 29, mechanical engineer and outdoorsman, paralyzed in motorcycle accident
- Had to use ventilator to breathe, stuck in nursing home
- 1989: decided he wanted to die – case taken to court
- 1989: Georgia Supreme Court sided with him
- However, after public attention, help getting out of nursing home and into job training, he changed his mind
- Died in 1995 of pneumonia
- Ethical dilemmas
- Who has responsibility of caring for severely disabled?
- Right to die if care, quality of life sub-par?
- If gov’t rules in favor of right to die for someone with disability, does this send negative message to others living with same disability?
http://www.springerlink.com/content/q82301lp607104h6/fulltext.pdf
http://jhppl.dukejournals.org/content/28/6/977.long
Thalidomide Revelations, 1962
Terri Schiavo Case, 2005 – Video
Terri Schiavo Case, 2005
Thalidomide Revelations, 1962 – Further Reading
Terri Schiavo Case, 2005 – Further Reading
Planned Parenthood v. Casey, 1992
Woman gives birth at 62, 1994
Human Embryonic Stem Cells, 1998
First Heart Transplant, 1967
Thomson’s “A Defense of Abortion,” 1971
Human Embryonic Stem Cells, 1998 – Further Reading
First Heart Transplant, 1967 – Further Reading
http://blogs.fda.gov/fdavoice/index.php/2012/02/50-years-after-thalidomide-why-regulation-matters/
http://jama.jamanetwork.com/article.aspx?articleid=200885
Karen Ann Quinlan Case, 1976 – Background
Karen Ann Quinlan Case, 1976 – Consequences
Karen Ann Quinlan Case, 1976 – Further Reading
http://www.sciencemag.org/content/282/5391/1145.full
http://www.nytimes.com/2001/09/03/world/christiaan-barnard-78-surgeon-for-first-heart-transplant-dies.html?pagewanted=all
http://www.cnn.com/HEALTH/9709/04/nfm.thalidomide/index.html
- 2005 JAMA article about case, ethics
- 2005 J Med Ethics article on Terri Schiavo
-
- 2005 PBS discussion of Terri Schiavo and medical ethics
- Recent FDA blog about consequences of case
- 1997 CNN article about reemergence of drug
- 2010 NYT article on Dr. Kelsey
- NYT article about recent GlaxoSmithKline settlement (illegal marketing, not reporting safety concerns)
http://abcnews.go.com/Archives/video/oct-21-2003-terri-schiavo-die-case-11606479
http://jme.bmj.com/content/31/7/376.full
http://www.sciencemag.org/content/318/5858/1917.abstract
- NYT obituary for Dr. Barnard
- BMJ article: “Christiaan Barnard: his first transplants and their impact on concepts of death”
- Recent CBS article about debate after Dick Cheney heart transplant
http://www.nytimes.com/2010/09/14/health/14kelsey.html
Nuremberg Trial and Code, 1946-1947
Nuremberg Trial and Code, 1946-1947 – Further Reading
- Moral philosophy paper by Judith Jarvis Thomson, published 1971
- Argues for permissibility of abortion
- Even assuming personhood of unborn (“Violinist” example)
- Precursor to Roe v. Wade, contemporary focus on ethics of abortion
- Link to paper
2005
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121917/
- July 15, 1962: The Washington Post publishes article about thalidomide causing limb deformities in human fetus
- Merrell, manufacturer of drug, had waged premarketing campaign to influence physicians before FDA approval
- Work by Dr. Frances O. Kelsey exposing dangers of drug and preventing it from reaching U.S. market led to Kefauver-Harris amendments to FDA
- “Substantial evidence of efficacy”
- Full and free consent of all subjects in drug trial
- Significance: role of money and political influence in human experiments, drug approval process
First Kidney Transplant, 1954
http://stemcells.nih.gov/info/basics/basics1.asp
- 1994: an Italian woman, 62, gives birth to healthy boy
- Had used IVF
- Oldest woman at time to give birth
- Prompted condemnation from Catholic Church, debate on whether to set age limits on pregnancy
- Link to recent UPenn Bioethics paper on age limits for pregnancy
- http://www.bioethics.upenn.edu/documents/too_old_for_a_baby.pdf
1967
- Link to 2007 article
-
- NIH website on stem cells
-
- 2007 NYT article about Dr. Thomson’s original ethical concerns, changing views on embryonic research
- 2009 NYT article about Obama’s reversal of Bush policy
- NPR discussion about recent breakthrough of stem cell eye therapy
- December 3, 1967, Cape Town: Dr. Chistiaan Barnard performs first successful heart transplant on 55-year-old Louis Washkansky
- Washkansky died 18 days later
- Donor Denise Darvall – “irreversibly fatal brain damage” from car accident, permission from father to use heart
- Ethical concerns
- Was donor truly dead?
- Dr. Barnard admitted later to injecting heart with potassium to render her technically dead
- Was heart taken without regard to wishes of source?
- How do you define death?
- Difference between heart death and brain death
- Introduction of respirators in 1950s allows for distinction
- Prolongation of life – quality vs. quantity
- Feb 25, 1990: Terri Schiavo, 26, suffers massive brain damage from lack of oxygen from cardiac arrest
- Diagnosed later with PVS, needed feeding tube
- 1998: Terri Schiavo's husband, Michael Schiavo, petitions to remove feeding tube
- Opposed by her parents – taken to court
- 2001: court ruled in favor of husband, ordered tube to be removed
- However, took until 2005 until tube removed permanently
- Ended up in U.S. Supreme Court, subject of national debate
- Congress and President Bush tried to step in unsuccessfully
- After death: autopsy revealed extensive brain damage
- Along with Quinlan and Cruzan, third major end of life case
First Kidney Transplant, 1954 – Further Reading
http://www.nytimes.com/1994/05/26/us/quinlan-case-is-revisited-and-yields-new-finding.html
- Five provisions of a Pennsylvania abortion act were challenged as unconstitutional under Roe v. Wade
- Made it to U.S. Supreme Court
- First case with serious chance of overturning Roe, since most justices appointed by Reagan and Bush
- Supreme Court: upheld Roe by plurality for most part
- Grounded in personal autonomy, equal citizenship (rather than privacy)
- New issues addressed:
- 24-hour waiting period, “viability” of fetus, “undue burden”
- Link to decision
- http://www.law.cornell.edu/supct/html/91-744.ZS.html
http://www.pbs.org/newshour/bb/health/jan-june05/shiavo_3-25.html
- 1994 NYT article about finding from Karen’s autopsy several years later
- 2009 New Yorker article about Karen
-
- 2005 Bayl Univ Med article about medical, ethical, and legal issues in severe brain injury
http://www.nytimes.com/2012/07/03/business/glaxosmithkline-agrees-to-pay-3-billion-in-fraud-settlement.html?pagewanted=all
http://www.nytimes.com/2007/11/22/science/22stem.html
- 1998, Univ of Wisconsin: Dr. James Thomson and lab first to announce isolation of stem cells using human embryos
- Major breakthrough in potential to study and treat diseases
- However, public outcry over using human embyos, even ones donated with parents’ consent and destined to be discarded
- Renews debate of when life begins
- Feb, 2001: President Bush announces limited gov’t funding of stem cell research on existing stem cell lines
- No new embryos allowed to be used
- 2007: Dr. Thomson part of team to publish article on induced pluripotent stem cells
- Adult cells “reprogrammed” to stem cells
- Diminished need for embryonic stem cells
- Mar, 2009: President Obama signs executive order reversing Bush policy on embryonic stem cell research
1976
http://history.nih.gov/research/downloads/nuremberg.pdf
http://www.cbsnews.com/8301-504763_162-57404411-10391704/dick-cheneys-heart-transplant-at-71-spurs-age-debate/
- Apr 14, 1975, NJ: Karen Ann Quinlan admitted to hospital in coma
- Had ingested barbiturates, Valium, and alcohol
- Declared in persistent vegetative state
- Parents asked to remove breathing tube
- Physician, threatened with prosecution, declined
- Parents took case to court
- Mar 31, 1976: NJ Supreme Court declares her life support can be removed by privacy rights, her parents can act as surrogates
- After tube removed, Karen began to breathe on own
- Lived in vegetative state in nursing home for 10 more years
http://www.newyorker.com/reporting/2009/11/30/091130fa_fact_lepore
http://www.nytimes.com/2009/03/10/us/politics/10stem.html
- First legal case about life support
- Drew national attention to medical, ethical, and legal issues surrounding right to die
- Technological progress allows life to continue
- Results
- Development of formal ethics committees in hospitals
- Advanced health care directives
- Ethical issues
- What is meaningful life?
- Who has right to decide?
- NEJM article – “Fifty Years Later: The Significance of the Nuremberg Code”
- WHO article – value and limitations of the Code
http://www.npr.org/templates/story/story.php?storyId=4233669
http://philoscience.unibe.ch/bib2lib/pdf/gedankenexperimente/Thomson_abortion/Thomson_abortion.pdf
http://www.npr.org/2012/01/27/145990101/stem-cell-eye-therapy-shows-promise
1946-1947
http://www.nejm.org/doi/full/10.1056/NEJM199711133372006
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1255938/
- NPR discussion about the surgery, 50 years later
- Georgetown paper – “Organ Transplantation: Ethical Dilemmas and Policy Choices”
- Recent NPR article about ethics of compensating organ donors
http://bioethics.georgetown.edu/pcbe/background/org_transplant.html
http://www.who.int/bulletin/volumes/85/8/07-045443/en/index.html
- 1946-1947: Doctors’ Trial at Nuremberg Tribunal - 20 Nazi physicians, three medical administrators
- Charged with “murders, tortures and other atrocities committed in name of medical science”
- Defense: no clear guidelines on human experimentation
- 1947: tribunal, led by American Dr. Andrew C. Ivy, proposes ten “basic principles that must be observed in order to satisfy moral, ethical and legal concepts” in medical experiments
- 1) “The voluntary consent of the human subject is absolutely essential.”
- 2) “The experiment should be such as to yield fruitful results for the good of society.”
- Others: prior animal experiments, avoidance of unnecessary physical and mental suffering, qualified researchers
- Significance: Hippocratic Oath’s “primum non nocere” – distinction between treatment, human experimentation
- Dec 23, 1954, Boston: first successful organ transplantation – Ronald Herrick donates kidney to dying identical twin, Richard
- Led by Dr. Joseph Murray
- Awarded 1990 Nobel Prize in Medicine for work
- Richard survived eight more years
- New concerns
- Ethical to perform major surgery on healthy person, remove organ to save another?
- Voluntary consent of donor
http://www.npr.org/2012/05/22/153293669/the-ethics-of-compensating-organ-donors
Baby Doe Case
Dr. Kevorkian Convicted
Advisory Committee on Human Radiation
Beecher's NEJM "Ethics and Clinical
Research"
Belmont Report
Nancy Cruzan Case
Partial-birth Abortion Ban Act
Baby Doe Case, 1982 – Background
Baby Doe Case, 1982 – Consequences
Baby Doe Case, 1982 – Further Reading
http://www.nytimes.com/1984/10/04/us/group-seeks-ouster-of-judge-in-baby-doe-case.html
http://jmp.oxfordjournals.org/content/30/4/331.long
- 1984 NYT article about activists trying to get rid of judge from case
- 2005 J Med Philos article arguing against Baby Doe regulations
- 2005 NYT Magazine article about guidelines for infant euthanasia
-
- 2009 GSU Law Review article about Baby Doe and the evolution of neonatal intensive care
1982
http://www.nytimes.com/2005/07/10/magazine/10WWLN.html?pagewanted=all
- April 9, 1982, Bloomington: Baby Doe born with Down syndrome and a life-threatening intestinal defect
- Parents declined to have surgery for the child to correct the intestinal problem
- Didn’t want child to grow up retarded
- Hospital, uncomfortable with decision, took case to court
- Indiana Supreme Court ruled in favor of parents, saying they made medically reasonable decision
- Baby Doe died few days later on Apr 15, 1982
- Mar 1983: At President Reagan’s request, Secretary of Health and Human Services Richard Schweiker issues new regulations to prevent deaths of children with disabilities
- “Baby Doe Squad” at DHHS created
- American Academy of Pediatrics challenged regulations, taken to U.S. Supreme Court
- Supreme Court: “Federal Government has no power to overrule parental decisions”
- Apr 15, 1985: Reagan signs law allowing federal funding to be withheld from states not complying with surveillance of neonatal intensive-care units
- Ethical issue
- Does anyone have right to decide baby’s life not worth living?
http://digitalarchive.gsu.edu/cgi/viewcontent.cgi?article=2389&context=gsulr
Beecher’s NEJM “Ethics and Clinical Research,” 1966
Beecher’s NEJM “Ethics and Clinical Research,” 1966 – Further Reading
Advisory Committee on Human Radiation Experiments, 1994
Dr. Kevorkian Convicted, 1999
Dr. Kevorkian Convicted, 1999 (con’t)
Advisory Committee on Human Radiation Experiments, 1994 – Video
Advisory Committee on Human Radiation Experiments, 1994 – Further Reading
Dr. Kevorkian Convicted, 1999 – Video
Dr. Kevorkian Convicted, 1999 – Further Reading
National Research Act, 1974
1966
- 2001 WHO piece discussing Beecher’s impact (includes original article)
- 1987 NEJM article about “Ethics” significance
- 1999 ASA article about Beecher
http://www.who.int/docstore/bulletin/pdf/2001/issue4/vol79.no.4.365-372.pdf
http://www.freep.com/article/20070527/NEWS05/70525061/SUICIDE-MACHINE-PART-1
http://www.cbsnews.com/video/watch/?id=7368313n
Belmont Report, 1978
http://www.hss.doe.gov/healthsafety/ohre/roadmap/achre/index.html
1999
Nancy Cruzan Case, 1990
http://www.nejm.org/doi/full/10.1056/NEJM198711053171906
Nancy Cruzan Case, 1990 – Further Reading
- Link to summary of final report from ACHRE
- 1994 NYT article about experiments, formation of committee
-
- PSU review of experiments, their significance
http://www.pbs.org/wgbh/pages/frontline/kevorkian/chronology.html
- Link to 1997 Detroit Free Press article
- PBS timeline of Kevorkian
- 2011 NYT obituary of Kevorkian
- 2011 Am J Bioeth article on Kevorkian
See "Partial-birth Abortion Ban Act, 2003" for more information
http://asatest.asahq.org/Newsletters/1999/09_99/beecher0999.html
- Jun 16, 1966: NEJM medicine publishes Henry K. Beecher’s “Ethics and Clinical Research”
- Beecher: anesthesiologist, researcher on placebo-effect
- “Ethics” presents 22 cases where human subject experimented on with no benefit to subject
- Studies jeopardized “health or the life of their subjects” without their knowledge
- Experiments carried out by mainstream and renowned researchers and institutions
- CWRU, UPenn, OSU, Harvard, Duke, NYU, etc…
- Article gained national attention – public outcry
- Ultimately, led to NIH and FDA regulations concerning clinical research and informed consent
Partial-birth Abortion Ban Act, 2003
http://www.nytimes.com/1994/04/11/us/cold-war-radiation-test-on-humans-to-undergo-a-congressional-review.html?pagewanted=all&src=pm
http://www.nytimes.com/2011/06/04/us/04kevorkian.html?_r=1
Partial-birth Abortion Ban Act, 2003 – Further Reading
- Jan 15, 1994: President Clinton forms ACHRE, chaired by Dr. Ruth Faden
- Result of DOE new openness policy, which involved release of 1.6 million classified records
- Some describe radiation experiments from 194os-7os
- Experiments – many people (including vulnerable) unknowingly injected with radiation to assess health effects for Cold War studies
- Minorities, children, elderly, prisoners, hospital patients injected without consent
- Often led to permanent harm or disability
- 1995: Clinton apologizes for tests
- U.S. also settled suits from survivors
- Again raises serious concerns about government-sponsored research
- 1990, Detroit: Dr. Jack Kevorkian helps woman recently diagnosed with Alzheimer’s commit suicide
- Used euthanasia device – patient administers deadly cocktail of drugs to self
- Not charged with murder (no laws on physician-assisted suicide in MI), but medical license revoked
- 1990-1998: Kevorkian assisted in deaths of estimated 130 people, all supposedly terminally ill
- 1997 Detroit Free Press article – doubts all were terminally ill, in pain; calls into question his psychiatric (and even medical) testing before procedure
- Potential gender bias, too - most of his patients female
- Nov, 1998: Kevorkian appears on 60 Minutes, which shows him delivering lethal cocktail to man with ALS
- Passed by Congress, signed into law on Jul 12, 1974
- Largely in response to outcry from Tuskegee experiments
- Led to establishment of 1974-1978 National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, first national bioethics commission
- Link to short history of U.S. bioethics commissions
- http://bioethics.gov/cms/history
- Apr, 1999: after successfully avoiding conviction many times, Kevorkian convicted of second-degree murder based on 60 Minutes piece
- Sentenced to 10-25 years in prison
- Let out on parole in 2007, died 2011
- Kevorkian’s efforts led to greater public awareness of issue
- Doctors more likely to help patients in pain
- However, also revealed dangers of euthanasia without thorough physical and psychiatric checks beforehand
http://www.nytimes.com/1990/12/27/us/nancy-cruzan-dies-outlived-by-a-debate-over-the-right-to-die.html?pagewanted=all&src=pm
1978
http://www.rps.psu.edu/mar96/science.html
http://www.tandfonline.com/doi/full/10.1080/15265161.2011.596400
1990
- 1990 NYT article after her death
- Link to Supreme Court decision
- Recent AACN Advanced Critical Care article about Nancy, end of life care since then
http://law2.umkc.edu/faculty/projects/ftrials/conlaw/cruzan.html
http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=US&vol=000&invol=05-380
- Jan 11, 1983, Missouri: Nancy Cruzan, 25, in automobile accident, lands face first in puddle
- Oxygen deprivation caused permanent brain damage, declared in persistent vegetative state
- Stuck in fetal position
- Her doctor later described her existence as “living hell”
- After four years of no further recovery, her parents and husband requested she be removed from feeding tube
- State of Missouri refused, taken to court
- 1990: Case taken to U.S. Supreme Court
- First right to die case heard by Supreme Court
- 5-4 ruling:
- People have right to refuse medical treatment under Due Process
- Need “clear and convincing” evidence of person’s wish (living will)
- After family found more proof of Nancy’s desires, life support removed, and Nancy died on Dec 26, 1990
- Her father committed suicide six years later from emotional toll of legal battle
- Link to Gonzales decision
- 2006 NPR article on the procedure
-
- 2007 Boston Globe article about a doctor’s response to Gonzales
- Sep 30, 1978: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research issues Belmont Report
- Commission created largely in response to Tuskegee study
- Report: identifies three fundamental ethical principles for using human test subjects
- Respect for persons (autonomy)
- Beneficence, non-maleficence
- Justice
- Still in use today in line with IRB
- Link to report
- http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html
http://www.npr.org/2006/02/21/5168163/partial-birth-abortion-separating-fact-from-spin
http://www.ncbi.nlm.nih.gov/pubmed/22290096
- Nov 5, 2003: President Bush signs partial-birth Abortion Ban Act of 2003 into law
- Prohibits these late-term abortions (usually 2nd trimester)
- Focused on method of abortion (as opposed to age, viability of fetus)
- 2007: In 5-4 decision, U.S. Supreme Court upholds ban in Gonzales v. Carhart
- Beginning of move towards restriction of abortion rights
http://www.boston.com/yourlife/health/women/articles/2007/08/10/shots_assist_in_aborting_fetuses/?page=1
Medicare and Medicaid
Oregon Assisted Suicide Legislation
Human Genome Project Completed
Jesse Gelsinger Case
Tarasoff v. Regents UC
U.S. Public Health Service Tuskegee Study Exposed
Elizabeth Bouvia Case, 1983
Elizabeth Bouvia Case, 1983 – Further Reading
http://www.nytimes.com/1984/01/03/us/quadriplegic-s-efforts-to-die-stir-deep-legal-and-ethical-issues.html?pagewanted=all
http://articles.latimes.com/1992-09-13/news/vw-1154_1_elizabeth-bouvia
- 1984 NYT piece on Elizabeth
-
- 1992 LA Times article about Elizabeth, her change of mind
- 2005 AMA summary and implications of case
-
- Link to short article about legal aspects of case
http://virtualmentor.ama-assn.org/2005/02/hlaw1-0502.html
- Sep 3, 1983, Riverside: Elizabeth Bouvia, 26, paralyzed from cerebral palsy and suffering from severe degenerative arthritis, checks herself into hospital
- Asks to be allowed to starve to death
- Hospital refuses, case taken to court
- Court sided with hospital
- However, they need four attendants to hold her down to insert tube through nose
- She claims this is battery and torture – case back to court
- After losing once more and appealing, Elizabeth finally won right to have tube removed
- After all this, reluctantly decided not to commit suicide – still alive today
- Ethics issues
- Right to die (for someone not terminally ill), quality of life, physician assisted suicide
http://books.google.com/books?id=tkorYKyJgF4C&pg=PA108&lpg=PA108&dq=elizabeth+bouvia+legal+case&source=bl&ots=rOC78v2AfB&sig=-8eMK8oCZTLjzQ9OfkbJ3L8NF7g&hl=en&sa=X&ei=rm4iUJ-YMoKC8ASS64DADQ&ved=0CFgQ6AEwBzgK#v=onepage&q=elizabeth%20bouvia%20legal%20case&f=false
The Hastings Center, 1969
Medicare and Medicaid, 1965 – Further Reading
Medicare and Medicaid, 1965
Oregon Assisted Suicide Legislation, 1994 – Video
http://www.cmms.hhs.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/downloads/05-06Winpg79.pdf
Oregon Assisted Suicide Legislation, 1994 – Further Reading
http://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.html
http://www.nytimes.com/2012/07/26/health/policy/medicaid-expansion-may-lower-death-rate-study-says.html?pagewanted=all
Oregon Assisted Suicide Legislation, 1994
- 2006 HHS article about significance of programs on medical profession
-
- Recent NYT article about Medicaid expansion lowering death rate
- Recent J Surg Res article about differences in insurance affecting outcomes after injury
- Recent WSJ article about large number of doctors “shunning” Medicaid
Jesse Gelsinger Case, 1999
Dolly the Sheep, 1996 - Further Reading
Dolly the Sheep, 1996 - Video
Dolly the Sheep, 1996
1965
- Gov’t website about Affordable Care Act’s affects on Medicaid (see link to timeline)
-
- NYT page on Medicaid
- 2011 J Law Med Ethics article – “The Ethical Implications of Health Spending: Death and Other Expensive Conditions”
- The Hastings Center website and blog on health care cost
http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicaid/index.html
Jesse Gelsinger Case, 1999 – Further Reading
http://www.ncbi.nlm.nih.gov/pubmed/22858381
- Founded by Drs. Daniel Callahan and Willard Gaylin
- Incorporated Mar, 1969 as Institute of Society, Ethics, and the Life Sciences
- Publishes bimonthly report and website on bioethical issues
- http://www.thehastingscenter.org/
- Some current topics Center addresses:
- Health Care Cost
- Conflicts of Interest in Research
- Genetic Testing and Screening
- Stem cells
- Jul 30, 1965: President Lyndon Johnson signs Social Security Act of 1965 into law, establishing Medicare and Medicaid
- Teddy Roosevelt, Franklin Roosevelt, Harry Truman, and John Kennedy had all pushed for similar programs at different points in their careers
- Medicare: national program that guarantees health insurance for Americans 65 and older, those with disabilities
- Medicaid: means-tested health program for families with low income
- Jointly funded by state and federal gov’t , run by state
- First national health insurance programs
- Mar 23, 2010: President Obama signs Patient Protection and Affordable Care Act into Law
- Among other things, mandates health insurance, eliminates pre-condition screening, provides greater subsidies for poor to buy insurance
- June 28, 2012: U.S. Supreme Court upholds majority of law (not Medicaid expansion)
- Some ethical issues
- Who is responsible for paying for health care?
- How does payment (or lack of) factor into quality of care?
- Which diseases, treatments should be covered under these programs?
http://onlinelibrary.wiley.com/doi/10.1111/j.1748-720X.2011.00582.x/pdf
http://online.wsj.com/article/SB10000872396390444246904577573531560195466.html
http://jme.bmj.com/content/37/3/171.long
http://www.nytimes.com/1999/11/28/magazine/the-biotech-death-of-jesse-gelsinger.html?pagewanted=all&src=pm
http://unesdoc.unesco.org/images/0013/001359/135928e.pdf
http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=3430&blogid=140
1994
U.S. Public Health Service Tuskegee Study Exposed, 1972 – Videos
http://www.healthlawyers.org/Publications/Journal/Documents/Vol%2040%20Issue%201/Physician-Assisted%20Suicide-%20Legal%20and%20Ethical%20Considerations.pdf
See "Human Genome Project Begins, 1990" for more information
- 2011 J Med Ethics article about law’s impact on vulnerable groups
-
- Recent Journal of Health Law article on ethics of law
- 2004 NYT article about Oregon man’s decision to use act
- 2011 J Palliat Med article about quality of death with physician-assisted suicide
U.S. Public Health Service Tuskegee Study Exposed, 1972 – Background
U.S. Public Health Service Tuskegee Study Exposed, 1972 – Consequences
- 1999 NYT article on Jesse
-
- Oxford piece on Jesse, ethical implications
- The Hastings Center article on Jesse, 10 years later
-
- The Hastings Center article on conflicts of interest in biomedical research
http://cirge.stanford.edu/May%209%20-%20Gelsinger%20vs.%20UPenn/Gelsinger%20-%20Oxford%20Textbook.pdf
Tarasoff v. Regents of University of California, 1976
Tarasoff v. Regents of University of California, 1976 – Further Reading
U.S. Public Health Service Tuskegee Study Exposed, 1972 – Further Reading
http://www.nytimes.com/2004/06/01/science/in-oregon-choosing-death-over-suffering.html?pagewanted=all&src=pm
http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4034
http://www.npr.org/2011/10/05/141089068/what-are-the-ethical-implications-of-cloning
- 2004 UNESCO report on cloning
- 2011 NPR discussion about advances in human cloning, its ethics
- Gov’t webpage about human cloning, its ethics
-
- 2007 NYT article about religious objections to human cloning
- 1994: Oregon approves Death with Dignity Act, becoming first state to legalize physician-assisted suicide with some regulations
- Terminal illness with six months to live
- 1997: Oregon voters approve initiative
- 1998: First legal, physician-assisted suicide in U.S. when Oregon woman takes lethal drugs prescribed by physician
- 2002: Netherlands first nation to legalize euthanasia
- Also legal now in Washington (2008), Montana (2009)
- 2006: U.S. Supreme Court, in 6-3 decision, upholds law in Gonzales v. Oregon
- Ethical implications
- Besides right to die and Hippocratic Oath issues, are vulnerable populations at risk?
- Elderly, minorities, those with mental health issues, etc.
1999
- Jul 5, 1996, Edinburgh: Dolly the Sheep born
- First mammal cloned from adult cell – lived six years
- Ian Wilmut, Keith Campbell of Roslin Institute created her using somatic cell nuclear transfer
- Invalidates assumption that cell differentiation irreversible
- New questions raised
- Who can create life? How?
- Should humans ever be cloned?
http://www.thehastingscenter.org/Publications/BriefingBook/Detail.aspx?id=2156
- Sep 13, 1999, UPenn: Jesse Gelsinger, 18, is injected with adenoviral vector in clinical trial
- Jesse had ornithine transcarbamylase deficiency, under control with diet, meds
- Trial to see if gene therapy would help babies with condition
- Sep 17, 1999: Jesse dies, having suffered from massive immune response to vector
- First gene therapy clinical trial death
- Subsequent FDA investigation reveals improper procedures in clinical trial by UPenn scientists, raises issues of informed consent
- Jesse included as substitute for another volunteer improperly
- Failure to report serious side effects of two patients
- Failure to report death of monkeys in animal trials on informed consent form
- Potential financial conflicts of interest
http://www.ornl.gov/sci/techresources/Human_Genome/elsi/cloning.shtml
http://online.liebertpub.com/doi/full/10.1089/jpm.2010.0425
1976
1972 (Began 1932)
http://www.stanford.edu/group/psylawseminar/Tarsoff%20I.htm
- CDC website devoted to study
- Includes timeline, transcript of Clinton’s apology, and implications for research
- NYT article day after story broke (Jul 26, 1972)
http://www.npr.org/programs/morning/features/2002/jul/tuskegee/
http://www.nytimes.com/2007/11/20/science/20tier.html?pagewanted=all
- 2002 NPR article – “Remembering the Tuskegee Experiments” (see bottom for more resources)
- 2001 Soc Sci Med article about how Tuskegee still affects African Americans’ views on gov’t research
- 1991 Am J Public Health article examining how study affected AIDS education
- Jul 25, 1972: Washington Evening Star runs headline on front page exposing experiments
- Study started in 1932 by Drs. Taliaferro Clark and Dr. Oliver Wenger of U.S. Public Health Service, ran for 40 years
- Purpose: examine effects of syphilis on human body through autopsies
- Mostly conducted on poor, uneducated black AL sharecroppers
- Problems
- 400 men who were diagnosed with syphilis, never knew
- Instead, were told they were being treated for “bad blood”
- When Penicillin became treatment in 1947, those infected were never given drug or told about it, and study never terminated
- On multiple occasions since study began, U.S. Public Health Service had reviewed it and given approval to continue
http://www.cdc.gov/tuskegee/index.html
http://www.apa.org/monitor/julaug05/jn.aspx
- Oct, 1969, UC Berkeley: Graduate student Prosenjit Poddar stalks and kills Tatiana Tarasoff
- Poddar told a psychologist at Berkeley of his intention beforehand
- The psychologist had contacted police, but never told Tatiana
- Poddar detained briefly, then released
- Tatiana’s parents attempted to sue the psychologist and UC
- California Supreme Court – health professional had “duty to warn” Tatiana
- "The protective privilege ends where the public peril begins."
- Ethical issue: doctor-patient confidentiality vs. safety of others
- Also, how far does duty extend?
- Warning vs. protection
- Public outcry at time of heightened racial tensions
- Other issues: government taking advantage of poor, vulnerable; informed consent problems; lack of benefits of research for participants
- 1973: Sen. Edward M. Kennedy holds congressional hearings
- CDC and PHS appointed ad hoc panel soon after – study terminated
- Led to 1974 National Research Act, 1974-1978 National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research
- Lingering distrust of African American community towards U.S. public health efforts
- Major problem during AIDS epidemic
- May 16, 1997: Bill Clinton formally apologizes to survivors
- Link to full text of decision
-
- 2005 APA article about Tarasoff, recent decisions about duty to warn
- 2002 JAAPL article about Tarasoff, critiquing it
-
- 2004 Stanford Bioethics article about Duty to Warn regarding hereditary diseases
- 2007 HEC Forum article about Duty to Warn regarding AIDS
http://www.sciencedirect.com/science/article/pii/S0277953600001787
http://jaapl.org/content/30/3/417.full.pdf
http://select.nytimes.com/gst/abstract.html?res=F40616F6345A137B93C4AB178CD85F468785F9
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1405662/?tool=pmcentrez
http://bioethics.stanford.edu/events/documents/pdfs/reporting_workshop/23_JAMA%20-%20Offit,%20Groeger,%20Turner.pdf
http://www.springerlink.com/content/w35863j4l1472644/fulltext.pdf
Barney Clark - First Artificial Heart
Harvard Definition of Brain Death
Seattle Dialysis Selection Committee
Bush Announces Limited Stem-Cell Research
Human Genome Project Begins
Baby Louise Brown - First IVF Birth
Willowbrook Experiments
Fletcher's "Morals and Medicine"
Baby M Case, 1987 – Further Reading
Roe v. Wade
Barney Clark – First Artificial Heart, 1982
Barney Clark – First Artificial Heart, 1982 – Further Reading
Baby M Case, 1987
http://hnn.us/articles/44902.html
- 2007 Columbia article about Barney
- Discusses ethical problems of procedure
- 2007 J Med Ethics article – “The Ethics of Implantable Devices”
-
- 2008 Philos Ethics Humanit Med article about LVAD ethics challenges
http://www.ucpress.edu/content/pages/10724/10724.ch01.pdf
1982
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2598199/
- 2007 “Surrogate Motherhood and the Politics of Reproduction”
- 2011 article about gay NJ couple, one of whom used sister as surrogate, and legal battle that followed for custody (Baby M cited)
- Recent NPR discussion on surrogacy and law
- Dec 1, 1982, Utah: Dr. Barney Clark, 61, becomes first man given total artificial heart
- Had idiopathic cardiomyopathy with Class IV congestive failure, too old for transplant
- Heart – Jarvik 7, designed by Dr. Robert Jarvik
- Survived 112 days
- However, suffered from blood clots, strokes, seizures, and ruptured valve on heart
- Quality vs. quantity of life debate revived
- Also, how do you assess costs and benefits of technology?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2527574/
http://www.nj.com/news/index.ssf/2011/12/nj_gay_couple_fight_for_custod.html
- 1985: Bill and Elizabeth Stern place ad for surrogate
- Elizabeth had MS – worried about carrying child
- Mary Beth Whitehead responded to ad, signed contract, artificially inseminated with Bill’s sperm
- Mar 27, 1986: Baby M born
- Day after giving baby to Sterns, Mary Beth asked for child back, claiming she was biological mother
- Case taken to court
- 1987: NJ Supreme Court awards Sterns custody
- “Best interest of child” analysis
- 1988: NJ Supreme Court invalidates surrogacy contracts
- Sterns still keep the baby, Whitehead gets visitation rights
- Question: what determines a parent?
http://www.npr.org/2012/04/14/150586618/legal-debate-over-surrogacy-asks-who-is-a-parent
Harvard Definition of Brain Death, 1968
Harvard Definition of Brain Death, 1968 – Further Reading
Seattle Dialysis Selection Committee, 1962
Seattle Dialysis Selection Committee, 1962 – Further Reading
1968
http://books.google.com/books?id=qUoEAAAAMBAJ&pg=PA102&source=gbs_toc_r&cad=2#v=onepage&q&f=false
http://www.hods.org/english/h-issues/documents/ADefinitionofIrreversibleComa-JAMA1968.pdf
Human Genome Project Begins, 1990 – Video
Human Genome Project Begins, 1990 – Further Reading
Human Genome Project Begins, 1990 – Background
Human Genome Project Begins, 1990 – Consequences
1962
Baby Louise Brown – First IVF Birth, 1978
Baby Louise Brown – First IVF Birth, 1978 – Further Reading
- Link to original LIFE article
- Excerpt from book by Albert Jonsen on article, its impact
- Recent article from Stanford Hoover Institution: “Supply, Demand, and Kidney Transplants”
- Recent NPR article about financial challenges to fair access of HIV drugs
- Article from Soc Sci Med – gives historical overview and analyzes significance and controversy of definition
- 2009 NYT article about unique case of declaring death
- 2009 NPR article about high rate of misdiagnosis of people thought to be in vegetative state
Willowbrook Experiments, 1956
Fletcher’s “Morals and Medicine,” 1954 – Further Reading
Fletcher’s “Morals and Medicine,” 1954
http://www.sciencedirect.com/science/article/pii/S0277953696002663
http://books.google.com/books?id=crh6QJWKg7AC&pg=PA7&lpg=PA7&dq=they+decide+who+lives+who+dies+life+magazine&source=bl&ots=f-bPS_yc9E&sig=1QcW0x1d_D6fP-1d1rnGuLFr0ug&hl=en&sa=X&ei=VNEWUIXYJsSkrQGB34DYDA&ved=0CFMQ6AEwAw#v=onepage&q=they%20decide%20who%20lives%20who%20dies%20life%20magazine&f=false‘
HIV Vaccine Trials, 1999
Roe v. Wade, 1973 – Video
- Aug 5, 1968: NEJM publishes article “A Definition of Irreversible Coma: Report of the Ad Hoc Committee at Harvard Medical School to Examine the Definition of Brain Death”
- Previously, death was defined as “an irreversible cessation of respiration and circulation”
- Obsolete: modern respirators, heart transplant
- Describes physical and neurological characteristics of irreversible coma
- Unresponsiveness, no movements or breathing, no reflexes, a flat electroencephalogram indicating a state of permanent and irreversible coma
- Paved groundwork for modern definition of death
- Problem – no universal criterion for some years after this
- State by state definitions often differed
Roe v. Wade, 1973 – Further Reading
http://www.nytimes.com/2010/11/02/health/02gene.html?_r=1&ref=myriad-genetics-inc
Roe v. Wade, 1973
HIV Vaccine Trials, 1999 – Further Reading
- Nov 9, 1962: LIFE publishes article, “They Decide Who Lives, Who Dies,” by Shana Alexander
- About anonymous committee in Seattle (mostly non-physicians) who selected patients for entry into new chronic hemodialysis program
- Controversy of using “social worth criteria”
- Were patients with similar socio-economic backgrounds as committee members selected?
- Ethical questions raised
- Who should have access to scarce life-saving technology?
- Who gets to choose these patients? How?
Willowbrook Experiments, 1956 – Video
http://www.nytimes.com/2009/12/20/magazine/20organ-t.html?pagewanted=all
See "Human Embryonic Stem Cells, 1998" for more information
Willowbrook Experiments, 1956 – Further Reading
http://www.hoover.org/publications/policy-review/article/6060
http://www.npr.org/templates/story/story.php?storyId=1355344
http://www.ornl.gov/sci/techresources/Human_Genome/elsi/elsi.shtml
- Government’s “Ethical, Legal, and Social Issues” of human genome project
- See links at bottom for further information
- OMIM article on the genetic basis of alcohol dependence
- 2009 J Health Polit Policy Law article on community-based discussions of genetic testing
- 2010 NYT article about gene patenting ruling
- 2010 NYT two-part article about progress decade after draft
-
- Recent WSJ article – “Soon, $1,000 Will Map Your Genes”
http://caselaw.lp.findlaw.com/cgi-bin/getcase.pl?court=us&vol=410&invol=113
http://www.npr.org/blogs/health/2012/07/26/157362343/treating-everybody-with-hiv-is-the-goal-but-who-will-pay
1990
http://www.npr.org/templates/story/story.php?storyId=120784397
http://www.nytimes.com/2010/06/13/health/research/13genome.html?scp=1&sq=%22human%20genome%22&st=cse
1978
- BBC overview of situation ethics
http://www.saavi.org.za/slack.pdf
- NPR discussion about Louise, safety of IVF 25 years later
- 2010 NYT article after Dr. Edwards’s Nobel Prize – discusses challenges of discovery, controversy afterward
- PBS interview with bioethicists about Louise, test tube babies, stem cell research
- See left side of page for links to other articles on IVF
- 2009 article about difficulties gay and lesbian couples have gaining access to fertility treatments
http://www.nytimes.com/2010/10/05/health/research/05nobel.html?_r=1
http://omim.org/entry/103780
http://www.nytimes.com/1991/10/30/us/dr-joseph-f-fletcher-86-dies-pioneer-in-field-of-medical-ethics.html
http://www.nytimes.com/2010/06/15/business/15genome.html?_r=1&ref=business
http://science.education.nih.gov/supplements/nih9/bioethics/guide/pdf/Master_5-4.pdf
http://www.pbs.org/wgbh/pages/frontline/clinic/wars/cases.html
1956 (Exposed 1972)
- Link to full text of decision
- PBS article about Roe, cases that followed
- The Hastings Center article on abortion
- Huffington Post article about relevance of decision today
- Benefits
- More personalized and advanced diagnosis, treatment, and prevention of diseases
- Better understanding of human biology, evolution
- Energy and environmental applications
- Ethical concerns – see gov’t page for more info
- Fairness of use (insurance, employers, courts, etc)
- Reproductive issues (fetal genetic testing)
- Gene testing, gene therapy
- Property rights, commercialization
- Other philosophical (genetic determinants of behavior, acceptable diversity)
- Jul 25, 1978, Manchester: Louise Joy Brown born
- First in vitro baby
- Her mother had damaged fallopian tubes
- Made possible by experiments from Drs. Patrick C. Steptoe and Robert G. Edwards
- Edwards awarded 2010 Nobel Prize in Medicine for work
- Ethical concerns raised
- Should babies ever be created outside womb?
- Possibility of “designing” babies now within reach
- Who owns fertilized embryo? Who are rightful parents?
- Oct, 1990: 15-year, international project with goal of mapping entire human genome begins
- Headed by NIH and DOE in US; scientists from UK, France, Australia, Japan, Spain; also private competition
- 3-5% annual budget for Ethical, Legal, and Social Implications (ELSI)
- Mar, 2000: President Clinton announces genome sequence cannot be patented, should be made available to all researchers
- 2000: With “shotgun” approach successful, NIH and Celera Genomics announce completed draft of entire human genome (publ. 2001)
- 2003: Project completed (publ. 2004)
- May, 2008: President Bush signs Genetic Information Nondiscrimination Act (GINA)
http://data.unaids.org/publications/IRC-pub01/jc072-ethicalcons_en.pdf
- 2000 paper – “Ethical Issues in HIV Vaccine Trials in South Africa”
- 2000 UNAIDS publication on HIV trials ethics
-
- Article about ethical issues in clinical trials in developing countries
- Recent NYT article about negative effect of HIV trial
- Overview, ethical dilemmas of Willowbrook
- Journal of Pediatrics article about study, debate that followed regarding informed consent of minors
- Recent article about lack of drug trials for children
http://www.pbs.org/wgbh/americanexperience/features/interview/ethical-questions/
1973
http://online.wsj.com/article/SB10001424052970204124204577151053537379354.html
http://www.thehastingscenter.org/Publications/BriefingBook/Detail.aspx?id=2400
- Joseph Fletcher – Episcopal Priest and professor, founder of situation ethics
- 1954: “Morals” defends patient’s right to choose (instead of Church, doctor) in birth control, euthanasia, sterilization, artificial insemination, and abortion
- "We need to educate people to the idea that the quality of life is more important than mere length of life. Our cultural tradition holds that life has absolute value, but that is really not good enough anymore. Sometimes, no life is better."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800818/?tool=pmcentrez
http://www.bbc.co.uk/ethics/introduction/situation_1.shtml
- 1956: Drs. Saul Krugman, Robert McCollum, and Joan Giles begin 16-year study of hepatitis at Willowbrook State Hospital
- With consent of parents, intentionally infected mentally retarded children with live strain of virus
- Reasoning: almost all children there eventually contracted hepatitis, induced infection would later immunize them, obtained parental consent, research led to vaccine
- 1972: a series of newspaper articles and an expose by Geraldo Rivera exposing abuses at Willowbrook lead to public outcry, end of study
- Problems
- Is informed consent possible for children, disabled?
- Direct benefits from research ambiguous
- Parents may have felt pressured to enroll their children in study to gain acceptance to Willowbrook
- Medical institution taking advantage of unsanitary conditions instead of trying to improve them
http://www.sciencedirect.com/science/article/pii/S0022347606003702
- 1999: HIV Vaccine Trials Network (HVTN) established by branch of NIH
- International collaboration of scientists working all over world, including developing countries
- Ethical issues
- Informed consent across cultural boundaries
- Economic and social considerations in developing countries
- Making sure not to create “double standards” of clinical trials (major differences between US, developing countries)
- Use of placebo
- If a treatment appears to be effective (even marginally), necessary to give to all in trial?
- Controlled experiment, replicable data vs. best interest of study participants
- Jan 22, 1973: In 7-2 decision, majority opinion by Justice Harry Blackmun, U.S. Supreme Court declares state law cannot restrict woman’s right to abortion in first trimester
- States can enact some regulations in second and third related to health of mother, only in third related to life of fetus
- Used 14th Amendment, Bill of Rights as justification
- “We need not resolve the difficult question of when life begins.”
- Significance – moved abortion debate to forefront of national politics, dividing country into two camps
- Ethical issues raised
- When does life begin? Who can decide this?
- Who can decide if a woman has right to an abortion?
- Health of mother vs. right to life of infant
- Role of religion in law, politics, medicine
http://www.sciencedirect.com/science/article/pii/S001502820902473X
http://www.hf.uib.no/i/filosofisk/ethica/who.pdf
http://www.huffingtonpost.com/2012/01/20/roe-v-wade-anniversary_n_1216869.html
http://news.yahoo.com/more-drug-trials-needed-conditions-affecting-kids-review-160408589.html?_esi=1
http://www.nytimes.com/2012/05/18/health/research/trial-vaccine-made-some-more-vulnerable-to-hiv-study-confirms.html
Acknowledgements
Sources – Pictures (con’t)
Sources – Books
Sources – Pictures
Sources – Pictures (con’t)
- Power Point, Prezi by Alex Grossman-McKee, Intern at Cleveland Clinic Lerner College of Medicine, Jul-Aug 2012
- Alex is studying Literary Arts, AB, and Economics, AB, at Brown University, Class of 2013
- Thanks to Dana Patton for composing initial list of events with brief summaries
- Thanks to Katherine Burke, MFA, for guidance using Prezi
- Thanks also to Martin Kohn, PhD, Director, Program and Medical Humanities, and the bioethics staff at Cleveland Clinic Center for Ethics, Humanities, and Spiritual Care for their help
- http://gxpperspectives.com/2011/02/13/informed-consent-questions-on-new-fda-requirement/
- http://www.usatoday.com/news/health/2004-12-19-transplant_x.htm
- http://andrewgoddard.squarespace.com/joseph-fletcher/
- http://jeanbont.pbworks.com/w/page/37083492/Thalidomide
- http://www.sciencedirect.com/science/article/pii/S0272638607001163
- http://en.wikipedia.org/wiki/File:Lyndon_Johnson_signing_Medicare_bill,_with_Harry_Truman,_July_30,_1965.jpg
- Baker, Robert, and Laurence B. McCullough. The Cambridge World History of Medical Ethics. Cambridge: Cambridge UP, 2009.
- Evans, John Hyde. The History and Future of Bioethics: A Sociological View. New York: Oxford UP, 2012.
- Jonsen, Albert R. The Birth of Bioethics. New York: Oxford UP, 1998.
- Jonsen, Albert R. A Short History of Medical Ethics. New York: Oxford UP, 2000.
- Primary source
- http://www.tomfolio.com/bookdetailssu.asp?b=55979&m=40
- http://law2.umkc.edu/faculty/projects/ftrials/conlaw/righttodie.htm
- http://caveofknowledge.com/on-this-day/hgp/
- http://alexa-dollythesheep.blogspot.com/2012/04/dolly-sheep.html
- http://www.jesse-gelsinger.com/jesses-intent2.html
- http://georgewbush-whitehouse.archives.gov/news/releases/2003/11/images/20031105-1_p35410-21-515h.html
- http://www.wired.com/science/discoveries/news/2008/06/dayintech_0611
- http://www.allvoices.com/contributed-news/6945645/image/64771703-louise-joy-brown
- http://www.wired.com/thisdayintech/2009/12/dayintech_1202jarvikheart/
- http://www.corbisimages.com/stock-photo/rights-managed/U2125484/elizabeth-bouvia-sitting-in-her-wheelchair
- http://www.amazon.co.uk/The-Switch-DVD/dp/B000FFJVOG
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- http://thelongestlistofthelongeststuffatthelongestdomainnameatlonglast.com/first288.html
- http://www.hss.cmu.edu/philosophy/faculty-london.php
- http://www.mit.edu/~philos/thomson.html
- http://www.tuskegeecenter.org/TSS_frame.html
- http://www.kansasfreepress.com/2010/01/37th-anniversary-of-roe-v-wade-a-time-to-be-thankful-for-our-doctors.html