Research Ethics in Critical Care Medicine

Total Page:16

File Type:pdf, Size:1020Kb

Research Ethics in Critical Care Medicine Research Ethics in Critical Care Medicine P. D. LUMB Research in critical care medicine is founded on the trust of our patients and their families. In order to understand the integrity of this mutually responsi- ble relationship, it is important to review the foundations upon which it is built. Two core questions define our understanding of the importance between the patient’s expectations and our inherent clinical responsibilities. It is equally important to recognise that much of what has become today’s accepted critical care practice derives from uncontrolled clinical experimen- tation that each of us perform in the context of providing optimal patient care. Therefore it is important to understand the founding principles of the ethical considerations of patient care and research in the intensive care unit (ICU): Where do the principles come from and what do we learn from their application? Stated simply, there are four concepts: beneficence, non-maleficence, respect for persons, and justice. It is more important, however, to understand what they mean and how they apply to patient care in the current environ- ment in which accountability, transparency, and increasingly informed con- sumers are creating an environment that is much different from the paternal- istic climate in which medicine was practiced for centuries. Indeed, the pres- ent state provides for increased opportunity as outcomes-based therapeutic interventions become standard practice. Primum non nocere, first do no harm; a simple sounding phrase, but it is the core of an interesting argument between research and routine in practice. Ethical principles are important because they are the foundation of all legitimate research with, and the care of, human beings. Equally, they inspire and support society’s confidence in research concepts and support biomedical research autonomy while provid- ing useful tools that aid in the design, approval, and adjudication of research protocols. Finally, they serve as a set of specific rules and procedures that enforce humanity and humility. 106 P. D. Lu mb Three interesting viewpoints are shown in the writings of individuals whose reputations stand for ethical, humane treatment. Moses Maimonides (1135-1204) believed that patients were ends in themselves and should not be used as a ‘means of learning new truths’, while Roger Bacon (1214-1294) stat- ed that ‘the body demands that no error be made in operating upon it and so experience is so difficult in medicine’. It is interesting to note the significant difference in the experience of Walter Reed, whose ‘Yellow Fever contract’ indicated that his ‘volunteers’ preferred to intentionally risk contracting yel- low fever because it was implied that by so doing they would receive the ‘greatest care and most skillful medical service’. As an added incentive to vol- unteer, those soldiers who agreed to be exposed to yellow fever were prom- ised payment in gold, a significant inducement at the time. It appears that Reed felt the disease to be so endemic in the region, and that its isolation and treatment were so important, that this type of experimentation was warrant- ed. Today’s institutional review boards (IRB) and practicing physicians may feel differently. The first signs of research controls relevant today appear in a 1900 series of Prussian prohibitions that included the following concepts: the competen- cy of the experimental subject must be confirmed; full disclosure of experi- mental risk must be provided to the subject and/or surrogate; and informed consent must be obtained. At Nuremberg, additional safeguards were intro- duced that included: the concept of ‘voluntary’ consent; that the results of the experiment were anticipated to be fruitful and for the good of society; and that the subject should be at liberty to discontinue the experiment at any time. It is interesting to note that after World War II and the introduction of the Nuremberg Code, in which Principles 1 and 9 restate the importance of voluntary consent and the ability to discontinue the experiment respectively, and despite the recognised abuses to individuals during internment, many physicians viewed the problem as primarily belonging to a particular place and time, i.e. Nazi Germany, and was not seen as relevant to their practice. This belief was shattered by publications in the United States that revealed the extent to which experimental subjects required protection and that a defini- tion of subject protection that included incarcerated individuals had to be established. Also, the influence of experimental design and appropriate appli- cation of statistical methods leading to justifiable conclusions became a trou- blesome topic. Specifically, two studies – the 1966 New England Journal of Medicine Beecher Study indicating that analysis and therefore conclusions in large numbers of publications were flawed and the 1972 exposure of the results of the Tuskegee syphilis study in which US federal inmates were denied treatment in order to allow the disease to progress naturally – indi- cated that even under the ‘best’ circumstances, experimentation had to be controlled. Research Ethics in Critical Care Medicine 107 The breach of medical and ethical trust leading to the requirement for and consequences of the Nuremberg declarations occurred because the intent of experimentation was not to investigate outcomes of the scientific application of clinical protocols designed to promote the healing process. Rather, the investigation concluded that blatant experiments on humans that was in no way motivated by a therapeutic premise had been performed. It is recognised that the consequences of participation in a controlled clinical trial may be, and in some cases tragically, unexpected. Nonetheless, there must be the underlying expectation and principle that therapeutic benefit underpins the therapeutic regimen and that outcome will be closely watched and appropri- ate interventions to terminate unnecessary studies made if interim data analysis warrants such action. The above statements underscore the importance of respect for persons that is one of the cardinal beliefs in the management of medical research endeavours. Respect for persons incorporates the following two convictions: those individuals should be treated as autonomous agents and that persons with decreased autonomy are entitled to protection. Despite the fact that these principles have been mentioned above, it is the following actions that must be implemented. There is an inherent requirement for all medical inves- tigators to recognise an individual patient’s autonomy and that, especially in critical care practice, individuals with diminished autonomy must be provid- ed protection. It is largely in this area that current critical care research is both hampered and aided. The concept of beneficence is an easy one to understand and simply stat- ed indicates that physicians should do no harm to their patients, and should always attempt to maximise possible benefits while minimising possible harms of therapeutic intervention. The obligations of beneficence affect indi- vidual investigators, the institutions in which they work, research sponsoring organisations, and society at large because they underpin the framework of human investigation. Development of IRB’s and pharmaceutical watchdog panels have developed in the past few years, yet today’s headlines and National Public Radio broadcasts still retain the ability to shock. Recent alle- gations that Merck attempted to hide early reports of Vioxx’s cardiac danger are now being defended; yet, superficial arguments have already lost the pub- lic’s trust in the company and make ongoing enrollment in current clinical investigations increasingly difficult. In the case of particular projects, investi- gators and their institutions are obliged to give forethought to the maximisa- tion of benefits and the reduction of risk that might occur from the research investigation. Despite numerous false steps, principles alluded to in the preceding dis- cussion have become more formally adopted in a number of well established rules. Namely, respect for a person is easily recognised as the well-established 108 P. D. Lu mb requirement to obtain informed consent from any study participant, and the concept of beneficence requires that odds ratios and risk minimisation are taken into account when designing experimental protocols. Statistical avenues must be available that will indicate if and when studies need to be terminated, either because the results are unexpectedly good and it would be unfair to withhold therapy from non-participants, or the converse. Justice is easily identified as the common practice to include multiple ethnic and cul- tural populations in any trial; certainly, no racial selection bias is acceptable, especially if there is a presupposition of increased benefit to be derived from study participation. There is an increased public awareness that in order to advance medical therapeutics and interventions human experimentation is required. Therefore, a new tension is apparent in the ethical undertaking of new clini- cal interventions and therapeutic trials. Redefinition of the situation in which the ethics codified at Nuremberg and in prior thought and practice (Maimonides, Bacon) equaled subject protection to the current requirement of medical innovation in which ethical principles must provide access to human subjects for medical therapeutic trials is necessary. This is a difficult paradox because all investigators
Recommended publications
  • Did I Do That?
    Did I Do That? ISSUES IN COMMUNICATION, DOCUMENTATION, AND RISK IN HEALTHCARE DECISIONS. Andy McLean, MD, MPH OBJECTIVES Describe risk and protective factors in doctor-patient communication Understand the importance of appropriate health record documentation in the era of patient-centered care Articulate an awareness of how to “expand the field” when involved in difficult healthcare decisions The Art of Medicine Medical Ethics • 4 Principles: • Autonomy* • Beneficence- (Dr. should act in Pt. best interest) • Non-Maleficence- “primum non nocere” prē-mu m-̇ ˌnōn-no -̇ ˈkā-rā (first, do no harm) Justice-fairness (as in, allocation of resources) Harm combinations Resulting from the underlying Resulting from the care/services medical condition provided to the patient Inherent risk of treatment Systems failure Provider performance Canadian Medical Protective Association What happened? Duty-A physician has a duty to provide competent care to a patient Breach-Did the physician’s conduct, whether by act or omission, fall below the applicable standards of care? Causation- “But for…” Proximate cause (foreseeability) Damages Breach- Omissions of Fact and Judgment Fact- Did you review all the facts you knew or should have known… Judgment- Once reviewed, did you make a reasonable clinical decision, and document such? It is recognized that physician’s aren’t perfect and that even with reasonable care, negative outcomes occur. You are much more likely to be “forgiven” if you documented how you weighed your decision (based on the facts…) “Foreseeability”
    [Show full text]
  • Defining Remission in Rheumatoid Arthritis: What Is It? Does It Matter?
    Editorial Defining Remission in Rheumatoid Arthritis: What Is It? Does It Matter? When the American College of Rheumatology (ACR) criteria for remission include 6 signs and symptoms: fatigue, preliminary criteria for remission1 were developed in 1981, joint pain, morning stiffness, joint tenderness, joint patients with established rheumatoid arthritis (RA) rarely swelling, and erythrocyte sedimentation rate (ESR); phys- experienced remission, although a number of patients with ical function and structural damage to joints are ignored. recent onset of polyarthritis had periods when their RA The DAS (Disease Activity Score) index uses a mathemat- temporarily regressed or remitted and a few had prolonged ical formula to arrive at a single composite quantitative remission or even permanent recovery from the disease. score representing tender joints (Ritchie index), swollen This was more frequent in children with oligoarthritis, and joints (44-joint count), Westergren ESR and patient’s global was generally considered to be a gift from God. The guiding assessment (0–100 visual analog scale) of disease activity6. principle for treatment of RA was “primum non nocere,” It is a useful continuous quantitative summary measure of exemplified by the therapeutic pyramid. Because RA was signs and symptoms of RA inflammation, similar to the expected to persist for the lifetime of the patient, available signs and symptoms included in the dichotomous ACR drugs were used cautiously so one would not run out of ther- remission criteria, but also ignores physical function and apeutic options too rapidly. For most patients therapy had structural damage. The DAS-28 uses the abbreviated 28- little effect on continued disease progression.
    [Show full text]
  • Physician Responsibility on the Frontiers of Tort Law
    DePaul Law Review Volume 57 Issue 2 Winter 2008: Symposium - Challenges to the Attorney-Client Relationship: Threats to Article 6 Sound Advice? Dissembling and Disclosing: Physician Responsibility on the Frontiers of Tort Law Robert L. Rabin Follow this and additional works at: https://via.library.depaul.edu/law-review Recommended Citation Robert L. Rabin, Dissembling and Disclosing: Physician Responsibility on the Frontiers of Tort Law, 57 DePaul L. Rev. 281 (2008) Available at: https://via.library.depaul.edu/law-review/vol57/iss2/6 This Article is brought to you for free and open access by the College of Law at Via Sapientiae. It has been accepted for inclusion in DePaul Law Review by an authorized editor of Via Sapientiae. For more information, please contact digitalservices@depaul.edu. DISSEMBLING AND DISCLOSING: PHYSICIAN RESPONSIBILITY ON THE FRONTIERS OF TORT LAW Robert L. Rabin* INTRODUCTION This Commentary addresses an issue that emerges as a common theme in the three papers in this Symposium Issue dealing with legal considerations in advising physicians: are there circumstances in which telling "less than the whole truth" is warranted?1 In a bygone era, physicians would have had no difficulty providing an affirmative answer to this question. Well into the twentieth century, it was com- mon practice to withhold from patients the dire news that they suf- fered from a terminal illness. In a different context, the consensus view until the latter part of the century was the so-called "physician's standard" in informed consent cases; that is, the practice of informing a patient of only those risks associated with an anticipated medical procedure that the physician deemed advisable to disclose to the pa- tient.
    [Show full text]
  • Code Gray.Pub
    Written by Christine Mitchell, RN, FAAN and Ben Achtenberg with a historical commentary by Susan Reverby, PhD and assistance from Joan Sawyer and Karen Wolf, RN, MS Contents INTRODUCTION ....................................................................................... 3 Background ............................................................................................3 Synopsis of the Film ..............................................................................3 Suggested Uses .......................................................................................4 Scheduling ..............................................................................................4 FILM AS A TOOL FOR DISCUSSION .......................................................4 WHAT IS NURSING ETHICS? ...................................................................5 GLOSSARY ...................................................................................................5 SOME GENERAL DISCUSSION QUESTIONS ........................................6 CASE 1: BENEFICENCE ............................................................................7 Description of the Case .........................................................................7 The Principle: Beneficence ...................................................................7 Questions for Discussion ......................................................................8 CASE 2: AUTONOMY ................................................................................9 Description
    [Show full text]
  • First, Do No Harm”: Old and New Paradigms in Prehospital Resuscitation in the Aquatic Domain
    International Journal of Aquatic Research and Education Volume 10 Number 2 Article 5 10-16-2017 “First, Do No Harm”: Old and New Paradigms in Prehospital Resuscitation in the Aquatic Domain John H. Pearn Lady Cilento Children's Hospital, Brisbane, Queensland, Australia, j.pearn@uq.edu.au Richard Charles Franklin James Cook University, richard.franklin@jcu.edu.au Follow this and additional works at: https://scholarworks.bgsu.edu/ijare Part of the Applied Ethics Commons, Bioethics and Medical Ethics Commons, Health and Physical Education Commons, Legal Theory Commons, Leisure Studies Commons, Medicine and Health Commons, Social and Philosophical Foundations of Education Commons, and the Social Control, Law, Crime, and Deviance Commons Recommended Citation Pearn, John H. and Franklin, Richard Charles (2017) "“First, Do No Harm”: Old and New Paradigms in Prehospital Resuscitation in the Aquatic Domain," International Journal of Aquatic Research and Education: Vol. 10 : No. 2 , Article 5. DOI: https://doi.org/10.25035/ijare.10.02.05 Available at: https://scholarworks.bgsu.edu/ijare/vol10/iss2/5 This Education Article is brought to you for free and open access by the Journals at ScholarWorks@BGSU. It has been accepted for inclusion in International Journal of Aquatic Research and Education by an authorized editor of ScholarWorks@BGSU. Pearn and Franklin: First, Do No Harm Abstract The balance between benefit and risk is central to the work of all those involved in aquatic services. The Hippocratic exhortation of Primum non nocere, “First, do no harm,” has a history of over 2000 years. Superficially, all would support this dictum, but harm can result from inaction.
    [Show full text]
  • The Hippocratic Oath and Principles of Medical Ethics
    MEDICINE AND PUBLIC POLICY The Hippocratic Oath and Principles of Medical Ethics Gilbert Berdine MD The Hippocratic Oath is associated with the morally right. This tradition remains in the modern practice of medicine, but over time fewer medical era. “As God is my witness I hereby pledge to …” can graduates have taken any form of the Hippocratic be found in modern rituals to stress the seriousness Oath. As of 2006, the State University of New York of purpose. Courts in the U.S. require prospective Upstate Medical School in Syracuse was the only witnesses to pledge their truthfulness: “Do you sol- U.S. medical school that administered the classic emnly swear or affirm that you will tell the truth, the version of the Hippocratic Oath to its graduates. The whole truth, and nothing but the truth, so help you Hippocratic Oath has been revised to make it more God?” This pledge becomes a source of contention in acceptable to modern schools, but the medical pro- a multi-cultural society as some members believe in fession no longer has a common set of promises that other deities. guide it. This article will look at the classic version of the Hippocratic Oath to see why it has been aban- Anyone who takes his or her religion seriously doned. Modern medical students wish to graduate would not pledge to a pagan god as this would be a into an ancient order of physicians, so they long for form of idolatry. This pledge is probably the main rea- a solemn ceremony, but it is difficult to craft a solemn son that the Oath has been abandoned in the modern ceremony that remains agreeable to a diverse group era, but what can take its place as a symbol of seri- of students.
    [Show full text]
  • Primum Non Nocere
    65 à la mort. Cependant, la formation en Primum Non oncologie met l’accent sur le trait- ement du cancer et fait très peu de Nocere: place à la relation d’aide en prépa- Reflections of a ration à la mort. Des médecins tels Bahá’í Oncologist que l’écrivain Atul Gawande veulent ramener le sujet de la mort dans la about Treating the conversation entre le médecin et Dying Patient le patient. De plus, bon nombre de religions, dont la foi bahá’íe, peuvent aider à examiner comment les mé- AARON ALIZADEH decins perçoivent et abordent le sujet de la mort. Dans le présent article, je Dedicated to Carley Elle Allison traite de mon expérience personnelle en tant qu’oncologue et en tant que July 18 1995 - March 31 2015 bahá’í en ce qui concerne le sujet de la mort. Abstract Medical oncology is a subspecialty of Resumen internal medicine that focuses on the Oncología médica es una subespecialidad treatment of cancer. Cancer is the sec- de la medicina interna que se encarga en el ond leading cause of mortality in the U.S. tratamiento del cáncer. El cáncer es la se- Therefore death is a frequent subject for gunda causa de mortalidad en los Estados oncologists. However, oncology train- Unidos. Por lo tanto la muerte es un tema ing emphasizes cancer therapy with little frecuente para los oncólogos. Sin embargo, guidance on counseling in preparation for la formación oncológica enfatiza el trata- death. Physicians such as the writer Atul miento del cáncer con poca orientación en Gawande are working to bring back the la preparación para la muerte.
    [Show full text]
  • Medical Ethics
    Medical Ethics Janyne Althaus, M.D., M.A. Dept. Gyn-Ob Div. Maternal-Fetal Medicine Johns Hopkins University School of Medicine Hippocratic Oath 12th-century Byzantine manuscript of the Oath Late 5th Century B.C. Basic Principles of Medical Ethics 1. Non-maleficence 2. Beneficence 3. Autonomy 4. Justice Primum non nocere Bloodletting High Oxygen for respiratory distress in premature infants Healing should be the sole purpose of medicine, and that endeavors like cosmetic surgery, contraception & euthanasia fall beyond its purview. Jehovah’s Witnesses Primary Elective Cesareans Cosmetic Gynecology Counseling parents of 24 week fetus Neonatal Intensive Care Units Transplants Forced sterilization of mentally retarded in Virginia United States of America v. Karl Brandt, et al. A sentence of death by hanging is pronounced by a US War Crimes Tribunal upon Adolf Hitler's personal physician, 43-year old Karl Brandt. Brandt was also Reich Commissar for Health and Sanitation. Of the 23 defendants, 7 were acquitted and 7 received death sentences; 9 received prison sentences ranging from 10 years to life imprisonment. Tuskegee Syphilis Experiment Peter Buxtun, PHS veneral disease investigator, the “whistleblower". •Conducted by the U.S. Public Health Service from 1932-1972 •600 Rural African-American men thought they were receiving free health care from the government. •By the end of the study in 1972, only 74 of the test subjects were alive. Of the original 399 men with syphilis, 28 had died of syphilis, 100 were dead of related complications, 40 of their wives had been infected and 19 of their children were born with congenital syphilis.
    [Show full text]
  • Daniel Patrick Moynihan and the Defense of Academic Medicine
    10 The Pharos/Spring 2017 Primum non nocere: Daniel Patrick Moynihan and the defense of academic medicine Joseph J. Fins, MD, MACP; Joan M. Leiman, PhD; and Herbert Pardes, MD Dr. Fins (AΩA, Weill Cornell Medical College, 2011, ...[M]edical education was one of the issues that Pat was Faculty) is the E. William Davis, Jr., MD, Professor of most interested in. He was deeply concerned with poverty Medical Ethics; Chief of the Division of Medical Ethics; in America & always worked on issues connected to that. Professor of Medicine; Professor of Medicine in Psychiatry; He also felt that the most important duty of a Senator was Professor of Medical Ethics in Neurology; and Professor to choose the best men/women as Federal judges. These of Health Care Policy and Research at Weill Medical were the 3 issues he cared most about…1 College of Cornell University. He is also the Director of Medical Ethics at New York-Presbyterian Weill Cornell Although Moynihan was not alone in his advocacy for Medical Center; Solomon Center Distinguished Scholar in academic medicine, it became one of his key legislative pri- Medicine, Bioethics and the Law at Yale Law School; and orities. While other leaders, like Senator Ted Kennedy (D- a member of The Pharos Editorial Board. MA) focused more on universal access to care, Moynihan’s Dr. Leiman is a Fellow at the New York-Presbyterian focus increasingly became the fate of academic medicine. Health Policy Center. Adam Clymer of The New York Times observed that Dr. Pardes (AΩA, State University of New York, Downstate Moynihan, “… carped on television about their [Clintons’] Medical Center, 1960) is Executive Vice Chairman, and health plan, quickly fixing on the role of teaching hospitals former President and CEO of New York-Presbyterian as the biggest issue in health care.” 2 Hospital.
    [Show full text]
  • The Medlaw Update and Health Care Law Committee
    The newsletter of the Medical Liability The MedLaw Update and Health Care Law Committee 10/15/2018 Volume 23 Issue 2 Feature Article Deflating Plaintiffs’ Use of the Hippocratic Oath in Medical Negligence Cases By Matthew Moriarty Lawyers representing plaintiffs in medical neg- for simple sound bites they can later display to a jury. ligence cases often ask doctors about their Conceding these points can usually be avoided, however, having taken the Hippocratic Oath. They want because the Hippocratic Oath questions are built upon a to gain a simple concession from the physician complete myth; contrary to common belief, medical oaths that they swore to uphold the principle of “pri- do not contain such a statement of primary duty. mum non nocere,” which means “first do no harm.” Here is a typical exchange: A Short History of Medical Oaths Q: As part of your job, is one of your ultimate goals when The Hippocratic Oath is the earliest known expression of you have a patient who comes into the emergency room, to medical ethics in the western world. Like many ancient keep them safe from harm? texts, its origins are unclear and its evolution extensive. It Yes. is named after Hippocrates, a Greek physician who report- Q. And you take an oath to do that, right -- do no harm? edly lived from approximately 450–370 B.C.E. But modern scholars are quite certain he did not personally write the A. That is correct. That’s the Hippocratic Oath. oath, asserting the view that it was written by a Pythago- The concept that an oath can give rise to a duty, in and rean sect after studying what is known as the Hippocratic of itself, is not the problem.
    [Show full text]
  • 2020 Annual Report
    ANNUAL REPORT 2020 Thank you so much for your interest in the CAN BOARD MEETINGS AND work of the North Carolina Medical Board. HEARINGS GO DIGITAL? YES. It is tradition for the current NCMB President to orient readers of the Like most organizations and individuals, agency annual report by writing a brief letter highlighting some of the NCMB had to be both resilient and most significant events of the previous calendar year. In a way, though, creative to continue working and serving that does not seem right because the Board Member who is President the public and the profession when the when this report is released takes office in November. That means that coronavirus pandemic hit. most of the work accomplished during the calendar year 2020 happened In mid-March, NCMB closed its Raleigh offices under the watch of my predecessor, Dr. Bryant Murphy, who served as to visitors and most staff transitioned to full- Board President from Nov. 1, 2019 – Oct. 31, 2020. time work-from-home. But perhaps the biggest As you know, 2020 brought a devastating and unwelcome surprise in challenge (among all the challenges COVID-19 the form of the ongoing coronavirus pandemic. NCMB was fortunate to brought) was figuring out how to continue have Dr. Murphy’s steady hand at the helm as this agency, like so many with NCMB’s bi-monthly Board Meetings and other organizations, determined how best to continue its work and be of periodic Hearings amid tight restrictions on service amid the unprecedented challenges of the pandemic. public gatherings. Some key accomplishments related to the pandemic: In May 2020, NCMB converted to a virtual meeting format for the first time in its • Virtually all NCMB staff shifted to full time telecommuting, history.
    [Show full text]
  • Swilling Hemlock: the Legal Ethics of Defending a Client Who Wishes to Volunteer for Execution J
    Washington and Lee Law Review Volume 63 | Issue 1 Article 5 Winter 1-1-2006 Swilling Hemlock: The Legal Ethics of Defending a Client Who Wishes to Volunteer for Execution J. C. Oleson Follow this and additional works at: https://scholarlycommons.law.wlu.edu/wlulr Part of the Legal Ethics and Professional Responsibility Commons Recommended Citation J. C. Oleson, Swilling Hemlock: The Legal Ethics of Defending a Client Who Wishes to Volunteer for Execution, 63 Wash. & Lee L. Rev. 147 (2006), https://scholarlycommons.law.wlu.edu/wlulr/ vol63/iss1/5 This Article is brought to you for free and open access by the Washington and Lee Law Review at Washington & Lee University School of Law Scholarly Commons. It has been accepted for inclusion in Washington and Lee Law Review by an authorized editor of Washington & Lee University School of Law Scholarly Commons. For more information, please contact lawref@wlu.edu. Swilling Hemlock: The Legal Ethics of Defending a Client Who Wishes to Volunteer for Execution J.C. Oleson* Table of Contents I. Introduction ..................................................................................148 II. Lawyers' Nightmares Do Come True: When the Client Volunteers for Execution ................................................... 150 A. Three Cornerstone Cases of American Capital Jurisprudence ......................................................................... 151 B. Death: A Growth Industry .................................................... 153 C. The Looking-Glass Ethics of the Volunteering Client ..........
    [Show full text]