Development of the University of Pittsburgh Medical Center policy for the care of terminally ill patients who may become organ donors after death following the removal of life support

In the mid 1980s it was apparent that the need for organ donors exceeded those willing to donate. Some University of Pittsburgh Medical Center (UPMC) physicians initiated discussion of possible new organ donor categories including individuals pronounced dead by traditional cardiac criteria. However, they reached no conclusion and dropped the discussion. In the late 1980s and the early 1990s, four cases arose in which dying patients or their families requested organ donation following the elective removal of mechanical ventilation. Controversy surrounding these cases precipitated open discussion of the use of organ donors pronounced dead on the basis of cardiac criteria. Prolonged deliberations by many committees in the absence of precedent ultimately resulted in what is, to our knowledge, the country's first policy for organ donation following elective removal of life support. The policy is intricate and conservative. Care was taken to include as many interested parties as possible in an effort to achieve representative and broad based support. This paper describes the development of the UPMC policy on non-heart-beating organ donation.     

The dead donor rule: should we stretch it, bend it, or abandon it?

The dead donor rule--that persons must be dead before their organs are taken--is a central part of the moral framework underlying organ procurement. Efforts to increase the pool of transplantable organs have been forced either to redefine death (e.g., anencephaly) or take advantage of ambiguities in the current definition of death (e.g., the Pittsburgh protocol). Society's growing acceptance of circumstances in which health care professionals can hasten a patient's death also may weaken the symbolic importance of the dead donor rule. We consider the implications of these efforts to continually revise the line between life and death and ask whether it would be preferable to abandon the dead donor rule and rely entirely on informed consent as a safeguard against abuse.     

Improved standards for laboratory animals?

In February 1993, Judge Charles R. Richey of the United States District Court issued a summary judgment in the case of Animal Legal Defense Fund, et al. v. The Secretary of Agriculture, et al. The decision, which was in favor of the Animal Legal Defense Fund, requires the U.S. Department of Agriculture to withdraw its current regulations governing exercise for dogs and the psychological well-being of nonhuman primates used for biomedical research and to issue new regulations containing only minimum, measurable standards. Both plaintiffs and defendants contended that they were seeking the best interests of the laboratory animals. The issue at stake is whether animals are better protected if the government establishes limited minimal standards or is allowed to require institutions to provide additional standards, which will be judged on the basis of their effectiveness in maintaining healthy animals. The Court avoided this dispute, however, by placing primary emphasis on applying the Administrative Procedures Act and stating that it was merely interpreting the "plain meaning" of the Animal Welfare Act, as amended. In this article, arguments are presented for interpreting the law in a far more flexible way than Judge Richey did. The conclusion is also reached that there were no winners in the Animal Legal Defense Fund case and that the real losers are the laboratory animals.     

Child and adolescent services research at the national institute of mental health: Research opportunities in an emerging field

This article describes an important new area of research on services for children and adolescents with mental disorders at the National Institute of Mental Health, the parameters of mental health services research for youth, and the opportunities that are available for grant-funded investigations in this area.     

Nonsuicidal physically self-damaging acts in adolescents

To determine the frequency and correlates of nonsuicidal physically self-damaging acts in 12–14 year olds, a two stage epidemiologic survey with a self-administered questionnaire (N=3283) followed by a psychiatric interview of a subsample of the adolescents and their parents (N=444) was used. Prevalence estimates of interview validated nonsuicidal physically self-damaging acts were 2.46% in males and 2.79% in females. Significant relationships were found between nonsuicidal physically self-damaging acts and suicidal ideation, major depression and undesirable life events. Data suggest that physically self-damaging acts occur at substantial rates during early adolescence. The strong correlation between nonsuicidal self-destructive acts and both suicidal ideation and major depression clarifies prior conflicting reports in the literature and suggests that a history of self-damaging acts should be taken into consideration when evaluating for possible depression and suicide risk.     

The effects of exposure to different sources of sexual information on sexual behavior: Comparing a “sex-expert system” to other educational material

Sexpert, an expert computer program designed to counsel couples on their sexual relationships, was evaluated. Eighty-one heterosexual couples were assigned to one of three experimental manipulations (Sexpert, video, and self-help book) or a control condition. Daily sexual behavior monitoring forms and structured retrospective reports served as measures of baseline and post-manipulation behavior. Daily monitoring of sexual behavior failed to show significant changes occurring after the manipulations. However, retrospective data concerning the postmanipulation period show that compared with the control, the Sexpert, video, and book manipulations had a significant positive impact on couples’ sexual behavior, communication, and learning about sexuality. Sexpert, video, and book were similarly evaluated, except that Sexpert was evaluated as more engaging. In addition, subjects retrospectively reported positive changes in communication, relationship satisfaction, and sexual behavior during the baseline period. This suggests that daily behavioral monitoring is intrusive and may confound the variables measured by it.     

Direct observation of quality of care in residential settings

Direct-observation procedures were used to objectively and efficiently assess several classes of service provided for individuals residing at two state facilities for the developmentally disabled. Time samples were taken of the condition of the clients' physical environment and of the clients themselves. The ongoing behavior of both clients and staff also was recorded. Each residence was observed at least three times during both regular work hours and evening/weekend hours. Results showed that both facilities scored high in the categories regarding the physical condition of the living areas, as well as the categories concerning the condition of the clients. Greater variability was seen in the data on client and staff behavior. More generally, the results indicate that time-sampling procedures can be used efficiently to collect data on multiple aspects of service delivery for large numbers of individuals.     

Properties of spatial representations: Data from sighted and blind subjects

Five questions concerning the properties of spatial representations are explored. (1) How accurately does a spatial representation correspond to the true scene? (2) If inaccurate, how does it differ? (3) Are representations of a familiar scene more accurate than those of an unfamiliar one? (4) Do representations of a scene currently in view differ from those retained in memory? (5) Do the representations of the blind have properties comparable to those-of the sighted? Seven sighted and 7 highly mobile blind subjects, all familiar with a room, and 6 sighted subjects unfamiliar with it, were asked to estimate the absolute distances between 10 salient objects in the room. The 14 familiar subjects made their estimates twice: while they were in the room, and while they were remote from it. Regression analyses showed that the estimates of all subjects had strong metric properties, being linearly related to true distance, with a true zero point; and multidimensional scaling showed that all subjects produced distance estimates that could be scaled in two dimensions to closely match the actual locations of the objects. Familiarity had no effect. The effect of location of testing was the same for both the sighted and the blind: all subjects displayed better spatial knowledge when tested in the room; and all subjects underestimated true distance substantially when tested out of the room. The results showed no qualitative differences as a function of blindness, at least for these highly skilled blind travelers.     

Visual influences on auditory pluck and bow judgments

In the McGurk effect, visual information specifying a speaker’s articulatory movements can influence auditory judgments of speech. In the present study, we attempted to find an analogue of the McGurk effect by using nonspeech stimuli—the discrepant audiovisual tokens of plucks and bows on a cello. The results of an initial experiment revealed that subjects’ auditory judgments were influenced significantly by the visual pluck and bow stimuli. However, a second experiment in which speech syllables were used demonstrated that the visual influence on consonants was significantly greater than the visual influence observed for pluck-bow stimuli. This result could be interpreted to suggest that the nonspeech visual influence was not a true McGurk effect. In a third experiment, visual stimuli consisting of the wordspluck andbow were found to have no influence over auditory pluck and bow judgments. This result could suggest that the nonspeech effects found in Experiment 1 were based on the audio and visual information’s having an ostensive lawful relation to the specified event. These results are discussed in terms of motor-theory, ecological, and FLMP approaches to speech perception.