BACKGROUND A blood cell saver, or autotransfusion system, is used to collect, wash, and return autologous blood collected from the surgical patient. This report describes a 55-year-old man who underwent combined mitral and aortic valve replacement surgery with cardiopulmonary bypass and had a successful outcome following intraoperative and postoperative autologous blood transfusion using a blood cell saver. CASE REPORT The patient did not accept blood transfusion for reasons of religious conscience and was in a critical condition, receiving palliative care. He needed combined mitral and aortic valve replacement surgery. The surgery was conducted using a cell saver (Sorin Xtra Autotransfusion System) in the intraoperative and postoperative periods for 24 h, to resolve this challenging case, from a technical and ethical point of view. The volume of red blood cells recovered intraoperatively was 1430 mL, with a hematocrit level of 40%, and 690 mL, with a hematocrit of 35%, in the postoperative period. Therefore, a significant volume of autologous blood was recovered. The autologous blood transfusion resulted in an excellent clinical outcome for the patient, who was discharged on the ninth postoperative day. CONCLUSIONS We can conclude that the use of a blood cell saver in cardiac surgery, in both intra- and postoperative periods, resulted in the maintenance of adequate hemoglobin and hematocrit levels, no infection postoperatively, and rapid and complete recovery of the patient. Thus, the use of the blood cell saver guaranteed the individual\'s autonomy to refuse blood products safely, with good clinical results, and without dependence on allogeneic blood transfusions.

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UNASSIGNED: The first act of assisted suicide in Italy was recently carried out. This event is an absolute novelty for the country, affected by recent legislative changes aimed only at introducing the right to interrupt health treatments and, therefore, carry out exclusively omissive end-of-life acts. These normative provisions lay their foundations in a cultural context centered on the protection of the right to life and health; however, the cases that have occurred over time, including the famous story of DJ Fabo, have led the Constitutional Court to re-evaluate these dictates, introducing in 2019 the right to resort to assisted suicide procedures within well-defined areas, including incurability of the condition, the serious suffering of the individual and the retained ability to stand trial. The case addressed concerns a quadriplegic subject who was the victim of a road accident. Following consultation with a specialized institution, the subject made the decision to undergo an assisted sui-cide procedure in Italy. Having obtained the authorization from the competent authorities, he started a fundraiser to finance the devices and drugs required and, finally, he died. The opening by Italy towards the assisted suicide procedure represents a great step towards a broad context, as well as a decisive act for the purpose of protecting the right to self-determination of the individual. However, the current legislative framework presents significant criticalities and shortcomings. In first place, the dissonance between the laws in force and the judicial sentences is likely to generate problems of uneven application of the rules in a country dominated by the principle of Civil Law. Furthermore, the need for the applicant to fully self-finance the procedure clearly clashes with the constitutional principle of free access to care. Then emerges the need for a guideline document regarding the completion of the procedure itself, the times, methods and drugs implied, in order to significantly reduce the decision-making process by the ethics committees that still weighs on each individual case. Finally, conside-ring what has been observed on the subject of voluntary termination of pregnancy, it is necessary to ask what will be the general orientation of the doctors called to perform the act and whether they will be given the opportunity to express their refusal. The case analyzed could represent the beginning of a new era for Italian culture, but the large-scale application of assisted suicide procedures requires the introduction of legislative provisions that definitively eliminate the critical issues that have emerged so far.

The case Mortier v. Belgium is the first case where the Court comments on the figure of euthanasia. The area of euthanasia in particular raises the issue of finding a balance between the protection of the patients\' right to life in Article 2 of the Convention and that of the right to respect for his or her private life and personal autonomy in Article 8 of the Convention. The Court confirmed the States must be afforded a margin of appreciation in finding this balance. However, it does not concern an unlimited margin as the Court reserved its power to review the States fulfilment of its obligations under Article 2. After deciding that there had been no breach of article 8 in the performing of euthanasia as such, the Court examined the positive obligation of Belgium to foresee in sufficient safeguards to protect the right to life.

This paper is a clinical ethics case study which sheds light on several important dilemmas which arise in providing care to patients from cultures with non-individualistic conceptions of autonomy. Medical professionals face a difficult challenge in determining how to respond when families of patients ask that patients not be informed of bad medical news. These requests are often made for cultural reasons, by families seeking to protect patients. In these cases, the right that patients have to their own medical information in order to make autonomous decisions is in tension with the possibility that patients could hold values that require limiting their autonomy with regard to medical information disclosure, often based on the idea that family should take on difficult decision-making as an act of care. We describe one such case, of an 83-year old Russian woman whose husband requested she not be informed of a new cancer diagnosis. The appropriate response to this request was to ask the patient about her values separately, without disclosing any medical information until her values were clear. This patient indicated she wanted the care team to uphold her husband\'s request. This response makes the importance of determining a patient\'s values before moving forward with disclosure clear: she would not have wanted to be informed of her cancer. We describe our conversation strategy, which allowed value exploration without disclosure and highlighted that the obligation to respect a patient\'s autonomy sometimes includes an obligation to allow a patient to choose to limit their own autonomy. This case also highlights that this kind of conversation prioritizes the patient\'s values rather than the family\'s or care team\'s, centering patients in the way that is ethically appropriate.

It is commonplace that care should be patient-centered. Nevertheless, no universally agreed-upon definition of patient-centered care exists. By consequence, the relation between patient-centered care as such and ethical principles cannot be investigated. However, some research has been performed on the relation between specific models of patient-centered care and ethical principles such as respect for autonomy and beneficence. In this article, I offer a detailed case study on the relationship between specific measures of patient-centered care and the ethical principle of respect for autonomy. Decision Quality Instruments (DQIs) are patient-centered care measures that were developed by Karen Sepucha and colleagues. The model of patient-centered care that guided the development of these DQIs pays special attention to the ethical principle of respect for autonomy. Using Jonathan Pugh\'s theory of rational autonomy, I will investigate how the DQIs relate to patient autonomy. After outlining Pugh\'s theory of rational autonomy and framing the DQIs accordingly (Part I), I will investigate whether the methodological choices made while developing these DQIs align with respect for autonomy (Part II). My analysis will indicate several tensions between DQIs and patient autonomy that could result in what I call \"structural paternalism.\" These tensions offer us sufficient reasons, especially given the importance of the ethical principle of respect for autonomy, to initiate a more encompassing debate on the normative validity of Decision Quality Instruments. The aim of the present paper is to highlight the need for, and to offer a roadmap to, this debate.

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OBJECTIVE: For residents in residential aged care, making choices in relation to food and mealtimes are opportunities to maintain a sense of self and autonomy. It is unknown, however, whether the concept of choice is adequately addressed in texts relating to residential aged care. The purpose of this review is to examine whether residents\' right to make choices regarding the meals they eat, is discussed in grey literature including, policies, standards, reports and guidelines, which all impact practice in residential aged care.
METHODS: Grey literature was located utilising; Google, Google Scholar and hand searching. Texts had to be in reference to residential aged care and were assessed using the Appraisal of Guidelines for Research and Evaluation II and Joanna Briggs Institute tools.
RESULTS: Twenty-nine texts were included in the final review, consisting of, 12 policies and standards, 12 guidelines and 5 reports. Choice was discussed broadly in the majority of texts, with no definition included for the level of choice that should be provided by residential aged care. The use of alternative meals to provide choice was discussed; however, texts varied in their requirements and recommendations as to what constituted an adequate alternative.
CONCLUSIONS: The ambiguity surrounding choice affects the practices within residential aged care and ultimately the service provided to residents. With most recommendations being only general in nature, residential aged care homes are not provided with sufficient guidance for meal planning. To ensure residents\' right to make choices in their meals is guaranteed, more definitive requirements and recommendations are needed.

Billy Best was diagnosed with Hodgkin lymphoma in 1994 at age 16 and became well-known when he ran away from home to avoid receiving further chemotherapy. His story became national news when, with the support of his adopted parents, he returned home and opted to use complementary and alternative medicine (CAM) instead of standard chemotherapy and radiation for his cancer treatment. Now 25 years since Billy Best entered the public eye, his story is one that is frequently referenced in pediatrics, bioethics, and other related fields. Here, the authors examine the evolution of various features of this case, including treatment of Hodgkin lymphoma, the interplay between medicine and the media, the role of CAM in pediatric care, navigating entrenched disagreements and how best to integrate adolescents into health care decision-making, and the role of narrative in medical practice. The authors explore the unique role of each of these facets of Billy Best\'s case, describing how each has or has not changed in the quarter century since that time amid the changing landscape of pediatric health care. Ultimately, although many advances have occurred since Billy Best\'s time, significant work remains. Additional effort will be required in the future to optimize communication, improve treatment toxicities from Hodgkin lymphoma without decreasing survival, integrate the voice and perspective of adolescents into their treatment decisions, and navigate the roles of CAM and the media in pediatric health care.

Advance directives are intended to extend patient autonomy by enabling patients to prospectively direct the care of their future incapacitated selves. There has been much discussion about issues such as whether the future incompetent self is identical to the agent who issues the advance directive or whether advance directives can legitimately secure patient autonomy. However, there is another important question to ask: to what extent and in what conditions is it ethically appropriate for one to limit the liberty or agency of one\'s future incompetent self by issuing an advance directive? In this paper, I use a virtue-ethical approach to explore this question, focusing on the case of an advance directive for the future self with moderate dementia. First, I examine virtuous attitudes with regard to autonomy and argue that one can manifest vices or ethically undesirable character traits in trying to intervene in the future self\'s life. In particular, I argue that this case can manifest vices such as disdainfulness, intellectual arrogance, and self-dictatorship, which is the vice of trying to control one\'s life to an excessive degree, and that a self-dictator fails to give due moral consideration to the future self\'s liberty or agency. I then introduce the Daoist idea of wu-wei, which recommends embracement of what happens in one\'s life, as one of the possible remedies for the overemphasis on the value of autonomy and control.