Ethics, health care and spinal cord injury: research, practice and finance

Ethical issues and dilemmas in spinal cord injury rehabilitation in the developing world: a mixed-method study

STUDY DESIGN

Mixed-method study (small group discussions and online literature search).

OBJECTIVES

Identify the ethical issues and dilemmas faced by rehabilitation professionals involved in the service delivery to the persons with spinal cord injury (SCI) in the low income and lower-middle-income countries (LIC/LMIC) located in Asia.

SETTING

Small group discussions in three biomedical conferences in Dhaka, Bangladesh and Kualalampur, Malaysia.

METHODS

Three small group discussions (30-45 min each) were held during three international conferences in 2019. The conferences brought together experts in the fields of neurology, rehabilitation, neurorehabilitation, and bioethics. A summary of SCI practice points and dilemmas were documented including goals of care, duties of rehabilitation professionals, health care worker-patient relationships, roles, and expectations of family members at different care settings.

RESULTS

There is a paucity of literature on this topic. The application of the principles of contemporary bioethics in the pluralistic societies of LIC/LMIC can be challenging. The ethical dilemmas faced by rehabilitation professionals working in LIC/LMIC are diverse and different from those reported from the Western and developed countries. Ethical issues and dilemmas identified were understanding patient autonomy in decision making, lack of insurance for SCI rehabilitation, financial challenges, challenges of providing emerging technology in SCI rehabilitation and SCI rehabilitation during disasters.

CONCLUSIONS

We have summarized the possible ethical issues and dilemmas which rehabilitation professionals in LIC/LMIC may encounter during delivery of SCI rehabilitation services. We hope it generates a discussion on an often-neglected aspect of SCI care in the LIC/LMIC and helps identify the complexities of ethical dilemmas unique to persons with SCI living in a developing country.

Reorganization of Higher-Order Somatosensory Cortex After Sensory Loss from Hand in Squirrel Monkeys

Unilateral dorsal column lesions (DCL) at the cervical spinal cord deprive the hand regions of somatosensory cortex of tactile activation. However, considerable cortical reactivation occurs over weeks to months of recovery. While most studies focused on the reactivation of primary somatosensory area 3b, here, for the first time, we address how the higher-order somatosensory cortex reactivates in the same monkeys after DCL that vary across cases in completeness, post-lesion recovery times, and types of treatments. We recorded neural responses to tactile stimulation in areas 3a, 3b, 1, secondary somatosensory cortex (S2), parietal ventral (PV), and occasionally areas 2/5. Our analysis emphasized comparisons of the responsiveness, somatotopy, and receptive field size between areas 3b, 1, and S2/PV across DCL conditions and recovery times. The results indicate that the extents of the reactivation in higher-order somatosensory areas 1 and S2/PV closely reflect the reactivation in primary somatosensory cortex. Responses in higher-order areas S2 and PV can be stronger than those in area 3b, thus suggesting converging or alternative sources of inputs. The results also provide evidence that both primary and higher-order fields are effectively activated after long recovery times as well as after behavioral and electrocutaneous stimulation interventions.

Experiences with euthanasia requests of persons with SCI in Belgium

Introduction

Living with SCI remains a challenge and some patients fear or are faced with an inability to master this challenge sufficiently to regain a satisfactory quality of life. The suicide rate within the population with SCI is elevated compared with the general population. Especially now that life expectancy of persons with SCI and age at onset of SCI are increasing, caregivers of persons with SCI can be confronted with requests for end-of-life care or even assistance in dying. Euthanasia remains worldwide a controversial topic, but has rarely been discussed in the context of SCI.

Case presentation

The medical history and the results of in-depth interviews with three persons with tetraplegia, between 36 and 88 years old, with a profound and repeated request for euthanasia testify of the importance of an open-minded dialogue concerning end-of-life questions, in which all options can be considered, and limits of patients' capacities and best care results are acknowledged.

Conclusion

These cases suggest that a well-regulated strictly controlled legal framework, handled with prudence and proficiency, can be an added value to the care for persons with SCI.

Are you "tilting at windmills" or undertaking a valid clinical trial?

In this review, several aspects surrounding the choice of a therapeutic intervention and the conduct of clinical trials are discussed. Some of the background for why human studies have evolved to their current state is also included. Specifically, the following questions have been addressed: 1) What criteria should be used to determine whether a scientific discovery or invention is worthy of translation to human application? 2) What recent scientific advance warrants a deeper understanding of clinical trials by everyone? 3) What are the different types and phases of a clinical trial? 4) What characteristics of a human disorder should be noted, tracked, or stratified for a clinical trial and what inclusion /exclusion criteria are important to enrolling appropriate trial subjects? 5) What are the different study designs that can be used in a clinical trial program? 6) What confounding factors can alter the accurate interpretation of clinical trial outcomes? 7) What are the success rates of clinical trials and what can we learn from previous clinical trials? 8) What are the essential principles for the conduct of valid clinical trials?