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Jewish medical ethics and end-of-life care.

While Judaism espouses the infinite value of human life, Judaism recognizes that all life is finite and, as such, its teachings are compatible with the principles of palliative medicine and end-of-life care as they are currently practiced. Jewish medical ethics as derived from Jewish law, has definitions for the four cardinal values of secular medical ethics: autonomy, beneficence, nonmaleficence, and justice, with the major difference between Jewish law and secular medical ethics being that orthodox or traditional Jews are perceived to limit their autonomy by choosing, with the assistance and advice of their rabbis, to follow God's law as defined by the Bible and post-Biblical sources. With an understanding of Jewish medical ethics as defined by Jewish law, various issues pertaining to the care of Jewish patients who are near the end-of-life can be better understood. Jewish tradition contains within its textual sources the concept of terminal illness. The shortening of life through suicide, assisted suicide, or euthanasia is categorically forbidden. For patients who are terminally ill, treatments that are not potentially curative may be refused, especially when harm may result. Under certain circumstances, treatments may be withheld, but active treatment already started may not usually be withdrawn. While patients should generally not be lied to regarding their conditions, withholding information or even providing false information may be appropriate when it is felt that the truth will cause significant harm. Pain and suffering must be treated aggressively, even if there is an indirect risk of unintentionally shortening life. Finally, patients may execute advance directives, providing that the patient's rabbi is involved in the process.

Ethics, Clinical↗

The relationship between religious activities and cigarette smoking in older adults.

BACKGROUND: The objective of this study was to examine the relationship between religious activities and cigarette smoking in community-dwelling older adults. METHODS: Cigarette smoking and religious activities were assessed in a probability sample of 3968 persons age 65 years or older participating in the Duke Populations for Epidemiologic Studies of the Elderly (EPESE) survey. Participants were asked if they currently smoked, if they ever smoked, and how many cigarettes per day they smoked. Attendance at religious services, participation in private religious activities (prayer or Bible study), and use of religious media (religious TV or radio) were also assessed. Data were available for Waves I-III of the survey (1986, 1989, and 1992). Analyses were controlled for age, race, sex, education, alcohol use, physical health, and in the longitudinal analyses, smoking status at prior waves. RESULTS: Cross-sectional analyses revealed that participants who frequently attended religious services were significantly less likely to smoke cigarettes at all three waves. Likewise, elders frequently involved in private religious activity were less likely to smoke (Waves II and III). Total number of pack-years smoked was also inversely related to both attendance at religious services and private religious activities. Watching religious TV or listening to religious radio, on the other hand, was not related to smoking at Waves I and II nor to total pack-years smoked, but was positively related to current smoking at Wave III. Among those who smoked, number of cigarettes smoked was inversely related to frequency of attendance at religious services (Wave I), private religious activities (Wave III), and religious TV/radio (Waves II and III). Retrospective and prospective analyses revealed that religiously active persons were less likely to ever start smoking, not more likely to quit smoking. CONCLUSIONS: Religiously active persons are less likely to smoke cigarettes, and if they do smoke, smoke fewer cigarettes. Given the association between smoking and disease, and the widespread prevalence of both smoking and religious activity, this finding has implications for public health.

Aged↗

Does private religious activity prolong survival? A six-year follow-up study of 3,851 older adults.

BACKGROUND: Previous studies have linked higher religious attendance and longer survival. In this study, we examine the relationship between survival and private religious activity. METHODS: A probability sample of elderly community-dwelling adults in North Carolina was assembled in 1986 and followed for 6 years. Level of participation in private religious activities such as prayer, meditation, or Bible study was assessed by self-report at baseline, along with a wide variety of sociodemographic and health variables. The main outcome was time (days) to death or censoring. RESULTS: During a median 6.3-year follow-up period, 1,137 subjects (29.5%) died. Those reporting rarely to never participating in private religious activity had an increased relative hazard of dying over more frequent participants, but this hazard did not remain significant for the sample as a whole after adjustment for demographic and health variables. When the sample was divided into activity of daily living (ADL) impaired and unimpaired, the effect did not remain significant for the ADL impaired group after controlling for demographic variables (hazard ratio [RH] 1.11, 95% confidence interval [CI] 0.91-1.35). However, the increased hazard remained significant for the ADL unimpaired group even after controlling for demographic and health variables (RH 1.63, 95% CI 1.20-2.21), and this effect persisted despite controlling for numerous explanatory variables including health practices, social support, and other religious practices (RH 1.47, 95% CI 1.07-2.03). CONCLUSIONS: Older adults who participate in private religious activity before the onset of ADL impairment appear to have a survival advantage over those who do not.

Activities of Daily Living↗

End-of-life decisions in HIV-positive patients: the role of spiritual beliefs.

OBJECTIVE: To describe the role of spiritual beliefs in HIV-positive patients' end-of-life decisions. DESIGN: Inperson, cross-sectional survey. SETTING: An HIV/AIDS floor of an urban, university teaching hospital. PATIENTS: Ninety hospitalized HIV-positive patients. MAIN OUTCOME MEASURES: Prior discussions about advance directives, possession of a living will (written advance directive), fear of death, professions of hope and purpose in life, religious beliefs and practices, guilt about HIV infection, and perception of HIV as punishment. RESULTS: Of 104 eligible patients, 90 agreed to be interviewed. Twenty-four per cent of patients had discussed their resuscitation status with a physician and 17% possessed a living will; 44% of patients felt guilty about their HIV infection, 32% expressed fear of death, and 26% felt their disease was some form of punishment. Prior discussions about resuscitation status were less likely in those who perceived HIV as punishment (P=0.009) and more likely in those who believed in God's forgiveness (P=0.043). A living will was more common in those who prayed daily (P=0.025) and in those whose belief in God helped them when thinking about death (P=0.065). Fear of death was more likely in those who perceived HIV as punishment (P=0.01) or felt guilty about having HIV (P=0.039), and less likely in those who read the Bible frequently (P=0.01) or attended church regularly (P=0.015). Outcome measures did not vary significantly according sex, race, HIV risk factors, or education level. CONCLUSIONS: In this HIV-positive population, spiritual beliefs and religious practices appeared to play a role in end-of-life decisions. Discussions about end-of-life decisions may be facilitated by a patient's belief in a forgiving God and impeded by a patient's interpretation of HIV infection as punishment. Health-care providers need to recognize patients' spiritual beliefs and incorporate them into discussions about terminal care.

Advance Care Planning↗

The "Eve" procedure: the transfer of vascularized seventh rib, fascia, cartilage, and serratus muscle to reconstruct difficult defects.

Very few microvascular units entertain the possibility of simultaneous vascularized transfer of bone, cartilage, muscle, and gliding fascia. In exceptionally complex conditions with loss of an essential joint, adjacent bone and functional muscle, reconstruction of all these structures at once may be necessary. At the same time, gliding tissue is often required to cover tendons. Reconstruction in one sitting prevents formation of dense scar tissue due to multiple interventions. Additionally, less bone resorption is seen if vascularized bone is used. Therefore, a more undisturbed tissue composition at the end is guaranteed. Moreover, rapid rehabilitation of moving function is possible with improvement in the final result. Finally, morbidity is lowered by using a single donor site, and costs are minimalized. We present four unique cases in which the seventh rib including the costochondral junction with overlying serratus muscle, branches of the thoracicus longus nerve, and adjacent fascia have been transferred as a microvascular unit to reconstruct two severely damaged hands and two other complex injuries. In analogy with the Bible story of the creation of "the woman," it is called the "Eve" procedure. The vascularized rib was used to reconstruct a first and fourth metacarpal bone, the ascending ramus of the mandible, and the clavicle. The rib cartilage was sculptured in four cases to reconstruct an articular surface. The serratus muscle served as coverage and filling for lost tissues. It also was used as a soft bed for facial nerve repair. In two cases muscle reinnervation was performed. The fascia provided gliding tissue surrounding reconstructed tendons or articular surfaces. In all cases a high degree of function was obtained with a good cosmesis. Rehabilitation was uneventful, and no reinterventions have been necessary. Donor-site morbidity was low. Therefore, this flap proved to be successful in complex injuries where bone, cartilage, muscle, and gliding tissue were needed simultaneously. Dynamic reconstruction was attempted in two cases and was successful in one.

Adolescent↗

Uncircumcision: a historical review of preputial restoration.

Throughout history, demands for restoration of the prepuce after circumcision were most commonly related to the political or religious persecution of the Jewish people. The first evidence for such a procedure is mentioned in the Bible: Under the reign of Antiochus IV (168 BC) Hellenistic ideals, such as public nakedness at athletic games or in public baths, emerged in Judea and forced Jews to stretch their shortened foreskins with a special weight, the Pondus Judaeus, to cover the glans (I. Maccabees 1). Similar efforts are reported in the Talmud during the time of Hadrian (132 AD). Celsius (25 BC-50 AD) was the first to give a detailed description of two surgical techniques for uncircumcision in his De medicina libri octo. Subsequent works, for example by Galen (131-200 AD) and Paulus Aeginata in the seventh century, only contained a repetition of these methods without presenting any new aspects. Ambroise Paré gave a new impetus in the sixteenth century, suggesting the insertion of a catheter into the distal urethra to guarantee free passage of urine during postoperative healing. In this past century, Johann Friedrich Dieffenbach was the first to dedicate a whole chapter to the problem of "posthioplastice" in a modern textbook of plastic surgery. Almost no written documents exist of uncircumcision during the Nazi era; nevertheless, surgical treatment seemed to be widespread as every circumcised man was in danger of being denounced as a Jew. Personal reports of patients and doctors performing surgical restoration of the prepuce are presented. Nowadays, reports on surgical foreskin restoration are still rare and alternative methods of nonsurgical skin-expansion have become more common. Several organizations were founded in America against routine infant circumcision and give advice to foreskin restoration seekers.

Circumcision, Male↗

Quality of life philosophy IV. The brain and consciousness.

In this article we look at the brain's structure and function from a philosophical perspective. Although the brain at micro-level, with its trillions of ultra-thin nerve fibers, is one of the most complicated structures in the known universe, you can still grasp its composition if you go up to the level of the cell. How this structure functions is not quite clear. You can understand its function at fiber level, because it is fairly simple, and you can understand it at cell level, but it is already vague. Roughly speaking, you can envision a single nerve cell as a tiny, independent computer whose behavior is dependent on continuous calculations of all input. At organ level, the function can be understood as an extremely complex pattern machine. Finally, the brain"s function can be understood at the cognitive level as what provides consciousness through its ability to keep order in our complicated reality. The superior function of the brain is to connect the real us, our higher self, to the surrounding world. The brain has been developed so that it can create all possible complex patterns. The connectivity seems to imply that the patterns of the human brain are 1000-dimensional. It is our vision that these complicated patterns arise from basic patterns in the quantum matter of which everything is created. In our opinion, our consciousness" special utilization of a patterned aspect of nature is what lies behind inscrutable statements like "Man is created in God"s image". We suggest that these patterns in matter are the basic, creative force that influences all living organisms. Unfortunately, science has only just begun to understand these patterns. The Bible's description of the origin of man is two people eating from the Tree of Knowledge and as punishment they are expelled from the Garden of Eden. What does that mean? It means that, as conscious creatures, we no longer were an unproblematic, harmonious part of the world around us. The great question is why this consciousness about the world, provided by the brain, is not a gift that makes life better instead of getting us expelled from the Garden of Eden. We think that our real problem is the fact that we are still not in control of our consciousness. Instead of it serving us, we have become its slaves. If we come to understand brain and consciousness in order to solve this basic problem of our existence, we shall again be able to become a coherent part of the world, both as individuals and as a species. We share the vision that such an understanding of the problems of consciousness will make medical science holistic and will bring quality of life, health, and the ability to function to its patients.

Animals↗

Perspective: evolution's struggle for existence in America's public schools.

The ongoing creation-evolution controversy in North America thrives on the widespread special creationist beliefs of a significant portion of the public. Creation science supports a literal interpretation of the Judeo-Christian Bible, an earth that is no more than 10.000 years old and created ex nihilo in six days by a monotheistic God, with no new kinds arising since the period of creation, and with a single flood of staggering force shaping layers of rocks and trapping the organisms fossilized within them. Despite decisions in numerous court cases that specifically exclude creationism and creation science from primary and secondary biology classes in America's public schools, creationists now work locally to minimize or remove evolution from science teaching standards. The nationally organized movement to resist the teaching of evolution has proven highly effective, influencing state and district school boards in addition to individual teachers and schools. Thus, if teaching about evolution and the nature of science is to survive in America's primary and secondary schools, scientists must likewise work with teachers and reach out to state and local school boards. In this perspective we outline the typical creationist arguments we encounter from students, teachers, school board members, and neighbors. We explain briefly how knowledge of both microevolution and macroevolution is important in medicine, agriculture, and biotechnology. We describe a science education controversy that arose within our own school district, how we responded, and what we learned from it. Finally, we argue that even modest outreach efforts to science teachers will be richly repaid.

Attitude↗

Erotomania and Fregoli-like state in Down's syndrome: dynamic and developmental aspects.

The present authors report the case of a 42-year-old female with Down's syndrome who developed a misidentification syndrome, erotomanic delusions towards her Bible instructor, and increasing grandiosity following the death of her father. The authors believe that her symptoms may be formulated in developmental and dynamic terms.

Activities of Daily Living↗

Religious activity improves life satisfaction for some physicians and older patients.

OBJECTIVE: To assess religious perceptions and activities of physicians and older patients and to determine whether religious activities are associated with life satisfaction. DESIGN AND SETTING: A cross-sectional survey of practicing Virginia internists and psychiatrists and hospitalized or institutionalized (nursing home) older adults. PARTICIPANTS: One hundred randomly sampled practicing physicians and 55 hospitalized or institutionalized older patients. METHODS: A mailed survey was used for the physicians and a structured interview for the patients. All subjects provided information pertaining to demographics and life satisfaction using the Life Satisfaction Index (LSI-B). For physicians or patients who engaged in any religious activity, the Intrinsic/Extrinsic Religiosity (I/E-R) scale was used. RESULTS: Of the 100 physicians (49 internists and 51 psychiatrists) who answered the survey (50% response rate), 75% used religious activity as a coping resource (39% somewhat, 36% definitely). There was a positive correlation between intrinsic religious activity (e.g., prayer, Bible reading) and life satisfaction (r = .293, P = .042). Of the 55 patients interviewed, 47 (86%) used religion as a coping resource, and intrinsic religious activity was positively associated with life satisfaction (r = .843, P < .001). Even after controlling for age, gender, health, and marital status, intrinsic religious activity remained a predictor of higher life satisfaction. CONCLUSIONS: Intrinsic religious activity is associated positively with life satisfaction in physicians and ill older adults.

Adaptation, Psychological↗

Wellness self-care by healthy older adults.

PURPOSE: To examine self-care behaviors in healthy older adults. The number of older adults continues to increase. Nurses need a framework for understanding and supporting healthy behaviors in this population. DESIGN: Descriptive. METHOD: Data about self-care behaviors were elicited in 1997 about how healthy older adults stay well. Using a key-informant criterion and critical case approach, a small convenience sample of 28 older adults (ages 57-83) responded to a questionnaire based on a self-care wellness model. FINDINGS: Age was not related to differences in healthy behaviors. Many informants reported no digestive or sleep difficulties. All were active, regularly kept in touch with family and friends, were confident their environment was safe, obtained sufficient sleep and rest, and managed stress well. All but one attributed their quality of life and zest for living to remaining active, eating healthy food, exercising, pacing themselves, doing preferred activities, and reading the Bible, or "feeding the life of the mind." CONCLUSIONS: Participant statements of actions can provide inspiration for less-active seniors and a beginning framework for nurses for understanding and supporting wellness self-care behaviors in older adults.

Adaptation, Psychological↗

Educating African pastors on mother-to-child transmission of HIV/AIDS.

PURPOSE: To educate pastors of the Assemblies of God in Burkina Faso concerning HIV/AIDS and mother-to-child transmission (MTCT). DESIGN: A pretest-posttest design was used with a convenience sample of 102 pastors attending the educational program on HIV/AIDS and MTCT in January, February, and March of 2005. The educational program was implemented in local Bible colleges in Ouagadougou, Burkina Faso. METHODS: Participants attended an 18-hour program on HIV/AIDS and MTCT. A picture booklet was designed and used to help explain the prevention of MTCT of HIV The pretest-posttest examination and follow-up evaluation were designed for this project. FINDINGS: Results of the pretest showed minimal knowledge of pastors regarding HIV/AIDS. The median composite scores on the knowledge questions increased from 16% on the pretest to 92% on the posttest. Within the 3-month follow-up period, 34 follow-up evaluations were received. Although all the responding pastors had recommended testing for expectant mothers, only 13 had discussed MTCT in their churches or communities. CONCLUSIONS: The educational program was effective in increasing the pastors' knowledge of HIV/AIDS and MTCT. Further research is needed to identify barriers to full utilization of that knowledge.

Adolescent↗

To be or not to be a Jew? A dilemma of Sigmund Freud?

The paper presents the position that Freud was not torn by the conflict "To be or not to be a Jew" as some have contended, but, rather, that he had resolved upon "to be ...", and did not long to reject his Jewish identity. What is maintained here is that evidence cited in support of supposed ambivalence regarding Jewish identity is better interpreted in terms of Freud's life-long ambivalence toward his father, his drive to denigrate and destroy him. Evidence is brough that it is his father, rather than himself, whom Freud identifies with the Moses figure - and the consequences of his identification are used to explain both his obsession with the Moses theme and his seeming digressions into Bible-analysis in "Moses and monotheism". The latter, which Freud described as a sequel to "Totem and Taboo", is seen as the acting out of the wish for parricide described in that work.

Freudian Theory↗

Use of malarial prophylaxis amongst a population of expatriate church workers in Northeast Zaire.

In common with much of subSaharan Africa, falciparum malaria is a major cause of mortality and morbidity amongst the indigenous population of northeast Zaire1 although there are some mountainous areas in the east of the region that are relatively free from the parasite. There are a significant number of expatriate church workers (missionaries) in the area who work mainly in the health and development sector or directly with the local church in bible translation, evangelism, etc. The lifestyle of these workers, who tend to live close to the indigenous population, and their length of stay in a malarious region means that they are at high risk of contracting malaria.1 This population has been inadequately studied concerning its use of chemoprophylaxis and other measures necessary to reduce the risk of malaria. Many countries have published guidelines2-4 on the use of chemoprophylaxis for the prevention of malaria in travelers. This study was planned to investigate whether these guidelines were being followed by this group of missionaries. It also enabled the author to investigate who or what influences decisions regarding malaria prophylaxis amongst this population.

Adolescent↗

14C dates from Tel Rehov: Iron-Age chronology, pharaohs, and Hebrew kings.

Stratified radiocarbon dates provide an independent chronological link between archaeological layers and historical data. The invasion by Pharaoh Shoshenq I (Shishak) is a key historical synchronism, approximately 925 B.C.E., mentioned in both Egyptian inscriptions and the Hebrew Bible. The list of places raided by Shoshenq, mentioned at Karnak (Egypt), includes Rehov (Israel). The site yielded a consistent series of radiocarbon dates from the 12th to 9th century B.C.E. Our results (i) suggest a revised Iron-Age chronology; (ii) date an archaeological stratum to Shoshenq's campaign; (iii) indicate the similarity of "Solomonic" and "Omride" pottery; and (iv) provide correlation with Greece and Cyprus.

Journal Article↗

From Shakespeare to Star Trek and beyond: a Medline search for literary and other allusions in biomedical titles.

OBJECTIVES: To document biomedical paper titles containing literary and other allusions. DESIGN: Retrospective survey. SETTING: Medline (1951 to mid-2005) through Dialog Datastar. MAIN OUTCOME MEASURE: Allusions to Shakespeare, Hans Christian Andersen, proverbs, the Bible, Lewis Carroll, and movie titles, corrected and scaled for five year periods 1950-4 to 2000-4. RESULTS: More than 1400 Shakespearean allusions exist, a third of them to "What's in a name" and another third to Hamlet-mostly to "To be or not to be." The trend of increasing use of allusive titles, identified from Shakespeare and Andersen, is paralleled by allusions to Carroll and proverbs; the trend of biblical allusions is also upward but is more erratic. Trends for newer allusions are also upwards, including the previously surveyed "paradigm shift." Allusive titles are likely to be to editorial or comment rather than to original research. CONCLUSIONS: The similar trends are presumably a mark of a particular learnt author behaviour. Newer allusions may be becoming more popular than older ones. Allusive titles can be unhelpful to reviewers and researchers, and many are now clichés. Whether they attract readers or citations is unknown, but better ways of gaining attention exist.

Medicine in Literature↗

Venous thrombosis: the history of knowledge.

Venous thrombosis is a frequent disease. It is surprising, therefore, that no case truly compatible with a diagnosis of venous thrombosis was apparently reported in the antiquity. There is no case that could be reasonably attributed to a venous thrombus in the writings of Hippocrates, Galenus, Celius Aurelianus, Ibn an-Nafiz, Avicenna and others. Venous thrombosis is not among the many diseases mentioned in the Bible. The term "leucophlegmasia", first used by Hippocrates and then by Celius Aurelianus, refers to cases of bilateral leg edema, most likely due to conditions such as heart failure, liver cirrhosis and renal insufficiency. Nothing compatible with a diagnosis of venous thrombosis can be found in pieces of art from ancient Egypt, Greece, Rome, Persia and South America. While in these sources there are sometimes representations of varicose veins and ulcers, unilateral leg edema or other pictures compatible with venous thrombosis are not featured. The first well documented case of venous thrombosis is depicted in a beautifully illustrated manuscript written in the 13th century and currently preserved in Paris at the Bibliothèque Nationale (MS Fr 2829, Folio 87). The manuscript describes the case of a young man from Normandy named Raoul who at the age of twenty developed unilateral edema in the right ankle that subsequently extended up to the thigh, with no obvious symptoms in the contralateral leg. Raoul was advised to visit the tomb of Saint Louis who was buried in the church of Saint Denis, where the patient spent several days confessing his sins and praying the saint. Afterwards he chose to collect the dust accumulating below the stone that covered the tomb and to apply it on the fistulae and ulcers of his foot. The openings stopped running and were filled with flesh. He was first obliged to use crutches but subsequently he could walk with a cane, to be eventually able to dispose of all devices, even though his foot throbbed a little. Raoul was cured as described above in the year 1271 and was still alive and well in 1282. Not only this is the first case of venous thrombosis, the young age of the patients leads us to suspect that Raoul had a thrombophilic condition.

History, 15th Century↗

The prevalence of religious coping among persons with persistent mental illness.

OBJECTIVE: The purpose of this study was to examine the prevalence of religious coping among persons with persistent mental illness and to gain a preliminary understanding of the relationship between religious coping and symptom severity and overall functioning. METHODS: A total of 406 individuals who were diagnosed as having a mental illness and who were patients at one of 13 Los Angeles County mental health facilities completed a survey consisting of the Religious Coping Index, the Symptom Checklist 90-R (SCL-90), the Global Assessment of Functioning (GAF) scale, and a 48-item demographic questionnaire. RESULTS: More than 80 percent of the participants used religious beliefs or activities to cope with daily difficulties or frustrations. A majority of participants devoted as much as half of their total coping time to religious practices, with prayer being the most frequent activity. Specific religious coping strategies, such as prayer or reading the Bible, were associated with higher SCL-90 scores (indicating more severe symptoms), more reported frustration, and a lower GAF score (indicating greater impairment). The amount of time that participants devoted to religious coping was negatively related to reported levels of frustration and scores on the SCL-90 symptom subscales. CONCLUSIONS: The results of the study suggest that religious activities and beliefs may be particularly compelling for persons who are experiencing more severe symptoms, and increased religious activity may be associated with reduced symptoms. Religion may serve as a pervasive and potentially effective method of coping for persons with mental illness, thus warranting its integration into psychiatric and psychological practice.

Adaptation, Psychological↗