The Various Causes of Leukemia - 825 Words

Acute Leukemia Student Name University Name Course Name Abstract This paper discusses the facts about leukemia and highlights various factors which become its causes. Description of the signs and symptoms of this disease are also discussed. There are specialized tests which are conducted to diagnose this disease. In addition, certain health patterns are described which are disturbed by leukemia. Acute Leukemia Leukemia is a wider term used to describe a range of anomalies. Cancer of the blood cells or bone marrow is referred to as leukemia (Rose, 2004). It is a condition in which the number of immature white blood cells increases at a rapid rate. When the number of immature cells increase to such a level that it becomes difficult for the bone marrow to generate new blood cells, this condition is called acute leukemia (Smith, 1996). Etiology There is no particular cause of this disease. It mainly occurs due to the mutation occurring in the genes. Some type of mutation can activate leukemia by putting off the tumour suppressor genes. In this way, they subdue the working of the cells and various functions like cell division, death and differentiation. Such mutations or changes occur in the genes when the body is exposed to some sorts of cancer causing substances or radiation. Some chemicals like benzene and viruses like T-Lymphotropic virus also contributes to this disease (Vardiman, Thiele et al., 2008). Path physiological Processes Due to the increased abnormalShow MoreRelatedLeukemia is the most Common Form of Cancer Among Children Worldwide1380 Words   |  5 Pagesblood cells is leukemia. As of the year 2012, the World Cancer Research Fund (WCRF) reports that leukemia represents a percentage of 2.5% of all cancers with 352 cases diagnosed per 1000. From a regional perspective, Qatar ranks at the 24th position for leukemia with a rate of 5.4 deaths per 100,000 as documented by the World Health Organization (WHO) in 2011. This paper covers an introduction into leukemia supported by epidemiological facts and focuses on acute lymphocytic leukemia, the possibleRead MoreEssay on Leukemia884 Words   |  4 PagesLeukemia Leukemia is a group of blood diseases characterized by cancer of the blood forming tissues. It was discovered in Europe during the XIX century when a group of doctors directed by John Hughes Bennett tested their patients and discovered theirRead MoreLeukemia1517 Words   |  6 PagesLeukemia, a word that means white blood, is a form of cancer that affects exactly what its name says; the white blood cells in your body. There are many different types of leukemia; some types are more common in adults, while some types are found mainly in children. Leukemia can range in severity and can affect people of all ages. During this paper we are going to explore the anatomy of leukemia, as well as the physiology. We will also learn about the statistics behind this disease, and any possibleRead MoreEssay on Leukemia: Cancer of the Blood1639 Words   |  7 Pagespicks up wastes from the cells for delivery to the urinary organs. These functions could not be provided for the individual cells without the blood. Like any other structure of the body, blood can be attacked by many types of disease, such as Leukemia. Leukemia is a general name given to a number of blood cancers that affect the blood. Blood transports hormones, enzymes, buffers, other types of biochemicals that are important in body functions. The blood is made of plasma and formed elements. PlasmaRead MoreDoes Down Syndrome Increase the Chances of Developing Leukemia?1098 Words   |  5 Pagessyndrome is a genetic disease that occurs in people that have 47 chromosomes instead of 46. Does the Down syndrome increase the chances of developing leukemia? What health risks are involved in trying to keep children from getting leukemia? I have personally seen the effects of Down syndrome. There have been clinical trials that have shown the results of leukemia on kids with Down syndrome. The life expectancy has gone up dramatically because of medicine. Down syndrome has affected the lives of many andRead MoreThe Epidemiology Of Leukemia And Advances1452 Words   |  6 PagesThe Epidemiology of Leukemia and Advances in Early Detection to Apply Chemotherapy I. Introduction II. Clinical Characteristics of Leukemia a. Overview the physiological stages of leukemia I. Acute lymphocytic leukemia II. Acute myelogenous leukemia III. Chronic lymphocytic leukemia IV. Chronic myelogenous leukemia b. Places of origin of leukemia I. Bone marrow II. Red blood cells III. Lymphatic tissue c. Early signs and the symptoms III. Tests are in use to diagnose and identify the explicitRead MoreCell Type : White Blood Cell / Leukocytes Disease1193 Words   |  5 PagesTYPE - WHITE BLOOD CELL/LEUKOCYTES DISEASE - LEUKEMIA Discovery of leukemia Who discovered leukemia – John Bunnett, Alfred Velpeau, Alfred Donne and Rudolf Virchow were the four me who discovered this disease When was leukemia discovered – It was discovered in 1845 but not given its name until 1847 in which Rudolf Virchow gave it the name leukemia Where was leukemia discovered – Symptoms of leukemia (signs) Common symptoms - Fever or chills - Persistent fatigue, weaknessRead MoreHematopoietic Stem Cells to Cure Leukemia980 Words   |  4 Pages Hematopoietic Stem Cells to Cure Leukemia Genetic Engineering consists in altering the DNA of a cell with the purpose of researching, as well as correcting genetic defects. (learn.genetics.edu) One of the human bodys cells has the ability to grow into any one of the bodys more than 200 cell types and this is called Stem Cells. They are not specialized and unlike mature cells, they can renew themselves and create new cells. Stem cells have a great potential, but extremely limited is theRead MoreWhat Does Turmeric Can Improve Liver Function?980 Words   |  4 Pagescarried out on animals have shown that turmeric can kill various viruses and bacteria’s. Additional studies on this area are on-going. 9. Helps prevent cancer The antioxidant action of curcumin allows it to protect the colon from the attacks coming from cellular DNA damaging free radicals. Since the cell turn over in the colon takes place every three days. The rapid cell replication and mutation action in the colon cell DNA can easily cause cancerous cell to form. Curcumin has the potency to fightRead MoreTreatment Of Acute Myeloid Leukemia1136 Words   |  5 PagesTreatment of acute myeloid leukemia (Bacarea, 2012) will be determined in each case taking into account the subtype of the disease, age, general condition of the patient and subsequently the response to initial treatment. The main goal of any treatment in leukemia or other hematologic malignancies is to achieve complete remission of the disease at the molecular level For this reason, there are two phases of treatment. Of remission induction and post-remission or consolidation phase maintenance with

Behaviorism Essay - 1778 Words

Behaviorism Psychology is the science of behavior. Psychology is not the science of the mind. Behavior can be described and explained without making reference to mental events or to internal psychological processes. The sources of behavior are external (in the environment), not internal (in the mind). Behaviorism is a doctrine, or a set of doctrines, about human and nonhuman animal behavior. An important component of many psychological theories in the late nineteenth century were introspection, the study of the mind by analysis of ones own thought processes. It was in reaction to this trend that behaviorism arose, claiming that the causes of behavior need not be sought in the depths of the mind but could be observed in the immediate†¦show more content†¦Behaviorism was first developed in the early 20th century by the American psychologist John B Watson (1878-1958). Watson was credited with the founding the behavioral movement. This is not because Watson made major contributions to the t heory of behaviorism but rather because he publicized the empirical method and made it the battle cry for a new school of psychology, aggressively opposed to subjective approaches. The dominant view of that time was that psychology is the study of inner experiences or feelings by subjective, introspective methods. Watson proposed to make the study of psychology scientific by using only objective procedures such as a laboratory experiments designed to establish statistically significant result. Watson supported his rejection of the introspective method by demonstrating, in a classic experiment, that a supposed subjective emotion such as fear could, like the salvation response of Pavlovs dogs, result from a simple, objective conditioning process. With the help of an associate Watson conditioned a fear of rats into an eleventh month boy. Before the experiment, Albert had no fear of rats. On the first day of the experiment Albert was shown a white rat. Watson than struck a medal bar wit h a hammer that caused a very loud noise. The first time it was done the boy was simply startled. As it happened again and again, he began to show signs of fright, crying, falling over,Show MoreRelatedBehaviorism : Behaviorism And Behaviorism847 Words   |  4 PagesBehaviorism When individuals hear the term Behaviorism today, they instantly know that it signifies some form of behavior considering that it is in the word itself. Nevertheless, what exactly is behaviorism? According to the Dictionary of Psychology, behaviorism is a theory of learning that is based upon the idea that all behaviors are obtained from outside observations and not in thoughts or feelings. In the twentieth century, three significant behaviorists John B. Watson, Ivan Pavlov and B.F.Read MoreSignificance Of Behaviorism And Behaviorism Essay925 Words   |  4 PagesSignificance of Behaviorism A rebellion against structuralism and functionalism began in 1913 with what was known as Behaviorism. This revolution was initiated by John B Watson in 1878 to 1958 (Ettinger, Reed, 2013). According to the book Psychology Explaining Human Behavior (2013), Behaviorism is a scientific approach to the study of behavior that emphasizes the relationship between environmental events and an organism’s behavior. The goal of Behaviorism is to recognize the process by which stimuliRead MoreBehaviorism1675 Words   |  7 Pagesthis philosophy you will see what I have noticed or feel what teachers should do when it pertains to the student and their education. Behaviorism in the psychology sense is a movement in psychology and philosophy that emphasized the outward behavioral aspects of thought and dismissed the inward experiential, and sometimes the inner procedural aspects. Behaviorism in the educational sense is primarily concerned with observable and measurable aspects of human behavior. In defining behavior, behavioristRead MoreBehaviorism Vs. Behaviorism Theory849 Words   |  4 PagesBehaviorism Approach to Life According to Ciccarelli and White (2010), behaviorism is the science of behavior that focuses on observable behavior only. An example of this is the environment a person is exposed to determines their behavior affecting their personality (McLeod, 2007). Furthermore, personality determines a person’s motivations and goals in life. With this said, this theory assist in better understanding interactions with people every day. For instance, all people have their own uniqueRead MoreBehaviorism And The Theory Of Behaviorism1816 Words   |  8 PagesIn this paper, the starting point resides with behaviorism. Nugent (2013) defines behaviorism as a legitimate approach to psychology in which the examination relies upon detectable, quantifiable facts and not on subjective thoughts and sentiments. To be objective and self-evident; under controlled conditions, both the stimulus and the response must be further investigated. Nugent (2013) explained Edward Thorndike was famous within the behaviorism community for his works regarding learning theoriesRead MoreThe Theory of Behaviorism900 Words   |  4 Pagesmental and emotional processes† (Press, 2013). In retort to this theory behaviorism came about. Behaviorism is predominantly concerned with observable and measurable aspects of human behavior. In other words behaviorism does not look at the biological aspects but it suggests that all behaviors are learned habits and changes in response to the environment. It endeavors to explain how these particular habits are formed. Behaviorism claimed that the causes of behavior was not necessarily found in the complexitiesRead MorePhilosophy of Behaviorism2347 Words   |  10 PagesPhilosophy of Behaviorism Tammie Williams Columbia College Abstract For hundreds of years there has been a fascination on how humans behave and how humans learn. This has been observed and studied by psychologists, educators, and scientists by means of humans and animals and how they perform in different environments. This fascination is known as behaviorism. This aspect of behaviorism deals with how a humans or animals respond to a certain stimuli and how a new behavior is then developed.Read MoreBehaviorism: Classical Conditioning1197 Words   |  5 PagesThere are four primary conditioning theories of behaviorism. These four theories are Pavlov’s (1849-1936) classical conditioning, Thorndike’s (1874-1949) connectionism (also known as law of effect), Guthrie s (1886-1959) contiguous conditioning, and Skinner’s (1904-1990) operant conditioning. According to the text (Shunk 2012) Classical conditioning was discovered around the beginning of the 20th century by Russian physiologist Ivan Pavlov. Pavlov was studying digestive process in dogs when heRead MoreBehaviorism And Its Effect On Behavior1079 Words   |  5 PagesBehaviorism began as a reaction against the introspective psychology that dominated the late 19th and early 20th centuries(Behaviorism 2). There are numerous factors that contribute towards the behaviors of various different animals. Behaviorism is a general subject including the different aspects within it, number of animals with behavioral issues, how animals should be treated and what enforces their behavioral characteristics. To begin this essay about behaviorism, it s beneficial to includeRead MoreTheories Of Behaviorism And Cognitivism Essay2002 Words   |  9 PagesIntroduction As two classic theories of learning and teaching, behaviorism and cognitivism have inspired a lot of great thinkers to make contributions to education. It is essential to point out the differences between the two theories so as to study how these two theories have been implemented to educational experiences. Studies have been made on the comparison on the two theories and their contribution to educational experiences. Bates (2016) had detailed analyses on the both theories and how they

Political Themes In The Metamorphosis By Steven Berkoff

This year we have been studying ‘The Metamorphosis’ by playwright Steven Berkoff; an adaptation of the novel by Franz Kafka. The play follows the story of Gregor, a working-class man who goes to sleep one evening and wakes up having transformed into a cockroach-like insect. The scene from the play that we have used as a stimulus was the scene in which Gregor actually transforms from a respected and depended upon son to being an alienated insect who is a burden to his family. In support of these themes, we have created a performance based on the 2008 recession , where thousands of people were affected and economically stable and dependent first world countries fell and transformed into countries where hundreds of thousands of people were†¦show more content†¦Brecht’s political theatre stems from his political views towards communism and the upper class society. Theatre that comments on political issues within society. Brecht began to have a dislike for th e capitalist society he was brought up in and wanted more of an equal approach to the world and the people around him. With epic theatre, Brecht wanted it to be both didactic (able to teach others) and dialectic (able to create discussions and ideas). The audience at no time during an epic play can be seen to be in a trance or take what they see on stage for granted. Our performance is reflective of Brecht and his Epic and Political theatre as we address many political topics such as Marxism and the divides between classes and the corruption of the government. We have props such as protest signs and banners to communicate Brecht’s political theatre to the audience. In the first episode, Brown’s Boys, there is a scene where MPs choke and die after ignoring the recession and protesters emerge into the audience chanting that ‘politics is dead’ and ‘they don’t really care about us’ while holding banners saying, ‘politics is deadâ€⠄¢ and ‘Gordon Clown’. This was done as it represented politics and the fact the seriousness of the situation was ignored; showing how quickly the issues with the recession spiralled out of control and became something that even the higher up in society were unable

River island in Ipswich in the UK Example

Essays on River island in Ipswich in the UK Essay River Island in Ipswich in the UK River Island in Ipswich in the UK For each available year, CALCULATE the Company’s: Gross profit margin = Gross profit /revenue =180,362,050/670538155 2006 = 0.27 2007 = 155,053,275/652,257,262 = 0.23 2008 = 165,588,865/677,359,466 = 0.24 2009 = 168785159/735570248 = 0.23 2010 =156152209/720328095 = 0.21 2011 =131.1/720.7 (Million) = 0.018 2012 = 139.3/739.7 = 0.18 Operating profit margin = Operating Income/Net sales 2006 =153645793/108534827 = 1.42 2007 = 131765867/95096280 = 1.38 2008 =132012406/110057792 = 1.19 2009 = 130341526/119735976 = 1.08 2010 = 113885312/110793773 = 1.02 2011 = 84.7/74.5 = 1.13 2012 =95.6/78.8 = 1.21 Net profit margin = Net profit/ Revenue 2006 =108534827/670538155 = 0.16 2007 =95096280/652257262 = 0.14 2008 =110057792/677359466 = 1.16 2009 =119735976/735570248 = 0.16 2010 = 94544873/720328095 = 0.01 2011 = 74.5/720.7 = 0.1 2012 = 78.8/739.7 = 0.1 Cash conversion cycle measures the amount time it takes for the company to transform its resource inputs into cash flow. It is an attempt to measure the length of time each net income is tied up in the production and sales before it can be converted to cash through sales. 2006 CCC = DIO +DSO – DPO DIO= (490176105-433075251)/2 =37582854/1342948.2 = 28 days DSO = average AR/Revenue per day = 3408312/1837090.8 =1.8 days DPO = Avarage AP/Revenue per day =0.2 days CCC =(DIO +DSO)-DPO =(28 +1.8) -0.2 2006 = 29.6 days 2007 = DIO = 23208606.5/1362202 = 17 days DSO = average AR/Revenue per day =1948968.5/1787006 = 1 day DPO = Avarage AP/Revenue per day = 385132.5/1787006 = 0.2 days 2007 CCC =(17 +1) -0.2 = -17.8 days 2008 CCC = DIO = 12551102/1402111 = 8.9 days DSO = average AR/Revenue per day = -393917/1855779.3 = -0.2 days DPO = Avarage AP/Revenue per day = -553841/1855779.3 = -0.3 days 2008 CCC =(8.9 +-0.2) –0.3 = 9 days DIO = 735570248/1552761.9 =473.7 days DSO = average AR/Revenue per day =2645844/ (735570248/365) =2645844/2015260.9 = 1.31 days DPO = Avarage AP/Revenue per day =1692193/2015260.9 = 0.8 days 2009 CCC = (473.7 +1.31) -0.8 = 474.9 Days 2010 CCC = DIO = -15242153/1545687.3 = -9.8 days DSO = average AR/Revenue per day =673272.5/1973501.6 =0.34 days DPO = Avarage AP/Revenue per day = 2330366/1973501.6 =1.2 days 2010 CCC = (-9.8+0.3) – 1.3 = - 10.8 days 2011 CCC DIO = 200000/1615342.5 = 0.1 Days DSO = 750000/1974520.5 = 0.3 days DPO =7500000/1974520.5 = 3.8 days 2011 CCC = (0.1+0.3) – 3.8 = -3.4 days 2. DESCRIBE and EXPLAIN the Company’s financial performance over this period. According to the consolidated Profit and Loss account at the end of 2006, the turnover was 670,538,155 which was an increase of  £75,165,708 from the 2005 turnover. The general performance of the company was better compared to the previous year as reflected by the gross profit and the operating profit. Gross profit grew by  £18,064,854 while net profit for the 2006 financial year was  £6,228,997 from the previous financial year. The company’s financial performance in 2007 was negative despite a higher turnover of  £652257262 which was a significant increase of  £46,417,213 from the previous year. The Cost of good sold went up by  £ 56,218,923. Affected the net operating profit which dipped by  £1,710,525. Despite the rise in the cost of goods sold, the performance for the 2008 fiscal year rose. The turnover was 677,359,466. This was  £25,102,204 higher compared to the previous financial year. The cost of goods rose by  £14,566,614 but this did not affect the profits as the company recorded a net operating profit of  £110057792. From the loss received the previous year, the profit for the 2008 saw an increase of  £14961512. There was a momentous rise of  £58,210,782 in the company’s turnover in the 2009 financial period (RIVER ISLAND, 2009 p7). Nevertheless, the rise in the cost of goods sold and the distribution and administration expenses led to a dip in the profits. For instance, the administration expenses rose from 33,576,459 to 38,443,633 (a difference of 4,867,174) Furthermore, the interest receivable was noticeably low compared to the previous year while interest payable rose exponentially from  £731, 1003 to 2,423,196. Therefore, the company paid  £1,622,193 more on interest and other charges. Still, the company managed a raise in its profits after taxation from 110,057,792 the previous year to  £119,735,976 in 2009. The turnover for the 2010 (RIVER ISLAND, 2010 p9) fiscal year was  £720,328,095. This was a significant depression of  £15,242,153. The implication was that the overall profit after taxation would reduce. Despite the reduction in the cost of goods sold. Distribution and administration expenses increased from  £38,443,633 the previous year to 42,266,897 (a difference of  £3,823,264) this affected the operating profit which plunged to  £113,885,312 from  £130,564,174 the previous financial year. The profit after taxation was reduced further by the higher taxation and increased charges on interest payables. As a result, the profit after taxation was  £ 94,544,873 this was a loss of  £25,191,103. The 2011 financial year saw a slight increase on the overall turnover of the company. However, the cost of production rose. Similarly, distribution and administration expenses and interest payable grew considerably. These affected the profits negatively resulting to a loss of  £20.1 million. In the 2012 financial year, the turnover rose to  £739.7 from  £720.1 (million). However, the cost of sales continued to rise to  £600.4 from  £589.6 million (RIVER ISLAND, 2012 p8). Though the distribution and administration expenses reduced, improving the operating profit, interest payable and other charges increased from  £8.6 million in 2011 to  £8.8 million in 2012. As a result, the company performed better in 2012 compared to 2011. The overall performance of the company across the six years show a downward trend with higher gross profit margin of 0.27 in 2006 to .018 in 2012. The cost of production, administration and distribution expenses and the interest payables grew exponentially across the six financial periods while the turnover reduced. This could be blamed to the external factors such as the economic crisis that begin in the late 2007 and peeked in 2008/2009. For instance sales in the clothing and textile sector of the economy fell due to the credit crunch due to the collapse in the consumer confidence, loss of employment. There was a 2.1% reduction in garment sales in the year 2008. Manufacturers and exporters also suffered. The volume of exports in the US fell both in value (10%) and volume (5%) and continued throughout the fiscal years. 3. In the 52 weeks to 29 December 2012, River Island Clothing Co Ltd paid over  £70 million in rent on its shops. a) CALCULATE the Business Rates payable for 2013-14 on the River Island shop that has been allocated to you. River Island Clothing Co. Ltd. i. 15a, TOWER RAMPARTS CENTRE, TAVERN STREET, IPSWICH, IP1 3BB (RIVER ISLAND WEBSITE, page1) a) The business rate = multiplier Ãâ€" ratable value = 29,250Ãâ€" n = 29,250n (this is because there is no value from the website indicating the multiplier). b) SUBMIT a copy of the relevant page from the Valuation Office Agency website with details of your shop’s rateable value. Source: Valuation Office Agency (http://www.2010.voa.gov.uk/rli/en/basic/find/valuation/2010/10720484000/8795776000/H) c) STATE one interesting fact about the town, city or suburb in which your shop is located. Ipswich is the oldest permanently inhabited town in the country with evidence of settlement dating far as 625 AD. It was the first town to be built by the Anglo-Saxons when they conquered Britain and was originally called Gypeswic. It was known for its large scale potteries that begun with the Fresian potters. These helped establish the town as a trading town References RIVER ISLAND. Annual Reports. Retrieved April 19, 2014, from http://www.riverisland.com/ RIVER ISLAND. Store Locater. Retrieved April 19, 2014, from http://www.riverisland.com/how-can-we-help/store-locator/Search?Query=IpswichWomen=falseMen=falseKids=falseChelseaGirl=falseSuperstore=falseHollowayRoad=falseAccessBoutique=false VALUATION OFFICE AGENCY. My valuation. Retrieved April 19, 2014, from http://www.2010.voa.gov.uk/rli/en/basic/find/valuation/2010/10720484000/8795776000/H

Poetry Commentary

Poetry Commentary- Where the Sidewalk ends) Essay The poet uses a prominent theme, various tones and an extended metaphor to make the poem moving and touching to the reader. Shell Silversides uses an extended metaphor to make the poem moving and intriguing. An extended metaphor is a metaphor that lasts for several sentences and sometimes for an entire work. For example, There is a place where the sidewalk ends, and before the street begins, and there the grass grows soft and white. The end of the sidewalk the poet describes represents the end of a journey. It also symbolizes the end of life when you et with your own impermanence and reach death. This is ironic, because the Hawk is proven to be an Insensitive killer, who uses his advantage of strength to kill and damage others; and is now insisting that the earth and its beauty belongs to him. Line 8 begins to develop the idea of the hawks superiority and control, as the world lies below him for Inspection. This Image also gives the Idea of the speakers omniscience, In the third stanza, the speaker clearly describes himself as having the role of God, or Creation. The hawk explains how It took all good efforts of Creation to create him, in fact so flawlessly that now he has taken over the role of the Creator. To further develop this idea, the poet describes the hawk as locked upon the rough bark. This gives the reader the Impression that the hawk has extreme stability wherever he shed to be, and that there is no force on earth which can remove him against his will. In contrast, in the next stanza the speaker describes himself in motion; the image created here is again one of control, as in line 13. The rest of this stanza conveys a powerful Image of a creature who Is both arrogant and violent. In line 15 he states that he needs no verbal reasons to persuade anyone that he is right. The final line of this stanza, my manners are tearing odd heads, emphasizes his power and aggression. In the penultimate stanza, this concept of omnipotence, total control, is again threatened. The predominant image created Is one of life-threatening power which cannot be opposed or contradicted. Uh. The last line states clearly and directly his confidence in his ability to do so. This ending is formulated as an incontrovertible fact, rather than a possibility. In conclusion, Hughes cleverly portrays the possible dangers and downsides involved for a country ruled by a tyrant with a fascist psychology, in a large metaphor, using the poem. I believe that this message is brought across very successfully, using the powerful image of an insensitive yet very powerful hawk.

Cloning Essay Research Paper CMF Ethics CloningSubmission free essay sample

Cloning Essay, Research Paper CMF Ethical motives: CloningSubmission from the CHRISTIAN MEDICAL FELLOWSHIP to the Medical Ethics Committee of the BRITISH MEDICAL ASSOCIATION on WITHDRAWING AND Withholding Treatment Introduction Christian Medical Fellowship is interchurch and has as members more than 4,500 British physicians and 1,000 British medical pupils who are Christians and who desire their professional and personal lives to be governed by the Christian religion as revealed in the Bible. We have members in all subdivisions of the profession, and through the International Christian Medical and Dental Association are linked with like-minded co-workers in over 60 other states. We on a regular basis make entries on ethical affairs to Governmental and other organic structures and, for illustration, commented at length [ 1 ] to the House of Lords Select Committee on Medical Ethical motives in 1993 on affairs which include those covered in this Submission. We are thankful for the chance to notice on the issues involved in the BMA # 8217 ; s Consultation Paper Withdrawing and Withholding Treatment and would be willing to assist farther if requested. Positional Statements The undermentioned constructs in our Avowal on Christian Ethical motives in Medical Practice are relevant to this Submission: In Relation to Human Life Admiting that God is the Creator, the Sustainer and the Lord of all life. Recognizing that human existences are alone, being made in the # 8216 ; image of God # 8217 ; . . . Keeping the deepest regard for single human life from its beginning to its terminal, including the unborn, the helpless, the disableds, and those advanced in age. In Relation to Patients Giving effectual service to those seeking our medical attention irrespective of age, race, credo, political relations, societal position or the fortunes which may hold contributed to their unwellness. Serving each patient harmonizing to their demand. . . Respecting the privateness, sentiments and personal feelings of patients and safeguarding their assurances. Talking truth to patients as they are able to accept it, bearing in head our ain fallibility. Making no injury to patients, utilizing merely those drugs and processs which we believe will be of benefit to them. Keeping as a rule that the first responsibility of physicians is to their patients, whilst to the full accepting our responsibility to advance preventative medical specialty and public wellness. We hold the Bible to be the revealed Word of God and happen this helpful in giving us rules such as the above to steer decision-making in the of all time more complex countries of moralss and pattern. General Remarks We regret the tight timetable allowed for the production of Submissions on such a critical affair. To go around a long and complex audience papers in July, merely before the vacation season, with a deadline of mid-October has meant that we have non been able to keep as broad a audience within our ain extensive constituency as we would hold wished. Although some of us felt the papers # 8216 ; meandered # 8217 ; , it is surely comprehensive and we find much to commend in the content. We would peculiarly commend # 8216 ; a given in favor of protracting life # 8217 ; in instances of uncertainty ( 2.1 ) , the debut ( # 8217 ; a-c # 8217 ; ) to Basic Moral Principles ( 2.8 ) , the refusal to categorize patients on the evidences of disablement ( eg 2.8.4 ) and the construct of # 8216 ; Best Interests # 8217 ; ( 2.9.4 ) . Specific Remarks Before trying replies to the specific inquiries posed in the audience papers, we make a figure of remarks of a # 8216 ; comparison and contrast # 8217 ; nature: Bring arounding and caring # 8211 ; non killing Although we acknowledge that this audience is non about mercy killing, that topic can neer be far off from the issues involved. We hold that knowing medical violent death is ever unneeded and ever incorrect [ 1 ] and has no topographic point in the pattern of medical specialty. Caring # 8211 ; non bring arounding ever Medicine has two traditional duties # 8211 ; to forestall decease and to alleviate enduring. One ( remedy ) deals with the measure of life, the other ( attention ) with its quality. At the bosom of the treatment of retreating and keep backing intervention is the shifting of the balance from the duty to forestall decease or preserve life to the duty to forestall agony and maximise quality of the progressively cherished clip that remains. Associated with this, it is indispensable for the populace and the profession to recognise that life has a natural terminal. For grounds possibly connected with general loss of committedness to the Christian religion and ethic, decease has become a tabu in our society. Rising patient outlooks of admiration remedy after admiration remedy add to the tendency for many patients and their households to deny the world of at hand decease. In add-on, many physicians overtreat deceasing patients or handle them unsuitably. This may be partially for the general social grounds given above, for grounds of # 8216 ; defensive medical specialty # 8217 ; , or for more personal grounds. Confronting deceasing patients may raise uncomfortable suggestions of the physician # 8217 ; s own mortality, physicians may bask giving interventions, or possibly they need more patients in their tests. One of our members has written movingly of these phenomena in the profession in a recent BMJ Personal View [ 2 ] . Whatever the accounts in general and in single instances, we are convinced that the medical profession has caused much of the present thrust for mercy killing amongst some in our society because of overtreatment. It is non needfully a failure for medical specialty when the clip comes that we can no longer remedy ; we so change the ends of medical specialty towards concentrating on lovingness, a doctrine so good demonstrated by the alleviative attention motion. The public needs on-going instruction about the restrictions of healing medical specialty. Real # 8211 ; non rare It is good said that # 8216 ; difficult instances make bad jurisprudence # 8217 ; , and whilst we recognise the specific and hard issue of retreating tubing eating in PVS patients, for illustration, we must admit that such instances are gratefully rare, and non let rules for decision-making to be driven by difficult instances entirely. As one of our geriatrician members put it in his grounds to us, # 8216 ; most people who die are old # 8217 ; . The rules for geting at ethical replies in withdrawing and keep backing intervention state of affairss must work out in pattern with those much larger patient groups with, for illustration, terrible shot. Principled counsel # 8211 ; non normative guidelines We believe a cardinal error in the by and large first-class thought in the audience papers is that # 8216 ; guidelines # 8217 ; will work out the jobs. Two really recent BMJ articles [ 3,4 ] have noted that physicians # 8216 ; are being flooded with guidelines # 8217 ; . Why is this? The reply likely lies in the current cultural state of affairs of fright and incrimination. As the audience papers says so good [ 5 ] : # 8216 ; how widespread is the feeling that when a individual dies person else must be responsible instead than merely unwellness or human mortality being the cause of decease # 8217 ; . Possibly the single wellness professional thinks unconsciously: # 8216 ; If a patient dies, person is to fault. That person mustn # 8217 ; t be me. I must cover myself. If I have followed the guidelines they can # 8217 ; t trap anything on me. # 8217 ; And in an progressively litigious society, employers will be dying to turn out that everything was done by the book. However, normative rulebooks don # 8217 ; t apply good to medicate. It isn # 8217 ; Ts like that. It is imprecise, and unsure. Possibly normative guidelines of the # 8216 ; If A, do B # 8217 ; kind may work for a few well-specified surgical conditions, but they are excessively stiff for ethical application in the huge bulk of serious unwellnesss. Clinical conditions wax and ebb, and therapies are iterative, tried on an empirical footing and possibly retreat on evidences which are more frequently # 8216 ; clinical # 8217 ; than # 8216 ; moral # 8217 ; . We call below for more nonsubjective research on intervention results and doubtless more cognition will be gathered, but medical specialty will ever stay an art every bit much as a scientific discipline. We believe it would be a great error for the BMA or others to seek narrowly normative ethical guidelines. Each patient, each unwellness, each state of affairs is unique. The profession needs a set of rules, ethical counsel along the lines we set out here, but non more guidelines of the type drenching the profession. Seniors at the bedside # 8211 ; non slaves to bureaucracy Admiting that much of medical specialty is an art, clinical experience is a great aid. Difficult intervention determinations of the type being considered by the BMA merit the presence of the most clinically experient physicians and nurses at the bedside. Patients deserve the best. Yet inappropriate direction civilization within the NHS may intend that those experient senior professionals can non give the clip they would wish to assisting do the best determinations at the bedside, by the way patterning best pattern to co-workers in preparation. We besides commend multidisciplinary squad attacks with shared information inputs. Often determinations are taken by inexperient juniors, as stray persons, and non by experient squads together. Possibly at that place necessitate to be cultural alterations and restructuring within some parts of the NHS so that patients and paperwork both have the precedences they deserve. Carers and clinicians # 8211 ; non commissions and tribunals We favour moralss determinations in health care being taken harmonizing to the # 8216 ; partnership of two experts # 8217 ; # 8211 ; the wellness professionals who have their proficient countries of expertness and the patient who is an expert in two things: how he or she feels and what he or she wants. Ideally, appropriate professional paternalism and appropriate patient liberty should be balanced in such a duologue between experts, to the benefit of both. Decisions would normally outdo be taken with the patient by carers and clinicians. We do non favor the development of clinical moralss commissions # 8211 ; most of the moralss commissions presently in being are research moralss commissions and many new constructions would necessitate to be set up, with doubtful benefit. Most of the hard intervention determinations under consideration are comparatively acute and commissions would be excessively slow to react. Nor do we in general favor widening the engagement of the tribunals. Whilst we believe determinations about backdown of tubing eating in PVS patients should still travel to tribunal, and that there should be no countries in medical pattern that the jurisprudence can non analyze, we do non favor further engagement of jurisprudence in moralss decision-making. Research # 8211 ; non rhetoric Whilst many facets of caring for a patient with a concluding unwellness will ever remain to some extent intuitive, we advocate nonsubjective research into factors finding intervention results. For illustration, multivariate analysis of clinical findings can help in doing anticipations ( eg APACHE marking in the ITU ) . Advice and decision-taking can therefore be as grounds based as possible, and continuously updated as new techniques make their impact. All the health care subjects should be committed to go oning instruction and the extension of proven best pattern. Many of these remarks endorse subdivisions of the audience papers, and we do them all in the most constructive spirit. Individual determinations will neer be easy and we advocate against any attack that makes them look so. However, a dependable set of ethical boundaries such as we have tried to bespeak within these seven sets of specific remarks should put helpful bounds for the hard determinations in each alone instance. Answers to # 8216 ; Section 3 # 8211 ; Specific inquiries on which the BMA is seeking positions # 8217 ; 1. Are there spreads which need make fulling in current UK ethical/legal counsel about retreating or keep backing life-prolonging interventions? Are at that place other legal and ethical jobs associated with withdrawing or withholding intervention which are non mentioned in this paper? As outlined above, we don # 8217 ; t believe there is presently the right sort of counsel that takes equal history of the natural history of the unwellnesss in inquiry or of their responses to therapy. Our ain conceptual model indicates the manner we view the legal and ethical issues. 2. Are international consensus paperss such as the 1992 Appleton International Consensus used in pattern when determinations need to be made? If so, is reappraisal of such guidelines necessary? Few of us are cognizant of the Appleton Consensus. We doubt this attack is much used by clinicians. 3. If counsel were to be produced, are at that place good grounds for separating between retreating and keep backing intervention? If so, what are they? In rule, and from a moral doctrine position, we agree with the BMA # 8217 ; s place that there is no ethical difference between retreating intervention which has become ineffectual and non presenting that intervention at an earlier phase. However, in pattern the two may good experience really different to professional and household carers and this must be taken into history at the bedside. 4. Be at that place good grounds for separating between the intervention of grownups and kids when pulling up counsel? If so, what are they? We do non believe there are valid moral differences, though it seems to be a gt ; ( well-documented [ 6 ] ) homo inherent aptitude to seek harder for kids. On clinical evidences, kids in many state of affairss will be given to make better than grownups and forecast is even more hard. For physiological but non moral grounds, counsel about intervention of kids may necessitate to be distinguished from intervention of grownups in some clinical state of affairss, since their resiliency greatly exceeds that of grownups. 5. When patients lack the ability to do determinations for themselves, will non recover awareness, and there is no clear indicant of their wants, should retreating or keep backing intervention be an issue to be decided by wellness professionals and households entirely? We presume from its phrasing that this inquiry addresses issues including the backdown of tubing eating in PVS patients. Because to halt giving nutrient and fluid to a patient will necessarily and surely do their life to stop, we believe this determination, if it has to be considered, should go on to come before the tribunals. Other intervention determinations which are more clearly # 8216 ; clinical # 8217 ; , such as sing keep backing antibiotics for dangerous infection, could ethically be taken by professionals and household together. If so, should the decision-making procedure conform to strict standards? N/A What sort of standards would be appropriate? N/A Are the 1s discussed in this paper sufficient? N/A 6. Is at that place a foreseeable phase at which retreating nutrition and hydration from patients who have irrevocably lost awareness would no longer necessitate to travel to tribunal? No. See ( 5 ) 7. Is there a function for moralss commissions to be involved in doing determinations about retreating or keep backing intervention from patients who can non show their ain positions? No ( see our Specific Comments above ) . Most current commissions are research moralss 1s. New constructions of unproved benefit would be needed. Many such determinations are excessively acute to expect # 8216 ; the following meeting of the commission # 8217 ; . 8. Are at that place peculiarly debatable determinations of this type which should be made merely by the tribunals? As stated, we believe determinations about retreating nutrient and fluid from patients in PVS should come to tribunal. Whilst every bit sincere physicians disagree about the purpose of retreating nutrient and fluid from such patients, the fact that the patient # 8217 ; s decease is the inevitable effect means this determination is different from others. If so, can unclutter parametric quantities be defined to distinguish those instances sufficiently debatable to necessitate legal overview from those which could lawfully be decided jointly by households and wellness professionals? It is the certainty of decease following the backdown of nutrient and fluid from patients non otherwise at the terminal of their natural lives which leads to this ethical quandary. For many professionals such action represents a breach of responsibility of attention, and is outside the # 8216 ; clinical # 8217 ; determination to halt efforts at remedy. There would be peculiar force per unit areas on nurses in such state of affairss. Would ambiguity about the footings of a patient # 8217 ; s refusal of intervention or about competency to do valid refusal be the type of instance where tribunals should be involved? Other illustrations of instances that should come to tribunal might include major struggles between parties that can non be resolved after # 8217 ; 2nd sentiments # 8217 ; . However, we reiterate our strong belief that there should be as small legal engagement in medical decision-making as possible. 9. Department of energies retreating or keep backing unreal nutrition and hydration signifier a separate class of determination from any other type of intervention which might be withheld or withdrawn? Yes. If so, why? The patient will necessarily decease as a effect of retreating nutrient and fluids, though the clip of decease may be unpredictable. Most wellness professionals feel this is incorrect # 8211 ; in the five old ages since the decease of Antony Bland a conservative estimation of 1-2,000 patients have gone into PVS and died of it. Merely ten or so instances have come before the tribunals in that period to bespeak permission to withdraw nutrient and fluids. This suggests that whatever the hard philosophical issues, the intuitions of approximately 99 % of household and professional carers are that such an action is incorrect. Does society demand to hold clear and rigorous standards for withdrawing or keep backing unreal nutrition and hydration? No. If so, what sort of standards? N/A Are the standards and precautions discussed in this paper ( e.g. a period of monitoring before a determination is made ; an independent 2nd medical sentiment ) sufficient? No. 10. When determinations about withdrawing or keep backing have to be made, what are the chief factors which wellness professionals presently take into history when discoursing the affair with competent patients? Likely forecast is the chief issue, but the unity of the wellness professional in inquiry is of import # 8211 ; he or she can so bias the presentation of information as to obtain the determination they would prefer the patient made. When make up ones minding how to continue for patients who can non show an sentiment? Communicating hard and unsure issues to the household, with the highest unity. 11. How should # 8220 ; best involvements # 8221 ; be defined for helpless people? What standards should be taken into history? In general, we agree with the papers # 8217 ; s treatment at 2.9.4. We would surely see capacity for relationships as valuable, but the absence of such capacity where there appears no awareness does non cut down the intrinsic worth of that individual in God # 8217 ; s eyes. They are ever of value because they remain made in the image of God and He has a go oning relationship with them. 12. If a patient has left no indicant of who should be consulted on his or her behalf, how widely should see be sought from people caring for an incapacitated grownup? Although there are no legal rights involved, it would surely be good pattern to seek the positions of those straight involved in attention. However, cautiousness is needed because of the emotional reactions of loved 1s, and their other involvements, which may or may non be subterranean motivations. Should the positions of blood relations take precedency over others? No. The societal work construct of # 8216 ; Most caring other # 8217 ; is likely the best usher. 13. Is conflict common between different classs of wellness professionals or between wellness professionals and relations? No, but it is non that unusual in most patterns and sections. Could conflict between wellness professionals be avoided or is it a positive goad to all-around treatment? # 8216 ; Conflict # 8217 ; in the sense of adversarial treatment can be constructive and should non be avoided at all costs. Are at that place good theoretical accounts for deciding differences within and between wellness squads, carers and relations? Prevention is better than remedy. Good communicating is of import, and the clip force per unit areas on short-handed and overworked squads are hence too bad. The duologue between the # 8216 ; partnership of two experts # 8217 ; is based on common regard and unfastened communicating, with the purpose being to happen consensus. 14. Is at that place still topographic point for separate sets of professional counsel, trying to reflect the peculiar position of each profession or is it desirable that all guidelines try to reflect a broad multi-disciplinary attack? No. The different wellness subjects should all be spouses in the same endeavor, and counsel must reflect normally recognized rules. 15. Should at that place be more research into how determinations about withdrawing or withholding intervention are made? Yes, but instead than subjective research on the behavior of wellness professionals who may non cognize why they are making what they are making, we would favour nonsubjective research on results to let the best clinical grounds base possible. These determinations are frequently more # 8216 ; clinical # 8217 ; 1s than # 8216 ; ethical # 8217 ; 1s. 16. Make you see that there is wide concern about the usage of the # 8220 ; dual consequence # 8221 ; statement refering intervention at the terminal of life? No. We hold the rule of purpose as critical in this whole country and have stated above that we believe knowing medical violent death is ever incorrect. Once explained decently, our experience is that wellness professionals and the populace readily understand and back up the construct. By the way, we find the wording # 8216 ; dual consequence # 8217 ; unneeded and unhelpful, looking in itself to propose # 8216 ; dual criterions # 8217 ; , ie lip service. We favour the individual word # 8216 ; purpose # 8217 ; . The physician # 8217 ; s purpose is the alleviation of hurting or enduring even though this may really on occasion shorten by hours or yearss a life which it is non possible to salvage. Of class, there may in pattern be hypocrisy, as physicians can feign one purpose while holding another, or there may be unconscious self misrepresentation about motivations. There are besides issues about the # 8216 ; knowledge spread # 8217 ; # 8211 ; we may mean one thing but because of limited foresight achieve another, the # 8216 ; intending good but making severely # 8217 ; state of affairs. However, despite these issues, # 8216 ; purpose # 8217 ; is the most helpful construct we have in this country. It has legal standing, and there are precautions. A precaution to # 8216 ; How do we cognize what the physician # 8217 ; s purpose really was? # 8217 ; would be to guarantee that major determinations were taken out in the unfastened with the widest possible treatment of foreseeable effects and affecting the patient every bit to the full as possible. In add-on, where the disposal of interventions is concerned, there would be pharmacological precautions in prescription records of drug dose and frequence. If so, is the concern shared by wellness professionals and the populace? Such concern as there is partially reflects echt confusion, which should be conformable to account and instruction. However, confusion is besides encouraged by the euthanasia motion as a misanthropic run scheme. It is in their involvements to seek and convert professionals and patients that # 8216 ; physicians are making mercy killings already with these large doses of powerful analgesics and what we need now is a jurisprudence to clear up the place # 8217 ; . Would wellness professionals welcome more argument about the deductions of # 8220 ; dual consequence # 8221 ; ? Some need this helpful and really clear point explained more efficaciously. 17. Are there add-ons or amendments that should be made to the list of general points refering withholding or retreating intervention mentioned in subdivision 2.11 of the treatment paper? We would merely underscore that parts of this by and large first-class drumhead seem to take excessively simplistic a position of the likely natural history of clinical conditions and of their responses to therapy. Patients can surprise us by acquiring better against the odds. 18. Make you cognize of any bing local or national guidelines which the BMA should take into history if it moves in front to pull up new counsel? No. Make you cognize of any advanced ways of deciding jobs connected with backdown or withholding of intervention? No, other than our attack which establishes the boundaries within which single determinations are taken. We do non believe that more normative guidelines will of all time give the best consequences. In these quandaries, a decision-making model is of more value than a expression. Ten cardinal constructs in sum-up: 1. Intentional violent death is ever unneeded and incorrect. 2. Life has a natural terminal and there is non needfully anyone to fault when a patient dies. 3. Doctors tend to overtreat towards the terminal of life, doing demand for mercy killing. 4. Society needs to interrupt its current tabu about confronting decease. 5. Sing the Christian religion is indispensable for a healthy geographic expedition of the construct of decease. 6. When accepting that remedy is either non possible or non sought by the patient, attention continues. 7. The most senior clinicians should be cardinal figures in these determinations. 8. Many of the hard determinations are more # 8216 ; clinical # 8217 ; than # 8216 ; ethical # 8217 ; . 9. Medicine is a biological scientific discipline with unsure results but research must better its grounds base. 10. Principles for counsel which define ethical boundaries are more helpful than normative guidelines. Mentions 1. Submission from the Christian Medical Fellowship to the House of Lords Select Committee on Medical Ethics. 1993 2. Personal position. Doctors contending, flying or confronting up to decease. Goodall J. British Medical Journal, 1 August 1998 ; 317: 355-6 3. Column. Where # 8217 ; s the main cognition officer? Muir Gray J A. British Medical Journal, 26 September 1998 ; 317: 832 4. Guidelines in general pattern: the new Tower of Babel? Hibble A, Kanka D, Pencheon D, Pooles F. British Medical Journal, 26 September 1998 ; 317: 862-3 5. Withdrawing and Withholding Treatment: a audience paper from the BMA # 8217 ; s Medical Ethics Committee. 1998. p5 6. Ibid. p14 Christian Medical Fellowship October 1998 Home page About CMF Ethics home page Site Index Copyright? 1998 Christian Medical Fellowship. 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