Zeitschriftenartikel zum Thema „Committee to Investigate the Concerns of the State Prison“

Serious concerns on the rights of Afghanistan’s women and girls have been raised ever since the Taliban returned to power on 15th August 2021. This paper uses a normative methodology to investigate the discrepancy of legal argument in the international law of succession in terms of status of Taliban within the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) framework. This paper confirmed that the Taliban is the de facto government of Afghanistan as the Taliban have effective and integrated control over a state territory and there is no competing entity with a solid constitutional claim. Therefore, the Taliban is bound by international law to guarantee that women enjoy equal educational rights, including access to school and curriculum. However, the current framework of CEDAW, including the CEDAW committee has not be able to cope with such issues, as it should be reformed in the next future.

Information technology (IT) has become an integral part of development in any organization. Dependence on IT brings concerns in organizations to handle its increasing complexity which necessitates the implementation of IT governance. However, IT governance is lacking in the public sector organizations of developing countries, leading to failure to realize the full potential value of IT. For Uganda's higher institutions of learning (HILs), implementation of IT governance is unexplored. Therefore, in this paper, the authors investigate the state of IT governance among the eight HILs in Uganda. Interviews were used to collect data which was categorized into structures, processes, and relational mechanisms. The results showed that the relational mechanisms like training were fairly implemented, while structures and processes like the IT steering committee and IT performance measurement respectively were poorly implemented.

Background ‘Engager’ is an innovative ‘through-the-gate’ complex care intervention for male prison-leavers with common mental health problems. In parallel to the randomised-controlled trial of Engager (Trial registration number: ISRCTN11707331), a set of process evaluation analyses were undertaken. This paper reports on the depth multiple case study analysis part of the process evaluation, exploring how a sub-sample of prison-leavers engaged and responded to the intervention offer of one-to-one support during their re-integration into the community. Methods To understand intervention delivery and what response it elicited in individuals, we used a realist-informed qualitative multiple ‘case’ studies approach. We scrutinised how intervention component delivery lead to outcomes by examining underlying causal pathways or ‘mechanisms’ that promoted or hindered progress towards personal outcomes. ‘Cases’ (n = 24) were prison-leavers from the intervention arm of the trial. We collected practitioner activity logs and conducted semi-structured interviews with prison-leavers and Engager/other service practitioners. We mapped data for each case against the intervention logic model and then used Bhaskar’s (2016) ‘DREIC’ analytic process to categorise cases according to extent of intervention delivery, outcomes evidenced, and contributing factors behind engagement or disengagement and progress achieved. Results There were variations in the dose and session focus of the intervention delivery, and how different participants responded. Participants sustaining long-term engagement and sustained change reached a state of ‘crises but coping’. We found evidence that several components of the intervention were key to achieving this: trusting relationships, therapeutic work delivered well and over time; and an in-depth shared understanding of needs, concerns, and goals between the practitioner and participants. Those who disengaged were in one of the following states: ‘Crises and chaos’, ‘Resigned acceptance’, ‘Honeymoon’ or ‘Wilful withdrawal’. Conclusions We demonstrate that the ‘implementability’ of an intervention can be explained by examining the delivery of core intervention components in relation to the responses elicited in the participants. Core delivery mechanisms often had to be ‘triggered’ numerous times to produce sustained change. The improvements achieved, sustained, and valued by participants were not always reflected in the quantitative measures recorded in the RCT. The compatibility between the practitioner, participant and setting were continually at risk of being undermined by implementation failure as well as changing external circumstances and participants’ own weaknesses. Trial registration number ISRCTN11707331, Wales Research Ethics Committee, Registered 02-04-2016—Retrospectively registered https://doi.org/10.1186/ISRCTN11707331.

The purpose of this study was to investigate the institutional history and documentary evidence of the North American Band Directors’ Coordinating Committee (NABDCC) during the first decade of its existence, from 1960 through 1970. The NABDCC constituted a forum of national band, music industry, and related associations, including the American Bandmasters Association, College Band Directors National Association, and the National Association of Music Merchants, for examining mutual concerns critically and for fostering discussion with experts outside of the wind profession. The research questions addressed the development of the NABDCC, important events in its history, and the specific issues in music education examined by the committee. Important issues in instrumental music that were discussed by the NABDCC included the role of the band in the school curriculum, music advocacy, federal and state legislation, standards-based education, and the inclusion of new musical styles and ensembles. Various themes across these issues emerged from the study, including the difficulties of collaboration within a multifaceted representation of specific interests and the oscillating relationship between music educators and the music industry. The results of this study contribute to enhanced understanding of 1960s instrumental music education, with implications for the present.

Concerns have been expressed very often as to why the intergovernmental relations in the federal system of many developing countries, especially in the Sub-Sahara Africa are predictably chequered. Lack of devolution of power to LGAs in Nigeria is usually at the expense of grassroots development especially with regards to infrastructure/social amenities. Besides, the confusion surrounding progressive decline in provision of rural infrastructure to the local government areas of the state despite humongous monthly fiscal allocations to the LGAs by Federation Account Allocation Committee (FAAC) equally creates existential problems to the rural dwellers. It is on this note that the study seeks to investigate the apparently disturbing paradox in Imo State. Data were sourced from both secondary and primary sources. Secondary data was sourced from government gazette and related literature while primary data was elicited from respondents through structured questionnaire. Multiple regression and graphical/pictorial analytical techniques were used for secondary and primary data respectively. The findings indicated that lack of transformative leadership exhibited in embezzlement of funds and indifference in leadership on the part of the State agents were the significant causes of poor development in the rural areas of Imo State. The study recommended inter alia; the enforcement of attitudinal change and punitive sanctions on the political and administrative classes in the state through legal measures to protect public funds for service delivery.

Background: Primary hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening, immune disorder characterized by a hyperinflammatory state in which patients typically develop fever, splenomegaly, cytopenias and coagulopathy. In patients with primary HLH, interferon gamma (IFNy) is considered to be the key player driving the hyperinflammatory state. The treatment goal of primary HLH is to stabilize the disease by controlling the associated hyperinflammation in order to bring patients to allogeneic hematopoietic stem cell transplantation (HSCT), the only potentially curative therapy. Current conventional therapy for HLH is based on the combined use of dexamethasone and etoposide, and, although effective in many patients, these drugs may promote the development of opportunistic infections and tissue toxicity, and are associated with high morbidity and mortality. Emapalumab is a fully human, anti-IFNy monoclonal antibody that neutralizes IFNy. It is approved by the FDA for the treatment of adult and pediatric patients with primary HLH with refractory, recurrent or progressive disease, or intolerance with conventional HLH therapy. Herein, we report on the safety of emapalumab in primary HLH seen in the pivotal phase 2/3 study (Locatelli et al. NEJM 2020) and investigate the relationship of adverse events (AE) to dose and duration of treatment. Methods: Due to the rare and life-threatening nature of the disease, the efficacy and safety of emapalumab was assessed in an open-label pivotal study (NCT01818492) which included patients aged ≤18 years with a diagnosis of primary HLH and active disease (Locatelli et al NEJM 2020). The initial dose of emapalumab was 1 mg/kg given intravenously every 3 days. Subsequent doses could be increased to 3, 6 and 10 mg/kg if required, based on predefined laboratory and clinical response parameters. Treatment duration was 8 weeks, with possible shortening to a minimum of 4 weeks, or extension up to the time of HSCT if needed. Analysis was performed on 34 patients at a database cut-off date of July 2017 (Locatelli et al NEJM 2020). The relationship of AE to emapalumab treatment was reported by the study investigator. The impact of treatment duration on AE or infection occurrence was measured by the number of events with onset in a predefined time interval from emapalumab initiation. The impact of the dosing scheme on AE and infection occurrence was assessed by the number of AEs or infections in a predefined dose range. Results: Overall, 29% of patients had at least one AE deemed related to emapalumab use. Most (90%) of these events were infusion-related reactions, all of which were mild to moderate and resolved. No severe or serious hypersensitivity reactions were reported. Infections caused by pathogens potentially favored by IFNy neutralization occurred in 1 patient during emapalumab treatment (disseminated histoplasmosis) and resolved with appropriate treatment. There was no increase in AE frequency or the number of viral, bacterial, or fungal infections with increased dose or duration of emapalumab treatment. Conclusion: Neutralization of IFNy with emapalumab in this very fragile population of patients with active primary HLH was associated with a favorable and manageable safety profile across all doses and treatment durations assessed, allowing for flexible and tailored use based on patient clinical response. In addition, 102 patients have been treated in the US following FDA approval, and post-marketing surveillance has not revealed any additional safety concerns with the use of emapalumab in primary HLH (cutoff date 19 May 2020). Taken together, these safety results suggest that emapalumab may offer an additional advantage over conventional HLH therapies. Disclosures Locatelli: Jazz Pharmaceeutical: Speakers Bureau; Medac: Speakers Bureau; Miltenyi: Speakers Bureau; Bellicum Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Jordan:Sobi: Consultancy. Allen:Sobi: Other: Scientific Steering Committee, Data And Safety Monitoring. Rizzari:Sobi: Consultancy, Other: Advisory Board. Rao:Sobi: Consultancy, Other: Advisory Board. Sevilla:Novartis: Other: Advisory Board; Amgen: Other: Advisory Board; Rocket Pharma: Consultancy; Sobi: Other: Advisory Board. Henry:Sobi: Consultancy. De Benedetti:Pfizer: Research Funding; Novartis Pharma: Research Funding; Sanofi-Aventis: Research Funding; Sobi: Consultancy, Research Funding; Abbvie: Research Funding; F Hoffmann-La Roche AG: Research Funding. Grom:Novartis Pharma: Consultancy; Sobi: Consultancy; AB2Bio: Consultancy. de Min:Sobi: Consultancy.

Abstract Gaucher Disease (GD) is a metabolic inherited disorder, that classically includes three clinical phenotypes. Type I GD (GD1) is considered as a non-neuronopathic variant and can mimic a hematologic disease; type II (GD2) is classified as an acute neuropathic form and type III (GD3) is characterized by a slower and progressive neurological involvement. A protective role of N370S mutation against neurological impairment had been previously hypothesized in GD1, however, increasing data and our experience show that patients with GD1 may present clinical signs of parkinsonism, frequently combined with cognitive impairment and behavioral alterations. Structural brain changes associated with cognitive impairments in GD patients, especially type I, has not yet been reported. The prospective study, called SENOPRO_GAUCHER, has investigated in depth, the neurological status in GD patients using a multidisciplinary approach, including 3Tesla magnetic resonance (3T MR). This study was approved by our Ethics Committee. Baseline data on neurological, psychological, psychiatric, somatosensory, and motor evaluations, and electroencephalography (EEG) surprisingly revealed two, or more, clinical and/or instrumental, neurological signs in all GD1 patients, and a wide spectrum of neurological abnormalities in all GD3 patients. We, hereby, report the results of investigations on brain structure of GD patients, compared to that of healthy subjects, using 3T MR, in order to evaluate whether brain alterations can predict neurocognitive impairment in GD patients, especially GD1. Out of 22 GD patients, assessed for neuropsychological and psychiatric functions, 19 (17 GD1, 2 GD3, median age = 44, range 17 - 68 years) underwent 3T MR examination. Regarding genotyping, all but one of the 17 GD1 patients was N370S mutation heterozygous. A Voxel-based Morphometry (VBM) analysis was performed to investigate brain structure in the 19 GD patients and in 19 healthy subjects with no neurological or neuropsychiatric disease. The healthy subjects, matched to patients by age, sex, and education, in addition to 3T MR, underwent neuropsychological assessment using Mini-Mental State Exam and Mental Deterioration Battery, to evaluate cognitive functions and mental deterioration, respectively. Qualitative MR examinations revealed unspecific abnormalities in 7/17 GD1 patients. In particular, cortical and/or subcortical areas of gliosis (4 patients), vascular ectasia extended from the left frontal surface of the brain to the lateral ventricle (1 patient), dilation of perivascular spaces in the sub-cortical and nucleus-basal area (1 patient), diffuse suffering of the brain white matter due to a chronic ischemic vascular damage (1 patient) were found. Concurrently, results of the VBM analysis revealed that a set of regions, mostly located in the prefrontal and parieto-occipital cortex, were significantly reduced in GD patients, compared to healthy subjects. The most affected regions included the frontal eye fields, the dorso-lateral prefrontal cortex, the posterior cingulate cortex, and the V3B area. Psychological and psychiatric evaluations underlined anxiety, depression, and somatic concerns in 10/17 GD1 patients, combined with cognitive impairments in two of them. Moreover, 1/2 GD3 and 5/17 GD1 patients showed cognitive impairments in attention, language, short-term memory, and executive cognitive functions. The local brain volume reductions, detected in GD1 patients, were in line with the cognitive impairments resulted in the neuropsychological assessment. Cortical reductions of fronto-parietal regions, responsible for the planning and execution of movements, are compatible with impairments in executive functions (digit-span) and visuo-spatial memory, found in GD1 patients. Moreover, impairments in short-term memory observed in GD1 patients are compatible with cortical reductions in the frontal cortex found by the VBM analysis. In conclusion, focal brain differences found between GD1 patients and healthy subjects may predict and clarify the cognitive impairments and behavioural alterations observed in GD patients. The brain structural analyses, associated with neuropsychological assessment, suggest that a multidisciplinary approach is necessary in evaluating GD1 patients. Disclosures Giona: Sanofi Genzyme: Consultancy, Research Funding, Speakers Bureau; Takeda: Speakers Bureau; Novartis: Consultancy.

The Sharjah International Conference on Physics of Advanced Materials (SICPAM) was held on April 23–25, 2023, on the beautiful campus of the University of Sharjah. It brought together more than 120 scientists from 21 countries. The list of invited speakers included leading scientists, editors of reputable journals, young researchers, and students in the field of material science from Europe, the USA and Asia. Materials have been the key behind major technological breakthroughs throughout history. Their properties can be engineered and optimized to develop specific applications. The transformation of iron into steel ignited the second industrial revolution and the development of railways before the end of the nineteenth century. Similarly, semiconductors enabled the design of solid-state devices that gave birth to modern electronics and the digital revolution (the third industrial revolution). Today, we are witnessing the birth of the fourth industrial revolution with the fast development of generative AI and the production of the first versions of quantum computers. Quantum materials are emerging as the building blocks of quantum technologies. The conference covered a wide range of materials and some of the advanced techniques that are used to investigate their properties, as well as the computational methods that are emerging as very powerful tools for material design and screening for diverse applications, including energy conversion and storage, gas sensing and biosensing, water treatment and desalination, etc. The conference was an enriching experience and an excellent opportunity for many scientists to develop connections and possible collaborations. We would like to express our high appreciations to the University of Sharjah for hosting the conference and members of the scientific and organizing committees who worked hard to make the event a great success that will remain in our memory for a long time. Our sincere thanks go to the sponsors who generously supported the conference, namely: Sharjah Electricity and Water Authority (SEWA), Sharjah Broadcasting Authority, Sharjah National Oil Corporation (SNOC) and Dubai Electricity and Water Authority (DEWA). Finally, I would like to address my deepest thanks to the co-Editors who worked tirelessly to ensure that all submitted papers are thoroughly reviewed and the referees’ concerns are properly addressed. Prof. Nouar Tabet, Chairman of the Scientific Committee List of Editors, Scientific Committee, Organizing Committee are available in the pdf

AbstractThe Review has chosen to open this edition with an interview with General Abdoulaye Kaka as a representative of State practice in counterterrorism detention. The journal chose to focus on Niger as a State that is affected by an ongoing armed conflict and which arrests, detains and tries suspected members of a non-State armed group under its domestic legal system.General Abdoulaye Kaka has been working as Head of Niger's Central Counterterrorism Agency (Service Central de Lutte Contre le Terrorisme) since 2014. He previously worked for the judicial police in Niger as head of the anti-gang section before opening the first office of the judicial police in Zinder. General Kaka worked for the United Nations (UN) police forces in Ivory Coast between 2006 and 2012, when he became the Commander-in-Chief of the Niger UN police forces.In his current role as Head of the Central Counterterrorism Agency, General Kaka oversees detention operations throughout the country, many of which involve suspected members of the group that calls itself Islamic State's West Africa Province (ISWAP), also known as Jama'atu Ahlis Sunna Lidda'awati wal-Jihad or, as it is most widely known under its former name, Boko Haram.Niger has suffered the effects of the ongoing conflict between ISWAP and State forces in the Lake Chad region, resulting in casualties, arrests and repeated displacement among civilians. The government of Niger contributes troops to the Multinational Joint Task Force, which conducts operations against the group. At the same time, the government arrests and detains suspected members of ISWAP as part of its counterterrorism efforts. These detention operations are coordinated by the Central Counterterrorism Agency. Established in 2011, the Central Counterterrorism Agency, successor to the counterterrorism section of the judicial police, is made up of representatives from the three primary law enforcement organizations in the country – the national police, the national guard and the gendarmerie – and is principally responsible for counterterrorism investigations in Niger.In Niger, the International Committee of the Red Cross (ICRC) helps people affected by conflict in the south-east or fleeing fighting in north-east Nigeria. With the Niger Red Cross, the ICRC delivers aid, treats the wounded, provides water and supports farmers. The ICRC also monitors compliance with international humanitarian law, visits detainees and helps them to maintain contact with their families.The ICRC visits people held by the authorities in at least five places of detention in Niger. After the visits, the ICRC shares its findings on the treatment and living conditions of the detainees confidentially with the authorities and urges them to take steps to address concerns. The ICRC also helps bolster prison management capacities and health services for detainees through technical and material support, and round-table discussions on these topics. The ICRC helps detainees, particularly minors, maintain contact with their families. At the request of foreign detainees, the ICRC informs their families or consular representatives of their detention. Lastly, the ICRC covers transportation costs for security detainees returning home after their release.

Abstract Background The COVID-19 outbreak is increasing and spreading rapidly globally, with over 20 million cases and 800, 000 thousand deaths reported in 216 countries as of 28th August 2020. Since the report of the index case in Nigeria in February 2020 by the Nigeria Center for Disease Control (NCDC), daily records of confirmed cases have been reported in all states in the country. On 3rd April 2020, an outbreak of Coronavirus disease-2019 (COVID-19) was confirmed in Ondo State, Southwest Nigeria. Field investigations were conducted by the State Ministry of Health (MoH) to identify and confirm additional cases. This paper provides the outcome of the epidemiological investigation of the outbreak to further guide outbreak response activities. Methods Outbreak settings Ondo State is in the South-West Zone of Nigeria with her capital at Akure. The State is situated between longitudes 40 151E and 60 001E of the Greenwich median and latitudes 50 451N and 70 451 N, which are to the North of the equator in the Southwestern geopolitical zones of the country. Field Investigation The investigation was conducted as part of outbreak control and response measures hence permission to conduct the study was obtained from the Ondo State Ministry of Health (OSMoH). Following an alert from clinicians at a government-owned Hospital, Akure, Ondo State on 30 March 2020, the index case of COVID-19, a 34-year-old male with recent travel history to India was investigated. He arrived at Ondo State on 21st March 2020 and presented at the hospital with cough, sore throat and running nose with the onset of symptoms on 23rd March 2020. The State public health emergency Rapid Response Team (RRT) comprising of Commissioner for Health, State Epidemiologist, State and LGA surveillance officers, and health development partners in the state visited the hospital to investigate and implement public health response. Nasopharygeal and oropharyngeal samples were collected and tested for COVID-19, and returned positive from the national reference laboratory on the 3rd of April 2020. Operational definitions During the onset of the outbreak, three categories of case definitions for COVID-19 were used to guide the outbreak investigations according to the Nigeria Center for Diseases Control (NCDC) guidelines. Suspect case: (1) This is a patient with acute respiratory illness (fever and at least one sign/ symptom of respiratory disease (e.g., cough, shortness of breath) and a history of travel to or residence in a country/area or territory reporting local transmission of COVID-19 disease during the 14 days prior to symptom onset; (2) or a patient/health care worker with any acute respiratory illness and has been in contact with a confirmed COVID-19 case in the last 14 days prior to the onset of symptoms; (3) or a patient with a severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness of breath) and requiring hospitalization and with no other aetiology that fully explains the clinical presentation; (4) or a case for whom testing for COVID-19 is inconclusive. Confirmed case: A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms. Probable case: Any suspected case for whom testing for COVID-19 is indeterminate test result or for whom testing was positive on a pan-coronavirus assay Data analysis The State COVID-19 line-list and case investigation forms of all COVID-19 cases from 19th March to 9th August 2020 were retrieved from the state disease surveillance unit, information on key variables were extracted and exported into SPSS version 20 and analyzed. Descriptive statistics such as frequency table, mean (standard deviation) and charts were used to describe key variables including LGA, age, sex, occupation and education and clinical conditions of cases. The week of report of cases and outcomes were used to generate the epidemic curve. The Chi-square test was used to compare categorical variables including the socio-demographic characteristics, clinical condition and outcome of cases. Two-sided P-values <0.05 were considered statistically significant. Results Socio-demographic characteristics of cases A total of 4353 suspected cases were reported and tested for COVID-19, of which 1316 COVID-19 cases were confirmed, with a case fatality rate of 2.2% recorded in 7 of the 17 Local Government Areas that reported at least a confirmed case (Figure 1). Most of the confirmed cases (1169; 88.8%), resides in urban areas (LGAs) (Table 1). Majority [1110 (84.3%)] were within the age group 20 to 59 years, with a mean age of 37.8 ±14.8 years. Males (713; 54.2%) were more affected compare to females (603; 45.8). More than three quarters (1009; 76.7%) of the cases had a tertiary level of education. Health care workers (404; 30.7%) were most affected compared to other professionals as shown in Table 1. Admission and clinical conditions of confirmed cases From Table 2, 88 (6.7%) of the confirmed cases were admitted as inpatient during investigation, while 325 (24.7%) were symptomatic. The first symptom reported by cases were as follows; cough (98; 30.2%), fever (74; 22.8%), headache (30; 9.2%), runny nose (39; 12.0%), sore throat (24; 7.4%) and difficulty in breathing (15; 4.6%). Figure 2 described the epidemic curve of the outbreak from March to August 2020. The index case was confirmed on April 4, 2020. Thereafter, there was a surge in the number of confirmed COVID-19 cases with the outbreak reaching its peak on July 2, 2020. Afterwards, fluctuations in the number of cases were observed before a steady decline was recorded between August 3, 2020 and August 9, 2020. Association between socio-demographic characteristics, clinical conditions and outcomes of cases In Table 3, significant proportion of death occurred among cases within the age group 60 years and above (14; 13.5%) compared to other age groups (p < 0.001). Death occurred more among males (26; 3.6%) compared to the females (3; 0.5%) (p < 0.001). Furthermore, symptomatic cases had higher proportion (27; 8.3%) of deaths compared to asymptomatic cases (2; 0.2%) (P < 0.001). Among the symptomatic cases, a high proportion of death was found among those with difficulty in breathing (3; 20%), fever (11; 14.9%), new loss of taste (1; 11.1%), cough (9; 9.2%) and sore throat (2; 8.3%) (P < 0.001) Conclusions The outcome of this investigation indicating high transmission among urban residence and health care workers are key public health concerns in the response to the COVID-19 outbreak in Ondo State, Nigeria. Furthermore, high case mortality among the older age groups requires public health intervention. Thus, we recommend intensified risk communication, enhanced surveillance activities, and use of community structures such as community and religious leaders, market and commercial vehicles associations, Ward Development Committee (WDC) and Village Development Committee (VDC) to ensure compliance with public health COVID-19 preventive measures particularly in the urban areas and among those facing a high risk of death. Furthermore, there is a need to prioritize public health interventions including training and vaccination among the vulnerable groups including health care workers who serve as front liners during case investigation, testing and case management. Key messages Enforcement of public health preventive measures particularly in urban settings, and supporting government to strengthen and monitor Infection Prevention and Control practices in hospital settings.

Photo ID 129550055 © Katarzyna Bialasiewicz | Dreamstime.com ABSTRACT It has been 26 years since medical aid in dying (“MAiD”) was first legalized in Oregon, and today, about 20 percent of people in the US live in jurisdictions that permit MAiD. The New York State legislature is currently considering a bill that would permit Medical Aid in Dying for terminally ill patients in certain defined circumstances. Those states now benefit from decades of experience, evidence, and reporting from MAiD jurisdictions. This demonstrates that legislation can simultaneously grant terminally ill citizens the civil right to access MAiD while also aggressively protecting all patients from coercion, manipulation, and harm. Given the copious evidence gathered in the past decades, concerns about abuse can no longer be credited as grounds for opposing the passage of legislation that is demonstrably both effective and safe. INTRODUCTION It has been 26 years since medical aid in dying (“MAiD”) was first legalized in Oregon,[1] and today, about 20 percent of people in the US live in jurisdictions that permit MAiD.[2] Other jurisdictions, including New York, are actively considering adopting MAiD laws. Those states now benefit from decades of experience, evidence, and reporting from MAiD jurisdictions, demonstrating that legislation can permit MAiD while also aggressively protecting all patients from coercion, manipulation, and harm. The data should allay the concerns of those who oppose MAiD due to the risk of abuse, coercion, and a hypothetical slippery slope. We, as a society, as clinicians, and as ethicists, must remain vigilant and prevent abuse of MAiD, given the potential risks in the community and in congregate care settings and the risk of patient exploitation by family members. However, given the copious evidence, concerns about abuse do not justify opposition to legislation that is effective and safe. I. New York’s MAiD Bill The New York State legislature is currently considering a bill that would permit MAiD for terminally ill patients in defined circumstances.[3] The bill applies only to adults with a terminal illness or condition that is “incurable and irreversible” and “will, within reasonable medical judgment, produce death within six months.” The bill contains numerous protective requirements: MAiD requests can only be made by the patient themself; requests cannot be made by healthcare agents, surrogates, or anyone else; MAiD requests must be made both orally and in writing to the patient’s attending physician; No person is eligible for MAiD solely because of age or disability; The patient’s attending physician must determine the patient has a qualifying terminal illness, has decision-making capacity, and has made a voluntary, informed decision to request MAiD, in the absence of coercion; These determinations must be confirmed by a second consulting physician in writing; If the attending physician has any concern that the patient may not have decision-making capacity, the patient must be referred to a mental health professional; The attending physician has additional duties to the patient, including ensuring the decision is informed, by discussing the patient’s condition and prognosis; discussing the MAiD process, and treatment alternatives like palliative and hospice care; offering referrals to other appropriate treatment, like palliative and hospice care; and educating the patient that their request can be rescinded at any time and offering them an opportunity to do so; The written request must be witnessed by at least two adults who cannot be (i) related to the patient, (ii) entitled to any portion of the patient’s estate, (iii) employed by a healthcare facility where the patient is receiving treatment or residing, (iv) or the attending physician, consulting physician, or mental health professional determining decision-making capacity; and MAiD medication must be self-administered by the patient, and it must be voluntarily ingested.[4] ARGUMENTS FOR AND AGAINST MAiD II. No Evidence of Abuse of Existing MAiD Laws MAiD supporters and critics alike have a concern about the abuse of MAiD. For this reason, MAiD laws throughout the US incorporate strict eligibility criteria and protective procedural requirements. For instance, patients are eligible only if they are terminally ill with six months or less to live, more than one physician must be involved, and requests must be witnessed (by individuals unrelated to the patient who will not profit from the patient’s estate). MAiD requests have been closely examined in the 27 years since Oregon became the first state to legalize the practice. The results show that these compassionate and protective measures have worked. There have been no documented or substantiated incidents of MAiD abuse since Oregon became the first to implement a MAiD law in 1997.[5] In 2019, the executive director of Disability Rights Oregon (DRO), an organization mandated by federal law to investigate complaints of abuse or neglect of people with disabilities, reported that DRO has never received a complaint that a person with disabilities was coerced into obtaining a prescription for MAiD drugs.[6] A recent study of aggregated data from all nine of the US jurisdictions with publicly available MAiD records from 1998 to 2002 found that 95.6 percent of those who died by MAiD were non-Hispanic white individuals, and 53.1 percent were male.[7] 72.2 percent of these individuals had at least some college education, 74 percent had a cancer diagnosis, and the median age of MAiD death was 74 years old. Only 11 percent of patients were uninsured. MAiD users tend to be white, older, educated, diagnosed with cancer, and insured. Fears that MAiD would overwhelmingly be used by (or on) the poor, the uninsured, the uneducated, or racial and ethnic minorities have not materialized. This data has actually raised a converse concern: that MAiD may, inequitably, not be readily available to less privileged populations or those with a diagnosis other than cancer.[8] Opponents of MAiD may argue that the recent relaxation of certain legal restrictions in some jurisdictions is evidence that the slippery slope to unrestricted euthanasia has begun. This is a mischaracterization. Certain restrictions have been adjusted. For instance, Oregon and Vermont removed the residency restriction that previously excluded non-residents from eligibility.[9] Both states changed the residency requirement due to lawsuits challenging the constitutionality of requiring residence.[10] New Jersey’s law will likely change soon, as well.[11] Initial MAiD laws were drafted to be highly restrictive out of concern about unintended and unforeseeable consequences. Given the gravity of the subject, decades ago, it was better to err on the side of caution, even if that meant excluding from eligibility people who ought to, ethically or legally, be included. Now, with nearly 30 years of experience and data, we can better determine which requirements are necessary to appropriately protect patients, clinicians, and society. Restrictions proven to be unnecessary can now be modified. The core purposes of MAiD laws and the rights and protections they provide are not changing. Rather, a few aspects of the regulations are being adjusted so they are not more restrictive than necessary to achieve their purpose. The ever-growing body of evidence that MAiD laws can adequately protect against abuse and the mythic slippery slope has assured many that their fears will not materialize.[12] For example, NYU bioethicist Arthur Caplan was once a vigorous opponent of MAiD. He worried that MAiD laws would lead to the abuse of the poor, uninsured, and disabled in service of cost-saving or the convenience of others. [13] But, after closely following the empirical evidence from MAiD early-adopters, Oregon and Washington, Caplan changed his mind. In 2018, he argued in favor of the NY MAiD bill before the New York State Assembly Standing Committee on Health.[14] Discussing his review of evidence from these states, Caplan stated: I found no cause for my concerns, none with respect to the slippery slope. There isn’t solid evidence of coercion or duplicity being exercised with respect to people who choose assistance in dying in either state. The police, government officials, families of those who have chosen to use the legislation and the general citizenry find no causes or basis for changing the laws due to abuse or misapplication . . . These slippery slope arguments are just not true . . . there is no current factual support for this slippery slope argument that vulnerable individuals are at risk for being coerced into using the law.[15] Decades of evidence has shown that legislation can simultaneously grant terminally ill patients access to MAiD while also protecting against coercion and abuse. In the face of this evidence, continuing to deny access to MAiD because of hypothetical abuse is unjust and unethical. III. Views of Opponents are Neither Grounded in Fact nor Consistent with Current End-of-Life Practices a. Risk of coercion One common argument heard today from some disability advocates who oppose MAiD goes something like this: Everybody who would qualify for and use MAiD is (or will become) a disabled person, so MAiD only kills people with disabilities. The most common reasons people choose to end their lives via MAiD are disability issues, like loss of autonomy, less ability to engage in activities, and loss of dignity. They argue that, instead of making it easier for disabled people to die, we should make sure that proper services and support exist so that disabled people do not choose to die. Such disability-rights-based arguments tend to assert that to avoid abuse, we must prohibit MAiD altogether. They argue that legalizing MAiD will inexorably lead to abuse and coercion, and disabled people will be pressured into suicide. Some even argue that MAiD laws are the first step to euthanasia, noting the path in other jurisdictions.[16] As an initial matter, people with disabilities deserve adequate support and services, and these are not always available to them. People with disabilities have faced tremendous discrimination in the healthcare system and have been historically prevented from accessing proper care and asserting their autonomy. Ensuring that all can access adequate end-of-life care, like palliative or hospice care, is an ongoing battle that ought not be abandoned. But fighting for adequate end-of-life care and legalizing MAiD are not mutually exclusive. In Oregon, 90 percent of those who access MAiD are enrolled in hospice and states with MAiD laws tend to have better access to palliative care than states without.[17] MAiD proponents seek only to add another choice for the dying, not to diminish any other options. This is reflected in the text of New York’s pending bill, which explicitly requires patient education and referrals to appropriate end-of-life services, like palliative care and hospice.[18] No one has openly argued that society should hold terminally ill patients hostage in order to obtain broader support and funding for palliative care, but that is the practical effect. Beyond the need for supportive services and proper access to the full range of end-of-life care options, the disability argument fails. First, the assertion that MAiD laws will be abused and disabled people will be coerced into suicide is not grounded in fact. To the contrary, real-life evidence gathered in over two decades of legal MAiD has shown no documented or substantiated incidents of abuse, as discussed above.[19] The slippery slope has simply not materialized. Advocates for people with disabilities who are opposed to MAiD have not clearly articulated exactly who is vulnerable to being coerced into obtaining a MAiD prescription or even how such coercion could logistically occur. Most people with disabilities are not vulnerable to MAiD abuse, as they do not have a qualifying terminal illness or lack decisional capacity due to a developmental disability and are therefore not eligible. MAiD opponents appear to be claiming that all those who qualify for MAiD are vulnerable and seek protection from MAiD laws. But this would include many of the people that, over the past decades, have aggressively and publicly advocated for access to MAiD – terminally ill people, like Brittany Maynard,[20] many of whom lobbied hard for the passage of MAiD laws while knowing that they themselves would die before the laws passed. Opponents of MAiD from a segment of the disability rights community are telling individuals who they claim, without permission, as members of the MAiD opposition community, that they must all endure unimaginable suffering without a MAiD option because they must be protected from theoretical coercive harm. People with disabilities should be allowed to make their own choices. No one, not even the most well-meaning advocate, should be allowed to obstruct a patient’s end-of-life choices – those choices belong to the patient alone. b. Argument That the Demand for MAID is a Result of Poor Disability Services Second, the argument that terminally ill patients would decline MAiD if only they had better disability services or support is disingenuous to the extent that it ignores the fact that people choosing MAiD are actively dying. No provision of supportive services can change this. And it is perfectly reasonable for someone who knows that they will die in less than six months to want some control over the manner of their death and to avoid the deterioration, indignity, and suffering that could come with it. The argument construes a MAiD death as a choice to die rather than live with a disability. But individuals choosing MAiD are not choosing death – death is coming and coming quickly. MAiD simply offers some control over this reality, giving patients an option that is safe, certain, and painless. Certainly, supportive hospice services should be available for these individuals. But there is no evidence demonstrating that any amount of service would eliminate the need and desire for the MAiD option. c. Inconsistent Positions on MAID and Other Ending Life Care Options: Palliative Sedation and VSED MAiD opponents who are concerned about abuse and coercion often hold inconsistent views on other currently available ending life care options.[21] For example, some argue that palliative sedation[22] renders MAiD unnecessary and does not present the same ethical problems.[23] However, whereas MAiD can only be chosen by the patient themself (and the patient must have decision-making capacity), the same is not true for palliative sedation. Palliative sedation, a valuable modality of end-of-life care, does not have to be initiated by the patient. If the patient is deemed not to have decision-making capacity to make that decision, their healthcare proxy can decide to initiate the process and continue it until the patient dies. Individuals other than patients often choose to begin palliative sedation and continue it to its inevitable conclusion. And because palliative sedation does not require enabling legislation, none of the protective safeguards incorporated in MAiD legislation are available to protect those who receive palliative sedation. Some may try to differentiate between palliative sedation and MAiD by saying that once started, palliative sedation can always be discontinued – it need not end in the patient’s death. This is true, but the very process of palliative sedation will inevitably make the patient insensible or unconscious or otherwise unable to exercise a choice to stop sedation. With MAiD, the patient must self-administer and ingest the medication on their own, with death following quickly. The patient can choose to forgo MAID up until the very moment of self-administration. Considering MAiD’s procedural safeguards, including that only the patient may choose and administer MAiD, MAiD patients are offered more protection from potential abuse than patients who receive palliative sedation. While some have vocally opposed MAiD for decades, there has not been similar opposition to the option of voluntarily stopping eating and drinking (VSED). With VSED, adults with decision-making capacity make a voluntary decision to refuse nutrition and hydration to die more quickly. People choosing VSED are, essentially, making the same choice that people choosing MAiD do. But VSED is a less predictable process that takes much longer to complete. Unfortunately, the process also carries a risk of unpleasant side-effects, though proper care can help mitigate them. Additionally, the practice of VSED is not constrained by statutorily defined protective measures, as is the case with MAiD – one does not even need to have a terminal illness to choose VSED.[24] It is logically inconsistent for those who oppose MAiD because of the perceived potential of abuse to hold different views about VSED.[25] If malevolent actors can unethically pressure or coerce patients into MAiD, they can also coerce them to stop eating and drinking. As with palliative sedation, it could be argued that an important difference is that VSED can be stopped, unlike MAiD. This argument fails clinically and ethically. As with palliative sedation, the VSED process eventually results in the patient losing consciousness and decision-making capacity. The patient generally becomes unarousable for a period that could last for days or even weeks. For this reason, it is crucial for VSED patients to express their choice in writing (or preferably in video recording)[26] to ensure that they will not be given nutrition or hydration when they are no longer able to enforce their refusal (or if they begin asking for nutrition or hydration). Therefore, there is a period in which the patient cannot decide to end the process, just as with palliative sedation. To the extent that someone is so concerned with potential abuse of MAiD that they seek to ban it but have not expressed similar concerns with VSED, these positions are inconsistent. At a NYS Bar Association-sponsored conference on MAiD in 2019, David Hoffman asked a MAiD opponent whether, “as someone who is looking out for the interests of a segment of the disability population,” she supports palliative sedation and VSED.”[27] Kathryn Carroll, who represented the Center for Disability Rights (“CDR”), confirmed that CDR did not oppose palliative sedation and did not offer a position on VSED. She noted the subtle difference in intention: I don’t believe the Center for Disability Rights has taken issue with palliative sedation. And my understanding is that there is a key difference between palliative sedation and assisted suicide, particularly in that palliative sedation, the point is not to bring about the death of the person, but to relieve the pain that they are experiencing. And so the death is more of a side effect rather than the intended outcome.[28] During the questioning, she provided no explanation as to why the potential for abuse would be different among palliative sedation, VSED, and MAiD.[29] The other MAiD opponent on the panel, Dennis Vacco, of Vacco v. Quill[30] fame, interjected but could not explain any ethically significant difference between VSED and MAiD. Instead, he focused solely on palliative sedation, stating that the relevant difference is that palliative sedation can be stopped: . . . treating the pain including what you referred to as terminal sedation, is not moral and legally and ethnically the same as physician-assisted suicide . . . The fact of the matter is – the difference is you can terminate that treatment, and it’s the permanent aspect of physician-assisted suicide that goes back to what I said 20 minutes ago. You can’t put the bright line anyplace else other than where it is.[31] But, as discussed above, that difference is of little import, given that palliative sedation results in patients without the ability or capacity to make the choice to stop treatment. Vacco then reverted to his concerns about the potential for coercion and the elusive slippery slope, referencing his primary argument that the only way to ensure there is no abuse of a MAiD law is not to have one at all: The bright line that is created by the law in the state of New York, which makes physician-assisted suicide a manslaughter in the second-degree, or assisting suicide by anybody, manslaughter in the second degree . . . is unfortunately the only place that line can be. That line should not move further toward accommodation. And we see here in the context of . . . all of the so-called protections in the statute. With every protection that is not prohibition, with every protection, you raise the possibility of abuse. You raise the possibility with every protection.[32] Neither Vacco nor Carroll addressed the fact that many common practices today can be the result of coerced decisions. These practices have none of the safeguards contained in MAiD legislation. As another panelist, David Leven, stated: consider that people who want to have life-sustaining treatment withdrawn, whether it’s a ventilator or feeding tube, they can also be coerced by family members. That can happen even more often, of course, because that process takes place more and more often, and there are none of the safeguards that we’re talking about here . . . there are risks involved in any process which might result in a hastened death. But there seems to be very little risk involved with medical aid in dying based on the experience in 40 years and the nine states which now permit medical aid in dying.[33] There is an inescapable inconsistency within the disability argument: one cannot logically be so concerned about the abuse of legalized access to MAiD to justify opposing all MAiD legislation while simultaneously supporting options like palliative sedation or VSED as abuse-free alternatives. d. Argument Against Speaking for a Community with Diverse Views Finally, while some disability advocates opposing MAiD will claim terminally ill patients as part of their community, they have no right or authorization to speak for the extremely heterogeneous group of terminally ill patients or the disability community[34] as a whole. The disability community is not homogenous; while some members oppose MAiD, others support it.[35] Recent polling indicates that MAiD may have broad support across the disability community.[36] e. MAiD Opponents Hold the Rights of the Terminally Ill Subordinate to Their Personal Morality and Unsubstantiated Theoretical Concerns The argument that does not get much attention, the one that is the simplest and perhaps even the most compelling, is that all killing is wrong, and the government ought not to be in the business of enabling it. That is certainly a compelling religious and moral argument against individuals engaging in any form of acts that result in ending a human life. But such an ethical or theological position does not dictate that individuals who hold different views on personal morality should be precluded by the state from accessing the most safe, certain, and painless means of addressing an invariably terminal illness. Arguments like the one described above by Vacco (that the only way to completely avoid potential MAiD abuse is to prohibit MAiD) are essentially claiming that the safest thing to do is to subordinate the suffering of the terminally ill to avoid the more subtle task of balancing the interests of two different groups of New York state citizens. But surely, that is the role of the legislature every day. And we should expect no less from the legislature on this issue. The best way to ensure no one dies in car accidents is to prohibit driving. But instead of doing so, we implement safety regulations (like speed limits) to balance the right to travel with the right of everyone else not to be killed in the process. Evidence demonstrates that MAiD legislation can also strike a balance between the rights of the terminally ill and the need to prevent harm. It is not justifiable to support a blanket prohibition of MAiD. CONCLUSION Opponents of MAiD have had decades to cite problematic case studies or formulate a compelling moral argument against it that is grounded in data rather than an assertion of their personal morality. Plainly, no one on either side of the MAiD legislative discussion wants to see anyone subjected to involuntary euthanasia or coerced into MAiD as a better alternative to palliative care when such a plan of care is a viable alternative to “ending life care.” However, enough time has passed, and the risk of coercion has been given sufficient study and debate that we can now conclude, as a society, that the rights of the terminally ill and the rights of persons committed to living their best and longest life with a disability are wholly compatible. It is time for the legislature to strike the appropriate balance and give the terminally ill a well-regulated, responsible pathway to obtaining medication that can relieve their suffering in a manner that is safe, certain, and painless. - [1] Oregon’s Death with Dignity Act, Oregon Health Authority, https://www.oregon.gov/oha/ph/providerpartnerresources/evaluationresearch/deathwithdignityact/pages/index.aspx [2] Elissa Kozlov et al., Aggregating 23 Years of Data on Medical Aid in Dying in the United States, 70 Journal of the American Geriatrics Society 3040 (2022). https://doi.org/10.1111/jgs.17925 [3] Medical Aid in Dying Act, A.995-A, N.Y. St. Assemb. (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/A995A; see also, Medical Aid in Dying Act, S.2445-A, N.Y. St. Senate (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/S2445A. [4] Id. [5] Ronald A. Lindsay, Oregon’s Experience: Evaluating the Record, 9 The American Journal of Bioethics 19 (2009), https://doi.org/10.1080/15265160802654137; Christopher A. Riddle, Medical Aid in Dying: The Case of Disability, in New Directions in the Ethics of Assisted Suicide and Euthanasia 234 (Michael Cholbi & Jukka Varelius eds., 2nd ed. 2023), https://doi.org/10.1007/978-3-031-25315-7; Health Law Section: Duties, Rights & the Law at the End of Life (2019), NY ST. BAR ASSOC. (Nov. 8, 2019), https://nysba.org/products/health-law-section-duties-rights-the-law-at-the-end-of-life-2019/; Medical Aid in Dying: Hearing on A.2383-A Before the New York State Assembly Standing Committee on Health (2018) (testimony of Arthur Caplan), transcript available at https://nystateassembly.granicus.com/DocumentViewer.php?file=nystateassembly_bc5bd4afc9fd8b9021781bc9e35e15ae.pdf&view=1; Fact: Medical Aid in Dying Laws Work to Protect Patients. (n.d.). Compassion & Choices. Retrieved September 5, 2023, from https://compassionandchoices.org/resource/fact-medical-aid-in-dying-laws-work-to-protect-patients; Frequently Asked Questions. (2021, December 7). Death With Dignity. https://deathwithdignity.org/resources/faqs/. [6] Bob Joondeph, Letter from Disability Rights Oregon (DRO), Compassion & Choices (Feb. 14, 2019), https://www.compassionandchoices.org/docs/default-source/default-document-library/disability-rights-oregon-dwd-letter-2-14-19.pdf. [7] Elissa Kozlov et al., Aggregating 23 Years of Data on Medical Aid in Dying in the United States, 70 Journal of the American Geriatrics Society 3040 (2022). https://doi.org/10.1111/jgs.17925 [8] Id. [9] Medical Aid in Dying: Act 39: Patient Choice and Control at the End of Life, Vermont Ethics Network, https://vtethicsnetwork.org/palliative-and-end-of-life-care/medical-aid-in-dying-act-39 (last visited Sept. 21, 2023). [10] Gideonse v. Brown, No. 3:21-cv-01568-AC (D. Or.); Bluestein v. Scott, No. 2:22-cv-00160 (D. Vt.). [11] Govatos v. Murphy, No. 2:23-cv-12601(D.N.J.). [12] Medical associations, historically opponents of MAiD, have begun adopting neutral positions, reflecting changing attitudes of the medical community. E.g., California Medical Association removes opposition to physician aid in dying bill, California Medical Association (May 20, 2015), https://www.cmadocs.org/newsroom/news/view/ArticleId/27210/California-Medical-Association-removes-opposition-to-physician-aid-in-dying-bill; Board directs CMS to develop and distribute “End-of-Life Act” education to members, Colorado Medical Society (November 22, 2016), https://www.cms.org/articles/board-directs-cms-to-develop-and-distribute-end-of-life-act-education-to-me; Vermont Medical Society Policy on End-of-life-Care, Vermont Medical Society (2017), https://vtmd.org/client_media/files/vms_resolutions/2017End-of-Life-Care.pdf (last accessed Sept. 21, 2023); but see Physician-Assisted Suicide, AMA Code of Ethics, https://code-medical-ethics.ama-assn.org/ethics-opinions/physician-assisted-suicide. (5.7 provides opinion opposing MAiD; opinion 1.1.7 provides opinion on conscientious objection.); The American Medical Association could vote to change its stance on medical aid in dying, Death with Dignity (Nov. 10, 2023), https://deathwithdignity.org/news/2023/11/ama-could-vote-to-change-stance-on-maid/ (Update notes that the AMA did not change its stance from opposed to neutral at its November 2023 interim meeting in Baltimore, but referred the resolutions for further study). [13] Medical Aid in Dying: Hearing on A.2383-A Before the New York State Assembly Standing Committee on Health (2018) (testimony of Arthur Caplan), transcript available at https://nystateassembly.granicus.com/DocumentViewer.php?file=nystateassembly_bc5bd4afc9fd8b9021781bc9e35e15ae.pdf&view=1. [14] Id. [15] Id. [16] Id. (noting the laws in Netherlands, Belgium and Canada.); see also National Council on Disability, The danger of assisted suicide laws: Part of the Bioethics and Disability series (2019). https://ncd.gov/sites/default/files/NCD_Assisted_Suicide_Report_508.pdf. [17] Sean Riley & Ben Sarbey, The unexamined benefits of the expansive legalization of medical assistance-in-dying, 19 J. Bioethical Inquiry 4, 663 (2022) (citing Oregon Health Authority Center for Health Statistics, Oregon Death with Dignity Act: 2018 Data Summary (2019), https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf and R. Sean Morrison, et al., America’s care of serious illness: A state-by-state report card on access to palliative care in our nation’s hospitals, 14 J. Palliat. Med. 10, 1094–1096 (2011)). [18] Medical Aid in Dying Act, A.995-A, N.Y. St. Assembly. (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/A995A [19] See also, Ben Colburn, Disability‐based Arguments against Assisted Dying Laws, 36 Bioethics 680 (2022) (cataloging research in multiple countries and concluding that “there is no evidence that assisted dying laws have a disproportionate effect on people with disabilities”). https://doi.org/10.1111/bioe.13036 [20] Eyder Peralta, As Planned, Right-To-Die Advocate Brittany Maynard Ends Her Life, NPR (Apr. 3, 2014), https://www.npr.org/sections/thetwo-way/2014/11/03/361094919/as-planned-right-to-die-advocate-brittany-maynard-ends-her-life (Activist Brittany Maynard moved to Oregon after she was diagnosed with a malignant brain tumor, because her home state did not permit MAiD at the time). [21] Ending life care is defined as the final stage of the end-of-life care continuum, where the patient chooses to end their life as a means to end their suffering or unacceptable quality of life. [22] Palliative sedation is defined as “the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life,” and it carries a risk of hastening death. Molly L. Olsen, Keith M. Swetz & Paul S. Mueller, Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments, 85 Mayo Clin Proc 949 (2010). https://doi.org/10.4065/mcp.2010.0201 [23] E.g. Disability Rights Toolkit for Advocacy Against Legalization of Assisted Suicide, Not Dead Yet, https://notdeadyet.org/disability-rights-toolkit-for-advocacy-against-legalization-of-assisted-suicide (last visited Dec. 8, 2023) (describing palliative sedation as “a legal solution to any remaining painful and uncomfortable deaths; one that does not raise the very serious hazards of legalizing assisted suicide”); Testimony of CDR’s Kathryn Carroll, Esq. Opposing NY Assisted Suicide Bill A2383A, Not Dead Yet (Apr. 23, 2018), https://notdeadyet.org/testimony-of-cdrs-kathryn-carroll-esq-opposing-ny-assisted-suicide-bill-a2383a. [24] Voluntarily Stopping Eating and Drinking: A Compassionate, Widely-Available Option for Hastening Death, (Timothy E. Quill et al. eds., 2021). https://doi.org/10.1093/med/9780190080730.001.0001 [25] This is not to say that MAiD and VSED are ethically identical. Different writers have articulated various reasons why MAiD and VSED are meaningfully different and meaningfully similar. Here we distinguish the potential for abuse, as this is the argument that persists among MAiD opponents, For a broader discussion on the ethics of VSED and how it compares to MAiD, see Voluntarily Stopping Eating and Drinking: A Compassionate, Widely-Available Option for Hastening Death, (Timothy E. Quill et al. eds., 2021). https://doi.org/10.1093/med/9780190080730.001.0001 [26] Id.; see also David N. Hoffman and Judy Schwarz, Can Patients Choose to Stop Eating–Even If They Have Dementia–and Can Health Care Facilities Get Paid for Taking Care of Them? Ethics and Reimbursement at the End of Life (Am. Health L. Ass’n Conf. on Long Term Care and the Law 2020). [27] Health Law Section: Duties, Rights & the Law at the End of Life (2019), NY St. Bar Assoc. (Nov. 8, 2019), https://nysba.org/products/health-law-section-duties-rights-the-law-at-the-end-of-life-2019/. [28] Id. [29] CDR still does not appear to have articulated a position on VSED. CDR is a major and vocal opponent of MAiD legislation in NY with considerable resources (they state their projected 2010 budget was approximately $29,000,000). About Us, Center for Disability Rights, https://cdrnys.org/about/. [30] Vacco v. Quill, 521 U.S. 793 (1997) (holding that there is no equal protection violation when N.Y. law criminalized assisted-suicide but permitted removal of life-support systems). [31] Health Law Section: Duties, Rights & the Law at the End of Life (2019), supra note 5. [32] Id. [33] Id. [34] Ben Colburn, Disability‐based Arguments against Assisted Dying Laws, 36 Bioethics 680 (2022) (providing evidence that “that people with disabilities, and disability rights organizations, have diverse views on the question of whether assisted dying should be legal”). https://doi.org/10.1111/bioe.13036 [35] Us for Autonomy, https://www.usforautonomy.org (last visited Sep 10, 2023); see also, Kathryn L. Tucker, Building Bridges Between the Civil Rights Movements of People with Disabilities and Those with Terminal Illness, 78 U. of Pitt. L. Rev. 329 (2017) (collecting and describing amici participation by disability advocates supporting end-of-life liberty). https://doi.org/10.5195/lawreview.2017.473 [36] E.g., USA/National Public Opinion Survey, Susquehanna Polling & Research, Inc. (Feb. 2023),https://d31hzlhk6di2h5.cloudfront.net/20230307/2e/9e/21/14/d37db7887f3f349202ae6f31/Raben_Crosstabulation_Report_2023.FINAL%20(1).pdf ).

Introduction What French food is would seem to be an unproblematic idea. Depending on one’s taste and familiarity, a croissant, or snails, might spring to mind. Those who are a little more intimate with French cuisine might suggest the taste of a coq au vin or ratatouille, and fewer still might suggest tarte flambée or cancoillotte. Whatever the relative popularity of the dish or food, the French culinary tradition is arguably so familiar and, indeed, loved around the world that almost everyone could name one or two French culinary objects. Moreover, as the (self-proclaimed) leader of Western cuisine, the style and taste epitomised by French cuisine and the associated dining experience are also arguably some of the most attractive aspects of French gastronomy. From this perspective, where French cuisine appears to be so familiar to the non-French, seeking to define what constitutes a French meal could seem to be an inane exercise. Nonetheless, in 2010, the Mission Française du Patrimoine et des Cultures Alimentaires (not officially translated), under the aegis of the French Ministry of Culture and Communication, put forward the nomination file “The Gastronomic Meal of the French” to UNESCO, defining in clear terms a particular image of French taste, in a bid to have the meal recognised as part of the Representative List of Intangible Cultural Heritage. With the number of specifically culinary elements protected by UNESCO more than doubling with the 2013 session of the Intergovernmental Committee for the Safeguarding of the Intangible Cultural Heritage, and with a further two in line for protection in the 2014 session, it would seem that an examination of these protected culinary traditions is in order. Rather than focusing on the problems associated with creating an intangible heritage list (Kurin; Smith and Akagawa), this article proposes an analysis of one nomination file, “The Gastronomic Meal of the French,” and the ideas which structure it. More specifically, this article will investigate how the idea of taste is deployed in the document from two different yet interconnected points of view. That is, taste as the faculty of discerning what is aesthetically excellent, and taste in its more literal gustative sense. This study will demonstrate how these two ideas of taste are used to create a problematic notion of French culinary identity, which by focusing on the framework of local (terroir) taste seeks to define national taste. By specifically citing local food stuffs (produits du terroir) and practices as well as French Republicanism in the formation of this identity, I argue that the nomination file eschews problems of cultural difference. As a result, “non-French food” and the associated identities it embodies, inherent in contemporary multicultural societies such as France with its large immigrant population, are incorporated into a cohesive, singular, culinary identity. French taste, then, is represented as uniform and embodied by the shared love of the French “art of good eating and drinking”. “Intangible” Versus “Tangible” Cultural Heritage: A Brief Overview The Intangible Cultural Heritage list was created to compliment UNESCO’s Tangible Cultural Heritage, that is, the famous World Heritage, list, which focuses on places of unique heritage. The Intangible Cultural Heritage list, for its part, concentrates on: traditions or living expressions inherited from our ancestors and passed on to our descendants, such as oral traditions, performing arts, social practices, rituals, festive events, knowledge and practices concerning nature and the universe or the knowledge and skills to produce traditional crafts (“What is Intangible Cultural Heritage?”) An examination of the elements which have been admitted to UNESCO’s Representative List of Intangible Cultural Heritage shows that there is a clear preference for traditional dances and songs. The culinary plays a very small role in the almost 300 elements currently protected by UNESCO. With the recent inscription of several additional, specifically culinary elements in December 2013, the number has more doubled but still remains low at ten elements. Out of the ten, only two of them seek to protect a cooking style: the “Mediterranean Diet” and “Traditional Mexican cuisine—ancestral, ongoing community culture, the Michoacán paradigm.” The other elements are specific culinary objects, such as Gingerbread from Northern Croatia, or culinary events, for instance the “Commemoration feast of the finding of the True Holy Cross of Christ in Ethiopia.” “The Gastronomic Meal of the French” belongs to the latter category, however is somewhat different since it is not an annual event and can take place at any time of the year as it is not related to a season or historical event. What really distinguishes the French document from the others on the list, however, is its emphasis on the idea of taste, which connects it to a long history of writing about taste in French cuisine, including of course Brillat-Savarin’s Physiology of Taste. In order to describe exactly what constitutes “The Gastronomic Meal of the French,” the authors refer frequently to two coextensive conceptions of taste, proposing that the taste of the meal is both a question of flavor and the aesthetic qualities of the diner as a whole. Whilst these ideas concerning the place of taste in French gastronomy appear to share numerous similarities to those elaborated in Brillat-Savarin’s work, I will focus on the way the conceptions of taste discussed in the dossier are used to formulate French identity. Taste: An Aesthetic Judgment, An Art When considering “The Gastronomic Meal of the French,” the closeness of the two ideas of aesthetic taste and gustative taste is perhaps clearer in French: the French verb dresser can be used to describe setting the table, an important aspect of the gastronomic meal, and arranging food on a plate. This link to aesthetics is important and in the nomination file the Gastronomic Meal of the French is taken as representative of the height of the French “art of good eating and drinking.” In the terms of the document the authors define the meal as “a festive meal bringing people together for an occasion to enjoy the art of good eating and drinking” (“Nomination file” 3). In evoking art here, they stress the importance that aesthetics play in the design of this meal. For them, the culinary art of the gastronomic meal involves both aesthetic and gustative concerns, since in order for the guests to savour the meal, the hosts must think as much about the delectability of their dishes as the classic French taste they must demonstrate in their table decoration and discussion about the food which they prepare. The participants’ conversation about the food during the meal and their comportment at the table are important elements of this taste, since they reinforce and aestheticize the dining experience. Moreover, both the host and guests must use “codified gestures” and certain expressions to discuss what they are eating and drinking so as to display by means of specific vocabulary that they are enjoying the meal (5). The art of conversation, then, is important in accomplishing one of the goals of the gastronomic meal, that being to share “the pleasure of taste” (8). The nomination file lists the gastronomic meal’s specific rites as involving the “setting [of] a beautiful table, the order of courses, food and wine pairing, [and] conversation about the dishes” (3). By listing these elements in this order, the authors highlight that aesthetic and gustative concerns are interrelated and equally important. What is more, just as the decoration of a table and conversing about the dishes could be seen to be arts in the largest sense of the term, so too should “the order of the courses” and the “food and wine pairing” be understood to be a question of aesthetic judgment. In other words, the role of these rites in the gastronomic meal is as much to reinforce the sophisticated aesthetics of the hosts’ meal as to delight the taste buds of the guests. The prominent role of the aestheticization of taste in the gastronomic meal is made even clearer elsewhere in the document when the authors specify how the table should be laid for a gastronomic meal. They write that this should be done according to the: classic French taste, based on symmetry that fans out from the centre and including a tablecloth, artistically folded napkins, objects whose shapes are appropriate for each course and designed to enhance tastes; and, depending on the circumstance, between two and five glasses, several plates and utensils, and sometimes a written menu. (5) Here the aesthetics of the table are not simply meant to be appreciated visually, but supposed to support and “enhance tastes”. The two forms of taste, then, are clearly complementary ingredients in the successful hosting of a gastronomic meal and hosts should pay equal attention to both. The authors state that the extra care paid to the aesthetics of the meal is meant to honour the guests and differentiate the meal from a standard, everyday meal (5). Since the two ideas of taste intersect, it naturally follows that the choice of the culinary products for the meal also contributes to the goal of creating a special dining experience. Taste as Gustative Experience, The Terroir For the authors, the French palate is not unified by a canon of specific dishes, but a shared “vision of eating well” (3). This collective vision encompasses several different ideas, including the structure of the meal, the recipes used and the choice of products. Just as with the aesthetic concerns above regarding table arrangements, the authors are quite particular about the configuration of the meal. For them, the gastronomic meal must respect the same structure: beginning with the apéritif (drinks before the meal) and ending with liqueurs, containing in between at least four successive courses, namely a starter, fish and/or meat with vegetables, cheese and dessert, the courses possibly numbering five or six depending on the occasion. (5) The structure of the meal is supposed to highlight the quality of the good products that the host has obtained and exhibit how their flavours go well together (5). In terms of the exact recipes used in the meal, the host might call upon a “repertoire of codified recipes” (3) in order to honour the shared “vision of eating well”. So deeply ingrained is this shared vision in the French psyche that the authors do not need to specify what the recipes are, and even go so far as to claim that the unknown list is “constantly growing” (5). This undefined catalogue of recipes and shared “vision of eating well,” then, arguably represent a banal form of national culinary identity, since these culinary practices constitute a “form of life, which is daily lived” (Billig 69) by the nation without being specified. More important than the recipes, however, is the “search for good products” (3). The hunt for good products begins with seeking out “local food products available at markets […] since they have a high cultural value” (6). The authors argue that the importance attached to these products symbolises the French commitment to non-standardised food products and “quality in terms of taste, nutrition and food safety” (6). The height of gustative taste is represented by the use of these local food products (produits du terroir) since they provide evidence of the hosts’ “knowledge of the characteristics of local production areas” (2). Just as above with the aesthetic concerns of the meal, when discussing one idea of taste, the other is never far away. In this case, the hosts’ knowledge of the local products, used in crafting the gustative experience, is meant to contribute the art of conversation which takes place during the meal. The hosts’ gustative and aesthetic tastes are on display and under analysis at every point in the meal. For the authors of the nomination file, then, French gustative taste is ruled by the idea of terroir. Successfully holding a gastronomic meal means that the hosts must be intimately familiar with France’s geography and the local products of France and use this knowledge to choose the right products. All of these very specific ideas concerning the aesthetic and gustative tastes illustrated in the document, then, raise interesting questions about inclusion and exclusion in the notion of French culinary identity they embody. Whose Taste Is It? So far I have argued that taste is the central preoccupation of the nomination file, which governs both aesthetic and gustative choices a host makes when organizing and holding a gastronomic meal. This discussion has elided some of the questions raised by the document’s definitions of taste, most notably the problem of whose taste is defined by the document. One possible response to this question is provided in quite clear terms by the document itself, when the authors talk about the antecedent of the current meal. For them, the meal evolved out of the values exemplified by “the high-society meal, transmitted through revolutionary France [and which] inspired working-class practices” (5). This reference to revolutionary French values reveals how the authors’ arguments about taste are informed by the values of the French Republic, a powerful notion in discussions about French national identity. As numerous critics have contended, the status of France as a republic significantly impacts on how national identity is constructed (McCaffrey), since it is conceived of through the idea of citizenship. Put simply, being a French citizen means that, for the state, one’s position as a citizen takes precedence over any cultural particularisms or clan and family solidarities (Jennings). To put it another way, whilst the individual person displays specificities, the citizen demonstrates the universal values held by all citizens of the French state (Schnapper). Citizenship is a political matter and any aspect of one’s private life is irrelevant to the state’s treatment of its citizens. In ignoring any particularisms that a citizen may have, French Republicanism seeks to universalise all values held by its citizens, simultaneously providing a common shared identity and a means to exclude anyone who fails to commit to these ideals. As Jennings has pointed out elsewhere, these Republican ideals have an interesting effect on how one considers French national identity in the contemporary diverse society that is France, since “despite an astonishing level of cultural and ethnic diversity, France has seen itself as and has sought to become a monocultural society” (575). In terms of the French culinary practices discussed here the associated problems with French Republicanism are clear, for such a “mono-culinary” representation of French foodways would potentially lead to significant portions of the population being left out of any such definition. Given the document’s reference to the Republic, the universalizing force displayed in the nomination file cannot simply be considered the result of the structure of UNESCO’s bureaucratic file, but should instead be understood as the expression of French Republican ideas of identity. Here it is the quality of local ingredients (produits du terroir) which characterise the universal pleasure of taste and the appreciation of local farming practices (terroirs) that the authors seek to elevate in the face of any imported tastes concurrently practised in France. The fact that the universal claims made in the French document are specific to it, and not inherent of UNESCO’s form, is evident when examining other nomination files, such as the traditional Mexican cuisine dossier. Whilst the Mexican dossier argues that the cuisine offers a “comprehensive cultural model” (4), its authors talk instead of communities whose identities display “distinct yet shared features, all of them together [making] for a flourishing cuisine throughout the country” (12). The Mexican file, thus, recognises that diversity is an integral part of its culinary model. For the French dossier, on the other hand, the Republican ideas are made patent by the authors’ insistence upon the homogenous nature of these culinary practices and tastes. They assert, for instance, that the meal is a “very popular practice, with which all French people are familiar” (3); that it displays a “homogeneity in the whole community” (3); that it embodies a “social practice […] associated with a shared vision of eating well” (3); and that it is part of a “shared history and that it carries the values on which French culture is based” (5). The authors also reference a small survey to support this supposition in which an incredible 95.7 per cent of respondents consider “the gastronomic meal to be part of their heritage and identity” (10). Furthermore they claim that the gastronomic meal transcends local customs, generations, social class and opinions, and adapts to religious and philosophical beliefs. Its values take in diversity and strengthen feelings of belonging for participants in the gastronomic meal. (5) This quotation demonstrates the Republic’s ability to transform the particular into the general, the individual into citizen. Here this transformative ability is seen in the authors’ assertion that the Gastronomic Meal of the French cuts across “local customs” and “social classes” to bring people together and reinforce the sense of a united nation. With this insistent discourse that the meal is unanimously accepted, understood, and practised by the entire nation, despite one’s particularisms, the authors of the file demonstrate how they seek to universalise the meal. The meal should no longer be considered as an object, for the authors seek to promote it to the status of a national myth which is deeply rooted in the national psyche, echoing the nation’s motto of “One Republic/cuisine united and indivisible for everyone.” The Republican nature of the universal tastes represented in the document is further reinforced when the authors emphasise the role of the State and its education system in ensuring that the right taste prevails. Just as many critics discussing the Republic regard the French education system’s role as one which constructs citizens (Janey), equipping them with the appropriate national values, the authors of nomination file argue that good taste is of national significance and ought to be taught in the education system. For them, this taste should be imparted to students in primary schools by regularly preparing and consuming meals so as to instruct them in “the rites of the gastronomic meal, including the choice of the right products” (8). The idea of the right taste is further impressed upon students through the annual “Taste Week” in which “educational activities on nutrition and the development of taste […] essential to maintaining the rites of the element [take place in schools]” (7). These activities include instruction in “the combining of flavours, pleasure of taste, choice of the right product, conversation and gastronomic discourse” (7). For those not at school, the “choice of the right product” (14) mentioned here is facilitated through yet another state sanctioned source of taste, the Inventory of Traditional Food and Agricultural Know-how. Conclusion The “Gastronomic Meal of the French” defines national culinary identity by combining several different ideas together. On one level, the authors draw together Benedict Anderson’s concept of “imagined communities” and Michael Billig’s notion of “banal nationalism.” They argue that there exists a state approved, written form this identity which is intimately linked to the French Republic and its history (Anderson), whilst also contending that the food practices are so well-known that they are banal facets of everyday lived experience (Billig). On another level, they draw these assertions regarding national identity together through the notion of taste, which the authors stress is integral to French culinary identity. In terms of gustative taste, the preference for terroir in the document points to how the local is used as a “conduit toward national self-understanding” (Gerson 215). Yet this approach leads to a problematic relationship between local and national concerns, which ought to be seen as part of a larger issue concerning the link between Republican values and the disciplining of French culinary identity and space. What it is tempting to ask—and the present paper is just the beginning—is how do state sanctioned bodies, like the Mission Française du Patrimoine et des Cultures Alimentaires combined with brotherhoods (confréries) and local organisations mentioned in the nomination file as well as the system of Appellations d’Origine Contrôlée, come together to discipline French culinary identity and taste? The examination of the present document seems to suggest that Republican Universalism is one key ingredient in this act of discipline. The hesitation between asserting a cohesive, national culinary identity whilst at the same time recognising the “diversity of traditions foods and cuisines” (5), appears to be representative of the hesitation in political discourse apparent in the modern Republic. The tensions exposed in this document are being played out in the policies concerning decentralisation and recognition to a certain extent of regional minorities in France. As Schnapper puts it, the great problem which the Republic currently faces is how can the state reconcile “the absolute of citizenship—the Republic—with the legitimate expression of particularistic allegiances in conformity with democratic values” (quoted, Jennings 152). Ultimately, what “The Gastronomic Meal of the French” shows is how pertinent Republican ideas still are in France, since, despite claims of a crisis in Republican values and the current debates in French parliament, they remain important in any consideration of French identity, not only in the political spectrum, but also in everyday cultural objects like food. References Anderson, Benedict. Imagined Communities: Reflections on the Origins and Spread of Nationalism. London: Verso, 1983. Billig, Michael. Banal Nationalism. London: Sage, 1995. Gerson, Stéphane. “The Local.” The French Republic: History, Values, Debate. Eds. Edward Berensen, Vincent Duclert, and Christophe Prochasson. London: Cornell UP, 2011. 213–20. Janey, Brigitte. “Frenchness in Perspective(s).” Hexagonal Varitations: Diversity, Plurality and Reinvention in Contemporary France. Eds Jo McCormack, Murray Pratt, and Alistair Rolls. Amsterdam: Editions Rodopi, 2011. 57–78. Jennings, Jeremy. “Citizenship, Republicanism and Multiculturalism in Contemporary France.” British Journal of Political Science 30 (2000): 575–98. Jennings, Jeremy. “Universalism.” The French Republic: History, Values, Debate. Eds. Edward Berensen, Vincent Duclert, and Christophe Prochasson. London: Cornell UP, 2011. Kurin, Richard, “Safeguarding Intangible Cultural Heritage in the 2003 UNESCO Convention: A Critical Appraisal.” Museum International 56.1/2 (2004): 66–77. McCaffrey, Edna. The Gay Republic: Sexuality, Citizenship and Subversion in France. Aldershot: Ashgate, 2005. Schnapper, Domonique. La Communauté des Citoyens. Paris: Gallimard, 1994. Smith, Laurajane, and Natsuko Akagawa. Intangible Heritage. New York: Routledge, 2008. UNESCO. “Convention for the Safeguarding of Intangible Cultural Heritage.” UNESCO, Culture Section 17 Oct. 2003. 12 Jun. 2013 ‹http://www.unesco.org/culture/ich/en/convention›. UNESCO. “Dossier de Candidature : Le Repas Gastronomique des Français.” UNESCO, Culture Section. Nov. 2010. 12 Jun 2013 ‹http://www.unesco.org/culture/ich/en/RL/00437›. UNESCO. “Nomination File: The Gastronomic Meal of the French.” UNESCO, Culture Section Nov. 2010. 12 Jun. 2013 ‹http://www.unesco.org/culture/ich/en/RL/00437›. UNESCO. “Nomination File: Traditional Mexican Cuisine—Ancestral, Ongoing Community Culture, the Michoacán Paradigm.” UNESCO, Culture Section Nov. 2010. 12 Jun. 2013 ‹http://www.unesco.org/culture/ich/en/RL/00400›. UNESCO. “What is Intangible Cultural Heritage?” UNESCO, Culture Section n.d. 12 Jun. 2013 ‹http://www.unesco.org/culture/ich/index.php?lg=en&pg=00002›.

Photo by Agni B on Unsplash ABSTRACT The number of scientific articles published per year has been steadily increasing; so have the instances of misconduct in medical research. While increasing scientific knowledge is beneficial, it is imperative that research be authentic and bias-free. This article explores why fraud and other misconduct occur, presents the consequences of the phenomenon, and proposes measures to eliminate unethical practices in medical research. The main reason scientists engage in unethical practices is the pressure to publish which is directly related to their academic advancement and career development. Additional factors include the pressure to get research funds, the pressure from funding sources on researchers to deliver results, how scientific publishing has evolved over the years, and the over-publication of research in general. Fraud in medical research damages trust and reliability in science and potentially harms individuals. INTRODUCTION Since the introduction of Evidence-Based Medicine (EBM) in the early 1990s, scientific articles published per year have increased steadily. No one knows the exact number of scientific articles published per year, but several estimates point to around 2,000,000.[1] EBM aims to integrate the clinical experience and the best available scientific knowledge in managing individual patients.[2] The EBM model is based on the accumulation of as much clinical and research data as possible, which has propelled a significant rise in research. Unfortunately, its incentive structure has also led to a rise in research misconduct. “Fraud in science has a long history.”[3] Cases of misconduct began to surface in the late 1980s and increased during the 1990s. Experts suggest that today fraud is “endemic in many scientific disciplines and in most countries.”[4] In recent reporting, the majority of cases of scientific fraud involved falsification and fabrication of the data, while plagiarism was much less frequent. 8 percent of scientists and 10 percent of medical and life-sciences researchers admitted to falsifying data at least once between 2017 and 2021 in a Dutch study of 6,813 researchers, while more than half engaged in at least one questionable research practice.[5] Questionable research practices include research design flaws or unfairness in decisions surrounding publication or grants.[6] In an older study, closer to 2 percent of those surveyed reported having engaged in falsification or fabrication,[7] while in a more recent survey of 3,000 scientists with NIH grants in the United States, 0.3 percent of the scientists responding admitted fabricating research data and 1.4 percent of them admitted plagiarizing.[8] These numbers are almost certainly not reflective of the true incidence of fraud as many scientists admitted that they engaged in a range of behaviors beyond fabrication, falsification, and plagiarism that undermine the integrity of science, such as changing the results of a study under pressure from a funding source or failing to present data that contradicts one’s previous research. It is also unclear whether surveys are the best method to investigate misconduct because a scientist answering the survey may be unsure of anonymity and may not be truthful. This article explores why misconduct occurs, presents the consequences, and proposes measures to eliminate unethical practices in medical research. In the 1999 Joint Consensus Conference on Misconduct in Biomedical Research, “scientific fraud” was defined as any “behavior by a researcher, intentional or not, that falls short of good ethical and scientific standards.”[9] ANALYSIS l. The Scientific Publishing Landscape There are several reasons scientists may commit misconduct and engage in unethical practices. There is an increasing pressure to publish, which the motto "publish or perish reflects.”[10] The number of scientific papers published by a researcher is directly related to their academic advancement and career development. Similarly, academic institutions rely on scientific publications to gain prestige and access research grants. Pressure to get research grants may create environments that make it challenging to research integrity. Researchers are often tempted to alter their data to fulfill the desired results, separately report the results of one research in multiple end publications, commonly referred to as “salami publication,” or even simultaneously submit their scientific articles to more than one journal. This creates a vicious cycle in which the need for funding leads to scientific misconduct, which in turn secures more research funding. Meanwhile, the pressure from the funding sources cannot be overlooked either. Although researchers must report the role of the funding sources, selection and publication bias often may advantage articles that support the interests of the financial sponsor. Disclosure does not alter the conflict of interest. The growing number of scientific articles published per year has practically overwhelmed the peer-review system. Manuscript submissions are often reviewed superficially or assigned to inexperienced reviewers; therefore, misconduct cases may go unnoticed. The rise of “predatory” journals that charge authors publication fees and do not review work for authenticity and the dissemination of information through preprints has worsened the situation. The way that profits influence scientific publishing has very likely contributed to the phenomenon of misconduct. The publishing industry is a highly profitable business.[11] The increased reliance on funding from sources that expect the research to appear in prestigious, open-access journals often creates conflicts of interest and funding bias. On the other hand, high-impact journals have not given space to navigate through negative results and previous failures. Nonsignificant findings commonly remain unpublished, a phenomenon known as “the file drawer problem.” Scientists often manipulate their data to fit their initial hypothesis or change their hypothesis to fit their results, leading to outcome-reporting bias. ll. Misconduct Concerning the Reporting and Publishing Data The types of misconduct vary and have different implications for the scientist’s career and those relying on the research. For example, plagiarism is generally not punished by law currently unless it violates the original author’s copyright. Nevertheless, publishers who detect plagiarism implement penalties such as rejection of the submitted article and expulsion of the author. While plagiarism can be either accidental or deliberate, in either case, it is a serious violation of academic integrity as it involves passing off someone else’s “work or ideas” as one’s own.[12] Plagiarism can be “verbatim” (copying sentences or paragraphs from previously published work without using quotation marks or referencing the source) or rephrasing someone’s work or ideas without citing them. In “mosaic” plagiarism, the work plagiarized comes from various sources. “Self-plagiarism” is defined as an author’s reproduction of their previous publications or ideas in the same or altered words. According to most scientific journals, all authors of an article in part must have contributed to the conception and design of the study, drafted the article, revised it critically, or approved of its final version.[13] The use of a ghost author (usually a professional writer who is not named an author) is generally not ethical, as it undermines the requirement that the listed authors created the article. Moreover, wasteful publication is another practice that contributes to misconduct. Wasteful publication includes dividing the results of one single study into multiple end publications (“salami slicing”), republishing the same results in one or more articles, or extending a previously published article by adding new data without reaching new conclusions. Wasteful publication not only skews the scientific databases, but also wastes the time of the readers, the editors, and the reviewers. It is considered unethical because it unreasonably increases the authors’ citation records. Authors caught engaging in such behaviors may be banned from submitting articles for years while the submitted article is automatically rejected. Wasteful publication is an example of how the pressure to publish more articles leads to dishonest behavior, making it look like a researcher has conducted more studies and has more experience. Conflicts of interest are not strictly prohibited in medicine but require disclosure. Although disclosure of financial interests is a critical step, it does not guarantee the absence of bias. Researchers with financial ties to a pharmaceutical company funding their research are more likely to report results that favor the sponsor, which eventually undermines the integrity of research.[14] Financial sponsors should not be allowed to influence publication; rather authors need to publish their results based on their own decisions and findings. lll. Misconduct in Carrying Out Scientific Research Studies Common forms of fabrication include concealing negative results, changing the results to fit the initial hypothesis or selective reporting of the outcomes. Falsification is the manipulation of experimental data that leads to inaccurate presentation of the research results. Falsified data includes deliberately manipulating images, omitting, or adding data points, and removing outliers in a dataset for the sake of manipulating the outcome. In contrast to plagiarism, this type of misconduct is very difficult to detect. Scientists who fabricate or falsify their data may be banned from receiving funding grants or terminated from their institutions. Falsification and fabrication are dangerous to the public as they can result in people giving and receiving incorrect medical advice. Relying on falsified data can lead to death or injury or lead patients to take a drug, treatment, or use a medical device that is less effective than perceived. Thus, some members of the scientific community support the criminalization of this type of misconduct.[15] Research involving human participants requires respect for persons, beneficence, justice, voluntary consent, respect for autonomy, and confidentiality. Violating those principles constitutes unethical human experimentation. The Declaration of Helsinki is a statement of ethical principles for biomedical research involving human subjects, including research on identifiable human material and data. Similarly, research in which animals are subjects is also regulated. The first set of limits on the practice of animal experimentation was the Cruelty to Animals Act passed in 1876 by the Parliament of the United Kingdom. Currently, all animal experiments in the EU should be carried out in accordance with the European Directive (2010/63/EU),[16] and in the US, there are many state and federal laws governing research involving animals. The incentives to compromise the ethical responsibilities surrounding human and animal practices may differ from the pressure to publish, yet some are in the same vein. They may generally include taking shortcuts, rushing to get necessary approvals, or using duress to get more research subjects, all actions that reflect a sense of urgency. lV. Consequences of Scientific Misconduct Fraud in medical research damages science by creating data that other researchers will be urged to follow or reproduce that wastes time, effort, and funds. Scientific misconduct undermines the trust among researchers and the public’s trust in science. Meanwhile, fraud in medical trials may lead to the release of ineffective or unsafe drugs or processes that could potentially harm individuals. Most recently, a study conducted by Surgisphere Corporation supported the efficacy of hydroxychloroquine for the treatment of COVID-19 disease.[17] The scientific article that presented the results of the study was retracted shortly after its release due to concerns raised over the validity of the data. Scientific misconduct is associated with reputational and financial costs, including wasted funds for research that is practically useless, costs of an investigation into the fraudulent research, and costs to settle litigation connected with the misconduct. The retraction of scientific articles for misconduct between 1992 and 2002 accounted for $58 million in lost funding by the NIH (which is the primary source of public funds for biomedical research in the US).[18] Of retracted articles, over half are retracted due to “fabrication, falsification, and plagiarism.”[19] Yet it is likely that many articles that contain falsified research are never retracted. A study revealed that of 12,000 journals reviewed, most of the journals had never retracted an article. The same study suggests that some journals have improved oversight, but many do not.[20] V. Oversight and Public Interest Organizations The Committee on Publication Ethics (COPE) was founded in 1997 and established practices and policies for journals and publishers to achieve the highest standards in publication ethics.[21] The Office of Research Integrity (ORI) is an organization created in the US to do the same. In 1996, the International Conference of Harmonization (ICH) adopted the international Good Clinical Practice (GCP) guidelines.[22] Finally, in 2017 the Parliamentary Office of Science and Technology (POST) initiated a formal inquiry into the trends and developments on fraud and misconduct in research and the publication of research results.[23] Despite the increasing efforts of regulatory organizations, scientific misconduct remains a major issue. To eliminate unethical practices in medical research, we must get to the root of the problem: the pressures put on scientists to increase output at the expense of quality. In the absence of altered incentives, criminalization is a possibility. However, several less severe remedies for reducing the prevalence of scientific misconduct exist. Institutions first need to foster open and frank discussion and promote collegiality. Reducing high-stakes competition for career advancement would also help realign incentives to compromise research ethics. In career advancement, emphasis should be given to the quality rather than the quantity of scientific publications. The significance of mentorship by senior, experienced researchers over lab assistants can bolster ethical training. Adopting certain codes of conduct and close supervision of research practices in the lab and beyond should also be formalized. The publication system plays a critical role in preserving research integrity. Computer-assisted tools that detect plagiarism and other types of misconduct need to be developed or upgraded. To improve transparency, scientific journals should establish clear authorship criteria and require that the data supporting the findings of a study be made available, a movement that is underway. Preprint repositories also might help with transparency, but they could lead to people acting on data that has not been peer-reviewed. Finally, publishing negative results is necessary so that the totality of research is not skewed or tainted by informative studies but does not produce the results researchers hoped. Consistently publishing negative results may create a new industry standard and help researchers see that all data is important. CONCLUSION Any medical trial, research project, or scientific publication must be conducted to develop science and improve medicine and public health. However, the pressures from the pharmaceutical industry and academic competition pose significant threats to the trustworthiness of science. Thus, it is up to every scientist to respect and follow ethical rules, while responsible organizations, regulatory bodies, and scientific journals should make every effort to prevent research misconduct. - [1] World Bank. “Scientific and technical journal articles”. World Development Indicators, The World Bank Group. https://data.worldbank.org/indicator/IP.JRN.ARTC.SC?year_low_desc=true. [2] Masic I, Miokovic M, Muhamedagic B. “Evidence Based Medicine - New Approaches and Challenges.” Acta Inform Med. 2008;16(4):219-25. https://www.bibliomed.org/mnsfulltext/6/6-1300616203.pdf?1643160950 [3] Dickenson, D. “The Medical Profession and Human Rights: Handbook for a Changing Agenda.” Zed Books. 2002;28(5):332. doi: 10.1136/jme.28.5.332. [4] Ranstam J, Buyse M, George SL, Evans S, Geller NL, Scherrer B, et al. “Fraud in Medical Research: an International Survey of Biostatisticians, ISCB Subcommittee on Fraud. Control Clin Trials. 2000;21(5):415-27. doi: 10.1016/s0197-2456(00)00069-6. [5] Gopalakrishna, G., Riet, G. T., Vink, G., Stoop, I., Wicherts, J. M., & Bouter, L. (2021, “Prevalence of questionable research practices, research misconduct and their potential explanatory factors: a survey among academic researchers in The Netherlands.” MetaArXiv. July 6, 2021. doi:10.31222/osf.io/vk9yt; Chawla, Dalmeet Singh, “8% of researchers in Dutch survey have falsified or fabricated data.” Nature. 2021. https://www.nature.com/articles/d41586-021-02035-2 (The Dutch study’s author suggests the results could be an underestimate; she also notes an older similar study that found 4.5 percent.) [6] Chawla. [7] Fanelli D. How many scientists fabricate and falsify research? A systematic review and meta-analysis of survey data. PLoS One. 2009;4(5):e5738. doi:10.1371/journal.pone.0005738 [8] Martinson BC, Anderson MS, de Vries R. “Scientists behaving badly” Nature. 2005;435(7043):737-8. https://www.nature.com/articles/435737a. [9] Munby J, Weetman, DF. Joint Consensus Conference on Misconduct in Biomedical Research: The Royal College of Physicians of Edinburgh. Indoor Built Environ. 1999;8:336–338. doi: 10.1177/1420326X9900800511. [10] Stephen Beale “Large Dutch Survey Shines Light on Fraud and Questionable Research Practices in Medical Studies Published in Scientific Journals,” The Dark Daily, Aug 30, 2021. https://www.darkdaily.com/2021/08/30/large-dutch-survey-shines-light-on-fraud-and-questionable-research-practices-in-medical-studies-published-in-scientific-journals/ [11] Buranyi S. Is the staggeringly profitable business of scientific publishing bad for science? The Guardian. June 27, 2017. https://www.theguardian.com/science/2017/jun/27/profitable-business-scientific-publishing-bad-for-science [12] Cambridge English Dictionary. https://dictionary.cambridge.org/us/dictionary/english/plagiarism [13] International Committee of Medical Journal Editors. Defining the Role of Authors and Contributors http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html [14] Resnik DB, Elliott KC. “Taking Financial Relationships into Account When Assessing Research.” Accountability in Research. 2013;20(3):184-205. doi: 10.1080/08989621.2013.788383. [15] Bülow W, Helgesson G. Criminalization of scientific misconduct. Med Health Care and Philos. 2019;22:245–252. [16] Directive 2010/63/EU of the European Parliament and of the Council of 22 September 2010 on the protection of animals used for scientific purposes. Official Journal of the European Union. https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2010:276:0033:0079:en:PDF [17] Mehra MR, Desai SS, Ruschitzka F, Patel AN. “RETRACTED: Hydroxychloroquine or Chloroquine with or without a Macrolide for Treatment of COVID-19: a Multinational Registry Analysis.” The Lancet. 2020. doi: 10.1016/S0140-6736(20)31180-6. [18] Stern AM, Casadevall A, Steen RG, Fang FC. “Financial Costs and Personal Consequences of Research Misconduct Resulting in Retracted Publications,” eLife. 2014;3:e02956. doi: 10.7554/eLife.02956. [19] Brainard, Jeffrey and Jia You, “What a massive database of retracted papers reveals about science publishing's ‘death penalty': Better editorial oversight, not more flawed papers, might explain flood of retractions,” Science, Oct 25, 2018 https://www.science.org/content/article/what-massive-database-retracted-papers-reveals-about-science-publishing-s-death-penalty [20] Brainard and You. [21] Doherty M, Van De Putte Lbacope. Guidelines on Good Publication Practice; Annals of the Rheumatic Diseases 2000;59:403-404. [22] Dixon JR Jr. The International Conference on Harmonization Good Clinical Practice Guideline. Qual Assur. 1998 Apr-Jun;6(2):65-74. doi: 10.1080/105294199277860. PMID: 10386329. [23] “Research Integrity Terms of Reference.” Science and Technology Committee, 14 Sept. 2017, committees.parliament.uk/committee/135/science-and-technology-committee/news/100920/research-integrity-terms-of-reference/.

Photo by 14825144 © Alita Xander | Dreamstime.com ABSTRACT The US government's approach to the War on Drugs has created laws to deter people from using illicit drugs through negative punishment. These laws have not controlled illicit drug use, nor has it stopped the opioid pandemic from growing. Instead, these laws have created a negative bias surrounding addiction and have negatively affected particularly vulnerable patient populations, including pregnant women with substance use disorder and newborns with neonatal abstinence syndrome. This article highlights some misconceptions and underscores the challenges they face as they navigate the justice and healthcare systems while also providing possible solutions to address their underlying addiction. INTRODUCTION Pregnant women with substance use disorder require treatment that is arguably for the benefit of both the mother and the fetus. Some suggest that addiction is a choice; therefore, those who misuse substances should not receive treatment. Proponents of this argument emphasize social and environmental factors that lead to addiction but fail to appreciate how chronic substance use alters the brain’s chemistry and changes how it responds to stress, reward, self-control, and pain. The medical community has long recognized that substance use disorder is not simply a character flaw or social deviance, but a complex condition that requires adequate medical attention. Unfortunately, the lasting consequences of the War on Drugs have created a stigma around addiction medicine, leading to significant treatment barriers. There is still a pervasive societal bias toward punitive rather than rehabilitative approaches to addiction. For example, many women with substance use disorder lose custody of their baby or face criminal penalties, including fines and jail time.[1] These punitive measures may cause patients to lose trust in their physicians, ultimately leading to high-risk pregnancies without prenatal care, untreated substance misuse, and potential lifelong disabilities for their newborns.[2] As a medical student, I have observed the importance of a rehabilitative approach to addiction medicine. Incentivizing pregnant women with substance use disorder to safely address their chronic health issues is essential for minimizing negative short-term and long-term outcomes for women and their newborns. This approach requires an open mind and supportive perspective, recognizing that substance use disorder is truly a medical condition that requires just as much attention as any other medical diagnosis.[3] BACKGROUND The War on Drugs was a government-led initiative launched in 1970 by President Richard M. Nixon with the aim of curtailing illegal drug use, distribution, and trade by imposing harsher prison sentences and punishments.[4] However, it is worth noting that one can trace the roots of this initiative back further. In 1914, Congress enacted the Harrison Narcotics Tax Act to target the recreational use of drugs such as morphine and opium.[5] Despite being in effect for over four decades, the War on Drugs failed to achieve its intended goals. In 2011, the Global Commission on Drug Policy released a report that concluded that the initiative had been futile, as “arresting and incarcerating tens of millions of these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”[6] One study published in the International Journal of Drug Policy in the same year found that funding drug law enforcement paradoxically contributed to increasing gun violence and homicide rates.[7] The Commission recommended that drug policies focus on reducing harm caused by drug use rather than solely on reducing drug markets. Recognizing that many drug policies were of political opinion, it called for drug policies that were grounded in scientific evidence, health, security, and human rights.[8] Unfortunately, policy makers did not heed these recommendations. In 2014, Tennessee’s legislature passed a “Fetal Assault Law,” which made it possible to prosecute pregnant women for drug use during pregnancy. If found guilty, pregnant women could face up to 15 years in prison and lose custody of their child. Instead of deterring drug use, the law discouraged pregnant women with substance use disorder from seeking prenatal care. This law required medical professionals to report drug use to authorities, thereby compromising the confidentiality of the patient-physician relationship. Some avoided arrest by delivering their babies in other states or at home, while others opted for abortions or attempted to go through an unsafe withdrawal prior to receiving medical care, sacrificing the mother's and fetus's wellbeing. The law had a sunset provision and expired in 2016. During the two years this law was in effect, officials arrested 124 women.[9] The fear that this law instilled in pregnant women with substance use disorder can still be seen across the US today. Many pregnant women with substance use disorders stated that they feared testing positive for drugs. Due to mandatory reporting, they were not confident that physicians would protect them from the law.[10] And if a woman tried to stop using drugs before seeking care to avoid detection, she often ended up delaying or avoiding care.[11] The American College of Obstetricians and Gynecologists (ACOG) recognizes the fear those with substance use disorders face when seeking appropriate medical care and emphasizes that “obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing.”[12] Mandatory reporting strains the patient-physician relationship, driving a wedge between the doctor and patient. Thus, laws intended to deter people from using substances through various punishments and incarceration may be doing more harm than good. County hospitals that mainly serve lower socioeconomic patients encounter more patients without consistent health care access and those with substance use disorders.[13] These hospitals are facing the consequences of the worsening opioid pandemic. At one county hospital where I recently worked, there has been a dramatic increase in newborns with neonatal abstinence syndrome born to mothers with untreated substance use disorders during pregnancy. Infants exposed to drugs prenatally have an increased risk of complications, stillbirth, and life-altering developmental disabilities. At the hospital, I witnessed Child Protective Services removing two newborns with neonatal abstinence syndrome from their mother’s custody. Four similar cases had occurred in the preceding month. In the days leading up to their placement with a foster family, I saw both newborns go through an uncomfortable drug withdrawal. No baby should be welcomed into this world by suffering like that. Yet I felt for the new mothers and realized that heart-wrenching custody loss is not the best approach. During this period, I saw a teenager brought to the pediatric floor due to worsening psychiatric symptoms. He was born with neonatal abstinence syndrome that neither the residential program nor his foster family could manage. His past psychiatric disorders included attention deficit disorder, conduct disorder, major depressive disorder, anxiety disorder, disruptive mood dysregulation disorder, intellectual developmental disorder, and more. During his hospitalization, he was so violent towards healthcare providers that security had to intervene. And his attitude toward his foster parents was so volatile that we were never sure if having them visit was comforting or agitating. Throughout his hospital course, it was difficult for me to converse with him, and I left every interview with him feeling lost in terms of providing an adequate short- and long-term assessment of his psychological and medical requirements. What was clear, however, was that his intellectual and emotional levels did not match his age and that he was born into a society that was ill-equipped to accommodate his needs. Just a few feet away from his room, behind the nurses’ station, were the two newborns feeling the same withdrawal symptoms that this teenager likely experienced in the first few hours of his life. I wondered how similar their paths would be and if they would exhibit similar developmental delays in a few years or if their circumstance may follow the cases hyped about in the media of the 1980s and 1990s regarding “crack babies.” Many of these infants who experienced withdrawal symptoms eventually led normal lives.[14] Nonetheless, many studies have demonstrated that drug use during pregnancy can adversely impact fetal development. Excessive alcohol consumption can result in fetal alcohol syndrome, characterized by growth deficiency, facial structure abnormalities, and a wide range of neurological deficiencies.[15] Smoking can impede the development of the lungs and brain and lead to preterm deliveries or sudden infant death syndrome.[16] Stimulants like methamphetamine can also cause preterm delivery, delayed motor development, attention impairments, and a wide range of cognitive and behavioral issues.[17] Opioid use, such as oxycodone, morphine, fentanyl, and heroin, may result in neonatal opioid withdrawal syndrome, in which a newborn may exhibit tremors, irritability, sleeping problems, poor feeding, loose stools, and increased sweating within 72 hours of life.[18] In 2014, the American Association of Pediatrics (AAP) reported that one newborn was diagnosed with neonatal abstinence syndrome every 15 minutes, equating to approximately 32,000 newborns annually, a five-fold increase from 2004.[19] The AAP found that the cost of neonatal abstinence syndrome covered by Medicaid increased from $65.4 million to $462 million from 2004 to 2014.[20] In 2020, the CDC published a paper that showed an increase in hospital costs from $316 million in 2012 to $572.7 million in 2016.[21] Currently, the impact of the COVID-19 pandemic on the prevalence of newborns with neonatal abstinence syndrome is unknown. I predict that the increase in opioid and polysubstance use during the pandemic will increase the number of newborns with neonatal abstinence syndrome, thereby significantly increasing the public burden and cost.[22] In the 1990s, concerns arose about the potentially irreparable damage caused by intrauterine exposure to cocaine on the development of infants, which led to the popularization of the term “crack babies.”[23] Although no strong longitudinal studies supported this claim at the time, it was not without merit. The Maternal Lifestyle Study (NCT00059540) was a prospective longitudinal observational study that compared the outcomes of newborns exposed to cocaine in-utero to those without.[24] One of its studies revealed one month old newborns with cocaine exposure had “lower arousal, poorer quality of movements and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes.”[25] Another study showed that at one month old, heavy cocaine exposure affected neural transmission from the ear to the brain.[26] Long-term follow up from the study showed that at seven years old, children with high intrauterine cocaine exposure were more likely to have externalizing behavior problems such as aggressive behavior, temper tantrums, and destructive acts.[27] While I have witnessed this behavior in the teenage patient during my pediatrics rotation, not all newborns with intrauterine drug exposure are inevitably bound to have psychiatric and behavioral issues later in life. NPR recorded a podcast in 2010 highlighting a mother who used substances during pregnancy and, with early intervention, had positive outcomes. After being arrested 50 times within five years, she went through STEP: Self-Taught Empowerment and Pride, a public program that allowed her to complete her GED and provided guidance and encouragement for a more meaningful life during her time in jail. Her daughter, who was exposed to cocaine before birth, had a normal childhood and ended up going to college.[28] From a public health standpoint, more needs to be done to prevent the complications of substance misuse during pregnancy. Some states consider substance misuse (and even prescribed use) during pregnancy child abuse. Officials have prosecuted countless women across 45 states for exposing their unborn children to drugs.[29] With opioid and polysubstance use on the rise, the efficacy of laws that result in punitive measures seems questionable.[30] So far, laws are not associated with a decrease in the misuse of drugs during pregnancy. Millions of dollars are being poured into managing neonatal abstinence syndrome, including prosecuting women and taking their children away. Rather than policing and criminalizing substance use, pregnant women should get the appropriate care they need and deserve. I. Misconception One: Mothers with Substance Use Disorder Can Get an Abortion If an unplanned pregnancy occurs, one course of action could be to terminate the pregnancy. On the surface, this solution seems like a quick fix. However, the reality is that obtaining an abortion can be challenging due to two significant barriers: accessibility and mandated reporting. Abortion laws vary by state, and in Tennessee, for instance, abortions are banned after six weeks of gestation, typically when fetal heart rhythms are detected. An exception to this is in cases where the mother's life is at risk.[31] Unfortunately, many women with substance use disorders are from lower socioeconomic backgrounds and cannot access pregnancy tests, which could indicate they are pregnant before the six-week cutoff. If a Tennessee woman with substance use disorder decides to seek an abortion after six weeks, she may need to travel to a neighboring state. However, this is not always a feasible option, as the surrounding states (WV, MO, AR, MI, AL, and GA) also have restrictive laws that either prohibit abortions entirely or ban them after six weeks. Moreover, she may be hesitant to visit an obstetrician for an abortion, as some states require physicians by law to report their patients' substance use during pregnancy. For example, Virginia considers substance use during pregnancy child abuse and mandates that healthcare providers report it. This would ultimately limit her to North Carolina if she wants to remain in a nearby state, but she must go before 20 weeks gestation.[32] For someone who may or may not have access to reliable transportation, traveling to another state might be impossible. Without resources or means, these restrictive laws have made it incredibly difficult to obtain the medical care they need. II. Misconception Two: Mothers with SUD are Not Fit to Care for Children If a woman cannot take care of herself, one might wonder how she can take care of another human being. Mothers with substance use disorders often face many adversities, including lack of economic opportunity, trauma from abuse, history of poverty, and mental illness.[33] Fortunately, studies suggest keeping mother and baby together has many benefits. Breastfeeding, for example, helps the baby develop a strong immune system while reducing the mother’s risk of cancer and high blood pressure.[34] Additionally, newborns with neonatal abstinence syndrome who are breastfed by mothers receiving methadone or buprenorphine require less pharmacological treatment, have lower withdrawal scores, and experience shorter hospital stays.[35] Opioid concentration in breastmilk is minimal and does not pose a risk to newborns.[36] Moreover, oxytocin, the hormone responsible for mother-baby bonding, is increased in breastfeeding mothers, reducing withdrawal symptoms and stress-induced reactivity and cravings while also increasing protective maternal instincts.[37] Removing an infant from their mother’s care immediately after birth would result in the loss of all these positive benefits for both the mother and her newborn. The newborns I observed during my pediatrics rotation probably could have benefited from breastfeeding rather than bottle feeding and being passed around from one nurse to the next. They probably would have cried less and suffered fewer withdrawal symptoms had they been given the opportunity to breastfeed. And even if the mothers were lethargic and unresponsive while going through withdrawal, it would still have been possible to breastfeed with proper support. Unfortunately, many believe mothers with substance use disorder cannot adequately care for their children. This pervasive societal bias sets them up for failure from the beginning and greatly inhibits their willingness to change and mend their relationship with their providers. It is a healthcare provider’s duty to provide non-judgmental care that prioritizes the patient’s well-being. They must treat these mothers with the same empathy and respect as any other patient, even if they are experiencing withdrawal. III. Safe Harbor and Medication-Assisted Treatment Addiction is like any other disease and society should regard treatment without stigma. There is no simple fix to this problem, given that it involves the political, legal, and healthcare systems. Punitive policies push pregnant women away from receiving healthcare and prevent them from receiving beneficial interventions. States need to enact laws that protect these women from being reported to authorities. Montana, for example, passed a law in 2019 that provides women with substance use disorders safe harbor from prosecution if they seek treatment for their condition.[38] Medication-assisted treatment with methadone or buprenorphine is the first line treatment option and should be available to all pregnant women regardless of their ability to pay for medical care.[39] To promote continuity of care, health officials could include financial incentives to motivate new mothers to go to follow-up appointments. For example, vouchers for groceries or enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offset financial burdens and allow a mother to focus on taking care of her child and her recovery. IV. Mandated Substance Abuse Programs Although the number of people sentenced to state prisons for drug related crimes has been declining, it is still alarming that there were 171,300 sentencings in 2019.[40] Only 11 percent of the 65 percent of our nation’s inmates with substance use disorder receive treatment, implying that the other 89 percent were left without much-needed support to overcome their addiction.[41] It is erroneous to assume that their substance use disorder would disappear after a period without substance use while behind bars. After withdrawal, those struggling with substance use disorder may still have cravings and the likelihood of relapsing remains high without proper medical intervention. Even if they are abstinent for some time during incarceration, the underlying problem persists, and the cycle inevitably continues upon release from custody. In line with the recommendations by Global Commission on Drug Policy and the lessons learned from the failed War on Drugs, one proposed change in our criminal justice system would be to require enrollment and participation in assisted alcohol cessation programs before legal punishment. Policy makers must place emphasis on the safety of the patient and baby rather than the cessation of substance use. This would incentivize people to actively seek medical care, restore the patient-physician relationship, and ensure that they take rehabilitation programs seriously. If the patient or baby is unsafe, a caregiver could intervene while the patient re-enrolls in the program. Those currently serving sentences in prisons and jails can treat their substance use disorder through medication assisted treatment, cognitive behavioral therapy, and programs like Self Taught Empowerment and Pride (STEP). Medication assisted treatment under the supervision of medical professionals can help inmates achieve and maintain sobriety in a healthy and safe way. Furthermore, cognitive behavioral therapy can help to identify triggers and teach healthier coping mechanisms to prepare for stressors outside of jail. Finally, multimodal empowerment programs can connect people to jobs, education, and support upon release. People often leave prisons and jail without a sense of purpose, which can lead to relapse and reincarceration. Structured programs have been shown to decrease drug use and criminal behavior by helping reintegrate productive individuals into society.[42] V. Medical Education: Narcotic Treatment Programs and Suboxone Clinics Another proactive approach could be to have medical residency programs register with the Drug Enforcement Administration (DEA) as Narcotic Treatment Programs and incorporate suboxone clinics into their education and rotations. Rather than family medicine, OB/GYN, or emergency medicine healthcare workers having to refer their patients to an addiction specialist, they could treat patients with methadone for maintenance or detoxification where they would deliver their baby. Not only would this educate and prepare the future generation of physicians to handle the opioid crisis, but it would allow pregnant women to develop strong patient-physician relationships. CONCLUSION Society needs to change from the mindset of tackling a problem after it occurs to taking a proactive approach by addressing upstream factors, thereby preventing those problems from occurring in the first place. Emphasizing public health measures and adequate medical care can prevent complications and developmental issues in newborns and pregnant women with substance use disorders. Decriminalizing drug use and encouraging good health habits during pregnancy is essential, as is access to prenatal care, especially for lower socioeconomic patients. Many of the current laws and regulations that policy makers initially created due to naïve political opinion and unfounded bias to serve the War on Drugs need to be changed to provide these opportunities. To progress as a society, physicians and interprofessional teams must work together to truly understand the needs of patients with substance use disorders and provide support from prenatal to postnatal care. There should be advocation for legislative change, not by providing an opinion but by highlighting the facts and conclusions of scientific studies grounded in scientific evidence, health, security, and human rights. There can be no significant change if society continues to view those with substance use disorders as underserving of care. Only when the perspective shifts to compassion can these mothers and children receive adequate care that rehabilitates and supports their future and empowers them to raise their children. - [1] NIDA. 2023, February 15. Pregnant People with Substance Use Disorders Need Treatment, Not Criminalization. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization [2] Substance Use Disorder Hurts Moms and Babies. National Partnership for Women and Families. June 2021 [3] All stories have been fictionalized and anonymized. [4] A History of the Drug War. Drug Policy Alliance. https://drugpolicy.org/issues/brief-history-drug-war [5] The Harrison Narcotic Act (1914) https://www.druglibrary.org/Schaffer/library/studies/cu/cu8.html [6] The War on Drugs. The Global Commission on Drug Policy. Published June 2011. https://www.globalcommissionondrugs.org/reports/the-war-on-drugs [7] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. Int J Drug Policy. 2011;22(2):87-94. doi:10.1016/j.drugpo.2011.02.002 [8] Global Commission on Drug Policy, 2011 [9] Women NA for P. Tennessee’s Fetal Assault Law: Understanding its impact on marginalized women - New York. Pregnancy Justice. Published December 14, 2020. https://www.pregnancyjusticeus.org/tennessees-fetal-assault-law-understanding-its-impact-on-marginalized-women/ [10] Roberts SCM, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2010;20(3):193-200. doi:10.1016/j.whi.2010.02.003 [11] Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190. doi:10.1097/ADM.0000000000000308 [12] Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist [13] R. Ghertner, G Lincoln The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. ASPE. Office of Assistant Secretary for Planning and Evaluation. DHHS Revised September 11, 2018 https://aspe.hhs.gov/reports/economic-opportunity-opioid-crisis-geographic-economic-trends [14] Midon, M. Z., Gerzon, L. R., & de Almeida, C. S. (2021). Crack and motor development of babies living in an assistance shelter. ABCS Health Sciences, 46, e021215-e021215. And for example, see Crack Babies: Twenty Years Later : NPR https://www.npr.org/templates/story/story.php?storyId=126478643 [15] Williams JF, Smith VC, the Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e20153113. doi:10.1542/peds.2015-3113 [16] CDC Tobacco Free. Smoking During Pregnancy. Centers for Disease Control and Prevention. Published April 11, 2022. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm [17] Abuse NI on D. What are the risks of methamphetamine misuse during pregnancy? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/methamphetamine/what-are-risks-methamphetamine-misuse-during-pregnancy [18] CDC. Basics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. Published July 21, 2021. https://www.cdc.gov/pregnancy/opioids/basics.html [19] Honein MA, Boyle C, Redfield RR. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics. 2019;143(3):e20183801. doi:10.1542/peds.2018-3801 [20] Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004–2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520 [21] Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 [22] Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 Pandemic on Opioid Overdose Deaths: a Spatiotemporal Analysis. J Urban Health Bull N Y Acad Med. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0 [23] Mayes LC, Granger RH, Bornstein MH, Zuckerman B. The Problem of Prenatal Cocaine Exposure: A Rush to Judgment. JAMA. 1992;267(3):406-408. doi:10.1001/jama.1992.03480030084043 [24] NICHD Neonatal Research Network. The Maternal Lifestyle Study. clinicaltrials.gov; 2016. https://clinicaltrials.gov/ct2/show/study/NCT00059540 [25] Lester BM, Tronick EZ, LaGasse L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002;110(6):1182-1192. doi:10.1542/peds.110.6.1182 [26] Lester BM, Lagasse L, Seifer R, et al. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003;142(3):279-285. doi:10.1067/mpd.2003.112 [27] Bada HS, Bann CM, Bauer CR, et al. Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study). Neurotoxicol Teratol. 2011;33(1):78-87. doi:10.1016/j.ntt.2010.06.005 [28] N, P, R. Crack Babies: Twenty Years Later. NPR. Published May 3, 2010. https://www.npr.org/templates/story/story.php?storyId=126478643 [29] Miranda L, Dixon V, September CRP on, 30, 2015. How States Handle Drug Use During Pregnancy http://projects.propublica.org/graphics/maternity-drug-policies-by-state [30] NCDAS: Substance Abuse and Addiction Statistics [2023]. NCDAS. https://drugabusestatistics.org/ [31] (Tenn. Code Ann. § 39-15-216). [32] Institute G. Interactive Map: US Abortion Policies and Access After Roe. https://states.guttmacher.org/policies/ [33] Whitesell M, Bachand A, Peel J, Brown M. Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. J Addict. 2013;2013:579310. doi:10.1155/2013/579310 [34] CDC. Five Great Benefits of Breastfeeding. Centers for Disease Control and Prevention. Published July 27, 2021. https://www.cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html [35] Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarkø L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr. 2013;102(11):1060-1066. doi:10.1111/apa.12378 [36] Ilett KF, Hackett LP, Gower S, Doherty DA, Hamilton D, Bartu AE. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med Off J Acad Breastfeed Med. 2012;7:269-274. doi:10.1089/bfm.2011.0096 [37] Pedersen CA, Smedley KL, Leserman J, et al. Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects. Alcohol Clin Exp Res. 2013;37(3):484-489. doi:10.1111/j.1530-0277.2012.01958.x [38] Montana SB0289. https://leg.mt.gov/bills/2019/billhtml/SB0289.htm [39] Mullins N, Galvin SL, Ramage M, Gannon M, Lorenz K, Sager B, Coulson CC. Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med. 2020 May/Jun;14(3):185-192. doi: 10.1097/ADM.0000000000000562. PMID: 31567599. [40] Drug Related Crime Statistics [2023]: Offenses Involving Drug Use. NCDAS. https://drugabusestatistics.org/drug-related-crime-statistics/ [41] Association APH. Online only: Report finds most U.S. inmates suffer from substance abuse or addiction. Nations Health. 2010;40(3):E11-E11. [42] Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) | NIDA Archives. Published January 17, 2018. http://archives.nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). 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[11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. 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BASTARDYAll children born before matrimony, or so long after the death of the husband as to render it impossible that the child could be begotten by him, are bastards.– Cro. Jac. 451William Toone: The Magistrates Manual, 1817 (66)On 4 September 1832, the body of a newborn baby boy was found washed up on the shore at the port town of Fremantle, Western Australia. As the result of an inquest into the child’s suspicious death, a 20-year-old, unmarried woman named Mary Summerland was accused of concealing his birth. In October 2014, 25-year-old Irish backpacker Caroline Quinn faced court in Perth, Western Australia, over claims that she concealed the birth of her stillborn child after giving birth in the remote north west town of Halls Creek during May of the same year. Both women denied the existence of their children, both appear to have given birth to their “illegitimate” babies alone, and both women claimed that they did not know that they had ever been pregnant at all. In addition, both women hid the body of their dead child for several days while the people they lived with or were close to, did not appear to notice that the mother of the child had had a baby. In neither case did any person associated with either woman seek to look for the missing child after it had been born.Despite occurring 182 years apart, the striking similarities between these cases could lead to the assumption that it is almost as if there were a written script of behaviour that would explain the actions of both young women. Close examination of the laws surrounding child murder, infanticide and concealment of birth reveals evidence of similar behaviours being enacted by women as far back as the 1600s (and earlier), and all are shaped in response to the legal frameworks that prosecuted women who gave birth outside of marriage.This article traces the history of child murder law from its formation in England in the 1600s and explores how early moral assumptions concerning unmarried mothers echoed through the lived experiences of women who killed their illegitimate babies in colonial Western Australia, and continue to resonate in the treatment of, and legal response to, women accused of similar crimes in the present day. The Unlicensed ChildThe unlicensed child is a term coined by Swain and Howe to more accurately define the social matrix faced by single women and their children in Australia. The term seeks to emphasise the repressive and controlling religious, legal and social pressures that acted on Australian women who had children outside marriage until the mid-1970s (xxi, 1, 92, 94). For the purposes of this article, I extend Swain and Howe’s term the unlicensed child to coin the term the unlicensed mother. Following on from Swain and Howe’s definition, if the children of unmarried mothers did not have a license to be born, it is essential to acknowledge that their mothers did not have a license to give birth. Women who had children without social and legal sanction gave birth within a society that did not allocate them “permission” to be mothers, something that the corporeality of pregnancy made it impossible for them not to be. Their own bodies—and the bodies of the babies growing inside them—betrayed them. Unlicensed mothers were punished socially, religiously, legally and financially, and their children were considered sinful and inferior to children who had married parents simply because they had been born (Scheper-Hughes 410). This unspoken lack of authorisation to experience the unavoidably innate physicality of pregnancy, birth and motherhood, in turn implies that, until recently unmarried mothers did not have license to be mothers. Two MothersAll that remains of the “case” of Mary Summerland is a file archived at the State Records Office of Western Australia under the title CONS 3472, Item 10: Rex V Mary Summerland. Yet revealed within those sparse documents is a story echoed by the events surrounding Caroline Quinn nearly two hundred years later. In September 1832, Mary Summerland was an unmarried domestic servant living and working in Fremantle when the body of a baby was found lying on a beach very close to the settlement. Western Australia had only been colonized by the British in 1829. The discovery of the body of an infant in such a tiny village (colonial Fremantle had a population of only 436 women and girls out of 1341 non-Aboriginal emigrants) (Gardiner) set in motion an inquest that resulted in Mary Summerland being investigated over the suspicious death of the child.The records suggest that Mary may have given birth, apparently alone, over a week prior to the corpse of the baby being discovered, yet no one in Fremantle, including her employer and her family, appeared to have noticed that Mary might have been pregnant, or that she had given birth to a child. When Mary Summerland was eventually accused of giving birth to the baby, she strongly denied that she had ever been pregnant, and denied being the mother of the child. It is not known how her infant ended up being disposed of in the ocean. It is also not known if Mary was eventually charged with concealment or child murder, but in either scenario, the case against her was dismissed as “no true bill” when she faced her trial. The details publically available on the case of Caroline Quinn are also sparse. Even the sex of her child has not been revealed in any of the media coverage of the event. Yet examination of the limited details available on her charge of “concealment of birth” reveal similarities between her behaviours and those of Mary Summerland.In May 2014 Caroline Quinn had been “travelling with friends in the Kimberly region of Western Australia” (Lee), and, just as Mary did, Caroline claims she “did not realise that she was pregnant” when she went into labour (Independent.ie). She appears, like Mary Summerland, to have given birth alone, and also like Mary, when her child died due to unexplained circumstances she hid the corpse for several days. Also echoing Mary’s story, no person in the sparsely populated Hall’s Creek community (the town has a populace of 1,211) or any friends in Caroline’s circle of acquaintances appears to have noticed her pregnancy, nor did they realise that she had given birth to a baby until the body of the child was discovered hidden in a hotel room several days after her or his birth. The media records are unclear as to whether Caroline revealed her condition to her friends or whether they “discovered” the body without her assistance. The case was not brought to the attention of authorities until Caroline’s friends took her to receive medical attention at the local hospital and staff there notified the police.Media coverage of the death of Caroline Quinn’s baby suggests her child was stillborn or died soon after birth. As of 13 August 2014 Caroline was granted leave by the Chief Magistrate to return home to Ireland while she awaited her trial, as “without trivialising the matter, nothing more serious was alleged than the concealing of the birth” (Collins, "Irish Woman"). Caroline Quinn was not required to return to Australia to appear at her trial and when the case was presented at the Perth Magistrates Court on Thursday 2 October, all charges against her were dropped as the prosecutor felt “it was not in the public interest” to proceed with legal action (Collins, "Case").Statutory MarginalisationTo understand the similarities between the behaviours of, and legal and medical response to, Mary Summerland and Caroline Quinn, it is important to situate the deaths of their children within the wider context of child murder, concealment of birth and “bastardy” law. Tracing the development of these methods of law-making clarifies the parallels between much of the child murder, infanticide and concealment of birth narrative that has occurred in Western Australia since non-Aboriginal settlement.Despite the isolated nature of Western Australia, the nearly 400 years since the law was formed in England, and the extremely remote rural locations where both these women lived and worked, their stories are remarkably alike. It is almost as if there were a written script and each member of the cast knew what role to play: both Mary and Caroline knew to hide their pregnancies, to deny the overwhelmingly traumatic experience of giving birth alone, and to conceal the corpses of their babies. The fathers of their children appear to have cut off any connection to the women or their child. The family, friends, or employers of the parents of the dead babies knew to pretend that they did not know that the mother was pregnant or who the father was. The police and medical officers knew to charge these women and to collect evidence that could be used to simultaneously meet the needs of the both prosecution and the defence when the cases were brought to trial.In reference to Mary Summerland’s case, in colonial Western Australia when a woman gave birth to an infant who died under suspicious circumstances, she could be prosecuted with two charges: “child murder” and/or “concealment of birth”. It is suggestive that Mary may have been charged with both. The laws regarding these two offences were focused almost exclusively on the deaths of unlicensed children and were so deeply interconnected they are difficult to untangle. For Probyn, shame pierces the centre of who we think we are, “what makes it remarkable is that it reveals with precision our values, hopes and aspirations, beyond the generalities of good manners and cultured norms” (x). Dipping into the streams of legal and medical discourse that flow back to the seventeenth century highlights the pervasiveness of discourses marginalising single women and their children. This situates Mary Summerland and Caroline Quinn within a ‘burden on society’ narrative of guilt, blame and shame that has been in circulation for over 500 years, and continues to resonate in the present (Coull).An Act to Prevent the Destroying and Murthering of Bastard ChildrenIn England prior to the 17th century, penalties for extramarital sex, the birth and/or maintenance of unlicensed children or for committing child murder were expressed through church courts (Damme 2-6; Rapaport 548; Butler 61; Hoffer and Hull 3-4). Discussion of how the punishment of child murder left the religious sphere and came to be regulated by secular laws that were focused exclusively on the unlicensed mother points to two main arguments: firstly, the patriarchal response to unlicensed (particularly female) sexuality; and secondly, a moral panic regarding a perceived rise in unlicensed pregnancies in women of the lower classes, and the resulting financial burden placed on local parishes to support unwanted, unlicensed children (Rapaport 532, 48-52; McMahon XVII, 126-29; Osborne 49; Meyer 3-8 of 14). In many respects, as Meyer suggests, “the legal system subtly encouraged neonaticide through its nearly universally negative treatment of bastard children” (240).The first of these “personal control laws” (Hoffer and Hull 13) was the Old Poor Law created by Henry VIII in 1533, and put in place to regulate all members of English society who needed to rely on the financial assistance of the parish to survive. Prior to 1533, “by custom the children of the rich depended on their relations, while the ‘fatherless poor’ relied on the charity of the monastic institutions and the municipalities” (Teichman 60-61). Its implementation marks the historical point where the state began to take responsibility for maintenance of the poor away from the church by holding communities responsible for “the problem of destitution” (Teichman 60-61; Meyer 243).The establishment of the poor law system of relief created a hierarchy of poverty in which some poor people, such as those suffering from sickness or those who were old, were seen as worthy of receiving support, while others, who were destitute as a result of “debauchery” or other self-inflicted means were seen as undeserving and sent to a house of correction or common gaol. Underprivileged, unlicensed mothers and their children were seen to be part of the category of recipients unfit for help (Jackson 31). Burdens on SocietyIt was in response to the narrative of poor unlicensed women and their children being undeserving fiscal burdens on law abiding, financially stretched community members that in 1576 a law targeted specifically at holding genetic parents responsible for the financial maintenance of unlicensed children entered the secular courts for the first time. Called the Elizabethan Poor Law it was enacted in response to the concerns of local parishes who felt that, due to the expenses exacted by the poor laws, they were being burdened with the care of a greatly increased number of unlicensed children (Jackson 30; Meyer 5-6; Teichman 61). While the 1576 legislation prosecuted both parents of unlicensed children, McMahon interprets the law as being created in response to a blend of moral and economic forces, undergirded by a deep, collective fear of illegitimacy (McMahon 128). By the 1570s “unwed mothers were routinely whipped and sent to prison” (Meyer 242) and “guardians of the poor” could force unlicensed mothers to wear a “badge” (Teichman 63). Yet surprisingly, while parishes felt that numbers of unlicensed children were increasing, no concomitant rise was actually recorded (McMahon 128).The most damning evidence of the failure of this law, was the surging incidence of infanticide following its implementation (Rapaport 548-49; Hoffer and Hull 11-13). After 1576 the number of women prosecuted for infanticide increased by 225 percent. Convictions resulting in unlicensed mothers being executed also rose (Meyer 246; Hoffer and Hull 8, 18).Infanticide IncreasesBy 1624 the level of infanticide in local communities was deemed to be so great An Act to Prevent the Destroying and Murthering of Bastard Children was created. The Act made child murder a “sex-specific crime”, focused exclusively on the unlicensed mother, who if found guilty of the offence was punished by death. Probyn suggests that “shame is intimately social” (77) and indeed, the wording of An Act to Prevent highlights the remarkably similar behaviours enacted by single women desperate to avoid the shame and criminal implication linked to the social position of unlicensed mother: Whereas many lewd Women that have been delivered of Bastard Children, to avoyd their shame and to escape punishment [my italics], doe secretlie bury, or conceale the Death of their Children, and after if the child be found dead the said Women doe alleadge that the said Children were borne dead;…For the preventing therefore of this great Mischiefe…if any Woman…be delivered of any issue of the Body, Male or Female, which being born alive, should by the Lawes of this Realm be a bastard, and that she endeavour privatlie either by drowning or secret burying thereof, or any other way, either by herselfe of the procuring of others, soe to conceale the Death thereof, as that it may not come to light, whether it be borne alive or not, but be concealed, in every such Case the Mother so offending shall suffer Death… (Davies 214; O'Donovan 259; Law Reform Commission of Western Australia 104; Osborne 49; Rose 1-2; Rapaport 548). An Act to Prevent also “contained an extraordinary provision which was a reversion of the ordinary common law presumption of dead birth” (Davies 214), removing the burden of proof from the prosecution and placing it on the defence (Francus 133; McMahon 128; Meyer 2 of 14). The implication being that if the dead body of a newborn, unlicensed baby was found hidden, it was automatically assumed that the child had been murdered by their mother (Law Reform Commission of Western Australia 104; Osborne 49; Rapaport 549-50; Francus 133). This made the Act unusual in that “the offence involved was the concealment of death rather than the death itself” (O'Donovan 259). The only way an unlicensed mother charged with child murder was able to avoid capital punishment was to produce at least one witness to give evidence that the child was “borne dead” (Law Reform Commission of Western Australia 104; Meyer 238; McMahon 126-27).Remarkable SimilaritiesClearly, the objective of An Act to Prevent was not simply to preserve infant life. It is suggestive that it was enacted in response to women wishing to avoid the legal, social, corporal and religious punishment highlighted by the implementation of the poor law legislation enacted throughout earlier centuries. It is also suggestive that these pressures were so powerful that threat of death if found guilty of killing their neonate baby was not enough to deter women from concealing their unlicensed pregnancies and committing child murder. Strikingly analogous to the behaviours of Mary Summerland in 19th century colonial Western Australia, and Caroline Quinn in 2014, the self-preservation implicit in the “strategies of secrecy” (Gowing 87) surrounding unlicensed birth and child murder often left the mother of a dead baby as the only witness to her baby’s death (McMahon xvii 49-50).An Act to Prevent set in motion the legislation that was eventually used to prosecute Mary Summerland in colonial Western Australia (Jackson 7, Davies, 213) and remnants of it still linger in the present where they have been incorporated into the ‘concealment of birth law’ that prosecuted Caroline Quinn (Legal Online TLA [10.1.182]).Changing the ‘Script’Shame runs like a viral code through the centuries to resonate within the legal response to women who committed infanticide in colonial Western Australia. It continues on through the behaviours of, and legal responses to, the story of Caroline Quinn and her child. As Probyn observes, “shame reminds us about the promises we keep to ourselves” in turn revealing our desire for belonging and elements of our deepest fears (p. x). While Caroline may live in a society that no longer outwardly condemns women who give birth outside of marriage, it is fascinating that the suite of behaviours manifested in response to her pregnancy and the birth of her child—by herself, her friends, and the wider community—can be linked to the narratives surrounding the formation of “child murder” and “concealment” law nearly 400 years earlier. Caroline’s narrative also encompasses similar behaviours enacted by Mary Summerland in 1832, in particular that Caroline knew to say that her child was “born dead” and that she had merely concealed her or his body—nothing more. This behaviour appears to have secured the release of both women as although both Mary and Caroline faced criminal investigation, neither was convicted of any crime. Yet, neither of these women or their small communities were alone in their responses. My research has uncovered 55 cases linked to child murder in Western Australia and the people involved in all of these incidences share unusually similar behaviours (Gardiner). Perhaps, it is only through the wider community becoming aware of the resonance of child murder law echoing through the centuries, that certain women who are pregnant with unwanted children will be able to write a different script for themselves, and their “unlicensed” children. ReferencesButler, Sara, M. "A Case of Indifference? Child Murder in Later Medieval England." Journal of Women's History 19.4 (2007): 59-82. Collins, Padraig. "Case against Irish Woman for Concealing Birth Dropped." The Irish Times 2 Oct. 2014. ---. "Irish Woman Held for Hiding Birth in Australia Allowed Return Home." The Irish Times 13 Aug. 2014. 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