Letteratura scientifica selezionata sul tema "Medical logic – Congresses"

The article defines the structural specifics of the scientific periodicals of the Kazan Physicians Society, characterizes the logic of its evolution, shows its place in the development of the general logic of qualitative changes in the methods of constructing and manifesting medical knowledge broadcast on its pages. The stages of the evolutionary transformation of the Diaries of the Physicians Society, which were the printed organ of the Physicians Society at the Imperial Kazan University, into a special edition the Kazan Medical Journal are analyzed in detail, the date of its official approval as a printed organ is specified. Based on the materials of the State Archives of the Republic of Tatarstan, many of which were not previously introduced into scientific circulation, the succession of the development of scientific periodicals was demonstrated, which makes it possible to reasonably indicate 1872 as the year when the Kazan Medical Journal started to be published. The article gives a brief description of the published volumes of this stage of the transformation of the Diaries of the Physicians Society, indicates the specifics of their formal, as well as content and, in particular, intertextual structure. The role and place of various types of published materials, such as original scientific articles, abstracts of current scientific literature of that time, annual literature reviews in various medical specialties, meeting reports of representatives of scientific societies, reports of medical congresses and the so-called doctoral disputes at Kazan University at that time, reports of practical health care institutions of Kazan, special correspondence, reviews of scientific works, scientific bibliography, were determined. An analysis of these elements evolution in the content of scientific periodicals made it possible to substantiate the logical model of the structural transformation of this printed organ as a special type of historical source, to determine the forms of its cultural and communicative functioning, to indicate its role in the development of the professional culture of the medical corporation of Kazan University and the city of Kazan.

Optimization is essential for applications since it can improve the results provided in different areas; for this task, it is beneficial to use soft computing techniques, such as bio-inspired algorithms. In addition, it has been shown that if dynamic parameter adaptation is applied to these algorithms, they can provide a better result. For this work, the main contribution is to carry out the dynamic parameter adaptation to the bird swarm algorithm using interval type-2 fuzzy systems to realize a new fuzzy bio-inspired algorithm. The design of the proposed fuzzy system consists of two inputs corresponding to the iterations and diversity. As outputs, it takes the values of C and S, which are parameters to be adjusted by the algorithm. Once the design and the experimentation are realized, they are divided into two study cases. The first consists of a set of complex functions of the Congress of Evolutionary Competition 2017. The second case study consists of optimizing the membership functions in a fuzzy system designed to provide the nocturnal blood pressure profile, which corresponds to a neuro-fuzzy hybrid model to obtain the risk of hypertension. Analyzing the 30 experiments performed in both case studies, we can observe that the results obtained are improved when compared with the original method and other proposed methodologies, achieving good results in the complex functions. In addition, the optimized fuzzy system will reach an average of 97% correct classification. Statistically, it can be concluded that there is significant evidence to affirm that the proposed method provides good results.

Despite growing awareness of the American state's active role in the early nineteenth century, scholars have tended to ignore the early republic's public health apparatus. The few studies that do chronicle antebellum health initiatives confine themselves to programs intended to directly reward citizens—and particularly those who contributed politically or economically to the nation's founding and expansion. As this detailed study of the Indian Vaccination Act of 1832 makes clear, however, antebellum policymakers saw value in providing medical care to those outside their settler citizenry. Blending liberal, republican, and ascriptive ideas, the vaccination program joined two competing political logics: one emphasizing the humanity of indigenous people and the importance of providing for their welfare, and the other prioritizing the state's interest in an efficient “removal” process. Evidencing far more autonomy and administrative capacity than the average nineteenth-century bureaucracy, the War Department played a pivotal role in petitioning Congress for, and ultimately administering, the vaccination program. Unwilling to cede regulatory power over indigenous health to more proximate local governments or private parties, the War Department preferred its own military manpower—a decision that would profoundly shape the design and reception of subsequent Native health programs.

Page Header OPEN JOURNAL SYSTEMS Journal Help USER Username catapan-anderson Password •••••••• Remember me NOTIFICATIONS View Subscribe LANGUAGE Select Language English JOURNAL CONTENT Search Search Scope All Browse By Issue By Author By Title Other Journals FONT SIZE HOME ABOUT LOGIN REGISTER SEARCH CURRENT ARCHIVES ANNOUNCEMENTS EBOOK PUBLISHER ON LINE CONGRESS Home > Vol 7, No 5 (2021) > Lima SÍNDROME DE BURNOUT EM ESTUDANTES DE MEDICINA / BURNOUT SYNDROME IN MEDICAL STUDENT Juliana Coelho Lima, Davi da Silva Motta, Isadora Garcia F. P. de Andrade, Albert Ferrari Tavares, Raquel Juliana de Oliveira Soares ABSTRACT A Síndrome de Burnout (SB) é um tipo de resposta prolongada a estresses emocionais e interpessoais crônicos no trabalho, levando o trabalhador a um esgotamento físico e mental. Embora tenha uma relação direta com o trabalhador, atualmente a SB também é diagnosticada em estudantes. Ela atinge principalmente os profissionais e estudantes que trabalham diretamente com outras pessoas, destacando, assim, os estudantes de medicina, já que eles estão intimamente ligados a outros em uma relação que permeia os âmbitos afetivos e emocionais. Objetivo: Analisar a prevalência da Síndrome de Burnout em estudantes de medicina de uma Universidade Privada na Cidade do Rio de Janeiro. O estudo foi do tipo exploratório, descritivo, de corte transversal, realizado em uma Universidade Privada situada na Cidade do Rio de Janeiro/RJ. Os participantes do estudo foram estudantes do curso de graduação em medicina. Para a coleta de dados utilizou-se um questionário com perguntas para caracterização dos participantes e o MBI-SS “Maslach Burnout Inventory – Student Survey.” Resultados: participaram do estudo 133 estudantes com idade média de 24 anos, 70% do sexo feminino e 93% solteiro, no qual 39 cursam o ciclo básico (29,4%), 75 o ciclo clínico (56,5%) e 18 estavam no internato (13,5%), sendo que 1 (0,8%) pessoa não respondeu esse quesito. Ao serem questionados pela quantidade de disciplinas que cursavam no semestre, 18 alunos (13,6%) cursavam de 1 a 3 disciplinas, 95 (71,4%) 4 a 6 disciplinas e 17 (12,8%) cursavam mais de 7 disciplinas. 3 (2,3%) participantes não responderam. Na avaliação dos resultados do Inventário de Burnout de Maslach para estudantes, verificamos que na categoria EE 19 alunos (14,29%) se encontravam em nível baixo a médio e 114 (85,71%) se encontravam no nível médio a alto. Já na categoria D, 97 (72,93%) estavam no nível baixo-médio e 36 (27,07%) no médio-alto. Por fim, na categoria EP 13 alunos (9,77) ficaram no nível baixo-médio, enquanto que 120 (90,23%) no nível médio alto. Conclusão: Considerando que a Síndrome de Burnout manifesta-se quando o estudante obtiver altas pontuações em exaustão emocional e descrença, associadas a baixas pontuações em eficácia profissional, conclui-se que neste estudo possuímos 8 alunos com dados compatíveis com a síndrome.

In the context of narcotic drug epidemics, racist logics can shape policy deliberation and delimit uptake. While critical public health scholars have situated the U.S. opioid epidemic as demonstrative of such logics, in rhetoric the opioid epidemic has failed to register as an important deliberative context for representational contestation regarding race and racism. Drawing on Jürgen Habermas’ (1985) steering mediums (steurungsmedium) and Michael Omi and Howard Winant’s (2015) racial formation theory, this essay analyzes the U.S. Anti-Drug Abuse Act of 1986 and Purdue Pharma executive J. David Haddox’s testimony before Congress to show the extent to which racial hegemony saturates juridical engagements at the federal level. Where wide-scale opioid use is concerned, this analysis demonstrates that disparate policy outcomes are largely a reflection of structural and representational inequality along racial lines. This essay thus invites scholars of health and medical rhetoric to consider how processes of controversy and medicalization function to preserve racial hegemony.

Photo ID 158378414 © Eduard Muzhevskyi | Dreamstime.com ABSTRACT There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities. INTRODUCTION Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve. BACKGROUND Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes.[1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research.[2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.”[3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops.[4] Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture. I. Global Cultural Perspective of Embryonic Stem Cells Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense,[5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research.[6] Consequently, global engagement in ESC research depends on social-cultural acceptability. a. US and Rights-Based Cultures In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism,[7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.”[8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed.[9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field.[10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture.[11] b. Ubuntu and Collective Cultures African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama, which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,”[12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth.[13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value.[14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society. Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.”[15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail. Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable.[16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus[17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines.[18] Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim.[19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research.[20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF. Their use is conditioned on consent, and available only to married couples.[21] The community's receptiveness to stem cell research depends on including communitarian African ethics. c. Asia Some Asian countries also have a collective model of ethics and decision making.[22] In China, the ethics model promotes a sincere respect for life or human dignity,[23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life.[25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research.[26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions.[27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency.[28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021.[29] However, issues still need to be addressed in implementing effective IRB review and approval procedures. The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy,[30] research ethics should also adapt to ensure respect for the values of its represented peoples. Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies.[31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells.[32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval,[33] and in another instance, the oocyte source was unclear and possibly violated ethical standards.[34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust. d. Middle East Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells,[35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research.[36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors.[37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so.[38] Jordan has a positive research ethics culture.[39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial.[40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation.[41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.”[42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes. e. Europe In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected.[43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44] For example, in Germany, Lebenzusammenhang, or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.”[45] Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount.[46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007.[47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization.[48] Spain’s approach differs still, with a comprehensive regulatory framework.[49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility.[50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices.[51] II. Religious Perspectives on ESC Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives. The Qur'an states: “And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.”[52] Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception.[53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible.[54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research.[55] In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided.[56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden.[57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all.[58] Acceptance varies on applied beliefs and interpretations. Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero,[59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all.[60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime.[61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit.[62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets.[63] Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life.[64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception:[65] “If she is found pregnant, until the fortieth day it is mere fluid,”[66] Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation.[67] Stem cell research is accepted due to application of these religious laws. We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory, which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions.[68] We only wish to show that the interaction with morality varies between cultures and countries. III. A Flexible Ethical Approach The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities. While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe.[69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation. For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent.[70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context,[71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders. This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research. Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values.[72] An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions.[73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion. IV. Concerns Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values.[74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions. Other concerns include medical tourism, which may promote health inequities.[75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments.[76] For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.”[77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices.[78] The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.”[79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds.[80] CONCLUSION While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research. For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society. This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model. - [1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. Orthopedic reviews, 14(3), 37498. https://doi.org/10.52965/001c.37498 [2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. Orthopedic reviews, 14(3), 37498. https://doi.org/10.52965/001c.37498 [3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities. International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk; Kimmelman, J., Hyun, I., Benvenisty, N. et al. Policy: Global standards for stem-cell research. Nature 533, 311–313 (2016). https://doi.org/10.1038/533311a [4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities. International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk [5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources: Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research. The New England journal of medicine, 351(3), 207–209. https://doi.org/10.1056/NEJMp048145; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos. The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy, 38(2/3), 264–284. http://www.jstor.org/stable/24439776; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells. The New England journal of medicine, 351(3), 209–211. https://doi.org/10.1056/NEJMp048147; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality. Bosnian journal of basic medical sciences, 4(1), 5–14. https://doi.org/10.17305/bjbms.2004.3453 [6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review. Restorative neurology and neuroscience, 28(4), 589–603. https://doi.org/10.3233/RNN-2010-0543 [7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics. Oxford University Press. [8] Sherley v. Sebelius, 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf [9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text; Bush, G. W. (2006, July 19). Message to the House of Representatives. National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html [10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells. National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells [11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells. Social Research, 73(3), 819–834. http://www.jstor.org/stable/40971854 [12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics. 22. 10.1186/s12910-021-00678-4. [13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics, 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight, 49(4). [14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324 [15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324 [16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa. Stem Cell Res Ther 4, 54 (2013). https://doi.org/10.1186/scrt204; Pew Research Center. (2014, May 1). Public health a major priority in African nations. Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/ [17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024. National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf [18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80, see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142 [19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia. UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html [20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142 [21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries. Middle East Fertil Soc J 24, 8 (2020). https://doi.org/10.1186/s43043-019-0011-0; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142 [22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics, 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247 [23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences, 8(1). https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199 [24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction. Frontiers in pharmacology, 13, 1013740. https://doi.org/10.3389/fphar.2022.1013740 [25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech. [26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students. Stem cells international, 2021, 6667743. https://doi.org/10.1155/2021/6667743 [27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students. Stem cells international, 2021, 6667743. https://doi.org/10.1155/2021/6667743 [28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine, 12(6), 647–656. https://doi.org/10.2217/rme-2017-0035 [29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences, 8(1). https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199 [30] Chen, H., Wei, T., Wang, H. et al. Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017. BMC Public Health 22, 434 (2022). https://doi.org/10.1186/s12889-022-12839-0 [31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan. Curr Stem Cell Rep 1, 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6 [32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production. NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production [33] Park, S. (2012). South Korea steps up stem-cell work. Nature. https://doi.org/10.1038/nature.2012.10565 [34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned. Accountability in research, 13(1), 101–109. https://doi.org/10.1080/08989620600634193. [35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 [36]Association for the Advancement of Blood and Biotherapies. https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia [37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 [38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics, 23(3), 260–268. https://doi.org/10.1111/dewb.12355; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know. Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know [39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics, 17(2), 228-241. https://doi.org/10.1177/1747016120966779 [40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics, 17(2), 228-241. https://doi.org/10.1177/1747016120966779 [41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3 [44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France. Biotechnology Law Report, 32(6), 349–356. https://doi.org/10.1089/blr.2013.9865 [45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3 [46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf [47] Regulation of Stem Cell Research in Germany. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany [48] Regulation of Stem Cell Research in Finland. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland [49] Regulation of Stem Cell Research in Spain. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain [50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered: Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110. Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ... Revista do Colegio Brasileiro de Cirurgioes, 41(5), 374–377. https://doi.org/10.1590/0100-69912014005013 Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India. Routledge. For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe [51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights. Cultura (Iasi, Romania), 14(2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent? Research Ethics, 13(1), 23-41. https://doi.org/10.1177/1747016116650235 [52] The Qur'an (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23 [53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life. Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/ [54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics, 31:399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386 [55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association, 12(4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf. [56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52. https://doi.org/10.5372/1905-7415.0801.260 [57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation. Journal of Religion and Health, 30(1), 35–41. http://www.jstor.org/stable/27510629; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva. A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm [59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. ((King James Bible. (1999). Oxford University Press. (original work published 1769)) Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…” In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David. Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…” These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth. [60] It should be noted that abortion is not supported as well. [61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day. Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html [62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells. Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology. Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf. [63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed. Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/ [64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society, (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law). Journal of assisted reproduction and genetics, 25(6), 271–276. https://doi.org/10.1007/s10815-008-9221-6 [66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet). Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en [67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [68] Gert, B. (2007). Common morality: Deciding what to do. Oxford Univ. Press. [69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association.; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. 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Photo by 168502358© Designer491|Dreamstime.com ABSTRACT Psychiatric Advance Directives (PADs) can protect the autonomy of those living with severe mental illness (SMI) and improve their treatment outcomes. However, their uptake is low for several documented reasons. Attempts to increase patient uptake of PADs can circumvent risks of undue provider influence in the facilitation process and promote optimal mental health outcomes with a peer-support model, thereby protecting patient autonomy in accordance with the principle of beneficence. Moreover, policymakers and mental health organizations should devote sufficient resources toward establishing peer-support specialist networks to mitigate the inequities those with SMI face. Capability theory can guide state leaders and directors in justifying the distribution of scarce resources to achieve these outcomes. INTRODUCTION Since the mid-twentieth century, scholars have increasingly rejected a strong paternalistic relationship between physician and patient, emphasizing the right of patients to accept or decline medical treatment.[1] With this greater emphasis on patient autonomy, a healthcare model of shared decision-making ascended in the 1980s.[2] Considering limitations in a patient’s capacity to make informed decisions in their treatment, the US Congress passed the Patient Self-Determination Act in 1990.[3] The act legally obliged hospitals and other care facilities that participate in Medicare and Medicaid to ask patients if they have an advance directive. In the absence of such a directive, these institutions are to ask if patients would like to complete one and to abide by it if presented by the patient.[4] These directives give patients control of future medical decisions in three key areas: entrusting an individual to act as a medical decision-making proxy, preferences for and consent to future treatment, and a statement of overall personal values and preferences to help inform future medical decisions by providers.[5] Although professionals initially crafted the law with end-of-life care in mind, 27 states now have mental health-specific provisions included in advance directive statutes.[6] As a subset of advance directives, psychiatric advance directives (PADs) are meant to protect patient autonomy during the treatment of psychiatric episodes when competence is compromised. Despite their promise and protection, PADs are underutilized by those with serious mental illness (SMI). In a survey of psychiatric patients, only 4-13 percent of respondents across multiple US sites reported having completed a PAD.[7] The same study indicated that 66-77 percent of respondents were interested in completing one if given assistance.[8] Having recognized the gap between patient interest and uptake, researchers have explored the possible reasons for this disparity. Several barriers have been identified and characterized at the system, health-professional, and service-user levels.[9] Although exploring interventions targeted at each level individually may be worthwhile, several barriers may be effectively overcome with one cross-level intervention. Specifically, a network of peer-support facilitators may be able to mitigate resource concerns of the system level, provider fears, reluctance, and lack of knowledge of PADs at the health-professional level, and a lack of trust and support among those with SMI within the service-user level.[10] Although the Patient Self-Determination Act mandated protections for patient autonomy, the law did not provide a sufficient mechanism to ensure the broad use of those protections. Much of the logistical burden falls on those living with SMI to educate themselves and initiate the completion of a PAD.[11] However, many of those living with SMI already face additional burdens that prevent their successful navigation of a complex healthcare system, including poverty, marginal housing, and food insecurity.[12] In addition, individuals with SMI tend to be more socially isolated, with few others to trust besides their providers.[13] Efforts to promote the uptake of PADs by those living with SMI that neglect these additional burdens risk exacerbating health inequities faced by those with SMI. Attempts to increase patient uptake of PADs should circumvent risks of undue provider influence in the facilitation process and promote optimal mental health outcomes with a peer-support model, thereby protecting patient autonomy per the principle of beneficence. Additionally, policymakers and mental health organizations should devote sufficient resources toward establishing peer-support specialist networks to mitigate the inequities those with SMI face. Capability theory can guide state leaders and directors in justifying the distribution of scarce resources to achieve these outcomes. I. System-Level Barriers to Psychiatric Advanced Directive Uptake At least three barriers to PAD uptake exist at the system level. Still, only one can be effectively addressed by peer-support specialists: resource implications to providers and administrators.[14] In one study, 71 percent of administrators and 52 percent of clinicians believed that a shortage of time would prevent adequate facilitation of PAD completion among those with SMI.[15] Logistical difficulties, such as incorporation into routine documentation and making them easily accessible, were mentioned by 25 percent of respondents in another study.[16] Professionals should take clinical burdens seriously since they can impact care and patient outcomes. Shifting to a peer-support model would alleviate these constraints on providers, who could then focus on other aspects of patient care. II. Health Professional-Level Barriers to Psychiatric Advance Directive Uptake Barriers at the health-professional level, which include a lack of knowledge and training, fear of complete treatment refusals, and a reluctance to facilitate PAD creation, keep patient uptake of PADs low.[17] Among these barriers is a need for more knowledge and training among healthcare professionals. In one study, 55 percent of health professionals had never heard of PADs; only 11 percent claimed they were "very familiar" with PADs.[18] In a survey of professionals, 45 percent voiced concern that the potential disadvantages such as the use of PADs to refuse medications could outweigh the benefits.[19] The reluctance of providers to assist service users in completing a PAD stemmed from concerns over time constraints and the providers’ ability to facilitate the completion of a PAD without bias.[20] These concerns are serious and hint at the asymmetrical power dynamic between providers and patients. By removing the responsibility of unbiased communication from the provider and placing it with peer-support facilitators, the risk to patient autonomy would be significantly lessened. III. Service User-Level Barriers to Psychiatric Advance Directive Uptake Several barriers exist at the service-user level that prevent the widespread adoption of PADs. These include a lack of trust, support, and knowledge of PADs, as well as a lack of understanding in completing a PAD.[21] Concerning trust, one study found that 43 percent of patients did not feel they had someone they could trust to help them complete their PAD.[22] Other studies indicated that patients had limited trust in their healthcare professionals.[23] Regarding the lack of support, one survey found that 94 percent of respondents would be unable to complete a PAD without assistance or without a facilitator.[24] Many patients lack knowledge and awareness of PADs, how to complete, and what to include in them.[25] Due to their complex legal nature, over half of the respondents in one survey indicated that they had problems understanding the PAD.[26] Similarly, 79 percent of clients interviewed in one study felt that PADs posed too much of a burden.[27] Through their shared lived experience, peer-support facilitators would be in a greater position to foster trust with patients and create the environment necessary for patients to explore their values and preferences through this process. IV. Circumventing Undue Provider Influence on Patient Autonomy The risk to patient autonomy is pervasive because of the advanced nature of medical practice and the dependence of patients to providers. In their delineation of bioethical principles, Beauchamp and Childress state: "To respect autonomous agents is to acknowledge their right to hold views, to make choices, and to take actions based on their values and beliefs."[28] This duty extends through a respectful attitude toward the patient and respectful action toward the patient.[29] On average, patients with SMI take 14.6 minutes to complete a PAD, which is well within the 30-minute time limit imposed by insurance reimbursement schedules.[30] However, as other researchers have indicated, this time of completion does not take into account the time required to inform and discuss the implications of future treatment decisions adequately.[31] Given that those living with SMI are often affected by cognitive deficits, the ability of a provider to relay complex health and legal information promptly may be further hamstrung.[32] By offloading the burden of providing efficient and practical education to patients with various levels of cognitive impairment, peer-support specialists could provide the necessary space and time to obtain informed consent and protect patient autonomy. Much of the moral force behind advance directives is the respect for patient autonomy, which has been a focus of researchers over the past several years.[33] Because psychiatric episodes severely limit the ability of a patient to make well-informed treatment decisions in a crisis, PADs are a way to protect the patient from paternalistic interventions. This takes on greater weight in treating patients experiencing a psychiatric episode when the threat and use of coercive treatment options are frequent.[34] Moreover, a report in North Carolina has uncovered a "culture of commitment" whereby providers routinely and reflexively override patient PADs through the legal execution of involuntary commitment.[35] This is despite the affirmation of the autonomy of psychiatric patients by the US District Court in Vermont, which concluded in Hargrave v. Vermont that clinicians could not overrule written directives regarding mental health treatment in non-emergency situations.[36] Although the invalidation of a PAD occurs during treatment, well after discussing and creating it, providers holding the view that PADs are of little utility may not accurately or effectively discuss their relevant features with patients. However, this issue could be side-stepped entirely with peer-support specialists who would be responsible for obtaining informed consent from the patient within the value structures espoused by the patient. V. Beneficence Through Peer Support A growing amount of research indicates how peer-support facilitation of PADs can improve the mental health outcomes of those with SMI. Studies show that adults with SMI can complete legally valid PADs with appropriate assistance and that these documents faithfully represent their preferences.[37] At a minimum, service users report no bias against peer specialists in facilitating PADs.[38] Peer-support specialists use their lived experience to foster empowerment among patients, serve as role models, and promote a patient-centered process in successful PAD completion.[39] Mitigating concerns from providers that PAD creation would include complete refusal of treatment, other studies have found that peer-facilitated PADs were significantly more likely to be prescriptive than PADs facilitated by non-peer clinicians.[40] Most importantly, peer-facilitated PADs effectively decrease compulsory hospital admissions and increase mental health outcomes such as self-perceived symptoms, empowerment, and recovery.[41] Providers have a prima facie duty to prevent harm from occurring to others, remove conditions that will cause harm to others, and help persons with disabilities.[42] This is often conceptualized within the patient-provider relationship, but it need not be. Although general beneficence is controversial in ethics circles, providers can promote the welfare of those they may never meet by relinquishing the responsibility of PAD facilitation to peer-support specialists.[43] In doing so, they remove the possibility of unduly influencing patient preferences, thereby reducing the risk of harm. Additionally, providers incur no additional costs, ameliorating concerns that they do not have the time or resources to facilitate PAD creation effectively.[44] Additionally, they would be implicitly endorsing a better treatment option, allowing them to meet the prima facie obligation to help persons with disabilities. VI. Relational Autonomy and Informed Consent in PAD Creation Shifting the burden of PAD facilitation from providers to peer-support specialists may not settle questions of undue influence. However, under their own SMI, peer-support specialists have lived experiences that strongly parallel others with SMI, which may augment patient autonomy overall. In support of this relational turn, Susan H. Williams explains: "Once the social sources of our identities are recognized, it becomes apparent that someone else who shares my culture [experience] might be able to understand me better than I understand myself.” [45] Essentially, the lived experience of peer-support specialists does not necessarily impede autonomy but can effectively enhance it through facilitated support.[46] Recognizing that individuals are embedded in social relations makes it clear that conceptions of autonomy that neglect emotions, communal life, social context, interdependence, reciprocity, and the development of persons over time are exceedingly narrow.[47] Within this framework of relational autonomy, peer-support specialists can guide service users through their struggles with SMI. So long as the interaction allows service users to act intentionally, with understanding, and without external influences, professionals can respect an individual's autonomy.[48] The enhancement in service-user autonomy ultimately arises from the relationship and shared experience with the peer-support specialist. Of course, peer-support specialists would be obligated to the affirmative duties necessary to ensure service users' understanding and informed consent. Peer-support specialists can achieve informed consent through a certification procedure and a manualized structured conversation that guides the patient to understand their preferences better.[49] To achieve informed consent, "the patient must have the capacity to be able to understand and assess the information given, communicate their choices, and understand the consequences of their decision.”[50] To this end, professionals must train peer-support specialists to apply standards of competence to service users prior to PAD facilitation. Although intervening with peer-support specialists can yield substantial benefits—including fewer coercive interventions, a better-working alliance with care providers, and higher odds that individuals will receive and adhere to their preferred medications— professionals must reach informed consent during each facilitation session.[51] VII. Guiding Distributive Justice: Capability Theory Capability theory is an account of justice opportunity that places a fundamental moral significance on individuals' ability to reach proper functioning and well-being.[52] Whether or not an individual can make use of a particular set of resources and convert them into a state of functioning depends on personal, sociopolitical, and environmental conditions ("conversion factors").[53] In this sense, liberty is not the absence of restraint from others or institutions but the freedom achieved through capability-enhancing relationships.[54] Within the context of bioethics, capability theory shifts focus toward creating circumstances by which individuals can direct their lives as they choose.[55] Acting in accordance with the principle of beneficence, peer-support specialists could enhance the capability of patients to be self-determined and autonomous, which would promote patient well-being and empowerment.[56] Those living with SMI, such as schizophrenia and bipolar disorder, are among the most disadvantaged in society, experiencing social and economic hardship related to their illness.[57] These individuals are often feared and rejected by others, which increases depression, lowers self-esteem, and engenders feelings of social isolation.[58] Compounding their challenges, especially for those facing structural inequalities, is insufficient access to appropriate mental health services supporting recovery.[59] Capability theory provides a sound justification for the resource distribution necessary to create and sustain a thriving network of peer-support specialists, to which those with SMI currently do not have access. Establishing this conversion factor would increase the uptake of PADs and motivate continued engagement in treatment, which is crucial for patients with SMI.[60] Governments and private and public mental healthcare organizations should prioritize establishing peer-support facilitator networks to provide those living with SMI with this much-needed resource. Funding should be directed to train peer-support specialists so that available treatment options are clearly communicated and informed consent is achieved. NAMI Peer-to-Peer and Integral Care (Travis County) Peer Support Specialists may provide effective support models. However, policymakers should take note of Virginia's facilitation model implementation efforts and consider potential roadblocks at the state and local levels.[61] Additionally, investment should be made into a nationwide PAD repository that providers can access electronically during intake so that patient preferences are respected throughout treatment. CONCLUSION Those living with severe mental illness experience disproportional disadvantages that limit their ability to access mental health resources that protect their autonomy during a crisis. These disadvantages should be acknowledged and addressed with the creation and sufficient funding of peer-support specialist networks to help these individuals complete and execute psychiatric advance directives during treatment. Efforts that attempt to promote psychiatric advance directive facilitation through providers risk undue influence and poor mental health outcomes, despite the duties of non-maleficence and beneficence. While different models may be explored, peer-support specialists can leverage the advantages of their shared lived experience with patients within a framework of relational autonomy following the principle of beneficence. Capability theory offers state, local, and organizational leaders’ guidance in promoting and justifying peer-support specialist networks, which protect patient autonomy, increase well-being, and decrease harm. PERSONAL PERSPECTIVE As someone who has voluntarily been admitted to a psychiatric health facility twice to treat manic episodes stemming from Bipolar I Disorder, I recognize the autonomy-persevering utility of psychiatric advance directives on a theoretical and experiential level. Through my research and the benefit of hindsight, I believe that a psychiatric advance directive could have facilitated my treatment regimens and perhaps mitigated some of the depersonalization and lack of control I felt. This experience informs my approach and contribution to the academic conversation surrounding the systematic barriers and ethical dilemmas preventing the widespread use of psychiatric advance directives. - [1] Madison K. Kilbride and Steven Joffe, "The New Age of Patient Autonomy," JAMA 320, no. 19 (2018): 1973-1974, https://doi.org/10.1001/jama.2018.14382. [2] Kilbride and Joffe, "The New Age of Patient," 1973-1974. [3] Patient Self-Determination Act, H.R. Res. 5067, 101st Cong. (Nov. 5, 1990) (enacted). [4] Billy Table, Jaime Thomas, and Virginia A. Brown, "Psychiatric Advance Directives as an Ethical Communication Tool: An Analysis of Definitions," The Journal of Clinical Ethics 31, no. 3 (2020): [353-363] [5] Heather Murray and Hal S. Wortzel, "Psychiatric Advance Directives: Origins, Benefits, Challenges, and Future Directions," Journal of Psychiatric Practice 25, no. 4 (2019): 303-307, https://doi.org/10.1097/PRA.0000000000000401. [6] Table, Thomas, and Brown, "Psychiatric Advance," 353-363. [7] J. Swanson et al., "Psychiatric Advance Directives among Public Mental Health Consumers in Five U.S. Cities: Prevalence, Demand, and Correlates.," The Journal of the American Academy of Psychiatry and the Law 34, no. 1 (2006): 43-57. [8] Swanson et al., "Psychiatric Advance," 43-57. [9] Laura S. Shields et al., "A Review of Barriers to Using Psychiatric Advance Directives in Clinical Practice," Administration and Policy in Mental Health and Mental Health Services Research 41, no. 6 (2013): 753-766, https://doi.org/10.1007/s10488-013-0523-3. [10] Charles M. Belden et al., "Appropriateness of Psychiatric Advance Directives Facilitated by Peer Support Specialists and Clinicians on Assertive Community Treatment Teams," Journal of Mental Health 31, no. 2 (2021): 239-245, https://doi.org/10.1080/09638237.2021.1952946.; Shields et al., "A Review," 753-766. [11] Tracy Peto et al., "Support Needed to Create Psychiatric Advance Directives," Administration and Policy in Mental Health 31, no. 5 (2004): 409-419, http://ezproxy.lib.utexas.edu/login?url=https://www.proquest.com/scholarly-journals/support-needed-create-psychiatric-advance/docview/210976273/se-2?accountid=7118. [12] Rachel C. Conrad et al., "Duties toward Patients with Psychiatric Illness," Hastings Center Report 50, no. 3 (2020): 67-69, https://doi.org/10.1002/hast.1139. [13] Murray and Wortzel, "Psychiatric Advance," 303-307. [14] Shields et al., "A Review," 753-766. [15] Christine M. Wilder et al., "A Survey of Stakeholder Knowledge, Experience, and Opinions of Advance Directives for Mental Health in Virginia," Administration and Policy in Mental Health and Mental Health Services Research 40, no. 3 (2013): 232-239, https://doi.org/10.1007/s10488-011-0401-9. [16] Maria J. O’Connell and Catherine H. Stein, "Psychiatric Advance Directives: Perspectives of Community Stakeholders," Administration and Policy in Mental Health 32, no. 3 (2005): 241-265, https://doi.org/10.1007/s10488-004-0843-4. [17] Shields et al., "A Review," 753-766. [18] O’Connell and Stein, "Psychiatric Advance," 241-265. [19] Eric B. Elbogen et al., "Clinical Decision Making and Views about Psychiatric Advance Directives," Psychiatric Services 57, no. 3 (2006): 350-355, https://doi.org/10.1176/appi.ps.57.3.350. [20] Debra Srebnik and Lisa Brodoff, "Implementing Psychiatric Advance Directives: Service Provider Issues and Answers," The Journal of Behavioral Health Services & Research 30, no. 3 (2003): 253-268, https://doi.org/10.1007/BF02287316.; I. Varekamp, "Ulysses Directives in the Netherlands: Opinions of Psychiatrists and Clients," Health Policy 70, no. 3 (2004): 291-301, https://doi.org/10.1016/j.healthpol.2004.03.003. [21] Shields et al., "A Review," 753-766. [22] Richard A. Van Dorn, Jeffrey W. Swanson, and Marvin S. Swartz, "Preferences for Psychiatric Advance Directives among Latinos: Views on Advance Care Planning for Mental Health," Psychiatric Services 60, no. 10 (2009): 1383-1385, https://doi.org/10.1176/ps.2009.60.10.1383. [23] Jeffrey W. Swanson et al., "Psychiatric Advance Directives: A Survey of Persons with Schizophrenia, Family Members, and Treatment Providers," International Journal of Forensic Mental Health 2, no. 1 (2003): 73-86, https://doi.org/10.1080/14999013.2003.10471180. [24] Eric B. Elbogen et al., "Effectively Implementing Psychiatric Advance Directives to Promote Self-determination of Treatment among People with Mental Illness.," Psychology, Public Policy, and Law 13, no. 4 (2007): 273-288, https://doi.org/10.1037/1076-8971.13.4.273. [25] Shields et al., "A Review," 753-766. [26] Marvin S. Swartz et al., "Patient Preferences for Psychiatric Advance Directives," International Journal of Forensic Mental Health 5, no. 1 (2006): 67-81, https://doi.org/10.1080/14999013.2006.10471231. [27] Richard A. Van Dorn et al., "Reducing Barriers to Completing Psychiatric Advance Directives," Administration and Policy in Mental Health and Mental Health Services Research 35, no. 6 (2008): 440-448, https://doi.org/10.1007/s10488-008-0187-6. [28] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (n.p.: Oxford University Press, 2019). [29] Beauchamp and Childress, Principles of Biomedical. [30] Sharad Philip et al., "EAT-PAD: Educating about Psychiatric Advance Directives in India," International Journal of Social Psychiatry 65, no. 3 (2019): 207-216, https://doi.org/10.1177/0020764019834591. [31] Table, Thomas, and Brown, "Psychiatric Advance," 353-363. [32] Julia M. Sheffield, Nicole R. Karcher, and Deanna M. Barch, "Cognitive Deficits in Psychotic Disorders: A Lifespan Perspective," Neuropsychology Review 28, no. 4 (2018): 509, https://doi.org/10.1007/s11065-018-9388-2. [33] Stavroula Tsinorema, "The Principle of Autonomy and the Ethics of Advance Directives," Synthesis Philosophica 59, no. 1 (2015). [34] Marie Chieze et al., "Coercive Measures in Psychiatry: A Review of Ethical Arguments," Frontiers in Psychiatry 12 (2021): https://doi.org/10.3389/fpsyt.2021.790886. [35] Taylor Knopf, "Health Providers Sometimes Ignore Mental Health Patients' Documented Wishes during Treatment," NC Health News, last modified February 7, 2023, https://www.northcarolinahealthnews.org/2023/02/07/health-providers-sometimes-ignore-mental-health-patients-documented-wishes-during-treatment/. [36] Diane McDevitt, "Psychiatric Advance Directives," The Nurse Practitioner 45, no. 4 (2020): 10-13, https://doi.org/10.1097/01.NPR.0000657304.67256.E5. [37] Marvin S. Swartz et al., "Implementing Psychiatric Advance Directives: The Transmitter and Receiver Problem and the Neglected Right to Be Deemed Incapable," Psychiatric Services 72, no. 2 (2021): 219-221, https://doi.org/10.1176/appi.ps.202000659. [38] Michele M. Easter et al., "Impact of Psychiatric Advance Directive Facilitation on Mental Health Consumers: Empowerment, Treatment Attitudes and the Role of Peer Support Specialists," Journal of Mental Health 30, no. 5 (2020): 585-593, https://doi.org/10.1080/09638237.2020.1714008. [39] Michele M. Easter et al., "Facilitation of Psychiatric Advance Directives by Peers and Clinicians on Assertive Community Treatment Teams," Psychiatric Services 68, no. 7 (2017): 717-723, https://doi.org/10.1176/appi.ps.201600423. [40] Belden et al., "Appropriateness of Psychiatric," 239-245. [41] Aurélie Tinland et al., "Effect of Psychiatric Advance Directives Facilitated by Peer Workers on Compulsory Admission among People with Mental Illness," JAMA Psychiatry 79, no. 8 (2022): 752, https://doi.org/10.1001/jamapsychiatry.2022.1627. [42] Beauchamp and Childress, Principles of Biomedical. [43] Beauchamp and Childress, Principles of Biomedical. [44] Shields et al., "A Review," 753-766. [45] Williams, "Comment: Autonomy and the Public-private Distinction in Bioethics and Law," Indiana Journal of Global Legal Studies 12, no. 2 (2005): 483, https://doi.org/10.2979/gls.2005.12.2.483. [46] Carlos Gómez-Vírseda, Yves De Maeseneer, and Chris Gastmans, "Relational Autonomy: What Does It Mean and How Is It Used in End-of-life Care? A Systematic Review of Argument-based Ethics Literature.," BMC Medical Ethics 20, no. 1 (2019): 76, https://doi.org/10.1186/s12910-019-0417-3. [47] Beauchamp and Childress, Principles of Biomedical. [48] Beauchamp and Childress, Principles of Biomedical. [49] Easter et al., "Facilitation of Psychiatric," 717-723. [50] Christine S. Cocanour, "Informed Consent-It's More than a Signature on a Piece of Paper," The American Journal of Surgery 214, no. 6 (2017): 993-997, https://doi.org/10.1016/j.amjsurg.2017.09.015. [51] Easter et al., "Facilitation of Psychiatric," 717-723. [52] Beauchamp and Childress, Principles of Biomedical. [53] Ingrid Robeyns and Morten Fibieger Byskov, "The Capability Approach," Stanford Encyclopedia of Philosophy, last modified December 10, 2020, https://plato.stanford.edu/entries/capability-approach/#toc. [54] Bruce Jennings, "Reconceptualizing Autonomy: A Relational Turn in Bioethics," Hastings Center Report 46, no. 3 (2016): 11-16, https://doi.org/10.1002/hast.544. [55] Beauchamp and Childress, Principles of Biomedical. [56] Easter et al., "Impact of Psychiatric," 585-593. [57] Amy J. Morgan et al., "Interventions to Reduce Stigma towards People with Severe Mental Illness: Systematic Review and Meta-analysis," Journal of Psychiatric Research 103 (2018): 120-133, https://doi.org/10.1016/j.jpsychires.2018.05.017. [58] Rose Weitz, The Sociology of Health, Illness, and Health Care: A Critical Approach, 8th ed. (Cengage, 2020), digital file. [59] Anita Ho and Joshua S. Norman, "Social Determinants of Mental Health and Physician Aid-in-dying: The Real Moral Crisis," The American Journal of Bioethics 19, no. 10 (2019): 52-54, https://doi.org/10.1080/15265161.2019.1654025. [60] Easter et al., "Impact of Psychiatric," 585-593. [61] Heather Zelle, Kathleen Kemp, and Richard J. Bonnie, "Advance Directives for Mental Health Care: Innovation in Law, Policy, and Practice," Psychiatric Services 66, no. 1 (2015): 7-9, https://doi.org/10.1176/appi.ps.201400435.

Novel coronavirus pneumonia strikes the city in 2020, making this year special. It also brings us to the attention of the city's public safety and health problem, which directly affects the city's healthy and sustainable development. During the Spring Festival, a large number of migrant workers in labour-intensive cities and towns returned to their places of residence, forming a large-scale population migration across the country, increasing the difficulty of controlling the epidemic. This paper analyzes the labour migration, medical support, government measures and residents of labour-intensive cities and towns, understands the underlying logic of the epidemic situation, puts forward some solutions for urban disaster prevention and control, and increases urban resilience. It mainly includes: 1) building a population mobility information platform, using big data and network to accurately locate, to guide the later epidemic prevention and control and to prevent secondary infection; 2)To solve the problem of insufficient implementation of urban medical supporting facilities and avoid infection on the way to medical treatment, we should set up a temporary medical treatment point according to the "cell neighbourhood" approach in the city; 3)Make good use of online official channels to shorten the time lag between governments in transmitting information and taking measures; 4) It is significant to encourage residents to join in the epidemic prevention and control, to improve the residents' awareness of prevention and control and the ability to distinguish the authenticity of information.

Abstract This paper discusses the design and control of the driving system of a modern mobile robot which is used for a variety of rough terrains in remote areas to catch ticks. The autonomous robot offers a new solution to the collection of insects employing a mobile robot equipped with a vision system, GPS, and tick collection attachment. The new collection method is designed for US Army medical researchers and other biologists. The method would alter the way the technology gathers insects instead of human manual labor. The robot is designed to work on diverse terrains, such as soft turf, gravel, wet soil, and rocky soil. A robotic solution to tick collection protects humans from a potential illness from bugs and insects, which may carry disease pathogens, injury from traveling across rough ground, and harm due to exposure to the elements. The robotic solution has the potential to apply to other research areas as well. This paper will address the driving system design and control, including motor selection, determining the wheels, power requirements calculation, battery selection, discussion of control methods and diagrams, the coding logics based on ROS, and simulation of the robot in different settings and terrains. The future work is also described at the end of the paper.

This article presents a design method aimed at addressing contradictory requirements during the conceptual design activities or new product development. Of several methods aimed at developing a “good design” (not necessarily solving a contradiction), a general formal method was proposed in the Axiomatic Design Theory (ADT) by NP Suh [1]. ADT views design as a process that translates a set of functional requirements into a set of design parameters through a design matrix. The goal of the axiomatic design is to force a designer to start from scratch and explore the relationship between functions of the product and its design characteristics. Because the design characteristics in this approach are determined from scratch, the contradictions theoretically will be eliminated at a high level, before the design is developed in more detail. The ADT, however, does not offer specific tools to address contradictory requirements. Hegel’s Logic claims that “there is absolutely nothing whatever in which we cannot and must not point to contradictions“[2]. In this paper, we argue that with the right focus, contradictions can be leveraged to develop a stronger design solution. While contradictory requirements to product characteristics arise in almost every project, most often they are addressed by searching for a useful compromise in a highly iterative procedure. A more efficient approach, presented in this paper, satisfies both sides of a contradictory requirement (at different moments of time, or for different parts of the object, or at different sections of its non-linear characteristic). It is shown that in many cases, the most important step is reframing of the initial problem, which can be done by listing contradictory requirements and indicating to which parts of the object / moments of time/ stages of its life cycle they apply. Once it is done, the solution can often transpire from the reformulated problem statement, or can be generated using a very limited set of separation principles. An additional option, which has not been previously recommended for resolving contradictions, is separation of contradictory requirements in the space of material or object parameters, by selecting non-linear material or device characteristics. For instance, a medical device needs to meet different requirements in different tests: high elasticity (for the kink test) and at the same time high strength (for the burst test). This means that the target material should meet contradictory requirements to a single characteristic, its stress-deformation curve. The contradiction can be resolved using the fact that high elasticity (the kink test) is required at relatively low deformations whereas high strength (the burst test) is required at large deformations. Generally, for selection of a non-linear characteristic, it is proposed to use a morphological table with non-linear characteristics of a material or of similar devices based on different operation principles (such as different I-V curves of a current limiting device). Several case studies dealing with different subject matter applications illustrate the proposed method. The case studies include medical devices (peripherally inserted central catheter, vena cava filter), aerodynamic tractor-trailer devices, current limiting devices. The case studies are based on real life projects that resulted in patented designs.