[Reblog] Climate Change and Medical Risk

From the 25 October 2013 post at The Center for Ethics and Humanities in the Life Sciences at Michigan State Universi

This post is a part of our Bioethics in the News series. For more information, click here.

By Sean A. Valles, Ph.D.

 After winning the 2007 Nobel Peace Prize, the UN’s Intergovernmental Panel on Climate Change has returned to the headlines. Heeding the growing body of climate evidence, they say, “it is extremely likely [95%-100% likely] that human influence has been the dominant cause of the observed warming since the mid-20th century” (IPCC Working Group I 2013, pp. SPM-2, SPM-12). Unfortunately, according to a March Gallup poll:

In contrast to majority acceptance of global warming as real, Gallup finds Americans less than alarmed. One-third worry “a great deal,” and 34% expect it to threaten their way of life. These could be the attitudes that matter most when it comes to Americans’ support for public policies designed to address the issue (Saad 2013).

That skepticism about climate change’s seriousness (and, to a lesser extent, about humans’ responsibility for it) is impeding democratic action in the US. The leadership provided by a skeptical vocal minority has turned the public dialogue into a dispute over uncertainties in how we predict future climate, whether it is accusing researchers of inadequate “objectivity” (LaFramboise 2013) or publicizing pieces of climate data that seem inadequately explained (Darwall 2013). I encourage my bioethics colleagues to help change the conversation, and re-frame the US climate change dialogue to focus on one crucial fact: even with lingering uncertainties, climate change poses health risks that we would be foolish to ignore.

A 2009 special report by TheLancet and University College London Institute for Global Health Commission declares, “climate change is the biggest global health threat of the 21st century” (Costello, et al. 2009, p. 1693). These are bold words, especially coming from TheLancet—one of the most prestigious medical journals. The report lists a number of health risks: more numerous heat waves will worsen respiratory and cardiovascular symptoms (Costello, et al. 2009, p. 1702), mosquitoes and mosquito-borne diseases will spread and flourish in newly warm areas (Costello, et al. 2009, p. 1702), and extreme weather events will become more common and stronger (impacting mental health, access to food, access to sanitation infrastructure, etc.) (Costello, et al. 2009, p. 1706). The list goes on, and policy groups such as the EPA have demonstrated that they take it quite seriously. A recent article in Bioethics by Cheryl Cox MacPherson explains that such risks make it clear “Climate Change Is a Bioethics Problem” (MacPherson 2013, p. 305).

Unfortunately, bioethicists’ involvement in the climate change dialogue—a crucialmedical dialogue—has been the exception rather than the norm. Bioethicists are already expert communicators, researchers, interdisciplinary collaborators, and public advocates in the management of multiple intersecting risks and ethical considerations. They apply this expertise to issues such as tissue donation, vaccination, and pharmaceutical testing. I recommend that they add climate change to their list of priorities. Economic constraints, individual liberty, public welfare, being mindful of social justice; these sorts of difficult climate change considerations are very much in bioethicists’ wheelhouse.

Mean surface temperature change for 1999–2008 relative to the average temperatures from 1940 to 1980 (Photo credit: Wikipedia)

Recent research on science communication indicates that pragmatically it would be a wise strategy to move health out of the background in the climate change dialogue. A recent study compared audience responses to three different presentations of climate change, “emphasizing either the risks to the environment, public health, or national security;” the researchers found that, “across audience segments, a public health focus was the most likely to elicit emotional reactions consistent with support for climate change mitigation and adaptation” (Myers, et al. 2012, p. 1105). Maibach et al. explains that the “dominant mental frame used by most members of the public to organize their conceptions about climate change is that of ‘climate change as an environmental problem’” (Maibach, et al. 2010, p. 2). We all hear plenty of talk about ‘saving the environment,’ but switching to a health frame would offer important benefits.

Re-defining climate change in public health terms should help people make connections to already familiar problems such as asthma, allergies, and infectious diseases experienced in their communities. The frame also presents the opportunity to involve additional trusted communication partners on the issue, notably public health experts and local community leaders (Maibach, et al. 2010, pp. 9-10).

Pictures of forlorn polar bears floating on melting blocks of ice have proved compelling for some people, but a health-centered approach looks more promising as a default strategy.

…

Read the entire blog item here

Related articles

• Climate change is real, ignore the denialists (irishtimes.com)
• Pacific nations ‘very disappointed’ by Tony Abbott’s climate scepticism (theguardian.com)
• A new European report on climate extremes is out (realclimate.org)
• International Journal of Global Warming — Special Issue on Loss and Damage from Climate Change (Full Text Reports)
  

  Source: International Journal of Global Warming
  From press release (EurekAlert!):

   

  An open access special issue of the International Journal of Global Warming brings together, for the first time, empirical evidence of loss and damage from the perspective of affected people in nine vulnerable countries. The articles in this special issue show how climatic stressors affect communities, what measures households take to prevent loss and damage, and what the consequences are when they are unable to adjust sufficiently. The guest-editors, Kees van der Geest and Koko Warner of the United Nations University Institute for Environment and Human Security (UNU-EHS) in Bonn, Germany, introduce the special issue with an overview of key findings from the nine research papers, all of which are available online free of charge.

  ‘Loss and damage’ refers to adverse effects of climate variability and climate change that occur despite mitigation and adaptation efforts. Warner and van der Geest discuss the loss and damage incurred by people at the local-level based on evidence from research teams working in nine vulnerable countries: Bangladesh, Bhutan, Burkina Faso, Ethiopia, The Gambia, Kenya, Micronesia, Mozambique and Nepal. The research papers pool data from 3269 household surveys and more than 200 focus groups and expert interviews.

  The research reveals four loss and damage pathways. Residual impacts of climate stressors occur when:

  • existing coping/adaptation to biophysical impact is not enough;
  • measures have costs (including non-economic) that cannot be regained;
  • despite short-term merits, measures have negative effects in the longer term; or
  • no measures are adopted – or possible – at all.

  The articles in this special issue provide evidence that loss and damage happens simultaneously with efforts by people to adjust to climatic stressors. The evidence illustrates loss and damage around barriers and limits to adaptation: growing food and livelihood insecurity, unreliable water supplies, deteriorating human welfare and increasing manifestation of erosive coping measures (e.g. eating less, distress sale of productive assets to buy food, reducing the years of schooling for children, etc.). These negative impacts touch upon people’s welfare and health, social cohesion, culture and identity – values that contribute to the functioning of society but which elude monetary valuation.

   

• The Majority of Americans Recognize the Climate is Changing (sustainableutah.wordpress.com)

 

Experiments in Collaboration: Interdisciplinary Graduate Education in Science and Justice

This grant caught my eye at least partly because I am now reading a rather dense biography on Robert Oppenheimer.
Oppenheimer was the director of the  Manhattan Project, the program that developed the first nuclear weapon during World War II. However, he later became the chairman of the General Advisory Committee of the Atomic Energy Commission,which later opposed the development of the hydrogen bomb. And he went on to support international control of atomic energy.

The Manhattan project, and the larger government-scientific community failed to look at the long term consequences of developing atomic weapons.

So it is refreshing to see, hopefully not too late !, that our government is willing to see the long term consequences of science and technology through grants as this.

From the article at PLos One

Over the past two decades, policy changes at the national level have created an increased focus on science-society relations. An example in the United States has been a subtle but significant shift in the foundational principles of the National Science Foundation (NSF): rather than assume societal benefits directly flow from support of science and engineering, the NSF now explicitly seeks to create knowledge that benefits society [1]–[4]. To achieve this goal, the agency moved in 1997 to adopt the Broader Impacts Criterion (BIC) to review grant proposals [5],[6]. Similarly, the 2007 America COMPETES Act increased ethics education requirements for graduate students and postdoctoral fellows without specifying content[7]–[10]. While these policy changes require scientists and engineers to practice science and engineering in new ways that engage “the public” and benefit “society,” few institutions provide physical spaces for cross-disciplinary contact and intellectual space for figuring out how practically to achieve these ends [10]–[13].

…

SJTP is a graduate-level research and education program that trains science and engineering students alongside students of social science, arts, and humanities to respond to the ethical and social justice questions that arise in their research. Rather than treating justice as a concern to be tacked onto an already formed research project, SJTP graduate fellows are provided with fellowship funding and faculty mentorship that supports them to explore questions of ethics and justice as they arise in their research.

…

The space, funding, and institutional recognition of the program give fellows the opportunity to reorient their research questions, methodologies, and goals around questions of science and justice.

…

 

Some related bioethics resources

• Bioethics Resources on the Web (NIH)
• Bioethics Forum (Hastings)
• BioethicsNet

Related articles

• Why Future Business Leaders Need Philosophy (bigthink.com)
• CATO: against all public funding of science (motls.blogspot.com)
• We need more mainstream social science, not less. (blogs.lse.ac.uk)

Public health extremism (Obama Care, Health Law, and Bioethics)

Johns Hopkins University Press Blog

Guest post by Maxwell J. Mehlman

In a November article for the New England Journal of Medicine, Harvard law professors Michelle Mello and Glenn Cohen argue that in upholding the Affordable Care Act’s individual insurance mandate as a tax the Supreme Court “has highlighted an opportunity for passing creative new public health laws.” As a bioethicist who writes extensively on the question of coercive public health this troubled me on several fronts.  In this case, Mello and Cohen give an example of the laws that they have in mind: higher taxes on people whose body-mass index falls outside of the normal range, who do not produce an annual health improvement plan with their physician, who do not purchase gym memberships, who are diabetic but fail to control their glycated hemoglobin levels, and who do not declare that they were tobacco-free during the past year.

Some of these suggestions seem ineffectual…

View original post 411 more words

[Book] Environmental Health Ethics

From the summary at Cambridge University Press

Environmental Health Ethics illuminates the conflicts between protecting the environment and promoting human health. In this study, David B. Resnik develops a method for making ethical decisions on environmental health issues. He applies this method to various issues, including pesticide use, antibiotic resistance, nutrition policy, vegetarianism, urban development, occupational safety, disaster preparedness, and global climate change. Resnik provides readers with the scientific and technical background necessary to understand these issues. He explains that environmental health controversies cannot simply be reduced to humanity versus environment and explores the ways in which human values and concerns – health, economic development, rights, and justice – interact with environmental protection.

Features

• Develops a method for ethical decision-making for environmental health controversies which incorporates insights from traditional ethical theories and environmental ethics
• Covers a wide range of timely and important issues, ranging from pesticide use to global warming
• Provides a description of the relevant background information accessible to an audience of educated non-specialists

Related articles

• Downloads Environmental Stressors in Health and Disease book (ybiuqfb.typepad.com)
• Street Science: Community Knowledge and Environmental Health Justice (Urban and Industrial Environments) e-book downloads (ymiorip.typepad.com)
• Tulane gets $18.7M for environmental health (miamiherald.com)
• Nano-pesticides: Solution or threat for a cleaner and greener agriculture? (eurekalert.org)
• Sewage Sludge Management: From the Past to Our Century (Environmental Health Physical, Chemical and Biological Factors) ebook (qysaubye.typepad.com)
• Dirty Soil and Diabetes: Anniston’s Toxic Legacy (climatecentral.org)
• Dade W. Moeller Publishes Fourth Edition of Environmental Health Textbook (prweb.com)
• Nano-pesticides: Solution or Threat for a Cleaner and Greener Agriculture? (merid.org)
• Pollution, Poverty, People of Color: No Beba el Agua–Don’t Drink the Water (newamericamedia.org)
• Research identifies specific bacteria linked to indoor water-damage and mold (eurekalert.org)
• UI center awarded $7.9 million grant for investigating environmental heath effects (thegazette.com)
• Good news on using recycled sewage treatment plant water for irrigating crops (eurekalert.org)

Trying to keep up with health care ethics (mis)adventures

From http://www.jsonline.com/features/health/drug-company-money-and-the-rise-of-opiod-usage-139609893.html

The 14 May 2012 HealthNewsReview.org post highlights three biomedical ethics items

• Journalists Bag a Big One: The American Pain Foundation (Reporting on Health, May 14, 2012)

“…The American Pain Foundation – an industry funded promoter of painkillers masquerading as a patient advocacy organization – closed its doors last week after it became the target of a U.S. Senate panel inquiry.The action by the U.S. Senate Finance Committee and the surprisingly quick collapse of the foundation were prompted by two journalistic investigations:The first was Charles Ornstein’s and Tracy Weber’s Dollars for Doctors series for ProPublica. In The Champion of Painkillers, which ran in December in The Washington Post, they describe how aggressive the American Pain Foundation has been in promoting opioids:..

..The other major journalistic investigation to draw the Senate’s attention was by John Fauber at the Milwaukee Journal Sentinel, working in collaboration with MedPage Today. For several years, Fauber has doggedly covered conflicts of interest in academic medicine, ethical problems, the growth in pain medicine and the resulting rise in painkiller addictions and deaths. As part of his Side Effects series, in February 2012, Fauber wrote about the American Pain Foundation and other groups that promote pain pills: Painkiller boom fueled by networking:”

• Making a Name for Yourself in the Ethics Busines (Chronicle of Higher Education, May 22, 2012)

By Carl Elliott

Let’s start with a quiz.  Can you tell which of these awards is real?

A) The Exxon Valdez Prize in Environmental Ethics

B) The Goldman Sachs Endowment in Business Ethics

C) The Richard Milhous Nixon Award for Ethics in Government

D) The Pfizer Fellowship in Bioethics

If you guessed D), you win. …

•  “Missing the Target: When Practitioners Harm More Than Heal.
  Two day conference at Georgetown University, June 14-15,  an Adriane Fugh-Berman’s PharmedOut.org event
  

  Topics Include:

  • “The Underuse of Classic Drugs”
  • “Are Medical Devices and Drugs Adequately Regulated?”
  • “Protecting Patients in Industry-Funded Trials”
  • “Risks of Cardiovascular Devices”
  • “Cancer Risks from CT Scans”
  • “Pharmaceutical Marketing and Adverse Health Outcomes”

   

Related articles

• American Pain Foundation Shuts Down as Senators Launch Investigation of Prescription Narcotics (propublica.org)
• Vets’ pain advocacy group shuts down amid federal investigation (stripes.com)

Academics ‘guest authoring’ ghostwritten medical journal articles should be charged with fraud, legal experts argue

From the 3 August 2011 Medical News Today article

ScienceDaily (Aug. 3, 2011) — Two University of Toronto Faculty of Law professors argue that academics who ‘lend’ their names, and receive substantial credit, as guest authors of medical and scientific articles ghostwritten by industry writers, should be charged with professional and academic misconduct and fraud, even if they contain factually correct information.

In an article published in PLoS Medicine, Professors Simon Stern and Trudo Lemmens argue “Guest authorship is a disturbing violation of academic integrity standards, which form the basis of scientific reliability.” In addition, “The false respectability afforded to claims of safety and effectiveness through the use of academic investigators risks undermining the integrity of biomedical research and patient care.”

In “Legal Remedies for Medical Ghostwriting: Imposing Fraud Liability on Guest Authors of Ghostwritten Articles,” Stern and Lemmens argue that since medical journals, academic institutions, and professional disciplinary bodies have not succeeded in enforcing effective sanctions, a more successful deterrence would be through the imposition of legal liability on the guest authors, “and may give rise to claims that could be pursued in a class action based on the Racketeer Influenced and Corrupt Organizations Act (RICO).”…

Read the entire news article
Journal Reference:
Simon Stern, Trudo Lemmens. Legal Remedies for Medical Ghostwriting: Imposing Fraud Liability on Guest Authors of Ghostwritten Articles. PLoS Medicine, 2011; 8 (8): e1001070 DOI: 10.1371/journal.pmed.1001070

Animals Containing Human Material: Time To Review The Ethics Say UK Scientists

From the 22 July 2011 Medical News Today article

 

Implanting mice with human tumors to test new anti-cancer drugs, injecting rats with human stem cells to find out how the brain repairs itself after a stroke, inserting human genes into the DNA of goats to make a protein that treats human blood clotting disorders; these are some examples of how science uses “animals containing human material” (ACHM). While they are invaluable tools for biomedical research, their use raises serious ethical questions, and a new report released on Thursday from the UK’s Academy of Medical Sciences says it is time to revisit these questions, and recommends the UK government set up an expert body to oversee experiments that use animals containing human material.

The report’s authors say that although the vast majority of research that uses animals containing human material, or “ACHM”, does not raise new ethical or regulatory questions, they are concerned that some sensitive areas like exploring cognition and reproduction, and giving animals human-like physical characteristics, need to be controlled.[Flahiff’s emphasis]..

..An example of a key area they highlighted that concerns scientists and the public, is using ACHM in brain research. What if, inserting human cells into the brains of animals results in animals having human-like “cerebral” functions: to be capable of consciousness, awareness and show human-like behaviour, they ask?

Click here to read the entire news article

Click here to link to the above report (Animals Containing Human Materials)and related downloads 

Related articles

• Regulations proposed for animal – human chimaeras (nature.com)
• Experts warn over humanising apes (independent.co.uk)

nformed-consent forms should be shortened, simplified, bioethicists say

From the Science Daily 15 July 2011 article

An in-depth review of consent forms provided to volunteers for HIV/AIDS research in the United States and abroad about study procedures, risks and benefits has found that the forms were extremely long and used wording that may have been complex enough to hinder full understanding, according to bioethicists at The Johns Hopkins University.
A systematic analysis of 124 informed-consent documents for U.S. government-sponsored, multinational HIV/AIDS research conducted in 2006 revealed that the forms spanned more than 20 pages, says the study’s lead investigator, Nancy Kass, Sc.D., deputy director for public health at the Johns Hopkins Berman Institute of Bioethics.
“While we were familiar with many fairly long consent forms for several different types of studies,” Kass says, “we were honestly surprised to see that the median length was 22 pages, and the median length for adult forms was a full 27 pages.”
Their study, described in the August issue of the Journal of General Internal Medicine, and funded by the National Institute of Allergy and Infectious Diseases, also found that commonly misunderstood research concepts — namely, randomization and placebos — seemed to be explained with far less attention. For instance, whereas confidentiality sections had a median length of about two pages, randomization was treated to just 53 words….

What can we do about death? Reinventing the American medical system

From the 31 May 2011 Eureka News Alert

(Garrison, NY) In a feature article in The New Republic,(subscription only, check your local public library for availability)  Daniel Callahan and Sherwin Nuland propose a radical reinvention of the American medical system requiring new ways of thinking about living, aging, and dying. They argue that a sustainable—and more humane— medical system in the U.S. will have to reprioritize to emphasize public health and prevention for the young, and care not cure for the elderly.

An interesting twist on their argument, which would aim to bring everyone’s life expectancy up to an average age of 80 years but give highest priority for medical treatment to those under 80, is that Callahan and Nuland are themselves 80 years old. Daniel Callahan, Ph.D., is cofounder and president emeritus of The Hastings Center and author most recently of Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System. Sherwin Nuland, M.D., is a retired Clinical Professor of Surgery at the Yale School of Medicine and author of How We Die and the Art of Aging. He is also a Hastings Center Fellow and Board member.

“The real problem is that we have medicine excessively driven by progress, which aims to rid us of death and disease and treats them as the targets of unlimited medical warfare,” said Callahan and Nuland. “That warfare, however, has come to look like the trench warfare of World War I: great human and economic cost for little progress. Neither infectious disease nor the chronic diseases of an aging society will soon be cured. Cancer, heart disease, stroke, and Alzheimer’s disease are our fate for the foreseeable future. Medicine and the public must adapt it to that reality, one that has mainly brought us lives that end poorly and expensively in old age.”

The article notes that the Affordable Care Act might ease the financial burden of this system, but not eliminate it. It reports, for example, that the cost of Alzheimer’s disease is projected to rise from $91 billion in 2005 to $189 billion in 2015, and to $1 trillion in 2025 – twice the cost of Medicare expenditures for all diseases now.

“We need to change our priorities for the elderly. Death is not the only bad thing that can happen to an elderly person,” the authors write. “An old age marked by disability, economic insecurity, and social isolation are also great evils.” They endorse a culture of care, not cure, for the elderly, with a stronger Social Security program and a Medicare program weighted toward primary care that supports preventative measures and independent living.

Callahan and Nuland point the way to a more sustainable path that reprioritizes the entire system. Among their recommendations:

• improve medicine at the level of public health and primary care, while reducing its use for expensive high-tech end-of-life care;
• shift resources for the elderly to greater economic and social security and away from more medical care;
• subsidize the education of physicians, particularly those who go into primary care, and decrease medical subspecialization;
• train physicians better to tell the truth to patients about the way excessively aggressive medicine can increase the likelihood of a poor death;
• shift the emphasis in chronic disease to care rather than cure;
• conduct a top-down, bottom-up, long-range study of the entire American system of health care, including the training of physicians, with a view toward reconstituting it along systematic lines that take science, humanistic concerns, economics, and social issues into account.

Related articles

• Andrew Reinbach: Health Care Could Kill Us: We Don’t Have to Let It (huffingtonpost.com)
• New at Reason: Ronald Bailey on Health Care Reform (reason.com)

Drug Maker Wrote Book Under 2 Doctors’ Names, Documents Say

Entire medical textbook written by pharmaceutical company …”a new level of chutzpah”

Excerpts from the November 2009 NY Times article

Two prominent authors of a 1999 book teaching family doctors how to treat psychiatric disorders provided acknowledgment in the preface for an “unrestricted educational grant” from a major pharmaceutical company.But the drug maker, then known as SmithKline Beecham, actually had much more involvement than the book described, newly disclosed documents show. The grant paid for a writing company to develop the outline and text for the two named authors, the documents show, and then the writing company said it planned to show three drafts directly to the pharmaceutical company for comments and “sign-off” and page proofs for “final approval.”

On a related note…Playing Doctor: How to Spin Pharmaceutical Research

An excerpt from this December 2010 Atlantic article

His first assignment was to produce scientific abstracts for studies of a newly approved antibiotic. Unfortunately, the antibiotic had a major weakness: it did not work against pneumococcus, one of the most common bugs a doctor will see. But this shortcoming was not something that the drug’s manufacturer— hich was funding the articles and abstracts—was keen to point out. So David and his fellow medical writers were told to avoid the topic.

Seven Ways Medical Conflicts of Interest Are Disguised

From a November 22, 2010 blog item by Martha Rosenberg

Still, disclosure is tricky for medical journals whose lifeblood is often drug ads and reprints of articles for drug companies to pass out to physicians. Here are some of the ways conflicts of interest are finessed. 


Omnibus Disclosure. All of a study’s authors are listed with all the pharma links in one block of solid type. Who goes with whom? You’ll never know, but the author with no links sure isn’t happy about shared guilt. 


Initials. “R.L.T. has consulted for Merck” is set in 8-point type at the end of the article. Will readers return to the study’s start, five pages ago, where there are eight authors, four with first names that begin with R? 


Disclosures You Have to Work For. COIs of CME faculty are often given online, but the information is tucked away in a pull-down, scroll menu. It is user-unfriendly—like the drug side effects found on the scrolling ads on the same site. 


One Disclosure Is Enough. When a previous article is cited in journal letters sections, the author disclosures are said to “be found with the original article.” Surely you have that issue, published four months ago, on your desk. 


Protective Coloring. Disclosures of drug company links are embedded between government grants and charitable foundations. Government grants and charitable foundations are not conflicts of interest. 


Paying Customers Only. Twenty million citations of medical literature appear on the U.S. National Library of Medicine website. Many have authors’ institutions and e-mails. But do the abstracts show COIs? Not unless you’re a paid subscriber. Password please. 


Paying Customers Only, Even When You Are Reading a Hard Copy. In hard copies of the Aug. 5 New England Journal of Medicine (NEJM), the disclosures of authors of “Suicide-Related Events in Patients Treated with Antiepileptic Drugs” are absent and said to be found with the “full text” of the article at NEJM.org. 



Online Tutorials Now Available for Bioethics Information

From a  November 24 Medlib-L(medical librarian)posting

The Bioethics Research Library at Georgetown (BRL) has developed a
1-minute Adobe Captivate tutorial for utilizing PubMed’s bioethics
subset limit.  This tutorial is available both as a Flash file
(http://bioethics.georgetown.edu/databases/howtosearch/) and as a Vimeo
video (http://vimeo.com/16661510)

BRL also has developed tutorials for its ETHXWeb (covers most topics in
bioethics), GenETHX (covers human genetics and ethics topics),
International Bioethics Organizations, and Syllabus Exchange databases.
The GenETHX tutorial demonstrates accessing the Bioethics Thesaurus
Database to identify appropriate search terms for complex concepts.
Bioethics Thesaurus terms, many of which are included in MeSH, are
useful for refining searches as well as for creating bioethics keyword
tags for online documents.

Links to the BRL database tutorials can be found at:
http://bioethics.georgetown.edu/databases/howtosearch/

An Express Library Technology Improvement Award from the
Southeastern/Atlantic Region of the National Network of Libraries of
Medicine enabled BRL to develop these tutorials.

Kathleen Schroeder, M.D., M.S.I
Subject Specialist, Science and Technology
Bioethics Research Library, Georgetown University