Cloning - National Academy of Sciences and Human Cloning :: Argumentative Persuasive Topics

National Academy of Sciences: Human Cloning The National Academy of Sciences (NAS) made headlines when it issued a broadside that would, if followed by Congress, grant an open-ended license for biotech researchers to clone human life. True, the NAS recommended that Congress ban "reproductive" cloning, that is, the use of a cloned embryo to produce a born baby. But it also urged that human cloning for purposes of experimentation--often called "therapeutic" or "research" cloning--remain unimpeded by legal restrictions. Such a public policy would permit virtually unlimited human cloning--so long as all the embryos created thereby were destroyed rather than implanted in a woman's womb. The recommendation from a well-known scientific organization did not appear at this particular time by coincidence. The Senate will soon consider S. 790, legislation authored by Sam Brownback (R-KS) that would prohibit any creation of human clones--whether for research purposes or for reproduction. The House passed a virtually identical ban in a bipartisan vote last summer, and President Bush strongly supports the bill. Thus the legal future of human cloning--and the potential fortunes to be made by Big Biotech in the United States--hang in the balance in the Brownback bill. Limiting the ban on human cloning to procedures designed to lead to the birth of a baby would accomplish next to nothing. Figuring out how to clone human life successfully is going to be very difficult. Thus, early research would likely focus on perfecting techniques. Should this be successful, researchers would next attempt to maintain the resulting embryonic clone for a week to two weeks--long enough to harvest their stem cells. (The biotech company Advanced Cell Technology announced it has created human clones and maintained them to the six-cell stage(Advanced), which is not long enough for stem cells to appear.) Should the stem-cell Rubicon be crossed, implantation of the embryonic clone would then be relatively easy. Hence, the next natural (dare I use the word?) step would be the manufacture of human clones not just for research or genetic manipulation but for implantation, gestation, and birth. In any case, the morally serious question is whether human cloning is permissible-- not when those cloned should be killed once created. Much as an original oil painting can be seen only dimly beneath its patina, an agenda to eventually permit unrestricted cloning for all purposes can be discerned between the lines in the NAS report.

Carrie Chapter Seventeen

That this was happening in Chamberlain, in Chamberlain, for God's sake, where he drank iced tea on his mother's sun porch and refereed PAL basketball and made one last cruise out Route 6 past The Cavalier before turning in at 2:30 every morning. His town was burning UP. Tom Quillan came out of the police station and ran down the sidewalk to Doyle's cruiser. His hair was standing up every which way, he was dressed in dirty green work fatigues and an undershirt and he had his loafers on the wrong feet, but Doyle thought he had never been so glad to see anyone in his life. Tom Quillan was as much Chamberlain as anything, and he was thereintact. ‘Holy God,' he panted. ‘Did you see that?' ‘What's been happening?' Doyle asked curtly. ‘I been monitorin' the radio,' Quillan said, ‘Motton and Westover wanted to know if they should send ambulances and I said bell yes, send everything. Hearses too. Did I do right?' ‘Yes.' Doyle ran his hands through his hair. ‘Have you seen Harry Block?' Block was the town's Commissioner of Public Utilities, and that included water. ‘Nope. But Chief Deighan says they got water in the old Rennet Block across town. They're laying hose now. I collared some kids, and they're settin' up a hospital in the police station. They're good boys, but they're gonna get blood on your floor, Otis.' Otis Doyle felt unreality surge over him. Surely this conversation couldn't be happening in Chamberlain. Couldn't. ‘That's all right, Tommy. You did right. You go back there and start calling every doctor in the phone book. I'm going over to Summer Street.' ‘Okay, Otis. If you see that crazy broad, be careful.' ‘Who?' Doyle was not a barking man, but now he did. Tom Quillan flinched back. ‘Carrie, Carrie White.' ‘Who? How do you know?' Quillan blinked slowly. ‘I dunno. It just sort of †¦ came to me.' From the national AP ticker, 11:46 Pm: CHAMBERLAIN, MAINE (AP) A DISASTER OF MAJOR PROPORTIONS HAS STRUCK THE TOWN OF CHAMBERLAIN, MAINE TONIGHT. A FIRE, BELIEVED TO HAVE BEGUN AT EWEN (U-WIN) HIGH SCHOOL DURING A SCHOOL DANCE, HAS SPREAD TO THE DOWNTOWN AREA, RESULTING IN MULTIPLE EXPLOSIONS THAT HAVE LEVELLED MUCH OF THE DOWNTOWN AREA. A RESIDENTIAL AREA TO THE WEST OF THE DOWNTOWN AREA IS ALSO REPORTED TO BE BURNING. HOWEVER, MOST CONCERN AT THIS TIME IS OVER THE HIGH SCHOOL WHERE A JUNIOR-SENIOR PROM WAS BEING HELD. IT IS BELIEVED THAT MANY OF THE PROM-GOERS WERE TRAPPED INSIDE. AN ANDOVER FIRE OFFICIAL SUMMONED TO THE SCENE SAID THE KNOWN TOTAL OF DEAD STOOD AT SIXTY-SEVEN. MOST OF THEM HIGH SCHOOL STUDENTS. ASKED HOW HIGH THE TOTAL MIGHT GO HE SAID: ‘WE DON'T KNOW. WE'RE AFRAID TO GUESS. THIS IS GOING TO BE WORSE THAN THE COCONUT GROVE.' AT LAST REPORT THREE FIRES WERE RAGING OUT OF CONTROL IN THE TOWN. REPORTS OF POSSIBLE ARSON ARE UNCONFIRMED. ENDS. 11:56 PM MAY 27 8943F AP There were no more AP reports from Chamberlain. At 12:06 AM., a Jackson Avenue gas main was opened. At 12:17, an ambulance attendant from Motton tossed out a cigarette butt as the rescue vehicle sped toward Summer Street. The explosion destroyed nearly half a block at a stroke, including the offices of The Chamberlain Clarion. By 12:18 A.M.. Chamberlain was cut off from the country that slept in reason beyond. At 12:10, still seven minutes before the gas-main explosion, the telephone exchange experienced a softer explosion: a complete jam of every town phone line still in operation. The three harried girls on duty stayed at their posts but were utterly unable to cope. They worked with expressions of wooden horror on their faces, trying to place unplaceable calls. And so Chamberlain drifted into the streets. They came like an invasion from the graveyard that lay in the elbow creek formed by the intersection of The Bellsqueeze Road and Route 6; they came in white nightgowns and in robes, as if in winding shrouds. They came in pyjamas and curlers (Mrs Dawson, she of the now-deceased son who had been a very funny fellow, came in a mudpack as if dressed for a minstrel show); they came to see what happened to their town, to see if it was indeed lying burnt and bleeding. Many of them also came to die. Carlin Street was thronged with them, a riptide of them, moving downtown through the hectic light in the sky, when Carrie came out of the Carlin Street Congregational Church, where she had been praying. She had gone in only five minutes before, after opening the gas main (it had been easy; as soon as she pictured it lying there under the street it had been easy), but it seemed like hours. She had prayed long and deeply, sometimes aloud, sometimes silently. Her heart thudded and laboured. The veins on her face and neck bulged. Her mind was filled with the huge knowledge of POWERS, and of an ABYSS. She prayed in front of the altar, kneeling in her wet and torn and bloody gown, her feet bare and dirty and bleeding from a broken bottle she had stepped on. Her breath sobbed in and out of her throat, and the church was filled with groanings and swayings and sunderings as psychic energy sprang from her. Pews fell, hymnals flew, and a silver Communion set cruised silently across the vaulted darkness of the nave to crash into the far wall. She prayed and there was no answering. No one was there – or if there was, He/It was cowering from her. God had turned His face away, and why not? This horror was as much His doing as hers. And so she left the church, left it to go home and find her momma and make destruction complete. She paused on the lower step, looking at the flocks of people streaming toward the centre of town. Animals. Let them burn, then. Let the streets be filled with the smell of their sacrifice. Let this place be called racca, ichabod, wormwood. Flex And power transformers atop lightpoles bloomed into nacreous purple light, spitting catherine-wheel sparks. High-tension wires fell into the streets in pick-up-sticks tangles and some of them ran, and that was bad for them because now the whole street was littered with wires and the stink began, the burning began. People began to scream and back away and touched the cables and went into jerky electrical dances. Some had already slumped into the street, their robes and pyjamas smouldering. Carrie turned back and looked fixedly at the church she had just left. The heavy door suddenly swung shut, as if in a hurricane wind. Carrie turned towards home. From the sworn testimony of Mrs Cora Simard, taken before The State Investigatory Board (from The White Commission Report). pp. 217-218: Q. Mrs Simard, the Board, understands that you lost your daughter on Prom Night, and we sympathise with you deeply. We will make this as brief as possible. A. Thank you. I want to help if I can, of course. Q. Were you on Carlin Street at approximately 12.12 when Carietta White came out of the First Congregational Church on that street? A. Yes. Q. Why were you there? A. My husband had to be in Boston over the weekend on business and Rhonda was at the Spring Ball. I was home alone watching TV and waiting up for her. I was watching the Friday Night Movie when the town hall whistle went off, but I didn't connect that with the dance. But then the explosion †¦ I didn't know what to do. I tried to call the police but got a busy signal after the first three numbers. I †¦ I†¦Then †¦ Q. Take your time, Mrs Simard. All the time you need. A. I was getting frantic. There was a second explosion – Teddy's Amoco station, I know now – And I decided to go downtown and see what was happening. There was a glow in the sky, an awful glow. That was when Mrs Shyres pounded on the door. Q. Mrs Georgette Shyres? A. Yes, they live around the corner. 217 Willow. That's just of Carlin Street. She. was pounding and calling: ‘Cora, are you in there? Are you in there?' I went to the door. She was in her bath-robe and slippers. Her feet looked cold. She said they had called Auburn to see if they knew anything and they told her the school was on fire. I said: ‘Oh dear God, Rhonda's at the dance.' Q. Is this when you decided to go downtown with Mrs Shyres? A. We didn't decide anything. We just went. I put on a pair of slippers – Rhonda's, I think. They had little white puffballs on them. I should have worn my shoes, but I wasn't thinking. I guess I'm not thinking now. What do you want to hear about my shoes for? Q. You tell it in your own way, Mrs Simard. A. T-Thank you. I gave Mrs Shyres some old jacket that was around, and we went. Q. Were there many people walking down Carlin street? A. I don't know. I was too upset. Maybe thirty. Maybe more. Q. What happened? A. Georgette and I were walking toward Main Street, holding hands just like two little girls walking across a meadow after dark. Georgette's teeth were clicking. I remember that. I wanted to ask her to stop clicking her teeth, but I thought it would be impolite. A block and a half from the Congo Church, I saw the door open and I thought: Someone has gone in to ask God's help. But a second later I knew that wasn't true. Q. How did you know? It would be logical to assume just what you first assumed, wouldn't it? A. I just knew. Q. Did you know the person who came out of the church? A. Yes. It was Carrie White. Q. Had you ever seen Carrie White before? A. No. She was not one of my daughter's friends. Q. Had you ever seen a picture of Carrie White? A. No. Q. And in any case, it was dark and you were a block and a half from the church. A. Yes, sir. Q. Mrs Simard, how did you know it was Carrie White? A. I just knew. Q. This knowing, Mrs Simard: was it like a light going on in your head? A. No, sir. Q. What way it A. I can't tell you. It faded away the way a dream does. An hour after you get up you can only remember you had a dream. But I knew. Q. Was there an emotional feeling that went with this knowledge? A. Yes. Horror. Q. What did you do then? A. I turned to Georgette and said: There she is. Georgette said: ‘Yes, that's her.' She started to say something else, and then the whole street was lit up by a bright glow and there were crackling noises and then the power lines started to fall into the street, some of them spitting live sparks. One of them hit a man in front of us and he b-burst into flames. Another man started to run and he stepped on one of them and his body just arched backward, as if his back had turned into elastic. And then he fell down. Other people were screaming and running, just running blindly, and more and more cables fell. They were strung all over the place like snakes. And she was glad about it. Glad! I could feel her being glad. I knew I had to keep my head. The people who were running were getting electrocuted. Georgette said: ‘Quick, Cora. Oh God, I don't want to get burned alive.' I said, ‘Stop that. We have to use our heads, Georgette, or we'll never use them again.' Something foolish like that. But she wouldn't listen. She let go of my hand and started to ran for the sidewalk. I screamed at her to stop – there was one of those heavy main cables broken off right in front of us – but she didn't listen. And she †¦ she†¦ oh, I could smell her when she started to burn. Smoke just seemed to burst out of her clothes and I thought: that's what it must be like when someone gets electrocuted. The smell was sweet like pork. Have any of you ever smelled that? Sometimes I smell it in my dreams. I stood still, watching Georgette Shyres turn black. There was a big explosion over in the West End-the gas main, I suppose – but I never even noticed it. I looked around and I was all alone. Everyone else had either run away or was burning. I saw maybe six bodies. They were like piles of old rags. One of the cables had fallen on to the porch of a house to the left, and it was catching on fire. I could hear the old-fashioned shake shingles poppin g like Corn. it seemed like I stood there a long time, telling myself to keep my head. It seemed like hours. I began to be afraid that I would faint and fall on one of the cables, or that I would panic and start to run. Like †¦ like Georgette. So then I started to walk. One step at a time. ‘Me street got even brighter, because of the burning house. I stepped over two live wires and went around a body that wasn't much more than a puddle. I-I-I had to look to see where I was going. There was a wedding ring on the body's hand, but it was all black. All black. Jesus, I was Oh dear Lord. I stepped over another one and then there were three, all at once. I just stood there looking at them. I thought if I got over those I'd be all right but †¦ I didn't dare. Do you know what I kept thinking of? That game you play when you're kids, Giant Step. A voice in my mind was saying, Cora, take one giant step over the live wires in the street. And I was thinking May P May P One of the m was still spitting a few sparks, but the other two looked dead. But you can't tell. The third rail looks dead too. So I stood there, waiting for someone to come and nobody did. The house was still burning and the flames had spread to the lawn and the trees and the hedge beside it. But no fire trucks came. Of course they didn't. The whole west side was burning up by that time. And I felt so faint. And at last I knew it was take the giant step or faint and so I took it, as big a giant step as I could, and the heel of my slipper came down not an inch from the last wire. Then I got over and went around the end of one more wire and then I started to run. And that's all I remember. When morning came I was lying on a blanket in the police station with a lot of other people. Some of them – a few-were kids in their prom get-ups and I started to ask them if they had seen Rhonda. And said †¦ they s-s-said †¦ (A short recess) Q. You are personally sure that Carrie White did this? A. Yes. Q. Thank you, Mrs Simard. A. I'd like to ask a question, if you please. Q. Of course. A. What happens if there are others like her? What happens to the world? From The Shadow Exploded (p. 15 1): By 12:45 on the morning of May 28, the situation in Chamberlain was critical. The school had burned itself out on a fairly isolated piece of ground, but the entire downtown area was ablaze. Almost all the city water in that area had been tapped, but enough was available (at low pressure) from Deighan Street water mains to save the business buildings below the intersection of Main and Oak a~. The explosion of Tony's Citgo on upper Summer Street had resulted in a ferocious fire that was not to be controlled until nearly ten o'clock that morning. There was water on Summer Street, there simply were no firemen or fire-fighting equipment to utilize it. Equipment was then on its way from Lewiston, Auburn, Lisbon and Brunswick, but nothing arrived until one o'clock. On Carlin Street, an electrical fire, caused by downed power lines, had begun. It was eventually to gut the entire north side of the street, including the bungalow where Margaret White gave birth to her daughter. On the west end of town, just below what is commonly caned Brickyard Hill, the worst disaster had taken place. The explosion of a gas main and a resulting fire that raged out of control through most of the next day. And if we look at these flash points on a municipal map (see page facing), we can pick out Carrie's route – a wandering, looping path of destruction through the town, but one with an almost certain destination: home †¦ Something toppled over in the living room, and Margaret White straightened up, cocking her head to one side. The butcher knife glittered dully in the light of the flames. The electric power had gone off sometime before, and the only fight in the house came from the fire up the street. One of the pictures fell from the wall with a thump. A moment later the Black Forest cuckoo clock fell. The mechanical bird gave a small, strangled squawk and was still. From the town the sirens whooped endlessly, but she could still hear the footsteps when they turned up the walk. The door blew open. Steps in the hall. She heard the plaster plaques in the living room (CHRIST, THE UNSEEN GUEST, WHAT WOULD JESUS DO, THE HOUR DRAWETH NIGH; IF TONIGHT BECAME JUDGMENT, WOULD YOU BE READY) explode one after the other, like plaster birds in a shooting gallery. (o i've been there and seen the harlots shimmy on wooden stages) She sat up on her stool like a very bright scholar who has gone to the head of the class, but her eyes were deranged. The living-room windows blew outward. The kitchen door dammed and Carrie walked in. Her body seemed to have become twisted, shrunken, cronelike. The prom dress was in tatters and flaps, and the pig blood had began to clot and streak. There was a smudge of grease on her forehead and both knees were scraped and raw-looking. ‘Momma,' she whispered. Her eyes were preternaturally bright, hawklike, but her mouth was trembling. If someone had been them to watch, he would have been struck by the resemblance between them. Margaret White sat on her kitchen stool, the carving knife hidden among the folds of her dress in her lap. ‘I should have killed myself when he put it in me,' she said clearly. ‘After the first time, before we were married, he promised. Never again. He said we just †¦ slipped. I believed him. I fell down and I lost the baby and that was God's judgment. I felt that the sin had been expiated. By blood. But sin never dies. Sin †¦ never †¦ dies.' Her eyes glittered. ‘Momma' ‘At first it was all right. We lived sinlessly. We slept in the same bed, belly to belly sometimes, and O, I could feel the presence of the Serpent, but we never did until.' She began to grin, and it was a hard, terrible grin. ‘And that night I could see him looking at me That Way. We got down on our knees to pray for strength and he†¦ touched me. In that place. That woman place. And I sent him out of the house. He was gone for hours, and I prayed for him. I could see him in my mind's eye, walking the midnight streets, wrestling with the devil as Jacob wrestled with the Angel of the Lord. And when he came back, my heart was filled with thanksgiving.' She paused, grinning her dry, spitless grin into the shifting shadows of the room. ‘Momma, I don't want to hear it!' Plates began to explode in the cupboards like clay pigeons. ‘It wasn't until he came in that I smelled the whiskey on his breath. And he took me. Took me! With the stink of filthy roadhouse whiskey still on him he took me †¦ and I liked it She screamed out the last words at the ceiling. ‘I liked it o all that dirty fucking and his hands on me ALL OVER ME!' ‘MOMMA!' (MOMMA!!) She broke off as if slapped and blinked at her daughter ‘I almost killed myself,' she said in a more normal tone of voice. ‘And Ralph wept and talked about atonement and I didn't and then he was dead and then I thought God had visited me with cancer; that He was turning my female parts into something as black and rotten as my sinning soul. But that would have been too easy. The Lord works in mysterious ways, His wonders to perform. I see that now. When the pains began I went and got a knife – this knife-‘ she held it up ‘-and waited for you to come so I could make my sacrifice. But I was weak and backsliding. I took this knife in hand again when you were three, and I backslid again. So now the devil has come home.' She held the knife up, and her eyes fastened hypnotically on the glittering hook of its blade. Carrie took a slow, blundering step forward.

Nursing Dissertations - Diabetes Mellitus Affects About 2% Of The UK Population - Nursing Dissertations - Free Essay Example

Sample details Pages: 9 Words: 2686 Downloads: 2 Date added: 2017/06/26 Category Statistics Essay Did you like this example? A holistic nurse prescribing: a case study Introduction Don’t waste time! Our writers will create an original "Nursing Dissertations Diabetes Mellitus Affects About 2% Of The UK Population Nursing Dissertations" essay for you Create order 1 the patient and their presenting symptoms. Mr Pickles presents an interesting, complex and therapeutically challenging problem. In essence he is a gentleman with multisystem pathology who presents with an almost incidental finding which he was clearly reluctant to discuss. It is a common finding amongst experienced healthcare professionals that in any consultation it is the last 30 seconds which is the most important. As the patient stands up to go, there is the just while Im here moment when they can bring up an issue that really troubles them and may not be the real presented reason for the consultation. In this essay we shall discuss the various aspects of this situation and the measures we can take to try to help him. (Parker and Lawton 2003) 2.a holistic assessment of the pt, including any relevant medical social and psychological issues. If we start with the initial presenting symptom under discussion the impotence it is easier to work backwards from that to discuss the possible pathophysiology that can be relevant. Impotence is said to occur whenever the male fails to get an erection when it is required. This, in itself is neither unusual nor necessarily pathological. It becomes a significant symptom when the male repeatedly fails to get an erection that is sufficient for intercourse. It is quite possible to get full spontaneous erections and yet still be impotent. This is one of the major diagnostic features that distinguishes the psychogenic impotence from the purely physical. (Ackerman MD, Carey MP. 1995) There are a number of obvious physical causes of erectile dysfunction that are relevant to Mr Pickles (see on), but equally there are a number of possible psychogenic causes that may be either primary factors or possibly secondary contributory factors in the aetiology of his problems. The fact that he has recently undergone major cardiac surgery is a very relevant factor. Patients will frequently suffer from a major change in body perception when they have come to a close realisation of their own mortality. If we add to this the fact that, as the major breadwinner in the family, it is likely that Mr Pickles would have felt a major blow to his self-esteem when he was made redundant from a responsible high esteem job and forced to become a taxi driver with long working hours. This is quite apart from the anxiety and fatigue that such a job would engender.(Beck J. 1995) It is possible that the medication that Mr Pickles is taking may have a bearing on his erectile dysfunction as the male erection is dependent on the hydrostatic pressure of the blood for its maintenance. Any medication that reduces the average blood pressure, will effectively reduce the capacity to acquire and maintain an erection. In addition to this the adrenergic beta-blocker group will also selectively block the sympathetic pathways that are vital to the neurovascular control of the mechanisms of erection. Pathophysiology of diabetes and impotence Both of these topics are huge subjects, so in this essay we will restrict out considerations to those aspects which are relevant to Mr Pickles and his problems. We know that Diabetes Mellitus affects about 2% of the UK population with a specifically higher incidence in both the Asian and Afro-Caribbean communities(Nathan 1998). There is also a marked genetic component in the development of Diabetes Mellitus. Mr Pickles has Type II diabetes mellitus which is associated with a number of factors including a high BMI and increasing age. At 56 yrs. old he is currently at the peak incidence age for Type II diabetes mellitus (Gregg et al. 2003). Diabetes Mellitus is known to be associated with a number of complications. The prevalence and incidence of the complications, in general, tends to increase with the length of time that the patient has been diabetic. There is also an independent variable for complications that is directly proportional to the degree of control (as measured by the HbA1 levels). In general terms, the better the control the lower the incidence of complications (Kissebah et al. 1999) As far as Mr Pickles is concerned, there are two major complications of Type II diabetes mellitus that are directly linked with impotence and they are cardio-(macro)vascular disease and neuropathy. (Wagner et al. 1998) We can deduce that Mr Pickles has macrovascular disease by virtue of the fact that he his recovering from a CABG. And this may well be a very relevant factor in his erectile dysfunction but also there is the question of neuropathy which typically occurs in about 2.4% of the general population, but this figure rises to above 8% in the diabetic patient over the age of 60 yrs. ( Hughes 2002) Impotence tends to occur, in varying degrees, in about 10-15% of men under 40 yrs. Its incidence increases with age to the extent that 40% of men at the age of 40 yrs report a degree of impotence and this prevalence rises to 70% at the age of 70 yrs. (Gregoire 1999). If we add to this basic clinical picture the fact that there are other factors such as hypertension, smoking, cardiac neurosis, loss of self-confidence, depression and iatrogenic causes (medication etc.) all of which may well be relevant to Mr Pickles, then it can be seen that there are a plethora of potential causes of his erectile dysfunction. (Barnes, DE. 2004) Both of the first two causes (hypertension and smoking) are independent risk factors for impotence, quite apart for the fact that they are also risk factors for the development of the macrovascular complications of Diabetes Mellitus (Bowering 2001) Mr Pickles diabetic state has been recently well controlled (HbA1 of 6.5%). This is important as the incidence of development of diabetic complications is reduced by between 34-76% (depending on the particular study) for every 10% reduction in the average HbA1 reading. (Bowering 2001). In addition to all of these considerations, atherosclerosis is also a major complication of Type II diabetes mellitus, which, presumably is relevant to Mr Pickles because of his CABG, and this may be a major factor in the development of his erectile dysfunction. Management plan 3.a plan/strategy based on critical understanding of physiological and pharmaceutical issues. Any management plan must firstly be based on an accurate diagnosis. At this point in time we do not have this luxury. As we have discussed, there are anyone of a huge number of possibilities in the aetiology of Mr Pickles erectile dysfunction problem. When confronted with a problem such as this, any experienced healthcare professional may reasonably chose to manage the problem by making a rational judgement of the probabilities of any one particular cause being relevant. Implicit in such a management strategy is the fact that there are some causes that my be correctable (iatrogenic, psychological, and life style related) and there are some that may not (macrovascular damage, neuropathy and atherosclerosis). It is reasonable, in such circumstances, to discuss the situation openly with Mr Pickles and discuss with him the various treatment options. Patient empowerment and education is a vital strategy to adopt in circumstances such as this as Mr Pickles is far more likely to comply and respond if he understands the rationale behind the treatment plan.(Howe and Anderson 2003) We would suggest that an appropriate strategy would be to initially tackle the situation on two fronts. The psychological aspects of the erectile dysfunction are probably best discussed with an experienced psychologist or councillor who has expertise in this particular area. This is important because there is a considerable skill in eliciting the relevant factors from the patient. Many patients are reticent about talking openly about their imitate sexual details and there has to be a careful build up of trust and empathy on both sides. Factors such as good eye contact and a non-judgemental body stance are essential on the part of the healthcare professional if the optimal result is to be obtained Not only can the issues that are relevant be explored, but also any one of a number of psychological treatment techniques can be employed. This is a matter of considerable clinical judgement and skill and therefore probably best done by an experienced healthcare professional in that area. The pharmaceutical area can also be addressed as Atenolol is clearly not the best anti hypertensive to use as, not only will it reduce the blood pressure (which it clearly is important to do) but it also produces a counter productive beta-blockade which will not help the erectile dysfunction problem. The difficulty is that, after the CABG, Atenolol does have a degree of action on the suppression of ectopic electrophysiological foci in the myocardium which is a recognised complication of the procedure. It also is thought to have a cardioprotective effect post-myocardial infarction. It is probably a good idea to change his anti-hypertensive medication, but in the circumstances, it is probably better to seek the advice of the surgical team who performed the CABG. before making the transition. The question of Viagra has been raised by Mr Pickles. This is not as straight forward as it might initially appear. Viagra has been shown to work well in these circumstances. It has the downside that it allows sexual intercourse which is associated with increased peaks of blood pressure. As Mr Pickles is still in the postoperative recovery phase (16 weeks) it would again be sensible to consult with the surgical team as to their advice on the issue. The other problem with Viagra is that if it transpires that the long term aetiology is actually psychological rather than purely physical, then the prescription of Viagra will often breed a feeling of psychological dependence which may firstly be both inappropriate and unnecessary and secondly, very hard to break. It is probably therefore inappropriate to consider such options at this stage in the management. 4.legal and professional accountability should be discussed. The legal and professional issues are largely covered in the making of a management plan. In any area of professional competence, the best defence against criticism or censure, is the fact that a healthcare professional works from a rational evidence-based plan. It is for this reason that we have set out the rational and reasoning for the plan that we have chosen to adopt. It is actually quite permissible (legally) for a healthcare professional to be wrong on any given issue, as long as they have come to a reasoned and rational decision based on the facts that were placed before them. And behaved in a way that the majority of their professional colleagues believe is reasonable in the circumstances. It is, of course, central to these considerations, that all actions are carefully and fully recorded in the patients notes Prescribing decisions 5.a critical discussion of influences on prescribing decisions. The area of prescribing for Mr Pickles is clearly important. To some extent, we have covered the reasoning behind the change of prescription earlier in this essay. There is a common misconception amongst many members of the public (and indeed many of the less experienced healthcare professionals) that the solution to every problem comes in the form of tablets on a prescription. The whole area of patient empowerment and education is often filled with issues of lifestyle change, healthy living, self care and positive thinking which can frequently be more effective that simply giving the patient a prescription. (Boule NG et al. 2001) In the context of the NHS, it is a common observation that sometimes a prescription is given because it is the most expedient short-term measure in a given situation, (Dawes RM et al. 1974), however, time invested in an explanation to a patient as to why other measures might be equally as important is rarely time wasted., (Corrigan B. 1974) Future management 6.consider your future prescribing activity based on experience gained from this case study. In any professional area of activity, the author likes to use the mechanism of reflective practice to allow a critical assessment of a past course of action to modify future actions when faced with a similar situation. (Gibbs, G 1988) On careful reflection of this case, I believe that I may have acted rather rashly in stopping the Atenolol as a first choice. On reflection, I believe that the Atenolol did need to be changed for any one of a number of other anti-hypertensive agents but I feel that, in retrospect, I would have been wiser to take advice from the surgical team before I made that decision. Further reflection and discussion with other healthcare professionals (Marks-Moran Rose 1996), suggested that another appropriate course of action would have been to stop the antihypertensive medication altogether for a short period. This is on the grounds that his hypertension was not severe and was hitherto well controlled. If the erectile dysfunction was simply a reflection of the fact that the medication was holding his blood pressure down to a level where erection could not easily occur, a few days off the medication may allow a transient increase in his blood pressure to the point that erection could occur. As long as one was careful to monitor his blood pressure to ensure that it did not rise too far, I have been advised that this would represent a reasonable therapeutic trial to establish whether the underlying causes were mainly physical or physiological.(Wagner G et al 1998). On the face of it, this does seem reasonable but I believe that I would have to take further advice before I was fully comfortable with that decision. It follows from what has already been discussed, that I also feel that I may have been too quick to consider the pharmacological interventions before making a complete holistic assessment of the patient. There are clearly a number of lifestyle adjustments that may be relevant here such as weight loss and increasing exercise and looking for a new focus in life (to minimise any element of depression) which would be comparatively easy to achieve with appropriate empowerment and education of the patient. (Funnell R et al 2004) All in all, this is not a straight forward case. There are many elements which require careful and considered assessment. I believe that it is one of those cases that helps to point out that although there is a huge emphasis to be placed on modern scientific understanding and application of medical principles, there is also a very large element of human understanding and caring that is so very important to the successful management of patients such as Mr Pickles (Waterlow J. 1998) References Ackerman MD, Carey MP. 1995 Psychologys role in the assessment of erectile dysfunction: historical precedents, current knowledge and methods. J Consult Clin Psychol 1995; 63: 862-87 Barnes, Darryl E. 2004 Action Plan for Diabetes Copyright 2004 ISBN: 0736054596 Pub. Human Kinetics Illinois USA Beck J. 1995 Hypoactive sexual desire disorder: an overview. J Consult Clin Psychol 1995; 63: 915-927. Boule NG, Haddad E, Kenny GP, et al. 2001 Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 2001;286:1218-27 Bowering (2001) Diabetic foot ulcers. Pathophysiology, assessment, and therapy. Can Fam Physician. 2001 May;47:1007-16. Dawes RM, Corrigan B. 1974 Linear models in decision making. Psychol Bull 1974;81:95-106. Funnell, and Robert M. Anderson, (2004) Empowerment and Self-Management of Diabetes Clinical Diabetes 22:123-127, 2004 Gibbs, G (1988) Learning by doing: A guide to Teaching and Learning methods EMU Oxford Brookes University, Oxford. 1988 Gregg, R. B. Gerzoff, C. J. Caspersen, D. F. Williamson, and K. M. V. Narayan (2003) Relationship of Walking to Mortality Among US Adults With Diabetes Archives of Internal Medicine, June 23, 2003; 163(12): 1440 1447. Gregoire 1999 ABC of sexual health: Assessing and managing male sexual problems BMJ, January 30, 1999; 318(7179): 315 317. Howe and Anderson 2003 Involving patients in medical education BMJ, Aug 2003; 327: 326 328. Hughes RAC. 2002 Regular review: Peripheral neuropathy BMJ, Feb 2002; 324: 466 469. Kissebah AH, Freedman DS, Peiris AN. 1999 Health risks of obesity. Med Clin North Am 1999; 73: 111-138 Marks-Moran Rose 1996 Reconstructing Nursing: Beyond Art and Science London: Balliere Tindall October, 1996 Nathan D. (1998) Some answers, more controversy, from UKPDS. Lancet 1998; 352: 832-833. Parker and Lawton 2003 Psychological contribution to the understanding of adverse events in health care Qual. Saf. Health Care, Dec 2003; 12: 453 457. Wagner G, Seanz de Tejada I. 1998 Update on male erectile dysfunction. BMJ 1998; 316: 678-682 Waterlow J. (1998) Prevention is better than cure. Nurs Times 1988; 84: 69-70 Appendix