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This essay provides a careful analysis of the implications of diferent senses of autonomy for diferent models of the physician-patient relationship discount 20gm diclofenac gel mastercard arthritis pain elbow. In so doing generic 20gm diclofenac gel visa arthritis guidelines, Pellegrino lays out cardinal conficts between autonomy and benefcence, and between autonomy and justice. In the process, Beauchamp and Childress’s principles are embedded in the re- alities of clinical decision making, as well as in the foundational scafold- ing of the physician-patient relationship. Rather than principles, we can speak of obligations freely undertaken when we freely ofer to help a sick person. The last essay in this section, “Patient and Physician Autonomy: Con- ficting Rights and Obligations in the Physician-Patient Relationship,” completes the analysis of the healing relationship, as well as of Pellegrino’s critical recasting of the signifcance of Beauchamp and Childress’s four principles. As Pellegrino notes, these principles mark points of strategic tension and ambiguity. Although the principle of benefcence is in tension with autonomy, the physician’s autonomy receives little attention, and the autonomy of medical ethics has come under threat. Pellegrino’s analysis of Beauchamp and Childress’s principles brings him to fve con- clusions: (1) autonomy and benefcence, if rightly understood, turn out to be complementary, not contradictory; (2) in both theory and practice, au- tonomy is not merely a negative but a positive principle as well; (3) the ac- tual content of the principles of benefcence and autonomy is defned in the context of specifc actions and decisions; (4) the physician’s autonomy both as a person and a professional must also be taken into consideration; and (5) medical ethics must maintain its autonomy over against political and socio-economic pressures. The third section of this collection brings together three major essays in which Pellegrino examines the nature of virtue in general, its meaning © 2008 University of Notre Dame Press An Introduction in the medical profession in particular, and moral challenges to the con- science and integrity of physicians. The frst essay, “Character, Virtue, and Self-Interest in the Ethics of the Professions,” confronts the place of pro- fessional virtue and the difculty of contemporary medical professionals recognizing the claims of virtue. Commercialization, competition, gov- ernment regulation, malpractice suits, and advertising, as well as public and media hostility have engendered a profound professional malaise. Pellegrino argues that, though these forces are real and threatening, the major danger is posed by defciencies in medical-professional character and virtue. Medical professionals, in order to maintain their integrity, will need to embrace an ethos of altruism and fdelity that will often be incon- gruent with the dominant, conventional morality. To do this, Pellegrino argues, medical professionals must recognize that professions are moral communities, able to sustain their members if their members sustain their professional moral communities. Success in establishing a sound founda- tion for the professional life requires recognizing (1) the vulnerability of patients, (2) the inequality between physicians and patients, (3) the special fduciary character of the professional in such relationships, (4) the ways in which professional knowledge does not exist for its own sake, (5) the professional relationship as able to bring both help and harm, and (6) the professional relationship as dependent on the professional being a mem- ber of a moral community with its own internal morality. The second of this trio of essays, “Toward a Virtue-Based Normative Ethics for the Health Professions,” invites the reader to confront the mean- ing and foundations of virtue. As Pellegrino reminds us, the classical me- dieval synthesis understood virtue as excellence of character, as a trait appropriately oriented to defning ends and purposes, as an excellence of reason, not emotion, as centered in practical judgment, and as a trait acquired by practice. Pellegrino contrasts this account with Alasdair Mac- Intyre’s account, which regards virtues as dispositions or acquired quali- ties necessary (1) to achieve the internal good of practices, (2) to sustain the communities in which individuals seek the higher good of their lives, and (3) to sustain traditions necessary for the fourishing of individual lives. Despite his defense of virtue ethics, Pellegrino frankly acknowledges the difculties of virtue-based accounts: (1) virtue-based accounts tend to be circular (i. All of this leads Pellegrino to underscore that virtue-based accounts cannot stand alone and must be lodged within a more comprehensive moral phi- losophy, which he acknowledges does not now exist. This problem is com- pounded in medicine, where the Hippocratic tradition is, at best, in dis- array. The practice of medicine is marked by moral pluralism, relativism, and the privatization of morality. In the face of these challenges, Pellegrino calls physicians to an act of profession that can tie them to their engage- ment in healing, so that they can come to appreciate professional virtue in terms of the telos of the clinical encounter: the patient’s good. Pellegrino lists among the virtues that should mark the good physician: fdelity to trust and promise, benevolence, efacement of self-interest, compassion and caring, intellectual honesty, justice, and prudence. Having spoken to professional virtue in the clinical context, Pel- legrino turns in the next essay to challenges to the physician’s moral con- science. His focus is on the conficts engendered as a result of practicing medicine in an often afrmatively secular culture. This tension is rooted in the circumstance that traditional Christians know things about medical morality unrecognized within secular society. In “The Physician’s Con- science, Conscience Clauses, and Religious Belief: A Catholic Perspec- tive,” Pellegrino lays out a geography of some of the resulting moral conficts, giving special attention to the rising reluctance of the state and others to confront honestly what should count as violations of conscience. For example, although religious exemption laws and conscience clauses have protected physicians from being directly coerced to engage in abor- tion or physician-assisted suicide, there is nevertheless often a require- ment that they refer patients to others to do things the Christian physician knows to be immoral (that is, since abortion is equivalent to murder, then referring a woman to an abortionist is equivalent to referring someone to the services of a hit man, even if one will not engage directly in the mur- der oneself).

Women’s Cosmetics thus reflects not so much a formal purchase diclofenac gel 20 gm otc arthritis diet what not to eat, textual Arabic influence as the regular personal interactions between Christians and Muslims living side-by-side in southern Italy and Sicily 20 gm diclofenac gel sale arthritis painkillers for dogs. To varying degrees, then, the three Trotula texts give us evidence of not simply how the diseases of women were formally theorized by medical writers eager to assimilate the new Arabic texts but also how local Salernitan prac- titioners, with or without formal training, conceptualized and treated the medical conditions of women. The specific characteristics of twelfth-century Salernitan culture thus form a necessary prelude to a detailed analysis of the Trotula texts. Salerno In trying to explain the efflorescence of medicine in eleventh- and twelfth- century Salerno, scholars have often wondered why this explosion in medical thought and writing happened here and not someplace else. For our purposes, it is necessary to understand why Salerno offered fertile ground for exchange between these cultures, and how women’s social status in Salerno may have played a role in the formation of women’s medicine. T C Between  and , a Spanish Jew named Benjamin toured through south- ern Italy, describing the communities in which he found co-religionists. Of Salerno, ‘‘where the Christians have schools of medicine,’’ he said ‘‘It is a city with walls upon the land side, the other side bordering on the sea, and there is a very strong castle on the summit of the hill. A Muslim traveler, al- Idrisi, writing a decade or two before Benjamin, had called Salerno ‘‘an illus- trious city, with flourishing merchants, public conveniences, wheat and other cereals. One part spreads out over the plain, the other the hill, And whatsoever you desire is provided by either the land or the sea. It was essentially refounded by the Lombards, who gradually built up the city from the harbor all the way to the top of the hill (fig. Amarotta, Salerno romana e medievale: Dinamica di un in- sediamento, Società Salernitana di Storia Patria, Collana di Studi Storici Salernitani,  (Salerno: Pietro Laveglia, ), p. Involved in Mediterranean trade, espe- cially with Muslim North Africa, which bought its grain, lumber, and linen cloth, Salerno was one of the wealthiest Italian cities of its day. Although not on the regular trades routes of Jewish or Arab merchants in the eleventh or twelfth century, Salerno is occasionally mentioned as a destination in mer- chants’ accounts coming out of Egypt. The ‘‘very strong castle on the summit of the hill’’ that Benjamin of Tudela had described began its exis- tence as a simple church at the end of the tenth century. A tower was added in the fifth decade of the eleventh century and then, between  and  under the threat of Norman invaders, it was transformed into a real fortress. Salerno’s cathedral, still famous for its mosaics, marbles, and bronze doors,  Introduction was constructed under the supervision of Archbishop Alfanus and dedicated in . The city had at least two dozen churches and nine monasteries, three of which were female houses. One of the earliest documents we have records the gift of a vineyard whose profits are to be used to support the monastery’s infirmary; the intent is that the sick nuns will pray for the donor’s soul. Three aqueducts, originally constructed in Roman times and later restored by the Lombard princes, brought water to the city; these waters were supplemented by spring water coming down from the hills, plus wells and cisterns (to collect rainwater) in private courtyards. The nuns of San Giorgio had such a bathhouse, and while we do not have specifics about its construction, documents from the male house of Santa Sofia suggest what it may have looked like. The latter seems to have been a substantial establish- ment, with at least two levels, furnaces and bronze cauldrons for providing hot water, and a pool. It was so luxurious, in fact, that contracts were drawn up allowing monastics from other houses (male and female) and secular clerics to come bathe there as well. Naples, on the Tyrrhenian coast north of Salerno, and Bari, on the eastern coast of the peninsula, were larger;21 nearby Amalfi was a more important center of international trade. The whole region of southern Italy shared in a relative bounty of grains, fruits, nuts, and other foodstuffs,22 with increasing surpluses of raw materials and textile goods to export to other lands. It was made the capital of the newly created Lombard principality of Salerno in . The city’s fortunes immediately took off, for it became the main supply center for the Amalfitan merchants, whose own hinterland was insuffi- cient to feed them and whose port was inadequate to sustain traffic in the heavy goods theyexported from southern Italy to north Africa. Norman pilgrims passing through southern Italy at the end of the tenth century had been asked to aid the city of Salerno in repelling an attack of Muslim invaders. Hired as mercenaries (by Christians as well as Muslims) during subsequent years, these Norman knights gradually became invaders themselves and bit by bit expanded their control over several southern Italian duchies.

Open back gowns while the bane of hospitalized patients world-wide represent the most practical means of combining protection with accessibility when shirt and pant style clothing is not practical or possible 20gm diclofenac gel with mastercard treating arthritis of the big toe, as when casts or external appliances interfere discount 20 gm diclofenac gel fast delivery rheumatoid arthritis in back and hips. Vanity issues aside it may be necessary to trim nails to address issues of hygiene (germs love to hide under nails) and prevent inadvertent self-injury by a patient who may flail about with pain or fever delirium. Having properly designed and sized clippers for the fingers and toes makes this task much easier for all concerned. Providing On-Going Care Having identified our goals we can move on the issue of how we are to address them. There are several areas that need to be addressed as part of the entire care “package” or plan. Databases: Vital Signs Having a database of vital signs is the key to recognizing abnormal vital signs later on. In an ideal situation you would have a record that details normal laying, sitting and standing blood pressures for your patient, as well as a resting pulse, and respirations, along with a temperature. Make sure to note whether the normal pulse is - 152 - Survival and Austere Medicine: An Introduction regular and strong in quality and rhythm, or irregular, weak, or bounding (very strong). Having a database of temperatures over time will allow you to gauge the effectiveness of antibiotics, for instance, or the onset of an infection. Similarly a person who is acutely dehydrated will see an increase in their temperature. Pulse Pulses may indicate a general state of health in the absence of illness or injury. A very rapid, thin pulse may indicate the presence of shock, whereas a slow pulse might signal that the patient is relaxed and relatively pain free. Since pulse rates vary widely amongst people the change in pulse rate and quality is more important than the rate itself. For example, for a person whose normal pulse rate at rest is 68 an increase of 20 per minute may indicate the presence of unaddressed pain. Blood Pressure Blood pressures are always obtained using a blood pressure cuff, either manually operated or electronic. Cuffs come in different sizes with a standard blood pressure cuff suitable for adolescents and adults. An upper arm larger than approximately 15 cm will require a larger cuff for an accurate reading or a false high will result. Conversely an arm smaller than approximately 8 cm will require a smaller diameter cuff or a false low reading will result. Breathing Normal breathing rates for an adult range between 14 and 20 per minute, or one breathe every 3 – 4 seconds. During times of illness this may increase, with more than 30 breaths a minute considered very significant. In addition to rate the apparent effort used to breath can also be indicative of distress or absence of same. Respiratory infections can cause labored breathing, evidenced by increased effort and rate. By tracking breathing rates and quality along with other vital signs it is possible to determine whether treatments are having a positive effect. Other Data to Collect and Record Bowel Movements As we age our bowel movements tend to become less frequent. Older - 153 - Survival and Austere Medicine: An Introduction adults may not have a proper bowel movement for several days without regular use of fiber in their diet and/or laxatives. As a rule a person should have one medium to large bowel movement at least every 3 days. Urination It is not necessary to record urine outputs for everyone but for some cases – especially burns - measuring output against fluids taken in (Intake and Output) is necessary to determine whether fluid balance is being maintained. The effects of disease, loss of fluids through other sources such as perspiration, vomiting, bowel movements, etc may affect this somewhat but as a general rule plan on a measured output of one and a half litres. Anything less than half this amount may be indicative of kidney malfunction and is cause for serious concern. For certain types of patients, such as burn cases or those with heart failure, matching Intake and Output (I & O) against daily weights can be critical to determine if an output deficit is the result of retained fluids. Weight Weight by itself may mean little other than as a general indication of nutritional status but changes in weight can be significant in terms of indicating changes in the patient’s condition.

Norovirus (Winter vomiting bug) Norovirus causes short lasting outbreaks of vomiting Exclusion: Staff or pupils who have had shigellosis and diarrhoea diclofenac gel 20 gm visa arthritis medication that starts with a c. The virus is very contagious and should be excluded for 48 hours after their frst formed extremely common buy 20 gm diclofenac gel visa can arthritis pain wake you up. Fortunately, most cases infection, it is recommended that the case should recover fully without complication. Environmental cleaning is also critical as norovirus can survive on surfaces such as door handles, Resources: Useful information on shigella can be light switches desks etc for a number of weeks. A signifcant proportion mononucleosis is an illness caused by the Epstein Barr of cases have no symptoms. The virus is spread from person-to-person via saliva, usually through kissing or being in close contact with a In Ireland, the infection is most commonly associated case or carrier. About a ffth of those who are infected with untreated water sources and with person to become long-term carriers, being infectious for more person spread. Infection may also be acquired after contact Precautions: Frequent hand washing and avoiding with the faeces of farm animals and visiting petting sharing of utensils will further reduce the risk of farms. Precautions: Preventive measures include care in Exclusion: Generally not necessary. Those involved in the way food is stored, prepared, and cooked, and by high risk body contact/collision sport should be excluded attention to basic hygiene in food handlers, affected from full team participation for 4 weeks (see Chapter 8 people, and those in contact with them. Young pupils may require supervision of hand washing after toilet use and before meals. If a school’s water is supplied from a private supply they should ensure the quality of this water. Coli, available on the Health Protection Surveillance Centre’s website at http://www. The bacteria that cause Hib live and rash with blisters, which appear especially in the in the nose and throat. Babies under one year of age are especially at of infected people and therefore can be spread by the risk of Hib disease. Some infected children can continue to shed the virus in their faeces Precautions: A Hib vaccine is available as part of the for several weeks after recovery. When a case infected may not develop any symptoms but can still of Hib disease occurs the local Department of Public spread the virus. Younger children are more provide an explanatory letter and leafet to parents and susceptible to infection due to close contact. Precautions: Frequent hand washing especially after Exclusion: Cases of serious Hib disease will be too ill to contact with secretions from the nose or throat and after attend school. If evidence exists of ongoing HaemophilusinfuenzaeFrequentlyAskedQuestions/ transmission within the school exclusion of pupils until the spots have gone may be necessary. The type of louse which affects the head is particularly common and anyone can catch hepatitis) them. Lice spread by direct head-to-head contact This is usually a mild illness, particularly in children, with an infected person and therefore tend to be more caused by a virus, which infects the liver. The incubation common in children as their play activities facilitate this period is between two-six weeks. Live lice are transmitted when the lice fever, loss of appetite, nausea, stomach ache and after are alive on a person’s head. Lice cannot live away from a few days, jaundice (a yellowing of the eyes and skin) a human host; most die within 3 days. The female lice lay eggs which glue to the hair and only become easily visible when they have hatched An infected person is infectious for approximately one and are empty (nits). Nits remain in the hair until it falls week before the start of, and for a week or so after the out, which may take up to 2 years. However, a person can be are usually the frst signs of headlice but are due to an infected without developing any symptoms and so can be allergic reaction which can take four to eight weeks to an unknown source of infection to others. The presence of nits (empty egg casts) does not mean that active infection is Hepatitis A is spread by hands which have not present and is not an indication for treatment.