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Certain finch species buy 10 mg nolvadex with mastercard, eg purchase nolvadex 20 mg amex, parrot finches and Diamond Firetails buy nolvadex 20mg fast delivery, are particu- Nematodes larly prone to developing intestinal obstructions Ascaridia: Two main types of roundworms affect from heavy Choanotaenia sp best 10 mg nolvadex. Both types of roundworms may be Tapeworms can be avoided by limiting access to in- associated with weight loss, diarrhea, general debil- termediate hosts and by using insect-proof screen- ity and sometimes neurologic symptoms. However, some birds may not accept thrush, thrush, blackbirds, Australian magpies, cur- these alternative foods and may die or be left suscep- rawongs and corvids. Fenbendazole, piperazine Effective anthelmintics for passerines include praz- and levamisole are useful in treating ascarid infections. Susceptibility does not depend on dietary preferences, and the parasite has Trematodes been found to cause disease in a variety of seed-eaters These parasites have complicated life cycles that (such as canaries), insectivorous and omnivorous spe- typically involve snails as initial intermediate hosts cies (such as weavers, whydahs, jays and mynahs) and other invertebrates as secondary intermediate and honeyeaters. It is unlikely that appropriate conditions for completion of the life cycle will be found, except Birds with low numbers of capillaria may be subclini- possibly in planted aviaries. Higher parasite loads may lead to weight loss, diarrhea, general ill health and death. These worms Trematodes are seen occasionally in wild-caught pas- may localize to a variety of sites along the gastroin- serines. Mechanical re- may be found by directly swabbing lesions or by fecal moval of worms and treatment with low doses of flotation. Aviary hygiene and removal of earthworms Arthropod Parasites are important control measures. Levamisole, fenben- Respiratory Mites: Respiratory acariasis (“air sac dazole and oxfendazole may be effective in some mite infection”) caused by Sternostoma tracheacolum cases. Occasionally, tricular and proventricular worm parasite does not the mites may be visualized by wetting the feathers affect psittacine birds. The parasite lives under the of the bird’s neck with alcohol and transilluminating koilin lining of the ventriculus, and characteristic the trachea with a bright source of light. Attempts present, they may be visible as tiny, dark, moving, to identify intermediate hosts in this species have pinhead-sized spots. Failure to see the mites does not been unsuccessful, but other species of Acuaria are rule out their occurrence because the mites may be believed to be transmitted by arthropod vectors. Other species of Ster- (which has been described in the House Sparrow, nostoma mites have been recorded in passerines in- starling, catbird and gallinaceous birds) and Spirop- cluding S. Cytodites nudus is another mite that has been asso- The parasite is found behind the nictitating mem- ciated with respiratory disease in free-ranging pas- brane or in the conjunctival sac or the nasolacrimal serines. Worms and may be found in the abdominal cavity as well as should be mechanically removed and any inflamma- the respiratory system. Respiratory Nematodes: Syngamus trachea (gape- Treatment is as described for other air sac mites. Corvids, starlings and black- External Parasites birds are particularly susceptible. Levamisole, ivermectin and Skin and Feather Mites fenbendazole are effective in treating this parasite, Scaly Mites: Knemidokoptes pilae (and several other but caution should be exercised when treating birds less common species) tend to cause hyperkeratotic with heavy infections. Scaly mite lesions start as pyhynchus are genera that have been reported on crusts on the plantar surface of the foot and gradually Passeriformes. Flexion of the joints of the digits causes ated with extensive dermatitis as well as cysts and the thickening keratin to split and gradually enlarge, skin tumors on hawfinches and a Lanceolate War- making it difficult for the bird to perch. Hanging a dichlorvos pest strip near birds af- lesions in passerines are sometimes referred to as fected with quill mites has eliminated the parasite in “tassel foot” because of this characteristic appearance some cases. Non- pathogenic feather mites of a variety of genera (An- lages, Megninia and Rivoltasia) may also occur. Several of the birds The proliferative hyperkeratotic lesions on this canary’s foot are had hyperkeratotic lesions on the feet and legs. Iron Storage Disease and Related Entities Epidermoptic mites may be easily identified on mi- Various Passeriformes species including Indian Hill croscopic examination of skin scrapings. Trombidi- Mynahs, Rothschild’s Mynahs, quetzals, Birds of form mites of the genus Neocheyletiella have also Paradise, Green Cat Birds and tanagers have been been reported to cause depluming mange in canaries reported to be susceptible to excessive accumulation of iron in the liver. Most of the birds died lice (Amblycera) that occur on passerines include within several days of presentation. These lice are not specialized Radiographs may reveal hepatic enlargement and for life on particular feathers and are able to move ascites in affected birds. Chewing lice (Ischnocera) are often specifi- elevated while total serum protein is low. Diagnosis cally adapted to a particular part of the bird’s body using biopsy is discussed in Chapters 13 and 20. At necropsy birds may show an enlarged, congested Some genera that affect passerines include Bruelia liver which may be tan in color (see Color 20). His- (on canaries and House Sparrows), Sturnidoecus (on tologically the distinction is made between he- starlings and other passerines), Degeeriella and Phi- mosiderosis, where there is no visible tissue altera- lopterus. Signs of the presence of lice include restless- tion but an increased amount of hemosiderin, and ness and biting, excessive preening and damage to hemochromatosis, where there are pathologic plumage. Some cases of baldness in canaries are changes in the hemosiderin-containing tissues. Iron-processing cells are absent from the spleen and the spleen does not contain iron pigments. Neoplasia including lymphosarcoma, hepatocellular carcinoma and erythroblastosis has been associated with iron storage disease. Iron storage disease is believed to be associated with high dietary iron lev- els in avian species with problems in processing iron. Susceptible species should be kept on low-iron diets such as fresh fruit and commercially available formulated rations that are low in iron (less than 60 parts per million) (see Chapter 20). Amyloidosis Amyloidosis is common in Gouldian Finches and is occasionally seen in other Passeriformes species. Social stress may play a role in the development Ethanol toxicity has been reported in free-ranging of the disease. The liver and kidneys may appear passerines (especially Cedar Waxwings) following normal at necropsy even though they may be se- the ingestion of hawthorn pommes or other fruits verely affected histologically. More often they will that have frozen and then thawed allowing yeast appear pale and yellowish. Many intoxicated birds die from accidents that occur Hepatic Lipidosis while they are “flying under the influence. Heavy metal toxicities caused by the consumption of The liver is swollen, yellow or tan in color and may wire are uncommon in passerines because they have float in formalin. Heavy metal particles may be identified Toxicosis on radiographs, but most affected birds die quickly. Canaries and finches are particularly susceptible to Removing the source of heavy metals and administra- inhalant toxins because they breathe more air per tion of chelation therapy are recommended. The oc- gram of body weight than larger birds, and they have currence of “new wire disease” can be reduced by a highly efficient gas exchange system (see Chapter scrubbing galvanized wire with a dilute acetic acid 22). Carbon monoxide exposure from any source (car solution and allowing it to weather before it is used exhaust, gas furnace leaks, kerosene stoves) can be for enclosure construction; however, even wire that is rapidly fatal. Carbon dioxide poisoning may occur in crowded, Neoplastic Diseases poorly ventilated shipping boxes.

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Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications generic nolvadex 10mg amex. Examples: ĉ or ç becomes c ⚬ Separate the edition from the title proper by a space and place it in parentheses ⚬ End edition information with a space nolvadex 20 mg amex, followed by Internet in square brackets and a period Example: Pharmakeutikon Deltion generic nolvadex 20mg online. Tis rule ignores some conventions used in non-English languages to simplify rules for English-language publications nolvadex 20mg without prescription. Examples: ŏ becomes o ū becomes u ⚬ Separate the edition from the title proper by a space and place it in parentheses ⚬ End edition information with a space, followed by Internet in square brackets and a period Example: Box 29 continues on next page... If you do, abbreviate them according to the Abbreviation rules for journal titles. Journal article on the Internet with journal title having an edition 1532 Citing Medicine Content Type for Journal Articles on the Internet (optional) General Rules for Content Type • A content type describes the format of the Internet item being cited • Begin type information with a lef square bracket • Enter the words "serial on the" • End content type with space Examples for Content Type 18. Regular prescriptions for benzodiazepines: a cross-sectional study of outpatients at a university hospital. Efect of intensive insulin therapy on abnormal circadian blood pressure pattern in patients with type I diabetes mellitus. Some Internet journal publishers use an article numbering scheme rather than pagination, or, in some cases, in place of volume, issue, and pagination. Online pediatric information seeking among mothers of young children: results from a qualitative study using focus groups. Assessing patient attitudes to computerized screening in primary care: psychometric properties of the computerized lifestyle assessment scale. Te predictive utility of nontraditional test scores for frst-year pharmacy student academic performance. Efect of intensive insulin therapy on abnormal circadian blood pressure pattern in patients with type I diabetes mellitus. A journal may publish a supplement, part, or special number to a date of publication rather than to a specifc volume or issue. Efect of intensive insulin therapy on abnormal circadian blood pressure pattern in patients with type I diabetes mellitus. However, the month and day of the month or the season must be included when citing a journal that has no volume or issue number. Risk factors for groin wound infection afer femoral artery catheterization: a case- control study. Risk factors for groin wound infection afer femoral artery catheterization: a case- control study. Journal article on the Internet with month(s)/day(s) included in date of publication 20. Journal article on the Internet with season(s) included in date of publication 21. Journal article on the Internet updated/revised afer publication Journals on the Internet 1541 22. Journal article on the Internet with date having a supplement Date of Update/Revision for Journal Articles on the Internet (required) General Rules for Date of Update/Revision • Journal articles may be updated or revised afer initial publication • Begin update/revision information with a lef square bracket • Use whatever word for update or revision is provided, such as updated or modifed • Always give the year of update/revision • Convert roman numerals to arabic numbers. Look for the date accompanied by such words as updated, modifed, revised, reviewed: • At the top, bottom, or sidebar of the frst screen or the bottom of the last screen of the article • In the source code for the article if it is displayed by the Web browser Box 39. Journal article on the Internet updated/revised afer publication Date of Citation for Journal Articles on the Internet (required) General Rules for Date of Citation • Give the date the article was seen on the Internet • Include the year month and day in that order, such as 2006 May 5 • Use English names for months and abbreviate them using the frst three letters, such as Jan Journals on the Internet 1543 • If a Date of Update/Revision is given, place the date of citation afer it and follow both dates with a right square bracket • If no Date of Update/Revision is given, place citation date information in square brackets • End date information with a semicolon placed outside the closing bracket Specific Rules for Date of Citation • Both a date of update/revision and a date of citation Box 42. Online pediatric information seeking among mothers of young children: results from a qualitative study using focus groups. Journal article on the Internet updated/revised afer publication Volume Number for Journal Articles on the Internet (required) General Rules for Volume Number • Omit "volume", "vol. A volume will occasionally have a subdivision such as a supplement, part, or special number. For example: - volume with supplement 2005 [cited 2007 Jan 10];5 Suppl: Box 43 continues on next page... Occasionally a journal publishes a series of issues without volumes, publishes a supplement, part, or special number to a date of publication rather than to a volume or issue, or uses an article numbering scheme in place of a volume and issue. Providing open access to past research articles, starting with the most important. Efect of intensive insulin therapy on abnormal circadian blood pressure pattern in patients with type I diabetes mellitus. Journal article on the Internet with volume having a subdivision other than an issue 25. Journal article on the Internet without standard volume or issue, but with article number 29. Journal article on the Internet without standard volume, issue, or article number Issue Number for Journal Articles on the Internet (required) General Rules for Issue Number • Omit "number", "no. An issue will occasionally have a subdivision such as a supplement, part, or special number. For example: - issue with supplement 2005 [cited 2007 Jan 10];15(1 Suppl): 2005 [cited 2007 Jan 10];(12 Suppl A): 2005 Mar [cited 2007 Jan 10];87(3 Suppl): - issue with part Box 46 continues on next page... Providing open access to past research articles, starting with the most important. Efect of intensive insulin therapy on abnormal circadian blood pressure pattern in patients with type I diabetes mellitus. Efect of intensive insulin therapy on abnormal circadian blood pressure pattern in patients with type I diabetes mellitus. Journal article on the Internet with volume having a subdivision other than an issue 1552 Citing Medicine 25. Journal article on the Internet without standard volume or issue, but with article number 29. Specific Rules for Location (Pagination) • Roman numerals used as page numbers • Discontinuous page numbers • Text such as a discussion, quiz, or author reply to a letter follows the article • No numbers appear on the pages of the article • Article numbers used for location • Articles that are videocasts or podcasts Box 51. Raccomandazioni per il trasporto inter ed intra ospedaliero del paziente critico = Recommendations on the transport of critically ill patient. If the entire article (not just a portion of one) is available as a videocast or podcast: • Enter the word Videocast or Podcast followed by a colon and a space • Give extent as the number of minutes needed to view/listen • Precede the extent with the word "about" unless the time is supplied in the article Box 56 continues on next page... Journal article on the Internet with location expressed as standard page numbers 31. Journal article on the Internet with location/extent expressed as estimated number of screens 34. Journal article on the Internet with location/extent expressed as estimated number of pages 35. Journal article on the Internet with location/extent expressed as an article number 37. Update on the recommendations for the routine use of pneumococcal conjugate vaccine for infants. Te hmuQ and hmuD genes from Bradyrhizobium japonicum encode heme-degrading enzymes.

Acta Parasit Polnonica 23:361- matodiasis in cockatoos due to Comp 56: 123-130 nolvadex 20mg on line, 1981 order 20 mg nolvadex visa. Schweiz Arch Tierheilk Baylisascaris procyonisas a cause of forme: Trypanosoma bakerin purchase 20mg nolvadex overnight delivery. Comp Anim Prac 1:36-39 buy nolvadex 20 mg with amex, tomiasis in a sulphur-crested cocka- caridia columbaeinfections in budg- conirmus (Mallophaga: Philopteri- 1987. Capillaria Zeder 1800 from the collec- al (eds): Cryptosporidiosis in Man 183:1089-1090, 1983. Shoshana R: Knemidokoptes: Mites Granulomatous encephalitis caused parasite membrane - membrane in- control. J Am Vet Med assoc 181:384- on feathers of the red-fronted para- by schistomiasis in swans. Gastroenterology 90:583-594, in psittacine birds: apparent in- schistosomiasis in Atlantic brant 1986. J Am Vet Med Assoc 175:359- complexa: Sarcocystidae) in the budg- cal observations on the sequence of Memorial University, St John’s, New- 361, 1979. Miltgen F, et al: Parahaemoproteus imported birds at postmortem exami- tions of canaries and pigeons. Many of the B items that birds may encounter during these quests can be dangerous. Contact with or consump- tion of certain plants, cleaners, pesticides and house- hold disinfectants may cause acute or chronic intoxi- cation. Based on their size and physiology, birds are more prone than mammals to intoxication by some compounds, such as volatile chemicals and fumes. It has been suggested that the con- sumption of foreign bodies (eg, metal, wood, jewelry), over-consumption of grit and coprophagy may all be mediated by malnutrition (Gerlach H, unpublished). Genevieve Dumonceaux Therefore, birds on a formulated diet would be ex- pected to chew less on plants, perches and toys than Greg J. Treat seizures and shock as or anyl substituent damage needed groups Drain cleaners Sodium hydroxide, Caustic to skin and mucous membranes, Flush affected areas with water or milk. Do not sodium hypochlorite irritation, inflammation, edema, necrosis, use emetics or lavage. Treat for shock and pain burns in mouth, tongue, pharynx Fireworks Nitrates, chlorates, Abdominal pain, vomiting, bloody feces, Crop or gastric lavage. Use methylene blue or mercury, antimony, rapid shallow respiration, chlorates may ascorbic acid for methemoglobinemia. Avoid gastric hydrocarbons, necrosis, mucosal irritation, aspiration or lavage or proceed with caution. Antibiotics and supportive care Matches Potassium chloride Gastroenteritis, vomiting, chlorates may Treat symptomatically. Use methylene blue or induce methemoglobinemia with ascorbic acid for methemoglobinemia cyanosis and hemolysis Paint/varnish Benzene, methanol, Dermal irritation, depression, narcosis, See “furniture polish. Provide fresh air if strong fumes are present Overheated non-stick Polytetrafluoroethylene Sudden death, dyspnea, depression, Fresh air or oxygen, fluids, steroids for cookware, drip pans, pulmonary hemorrhage pulmonary edema, antibiotics, supportive care heat lamps, irons, ironing board covers Poor grade peanuts, Mycotoxins: aflatoxin, Gastrointestinal irritation, dermal Clean feed, antibiotics for secondary peanut waste, moldy ochratoxin, irritation, oral necrosis, secondary infections. Brodifacoum, treat for 28-30 days Rodenticides Cholecalciferol Causes hypercalcemia and renal failure, Activated charcoal, fluid therapy. Do not give bicarbonate orally for necrosis from chewing on pencils acid poisonings Many of the therapeutic recommendations for the above products have been taken from small animal sources. Toxin-contami- nated water, air and food supplies can affect birds through direct contact or through poisoning of com- ponents in the food chain. Often the intoxication is subtle, and poisons accumulate over time (eg, lead in waterfowl, organochlorines in birds of prey). Birds of prey and fish-eating birds are particularly susceptible to contaminants in the food chain be- cause of biologic magnification. It is of interest that the health of free-ranging birds is frequently ignored as a sensitive indicator of human-induced damage to our environment. In this case, a conure was In addition to human-related toxins, food and water presented with lead poisoning secondary to the consumption of supplies encountered by free-ranging birds may also lead-containing solder used to hold his feeding dish. The case was further complicated by gastrointestinal impaction secondary to the be contaminated by biologic organisms that produce ingestion of pieces of the plastic dish and malnutrition caused by their own toxins, including molds (mycotoxins), bac- a diet of wild bird seeds. Clinicians should carefully evaluate the teria (endotoxins) and certain blue-green algae environment in birds with clinical signs consistent with toxicity. Birds are generally more susceptible to inhaled toxins When submitting samples for toxicologic analysis, it than mammals because of their rapid metabolic rate, is best to call the laboratory for information on small size, highly efficient respiratory system and low proper sample preparation and shipment. In comparison, many compounds that ratories request frozen samples (except whole blood), cause intoxication following ingestion by mammals are preferably individually wrapped to prevent cross- relatively nontoxic in companion birds; however, birds contamination. Samples submitted for heavy metal should be restricted from access to compounds known analysis should not be wrapped in foils or contact any to be toxic in mammals (Figure 37. Complete request forms, in- cluding the specific analyses to be run and the spe- Products that produce fumes, fogs or mists are not cies involved, improve the speed and accuracy of the recommended for use in areas where birds are pre- results. Good ventilation should be maintained to pre- vent the accumulation of harmful gases and fumes. Further information on products and chemicals as Some toxins may be absorbed directly through the well as assistance with poisonings is available from skin causing systemic intoxication, while others the National Animal Poison Control Center, Univer- cause localized reactions (eg, nicotine dermatitis). This center’s experience is limited when A bird’s response to a toxin may vary depending on dealing with companion birds and they often refer the age, size, health status and plane of nutrition of calls to experienced practitioners. A malnourished bird is A useful conversion in toxicology analysis is 1 ppm = more likely to develop clinical problems from a toxin 100 µg/dl. A bird suffering from chronic malnutrition is more likely to develop pansystemic diseases following exposure to toxic agents. Lead is inconspicu- ously included in numerous products found around the home and the precise cause of lead intoxication is frequently undetermined. The common lead weights used to balance wheels may be an underestimated source of contamination within a bird’s environment. Once ingested, the lead is de- graded by acids in the stomach and absorbed into the bloodstream. Unless paints state that they are “lead free” they may still have toxic levels of lead in the drying agent rather than in the base. Lead exposure may also occur through the inhalation of fumes from lead-containing gasoline (Figure 37. Radiographic and clinical pa- poisoning in waterfowl, cranes and pigeons may thology data were unremarkable. The bird’s only cause ileus of the crop, esophagus, proventriculus clinical signs were diarrhea, anorexia and depres- and ventriculus. Response to chelation therapy product label nor information sheet divulged that it (lead or zinc) or antitoxin (botulism) is suggestive of contained such a high level of lead.

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The second construal of the principle of beneficence better protects patient autonomy order nolvadex 10mg fast delivery. It says that patients should have the right to determine what they judge to be in their own best interests (within the constraints of good medical practice) from the point of view of their own stable values and life goals discount nolvadex 20mg on line. This means that patients do not have to make medical decisions for themselves that are consistent with what a majority of reasonable persons in similar medical circumstances would choose generic nolvadex 10 mg with mastercard. After all cheap nolvadex 20mg, the argument might go, we allow patients to pursue cosmetic surgery, for the sake of nothing more medically urgent than vanity, even though there are some serious medical risks attached to some of those procedures. This question has a rhetorical ring to it, as if the answer were entirely obvious, but there is room for argument and judgment. To follow up further on that, we would have to specify a number of empirical facts, largely related to Donald’s ability to make decisions that were autonomous enough to warrant moral respect. The fourth ethical principle that has a bearing on our case is the principle of justice. As with the prior principle, there are several different construals we need to consider. Con- sider the case of a physician who has two patients with the same degree of coro- nary artery disease. However, the physician only refers the patient whom he really liked for the surgery. He does not refer the other whom he strongly disliked because the other patient had a history of noncompliance. This will mean that individuals who are financially more well off will have greater access to more expensive experimental therapies. The vast majority of goods and services are distributed in our society on the basis of an individual’s ability to pay. These sorts of consequences are generally not associated with access to other consumer goods, which is why health care might be seen as being morally special. Still, as we shall see below, very few would be prepared to argue that every- one in our society has a moral right to any or all of the health care they might want or need that would offer them any health benefits. Consequently, the most common justice arguments related to health care are that all in our society ought to have assured access to some basic package of health services, perhaps a fairly thick package of health services as proposed by the Clinton Administration in 1993. But even that more generous package would not have guaranteed anyone access to experimental medical therapies of the sort we are discussing. In his case, it would be fair to conclude that this would not be a matter of great moral consequence. In that period of time there is a reasonable chance these thera- peutic interventions will be perfected, which is to say they would become part of the standard medical armamentarium covered by health insurance. In the meantime the quality of his life will continue to be compromised; but he will not have been made worse off by this denial, so this would seem to be a morally tolerable outcome. Edward has some sort of cancer that has not been effectively treated by any current therapies. We have another gene therapy trial that is aimed at attacking the sort of cancer that Edward has. Edward will be dead in a year; he will have no opportunity to wait until the therapy is per- fected and disseminated. Still, he might argue that he has a just claim to at least a fair chance of access to such a trial. The argument might take this form: Gene therapy is not a product of the private effort and investment of some small group of individuals, as would be true with other consumer products. Rather, enormous public investments (tax dollars and university research facilities and training of the researchers them- selves) have made these successes possible. All in our society have contributed to the success of that effort; and consequently, all ought to have at least a fair chance to reap the rewards of that effort. It is unfair that only those who have been espe- cially economically fortunate already should have primary access to such tech- nologies, especially when life itself is at stake. For now it is sufficient to note that not all cases of access to experimental gene therapy are morally alike. There are subtle moral considerations that might tilt our judgment one way or another in a given case. Here is one more example of the sort of considerations that might raise issues of justice. Researchers want a therapeutic outcome for patients in these trials; this is the goal they share with standard medical practice. But they also seek to advance medical knowledge, which needs to be done very systematically. As a result, it will often be the case that patients will be denied access to one of these clinical trials if, in addition to their primary medical problem for which they are seeking entry to the trial, they have a serious co-morbid condition that could poten- tially compromise the quality of the clinical data they are seeking to gain. Is there any ethical justification for denying such patients an equal chance to be a participant in such a trial, especially if we have in mind an Edward-like patient as opposed to a Donald-like patient? To make certain that the ethical issue here is clear we need to emphasize that no matter what the co-morbid condition is that we imagine, those patients have just as good a chance of a successful therapeutic outcome in that trial as any other patient in the trial. That is, these researchers will claim that they are seeking to bring about the greatest good for the greatest number. More precisely, if the clinical data that is gathered in these trials is “tainted” through unknown effects associated with these co-morbid conditions, then there may be some tragic bad outcomes that come about when the results of these trials become part of standard clinical practice. So we have to imagine that there might be at some point in the future a large pool of potential patients who might be seriously harmed as a result of an incorrect clinical conclusion that we draw now. Researchers claim that they are morally obligated to do all in their power to prevent such possible future disasters. The whole point of both moral and political rights is to protect individuals against the encroachments of large and powerful social organizations, either in the private or public sector. Individuals may not have their deep moral rights violated for the sake of advancing some larger social good. The moral basis for this judgment is the Kantian principle of respect for persons we discussed earlier. Individuals cannot be simply used as mere things to advance even noble social goals without their free consent. A standard example in the ethics literature is the skid row bum who drunkenly stumbles in the street to be hit by a car. His head injuries are such that if surgery is done immediately he will likely be restored to something close to his former state of health. However, if surgery is delayed several hours, his con- dition will worsen and he will end up brain dead. His organs can then be used to save the lives of five other upstanding citizens who very much want to live but who otherwise would die of organ failure. We would certainly judge that any transplant surgeon who took advantage of a situation like this would be doing something grossly unethical. Someone might argue in response that there is a major disanalogy between this case and our Edward-like gene therapy case (where Edward is denied access to a clinical trial because of some co-morbid condition), namely, that our skid row bum is negligently harmed by delaying the surgery that will certainly benefit him. Edward is not treated negligently; he is simply being denied the opportunity to benefit from access to the trial.

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