Unique ethical issues arise in the practice of emergency medicine, and common ethical problems are often more difficult to address in the emergency department than in other medical settings. This article is Part 2 of the Series “Ethics in the Trenches” and it presents and analyses 2 cases — each dealing with an ethical challenge that emergency physicians are likely to encounter. The first case deals with patient refusal of care. When a patient refuses recommended care, the emergency physician must ensure the patient’s decision is informed and that the patient comprehends the implications of his or her choice. The second case deals with patient involvement in criminal activities. Emergency physicians often encounter patients who have engaged in illegal activities. Although certain activities must be reported, physicians should be mindful of their responsibility to protect patient privacy and confidentiality.

In this study, we developed a system allowing interfacial adhesionmeasurements as a function of mode-mixity, from pure tension to pure shear.Results show that the debonding energy increases, by a factor of 3 to 10, asthe amount of shear stress increases, approaching mode II conditions. Forlow k dielectrics, the debonding energy was found to decrease withincreasing porosity and increase with increasing plasticity. The crackpropagation is also dependent on mode-mixity.

The present paper discusses the four-point bending technique employed at The University of Texas at Austin (UT Austin) to characterize adhesion strength of ultra low-k dielectric materials to CVD barrier layers. Adhesion energy between an ultra low-k dielectric material and a barrier layer was measured as a function of porosity (2.0 < k < 2.3). It was found that the fracture energy decreases with the dielectric constant, which correlates with mechanical properties such as Young's modulus and hardness. Adhesion measurement data was also obtained for different lowk / barrier layer interfaces. The independence of interfacial fracture energy on the type of interface suggests that cohesive failure occurs in the low-k material layer and not at the interface. In addition, the very low fracture energies (G < 3 J/2) confirm the weak mechanical properties of such highly porous materials. Experimental results are illustrated with analysis of failure surfaces using Auger Electron Spectroscopy and Scanning Electron Microscopy.

Ethical issues can be more difficult to address in the emergency department than in other settings. We present two cases, with the goal of stimulating moral reflection and encouraging emergency physicians to gain a better understanding of two important ethical issues: advance directives and resource allocation decisions.

Understanding the legal and ethical basis for advance directives allows emergency physicians to determine when the directives should be followed and when they should be questioned. Resource allocation decisions are among the toughest decisions emergency physicians make. Although patients or substitute decision-makers define the value of a treatment goal, emergency physicians must ensure that this goal does indeed represent the patient’s wishes, that it is achievable, and that competing claims for the same resource are considered.

Learning from others’ experiences and preparing for ethical problems in advance will help physicians feel more comfortable in dealing with ethical issues.

Jusqu’à quel point la loi s’est-elle immiscée dans la pratique médicale? Les tribunaux peuvent-ils nous «obliger» à réanimer des patients lorsque nous jugeons l’intervention inutile? M. A.S., un homme âgé de 79 ans arrive difficilement à parler et à avaler à la suite de plusieurs AVC. Il a subi une trachéostomie et il ne peut exprimer ses propres souhaits. En 1998, lorsqu’il fut admis dans un hôpital de réadaptation, ses médecins rédigèrent un ordre de ne pas réanimer. Par la suite, comme l’ont rapporté les journaux, l’épouse de M. A.S. obtint une injonction «obligeant» le personnel de l’hôpital à administrer la réanimation dans le cas d’un arrêt cardiaque. Cette cause bien connue est présentement en litige devant les tribunaux du Manitoba. Qui a le dernier mot lorsque les médecins et les patients sont en désaccord? Quelles leçons doivent en tirer les médecins d’urgence? Le présent article discute des questions éthiques entourant la réanimation.

This paper began by reviewing several major conceptual and methodological difficulties surrounding the measurement of political alienation/allegiance and proceeded to describe the level and the sources of alienation (as measured by our preliminary indicator, the PAI) within the San Francisco-Oakland Bay Area. We defined political alienation as a relatively enduring sense of estrangement from or rejection of the prevailing political system and emphasized the importance of distinguishing this attitude from disapproval of incumbent officeholders.

It is remarkable that bright hydrogen lines, requiring 13 volts for their production should appear in the spectra of objects as cool as long-period variables. The reversing layer and the photosphere, with temperatures of about 2000°, have nothing like the necessary amount of energy to offer. The curious irregularities in the Balmer series do not yield the interpretation, it is now clear that they are due to absorption by overlying gases. This fact indicates one important item, namely, that the origin of the bright line is not in an extended outer atmosphere, but in a level lying near, and even partly below the photosphere.

Element number 43, now called technetium, has had a curious history. As a hypothetical element, when the implications of the periodic table were first realized, it was called eka-manganese after its chemical homologue. In 1925 three German chemists announced its detection by means of lines in the X-ray spectrum, and gave it the name masurium; but their discovery has not been confirmed and is now considered erroneous, although their parallel discovery of rhenium, element number 75, was valid.