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This chapter outlines the framework and goals of this cross-national study of amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) policy. It also describes the key features of ALS/MND and discusses criteria and associated challenges in making the diagnosis and the importance of excluding ALS/MND mimics. Epidemiology, genetics and possible environmental risk factors for ALS/MND are reviewed. Management of symptoms, challenges confronting caregivers, including access to palliative care and hospice during the end-of-life, and the broad range of ethical issues surrounding ALS/MND care are highlighted. This chapter examines the often-ignored public policy context and the importance of cultural and religious factors in understanding policy differences which exist across countries. Finally, this chapter introduces the countries selected for this study and summarizes the key topics of importance the authors were asked to address in their chapters.

This chapter examines the commercial aspects and big business surrounding Alzheimer’s disease (AD). It argues that the strong public fear of AD, heightened by often dramatic media coverage, heightens the likelihood of exploitation of vulnerable people looking for a fix to declining cognition. After examining the wide range of products being marketed and discussing the scientific evidence of medical and other treatment approaches, it argues for greater regulation particularly over direct-to-consumer marketing of purported remedies and even cures for dementia.

Introduction Patients with chronic conditions largely depend on proper medications to maintain health. This study aims to examine, for patients with diabetes and hypertension, whether the appropriateness of the quantity of drug obtained is associated with favorable healthcare outcomes and lower expenses. Methods This study utilized a longitudinal design with a seven-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. The patients under study were those aged 18 years or older and newly diagnosed with type 2 diabetes or hypertension in 2002. Generalized estimating equations were performed to examine the relationship between medication supply and health outcomes as well as expenses. Results The results indicate that while compared with patients with an appropriate medication supply, patients with either an undersupply or an oversupply of medications tended to have poorer healthcare outcomes. The study also found that an excess supply of medications for patients with diabetes or hypertension resulted in higher total healthcare expenses. Conclusion Either an undersupply or an oversupply of medication was associated with unfavorable healthcare outcomes, and that medication oversupply was associated with the increased consumption of health resources. Our findings suggest that improving appropriate medication supply is beneficial for the healthcare system.

After discussing what cognitive enhancement (CE) is and how it differs from therapy, this chapter will provide an overview of a range of nootropic drugs, devices and procedures that are, or are proposed to be, used for enhancement. Those covered include: methylphenidate; modafinil; amphetamines; beta-blocking drugs such as propranolol; donepezil; brain games; neurofeedback; transcranial direct current stimulation; transcranial magnetic stimulation; deep brain stimulation; and brain-computer interfaces (BCI). It then summarizes the latest scientific data on the effcacy of these interventions. It also includes an analysis of the current prevalence of CE use.

The World Health Organization's 2008 report asserted that the focus on primary healthcare (PHC) within health systems should increase, with four sets of reforms required. The WHO's PHC advocacy is well founded, yet its report is a policy document that fails to address adoption and implementation questions within WHO member countries. This paper examines the prospects for the WHO PHC agenda in 12 high-income health systems from Asia, Australasia, Europe and North America, comparing performances against the WHO agenda.A health policy specialist on each of the 12 systems sketched policy activities in each of the four areas of concern to the WHO: (a) whether there is universal coverage, (b) service delivery reforms to build a PHC-oriented system, (c) reforms integrating public health initiatives into PHC settings and (d) leadership promoting dialogue among stakeholders.All 12 systems demonstrate considerable gaps between the actual status of PHC and the WHO vision when assessed in terms of the four WHO reform dimensions, although many initiatives to enhance PHC have been implemented. Institutional arrangements pose significant barriers to PHC reform as envisioned by the WHO.PHC reform requires more attention from policy makers. Meanwhile, the WHO PHC report is perhaps too idealistic and fails to address the fundamentals for successful policy adoption and implementation within member countries.CONTEXTE : Le rapport 2008 de l'Organisation mondiale de la Santé affirme qu'il faut mettre plus d'accent sur les soins de santé primaires (SSP) dans les systèmes de santé, au moyen de quatre séries de réformes. Cette position de l'OMS est bien fondée, cependant le rapport est un document de politiques qui n'aborde pas les questions d'adoption et de mise en œuvre dans les pays membres de l'OMS. Cet article étudie le potentiel du programme de l'OMS sur les SSP dans 12 systèmes de santé à revenu élevé en Asie, en Australasie, en Europe et en Amérique du Nord, en y comparant le rendement en fonction du programme de l'OMS. MÉTHODE : Pour chacun des 12 systèmes de santé, un spécialiste des politiques de santé a brossé le tableau des activités politiques liées aux champs d'intérêt de l'OMS : (a) présence ou non d'une couverture universelle, (b) réformes des prestations de services pour créer un système axé sur les SSP, (c) réformes qui intègrent les mesures de santé publique au sein des établissements de SSP et (d) leadership qui favorise le dialogue au sein des intervenants. RÉSULTATS : Après évaluation en fonction des quatre volets de réforme proposés par l'OMS, chacun des 12 systèmes présente des écarts considérables entre le statut réel des SSP et la vision de l'OMS, bien que plusieurs initiatives d'accroissement des SSP y aient été mises en place. Les arrangements institutionnels constituent des obstacles considérables pour la réforme des SSP telle qu'envisagée par l'OMS. CONCLUSIONS : La réforme des SSP nécessite plus d'attention de la part des responsables de politiques. Par ailleurs, le rapport de l'OMS sur les SSP est peut-être trop idéaliste et ne permet pas d'aborder les aspects fondamentaux qui visent une pleine adoption et la mise en œuvre des politiques dans les pays membres.

Investigational, conceptual, and interventional advances in the neurosciences strain consensus in research ethics, clinical ethics, legal ethics, and jurisprudence and demand innovative adaptation in public policy. I review these advances, ask how they might change a range of policies, and conclude that their implications — particularly relating to aggression — are likely to have been underestimated.

This paper analyses the policy issues surrounding the definition of death within the context of technological and social changes. Increasingly precise brain imaging techniques, combined with demographic trends and heightened health budget pressures, are bound to accentuate calls for redefining death in terms of partial- or higher-brain criteria. In addition to questioning our notions of consciousness and of what human life entails, a shift toward higher-brain definitions of death have critical public policy implications, which must be thoroughly debated. Adding patients in a persistent vegetative state or with end stage Alzheimer's disease to the ranks of the dead raises many difficult questions, for instance, must the NHS or insurers fund continuing care for a legally dead but still breathing patient whose family cannot let go? The implications for disposal of breathing patients who lack brain functions deemed essential to life are substantial. The public is likely to find it difficult to accept burial o...

In vitro fertilization (IVF) and other assisted reproduction technologies (ARTs) have become widely accepted as therapy for a wide array of fertility problems and accompanied by the rapid expansion of clinics that provide a full range of ARTs. Although these technologies undoubtedly offer benefits for some individuals, they raise important questions over reproductive rights to safe and effective treatment as well as access. This article analyzes current data concerning the safety, effectiveness, and cost of IVF. It concludes that IVF and related techniques have been transformed too rapidly and easily from experimental to therapy status, despite evidence that suggests considerable caution is warranted. Unfortunately, the widespread diffusion of IVF has preceded rather than followed firm evidence of its value in extending the reproductive rights of women and couples. Resources might better be directed toward prevention of fertility problems and discovering the causes of infertility.

This brief review of the efficacy, safety, and costs of IVF demonstrates that this procedure has become accepted medical practice without adequate scientific assessment. Its rapid proliferation especially in the market-oriented USA system, has preceded the type of outcomes research that is essential in order to protect both individual patients and the health care system. In addition, concern over the psychological costs borne by the vast majority of women who unsuccessfully pursue pregnancy through these techniques should warrant a level of caution which to date has not been forthcoming. The demand for pregnancy, the organisation of medical specialties surrounding these procedures, the open-ended reimbursement and incentive structure, and powerful market forces make it unlikely that IVF and a whole range of medical technologies can be regulated without some semblance of a national health system. These findings clearly reinforce the themes raised by the Radical Statistics Health Group and illustrate some of the weaknesses of a market approach to medical care.

This chapter demonstrates how cognitive neuroscience clearly challenges the traditional Standard Social Science Model (SSSM). Despite the rapid expansion of the understanding of brain structure and function in recent years, we still are in our infancy in terms of developing a unifying theory of how it operates. As a result, considerable controversy surrounds neuroscience in at least four broad areas: the mind/brain distinction; the organization of the brain; the impact of genetics on the brain; and the role of the brain in determining human behavior. After briefly discussing the first three of these concerns, the chapter focuses on the implications of the findings of neuroscience on our understanding of the role of the brain in human behavior particularly as it relates to addictive behavior, free will, and individual responsibility.

Major alterations in the United States health-care system will be necessary in the coming decades if we are to avert a crisis of immense proportions. Many seemingly unrelated demographic, social, and technological trends in reality constitute a concatenation that promises to accentuate traditional dilemmas in medical policy making. The aging population, the proliferation of high-cost biomedical technologies designed primarily to prolong life, conventional retroactive reimbursement schemes by third-party payers, and the realization that health-care costs are outstripping society’s perceived ability to pay all lead to pressures for expanded public action. At the same time, social institutions appear both unable and unwilling to make the difficult decisions in this area traditionally viewed as outside the public arena.

As rapid advances in human genetic research are transferred into new areas of genetic technology, questions relating to the use of these techniques will escalate. This paper examines some of the policy concerns surrounding recent developments in genetic screening. It discusses the impetus and implications of genetic screening in general, examines various applications, and analyzes the costs and benefits of screening programs currently in existence. Special emphasis is placed on whether or not screening should be considered a matter of public health and mandated on those grounds. This paper argues against any compulsory screening programs except where the disease is easily identified, applicable across social groups, and treatable. While screening services for carriers of genetic disease and prenatal diagnosis should be made available and education programs should be expanded substantially, the burden of proof for involuntary programs is placed on the proponents. There is little public health justification at this time for mandatory screening though this does not preclude future public health demands. It is argued that the goals and justification of various human genetic technologies must be examined at this time due to the rapid advancement of the research as well as the ultimate benefits promised for humankind.Policy issues associated with different forms of genetic screening--prenatal diagnosis, phenylketonuria screening in newborns, and carrier screening programs--are examined. Criteria are suggested for cost-benefit analyses of proposed programs, and data from available studies on some genetic defects are provided. The author sees little public health justification at this time for mandatory screening; he argues against any compulsory screening programs except where the disease is easily identified and treatable. Moreover, mandatory programs should never be considered unless voluntary trial programs have proved to be socially and technically feasible.

A steroid-lactonase has been obtained from disrupted cells of Cephalosporium acremonium . Properties of the purified enzyme are described. Testololactone derivatives are hydrolyzed by the enzyme, but steroids containing γ-lactones, e.g., digitoxigenin and a spirolactone, are not.

Selected steroids give rise to 1α,2α-dihydroxylated products when fermented with nocardia corallina (ATCC 999). Preparation of the 1α,2α-dihydroxy derivatives of 17α-ethynyl-17β-hydroxyandrost-4-en-3-one (I), 9α-fluoro-11β,17β-dihydroxy-17α-methylandrost-4-en-3-one (VI), and 11β,21-dihydroxy-16α,17α-isopropylidenedioxypregn-4-ene-3,20-dione (XII) is described. Induction of the required enzymes by prior exposure of N. corallina to androstenedione was necessary to obtain the 1α,2α-dihydroxy products from I and XII.