Zychol Chemicals Case Study Answers

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Globalization & Development of economies Essay

Globalization has been perceived as a beneficial factor in the development of economies, technological advancements as well as sociological and political development. However, not everyone gains from these benefits. Instead, other nations particularly the developing states are subjected to the dangerous effects of globalization. The truth about globalization is while the benefits may be enjoyed by a few individual states, the negative impacts of globalization are felt by all the nations in the world. Globalization and the associated changes in the social work organization has led to a creation of economic systems where various corporations are increasingly moving around the world to find the cheapest labor possible. A good example is out the trend of outsourcing, which is quite common in the modern world of business. Cheap labor in this context is reproduced through political, social, technological and economic means which allows corporations to pay extremely low wages to the workers. Globalization has led to a number of technological innovations and technology has played a pivotal role in the reshaping of the social organization of work. The introduction of computers and information technologies has greatly changed the work setting. For instance, the shift from demands for physical work to mental, intellective operations and information handling has substituted the skills of all collar workers. This has reshaped the social organization of work. The overall effect of such changes is the reduction of employment and the eventual reduction in the wage levels among the workers performing physical work. The social organization changes of capitalism have intensified the effect of globalization and affected how employment and labor relationship is regulated. This has mainly been seen through the intensification of acquisition and cross-border mergers where companies value the importance of mergers and acquisitions in order to increase the strength of business. There has also been a pronounced trend of the global corporations of transforming themselves into organizers and coordinators of activities performed by suppliers, contractors and sub-contractors. This has had a significant effect to the regulation of employment and labor relationship leading to the production of cheap labor. Through globalization, employers can easily subcontract and outsource cheap labor from different states which further allows global corporate to externalize and reduce the costs that are incurred from employing directly. Outsourcing of labor makes the employers to pay low wages since they can choose to employ from states where cheap labor is readily available. The political instability, poor living standards and poorly developed economies in developing states have all contributed to the reproduction of cheap labor and global corporations are taking advantage of this. In order to avoid further tearing of the social fabric caused by globalization, consumers and /or producers of cheap labor should devise machineries to provide salient working conditions with improved wage levels. This can be achieved by setting the international wage minimums that will prevent the overexploitation of workers from the developing countries. All workers with similar qualifications should earn on the basis of a unified wage rate. The increased acquisition and merging of companies can be beneficial as it increases the strength of business in a synergistic manner. However, agreements should first be made to integrate the social values of each company and respect the rights of employees of each of the merged companies. Through this, the benefits of globalization can be reaped by both the developing and the developed states or the producers and consumers of labor. Reference: Amin, M. (2009). The effect of globalization, labor fexibilization and national industrial relations systems on human resource management. International Business Research. 2(4), 36-45. http://www. ccsenet. org/journal/index. php/ibr/article/viewFile/3910/3434

Community Teaching Essay

Health promotion is very important in today’s society. There are many things people can do in order to maintain good health, yet most are uninformed about this. Obesity is one of the leading health concerns in America and must be dealt with immediately. It is because of this that a student has decided to teach a fifth grade class with twenty three students about what obesity is, what problems it causes, and how it can be avoided. The teacher uses visual aids, games, trivia, and much more in order to get the students more interested in what they are going to learn. The teacher informs the students about how important it is to make healthy eating choices by using the food pyramid as a guideline. Students are also informed that exercise is key to living a healthy lifestyle. The teacher begins the class by playing a quick game. The teacher then asks the students to each take out a piece of paper and write down as many fruits and vegetables as they can. The students are told that the person who has thought of the most fruits and vegetables will win a prize. When finished with the game, the teacher will then introduce the topic of obesity to the children and the importance of preventing it by eating healthy foods. Students are told that â€Å"obesity is defined as having an excessive amount of body fat. Obesity is more than just about looks. It increases your risk of diseases and health problems such as heart disease, diabetes and high blood pressure† (J.Crawford,2014). The teacher then tells the students that in the past ten years, obesity in children in the U.S has gone from 7-18 percent (CDC,2012). The main portion of this lesson revolves around the food pyramid. The food pyramid consists of 6 essential healthy food groups: Grains/rice, fruits, vegetables, dairy, meat/fish/poultry, fats/oils/sweets. The food pyramid acts as a guideline by showing students the necessary servings of each food group in order to stay healthy. It is essential for students to understand the food pyramid because it is a roadmap to healthy living. The students were not only taught about healthy eating, but also other ways to ensure that they maintain their health. One thing they were taught is the importance of being active daily. Students can do things such as playing sports, running, or bike riding in order to stay healthy and have fun doing it. It was said that rather than avoiding all types of junk food, it is better to simply eat it in moderation. The end of the lesson consisted  of trivia questions that the children answer in order to win a prize. By teaching the students this information, the teacher can ensure that they will live a better life. The epidemiological rationale for this topic is very serious. Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years (CDC,2014). The percentage of children age 6-11 years in the U.S. who were obese increase from 7% in 1980 to nearly 18% in 2012. Rate of obese adolescents ages 12-19 years increase from 5% to nearly 21% over the same period (CDC,2014). Obese adolescents are more likely to have pre-diabetes. Children and adolescents who are obese are at greater risk for coronary heart disease, bone and joint problems, sleep apnea, social and psychological problems such as poor self esteem. â€Å"Reducing childhood obesity is a public health priority that has substantial health and economic benefits†(Maurer, Frances, C. Smith, 2013.) The teacher claims that the overall teaching experience was quite enjoyable. It is extremely beneficial to be able to teach young children about topics that they are not well informed about. By teaching children about such serious health hazards at a young age, it is more likely that they will strive to take the necessary measures in order to avoid these hazards. The teaching experience allowed the teacher to see how much children knew about health promotion as well as what they wanted to know. The teacher learned how to make different topics easily understandable for children and as well as making the entire learning process fun and enjoyable. This experience helped the teacher realize that even by teaching a small group of children from one school, it is possible to make a difference in the health and wellbeing of America’s children. The community responded rather positively to the teaching. The students were excited to learn about new health promotion tips through a series of games and activities. The children were shocked to see how serious obesity really is as well as how many children it has affected throughout the country. Before this lesson, the children believed that eating healthy meant cutting out all types of sweets and sugary drinks completely. The children were elated to hear that they can be healthier while still enjoying some of their favorite desserts. Kids  react positively to games and rewards because it makes learning more fun. By getting the kids’ attention, the teacher ensures that they are listening and paying close attention to everything that the teacher has to say. After learning about obesity and the many negative affects that come from it, the children promised to change their eating habits as well as be more active in order to make sure that they stay fit throughout their lives. The children agreed to eat more fruits and vegetables and to play outside much more. The children have promised to limit the amount of time they watch television and play on the computer and replace it with riding their bikes or going to the park. This teaching process has taught the teacher about not only her strengths, but her weakness’ as well. The teacher is easily able to relay information in simple terms so that the children can understand as well do things such as creating games and trivia in order to make the lesson more exciting. Some weakness’s or improvements that the teacher can make includes being able to connect with the students on a closer level in order to truly help them understand the topic as well as finding new and creative ways to reward the kids when they answer questions correctly. At the end of the lesson, the students were asked to take a short survey regarding how well the teacher taught the lesson as well as how much the kids enjoyed it. Though the teacher received high scores from each child, she knows that there is still room for improvement and is determined to make these changes for the next teaching session that may occur.

Budgeting Assignment Example | Topics and Well Written Essays - 1500 words

Budgeting - Assignment Example Budgeting can be described as the careful planning of an organization’s funds based on the various costs and expenditures that a business faces and the means in which these funds will be distributed amongst them (Lasher, 2010). A simpler and straight forward explanation would be that budgeting is simply the development of a budget. A budget can be defined as an economic plan for a certain period of time according to available funds (Obstfeld, 2008). A company cannot function without budgeting, and it is essential that the methods and techniques used during this process are appropriate to the business in particular in terms of the approach and objectives that feature in that particular organization (Bartle & Shields, 2008). Good budgeting results in financial success for that particular accounting period and will reduce the risk of a company mismanaging the funds that are available to them which in serious situations could lead to disastrous results if not kept in check such as bankruptcy among others (Lasher, 2010). Once a proper budgeting plan has been established, however, these risks have a higher chance of being avoided and put the company in a better position to maintain their position in terms of economic stability. Purposes of Budgeting There are a number of purposes of budgeting that can be identifies as the main reasons for the activity, some of these include: Financial Forecasting – Budgeting provides an overview of the expected financial position of a firm at the end of an accounting period if the various strategies implemented succeed in achieving the objectives set out for them at the beginning of the period (Diamond, 2008). Budgeting allows the organization to predict the economic situation they will find themselves in at the end of a certain period if everything goes according to plan in terms of revenue and expenditure. Establishment of constraints – Budgeting also ensures that a company does not mismanage the funds at their disposal in a manner that may lead to irrecoverable financial difficulties through the placement of constraints on the maximum amount of money they can spend on a particular activity or area (Lasher, 2010). The establishment of these constraints ensures that the company remains within the economic safety net that is created by the budget and avoids any financial risks that would have otherwise potentially occurred. Comparison – Budgeting allows the actual finances of the business to be compared with the predictions that have been set out in the forecast in a bid to determine whether they are actually achievable or should they be adjusted if necessary (Lasher, 2010). This method of comparison allows the company to take a look at the economic success that the business achieves and the potential success it will be able to attain in the future (Blaug, 2007). This ensures that the company can plan appropriately according to these comparisons in relation to the financial position of the company. These can be considered to be the main purposes behind budgeting and represent the importance of this activity to a successful business. Budgeting Process There are a number of stages that exist within a conventional budgeting process that can be implemented on a global scale by various companies (Lasher, 2010). These steps follow a protocol that allows the organization to properly develop a means of appropriately allocating the available funds to the various different parts of the business according to the particular needs of these sectors as well as the objectives that have been set out (Diamond, 2008). These stages are as follows; †¢ Firstly the main objectives of the business are identified in relation to activities that will require funding so as to accomplish

Battles fought by Ancient Greeks and their neighbors Essay

Battles fought by Ancient Greeks and their neighbors - Essay Example The total weight of a hoplite's equipment and armor was 50-60 pounds. Generally, only the wealthy and upper-middle class served as hoplites due to the high costs of the equipment. At first, the spears were about seven feet long, and the formation was about six to seven ranks deep. In combat the phalanx would move towards the enemy in unison, forming a thick wall of spears. When two phalanxes fought, one would attempt to either break the formation of the other or occasionally push the soldiers in the opposing phalanx over. Eventually some more advanced tactics were developed, such as sudden attacks on a certain point in a phalanx. The phalanx was a strong formation that had high shock power and could defend against charging heavy cavalry. However, the formation was also slow, and it needed to be set up before battle. Light infantry was also used often by Greek city-states. Types of light infantry included peltasts, or javelin throwers; archers; and slingers. Peltasts were the most common type of light infantry. They fought with swords and javelins, and they wore only light armor and shields. Archers carried a bow and arrow, and slingers carried a sling that could be used to hurl small stones or lead slugs at an enemy. The equipment carried by the light infantry was cheaper than that carried by the hoplites, and many poorer citizens fought as light infantry. While light infantry could not withstand a charge of heavy infantry if it was trapped, it was more mobile, and could wear down the enemy from afar. Cavalry was also occasionally used by the Ancient Greeks. Originally light cavalry that threw javelins was used, but the Macedonians developed a type of heavy cavalry known as The Companion Cavalry. These cavalrymen carried nine to twelve foot lances and wore heavy armor. Light cavalry was used fo r reconnaissance and harassment, and the companions were used to make a decisive charge that would overrun an enemy force and win the battle. Ancient Greek naval forces used a type of warship called the trireme. This ship was propelled by three rows of oars. The rowers were slaves in many states, and poor citizens in Athens. Triremes carried marines for boarding an enemy ship, archers, a battering ram and some small ballistae and catapults. One common tactic that was used was ramming, which is where a ship would speed up and try to collide with another ship with its battering ram so that a hole would be broken in the other ship. The other major tactics were boarding and a tactic where a ship would brush against another to try to break the oars in the other ship. The first major battles that the Greeks fought against opponents from outside Greece were in the Persian Wars. These wars lasted from 499 BC to 448 BC. The Persians used different tactics than the Greeks. Persian forces were mostly made up of light infantry that used bows, spears, and swords. Persian infantry had only light armor and wicker shields. Persian tactics involved the use of large amounts of archery. Usually, only the front ranks of the Persian infantry would engage in melee combat, while the other ranks showered the enemy with arrows. The Immortals were an elite unit that consisted of only the best warriors. Only Medians, Elamites, or Persians could serve in this unit. The Immortals always kept their strength at 10,000 men, and they served as the

Resume and Cover Letter Essay Example | Topics and Well Written Essays - 750 words

Resume and Cover Letter - Essay Example Here are a few ways that I fit your qualifications: As you can see, I have many of the qualities that you need. Please take a few minutes to look over my resume, then I would like to come in and talk with you about this position at a time mutually convenient. Heres some tips, not necessarily in any order, for resumes. I was a Career Counselor and Ive reviewed and done zillions of resumes, and helped others do the same. Please look this over and tweak it to your liking. I didnt have your major, so I put the marketing/management major in. 1. I rearranged your resume to "fit" the sample that the teacher gave. Now, you can easily take out the internship stuff and use employment things instead. However, this will give you a good basis. The reason I did this was so that we could do the cover letter to match the resume. With more time I might have looked up a "fake" job posting, but I didnt know where you were, and it was much easier to do it this way. 2. The resume must match the job you are applying for and the cover letter must match the job posting and the resume. Employers will be looking at HOW you FIT their position. So, you only want to put on it relevant experience. You dont have to put everything down. 6. Professional strengths should be those things that you do well that are relevant for the job you are applying for. Again, you don’t have to list everything. Just those things that are relevant that will entice them to look at the rest of the resume. 8. I took out the doctors names on two of the jobs -- you could put their names as a reference, or use them when they ask for references. If they ask you who you worked for in the interview, you can tell them then. You don’t want them (necessarily) to call the doctors and ask about you before they interview you. Therefore, dont put the info on there. 10. On the Cover letter, I would list point by point the skills that you have that match the job

Transportation and Facilities Management role in Military Essay

Transportation and Facilities Management role in Military - Essay Example In the proving this commitment, the US Army Force has a well instituted program scale named Optimal Stationing Army Force (OSAF) that has helped in setting and making of viable organizational strategies (Dell 421). OSAF has fundamentally helped the US Army in organizing various installation programs and setting up of operational platform for the US Army Force. The Optimal Stationing Army Force has been significantly applied in the 2005 Base Realignment and Closure (BRAC). The OSAF provides a significant tool for planning and scheduling the installation and reinforcement of the military forces in manner destined at cutting expenditure and resources spent in maintaining and sustaining the US Army (Dell 421). Every military plan conducted on the basis of the OSAF is done in such way that it will be implemented under the lowest possible cost. OSAF program dictates that every stationing plan for any army unit has to meet particular standards without which the particular unit may be disreg arded. The standards include the availability of field for maneuver training, buildings and various requirements for training a unit. The OSAF also provides strict and explicit mechanism for determining and evaluating every station plan. With the provisions in the OSAF, Army leaders have been able to guide stationing analysts on the appropriate channels and systems to rely upon, those to change and those to ignore in making decisions that meet qualitative and qualitative metrics of Army Stationing. Furthermore, Army has substantially used the OSAF program as a tool for determining appropriate conditioning of various facilities as well as upgrading the underdeveloped and outdated facilities (Dell 423). The Optimal Stationing Army Force (OSAF) is said to cover and perhaps judgmental of only five types of Army installations out of the total thirteen types of the Army installation. The five types of installation stations run by OSAF include the maneuver centers, professional schools con trol and command, major training bases and training schools. As observed by Dell the installation centers operated by OSAF are somewhat different from the other centers not operated by OSAF as determined by the high population of soldiers in the OSAF operated stations (424). In dictating the installation costs, OSAF uses the principles of the Cost of Base Realignment Action (COBRA) Army to arrive at the per-person cost of running particular installation station. The cost of running an individual installation station is calculated in terms of the location, medical costs, repair costs housing operations, modernization costs and the amount of allowances offered. According to Dell the installation programs of various stations face numerous problems and challenges that are however solved and settled by the OSAF (424). One of the noted problems that faces and affects the smooth achievement of the installation programs in various stations is the unpredictability of the actual costs and exp enditures. This results from the variability in the installation costs of different units in particular stations. Another problem faced in the installation program of stations relies upon the high transport costs of the soldiers and their families during their

The Representation of Crime in London's Media Essay

The Representation of Crime in London's Media - Essay Example Media like to present the most sensational news to the readers. In the case of crimes also there is a tendency to publish the ideal victims more frequently than the other victims. It has become so common in the world and the same is with the media in London. The part played by media in representing the crimes cannot be neglected as in the new era of information technology. The Book titled Victims, Crime and Society edited by Pamela Davies, Peter Francis, and Chris Gheer state the importance of media in dealing with the reporting of crimes and the related matters very well. They consider media as, â€Å"They are of fundamental importance to those who would promote a particular view of crime victims and victimization, or seek to challenge or change existing views† (Davies, Francis & Greer, 2007, p.8). So the news articles in media influence people and make a vision of the reality in the minds of readers. The points of a medium are different from another and so the reality is cat egorized in each and every newspaper. The visual media also is filled with the elements of crime in it. The people of London cannot get away from the clutches of TV and internet. They are attached to it very deeply. The crimes appear in these agencies attract people’s attention to it. ... Surely, the involvement of media can be seen in each and every crime recorded in media. Not all crimes get space in the media and those crimes which have news value find its space in the media. Chris Greer comments, â€Å"†¦there exists a hierarchy of victimization, both reflected and reinforced in media and official discourses. At one extreme, those who acquire the status of ‘ideal victim’ may attract massive levels of media attention, generate collective mourning on a near global scale, and drive significant change to social and criminal justice policy and practice (Greer, 2004, p.22). The writer further gives the description of ideal victims as â€Å"a person or category of individuals who- when hit by crime-most readily are given the complete and legitimate status of being a victim, including those who are perceived as vulnerable, defenseless, innocent and worthy of sympathy and compassion† (Greer, 2004, p.22). In this manner those persons who can catch attention and sympathy of the readers easily is grouped into ideal victim. The ideal victim should possess a note of compassion and sympathy from the readers. The more intensity of the ideal victims, the higher is the chances for its appearance in news media. These persons increase the circulation of the media in the society. Crime is a key ingredient of a news media. Almost in every news media there is special space for adding crime stories, just like giving special space for sports news. David Levinson in Encyclopedia of Crime and Punishment, Volume1-4 rightly puts, â€Å"Researchers analyzing a variety of different types media and media markets have found that crime accounts for between 20 and 50 percent of the total space available for news† (Levinson,

Ben Franklin Essay Example | Topics and Well Written Essays - 250 words

Ben Franklin - Essay Example 82). Franklin decided with these two sentences that he will respect other nation’s options but still the United States has its own conceptions to follow. Franklin also logically researched on a number of different thoughts on the diverse virtues, which he wanted to include locating the best description for his virtues list (Lauter et al. 82). "The Speech of Polly Baker," on the other hand, seems to be an optimistic and "amusing story". Nevertheless, Franklin presents a logical protest against a law, which punished females for out-of-wedlock sexual relations through whippings and imposing fines whereas the male of went without any penalty (Lauter et al. 94). Through the woman’s use of logical rhetorical questions to the judges, Franklin reveals the unfairness of the then U.S. justice system. Two examples include, â€Å"God has been pleased to add his divine Skill and admirable Workmanship in the Formation of their Bodies, and crown’d it by furnishing them with rational and immortal Souls?† and â€Å"You have already excluded me from all the Comforts of your Church Communion: Is not that sufficient† (Lauter et al.

The Sons Veto Essay Example for Free

The Sons Veto Essay Compare aspects of prejudice in Roll Of Thunder, Hear My Cry, by Mildred Taylor, and, The Sons Veto, by Thomas Hardy. Prejudice: The act of prejudging a subject or group of subjects on the basis of opinions that are not grounded in fact or experience. Prejudice can be on the basis of race, religion, political view, age, appearance or cultural affiliation Many people have different views on prejudice, what it is and whether its right or wrong. Some people may believe that prejudice is racism, but prejudice is when you have an opinion of someone or something without knowledge of what they or it are really like. It may be class or colour, rich or poor, its all prejudice. In this essay I will compare the aspects of prejudice in Roll Of Thunder, Hear My Cry by Mildred Taylor, and, The Sons Veto, by Thomas Hardy. I will look at how segregation is achieved in each story and the consequences of it. Roll Of Thunder, is a story about a black family in the southern states of America in the 1930s. At this point in American history, prejudice against blacks was at an all time high. Sharecropping was a part of life then. The story focuses on the Logan family and their struggle against racism. They have their own land, so they dont have to share-crop, but the local land owner, Harlan Granger, wants their land, and this book is about their struggle to keep it, and their fight against racism. The Sons Veto, is a story of a young woman who has suffered from class prejudice for all her life since she fell down some stairs and was forced to use a wheelchair. Before she had her injury she was courting a gardener named Sam, when she had her injury, the vicar she was serving felt sorry for her, and decided that he should marry her. Now, because of the social status of the vicar, she could not refuse, but this would be social suicide for the vicar. The story shows the prejudice that Sophy has to suffer, and how even those very close to you, can prejudge. In the very beginning of Roll Of Thunder, the Logan children have a long walk to school, as they are walking along the dirty, dusty road, a school bus from the Jefferson Davis School, a white school comes speeding towards the children. The bus driver deliberately drives the children towards the muddy banks of the road, he comes so close that the children are forced to dive into the bank. As the bus speeds past there are white children on the bus laughing and shouting nigger, nigger, mud eater and other comments, this shows us that racism is very prominent here because even children are taught to speak like this to people. Another matter is when little man receives his badly conditioned book from miss Crocker, he is incensed that the books have been discarded by white pupils and handed down to the inferior black schools as soon as they are no longer good enough for white pupils. The point is also driven by the fact that there is chart in the book, which states the condition that the book that is in, and the colour of the pupil using it. It states that the book has been in circulation for eleven years and now that the book is in a dismal state, the book is given to the nigra student. The perception of societys feelings to the blacks is made clear to us early in the story by these incidents, showing us that the whites thing they are somehow better than the blacks, and deserve better books and equipment, we also see that blacks are hated so much that even children are taught to taunt them, and make fun of them. In The Sons Veto, the story is started off at a charity fair, and Sophy, the main character in the story, is sitting in a wheelchair, with passers by staring at her as they move past. Why do they need to look? Is it abnormal for a person in a wheelchair to come to a charity fair? No, what we are seeing is the attitude of people towards others of a lower class than themselves. The book says a boy of 12 or 13 who stood beside her, and the shape of whose hat and jacket implied that he belonged to a well known public school. The immediate bystanders could hear that he had called her mother. This show us that the bystanders are surprised to see a woman like that, of a working class, to be the mother of a well made boy like this. A little later Sophy talks to Randolph, her son, and she says He have been so comfortable these last few hours that I am sure he cannot have missed us immediately after Randolph exclaims Has, dear mother, not have! He speaks with impatient fastidiousness that was almost harsh, and Sophy immediately adopts the correction with no retaliation or resent for him making it, this is showing us that its not just society that looks down on her, but her own son! The perception of society towards Sophy is made clear early on the story because of both of these incidents, the passers by staring at her, and her son correcting her grammar. In Roll Of Thunder we see many cases of segregation by colour, segregation is when one group of people separate themselves to better social standards that another group of people. One of the earliest cases we see is that the white pupils from the Jefferson High come past in a school bus, but the Logan children have to walk to school, This is where the segregation of the classes really begins.

Major Depressive Disorder

Major Depressive Disorder Major Depressive Disorder Preface Today, there are so many people suffering from so many diseases. Likewise, so many people started to feel depressed without a reason. Maybe there should be a reason but most people fail to find it and live their life as it goes by. Now, depressive disorder has become one of major diseases. Boys, girls, teenagers, 20s, 30s, 40s, most people regardless of their age are suffering from major depressive disorder. Because of this, suicidal rate has been increased far more than ever. Maybe, because of technological revolution, many people started to feel as if they are alone, for people talk through internet, telephone, and so on, they do not feel as if somebody is beside them. Because of this, I wanted to research on ‘major depressive disorder to figure out what are causing this and what are some ways to prevent this. Symptoms and Signs Major depression is a serious illness that affects a persons family and personal relationships, work or school life, sleeping and eating habits, and general health. Its impact on functioning and well-being has been equated to that of chronic medical conditions such as diabetes. A person suffering a major depressive episode usually exhibits a very low mood, which pervades all aspects of life, and an inability to experience pleasure in activities that formerly were enjoyed. Depressed people may be preoccupied with, or ruminate over, thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness, hopelessness, and self-hatred. In severe cases, depressed people may have symptoms of psychosis. These symptoms include delusions or, less commonly, hallucinations, usually of an unpleasant nature. Other symptoms of depression include poor concentration and memory (especially in those with melancholic or psychotic features), withdrawal from social situations and activities, reduced sex drive, and thoughts of death or suicide. Insomnia is common among the depressed. In the typical pattern, a person wakes very early and is unable to get back to sleep. Hypersomnia, or oversleeping, is less common. Appetite often decreases, with resulting weight loss, although increased appetite and weight gain occasionally occur. The person may report multiple physical symptoms such as fatigue, headaches, or digestive problems; physical complaints are the most common presenting problem in developing countries, according to the World Health Organizations criteria for depression. Family and friends may notice that the persons behavior is either agitated or lethargic. Depressed children often display an irritable rather than a depressed mood, and show varying symptoms depending on age and situation. Most exhibit a loss of interest in school and a decline in academic performance. They may be described as clingy, demanding, dependent, or insecure. Diagnosis may be delayed or missed when symptoms are interpreted as normal moodiness. Depression may also coincide with attention-deficit hyperactivity disorder (ADHD), complicating the diagnosis and treatment of both. Older depressed persons may have cognitive symptoms of recent onset, such as forgetfulness, and a more noticeable slowing of movements. Depression often coexists with physical disorders common among the elderly, such as stroke, other cardiovascular diseases, Parkinsons disease, and chronic obstructive pulmonary disease. Causes The biopsychosocial model proposes that biological, psychological, and social factors all play a role to varying degrees in causing depression. The diathesis-stress model posits that depression results when a preexisting vulnerability, or diathesis, is activated by stressful life events. The preexisting vulnerability can be either genetic, implying an interaction between nature and nurture, or schematic, resulting from views of the world learned in childhood. These interactive models have gained empirical support. For example, researchers in New Zealand took a prospective approach to studying depression, by documenting over time how depression emerged among an initially normal cohort of people. The researchers concluded that variation among the serotonin transporter (5-HTT) gene affects the chances that people who have dealt with very stressful life events will go on to experience depression. Specifically, depression may follow such events, but seems more likely to appear in people w ith one or two short alleles of the 5-HTT gene. A Swedish study estimated the heritability of depression—the degree to which individual differences in occurrence are associated with genetic differences—to be approximately 40% for women and 30% for men, and evolutionary psychologists have proposed that the genetic basis for depression lies deep in the history of naturally selected adaptations. A substance-induced mood disorder resembling major depression has been causally linked to long-term drug use or abuse, or to withdrawal from certain sedative and hypnotic drugs. Biological Monoamine hypothesis Most antidepressant medications increase the levels of one or more of the monoamines—the neurotransmitters serotonin, norepinephrine and dopamine—in the synaptic cleft between neurons in the brain. Some medications affect the monoamine receptors directly. Serotonin is hypothesized to help regulate other neurotransmitter systems; decreased serotonin activity may allow these systems to act in unusual and erratic ways. According to this permissive hypothesis, depression arises when low serotonin levels promote low levels of norepinephrine, another monoamine neurotransmitter. Some antidepressants enhance the levels of norepinephrine directly, whereas others raise the levels of dopamine, a third monoamine neurotransmitter. These observations gave rise to the monoamine hypothesis of depression. In its contemporary formulation, the monoamine hypothesis postulates that a deficiency of certain neurotransmitters is responsible for the corresponding features of depression: Norepinephrine may be related to alertness and energy as well as anxiety, attention, and interest in life; lack of serotonin to anxiety, obsessions, and compulsions; and dopamine to attention, motivation, pleasure, and reward, as well as interest in life. The proponents of thi s theory recommend the choice of an antidepressant with mechanism of action that impacts the most prominent symptoms. Anxious and irritable patients should be treated with SSRIs or norepinephrine reuptake inhibitors, and those experiencing a loss of energy and enjoyment of life with norepinephrine- and dopamine-enhancing drugs. Schematic of a synapse between an axon of one neuron and a dendrite of another. Synapses are specialized gaps between neurons. Electrical impulses arriving at the axon terminal trigger release of packets of chemical messengers (neurotransmitters), which diffuse across the synaptic cleft to receptors on the adjacent dendrite temporarily affecting the likelihood that an electrical impulse will be triggered in the latter neuron. Once released the neurotransmitter is rapidly metabolised or pumped back into a neuron. Antidepressants influence the overall balance of these processes.In the past two decades, research has revealed multiple limitations of the monoamine hypothesis, and its explanatory inadequacy has been criticized within the psychiatric community. Intensive investigation has failed to find convincing evidence of a primary dysfunction of a specific monoamine system in patients with major depressive disorders. The medications tianeptine and opipramol have long been known to have antidepressant properties despite the fact that the former is a serotonin reuptake enhancer and the latter has no effect on the monoamine system. Experiments with pharmacological agents that cause depletion of monoamines have shown that this depletion does not cause depression in healthy people nor does it worsen symptoms in depressed patients—although an intact monoamine system is necessary for antidepressants to achieve therapeutic effectiveness. According to an essay published by the Public Library of Science (PLoS), the monoamine hypothesis, already limited, has been further oversimplified when presented to the general public as a mass marketing tool. Other theories MRI scans of patients with depression have reported a number of differences in brain structure compared to those without the illness. Although there is some inconsistency in the results, meta-analyses have shown there is evidence for smaller hippocampal volumes and increased numbers of hyperintensive lesions. Hyperintensities have been associated with patients with a late age of onset, and have led to the development of the theory of vascular depression. There may be a link between depression and neurogenesis of the hippocampus, a center for both mood and memory. Loss of hippocampal neurons is found in some depressed individuals and correlates with impaired memory and dysthymic mood. Drugs may increase serotonin levels in the brain, stimulating neurogenesis and thus increasing the total mass of the hippocampus. This increase may help to restore mood and memory. Similar relationships have been observed between depression and an area of the anterior cingulate cortex implicated in the modulation of emotional behavior. One of the neurotrophins responsible for neurogenesis is the brain-derived neurotrophic factor (BDNF). The level of BDNF in the blood plasma of depressed subjects is drastically reduced (more than threefold) as compared to the norm. Antidepressant treatment increases the blood level of BDNF. Although decreased plasma BDNF levels have been found in many other disorders, there is some evidence that BDNF is involved in the ca use of depression and the mechanism of action of antidepressants. Major depression may also be caused in part by an overactive hypothalamic-pituitary-adrenal axis (HPA axis) that is similar to the neuro-endocrine response to stress. Investigations reveal increased levels of the hormone cortisol and enlarged pituitary and adrenal glands, suggesting disturbances of the endocrine system may play a role in some psychiatric disorders, including major depression. Oversecretion of corticotropin-releasing hormone from the hypothalamus is thought to drive this, and is implicated in the cognitive and arousal symptoms. Depression may be related to the same brain mechanisms that control the cycles of sleep and wakefulness.Depression may be related to abnormalities in the circadian rhythm, or biological clock. For example, the REM stage of sleep, the one in which dreaming occurs, may be quick to arrive and intense in depressed people. REM sleep depends on decreased serotonin levels in the brain stem, and is impaired by compounds, such as antidepressants, that increase serotoninergic tone in brain stem structures. Overall, the serotonergic system is least active during sleep and most active during wakefulness. Prolonged wakefulness due to sleep deprivation activates serotonergic neurons, leading to processes similar to the therapeutic effect of antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs). Depressed individuals can exhibit a significant lift in mood after a night of sleep deprivation. SSRIs may directly depend on the increase of central serotonergic neurotransmission fo r their therapeutic effect, the same system that impacts cycles of sleep and wakefulness. Research on the effects of light therapy on treating seasonal affective disorder suggests that light deprivation is related to decreased activity in the serotonergic system and to abnormalities in the sleep cycle, particularly insomnia. Exposure to light also targets the serotonergic system, providing more support for the important role this system may play in depression. Sleep deprivation and light therapy both target the same brain neurotransmitter system and brain areas as antidepressant drugs, and are now used clinically to treat depression. Light therapy, sleep deprivation and sleep time displacement (sleep phase advance therapy) are being used in combination quickly to interrupt a deep depression in hospitalized patients. The hormone estrogen has been implicated in depressive disorders due to the increase in risk of depressive episodes after puberty, the antenatal period, and reduced rates after menopause. Conversely, the premenstrual and postpartum periods of low estrogen levels are also associated with increased risk. The use of estrogen has been under-researched, and although some small trials show promise in its use to prevent or treat depression, the evidence for its effectiveness is not strong. Estrogen replacement therapy has been shown to be beneficial in improving mood in perimenopause, but it is unclear if it is merely the menopausal symptoms that are being reversed. Other research has explored potential roles of molecules necessary for overall cellular functioning: cytokines and essential nutrients. The symptoms of major depressive disorder are nearly identical to those of sickness behavior, the response of the body when the immune system is fighting an infection. This raises the possility that depression can result from a maladaptive manifestation of sickness behavior as a result of abnormalities in circulating cytokines. Deficiencies in certain essential dietary nutrients, particularly vitamin B12 and folic acid, have been associated with depression; other agents such as the elements copper and magnesium, and vitamin A have also been implicated. Prevention A 2008 meta-analysis found that behavioral interventions, such as interpersonal therapy, are effective at preventing new onset depression. Because such interventions appear to be most effective when delivered to individuals or small groups, it has been suggested that they may be able to reach their large target audience most efficiently through the Internet. However, an earlier meta-analysis found preventive programs with a competence-enhancing component to be superior to behaviorally oriented programs overall, and found behavioral programs to be particularly unhelpful for older people, for whom social support programs were uniquely beneficial. Additionally, the programs that best prevented depression comprised more than eight sessions, each lasting between 60 and 90 minutes; were provided by a combination of lay and professional workers; had a high-quality research design; reported attrition rates; and had a well-defined intervention. The Coping with Depression course (CWD) is claim ed to be the most successful of psychoeducational interventions for the treatment and prevention of depression (both for its adaptability to various populations and its results), with a risk reduction of 38% in major depression and an efficacy as a treatment comparing favorably to other psychotherapies. References http://en.wikipedia.org/wiki/Depressive_disorder#Prevention

Analysing the Concept of Informed Consent in Healthcare

Analysing the Concept of Informed Consent in Healthcare Chapter 1-Introduction 1.1 In modern society, everyone has the basic right to consent to medical treatment. However, this is a recent development as consent was not always considered a critical issue in medical treatment. Hippocrates himself, advised doctors that they should conceal the effects of medical treatment from their patients, his reasoning being he believed that when patients were given relevant information they would take a turn for the worse. It was not standard practice for patients to question a doctors decision or authority. Recent changes have contributed to this change in attitude and as such altered the method of practice of a doctors obligation. The final years of the twentieth century as witnessed the most dramatic shift in the reputation of the medical profession within the United Kingdom, due to scandal after scandal plaguing doctors. Major news headlines left the doctor-patient relationship in a state of concern, for example, Doctors who steal organs face jail.This headline refers to the Bristol and Liverpool Hospital where it was discovered that they were retaining childrens organs, without consent or knowledge of the parents. It became apparent in the Bristol and Liverpool reports that organ retention, of both children and adults was widespread practice. Another significant humiliation for the medical profession was the case of Harold Shipman, a general practitioner who was convicted of murdering fifteen of his patients. Whether these circumstances are due to the actions of individualist or media influence makes little difference to the effect they had on societys viewpoint. There was need for change and this brought about the introduction of regulations and guidelines that protected both the patient and the doctor. 1.2 Informed consent was seen to break the doctor knows best concept and established a liberated choice for the patient. The locus classicus for informed consent is contained within the case Schloendroff v Society of New York Hospital, where it was held, â€Å"Every person being of adult years and sound mind has a right to determine what shall be done with his own body.† There are many examples within the UK system which confirms this principle of law, one being the case Re A (Minors) in which Robert Walker L.J stated, â€Å"Every human beings right to life carries with it, as an intrinsic part of it, rights of bodily integrity and autonomy The principle underpins the common law concerning consent to treatment within the UK. The consent that a patient has the right to choose is a fundamental part of receiving medical treatment. No considerations need to be examined whether the choice is rational or irrational, as the patient has an absolute right. 1.3 The Department of Health 1993 stated, â€Å"Consent is the voluntary and continuing permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature and likely risks of the treatment including the likelihood of its success and any alternatives to it.† Meaning any permission given under any unfair or undue pressure is not consent. Consent may be expressed or implied, however the validity of informed consent does not depend upon the form in which it is given 1.4 This dissertation will firstly consider the development of informed consent, as the English courts initially had reservations of its establishment and for this reason was gradually introduced in stages, until the case of Chester v Afshar which saw the full acceptance of the doctrine. It needs to be considered how the medical profession dealt with this change and in addition how patients themselves are exercising such powers. The effect in which the Human Acts 1998 has had on the courts decision making process will also be analysed to observe the relevance this may have had on informed consent. Another factor of informed consent includes giving sufficient information and the patients understanding of this. For informed consent to exist, the patient must have all the relevant information and capability to make an informed choice as to the treatment they decide to receive. This was made apparent in the case Reibiu v Hughes, where Laskin J stated, â€Å"the genuineness of consent to medical treatment depends on proper disclosure of the risks it entails† For informed consent to exist within the UK; provisions need to be made for those who are simply unable to give an informed choice. The capacity of a patient needs to be considered and if they lack this then a doctor must make a decision as to what is in the patients best interest. This can be seen to restrict informed consent as it goes against its true principle, however if a patient can not make an informed choice for themselves then it is only passable that someone has to act on their behalf. This dissertation will examine the procedure for this and how the law enables decisions to be made fairly and respectably. Chapter 2-The Development of Informed Consent 2.1 The area of law that needs to be established is the nature and scope of the duty to inform and the extent to which this has been incorporated into the English legal system. The existence of a duty to warn came about when the relationship between a doctor and the patient, which was based solely on trust, began to erode. There was a need for scrutiny and examination within the medical profession and this was achieved through the development of the law. The scope of the doctors duty of care is determined by a reference to the Bolam case. Mr Bolam agreed to electroconvulsive therapy to help improve his depression. He suffered fractures in the course of the treatment. The risk was known to his doctor, but he had not informed Mr Bolam of such. Mr Bolam alleged that the failure to warn him of the risk was negligent. The judge found that the amount of information harmonized with accepted medical practice and dismissed his claim. The judge, McNair J, directed the jury to the principle that, â€Å"A doctor is not guilty of negligence if he has acted in accordance with the practice accepted as proper by a responsible body of medical men skilled in that particular art† Therefore, the defendant doctor had conformed with a practice which was approved by a responsible body of medical opinion. This test was known as the Bolam test and it determines whether the doctor fell below â€Å"the standard of the ordinary skilled man exercising and professing to have that special skill† 2.2 Where there is a difference of judgment between two differing medical opinions, the defendant will be given the benefit of the doubt. As a result a doctor would not be found negligent if the court is satisfied that there is a responsible body of medical opinion that considers the doctor had acted appropriately. This responsible body need not be the majority of the profession. It appears that the courts allowed the medical profession to set their own standard. A doctor simply needed to provide an expert testimony and the courts assumed that it must be responsible. In exceptional cases, the courts perceived some established practice to be substandard, however it appears that only one reported case has materialized where such a judgement has occurred. The case, Hucks v Cole, where a woman contracted puerperal fever due to her doctor failing to treat her with penicillin for her septic toe and finger. Although a number of distinguished doctors gave evidence that they would not have administrated penicillin, the Court of Appeal found the defendant to have been negligent. The Judge, Sachs LJ, commented that the courts have to be in a position to verify that the medical opinion stood up to logical analysis and that they are not merely tailored to fit the requirements of the respective parties cases. This judgement was one of rarity, as Judges would not ordinarily cross examine a doctors opinion on a logical basis. 2.3 Often cases were even more favourable to the doctor, as is witnessed in the case Hatcher v Black. In this case Lord Denning stated, â€Å"As a matter of law it might be justifiable for a doctor to tell a lie, when he only does that which many a wise and good doctor would do.† It can be concluded from this that it is entirely for the individual doctor to determine what to inform his patient, even if the doctor went so far as to opt for what his lordship termed a therapeutic lie. Professor Michael Jones expressed the state of play as a football score, â€Å"In six medical negligence claims before the House of Lords between 1980-1999 the score stood at Plaintiffs 0, Defendants 6†. 2.4 The Bolam test which was adopted by English law focused on accepted practice and responsible profession opinion. The story was very different in America, as the American Courts rejected the professional medical standard and instead emphasised the patients right to know what the risks are inherent in the treatment. In Canterbury v. Spence a US Court stated that the prudent patient should prevail and its the doctors duty to disclose to their patient any material risk in a proposed line of treatment. The prudent patient principle emphasises what the doctor needs to inform the patient, according to what the average reasonable patient would want to know about potential risks and treatment options. This is made evident when the Judge commented, â€Å"A risk is material when a reasonable person†¦.is likely to attach significance to the risk† Contrary to the English Courts, the USA placed more importance on the patients rights and exigencies than those of the doctors. However, soon after the Bolam decision the English law was making changes towards incorporating this American style of law, to incorporating the doctrine of informed consent. 2.5 The question that needs to be examined is to what extent the Bolam test does or should apply to the duty to inform. Sidaway v Board of Governors of the Bethlem Royal Hospital was the subsequent, leading case to appear before the House of Lords that approached such a matter. While the majority of Lordships legitimatised the traditional test expressed in the case of Mr Bolam, the individual judgements were small steps towards informed consent. Four out of the five Law Lords rejected the transatlantic test that a duty to inform a patient should be based on the reasonable or prudent patient and Lord Scarman alone favoured this manner of law. 2.6 Lord Scarman made it apparent that he considered the patient to have the right to choose what happens to his body, which signified the patient needs to know the risks so can exercise an informed choice. He went on to express what he held to be the suitable relationship between a doctor and his patient, â€Å"There is room in our law for a legal duty to warn a patient of the risk inherent in the treatment proposed†. He went on to consider the doctrine of informed consent and its relevance in the Canterbury case, â€Å"I think the Canterbury propositions reflect a legal truth which too much judicial reliance on medical judgment tends to obscure† Lord Scarman acknowledged the patients rights and that the prudent patient principle made the doctors much more accountable for their actions. As such he rejected the current medical practice that a patient will be informed if he needs to be, as opposed to if he wants to be. Doctors, in Lord Scarmans view, should be liable where the risk is such that in the courts view a prudent person in the patients situation would have regarded it significant. He appears to suggest that the onus proof rests on the doctor to satisfy the court as to the reasonableness of any non-disclosure and therefore suggesting a support for informed consent. However, it must be noted that he did not find in favour of Miss Sidaway, on the basis that she failed to establish that the less than one per cent risk was such that a reasonable patient would consider significant. 2.7 In spite of this the speech of Lord Scarman has stood as a symbol of hope to those who argue for informed consent to be introduced into English law. Lord Diplock rejects Lord Scarmans scrutiny, as he maintains that the Bolam test covers all aspects of the doctors duty to care to his patient. However, he distinguished from the position where a patient asks a question about treatment, by stating â€Å"if the patient in fact manifested this attitude by means of questions the doctor would tell him whatever it was the patient wanted to know.† This illustrates that while Lord Diplock believed doctors were not be required to inform the patient of risks, he does not fully discount the patients rights. Lord Bridge also rejected the notion that a patient should be warned of all risks, yet â€Å"when questioned specially by a patient of apparently sound mind about risks involved in a particular treatment proposed, the doctors duty must, in my opinion, be to answer both truthfully and as fully as the question requires.† This gives the patient the option of asking for information from the doctor and if the doctor failed to do so then his duty of care could be in breach. However, Lord Templeman, expressed that this is not clear cut, as â€Å"the court will be slow to conclude that the doctor has been guilty of a breach of duty owed to the patient merely because the doctor omits some specific item of information.† It was important that Lord Scarman recognised the doctrine of informed consent and that the remaining four judges recognised the meaning of a patients ability to enquire and the doctor responsibility to notify. 2.8 It seemed that English legal system was initially hesitant to adopt informed consent into medical law. However, the approach taken in the case Gold v Haringey Health Authority contradicts that expressed by their Lordships in Sidaway. The claimant, in this case, indicated that she did not wish to have any more children and was advised to undergo a sterilisation operation after the birth of her third child. The operation was carried out but the claimant later became pregnant and gave birth to her fourth child. The Judge at first instances applied his own analysis as to what information the doctor should have given and found the defendant negligent. Upon appeal, Lloyd L.J held that the Bolam test should be strictly applied and he dismissed the view of the judge prior to him. He asserted that for the purposes of establishing the test as to the duty of care owed by a doctor to a patient no distinction needed to be made between advice given in a therapeutic and non-therapeutic context. In reference to Sidaway he stated, â€Å"the House of Lords could have adopted the doctrine of informed consent favoured in United States of America and Canada, but the House of Lords decided not to follow that path.† It seems clear from the Sidaway judgement that the nature to inform is more extensive than that of the Bolam test where no information is required. The decision in Gold repealed any progress been made towards informed consent and the judgement seemed to convey patient autonomy to be rather trivial 2.9 The view of Diplock in Sidaway has been regarded as the authoritative statement regarding the extent of the doctors duty. There has been a move away from the Diplock approach as seen in the case Pearce v. United Bristol Health Care NHS Trust which altered the analysis of a doctors obligation. Mrs Pearce, who was expecting her sixth child, was two weeks past her due date of delivery. She discussed the possibility of induction with her obstetrician who warned her of the risks of induction and caesarean surgery, but did not tell her that there was a 0.1 to 0.2 per cent risk of stillbirth associated with non-intervention. Mrs Pearces child was stillborn and she alleged that failure to warn her of the full risks was negligent. Lord Woolf, in this case, held that the patient had the right to know and stated the doctor should normally inform a patient of â€Å"a significant risk which would affect the judgment of a reasonable patient.† It was decided, however, that while a doctor is under an obligation to warn, the 0.1 to 0.2 per cent risk of stillbirth was not classed a significant risk. While the Pearce judgment did not go so far as to fully accept the doctrine of informed consent, it adopted elements of the reasonable test. The judgement goes a certain distance to reconcile the approaches of Lord Scarman, Lord Bridge and Lord Templeman in Sidaway. It isolated Bolam, which by Professor Margaret Brazier,who has wrote many publications on issues of medical law, was considered good as Bolam was â€Å"out of control and out of context, it came close to acquiring democratic status in some quarters.† The test for duty to warn was now suggested to be that the reasonable doctor must tell the patient what a reasonable patient wanted to know. The judgement signified a more patient-friendly approach and made greater demands on the level of disclosure. Chapter 3: Further development towards the doctrine of informed consent 3.1 The medical professional has taken steps to further achieve the full introduction of informed consent into the medical world. The General Medical Council (GMC) produced comprehensive guidance to, doctors on seeking the patients consent in Seeking Patient Consent: The Ethical Considerations February 1999 (appendix I). These guidelines make particular reference to the requirement on doctors to attain informed consent, a doctrine which a few years earlier was alien to English law. Since 1992 Professor Sir Ian Kennedy LLD, a former member of the GMC, has been arguing that doctors need specific guidelines on what constitutes good practice. At that time he was the voice of the minority, however due to dramatic change in the doctor-patient relationship the GMC recognised guidelines needed to be established. The standard adopted in these guidelines resembles elements of the prudent patient test specifically that of the judgment made by Lord Scarman in Sidaway. Guidance from the GMC directs doctors to†¦take appropriate steps to find what patients want to know and ought to know about their condition and its treatment. Andrew Hockton believed that the guidelines, â€Å"should now be considered to amount to more an ethical obligation: they provide at least, a starting-point for measuring the extent of a doctors duty of care to patients† It appears that the guidelines are considered to be a benchmark for doctors to monitor their legal duty of care, to which the Bolam test fails to create. This dissertation professes that perhaps this is the responsible body of medical opinion and it seems the medical profession are setting a higher standard for both themselves and the patient. 3.2 It must be noted the development of the Human Rights Act 1998, has extended the doctrine of informed consent in medical treatment. Incorporation of the European Convention of Human Rights under the Human Rights Act encourages the courts to focus more on the patients rights. This area of law includes Article 2 (the right to life), Article 3 (prohibition on inhuman or degrading treatment) and Article 8 (the right to respect for private and family life which includes the right to bodily integrity). The case R(on the application of Wilkinson) v Broadmoor Hospital illustrates how the introduction of the rights affected certain aspects of medical law. A mental patient appealed concerning a decision to administer treatment without his consent and under restraint. He claimed it infringed his rights under the European Convention of Human Rights 1950, Art.2, Art.3 and Art.8. The judge allowed the appeal stating that under the 1998 Act, it was no longer appropriate to forcible treat detained patients without a court judgement granting so. While the decision in this case would not have been so without the introduction of the Human Rights Act, it had little effect on the majority of medical consent cases. The Act was expected to have a great impact upon issues of medical consent, however it does not seem to have made a dramatic difference on the Courts decision making. 3.3 The most recent case that has dealt with the issue of informed consent is Chester v Afshar, where the claimant underwent surgery and suffered nerve damage leading to paralysis. The surgeon failed to warn Miss Chester of the inherent risk in surgery and the House of Lords decided that the risk was of sufficient quantity to determine the defendant had inadequately warned. The case is considered to show the importance the courts attached to the principle of autonomy, as Lord Hope reiterates when he states, â€Å"the duty to warn has at its heart the right of the patient to make an informed choice as to whether and if so when and by whom to be operated on.† The claimants evidence verified had she been warned of the risk she would not have agreed to surgery without at least seeking a second opinion on the necessity and risks of surgery. Therefore, a causation link was adopted by the courts to further prove negligence by the doctor. 3.4 In this case it was sufficient for her to prove that, if properly warned, she would not have consented to the operation. Dr Afshar was found to violate her right to choose, which meant she was unable to seek further advice or alternatives. Therefore, a claimant pursuing a claim in this area must prove if the information had been given, their decision as to the treatment would have caused extra consideration. Lord Steyn asserted that individuals have a right to make important decisions affecting their lives for themselves†¦in modern law paternalism no longer rules. This case was a ground breaking decision by the House of Lords, as it introduced fully informed consent and it addressed the purpose and rationale behind a doctors duty to warn. 3.5 Historically the law as taken the view that doctors are honourable and true, essentially allowing the medical profession themselves to dictate the duty to disclose. As a result of the decision made in Chester v Afshar this outlook has changed somewhat and it appears to provide a new dawn for patients rights. It has created a remedy for patients who have received insufficient information, where previously the majority of case had failed to provide such a remedy. The days of Lord Denning are long gone, meaning the doctor-friendly Bolam principle has practically been condemned worthless. While the judgement can be seen to address the reality of responsible expectations of society, it seems the judgment leaves the court with a difficult job determining who, between the patient and the doctor, is effectively legitimate when it comes to what information is disclosed. More specifically the outcome is likely to be met with distaste from doctors and there is already evidence of growing concern from within the profession. Despite the doctors concern the law of informed consent has moved on considerably from the reality where the majority of cases would fail to offer a remedy for those who had not been completely informed. As was stated by Sarah Devaney in a Medical Law Review, that back then, â€Å"It did not matter whether or not doctors were wearing the flak jackets of consent, as patients wishing to make claims about lack of information were in any event carrying unloaded guns. However, after cases, time and the materialization of certain events the doctrine of informed consent began to take effect in English law. Chapter 4: The Degree of Sufficient Information 4.1 Informed consent is based on the requirements of appropriate information to allow patients to make an informed choice. The law fails to formulate a standardize figure which can be consider significant and therefore it can only be gauged on previous cases and what the accepted amount has or has not been within these circumstances. More specifically, as no clear indication has been articulated, the judgement will be dependant on the individual facts of the case, as long as this coincides with the authoritative case law. What is clear is that failure to advise sufficiently as to the nature and purpose of the procedure may give rise to an action against the doctor. If the patient is given inadequate information, then how they able to make an informed decision and therefore be said to have given real consent? 4.2 The leading case Chester v Afshar (as discussed above) contradicted any previous beliefs of the court and that of the medical profession. The case prior to Chester was Pearce v United Bristol Health Care (as discussed above) where Lord Woolf stated that the doctor should normally inform a patient of a significant risk which would affect the judgement of a reasonable patient. It considered the balance of percentages and whether this balance would have effected the patients decision to have the treatment. The risk of 1-2 per cent in this case was not considered to be sufficient to represent a significant risk. The decision in Chester made it clear that a 1-2 per cent risk was an adequate percentage for the doctor to warn the patient. Even though, the doctor appropriately informed according to the Pearce decision and the GMC standards, Chester v Afshar brought a new way of thinking to the table. 4.3 Chester disregarded the concept of what a reasonable patient would want to know and instead looked at what each individual patient wanted to know for themselves. This meant it was more plausible for the doctor to consider the patients personality, concerns and wants and information given must be relevant to the patients decision. The involvement of the causation link enabled patients to assert their rights over decision not only on the surgery itself, but in addition on the circumstances in which it was under, for example the time, place and in whose hands the operation should be performed. The causation link made it easier for patients to receive a remedy at law, as long as they could prove that had they been sufficiently warned of the risks they wouldnt have undergone the treatment. This does not mean they need to prove that they would not have had the operation at any time, just not at that moment in time in which they did. The doctor needs to make acknowledgment to both warn of a significant risk and risks which a patient would consider relevant, even if not below significance. It left the doctors with the delicate job of determining what information individual patients wanted to know. This contemporary approach sent shock waves through the medical profession and the GMC had to amend their guidelines, as they now failed to reach a high enough standard. The new guidelines can be found In Good Medical Practice 2006. (see Appendix II) 4.4 Professional guidelines now go further and state the doctor must do his best to discover the patients individual needs and priorities to analysis what information that individual may require. When consenting to treatment patients should be aware of certain factors such as, diagnosis, prognosis, various treatment options, probabilities of success and possible side effects. This was the situation in the case Smith v Tunbridge Wells Health Authority, where a claim was brought against a 28 year old man who was not warned of the risk of impotence inherent in rectal surgery. His claim succeeded despite the risk being considered significantly low, as the judge found failure to warn such a patient of a risk of such importance to him was neither reasonable nor responsible. The doctor needed to have balanced the small risk of importance against the importance it possessed on his life. 4.5 The most effective way of obtaining consent that is currently in the English medical system is consent forms. Consent forms place emphasis on the patients rights; it gives them a sense of control and perhaps recaptures some of the faith that is said to have disappeared between doctors and patients. There is no requirement in English law that consent forms should be in writing, however the Department of Health have recommended the use model consent forms (see appendix III). The most prominent aspect is the fact it does not shy away from informed consent and instead seems to embrace it. It attempts to ensure that patients are aware that they are entitled to ask questions and expect explanations do with the medical treatment they receive. Unfortunately this way of operating is time consuming and is limited to operations and major procedures. It would not be viable for such things as checking a patients throat or examining a patients stomach, as these everyday occurrences are too frequent and considered to be too minor. Some see the consent form as purely evidential yet other believes them to signify fairness to both the patient and the doctor. It creates patient awareness of the fact that they have the right to know and for this right to be attained the patient needs to make it aware what they specifically want to know. This does not extinguish the doctors duties, he must still follow the guidelines set out in obtaining informed consent, for example, explaining the treatment and its implications. In the case Abbas v Kenny the judge stated the obligation is not placed upon the patient and it simply reaffirms their rights, yet it is still the doctors responsibility to â€Å"take into account the personality of the pati ent and the likelihood of misfortune.† 4.6 Even if a warning is given, it can not be consider a suitable warning if it is insufficiently clear to the patient and affects their ability to make a decision on information they fail to comprehend. The doctor must take responsible steps to ensure that advice is understood by the patient. To what extent is it the doctors duty to make sure the patient understands? Chapter 5: A Patients Capability to Understand 5.1 There is a rebuttable presumption that adults have capacity to consent to or refuse treatment. Therefore to make consent valid they must possess the capacity to understanding the method, consequences and benefits. If one fails to understand the information given and the inherent risks of treatment then it can not be regarded as informed consent. Care must be taken to not automatically presume those with learning difficulties are incapable; it is important for doctors to not underestimate a person from their faà §ade. Capacity is not a question of decree of intelligence or maturity of the person concerned, it incorporates elements of ability and belief. 5.2 There are different functions of what must be understood. The must frequently cited case in this context is Re C (Adult: Refusal of Medical Treatment) in which, Thorpe J, held that the person must understand the nature, purpose and effect of the procedure. In other words, sufficient knowledge constitutes the general functions of treatment. Another function that capacity can occupy is that held in Re T (Adult: Refusal of Traetment) where Lord Donaldson referred to knowledge in broad terms of the nature and effect of the procedure to which consent was given. The level of understanding was made important in this case and that this will differ according to the gravity of the decision. More specifically, the more serious a decision the greater capacity required and accordingly patients may have capacity to make some decisions but not others. 5.3 Assessment of a patients capacity is determined by reference to the Thorpe. Js three stage test in Re C it states the courts will assess the patients ability: to take in and retain treatment information; to believe it; to weigh that information, balancing risks and needs. In this case, a sixty-eight-year old patient was being detained in a special hospital, as he survived from schizophrenia. Despite this, the Judge ruled that the patient remained capable of understanding what he was told about the proposed treatment and the proposed risks involved. By satisfying the three points, a patient can verify that information can be given by the doctor, thought through and decided on and therefore the doctrine of informed c

Summer Reading :: essays research papers

Over the course of this summer I read four books. The books I read were Harry Potter and the Order of the Phoenix by J K Rowling, The Giver by Lois Lowry, Among the Hidden by Margaret Peterson Haddix, and Number the Stars by Lois Lowry again.  Ã‚  Ã‚  Ã‚  Ã‚  Harry Potter and the Order of the Phoenix by J K Rowling was the first book I read this summer and I really liked it. I decided to read the 5th Harry Potter book because I had it and I never really got a chance to read it. The book begins were it had left you of in the 4th book when Harry is just about to enter his 5th year at Hogwarts. He still lives with his aunt and uncle whom he hates because they are mean and evil to him. The letters from his friends are very dull and they have nothing to say, which confuses him and makes him furious. He is also mad because he’s still stuck with the Dursleys all summer long. The story goes with his adventures and challenges throughout his 5th year. The genre is fantasy complete wi th magic. I would recommend this book to anybody who likes the Harry Potter books. I would also recommend that if you have never read any of the previous books you start from the beginning. I can’t wait ‘till the next book comes out!   Ã‚  Ã‚  Ã‚  Ã‚  The next book I read was The Giver by Lois Lowry which I actually bought a couple years ago at a book fair. It sat on my shelf for two years then it was recommended to me again, so this time I read it. I ended up liking it so much I contacted the author via email and asked if she would ever consider selling the movie rights. She replied and said that the movie rights have been sold and there’s a movie in the making. The story is about a boy named Jonas living in the perfect utopia where there is no war, no crime, and no hate. The ceremony of twelve’s is very soon and that is the most important ceremony of all; it is when your assignment or job for life is decided. Little does Jonas know that he is about to receive the most important assignment of all. Shortly after the assignment is given he meets The Giver. This sci-fi book is one of the best books I’ve read and is also a Newberry Award winning book.

Essay --

The purpose of the present study Stanley 46 (1999) was to profile competitive junior female tennis players and determine if differences in fitness exist between state (n = 13, age=16.23 yrs) and district (n = 10, age = 17.10 yrs) standard female tennis players. The fitness components measured included: maximal aerobic capacity (graded treadmill test to volitional exhaustion with direct oxygen analysis), strength (grip strength), power (vertical jump), speed (20 yard dash), muscular endurance (60second sit-up), agility (spider test), flexibility (sit and reach) and body composition (restricted anthropometric profile). A questionnaire was also administered to determine fitness training habits and attitudes to fitness. A series of unpaired t-tests found no significant differences between the groups on any of the body composition or fitness variables. The only significant difference occurred with the subjects playing age where the state group had been playing tennis for a significantly l onger time (8.46 yrs) than the district group (6.55 yrs). The results of the present study showed that the fitness level of the girls was sub-standard. This may partly explain the current lull in the performance of Australia's female tennis players. Questionnaire results showed that most girls were spending considerable time doing fitness training each week however, the questionnaire also showed that most of the girls did not have a fitness program to follow and would like a program written for them. To succeed at the highest level the tennis player must be proficient in all three areas of skill, psychology and fitness. Graetzer., & Shultz. 47 (1995) assessed aerobic and anaerobic power and capacity, muscular strength, flexibility, balance, and blood ... ...yers (4,063 m and 4,050 m vs. 3,866 m), respectively. However, in light of the distance-covered values (i.e., 2066-5251 m) found by Manchado. et al. (2008), the study was not very clear on the basis of the practical significance of these differences is unclear. The wing players are also engaged in more high intensity work, than the back-court players (1.35%) and pivots (2.32%). On offense, wing players received less tackles (7.5 per match) than back-court players (15.9) and pivots (25.4). On defence, wing players performed fewer tackles (11.8 per match) than back-court players (24.6) and pivots (27.4). Wing players also engaged in more quick runs (4.4 per game) compared to back-court players (1.35) and pivots (2.47). In, summary, wing players did more high intensity work, covered greater distances and engaged in fewer tackles than both back court players and pivots.

Religious Traditions and History Essay

Polytheism, the belief in many gods, is perhaps the oldest known religion. The best known example is the Greek/Roman mythology, which included Zeus, Apollo, and Aphrodite, among others. One trait that is true of most Polytheistic sects is that there is a god that is above all others. â€Å"All African religions are monolithic in the sense that there is a single High God, who is said to be the creator of the world, and of mankind, and a central source of order and of whoever sense is to be found.† Another example would be Zeus. Most ancient societies believed in gods that were in charge of specific areas, such as rain, fertility, and a god of nature. These types of societies cooperate with nature. This doesn’t mean that all Polytheistic societies revered the natural world. The Romans exploited the natural resources of their surroundings. One common thread in most of these societies is that, compared to other religions, Polytheism is much more tolerant with the individual . Hinduism and Polytheism Hinduism is a religion founded in India around 1000 B.C. The religions practice a form of Polytheism. This religion doesn’t believe in one form of a god. They believe in the authority of the Vedas and Brahmans. These fundamental beliefs differentiate Hinduism from monotheistic, believing in one god, and most of the world’s major religions. There are many different gods in the Hindu religion. The most common are Ganesha, Shiva, Hanuman, Durga, and Lakshmi. What developed was a caste or class system called ‘varnas’. The different castes were assigned a task that was fitting for their class. â€Å"The expansion of towns brought about an increase in the number of artisans who were organized in guilds (shreni).† This system was good for commercial activities. The main goals of Hinduism are life-affirming goals of Dharma (virtue), Artha (success) and Kama (pleasure), while the life-negating goal is that of moksha (release). All except moksha can be done in any part of a person’s life. Confucianism and Buddhism People think that Confucianism and Buddhism are one and the same. Confucianism, which originated in China, teaches honesty, kindness, respect the earth, and good moral character. Confucius had a distain about gods and spirits and preferred to try to understand man. â€Å"Confucius (the Master) is more correctly Kong Qiu or Kong Fuzi (551-479 B.C.). He was the founder of a way of life, philosophy, or religion named Confucianism after a Latinized form of the founder’s name.† Buddhism, which started at about the same time as Confucianism, was started by Siddhartha Gautama, the Buddha. Buddha, which means â€Å"the enlightened one†, which was the name he received from his followers. Buddhism is different from Confucianism in that it didn’t teach about the family or rituals of this world, rather it taught enlightenment which leads to nirvana. There are eight awarenesses of enlightenments. â€Å"Freedom From Desire, Satisfaction, Serenity, Meticulous Effort, Correct Remembrance, Samadhi, Wisdom, and avoiding idle talk.† The Chinese during this time asked the Buddhist monks, why do you not marry? Their answer was â€Å"Wives, children, and property are the luxuries of the world, but simple living and inaction are the wonders of the Way.† The Buddhist’s wanted was to live a simple life and reach enlightenment and thus nirvana. Christianity Christianity is a salvation religion. Christians and Buddhists turned to the idea of salvation around the same time. Salvation means escape your earthly bonds. If you don’t follow a righteous path, meaning free of sin, then you are destined to be cast into the pit of darkness, otherwise known as hell. The new testament of the bible is what guides these true believers. The Catholics say, for instance, that if you sin and repent by going to confession your sins will be forgiven. This is the only way to ensure that the soul is clean. The idea of all Christian orthodoxy is that they follow the teachings of Christ, which has many different interpretations. Thus it follows that when you die you will go to heaven. Some believe that the Earth is 6000 years old and believe that the bible is literally god’s word. They refuse to believe in science, saying that it’s flawed in some way. Others believe that the Earth is indeed older than 6000 years. These Christians believe that the bible is a parable, teaching them how to live everyday life as a Christian. Modern orthodoxy believes that Christian’s are observers of nature, rather than one with the Earth. Religion, Science and Nature Religion has a profound imprint on our natural surroundings. In general, the Eastern and most Polytheistic religions are more reverential toward nature. The Western religions tend to abuse nature. The invention of the plow is a prime example. The West thinks of it as a means to increase the food supply and disregards the environmental impact. The East and the Polytheist refer to it as â€Å"Mother Earth† and treat her much more delicately. The contrast between the two couldn’t be more stark. The East will try to balance their needs with nature. The West uses nature and sometimes destroys parts of it. The idea that we are separate from nature is a Western ideal. The East, in general, believes that we are one with nature and must take care of it. Science in the West was not in tune with medieval orthodoxy. It was interested in facts. The Eastern philosophy used science with a spiritual twist. Fang Yizhi observed of western science, â€Å"use a variety of techniques for swift computations, but they are still out of touch with general principles.† They used the mind and not the natural world. Summary There are many different religions that teach many different methods of how to live your life while on this world. Most worship one god, monotheistic, others worship many gods. Polytheists, which literally mean many gods, roots are seen in Greek/Roman mythology. Buddhism believes that there is no god, just a path to enlightenment. Once they’ve reached enlightenment, they’ve achieved nirvana. Confucianism and Buddhism are from China, but have very different belief systems. â€Å"Confucianism is perhaps best understood as an all-encompassing humanism that neither denies nor slights Heaven.† They believe that they are one with nature. Christians recognize only one god. They are labeled as a salvation religion. They hope to be able to break the bonds of this Earth by living a relatively good life with the reward being heaven. If you don’t accept Jesus into your life, you are destined to eternity in hell. It’s safe to say that the world’s religions have varied belief systems. Some believe in the after-life, while others believe that feel that we are Earth bound only. Most of the world believes in a single god. Polytheism and Hinduism say that there are many gods. They differ from Eastern religions in that they see themselves as observers rather than one with the Earth. The East and West see nature differently. While the West observe nature, the East embraces the idea of being part of nature. This is a very fundamental philosophy that can’t be overstated. The bottom line is that there are almost as many belief systems as there are people on Earth. It includes, but not only, monetary considerations, faith, and devotion. The only ones that know what’s going on, assuming there is an after-life, are the dead and buried. Citations The West and the World, A History of Civilization, From the Ancient World to 1700, Kevin Reilly, 95 2 The West and the World, A History of Civilization, From the Ancient World to 1700, Kevin Reilly, 334 3 The West and the World, A History of Civilization, From the Ancient World to 1700, Kevin Reilly, 146 4 http://ancienthistory.about.com/od/china/f/022808Confucius.htm 5 http://buddhism.about.com/od/basicbuddhistteachings/tp/awarenesses.htm 6 The West and the World, A History of Civilization, From the Ancient World to 1700, Kevin Reilly, 103 7 Kevin Reilly, The West & World: A History Of Civilization from the Ancient World to 1700, Page 349 8 http://www.religionfacts.com/a-z-religion-index/confucianism.htm

Last Sacrifice Chapter Twenty-one

I DIDN'T GET TO DRIVE. â€Å"General' Sydney didn't either, much to her outrage, though Dimitri did some fast- talking to explain why. It all started when Victor discovered his car was having â€Å"engine trouble.' He wasn't very happy about that. He made no accusations, but I think everyone there–even Sonya and Robert–could guess the malfunction wasn't coincidental. This meant we all had to pile in the CR-V, which hadn't been designed to seat so many people–which was why Dimitri had come up with a creative seating plan. Of course, one of those â€Å"seats' turned out to be the cargo space in the back. It was good-sized, but when Sydney learned it was her seat, she accused Dimitri of adding insult to the injury of taking her keys. I wouldn't tell her so, but putting her back there was a sound choice. Dimitri's seating chart was configured to minimize threats inside the car. Dimitri drove, with Robert going shotgun, and me between Victor and Sonya in the backseat. This put a guardian in each row, separated the brothers, and kept the spirit users apart too. When I argued that he and I could switch spots and still maintain the same security, Dimitri pointed out that having me at the wheel wouldn't be safe if I had to suddenly flip to Lissa's mind. It was a fair point. As for Sydney †¦ well, she was neither a threat nor a fighting force, so she got offloaded to the back. And speaking of dead weight †¦ â€Å"We have got to get rid of Victor and Robert now,' I murmured to Dimitri, as we loaded the CR-V with groceries and our meager luggage (further reducing Sydney's space, much to her outrage). â€Å"They've done what we needed. Keeping them is dangerous. It's time to turn them over to the guardians.' The brothers wanted to continue on with us in order to find Lissa's sibling. We were letting them–but not out of generosity. We simply couldn't let them out of our sights yet. â€Å"Agreed,' Dimitri said, frowning slightly. â€Å"But there's no good way to do it. Not yet. We can't leave them tied up beside the road; I wouldn't put it past them to escape and hitchhike. We also can't turn them in ourselves, for obvious reasons.' I set a bag inside the car and leaned against the bumper. â€Å"Sydney could turn them in.' Dimitri nodded. â€Å"That's probably our best bet–but I don't want to part with her until we get to †¦ well, wherever we're going. We might need her help.' I sighed. â€Å"And so, we drag them along.' â€Å"Afraid so,' he said. He gave me wary look. â€Å"You know, when they are in custody, there's a very good chance they'll have quite a story to tell the authorities about us.' â€Å"Yeah.' I'd been thinking about that too. â€Å"I guess that's a problem for later. Gotta deal with the immediate problems first.' To my surprise, Dimitri smiled at me. I would have expected some prudent, wise remark. â€Å"Well, that's always been our strategy, hasn't it?' he asked. I smiled in return, but it was short-lived, once we hit the road. Mercifully, Victor wasn't his usual annoying chatty self–which I suspected was because he was growing weak from lack of blood. Sonya and Robert had to be feeling the same way. This was going to be a problem if we didn't get a feeder soon, but I didn't know how we were going to pull that off. I had the impression Sydney hadn't realized any of this yet, which was just as well. Being a human among a group of hungry vampires would certainly make me nervous. She was actually probably safer sequestered in the back from everyone else. Sonya's directions were vague and very need-to-know. She only gave us short-term information and often wouldn't warn about a turn until we were right on top of it. We had no idea where we were going or how long it would take. She scanned a map and then told Dimitri to go north on I-75. When we asked how long our trip would take, her response was: â€Å"Not long. A few hours. Maybe more.' And with that mysterious explanation, she settled back in her seat and said no more. There was a haunted, pensive expression on her face, and I tried to imagine how she felt. Only a day ago she'd been Strigoi. Was she still processing what had happened? Was she seeing the faces of her victims as Dimitri had? Was she tormenting herself with guilt? Did she want to become Strigoi again? I left her alone. Now wasn't the time for therapy. I settled back, preparing myself to be patient. A tingle of consciousness suddenly sparked in the bond, shifting my attention inward. Lissa was awake. I blinked and looked at the dashboard clock. Afternoon for humans. The Moroi at Court should have been long asleep by now. But no, something had awakened her. Two guardians stood at her door, faces impassive. â€Å"You have to come with us,' one of them said. â€Å"It's time for the next test.' Astonishment filled Lissa. She'd known the next test was â€Å"coming soon' but hadn't heard any further details since returning from the endurance test. That trip had taken place during the Moroi night too, but she'd at least had fair warning. Eddie stood nearby in her room, having replaced my mother as Lissa's protection a few hours ago. Christian sat up in Lissa's bed, yawning. They hadn't gotten hot and heavy, but Lissa liked having him around. Snuggling with her boyfriend while Eddie was in the room didn't seem as weird to her as it did when my mom was there. I didn't blame her. â€Å"Can I change?' Lissa asked. â€Å"Be quick,' said the guardian. She grabbed the first outfit she could and hurried to the bathroom, feeling confused and nervous. When she came out, Christian had pulled on his jeans already and was reaching for his T-shirt. Eddie meanwhile was sizing up the guardians, and I could guess his thoughts because I would have shared the same ones. This wakeup call seemed official, but he didn't know these guardians and didn't totally trust them. â€Å"Can I escort her?' he asked. â€Å"Only as far as the testing area,' said the second guardian. â€Å"What about me?' asked Christian. â€Å"Only as far as the testing area.' The guardians' answers surprised me, but then, I realized it was probably common for monarch candidates to go to their tests with entourages–even unexpected tests in the middle of the night. Or maybe not so unexpected. The Court's grounds were virtually deserted, but when her group reached their destination–a small, out of the way section of an old brick building–she had to pass several groups of Moroi lining the halls. Apparently, word had gotten out. Those gathered stepped aside respectfully. Some–probably advocates of other families–gave her scowls. But lots of other people smiled at her and called out about â€Å"the dragon's return.' A few even brushed their hands against her arms, as though taking luck or power from her. The crowd was much smaller than the one who'd greeted her after the first test. This eased her anxiety but didn't shake her earlier resolve to take the tests seriously. The faces of the onlookers shone with awe and curiosity, wondering if she might be the next to rule them. A doorway at the end of the hall marked the conclusion of her journey. Neither Christian nor Eddie needed to be told that this was as far as they could go. Lissa glanced at the two of them over her shoulder before following one of the guardians inside, taking comfort from her loved ones' supportive faces. After the epic adventure of the first test, Lissa expected something equally intimidating. What she found instead was an old Moroi woman sitting comfortably in a chair in a mostly empty room. Her hands were folded in her lap, holding something wrapped in cloth. The woman hummed, seeming very content. And when I say old, I mean she was old. Moroi could live until their early 100s, and this woman had clearly crossed that mark. Her pale skin was a maze of wrinkles, and her gray hair was wispy and thin. She smiled when she saw Lissa and nodded toward an empty chair. A small table sat beside it with a glass pitcher of water. The guardians left the women alone. Lissa glanced around her surroundings. There were no other furnishings, though there was a plain door opposite the one she had come through. She sat down and then turned toward the old woman. â€Å"Hello,' said Lissa, trying to keep her voice strong. â€Å"I'm Vasilisa Dragomir.' The woman's small smile grew, showing her yellowed teeth. One of her fangs was missing. â€Å"Always such manners in your family,' she croaked. â€Å"Most people come in here and demand we get down to business. But I remember your grandfather. He was polite during his test as well.' â€Å"You knew my grandfather?' exclaimed Lissa. He had died when she was very, very young. Then, she picked up another meaning in the woman's words. â€Å"He ran for king?' The woman nodded. â€Å"Passed all his tests. I think he would have won the election, if he hadn't withdrawn at the last moment. After that, it was a coin's toss between Tatiana Ivashkov and Jacob Tarus. Very close, that one. The Taruses still hold a grudge.' Lissa had never heard any of this. â€Å"Why'd my grandfather withdraw?' â€Å"Because your brother had just been born. Frederick decided he needed to devote his energy to his fledgling family, instead of a nation.' Lissa could understand this. How many Dragomirs were there back then? Her grandfather, her father, and Andre–and her mother, but only by marriage. Eric Dragomir hadn't had any brothers or sisters. Lissa knew little about her grandfather, but in his place, she decided that she too would have rather spent time with her son and grandson, instead of listening to the endless speeches Tatiana had had to deal with. Lissa's mind had wandered, and the old woman was watching her carefully. â€Å"Is †¦ this the test?' asked Lissa, once the silence had gone on too long. â€Å"Is it, like, an interview?' The old woman shook her head. â€Å"No. It's this.' She unwrapped the object in her lap. It was a cup–a chalice or a goblet. I'm not sure which. But it was beautiful, made of silver that seemed to glow with its own light. Blood-red rubies were scattered along the sides, glittering with each turn of the cup. The woman regarded it fondly. â€Å"Over a thousand years old, and it still gleams.' She took the pitcher and filled the chalice with water while Lissa and I processed the words. A thousand years? I was no metal expert, but even I knew silver should have tarnished in that time. The woman held out the cup to Lissa. â€Å"Drink from it. And when you want to stop, say'stop.† Lissa reached for the cup, more confused than ever by the odd instructions. What was she supposed to stop? Drinking? As soon as her fingers touched the metal, she understood. Well, kind of. A tingle ran through her, one she knew well. â€Å"This is charmed,' she said. The old woman nodded. â€Å"Infused with all four elements and a spell long since forgotten.' Charmed with spirit too, thought Lissa. That too must have been forgotten, and it put her on edge. Elemental charms had different effects. Earth charms–like the tattoo she'd been given–were often tied with minor compulsion spells. The combination of all four in a stake or ward provided a unified blast of life that blocked the undead. But spirit †¦ well, she was quickly learning that spirit charms covered a wide range of unpredictable effects. The water no doubt activated the spell, but Lissa had a feeling that spirit was going to be the key player. Even though it was the power that burned in her blood, it still scared her. The spell woven into this cup was complex, far beyond her skills, and she feared what it would do. The old woman stared unblinkingly. Lissa hesitated only a moment more. She drank. The world faded away, then rematerialized into something completely different. She and I both recognized what this was: a spirit dream. She no longer stood in the plain room. She was outdoors, wind whipping her long hair in front of her face. She brushed it aside as best she could. Other people stood around her, all of them in black, and she soon recognized the Court's church and graveyard. Lissa herself wore black, along with a long wool coat to protect against the chill. They were gathered around a grave, and a priest stood near it, his robes of office offering the only color on that gray day. Lissa took a few steps over, trying to see whose name was on the tombstone. What she discovered shocked me more than her: ROSEMARIE HATHAWAY. My name was carved into the granite in regal, elaborate font. Below my name was the star of battle, signifying that I'd killed more Strigoi than could be counted. Go me. Beneath that were three lines of text in Russian, Romanian, and English. I didn't need the English translation to know what each line said because it was standard for a guardian's grave: â€Å"Eternal Service.' The priest spoke customary funeral words, giving me the blessings of a religion I wasn't sure I believed in. That was the least weird thing here, however, seeing as I was watching my own funeral. When he finished, Alberta took his place. Lauding the deceased's achievements was also normal at a guardian's funeral–and Alberta had plenty to say about mine. Had I been there, I would have been moved to tears. She concluded by describing my last battle, how I'd died defending Lissa. That actually didn't weird me out so much. I mean, don't get me wrong. Everything going on here was completely insane. But, reasonably speaking, if I was actually watching my own funeral, it made sense that I would have died protecting her. Lissa didn't share my feelings. The news was a slap in the face to her. She suddenly became aware of a horrible empty feeling in her chest, like part of her was gone. The bond only worked one way, yet Robert had sworn losing his bondmate had left him in agony. Lissa understood it now, that terrible, lonely ache. She was missing something she'd never even known she'd had. Tears brimmed in her eyes. This is a dream, she told herself. That's all. But she'd never had a spirit dream like this. Her experiences had always been with Adrian, and the dreams had felt like telephone calls. When the mourners dispersed from the graveyard, Lissa felt a hand touch her shoulder. Christian. She threw herself gratefully into his arms, trying hard to hold back sobs. He felt real and solid. Safe. â€Å"How did this happen?' she asked. â€Å"How could it have happened?' Christian released her, his crystal-blue eyes more serious and sorrowful than I'd ever seen. â€Å"You know how. Those Strigoi were trying to kill you. She sacrificed herself to save you.' Lissa had no memory of this, but it didn't matter. â€Å"I can't †¦ I can't believe this is happening.' That agonizing emptiness grew within her. â€Å"I have more bad news,' said Christian. She stared in astonishment. â€Å"How could this get any worse?' â€Å"I'm leaving.' â€Å"Leaving †¦ what? Court?' â€Å"Yes. Leaving everything.' The sadness on his face grew. â€Å"Leaving you.' Her jaw nearly dropped. â€Å"What †¦ what's wrong? What did I do?' â€Å"Nothing.' He squeezed her hand and let it go. â€Å"I love you. I'll always love you. But you are who you are. You're the last Dragomir. There'll always be something taking you away †¦ I'd just get in your way. You need to rebuild your family. I'm not the one you need.' â€Å"Of course you are! You are the only one! The only one I want to build my future with.' â€Å"You say that now, but just wait. There are better choices. You heard Adrian's joke. â€Å"Little Dragomirs'? When you're ready for kids in a few years, you're going to need a bunch. The Dragomirs need to be solid again. And me? I'm not responsible enough to handle that.' â€Å"You'd be a great father,' she argued. â€Å"Yeah,' he scoffed, â€Å"and I'd be a big asset to you too–the princess married to the guy from the Strigoi family.' â€Å"I don't care about any of that, and you know it!' She clutched at his shirt, forcing him to look at her. â€Å"I love you. I want you to be part of my life. None of this makes sense. Are you scared? Is that it? Are you scared of the weight of my family name?' He averted his eyes. â€Å"Let's just say it's not an easy name to carry.' She shook him. â€Å"I don't believe you! You're not afraid of anything! You never back down.' â€Å"I'm backing down now.' He gently removed himself from her. â€Å"I really do love you. That's why I'm doing this. It's for the best.' â€Å"But you can't †¦' Lissa gestured toward my grave, but he was already walking away. â€Å"You can't! She's gone. If you're gone too, there'll be no one †¦' But Christian was gone, disappearing into fog that hadn't been there minutes ago. Lissa was left with only my tombstone for company. And for the first time in her life, she was really and truly alone. She had felt alone when her family died, but I'd been her anchor, always at her back, protecting her. When Christian had come along, he too had kept the loneliness away, filling her heart with love. But now †¦ now we were both gone. Her family was gone. That hole inside threatened to consume her, and it was more than just the loss of the bond. Being alone is a terrible, terrible thing. There's no one to run to, no one to confide in, no one who cares what happens to you. She'd been alone in the woods, but that was nothing like this. Nothing like it at all. Staring around, she wished she could go sink into my grave and end her torment. No †¦ wait. She really could end it. Say ‘stop,' the old woman had said. That was all it took to stop this pain. This was a spirit dream, right? True, it was more realistic and all- consuming than any she'd ever faced, but in the end, all dreamers woke up. One word, and this would become a fading nightmare. Staring around at the empty Court, she almost said the word. But †¦ did she want to end things? She'd vowed to fight through these trials. Would she give up over a dream? A dream about being alone? It seemed like such a minor thing, but that cold truth hit her again: I've never been alone. She didn't know if she could carry on by herself, but then, she realized that if this wasn't a dream–and dear God, did it feel real–there was no magic â€Å"stop' in real life. If she couldn't deal with loneliness in a dream, she never would be able to while waking. And as much as it scared her, she decided she would not back down from this. Something urged her toward the fog, and she walked toward it–alone. The fog should have led her into the church's garden. Instead, the world rematerialized and she found herself in a Council session. It was an open one, with a Moroi audience watching. Unlike usual, Lissa didn't sit with the audience. She was at the Council's table, with its thirteen chairs. She sat in the Dragomir seat. The middle chair, the monarch's chair, was occupied by Ariana Szelsky. Definitely a dream, some wry part of her thought. She had a Council spot and Ariana was queen. Too good to be true. Like always, the Council was in a heated debate, and the topic was familiar: the age decree. Some Council members argued that it was immoral. Others argued that the Strigoi threat was too great. Desperate times called for desperate actions, those people said. Ariana peered down the table at Lissa. â€Å"What does the Dragomir family think?' Ariana was neither as kind as she'd been in the van nor as hostile as Tatiana had been. Ariana was neutral, a queen running a Council and gathering the information she needed. Every set of eyes in the room turned toward Lissa. For some reason, every coherent idea had fled out of her head. Her tongue felt thick in her mouth. What did she think? What was her opinion of the age decree? She desperately tried to dredge up an answer. â€Å"I †¦ I think it's bad.' Lee Szelsky, who must have taken the family spot when Ariana became queen, snorted in disgust. â€Å"Can you elaborate, princess?' Lissa swallowed. â€Å"Lowering the guardian age isn't the way to protect us. We need †¦ we need to learn to protect ourselves too.' Her words were met with more contempt and shock. â€Å"And pray tell,' said Howard Zeklos, â€Å"how do you plan to do that? What's your proposal? Mandatory training for all ages? Start a program in the schools?' Again Lissa groped for words. What was the plan? She and Tasha had discussed it lots of times, strategizing this very issue of how to implement training. Tasha had practically pounded those details into her head in the hopes Lissa could make her voice heard. Here she was now, representing her family on the Council, with the chance to change things and improve Moroi life. All she had to do was explain herself. So many were counting on her, so many waiting to hear the words she felt so passionately about. But what were they? Why couldn't Lissa remember? She must have taken too long to answer because Howard threw his hands up in disgust. â€Å"I knew it. We were idiots to let a little girl on this Council. She has nothing useful to offer. The Dragomirs are gone. They've died with her, and we need to accept that.' They've died with her. The pressure of being the last of her line had weighed on Lissa since the moment a doctor had told her that her parents and brother had died. The last of a line that had empowered the Moroi and produced some of the greatest kings and queens. She'd vowed to herself over and over that she wouldn't disappoint that lineage, that she would see her family's pride restored. And now it was all falling apart. Even Ariana, whom Lissa had considered a supporter, looked disappointed. The audience began to jeer, echoing the call of removing this tongue-tied child from the Council. They yelled for her to leave. Then, worse still: â€Å"The dragon is dead! The dragon is dead!' Lissa almost tried again to make her speech, but then something made her look behind her. There, the twelve family seals hung on the wall. A man had appeared out of nowhere and was taking down the Dragomir's crest, with its dragon and Romanian inscription. Lissa's heart sank as the shouts in the room became louder and her humiliation grew. She rose, wanting to run out of there and hide from the disgrace. Instead, her feet took her to the wall with its seals. With more strength than she thought herself capable of possessing, she jerked the dragon seal away from the man. â€Å"No!' she yelled. She turned her gaze to the audience and held up the seal, challenging any of them to come take it from her or deny her her rightful place on the Council. â€Å"This. Is. Mine. Do you hear me? This is mine!' She would never know if they heard because they disappeared, just like the graveyard. Silence fell. She now sat in one of the medical examining rooms back at St. Vladimir's. The familiar details were oddly comforting: the sink with its orange hand soap, the neatly labeled cupboards and drawers, and even the informative health posters on the walls. STUDENTS: PRACTICE SAFE SEX! Equally welcome was the school's resident physician: Dr. Olendzki. The doctor wasn't alone. Standing around Lissa–who sat on top of an examination bed–were a therapist named Deirdre and †¦ me. Seeing myself there was pretty wacky, but after the funeral, I was just starting to roll with all of this. A surprising mix of feelings raced through Lissa, feelings out of her control. Happiness to see us. Despair at life. Confusion. Suspicion. She couldn't seem to get a hold of one emotion or thought. It was a very different feeling from the Council, when she just hadn't been able to explain herself. Her mind had been orderly–she'd just lost track of her point. Here, there was nothing to keep track of. She was a mental mess. â€Å"Do you understand?' asked Dr. Olendzki. Lissa suspected the doctor had already asked this question. â€Å"It's beyond what we can control. Medication no longer works.' â€Å"Believe me, we don't want you hurting yourself. But now that others are at risk †¦ well, you understand why we have to take action.' This was Deirdre. I'd always thought of her as smug, particularly since her therapeutic method involved answering questions with questions. There was no sly humor now. Deirdre was deadly earnest. None of their words made sense to Lissa, but the hurting yourself part triggered something in her. She looked down at her arms. They were bare †¦ and marred with cuts. The cuts she used to make when the pressure of spirit grew too great. They'd been her only outlet, a horrible type of release. Studying them now, Lissa saw the cuts were bigger and deeper than before. The kinds of cuts that danced with suicide. She looked back up. â€Å"Who †¦ who did I hurt?' â€Å"You don't remember?' asked Dr. Olendzki. Lissa shook her head, looking desperately from face to face, seeking answers. Her gaze fell on me, and my face was as dark and somber as Deirdre's. â€Å"It's okay, Liss,' I said. â€Å"It's all going to be okay.' I wasn't surprised at that. Naturally, it was what I would say. I would always reassure Lissa. I would always take care of her. â€Å"It's not important,' said Deirdre, voice soft and soothing. â€Å"What's important is no one else ever gets hurt. You don't want to hurt anyone, do you?' Of course Lissa didn't, but her troubled mind shifted elsewhere. â€Å"Don't talk to me like a child!' The loudness of her voice filled the room. â€Å"I didn't mean to,' said Deirdre, the paragon of patience. â€Å"We just want to help you. We want you to be safe.' Paranoia rose to the forefront of Lissa's emotions. Nowhere was safe. She was certain about that †¦ but nothing else. Except maybe something about a dream. A dream, a dream †¦ â€Å"They'll be able to take care of you in Tarasov,' explained Dr. Olendzki. â€Å"They'll make sure you're comfortable.' â€Å"Tarasov?' Lissa and I spoke in unison. This other Rose clenched her fists and glared. Again, a typical reaction for me. â€Å"She is not going to that place,' growled Rose. â€Å"Do you think we want to do this?' asked Deirdre. It was the first time I'd really seen her cool facade crumble. â€Å"We don't. But the spirit †¦ what it's doing †¦ we have no choice †¦' Images of our trip to Tarasov flashed through Lissa's mind. The cold, cold corridors. The moans. The tiny cells. She remembered seeing the psychiatric ward, the section other spirit users were locked up in. Locked up indefinitely. â€Å"No!' she cried, jumping up from the table. â€Å"Don't send me to Tarasov!' She looked around for escape. The women stood between her and the door. Lissa couldn't run. What magic could she use? Surely there was something. Her mind touched spirit, as she rifled for a spell. Other-Rose grabbed a hold of her hand, likely because she'd felt the stirrings of spirit and wanted to stop Lissa. â€Å"There's another way,' my alter ego told Deirdre and Dr. Olendzki. â€Å"I can pull it from her. I can pull it all from her, like Anna did for St. Vladimir. I can take away the darkness and instability. Lissa will be sane again.' Everyone stared at me. Well, the other me. â€Å"But then it'll be in you, right?' asked Dr. Olendzki. â€Å"It won't disappear.' â€Å"I don't care,' I told them stubbornly. â€Å"I'll go to Tarasov. Don't send her. I can do it as long as she needs me to.' Lissa watched me, scarcely believing what she heard. Her chaotic thoughts turned joyous. Yes! Escape. She wouldn't go crazy. She wouldn't go to Tarasov. Then, somewhere in the jumble of her memories †¦ â€Å"Anna committed suicide,' murmured Lissa. Her grasp on reality was still tenuous, but that sobering thought was enough to momentarily calm her racing mind. â€Å"She went crazy from helping St. Vladimir.' My other self refused to look at Lissa. â€Å"It's just a story. I'll take the darkness. Send me.' Lissa didn't know what to do or think. She didn't want to go to Tarasov. That prison gave her nightmares. And here I was, offering her escape, offering to save her like I always did. Lissa wanted that. She wanted to be saved. She didn't want to go insane like all the other spirit users. If she accepted my offer, she would be free. Yet †¦ on the edge or not, she cared about me too much. I had made too many sacrifices for her. How could she let me do this? What kind of friend would she be, to condemn me to that life? Tarasov scared Lissa. A life in a cage scared Lissa. But me facing that scared her even more. There was no good outcome here. She wished it would all just go away. Maybe if she just closed her eyes †¦ wait. She remembered again. The dream. She was in a spirit dream. All she had to do was wake up. Say â€Å"stop.' It was easier this time. Saying that word was the simple way out, the perfect solution. No Tarasov for either of us, right? Then, she felt a lightening of the pressure on her mind, a stilling of those chaotic feelings. Her eyes widened as she realized I had already started pulling away the darkness. ‘Stop' was forgotten. â€Å"No!' Spirit burned through her, and she threw up a wall in the bond, blocking me from her. â€Å"What are you doing?' my other self asked. â€Å"Saving you,' said Lissa. â€Å"Saving myself.' She turned to Dr. Olendzki and Deirdre. â€Å"I understand what you have to do. It's okay. Take me to Tarasov. Take me where I won't hurt anyone else.' Tarasov. A place where real nightmares walked the halls. She braced herself as the office faded away, ready for the next part of the dream: a cold stone cell, with chains on the walls and people wailing down the halls†¦. But when the world put itself back together, there was no Tarasov. There was an empty room with an old woman and a silver chalice. Lissa looked around. Her heart was racing, and her sense of time was off. The things she'd seen had lasted an eternity. Yet, simultaneously, it felt like only a couple seconds had passed since she and the old woman had conversed. â€Å"What †¦ what was that?' asked Lissa. Her mouth was dry, and the water sounded good now †¦ but the chalice was empty. â€Å"Your fear,' said the old woman, eyes twinkling. â€Å"All your fears, laid out neatly in a row.' Lissa placed the chalice on the table with shaking hands. â€Å"It was awful. It was spirit, but it †¦ it wasn't anything I've seen before. It invaded my mind, rifling through it. It was so real. There were times I believed it was real.' â€Å"But you didn't stop it.' Lissa frowned, thinking of how close she had come. â€Å"No.' The old woman smiled and said nothing. â€Å"Am I †¦ am I done?' asked Lissa, confused. â€Å"Can I go?' The old woman nodded. Lissa stood and glanced between the two doors, the one she'd entered through and the plain one in the back. Still in shock, Lissa automatically turned toward the door she'd come through. She didn't really want to see those people lined up in the hall again but swore she'd put on a good princess face. Besides, there'd only been a fraction here compared to the group who'd greeted her after the last test. Her steps were halted when the old woman spoke again and pointed toward the back of the room. â€Å"No. That's for those who fail. You go out this door.' Lissa turned and approached the plain door. It looked like it led outdoors, which was probably just as well. Peace and quiet. She felt like she should say something to her companion but didn't know what. So, she simply turned the knob and stepped outside †¦ Into a crowd cheering for the dragon.