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Current controversies in clinical ethics
·Bernard Lo, M.D.
·April 21, 2009
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Overview of talk
<= span style=3D'font-weight:normal'>·Organ transplantation
·Conscientious objections to providing care
<= span style=3D'font-weight:normal'>·Conflicts of interest
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Ethical controversies regar= ding organ transplantation
·Need >> Supply
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Questions about organ transplantation
·Are there ethical prob= lems with:
<= span style=3D'font-weight:normal'>·Advertising for donors?
<= span style=3D'font-weight:normal'>·Donation after cardiac death?
<= span style=3D'font-weight:normal'>·Payment for organs?
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Ethical concerns about fairness
·P= ortrays candidate as exception to allocation criteria
·May have poor survival after transplant
·O= ther candidates have moving stories
·F= avors wealthy and well-educated
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Donation after cardiac death (DCD)
<= span style=3D'font-weight:normal'>·Life support withdrawn in OR =
<= span style=3D'font-weight:normal'>·Death declared
<= span style=3D'font-weight:normal'>·Organs promptly retrieved ·More potential donors than a= fter brain death
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= Origin= al Article
Pediatric Heart Transplantation after Declaration of Cardiocirculatory Death
Mark M.= Boucek, M.D., Christine Mashburn, B.S.N., Susan M. Dunn, M.B.A., Rebecca Frizell, B.S.N., Leah Edwards, Ph.D., Biagio Pietra, M.D., David Campbell, M.D., fo= r the Den= ver Children's Pediatric Heart Transplant Team
N Engl J Med
Volume 359(7):709-714
August = 14, 2008
Delay in declaring death compromises viability of heart, not kidney or liver

3 cases of successful cardiac transplantation from DCD.
Donor mean age 3.7 days
Recipients mean age 2.2 months
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Time between asystole and = declaration of death
<= span style=3D'font-weight:normal'>·First 2 donors 3 minutes
<= span style=3D'font-weight:normal'>·3rd donor 75 seconds
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Is asystole in donor irreversible?
·Autoresuscitation not reported after more than 65 seconds ·SCCM: wait 2 minutes after asystole before declare death, preferably 5 ·IOM: wait 5 minutes after asystole before declare death
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Ethical concerns
·W= as declaration of death manipulated to allow organ transplantation?
·M= ay not compromise care of donor or cause death by remove organ
·May not end one life to benefit another
San Luis Obispo surgeon inject improper doses of morphine, midazolam, Betadine to hasten death
But if insert catheters, infuse heparin, start ECMO
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Payment to donors
1.Compensation for expenses <= /div>
·Neither loss nor gain
·Travel, costs of donation
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Payment to donors
2.Insure against future losses
·Future disability
·Future medical expenses
·Give as insurance rather than cash
Medical expenses related to donation or not?
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Payment to donors
3.Cash payments for organs
•Exploitation of poor
•Commodify human body
•Undermine altruistic donation
Occurs in many countries
Illegal in U.S.
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Predictions
<= span style=3D'font-weight:normal'>·Tighter rules on advertising, DCD
<= span style=3D'font-weight:normal'>·More compensation and insurance
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Conscientious objection
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May MD refuse to provide med= ical care because of conscientious objection?
1.Yes
2.It depends
3.No
4.Not sure
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Benitez v. North Coast Women’s Medical Care Group
·M= s. B denied IVF in 1999
·Exclusive contract with insurance plan
·After 11 months of treatment, refused donor insemination because she is lesbian
&= #8226;Told other MDs would do insemination
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California Civil Rights Act
·&= #8220;No discrimination because of sex, race, color, religion, ancestry, national origin, disability, medical condition”
·Protected categories
·Courts include sexual orientation
Not clear whether includes marital status
Applies to physician 0ffices, clinics, hospitals
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CA Supreme Court (8/08)
·= ;Refusal violates Civil Rights Act
·= ;MDs free to voice objections
·Does not substantially burden religious belief or practice
Vote 7-0
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Federal regulations (Dec 2008)
·R= ecipients of federal funding may not
·Require HCWs to perform or participate in
&= #8226;Abortion
&#= 8226;Health service contrary to religious beliefs or moral objections
&= #8226;Counseling or referral
·Discriminate for refusing to perform
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Federal regulations (Dec 2008)
·No provision to communicate refusal to patients or instituti= on
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Dilemmas because countervailing ethical guidelines
1.Respect conscientious objection
·Not require peo= ple to violate their core moral belief or integrity
·Respect even if disagree with belief
·Often closes off discussion
Promote opposite of insincerity, hypocrisy, bad faith

Contra + valere =3D to be of worth
To be of worth against
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Dilemmas because countervailing ethical guidelines
2.Provide care to patients
·No discrimination
·Difficult for patient to change providers
·Continuity of c= are
Too sick, insurance restrictions

Contra + valere =3D to be of worth
To be of worth against
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Dilemmas because countervailing ethical guidelines
3.Balance conflicting obligations
·Inform instituti= on and patient in advance
•Before relationship established
·Obligation may f= all on institution to find willing provider to provide care
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Conflicts of interest
Questions for audience
=
·Investment advisor gets payment from a stock fund in addition to commission from clients and does not tell them.  Is this ethically appropriate?
1.Y= es
2.N= o
3.N= ot sure
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What is a conflict of interest?
·Primary interest in well-being of clients, patients or integrity of research ·S= econdary interest in personal gain ($, professional advancement) ·S= pecial relationships of trust, dependency
Risk that primary interest unduly influenced by 2ary interest
$ are fungible, quantifiable
Held to higher standard
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Conflicts of interest
Questions for audience
·Changed practice based on article sponsored by drug manufacturer?
<= span style=3D'font-weight:normal'>·Had meal from drug manufacturer? = ;
<= span style=3D'font-weight:normal'>·Given patients drug samples?
·Received payment = from drug company?
In 2007 article, 83% meals, 78% samples, 28% payments for consulting, giving lect= ure, enroll patients
In 2007, 60% department chairs and leaders
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Biederman case
·Research supporting diagnosis of bipolar disorder in children and treatment with antipsychotics=
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Biederman case
·T= ies to manufacturers of psychiatric drugs&= #13;
·Research grants and consulting
·Director of J & J Center for Pediatric Psychopathology Research
&= #8226;“Move forward the commercial goals of J & J”
Risperidone
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Biederman case
·Di= d not report $1.4 million in income from drug companies, as required by
·Universities
·NIH
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The New York Times
·Expert or shill?
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Concerns about COIs
·Di= sagreements and errors inevitable
·Due to reasonable differences of opin= ion, lapses, or financial gain?
·D= isclosure not remove risk of bias
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Concerns about industry-sponsored clinical trials
·A= cademic investigators lack
·Access to data
·Independent statistical analysis
·F= irst draft by medical writers
Ghostwriting in 13% in 1998 study
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Concerns about industry-sponsored clinical trials
<= span style=3D'font-weight:normal'>·Favorable conclusions
<= span style=3D'font-weight:normal'>·Not report negative findings
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Not report negative findings
<= span style=3D'font-weight:normal'>·SSRIs in children
<= span style=3D'font-weight:normal'>·Aprotinin
<= span style=3D'font-weight:normal'>·Ezetimibe plus statin
Bovine pancreatic trypsin inhibitor, slows down fibrinolysis, to reduce bleeding during complex surgery
Increased mortality, acute renal failure, MI, revascularization
Withdrawn from market
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Biased reporting has impact on
<= span style=3D'font-weight:normal'>·Clinical practice
<= span style=3D'font-weight:normal'>·Practice guidelines
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Mission of drug companies
·“Drug companies have to continue to be successful businesses… But their primary mission is products that sav= e lives and improve lives.”
·“This is an area that’s different from ice cream, bubble gum, a= nd automobiles.” 
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New FDA regulations
<= span style=3D'font-weight:normal'>·Disclose results at clinicaltrials.gov&#= 13;
<= span style=3D'font-weight:normal'>·Loopholes
Does not cover unapproved products. HHS to consider extending requirements to unapproved products

Completed after September 2007
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·P= rovide access and cost savings to patients
·Patients who lack drug coverage
·Trial of new drug
·C= ompanies spent $20 billion for detailing, $16 billion for samples<= /span>
Drug samples
2004 data
700,000 MDs in clinical practice
So spend $3000 on detailing and over $2000 on samples for each physicia= n in clinical practice
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Evidence regarding drug samples
·Poor and uninsured slightly less likely to receive samples <= /span>
·MDs tend to use samples rather than their usually preferred drug
·MDs whose Rx did not follow practice guidelines more likely to provide samples
Overall 12% received a sample

Evidence is suggestive rather than definitive
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New developments
1.Bans on gifts
·PhRMA,
2.Ban meals
·Partners, Hopkins
3.Ban payment for attending a presentation
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New developments
4.Bans on speakers bureaus
·Hopkins, Partner= s, UCSF
5.Bans on drug samples
·Hopkins, Iowa, Florida State
·Only to central pharmacy
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New developments
6.Public disclosure of payments by companies to MDs
·Required by some legal settlements
·Some state laws = (MN, VT, MA)
·Voluntary by some companies
·Recommended by M= edPAC
Some states make public disclosure by MD to university
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<= /div>
<= /div>
<= /div>
Page ‹#›
Body Text
Second Level
Third Level
Fourth Level
Fifth Level
Delay in declaring death compromises viability of heart, not kidney or liver
3 cases of successful cardiac transplantation from DCD.
Donor mean age 3.7 days
Recipients mean age 2.2 months
San Luis Obispo surgeon inject i= mproper doses of morphine, midazolam, Betadine to hasten death
But if insert catheters, infuse heparin, start ECMO
Medical expenses related to dona= tion or not?
Occurs in many countries
Illegal in U.S.
Not clear whether includes marital status
Applies to physician 0ffices, clinics, hospitals
Vote 7-0
Promote opposite of insincerity, hypocrisy, bad faith
Contra + valere =3D to be of worth
To be of worth against
Too sick, insurance restrictions
Contra + valere =3D to be of worth
To be of worth against
Risk that primary interest unduly influenced by 2ary interest
$ are fungible, quantifiable
Held to higher standard = ;
In 2007 article, 83% meals, 78% = samples, 28% payments for consulting, giving lecture, enroll patients
In 2007, 60% department chairs and leaders
Risperidone
<= p:notes id=3D"96" layout=3D"notes" slots=3D"slideImage,body">
Ghostwriting in 13% in 1998 stud= y
Bovine pancreatic trypsin inhibi= tor, slows down fibrinolysis, to reduce bleeding during complex surgery
Increased mortality, acute renal failure, MI, revascularization <= /div>
Withdrawn from market <= /span>
Does not cover unapproved produc= ts. HHS to consider extending requirements to unapproved products
Completed after September 2007
2004 data
700,000 MDs in clinical practice
So spend $3000 on detailing and over $2000 on samples for each physician = in clinical practice
Overall 12% received a sample
Evidence is suggestive rather than definitive
Some states make public disclosu= re by MD to university
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MakeNotesVis() ) return runAnimations =3D _InitAnimations(); =09 if( IsWin("PPTSld") ) parent.SldUpdated(GetSldId()) g_origSz=3DparseInt(SlideObj.style.fontSize) g_origH=3Dsld.style.posHeight g_origW=3Dsld.style.posWidth g_scaleHyperlinks=3D(document.all.tags("AREA").length>0) if( g_scaleHyperlinks ) InitHLinkArray() if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) ) document.body.scroll=3D"no" _RSW() if( IsWin("PPTSld") && parent.IsFullScrMode() ) FullScrInit(); =09 MakeSldVis(); ChkAutoAdv() if( runAnimations ) { if( document.all("NSPlay") ) document.all("NSPlay").autoStart =3D false; if( sld.filters && sld.filters.revealtrans ) setTimeout( "document.body.start()", sld.filters.revealtrans.duration * = 1000 ); else document.body.start(); } } function MakeSldVis()=20 { var fTrans=3Dg_showAnimation && SldHasTrans() if( fTrans )=09 { if( g_bgSound ) { idx=3Dg_bgSound.indexOf(","); pptSound.src=3Dg_bgSound.substr( 0, idx ); pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1))); } SlideObj.filters.revealtrans.Apply()=09 } SlideObj.style.visibility=3D"visible" if( fTrans ) SlideObj.filters.revealtrans.Play() } function MakeNotesVis()=20 { if( !IsNts() ) return false=20 SlideObj.style.display=3D"none" nObj =3D document.all.item("NotesObj") parent.SetHasNts(0) if( nObj ) {=20 nObj.style.display=3D"" parent.SetHasNts(1) } return 1 } function ChkAutoAdv() { if(SldHasTrans()) SlideObj.onfilterchange=3DAutoAdv else AutoAdv() } function AutoAdv() { if(!IsWin("PPTSld") || !gUseSldTimings )return var sld=3DGetCurSld() if( (sld.mAdvDelay>0) && !parent.IsFramesMode() ) setTimeout("parent.GoToNextSld()",sld.mAdvDelay) } function GetObj(id) { if(g_supportsPPTHTML) return document.all(id); else return document.getElementById(id); } function SldHasTrans() { return SlideObj.style.filter !=3D ""; } function GetSldId()=20 { var regExp =3D /file:\/\/\//i var pos =3D location.href.search(regExp) if (MHTMLPrefix !=3D "" && pos !=3D -1) sId =3D location.href.substring(pos) else { sId =3D RemoveFilePrefixFromHref(location.href); var regExp =3D /\// var fixedHref =3D sId var pos =3D -1 =09 pos =3D fixedHref.search(regExp) while (pos !=3D -1) { fixedHref =3D fixedHref.replace(regExp, "\\") pos =3D fixedHref.search(regExp) } =09 if (g_fBaseHyperlink =3D=3D true) sId =3D "file:///" + fixedHref; else sId =3D fixedHref.substring(fixedHref.lastIndexOf('\\') + 1) } =09 return sId } function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx= tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl= e.display=3D'none'; return true } return false } function IsWin( name ) { return window.name =3D=3D name } function IsNts() { return IsWin("PPTNts") } function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) } function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"= && navigator.appVersion.indexOf("Windows")>0 ) } function SupportsPPTHTML() { var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0 if( msie >=3D 0 ) ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) ) else ver=3DparseInt(appVer) return( ver >=3D 4 && msie >=3D 0 ) } function _RSW() { if( !g_supportsPPTHTML || IsNts() || ( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) ) return var padding=3D0; if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6 cltWidth=3Ddocument.body.clientWidth-padding cltHeight=3Ddocument.body.clientHeight-padding factor=3D(1.0*cltWidth)/g_origW if( cltHeight < g_origH*factor ) factor=3D(1.0*cltHeight)/g_origH newSize =3D g_origSz * factor if( newSize < 1 ) newSize=3D1 s=3DSlideObj.style s.fontSize=3DnewSize+"px" s.posWidth=3Dg_origW*factor s.posHeight=3Dg_origH*factor s.posLeft=3D(cltWidth-s.posWidth+padding)/2 s.posTop=3D(cltHeight-s.posHeight+padding)/2 if( g_scaleHyperlinks ) ScaleHyperlinks( factor ) } function _InitAnimations() { animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined'; isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode(); g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc= reen && parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } } function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) || (event && (event.keyCode=3D=3D32) ) ) parent.GoToNextSld(); } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 0; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram= es", gIsEndShow=3D0, NUM_VIS_SLDS=3D44, SCRIPT_HREF=3D"script.js", FULLSCR_= HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var g_fBaseHyperlink =3D false; var gMainDoc=3Dnew Array(new hrefList("slide0040.htm",1,-1,1),new hrefList(= "slide0041.htm",1,-1,1),new hrefList("slide0042.htm",1,-1,1),new hrefList("= slide0085.htm",1,-1,1),new hrefList("slide0086.htm",1,-1,1),new hrefList("s= lide0023.htm",1,-1,1),new hrefList("slide0036.htm",1,-1,1),new hrefList("sl= ide0034.htm",1,-1,1),new hrefList("slide0116.htm",1,-1,1),new hrefList("sli= de0035.htm",1,-1,1),new hrefList("slide0024.htm",1,-1,1),new hrefList("slid= e0031.htm",1,-1,1),new hrefList("slide0030.htm",1,-1,1),new hrefList("slide= 0117.htm",1,-1,1),new hrefList("slide0079.htm",1,-1,1),new hrefList("slide0= 047.htm",1,-1,1),new hrefList("slide0118.htm",1,-1,1),new hrefList("slide00= 50.htm",1,-1,1),new hrefList("slide0052.htm",1,-1,1),new hrefList("slide012= 0.htm",1,-1,1),new hrefList("slide0121.htm",1,-1,1),new hrefList("slide0056= .htm",1,-1,1),new hrefList("slide0129.htm",1,-1,1),new hrefList("slide0076.= htm",1,-1,1),new hrefList("slide0127.htm",1,-1,1),new hrefList("slide0128.h= tm",1,-1,1),new hrefList("slide0087.htm",1,-1,1),new hrefList("slide0092.ht= m",1,-1,1),new hrefList("slide0093.htm",1,-1,1),new hrefList("slide0094.htm= ",1,-1,1),new hrefList("slide0095.htm",1,-1,1),new hrefList("slide0096.htm"= ,1,-1,1),new hrefList("slide0097.htm",1,-1,1),new hrefList("slide0098.htm",= 1,-1,1),new hrefList("slide0104.htm",1,-1,1),new hrefList("slide0130.htm",1= ,-1,1),new hrefList("slide0106.htm",1,-1,1),new hrefList("slide0107.htm",1,= -1,1),new hrefList("slide0108.htm",1,-1,1),new hrefList("slide0109.htm",1,-= 1,1),new hrefList("slide0111.htm",1,-1,1),new hrefList("slide0123.htm",1,-1= ,1),new hrefList("slide0132.htm",1,-1,1),new hrefList("slide0084.htm",1,-1,= 1)); /********************************************* Frameset functions These functions control slide navigation and state of the frameset. **********************************************/ function RemoveFilePrefixFromHref(href) { var regExp =3D /^file:\/\/\//i; return href.replace(regExp, "") } function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) {=09 var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix();=20 function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') {=20 href=3Dnew String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if (MHTMLPrefix !=3D "") href =3D RemoveFilePrefixFromHref(href) if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; =09 if (MHTMLPrefix !=3D "") PPTSld.location.replace(MHTMLPrefix+RemoveFilePrefixFromHref(obj.mSldHref= )) else PPTSld.location.replace(obj.mSldHref) =09 if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 if (MHTMLPrefix !=3D "") PPTSld.location.replace(MHTMLPrefix+RemoveFilePrefixFromHref(href)) else PPTSld.location.replace(href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr= row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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charset="us-ascii" PowerPoint Presentation ------=_NextPart_01C9E9E5.DBA201E0 Content-Location: file:///C:/58D9C639/EthicsControversies_April2009_files/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"
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