Background and ObjectivesVaried meanings of death within medicine, bioethics, and society at large often produce disagreement and frustration between physicians and surrogate decision makers. We investigated whether teaching medical students about the philosophical aspects of death would change their attitude toward surrogate decision makers who assert nonstandard views of death.MethodsAn 80-minute lecture covering philosophical debates surrounding medico-legal standards of death was given to second-year medical students at Oakland University William Beaumont School of Medicine during a neuroscience course. Participants completed a questionnaire containing Likert scale and open-ended questions before and after the intervention assessing their acceptance of, frustration toward, and likelihood of accommodating a request for surrogate decision makers who posited either a whole-brain, high-brain, or circulatory view of death. Change in knowledge was analyzed using the McNemar test, whereas attitudinal scores were compared with pairedttests. Open-ended responses were narratively analyzed to identify themes that elaborate quantitative findings.ResultsA total of 43 paired responses were analyzed from second-year medical students. Following the intervention, students expressed less frustration (χ¯diff= −0.64, 95% CI −0.15 to −1.15), greater likelihood of accommodating ventilator removal (χ¯diff= 0.60, 95% CI 0.41–0.85), and greater acceptance (χ¯diff= 0.63, 95% CI 0.28–0.91) of surrogates who endorsed a whole-brain view of death. Although students rated the high-brain view as more acceptable after the lecture (χ¯diff= 0.63, 95% CI 0.28–0.91), they were not more likely to remove a ventilator from a patient who had experienced high-brain death (χ¯diff= 0.19, 95% CI −0.30 to 0.67). Students were less likely to continue artificial ventilation for a brain-dead patient (χ¯diff= −0.61, 95% CI −0.91 to −0.30) despite no change in frustration toward the surrogate (χ¯diff= −0.26, 95% CI 0.20 to −0.70).DiscussionChanges in attitudes across the 3 views of death suggest that increased awareness of the philosophical debate facilitates reflection of students' understanding and opinion of death. These findings support implementation of educational interventions to prepare students for future work with surrogate decision makers holding diverse sets of views on death.

Vitamin A and its biologically active metabolites, all-trans and 9-cis retinoic acid (RA), are thought to be important in generating and modulating immune function. However, RA modulates the function of many types of immune cells, and its specific role in dendritic cell (DC) activation, Ag presentation, and T cell effector function has not been fully characterized. Because RA works primarily through RA receptor (RAR)α, we examined mice with a myeloid cell–specific defect in RA signaling. These transgenic mice have a CD11c-cre–driven expression of a truncated form of RARα that specifically blocks the signaling of all forms of RARs in myeloid cells. This defect results in abnormal DC function, with impaired DC maturation and activation, and reduced Ag uptake and processing. These DC abnormalities were associated with a reduced ability to mount Ag-specific T cell responses to immunization despite having normally functioning T cells. In contrast, the loss of DC-specific RA signaling did not significantly alter levels of Ag-specific Abs postimmunization and resulted in an increase in bronchial IgA. Our findings indicate that RA signaling in DCs is crucial for immune activation, and its absence impairs the development of Ag-specific effector functions of T cell immunity.