Issue in Contemporary Management Essay Example | Topics and Well Written Essays - 1000 words

Issue in Contemporary Management - Essay Example It is difficult for a small organization to effectively manage, control and coordinate between different diverse organizations. Moreover, statutory power given to LOCOG regarding ownership, compensation, and regulation is temporary. In other words, LOCOG has to give up all the infrastructure facilities developed for the London Olympics after the Olympics which will definitely reduce their revenues after the London Olympics. Infrastructure development opportunities are immense as part of conducting London Olympics. Development of infrastructure to world-class level will change the face of London city. LOCOG will receive a share from international Olympics committee’s broadcasting revenue and also from their own marketing efforts. This revenue can be utilized for the economic development and regeneration. Increased employment opportunity is another advantage of conducting Olympics in London. The public will also get an opportunity to know more about different culture which will help to grow the English culture. It is impossible to conduct Olympics without causing some inconvenience to the public. Some of the local businesses needed to be displaced to develop infrastructure for the London Olympics. This displaced business groups may engage in legal battle with LOCOG. Infrastructure development to world class standards is a major challenge. Ensuring value for money and economic benefits to the cost bearing public is another threat to the LOCOG. The public is lavishly extending their support to the Olympics considering a huge return in terms of economic development and infrastructure development. Failure to fulfil the expectations of the public may create problems for LOCOG in future. Stage management and coordination of events are also not an easy task for LOCOG considering its small structure. Propaganda spreading through media is another threat for this event. Many people are spreading the

Death Penalty (Opposing Viewpoint) Essay Example | Topics and Well Written Essays - 750 words

Death Penalty (Opposing Viewpoint) - Essay Example The practice of capital punishment is on the other hand supported by many who believe that some acts should carry this punishment so as to set a precedent for the coming generation. This essay would revolve around the support of capital punishment by the individuals who believe that it can be beneficial for the whole society. The Supporters of Capital Punishment hold the view that Bible is a contemporary source of cultural and religious values for most people residing in North America. The Old Testament of the Jews along with the New Testament of Christians speaks in favor of Capital Punishment. Christians who are in support of Capital Punishment give reference to the Old Testament when Noah was called by God and HE said, â€Å"Whoever sheds the blood of a human, by a human shall that person’s blood be shed.† This passage is often cited by believers of Capital Punishment. In Bible God created human in his image. Then human did sin, he was forgiven by the God; human again did sin and was pardoned by the God. The process of God’s forgiveness and reinstatement also lessens the effect of death penalty (Capital Punishment in America: A Balanced Examination 2011). Advocates of Capital Punishment view it as a revenge for awful crimes. Those who support the death sentence declare that it is a uniquely effective punishment that discourages crimes. In Saudi Arabia, for instance the death penalty rate is very high and so the crime rate is very low as compared to other countries. Promoters of Capital Punishment want Governments to execute well and they consider Capital Punishment as an issue of criminal justice policy. If we take up the case of Michael Perry, he was sentenced to death but his partner in crime, Jason Burkett was found guilty of all three murders of Sandra, her son Adam and his friend Jeremy Richardson but, was only sentenced to a life time prison by a narrow jury vote and will come out in 2041 (The Guardian, 2011). Will he be redeemed when he comes out of prison? Probably not; if advocates in opposition of Capital Punishment believe that he can be reformed and brought back to life. It is not possible because a life in prison makes a person suffocated and frustrated. Again, we can blame our Government and law agencies rather than debate over Capital Punishment. Jails are crowded and prisoners are treated so badly that mostly they either commit suicide or kill other prisoners. According to IdahoStatement.com, Paul Blomberg’s daughter was kidnapped, raped and then murdered in 2000. Her name was Samantha Maher and she was only 22 by then. Her father gave testimonies in front of the jury trails and even though there were two sentenced hearings for Darrell Payne, seven years from now; nothing has happened to this man up till now. He was given death penalty twice but due to incompetent law enforcement agencies, nothing has been done to him until today. Being a logical person, can one think he can be redeemed and reformed? Not necessarily. Blomberg now beliefs that Idaho system does not really execute criminals which are on the death row. In 1979, the Idaho death penalty was reinstated but even after that thre e Death Row convicts have been freed and only can have been executed. Out of the 40 people who were sentenced to death have their sentences changed now and are no longer obliged for execution. (Orr 2011) Many supporters of the capital punishment believe that for every person that is sentenced to deat

Healthcare Internship Reflection | Cancer Center

Healthcare Internship Reflection | Cancer Center Crystal Mullen Last month I received the privilege of being hired to work as a secretary for The University of Texas MD Anderson Cancer Center in Houston, Texas. As the name implies their sole focus and overall market involves finding cures and treatments for cancer. In fact they operate on a very aggressive mission to completely eliminate cancer by integrating patient care, prevention, and research programs. Furthermore, MD Anderson provides education about cancer research, prevention, and treatment information that ranges from their graduate and undergraduate programs at the University of Texas to MD Anderson employees and even to the general public (University of Texas MD Anderson Cancer Center, 2014). Finally though not exhaustively, MD Anderson seeks to become and remain a world renowned cancer center through science, excellent people, and research-driven patient care. The motto for MD Anderson is â€Å"We are Making Cancer History (University of Texas MD Anderson Cancer Center, 2014)†. One of the biggest surprises I learned when I began working for MD Anderson is that although their sole focus is eliminating cancer, that singular mission is has multiple areas of focus. This is because they have incomparable resources and a wealth of capabilities, MD Anderson is exceptionally qualified to increase the pace of transforming scientific discoveries regarding cancer into innovative clinical treatments and advances that lower the number of deaths due to cancer deaths. Their discoveries have lead MD Anderson to divide their work into six forms of cancer – otherwise known to them as â€Å"moon shots†. Along with those moon shots, MD Anderson focuses a great deal of science, research and patient care on Non-Hodgkins Lymphoma. The cancers listed in the moon shot program include breast and ovarian, Leukemia (ALM / MDS), Leukemia (CLL), Lung, Melanoma, and prostate. These six moon shots, along with Non-Hodgkins Lymphoma, will ultimately lead to cures for all types of cancer (Moon Shots Program, 2014). BREAST AND OVARIAN MD Anderson’s moon shot program for breast and ovarian cancer concentrates on triple-negative breast cancer and on high-grade serous ovarian cancer. These concentrations have resulted in exciting, innovative projects that often results in the quick detection and treatment of these deadly cancers. One aspect of the moon shot program for breast and ovarian cancer involves universal genetic testing. Patients diagnosed with triple-negative breast cancer and high-grade serous ovarian cancer are provided genetic counseling and testing. Furthermore, MD Anderson reaches out to at risk family members to immediately identify individuals for preventive screening. Another aspect of the moon shot program for breast and ovarian cancer involves pinpointing genetic markers/mutations to discover how these cancers respond and then adapt to cancer treatments. This data will helps physicians develop individualized treatment plans for each of their patients. Finally though not exhaustively, a thir d aspect of the moon shot program for breast and ovarian cancer involves early detection. The cancer investigators for MD Anderson focus on biomarkers that appear promising to identify and study these cancers in their earliest stages to provide better treatment conclusions (Moon Shots Breast and Ovarian, 2014). LEUKEMIA (AML/MDS) One of MD Anderson’s moon shot program for leukemia involves acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) leukemia. These two diseases are being combatted by tacking drug resistance, applying supercomputing, artificial intelligence, and AML targeted therapy such as blood stem cell transplants. First of all, AML/MDS Moon Shot strives to understand a class of drugs that form the molecular basis of drug resistance to find alternative therapies that circumvents this challenge. Furthermore, AML/MDS Moon Shot is developing a new, innovative system that takes advanced supercomputing technology and integrates this technology with individualized research data into a secure database. Advanced analytics, combined with the technology of IBM’s Watson, otherwise known as the world’s smartest computer, enables clinicians to collect new insights for patient care and research. Finally, though not exhaustively, the moon shot engages in another research option f or AML / MDS involves blood stem cell transplantation and cellular therapy. This form of research has an excellent record of both improving the safety and impact of this form of treatment (Moon Shots Leukemia (AML/MDS), 2014). LEUKEMIA (CLL) Another one of MD Anderson’s moon shot program for leukemia involves chronic lymphocytic leukemia (CLL), MD Anderson has made great progress in this against this form of cancer. Scientists and physicians has driven one this most common form of adult leukemia close to the brink of extinction. This has been accomplished by developing cutting edge drug therapies and taking immunotherapy to eliminate residual CLL. First of all, the CLL Moon Shot team is actively studying a breakthrough class of drugs that thwarts the critical signaling in the malignant cells. These experimental drugs have proven to be excellent at preventing CLL cells from signaling their dramatic effect on the leukemic cells while creating minimal impact on other healthy cells. Furthermore, there is an additional CLL moon shot is famous for developing immunotherapy techniques to locate and destroy the remaining CLL (Moon Shots: Leukemia (CLL), 2014). LUNG Lung cancer is the most pervasive impact on our population out of other cancers. Because of its massive spread throughout the U.S. population, MD Anderson lists lung cancer as one of their Moon Shots Program. This particular battle is fought on three fronts: prevention, early detection, and treatment of advanced disease. First of all, because 80% of all lung cancers are tobacco based, the Lung Cancer Moon Shot program has launched initiatives to help in the prevention of tobacco based lung such as personalized tobacco cessation programs, social media, and referrals to successful tobacco treatment programs. Furthermore, through early detection of lung cancer diagnosing, the rate for a cure greatly increases. MD Anderson has played a significant role in the National Lung Cancer Screening Trial (NLST) that deaths by lung cancer are often lowered by as much as 20% when smokers were screened early with the use of a low-dose CT scan. Finally, MD Anderson has found treatment options for pat ients with advanced stage lung cancer haven’t changed much in the last 20 years so they intend on redirecting this trend with a new program called the GEMINI Project. This uses the latest cutting edge technologies to conduct a lung cancer profile from a molecular perspective. This will bypass carpet-bombing the cancer with non-specific chemotherapies in favor of using specifically targeted therapies, which is more like â€Å"smart bombing the lung tumors without any damaging side effects (Moon Shots: Lung, 2014). MELANOMA Because instances of melanoma and skin cancer deaths have risen over the past 50 years, MD Anderson’s moon shot scientists and physicians have attacked this form of cancer through prevention and through personalized integrated management of the cancer. The MD Anderson melanoma team pursues an aggressive prevention campaign to reduce the exposure to UV light in both children and adolescents with an innovative, all-inclusive program that includes both behavioral interventions and educational outreach to discourage excessive sun exposure through tanning and replace that activity with alternative sun protection practices. Furthermore, the moon shot team uses individualized and cohesive and management of melanoma. If patients are diagnosed early surgery is usually the next step. Although many forms of melanoma are resistant to treatments scientific breakthroughs in researching this diseases have led to this disease the development new immunotherapy agents that accurately and effect ively combats even the more advanced stages of melanoma (Moon Shots: Melanoma, 2014). PROSTATE The last form of cancer listed in the Moon Shot program is prostate cancer. The National Cancer Institute, has estimated there will be 238,590 new cases diagnosed this year, resulting in approximately 30,000. I order to lower the mortality rate of this form of cancer, the Prostate Cancer Moon Shot program has concentrated on three areas: lowering instances of overtreatment; combining therapies used in advanced and early stages of the disease; and creating targeted therapies, such as immunotherapy as an alternative to traditional treatment methods. The goal is to use these treatment and therapy options in order to effectively and timely shift the process from simply treating to actually curing prostate cancer (Moon Shots: Prostate, 2014). NON-HODGKINS LYMPHOMA Although not part of the â€Å"Moon Shots† program, MD Anderson is aggressively fighting against, Non-Hodgkin’s Lymphoma. At MD Anderson their goal is to treat this form of cancer with new treatments that are tailored to each patient and using targeted, biological agents that empower a human body to combat the cancer. Our teams of specialized physicians, as well as support staff including nurses, physician assistants, dietitians, social workers and many others, work closely together – and with you – to give you higher chance for successful treatment (Non-Hodgkins Lymphoma). Conclusion: Based on what I’ve read, and what I’ve observed working at this health system, I believe MD Anderson, is successful in treating the multiple forms of cancer. In fact, if there was a brand new form of cancer to emerge, I would think this cancer center would have the equipment, the technology and the clinical personnel to combat this newest manifestation of cancer. My only recommendation is that they maintain the current list if cancers found in their â€Å"moon shots† while also addressing other cancerous diseases. If this is done they will only continue to grow in their success. References Center, U. o. (2014). Moon Shots Breast and Ovarian. Retrieved June 22, 2014, from MD Anderson.org: http://www.cancermoonshots.org/moon-shots/breast-ovarian/ University of Texas MD Anderson Cancer Center. (2014). About Us. Retrieved June 22, 2014, from MD Anderson.org: http://www.mdanderson.org/about-us/index.html University of Texas MD Anderson Cancer Center. (2014). Moon Shots Leukemia (AML/MDS). Retrieved June 22, 2014, from MD Anderson.org: http://www.cancermoonshots.org/moon-shots/leukemia-aml-mds/ University of Texas MD Anderson Cancer Center. (2014). Moon Shots Program. Retrieved June 22, 2014, from MD Andderson.org: http://www.mdanderson.org/about-us/facts-and-history/moon-shots-program/index.html University of Texas MD Anderson Cancer Center. (2014). Moon Shots: Leukemia (CLL). Retrieved June 22, 2014, from MD Anderson.org: http://www.cancermoonshots.org/moon-shots/leukemia-cll/ University of Texas MD Anderson Cancer Center. (2014). Moon Shots: Lung. Retrieved June 22, 2014, from MD Anderson Cancer Center: http://www.cancermoonshots.org/moon-shots/lung/ University of Texas MD Anderson Cancer Center. (2014). Moon Shots: Melanoma. Retrieved June 22, 2014, from MD Anderson Cancer Center: http://www.cancermoonshots.org/moon-shots/melanoma/ University of Texas MD Anderson Cancer Center. (2014). Moon Shots: Prostate. Retrieved June 22, 2014, from MD Anderson.org: http://www.cancermoonshots.org/moon-shots/prostate/ University of Texas MD Anderson Cancer Center. (n.d.). Non-Hodgkins Lymphoma. Retrieved June 22, 2014, from MD Anderson.org: http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-types/non-hodgkins-lymphoma/index.html

SWOT Analysis for Zoecon, and the Product, ROACH ENDER Essay -- essays

SWOT Analysis for Zoecon, and the Product, ROACH ENDER Main Problem Analysis   Ã‚  Ã‚  Ã‚  Ã‚  While no real problem exists with Zoecon, there is a conflict of interests in regard to how Strike ROACH ENDER is marketed. A meeting was set in which Zoecon executives were to analyze and discuss the test market results for the Strike ROACH ENDER, after it was placed in a consumer test market for six months in four cities representative of the 19-city market where 80 percent of roach insecticides were sold. These four cities included: Charleston, South Carolina; Beaumont, Texas; Charlotte, North Carolina; and New Orleans, Louisiana.   Ã‚  Ã‚  Ã‚  Ã‚  After these six months, executives were to determine which option would benefit Zoecon, resulting in the greatest return on profit. After analyzing the results, executives came up with three different options in which to market Strike ROACH ENDER. These options included:   Ã‚  Ã‚  Ã‚  Ã‚  Option One: was to expand the Strike ROACH ENDER distribution to the 19 cities where Strike FLEA ENDER was being sold. The research conducted by Zoecon's private marketing research group showed that the 19 cities accounted for 80 percent of roach insecticide volume. The executives at Zoecon agreed that the primary direct costs associated with distributing Strike ROACH ENDER to these 19 cities would be a price of $1,016,000. This cost would cover the advertising and promotions for the purpose of creating brand awareness in these 19 cities. The executives also agreed that the set-up/auditing, marketing research, and miscellaneous costs would not be repeated in order to expand distribution.   Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Option Two: Executives believed that Zoecon should focus on directing their resources to Pest Control Operators, (PCO's). They noted that GENCOR (hydropene) had been greatly received by PCOs in 1984. At the end of this year, many PCOs were promoting GENCOR's benefits to their customers. These Zoecon executives agreed that with an annual investment of $500,000 every year above the 27 percent of sales would be enough for trade advertising and and sales efforts towards accelerating use.   Ã‚  Ã‚  Ã‚  Ã‚  Option Three: Zoecon executives suggested that they pursue opportunities for selling hydropene to the makers of d-Con, Black Flag, and Raid for use in their products. While this strategy had worked in the past for PRECOR (methopene), it could pose as a threat or possible... ... above their competition. Weaknesses:   Ã‚  Ã‚  Ã‚  Ã‚  While there isn't a great deal of weaknesses to this option, executives might still agree that our competition will take advantage of our opportunity for growth in the consumer market. While this may be true, the results could be much worse if Zoecon jumps into the consumer market before gaining the reputation and earnings they would have produced from starting with the PCO's support behind their product. Zoecon has a specially designed product that is backed by strong, scientific research. Even though Zoecon's competitors will have a few years to breathe freely, after developing widespread attention from professionals, and gaining competitive edge, Zoecon is bound to quickly surprise the consumer market in the future. Threats:   Ã‚  Ã‚  Ã‚  Ã‚  The only potential threats to this option is new innovations, or a lack of timing. Zoecon's patents will eventually time out, which will give competition access to the controlled compounds that Zoecon formulated. Although this threat could potentially destroy Zoecon's existence, the chances of this happening are very slim to nearly impossible unless every one of their plans fail in the PCO market.

Ethical Challenges in the Era If Health Care Reform

Ethics, Law, and Policy Vicki D. Lachman Ethical Challenges in the Era Of Health Care Reform n truth, the United States is at the beginning of a long overdue and a much needed health care reform. We have seen the dismal statistics about our high cost health care system and some of the less than stellar outcomes (e. g. , infant mortality) (Callahan, 2011; World Health Organization [WHO], 2011)). The purpose of this article is not to complain about the current health care system, but instead to focus on existing reform efforts — The Patient Protection and he Affordable Care Act (ACA), the ethical justifications for its creation, and ethical challenges it brings. I Key Features of the Law ACA offers new ways for consumers and providers to hold insurance companies accountable. The most important parts of the law are features described in the following discussion. Because of space limitation, I will highlight some elements of the law that are enacted through 2014 and clearly impact nursing. These selected features include insurance choices, insurance costs, rights and protection, and people age 65 and older. Insurance ChoicesThe intention of the law is to expand health care coverage to most U. S. citizens and permanent residents by requiring most people to have or purchase health insurance (HealthCare. gov, 2012a). Citizens will have a choice of private insurance, employer-paid insurance, Medicaid, Medicare, or state-based insurance exchanges. Affordable Insurance Exchanges. Individuals and small businesses can purchase coverage through these exchanges, with premium and cost-sharing credits available to individuals and families with income between 133%-400% of the federal poverty guideline (in 2011, the overty guideline was $18,530 for a family of three) (Werhane & Tieman, 2011). Businesses with 50 or more employees need to make coverage available, and businesses with less than 25 employees will qualify for tax credits to offset their cost (Kaiser Family Foun dation, 2011). Consumer Operated and Oriented Plan (CO-OP). The ACA produces a new kind of non-profit health insurer, called a Consumer Operated and Oriented Plan (CO-OP). CO-OPs are meant to offer consumer-friendly, affordable health insurance options to individuals and small businesses. By January 1, 2014, individuals will be able to buy a CO-OPVicki D. Lachman, PhD, APRN, MBE, FAAN, is Clinical Professor, and Director, Innovation and Intra/Entrepreneurship in Advanced Practice Nursing, Drexel University, College of Nursing and Health Professions, Philadelphia, PA. 248 health plan through the Affordable Insurance Exchanges. Pre-existing condition insurance plan. All covered benefits are available to individuals, even to treat a pre-existing condition. This program offers temporary protection for people with pre-existing conditions until 2014, when insurance companies can no longer deny individuals coverage based on their health status.Young adult coverage. Individuals can add or k eep their children on their health insurance policy until they reach age 26. The law makes it easier and more affordable for young adults to get health insurance coverage. Insurance Costs ACA holds insurance companies accountable. It also helps individuals keep their costs down. Value for individual’s premium dollar. ACA requires insurers selling policies to individuals or small groups to spend at least 80% of premiums on direct medical care and efforts to improve the quality of care. Unfortunately, this does not apply to self-insured plans.Lifetime and annual limits. ACA restricts and phases out the annual dollar limits a health plan can place on most of its benefits. Furthermore, ACA eliminates these limits completely in 2014. Rate review. Insurance companies must now justify proposed rate increases for health insurance. Insurance companies cannot raise rates by 10% or more without first explaining the reasons to the state or federal rate review program. Rights and Protecti ons The ACA puts consumers in charge of their health care, not insurance companies. The following rights and consumer protections are available. Preventive care.Individuals may not have to pay a copayment, co-insurance, or deductible to receive recommended preventive health services, such as screenings (e. g. , mammograms and colonoscopies), vaccinations (e. g. measles, polio, or meningitis), and counseling (e. g. , smoking cessation, weight loss, healthy eating). Doctor choice and ER access. Individuals can choose any available participating primary care provider and they can access out-of-network emergency rooms without prior approval. ACA prohibits health plans from requiring a referral from a primary care provider before women can seek coverage for obstetrical or ynecological (OBGYN) care. People 65 and older. ACA offers eligible elders a range of preventive services with no cost-sharing. ACA also provides discounts on drugs when older adults are in the coverage gap known as the â€Å"donut hole. † July-August 2012 †¢ Vol. 21/No. 4 Ethical Challenges in the Era of Health Care Reform TABLE 1. Views of Liberal Egalitarians vs. Libertarians and Free-Market Advocates Liberal Egalitarians Libertarians and Free-Market Advocates Health care is a fundamental good and access to this good Role of government is confined to protecting the freedom of all allows us to become full members of society. ersons to choose their own goals and means to pursue them. This right to health care must be exercised by removing all People have a right to non-interference. barriers to access. Justice, equality, and community are values. Freedom and personal responsibility are values. Health care is a right. Health care is a commodity. Single-payer system is the solution. Decentralized market mechanisms with personal payment are the solution. Preventive services. The list is significant and begins with an annual wellness visit. Other important preventive services include bone mass measurement; cervical cancer creening, including Pap smear tests and pelvic exams; colorectal, prostate, and diabetes screening; influenza, pneumonia, and hepatitis B immunizations; and many other services. There are other services and features in the ACA that could be discussed, but we will now move to discuss the ethical justifications for the ACA. The controversy it has created in the eyes of individuals with a free-market or libertarian view will be compared to those with a liberalegalitarian outlook. Ethical Justifications for the ACA Since 1986, the Emergency Treatment and Labor Act has prohibited hospitals from refusing acute care to any ndividual who could not afford to pay (CMS. gov, 2012). â€Å"Consequently, $100 billion of care annually is ‘costshifted’ onto patients who can pay, almost all whom are insured. This shift raises the average annual health insurance premium roughly $1,000 for every insured family† (Crowley, 2009, p. 10). This lack of distributive justice for the insured is one reason why insurance is being mandated in ACA. It is equally unfair to mandate that all citizens have insurance if insurance is not affordable, as this could cause significant harm to individuals and families already struggling financially.Therefore, the ethical principles of beneficence and nonmaleficence are supported by the features of Affordable Insurance Exchanges and the development of Consumer Operated and Oriented Plans. Ethical reasoning for health care reform has relied primarily on distributive justice as justification for change, specifically due to lack of access to care for the underinsured and uninsured (Lachman, 2009). According to the U. S. Census Bureau, 46. 3 million people in the United States were uninsured in 2008 (ProCon. org, 2012). The United States is the only developed nation in the world hat does not guarantee health coverage. Table 1 offers a comparison of views of persons who support distributive justice, see health care as a right, and therefore want a single-payer system with those individuals who want to continue the free-market system. â€Å"To single-payer advocates, the primary goal of health policy is ensuring that everyone can obtain some minimal level July-August 2012 †¢ Vol. 21/No. 4 of health care† (Sade, 2007, p. 1429). Making access to health care widely available permits individuals to be fully functioning members of society and the moral ommunity (a group of people drawn together by a common interest in living according to a particular moral philosophy). On the other hand, Americans who are libertarians and free-market advocates mostly look beyond the natural (genetic) and social (upbringing) lottery that places some at a disadvantage and instead look to the individual’s free will and personal responsibility for actions (Callahan, 2011; Pariser, 2012; Trotter, 2011). They believe health care is one of the many options from which to choose to improve the ir lot in life. Their belief in personal responsibility can make them unsympathetic o people with unhealthy lifestyles for whom they would ultimately have to spend their insurance dollars. They also resent having to fund treatments they personally would not choose (e. g. , transplants, mechanical ventilation for person in persistent vegetative state). Though many wealthy individuals support health care reform out of benevolence, they do fear the loss of freedom which is central to their value system. However, two additional factors drive change for health care reform — significant cost and quality problems. In 2007, health care expenditures totaled $2. 2 trillion, 16. 2% of the U.S. economy. Health care employs more than 14 million people and is the largest industry in the United States. Of the 193 WHO member states, the United States is ranked first in per capita health care expenditures ($6,719) (ProCon. org, 2012). The present health care system is not giving the utility f or the dollars spent. This cost problem is a reason that ACA has a focus on physicians counseling individuals on end-of-life options. It found that about 30 percent of Medicare dollars are spent during the last year of life, and half of that is spent during the last 60 days. In 2009 dollars, Dr.Gordon calculated, that amounts to $70 billion a year, much of it spent on futile care that prolongs suffering (Brody, 2009, para 20). Unfortunately, politics initially got in the way in 2009 with the â€Å"death panel† jargon and this counseling was dropped from ACA; however, this end-of-life options counseling was incorporated into 2011 Medicare reimbursement for health care providers (HealthCare. gov, 2012b). 249 Ethics, Law, and Policy WHO (2011) statistics also indicate the money spent is not putting us at the top of the list in quality outcomes. The infant mortality rate for the United States in 2009 was even deaths per 1,000 live births, ranking the United States 43rd among WHO nations. Rates for Sweden, Spain, Italy, Germany, France, Czech Republic, Slovenia, and Iceland are all half of the United States rate. Quality is a focus of ACA in the preventive realm and with quality measurement. Two essential principles of the ACA are that: 1. Provider reimbursement for health services is based, in part, on the relative quality and patient experience of the care provided. 2. Information about that comparative quality and patient experience will be publicly accessible. Quality and patient satisfaction will be rewarded by ata from hospital comparison required by the Hospital Consumer Assessment of Healthcare Providers and Systems for Medicare patients. â€Å"The implications of Value-Based Purchasing (VBP) regulations for hospitals are clear — FY2013 implementation at 1% of base DRG payments, rising to 2% by FY2017† (Acton, 2012, para 2). Hospitals will have to earn it back by achieving and maintaining high quality and positive patient experiences. T his consequential focus in the patient care experience supports the autonomous choice of the patient for hospitals and physicians. Ethical Challenges of ACA Legal ChallengeBefore discussing three key ethical challenges health care providers will face, the legal challenge before the Supreme Court needs to be addressed. This challenge determined if the ACA requirement to purchase health insurance violates Article 1, Section 8, Clause 3 of the U. S. Constitution: Congress shall have the Power To lay and collect Taxes, Duties, Imposts, and Excises, to pay the Debts and provide for the common Defence and the general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States†¦ (Werhane & Tieman, 2011, p. 83)The argument against this mandate is that the government has never required people to buy any good or service as a condition of lawful residence in the United States. However, every working person is required to pay into Social Security and Medicare. The counter argument is that these are government-mandated and governmentrun programs. This argument ultimately could support a Supreme Court decision of only a government-run singlepayer system, an action libertarians and free-market advocates oppose. Second, there are requirements for car insurance for drivers, and flood insurance for persons ho live within authorized distance from a possible flood plain. Because all people will need health care at some point in their lives, the argument could be made that insurance should be a requirement so as not to burden the moral community with the costs of those who do pay for insurance (Hamel & Nairn, 2011). 250 On June 28, 2012, the U. S. Supreme Court endorsed most of the Patient Protection and Affordable Care Act, including the contentious individual mandate that requires most Americans to obtain health insurance. In a 5-4 decision, the court said the federal government has he power to fine Americans who do not ac quire insurance because it is considered a tax (Jaslow, 2012). Electronic Medical Records The requirement for electronic records could generate a significant ethical challenge for privacy and confidentiality. Unfortunately, the $20 billion for health information technology from the American Recovery and Reinvestment Act (ARRA) did little to change the current HIPPA privacy paradigm (Crowley, 2009). Furthermore, it is likely patients will carry their personal health records in their own electronic devices or retrieve them through the Internet.A transformation in rural health care is likely through telehealth and telehomecare. These innovations will bring expertise to patients to facilitate the best choice in their treatment decisions. The challenge will be to assure informed consent and confidentiality in this expanded digital age. Chronic Disease Management Individuals with chronic illness benefit significantly from palliative care services, not just at end-of-life care but througho ut the disease progression. The ACA focus on chronic disease management is best exemplified by this phrase: â€Å"An integrated care approach to managing illness hich includes screenings, check-ups, monitoring and coordinating treatment, and patient education† (HealthCare. gov, 2012b, para 1). Feministic ethics, with its focus on managing the particulars of any person’s situation, celebrates this personalized service to individuals who must manage illnesses often for many years. In her book, Caring: A Feminine Approach to Ethics and Moral Education, Nell Noddings (2003) argued that a morality based on rules is inadequate. She contended this approach loses the richness of the moral dilemmas people face, and nly situational and contextual knowledge of the individual can help resolve the moral quandaries of life. Shaping Health Care Policy According to the Code of Ethics for Nurses, provision 9 (American Nurses Association [ANA], 2001), nurses have an obligation to  "work individually as citizens or collectively through political action to bring about social change† (p. 25). This responsibility to shape social (health care) policy calls for nurses to voice concerns about the meaning of the rejection of the individual mandate for society. The libertarians and free-market advocates reinforce a caricature of American individualism and weaken a sense of responsibility for oneself and fellow citizens†¦It neglects one side of the equation, forgetting that we are not only individuals with the freedom to choose, but also members of society called to uphold a common good. (Hamel & Nairn, 2011, p. 94) continued on page 245 July-August 2012 †¢ Vol. 21/No. 4 Ethics, Law, and Policy REFERENCES continued from page 250 Therefore, nurses and nursing associations have the ethical challenge to stand firm for patients and ensure the long-term sustainability of our health care system.Nurses need to advocate for the people without a voice — t hose discriminated against because of health status and lack of insurance. Conclusion ACA has provided a forum for debate about not only health care insurance, mechanisms to maintain financial stability of its systems, and strategies to ensure access to millions of people, but also has contributed to defining American society’s values. It is easy to argue against the individual mandate impingement on choice and freedom. However, other provisions provide children, adults, and elders with coverage and services that will help keep hem healthy and support them in their management of chronic diseases, while quelling the fear of bankruptcy. The Supreme Court will decide the legal matters in ACA, but it will not resolve the ethical matters. Can Americans continue to allow the self-protective practices of insurance companies in excluding high-risk individuals (e. g. , pre-existing conditions, lifetime caps on benefits)? The principle of autonomy was never meant to abandon the moral r elationships that continue to be necessary for the human good. â€Å"The nurse respects the worth, dignity and rights of all human eings irrespective of the nature of the health problem† (ANA, 2001, p. 7). July-August 2012 †¢ Vol. 21/No. 4 Acton, A. (2012). The hidden risk (or reward) of HCAHPS. Retrieved from http://blog. healthstream. com/blog/bid/103384/The-Hidden-Risk-orReward-of-HCAHPS American Nurses Association (ANA). (2001). Code of ethics for nurses with interpretative statements. Silver Spring, MD: Author. Brody, J. E. (2009). End-of-life issues need to be addressed. Retrieved from http://www. nytimes. com/2009/08/18/health/18brod. html Callahan, D. (2011). Health care reform: Can a communitarian perspective be salvaged?Theoretical Medicine and Bioethics, 32(5), 351-362. CMS. gov. (2012). Emergency Medical Treatment & Labor Act (EMTALA). Retrieved from http://www. cms. gov/Regulations-and-Guidance/ Legislation/EMTALA/index. html? redirect=/EMTALA/ Crowley, M. ( 2009). Connecting American values with health care reform. Garrison, NY: The Hastings Center. Hamel, R. , & Nairn, T. (2011). The individual mandate: A rancorous moral matter. Health Progress, 92(4), 88-95. HealthCare. gov. (2012a). Affordable Care Act. Retrieved from http://www. healthcare. gov/law/full/ HealthCare. gov. (2012b). Chronic disease management.Retrieved from http://www. healthcare. gov/glossary/c/chronic. html Jaslow, R. (2012). Medical groups laud Supreme Court’s decision on Affordable Care Act. Retrieved from http://www. cbsnews. com/8301504763_162-57462837-10391704/medical-groups-laud-supremecourts-decision-on-affordable-care-act/ Kaiser Family Foundation. (2011). Summary of new health reform law. Retrieved from www. kff. org/healthreform/8061. cfm Lachman, V. D. (2009). Ethical challenges in healthcare: Developing your moral compass. New York, NY: Springer. Noddings, N. (2003). Caring: A feminine approach to ethics and moral education.Berkeley, CA: Universit y of California Press. Pariser, D. M. (2012). Ethical considerations in health care reform: Pros and cons of the affordable care act. Clinics in Dermatology, 30(2), 151-155. ProCon. org. (2012). Right to healthcare: Did you know? Retrieved from http://healthcare. procon. org/ Sade, R. M. (2007). Ethical foundations of health care system reform. Annuals of Thoracic Surgery, 84(5), 1429-1431. Trotter, G. (2011). The moral basis for healthcare reform in the United States. Cambridge Quarterly of Healthcare Ethics, 20(1), 102-107. Werhane, P. , & Tieman, J. 2011). Clearing the brush: Myths surround the Affordable Care Act. Health Progress, 92(4), 82-84, 86-87. World Health Organization (WHO). (2011). World health statistics 2011. Retrieved from http://www. who. int/whosis/indicators/WHS2011_ IndicatorCompendium_20110530. pdf 245 Copyright of MEDSURG Nursing is the property of Jannetti Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listser v without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

The Lost Duke of Wyndham Chapter Eighteen

Three minutes,† Jack said, the moment he pulled the door shut. Because truly, he did not think he could last any longer than that. Not when she was dressed in her nightgown. It was an ugly thing, really, all rough and buttoned from chin to toe, but still, it was a nightgown. And she was Grace. â€Å"You will never believe what has happened,† she said. â€Å"Normally an excellent opening,† he acknowledged, â€Å"but after everything that has happened in the last two weeks, I find myself willing to believe almost anything.† He smiled and shrugged. Two pints of fine Irish ale had made him mellow. But then she told him the most amazing story. Thomas had given her a cottage and an income. Grace was now an independent woman. She was free of the dowager. Jack lit the lamp in his room, listening to her excitement. He felt a prickle of jealousy, though not because he did not think she should be receiving gifts from another man – the truth was, she'd more than earned anything the duke chose to portion off to her. Five years with the dowager – Good God, she ought to be given a title in her own right as penance for such as that. No one had done more for England. No, his jealousy was a far more basic stripe. He heard the joy in her voice, and once he'd banished the dark of the room, he saw the joy in her eyes. And quite simply, it just felt wrong that someone else had given her that. He wanted to do it. He wanted to light her eyes with exhilaration. He wanted to be the origin of her smile. â€Å"I will still have to go with you to County Cavan,† Grace was saying. â€Å"I can't stay here by myself, and I wouldn't want Amelia to be alone. This is all terribly difficult for her, you know.† She looked up at him, so he nodded in response. Truthfully, he hadn't been thinking very much of Amelia, selfish as that was. â€Å"I'm sure it will be awkward with the dowager,† Grace continued. â€Å"She was furious.† â€Å"I can imagine,† Jack murmured. â€Å"Oh, no.† Her eyes grew very wide. â€Å"This was extraordinary, even for her.† He pondered that. â€Å"I am not certain if I am sorry or relieved that I missed it.† â€Å"It was probably for the best that you were not present,† Grace replied, grimacing. â€Å"She was rather unkind.† He was about to say that it was difficult to imagine her any other way, but Grace suddenly brightened and said, â€Å"But do you know, I don't care!† She giggled then, the heady sound of someone who can't quite believe her good fortune. He smiled for her. It was infectious, her happiness. He did not intend that she should ever live apart from him, and he rather suspected that Thomas had not given her the cottage with the intention that she live there as Mrs. Jack Audley, but he understood her delight. For the first time in years, Grace had something of her own. â€Å"I'm sorry,† she said, but she could not quite hide her smile. â€Å"I should not be here. I didn't mean to wait up for you, but I was just so excited, and I wanted to tell you, because I knew you'd understand.† And as she stood there, her eyes shining up at him, his demons slipped away, one by one, until he was just a man, standing before the woman he loved. In this room, in this minute, it didn't matter that he was back in Ireland, that there were so many bloody reasons he should be running for the door and finding passage on the next ship to anywhere. In this room, in this minute, she was his everything. â€Å"Grace,† he said, and his hand rose to touch her cheek. She curled into it, and in that moment he knew he was lost. Whatever strength he'd thought he possessed, whatever will to do the right thing – It was gone. â€Å"Kiss me,† he whispered. Her eyes widened. â€Å"Kiss me.† She wanted to. He could see it in her eyes, feel it in the air around them. He leaned down, closer†¦but not enough so their lips touched. â€Å"Kiss me,† he said, one last time. She rose on her toes. She moved nothing else – her hands did not come up to caress him, she did not lean in, allowing her body to rest against his. She just rose on her toes until her lips brushed his. And then she backed away. â€Å"Jack?† she whispered. â€Å"I – † He almost said it. The words were right there, on his lips. I love you. But somehow he knew – he had no idea how, just that he did – if he said it then, if he gave voice to what he was certain she knew in her heart, it would scare her away. â€Å"Stay with me,† he whispered. He was through being noble. The current Duke of Wyndham could spend his life doing nothing but the right thing, but he could not be so unselfish. He kissed her hand. â€Å"I shouldn't,† she whispered. He kissed her other hand. â€Å"Oh, Jack.† He raised them both to his lips, holding them to his face, inhaling her scent. She looked at the door. â€Å"Stay with me,† he said again. And then he touched her chin, tipped her face gently up, and laid one soft kiss on her lips. â€Å"Stay.† He watched her face, saw the conflicted shadows in her eyes. Her lips trembled, and she turned away from him before she spoke. â€Å"If I – † Her voice was a whisper, shaky and unsure. â€Å"If I stay†¦Ã¢â‚¬  He touched her chin but did not guide her back to face him. He waited until she was ready, until she turned on her own. â€Å"If I stay†¦Ã¢â‚¬  She swallowed, and shut her eyes for a moment, as if summoning courage. â€Å"Can you†¦Is there a way you can make sure there is no baby?† For a moment he could not speak. Then he nodded, because yes, he could make sure there was no baby. He had spent his adult life making sure there would be no babies. But that had been with women he did not love, women he did not intend to adore and worship for the rest of their lives. This was Grace, and the idea of making a baby with her suddenly burned within him like a shining, magical dream. He could see them as a family, laughing, teasing. His own childhood had been like that – loud and boisterous, racing across fields with his cousins, fishing in streams and never catching a thing. Meals were never formal affairs; the icy gatherings at Belgrave had been as foreign to him as a Chinese banquet. He wanted all of that, and he wanted it with Grace. Only he hadn't realized just how much until this very moment. â€Å"Grace,† he said, holding her hands tightly. â€Å"It does not matter. I will marry you. I want to marry you.† She shook her head, the motion fast and jerky, almost frenzied. â€Å"No,† she said. â€Å"You can't. Not if you are the duke.† â€Å"I will.† And then, damn it all, he said it anyway. Some things were too big, too true, to keep inside. â€Å"I love you. I love you. I have never said that to another woman, and I never will. I love you, Grace Eversleigh, and I want to marry you.† She shut her eyes, looking almost pained. â€Å"Jack, you can't – â€Å" â€Å"I can. I do. I will.† â€Å"Jack – â€Å" â€Å"I am so tired of everyone telling me what I cannot do,† he burst out, letting go of her hands to stalk across the room. â€Å"Do you understand that I don't care? I don't care about the bloody dukedom and I certainly don't care about the dowager. I care about you, Grace. You.† â€Å"Jack,† she said again, â€Å"if you are the duke, you will be expected to marry a woman of high birth.† He swore under his breath. â€Å"You speak of yourself as if you were some dockside whore.† â€Å"No,† she said, trying to be patient, â€Å"I do not. I know exactly what I am. I am an impoverished young lady of impeccable but undistinguished birth. My father was a country gentleman, my mother the daughter of a country gentleman. We have no connections to the aristocracy. My mother was the second cousin to a baronet, but that is all.† He stared at her as if he hadn't heard a word she'd said. Or as if he'd heard but hadn't listened. No, Grace thought miserably. He'd listened but he hadn't heard. And sure enough, the first words from his mouth were: â€Å"I don't care.† â€Å"But everyone else does,† she persisted. â€Å"And if you are the duke, there will be enough of an uproar as it is. The scandal will be amazing.† â€Å"I don't care.† â€Å"But you should.† She stopped, forcing herself to take a breath before she continued. She wanted to grab her head and press her fingers into her scalp. She wanted to make fists until her fingernails bit into her skin. Anything – anything that would eat away at this awful frustration that was pulling her inside out. Why wasn't he listening? Why couldn't he hear that – â€Å"Grace – † he began. â€Å"No!† She cut him off, perhaps more loudly than she ought, but it had to be said: â€Å"You will need to tread carefully if you wish to be accepted into society. Your wife does not have to be Amelia, but it must be someone like her. With a similar background. Otherwise – â€Å" â€Å"Are you listening to me?† he cut in. He grasped her shoulders, holding her in place until she looked up at him, directly into his eyes. â€Å"I don't care about ‘otherwise.' I don't need for society to accept me. All I need is you, whether I live in a castle, a hovel, or anything in between.† â€Å"Jack†¦Ã¢â‚¬  she began. He was being naive. She loved him for it, nearly wept with joy that he adored her enough to think he could so thoroughly flout convention. But he didn't know. He had not lived at Belgrave for five years. He had not traveled to London with the dowager and seen firsthand what it meant to be a member of such a family. She had. She had watched, and she had observed, and she knew exactly what was expected of the Duke of Wyndham. His duchess could not be a nobody from the neighborhood. Not if he expected anyone to take him seriously. â€Å"Jack,† she said again, trying to find the right words. â€Å"I wish – â€Å" â€Å"Do you love me?† he cut in. She froze. He was staring at her with an intensity that left her breathless, immobile. â€Å"Do you love me?† â€Å"It doesn't – â€Å" â€Å"Do†¦you†¦love me?† She closed her eyes. She didn't want to say it. If she did, she would be lost. She would never be able to resist him – his words, his lips. If she gave him this, she would lose her last defense. â€Å"Grace,† he said, cradling her face in his hands. He leaned down and kissed her – once, with aching tenderness. â€Å"Do you love me?† â€Å"Yes,† she whispered. â€Å"Yes.† â€Å"Then that is all that matters.† She opened her lips to try one last time to talk sense into him, but he was already kissing her, his mouth hot and passionate on her own. â€Å"I love you,† he said, kissing her cheeks, her brows, her ears. â€Å"I love you.† â€Å"Jack,† she whispered, but her body had already begun to hum with desire. She wanted him. She wanted this. She did not know what tomorrow would bring, but at this moment she was willing to pretend that she did not care. As long as – â€Å"Promise me,† she said urgently, grasping his face firmly in her hands. â€Å"Please. Promise me that there will be no baby.† His eyes shuttered and flared, but finally he said, â€Å"I promise you I will try.† â€Å"You will try?† she echoed. Surely he would not lie about this. He would not ignore her plea and later pretend that he'd â€Å"tried.† â€Å"I will do what I know how to do. It is not completely foolproof.† She loosened her grip and showed her acquiescence by allowing her fingers to trail along his cheeks. â€Å"Thank you,† she whispered, leaning up for a kiss. â€Å"But I promise you this,† he said, sweeping her into his arms, â€Å"you will have our baby. I will marry you. No matter who I am, or what my name is, I will marry you.† But she no longer had the will to argue with him. Not now, not when he was carrying her to his bed. He laid her down atop the covers and stepped back, quickly undoing the top buttons of his shirt so he could pull it over his head. And then he was back, half beside her, half atop her, kissing her as if his life depended upon it. â€Å"My God,† he almost grunted, â€Å"this thing is ugly,† and Grace could not help but giggle as his fingers attempted to do their magic on her buttons. He let out a frustrated growl when they did not comply, and he actually grasped the two sides of her nightgown, clearly intending to wrench it apart and let the buttons fly where they might. â€Å"No, Jack, you can't!† She was laughing as she said it; she didn't know why it was so funny – surely de-flowerings were meant to be serious, life-altering affairs. But there was so much joy bubbling within her. It was difficult to keep it contained. Especially when he was trying so hard to complete such a simple task and failing so miserably. â€Å"Are you sure?† His face was almost comical in its frustration. â€Å"Because I am fairly certain that I do a service to all mankind by destroying this.† She tried not to laugh. â€Å"It's my only nightgown.† This, he appeared to find interesting. â€Å"Are you saying that if I tear it off, you will have to sleep naked for the duration of our journey?† She quickly moved his hand from her bodice. â€Å"Don't,† she warned him. â€Å"But it's so tempting.† â€Å"Jack†¦Ã¢â‚¬  He sat back on his heels, gazing down at her with a mixture of hunger and amusement that made her shiver. â€Å"Very well,† he said, â€Å"you do it.† She had been intending to do just that, but now, with him watching her so intently, his eyes heavy-lidded with desire, she felt almost frozen in place. How could she be so brazen as to strip before him? To peel her clothing from her body – to do it herself. There was a difference, she realized, in taking off her own clothing and allowing herself to be seduced. Slowly, fingers trembling, she reached for the top button of her nightgown. She couldn't see it; it was far too high, almost to her chin. But her fingers knew the motions, knew the buttons, and almost without thinking, she slipped one free. Jack sucked in his breath. â€Å"Another.† She obeyed. â€Å"Another.† And again. And again, until she reached the one that lay between her breasts. He reached down then, his large hands slowly spreading the two sides of her gown open. It did not reveal her to him; she'd not unbuttoned enough for that. But she felt the cool air on her skin, felt the soft tickle of his breath as he leaned down to place one kiss on the flat plane of her chest. â€Å"You are beautiful,† he whispered. And when his fingers moved this time to the buttons on her nightgown, he mastered them with no difficulty at all. He took her hand and gave it a gentle tug, indicating for her to sit up. She did, closing her eyes as the nightgown fell away. With her vision dark, she felt more keenly, and the fabric – nothing but a plain, serviceable cotton – raised shivers of sensation as it slid along her skin. Or maybe it was just that she knew he was looking at her. Was this what it had felt like for that woman? The one in the painting? She must have been a woman of some experience by the time she'd posed for Monsieur Boucher, but surely there had to be a first time for her, as well. Had she, too, closed her eyes so she could feel a man's gaze upon her body? She felt Jack's hand touching her face, the tips of his fingers softly trailing along the line of her neck to the hollow of her shoulder. He paused there, but only for a moment, and Grace sucked in her breath, waiting for the intimacy that awaited her. â€Å"Why are your eyes closed?† he murmured. â€Å"I don't know.† â€Å"Are you afraid?† â€Å"No.† She waited. She gasped. She even jumped, just a little, when his fingers slid along the outer curve of her breast. She felt herself arching. It was strange. She'd never thought about this, never even wondered what it might be like to have a man's hands stroking her in this way, but now that the moment was upon her, she knew exactly what she wanted him to do. She wanted to feel him cupping her, holding her entirely in his palm. She wanted to feel his hand brushing against her nipples. She wanted him to touch her†¦dear God, she wanted him to touch her so badly, and it was spreading. It had moved from her breasts to her belly, to the hidden spot between her legs. She felt hot, and tingly, and searingly hungry. Hungry†¦ there. It was without a doubt the strangest and most compelling sensation. She could not ignore it. She didn't want to ignore it. She wanted to feed it, indulge it, let him teach her how to quench it. â€Å"Jack,† she moaned, and his hands moved until he was cradling both of her breasts. And then he kissed her. Her eyes flew open. His mouth was on her now, on the very tip, and she actually clasped one of her hands to her mouth, lest she scream with the pleasure of it. She hadn't imagined†¦She'd thought she'd known what she wanted, but this†¦ She hadn't known. She clutched at his head, using him for support. It was torture, and it was bliss, and she was barely able to breathe by the time he dragged his mouth back up to hers. â€Å"Grace†¦Grace†¦Ã¢â‚¬  he murmured, over and over, his voice sliding into her skin. It felt as if he was kissing her everywhere, and maybe he was – one moment it was her mouth, and next her ear, and then her neck. And his hands – they were wicked. And relentless. He never stopped moving, never stopped touching her. His hands were on her shoulders, and then her hips, and then one of them started sliding down her leg, tugging at her nightgown until it slipped off her entirely. She should have been embarrassed. She should have felt awkward. But she didn't. Not with him. Not when he was gazing down at her with such love and devotion. He loved her. He'd said he did, and she believed him, but now she felt it. The heat, the warmth. It shone from his eyes. And she understood now how a woman might find herself ruined. How could anyone resist this? How could she resist him? He stood then, breathing hard, working at the fastenings of his breeches with frantic fingers. His chest was already bare, and all she could think was – He's beautiful. How could a man be so beautiful? He'd not led a life of leisure; this, she could see. His body was lean and firm, his skin marred here and there with scars and calluses. â€Å"Were you shot?† she asked, her eyes falling on a puckered scar on his upper arm. He looked down, even as he pushed off his breeches. â€Å"A French sniper,† he confirmed. He smiled, rather lopsidedly. â€Å"I am fortunate he was not better at his craft.† It should not have been so amusing. But the statement was so†¦ him. So matter of fact, so understated and dry. She smiled in return. â€Å"I almost died, too.† â€Å"Really?† â€Å"Fever.† He winced. â€Å"I hate fevers.† She nodded, pinching the corners of her lips to keep from smiling. â€Å"I should hate to be shot.† He looked back at her, his eyes alight with humor. â€Å"I don't recommend it.† And then she did laugh, because it was all so ludicrous. He was standing there naked, for heaven's sake, clearly aroused, and they were discussing the relative unpleasantness of gunshot wounds and fevers. He crawled onto the bed, looming over her with a predatory expression. â€Å"Grace?† he murmured. She looked up at him and nearly melted. â€Å"Yes?† He smiled wolfishly. â€Å"I'm all better now.† And with that, there were no more words. When he kissed her this time, it was with an intensity and fervor that she knew would carry them through to completion. She felt it, too – this desire, this relentless need – and when he nudged his leg between hers, she opened to him immediately, without reservation, without fear. How long he kissed her, she couldn't possibly have known. It seemed like nothing. It seemed like forever. It felt like she had been born for this moment, with this man. As if somehow, on the day of her birth, this had all been preordained – on October the twenty-eighth, the year of our Lord 1819, she would be in Room 14 of the Queen's Arms Inn, and she would give herself to this man, John Augustus Cavendish-Audley. Nothing else could possibly have happened. This was how it was meant to be. She kissed him back with equal abandon, clutching at his shoulders, his arms, anywhere she could gain purchase. And then, just when she thought she could handle no more, his hand slipped between her legs. His touch was gentle, but still, she thought she might scream from the shock and wonder of it. â€Å"Jack,† she gasped, not because she wanted him to stop, but because there was no way she could remain silent amidst the onslaught of sensation brought forth by that simple touch. He tickled and teased, and she panted and writhed. And then she realized that he was no longer just touching her, he was inside of her, his fingers exploring her in a manner so intimate it left her breathless. She could feel herself clench around him, her muscles begging for more. She didn't know what to do, didn't know anything except that she wanted him. She wanted him, and something only he could give her. He shifted position, and his fingers moved away. His body lifted off hers, and when Grace looked up at him, he seemed to be straining against some irresistible force. He was holding himself above her, supporting himself on his forearms. Her tongue moved, preparing to say his name, but just then she felt him at her entrance, pressing gently forward. Their eyes met. â€Å"Shhh,† he murmured. â€Å"Just wait†¦I promise†¦Ã¢â‚¬  â€Å"I'm not scared,† she whispered. His mouth moved into a lopsided smile. â€Å"I am.† She wanted to ask what he meant and why he was smiling, but he began to move forward, opening her, stretching her, and it was the strangest, most amazing thing, but he was inside of her. That one person could enter another seemed the most spectacular thing. They were joined. She could not think of any other way to describe it. â€Å"Am I hurting you?† he whispered. She shook her head. â€Å"I like it,† she whispered back. He groaned at that, and thrust forward, the sudden motion sending a wave of sensation and pressure through her. She gasped his name and grabbed his shoulders, and then she found herself in an ancient rhythm, moving with him, as one. Moving, and pulsing, and straining, and then – She shattered. She arched, she moaned, she nearly screamed. And when she finally came down and found the strength to breathe, she could not imagine how she could possibly still be alive. Surely a body could not feel that way and live to repeat it. Then, abruptly, he pulled out of her and turned away, grunting and groaning his own satisfaction. She touched his shoulder, feeling the spasms of his body. And when he cried out, she did not just hear it. She felt it, through his skin, through her body. To her heart. For a few moments he did not move, just lay there, his breathing slowly returning to normal. But then he rolled back over and gathered her into his arms. He whispered her name and kissed the top of her head. And then he did it again. And again. And when she finally fell asleep, that was what she heard in her dreams. Jack's voice. Soft, whispering her name. Jack knew the exact moment she fell asleep. He was not sure what it was – her breathing had already softened to a slow, even sigh, and her body had long since stilled. But when she fell asleep, he knew. He kissed her one last time, on her temple. And as he looked down at her peaceful face, he whispered, â€Å"I will marry you, Grace Eversleigh.† It did not matter who he was. He would not let her go.