: This paper considers whether a physician is criminally liable for administering a dose of painkillers that hastens a patient's death. The common wisdom is that a version of the doctrine of double effect legally protects the physician. That is, a physician is supposedly acting lawfully so long as the physician's primary purpose is to relieve suffering. This paper suggests that the criminal liability issue is more complex than that. Physician culpability can be based on recklessness, and recklessness hinges on (...) whether a physician has taken an unjustifiable risk of hastening death. The authors identify three conditions of justifiability. Their analysis helps to explain the distinction between euthanasia, which is legally banned, and the use of risky analgesics, which is permitted in limited circumstances. (shrink)

McGovern, Kevin Physician and ethicist Professor Paul Komesaroff and former judge Stephen Charles QC have proposed legislation to protect health professionals from the risk of criminal prosecution when in appropriate circumstances they provide pain relief which may shorten a patient's life. For this protection, they recommend that four conditions must all be satisfied: the patient has a terminal illness; the intention is to relieve pain and suffering; the treatment is reasonable in terms of current medical practice; and (...) the treatment is necessary to relieve pain and suffering. This article examines their proposal, supports it, and joins in the call for Victorian legislation which achieves this purpose. (shrink)

The Helsinki Declaration is the universally accepted standard for ethical behavior in research involving human subjects. The Declaration calls for research studies to compare new therapies to the best current therapies. Despite this standard, multiple studies of pain relief interventions in newborns have recruited placebo controls instead of active controls using the best current therapy. These studies are evaluated using the standards required by the Helsinki Declaration, and the reasons for the ethical shortcomings of these studies are explored.

In lieu of an abstract, here is a brief excerpt of the content:A New Look at Animal-to-Human Organ TransplantationCharles R. McCarthy (bio)The acute shortage of organs available for transplantation into human beings combined with a new scientific understanding of the immune systems of both humans and animals make it probable that animal-to-human solid organ transplants (xenografts) may soon be attempted at a frequency rate unknown in the past. 1 Optimism about successful animal-to-human organ transplantation is greater than at any previous (...) time. The creation of a reliable supply of animal organs appears to be technically feasible. At least five major transplant centers in the United States are currently considering plans to pursue xenotransplantation. Although, at the time of this writing, no federal guidelines prohibit animal-to-human organ transplantation, the institutions considering such programs are awaiting deliberations on the subject by the Institute of Medicine (IOM), the Food and Drug Administration (FDA), and the Department of Health and Human Services (DHHS).The demand for organs suitable for transplantation into human beings greatly exceeds the supply. According to the United Network for Organ Sharing (UNOS 1996a), approximately 44,000 patients in the United states awaited organ transplantation at the end of 1995. In 1994, more than 3,000 patients died while on the transplant waiting list, and the demand for transplantable organs increases annually (UNOS 1996b). The figures do not include the hundreds or perhaps thousands of patients who could profit from a transplant, but who do not meet the requirements of the UNOS waiting list. Even if efforts to persuade persons to donate organs are redoubled, and even if the consent to donate organs should become a legal presumption, there is little prospect of developing a sufficient supply of transplantable human organs to meet the growing demand.As technical and biological barriers to successful animal-to-human xenografts are lowered, the prospect of raising dedicated colonies of animals, genetically altered to reduce the chances that human hosts will reject organs derived from them, is being seriously discussed. 2 Such colonies do not exist at the present time. [End Page 183] However, if new techniques for animal-to-human transplantation prove successful, it is likely that animal colonies will be established to provide a ready and predictable supply of organs for transplantation to humans. Some believe that commercial investment in colonies of purpose-bred animals to serve as a source of transplantable organs is close at hand (Leventhal 1994).New drugs and new combinations of existing drugs have improved the chances of successful medical outcomes for patients who receive solid organ transplants. It is now recognized that serial application of immunosuppressive drugs can reduce the likelihood of both short- and long-term organ rejection (Makowka 1994). Improved understanding of both human and animal immune systems, insights into histocompatibility, new agents to control graft-versus-host disease, animal breeding programs for the production of transgenic animals, and improved surgical techniques have opened, as never before, the possibility of successful transfer of organs from animals to humans. Some rate the chances of good patient outcomes (usually measured in terms of time of patient survival) as high, others make more conservative predictions, but virtually all experts believe that the chances for successful human patient outcomes resulting from xenotransplantation are improved. Because many patients face immanent death unless their organs can be replaced, there can be little doubt that many humans will readily consent to xenotransplantation.History Suggests CautionDespite the advances in immunosuppression, the frequency of failure in past animal-to-human xenograft attempts should temper the optimism of the transplant community. To date, all efforts to prolong human life by implanting solid organs from animals into human recipients have failed. The first attempts at animal-to-human xenotransplantation early in the twentieth century resulted in the early death of all recipients (Neuhof 1923). More sophisticated efforts at xenotransplantation occurred in the late 1960s and early 1970s, a period when anti-rejection drugs began to make allografts more feasible. Although one human recipient of a xenograft survived for nine months (with poor quality of life), most patients died within a matter of minutes, hours, or a few days following the transplantation of organs from chimpanzees or baboons (Starzl... (shrink)

The Helsinki Declaration, first published in 1964, is the universally accepted standard for ethical behavior in research involving human subjects. The Declaration was formulated in response to the abuses of human subjects by the scientists in Nazi Germany and to update the Nuremberg Code. Amended in 1975, 1983, 1989, 1996, and 2000, the Declaration provides the foundation for the United States federal regulations for research involving human subjects.To conform to standards developed in the Declaration, a researcher must fulfill the following: (...) respect the autonomy of the individual; promote and safeguard the individual’s health; provide informed consent without coercion; take special measures with vulnerable populations; compare new therapies to the best current therapies; have a thorough scientific knowledge of the subject; assess risk versus benefit of the intervention; perform studies that will ultimately benefit the population involved in the research; accurately report their findings; and fully disclose ethical concerns in their research protocols. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt (...) with pain medications that might have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

The problem is pain. Patients and their families tell the story:He is your son. You love him. You want to help him in every way you can, but when he is in that kind of pain, you are helpless in a sense. Im his daddy. It was-what was I supposed to do for him? I felt, you know, helpless.It terrifies you. You want to run away from it. Pain is something you wish would kill you but does (...) not. Agony results from the pain that does not have the decency to knock you out.[W]e had a good family, but how much can you watch? How much suffering can you watch from your child, your 7-year-old child, and still keep your mind?I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life. (shrink)

The problem is pain. Patients and their families tell the story:He is your son. You love him. You want to help him in every way you can, but when he is in that kind of pain, you are helpless in a sense. Im his daddy. It was-what was I supposed to do for him? I felt, you know, helpless.It terrifies you. You want to run away from it. Pain is something you wish would kill you but does (...) not. Agony results from the pain that does not have the decency to knock you out.[W]e had a good family, but how much can you watch? How much suffering can you watch from your child, your 7-year-old child, and still keep your mind?I am a forty-six-year-old registered nurse who specializes in oncology care and education. I am also a patient who suffers from chronic nonmalignant pain, and this malady has been the most frightening, the most humiliating, and the most difficult ordeal of my life. (shrink)

This paper is another of the papers presented at a conference on Pain organised under the auspices of the London Medical Group. Mark Swerdlow deals with the work of pain relief clinics and explores their value. He gives the background as to what these clinics are, describes who is treated, how they are staffed and finally offers his opinion as to their effectiveness.

This paper examines pain and pain relief in the Caribbean, where pain is widely perceived as an unavoidable part of life, and where unnecessary suffering results from untreated and under treated pain. Barriers to pain relief in the Caribbean include patient and family attitudes, inadequate knowledge among health professionals and unduly restrictive regulations on the medical use of opioids. Similar barriers exist all over the world. This paper urges medical, nursing and public health (...) professionals, and educators to examine attitudes towards pain and pain relief and to work towards making effective pain relief and palliation more accessible. It recommends that i) health professionals and officials be better educated about pain, palliation and opioids, ii) regulatory restrictions be updated in light of clinical and scientific evidence, iii) opioid procurement policies be adjusted to facilitate increased medical use, iv) medical charts and records be modified to routinely elicit and document patients levels of pain, and v) educational campaigns be developed to inform the public that moderate and severe pain can be safely relieved at the end of life and other stages of life. The professional, respectful, and beneficent response to patients in pain is to provide rapid and aggressive pain relief or to urgently consult a pain or palliative specialist. When a health system hinders such efforts the ethical response is to identify, facilitate and advocate for overcoming barriers to improvement. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Criminal Law, Pain Relief, and Physician Aid in DyingFaye Girsh, Ed.D., Executive DirectorMadam:The article by Cantor and Thomas on “Pain Relief, Acceleration of Death, and Criminal Law” (KIEJ, June 1996) was a tortured attempt to develop criteria for the humane and compassionate physician who tries to serve the needs of a patient in unremitting pain. There are three areas that merit comment.The authors dealt (...) with pain medications that might have the undesirable side effect of causing death. They did not mention tolerance, which usually occurs in a patient with chronic pain and which would require exceedingly high doses to be effective. They did not mention barbiturates, which are preferable to opiates in causing death and which are used increasingly by compassionate physicians to answer the pleas of their suffering patients, but for which there is no excuse about alleviating pain. Would the criminal law just call the prescription of a lethal dose of barbiturates a reckless act and require conviction? Fortunately, juries, as the authors point out, do not balance these formulas on the head of a pin. When they see the circumstances under which these doctors do help their patients, they choose to nullify the law and would ignore the suggestions made in this article.The authors refer to the “consent” of the patient. They do not mention that these doctors are operating with more than consent; they are administering these medications because suffering patients are begging them to put them out of their pain and the indignities of the dying process. The article discusses the process as though it were the same as consent to elective surgery. These patients—with AIDS, cancer, and hopeless neurological degeneration—are not simply agreeing to a procedure; they are desperately seeking a way out. If the criminal law were to develop criteria for physician aid in dying, certainly one of them should be the active, witnessed, repeated request of such a patient for a certain, quick, painless, gentle death.The third point is that physicians do not face prosecution when administering no treatment to a patient whose life could be saved with treatment but who chooses not to receive it. This has been upheld by the U.S. Supreme Court; no criteria for suffering, alternatives, terminality, justifiability, or unbearability are required. The doctor can stand by while the patient dies what may be a protracted, difficult death, but it is within the law. What matters in this situation is the decision of the patient to refuse treatment, and that is absolute. How ironic that the patient who cannot refuse treatment must, with his or her doctor, jump through all these hoops to achieve a peaceful death.One worries that the physician who must balance the risk of “risky pain relief” against the accusation of recklessness will err in the direction of allowing [End Page 103] the patient to bear the pain rather than help with a dose of analgesics that might be considered beyond the stipulated “risk.”Why don’t we just be honest about it? Allow dying or hopelessly ill patients to make the decision about what they want by passing a carefully defined law allowing euthanasia rather than balancing the risk and trying to determine the “purpose” of the physician’s ministrations. We protect some patients from themselves while allowing others almost complete autonomy to make the choice of ending their lives. The authors were right in saying that proponents of rational laws consider this sheer hypocrisy.Faye Girsh, Executive DirectorHemlock Society U.S.A. Denver, COFaye Girsh misconceives our article’s objective as an “attempt to develop criteria” for the humane physician. Our goal in writing the paper was to analyze the current criminal law framework in the hope of sharpening debate and engendering normative critiques. We readily acknowledge tensions in the current legal framework and would support changes in that framework.Copyright © 1997 The Johns Hopkins University Press... (shrink)

This paper examines pain and pain relief in the Caribbean, where pain is widely perceived as an unavoidable part of life, and where unnecessary suffering results from untreated and under treated pain. Barriers to pain relief in the Caribbean include patient and family attitudes, inadequate knowledge among health professionals and unduly restrictive regulations on the medical use of opioids. Similar barriers exist all over the world. This paper urges medical, nursing and public health (...) professionals, and educators to examine attitudes towards pain and pain relief and to work towards making effective pain relief and palliation more accessible. It recommends that i) health professionals and officials be better educated about pain, palliation and opioids, ii) regulatory restrictions be updated in light of clinical and scientific evidence, iii) opioid procurement policies be adjusted to facilitate increased medical use, iv) medical charts and records be modified to routinely elicit and document patients levels of pain, and v) educational campaigns be developed to inform the public that moderate and severe pain can be safely relieved at the end of life and other stages of life. The professional, respectful, and beneficent response to patients in pain is to provide rapid and aggressive pain relief or to urgently consult a pain or palliative specialist. When a health system hinders such efforts the ethical response is to identify, facilitate and advocate for overcoming barriers to improvement. (shrink)

Background: There are intriguing and challenging ethical dilemmas in the practice of palliative care in a traditional developing society.Objective: To review the different ethical issues involved in cancer and palliative care in developing countries, with special reference to India.Methods: Published literature on pain relief and palliative care in the developing countries was reviewed to identify ethical issues and dilemmas related to these, and ways in which ethical principles could be observed in delivery of palliative care in such countries (...) are discussed.Results: The literature review revealed a number of ethical dilemmas and challenges that professionals, cancer patients and their families encountered during palliative care. It was noted that patients’ preferences and decisions are influenced by family members. Dilemmas leave the professionals and families confused about how ethical their actions have been. Specific ethical issues were noted in relation to the availability and use of oral morphine for pain relief, spiritual care, lack of adequate palliative care services, and palliative care education.Conclusions: The four principles of ethics posed difficulties in understanding the complex ethical issues in a developing country with a traditional background. Ethical issues need to be handled delicately and sensitively in palliative care settings, within the framework of the traditions and culture of the society and financial constraints. The possible role of ethics committees in palliative care settings to help decision-making needs to be studied and discussed. (shrink)

Kamm’s response to Tse’s comments deals with the following issues (among others): (1)the relevance of empirical facts to moral arguments about physician assisted suicide (PAS); (2) the moral relevance of the difference between foreseen risk and certainty of death as well as the difference between certain death and immediate death; (3) whether intention matters to the permissibility of giving morphine for pain relief (MPR) and whether objective factors can be the same whether one intends MPR or death (...) in giving morphine; (4) the relevance of the permissibility of MPR or terminating life-saving treatment for the permissibility of PAS. (shrink)

BackgroundEnhancement involves the use of biomedical technologies to improve human capacities beyond therapeutic purposes. It has been well documented that enhancement is sometimes difficult to distinguish from treatment. As a subtype of enhancement, neuroenhancement aims to improve one’s cognitive or emotional capacities.Main bodyThis article proposes that the notion of neuroenhancement deserves special attention among enhancements in general, because apart from the notion of treatment, it also overlaps with other concepts such as prevention, pain relief, and pleasure seeking. Regarding (...) prevention, patients’ mental endurance can be enhanced when a patient is prescribed a selective serotonin reuptake inhibitor for the purpose of preventing the relapse of depression following a stressful situation. As for pain relief, psychiatrists use medication to alleviate distress in patients who experience various types of anxiety; the alleviation of distress is equal to psychological pain relief, but is also an enhancement of the patient’s temperamental traits. Regarding pleasure seeking, insidious transition exists between neuroenhancement and pleasure seeking when using psychotropic drugs. It is well known that people use psychostimulants for recreational purposes and to induce overconfidence in one’s performance. The polysemy of psychotropics derives from their effects on human sensibility. Therefore, when using psychotropic agents, psychiatrists should pay close attention to what the agent is used for on each patient in each situation, and explicitly share the continuity and overlap in the purpose of prescribing a medication with the patients to make a better clinical decision.ConclusionsThe notion of neuroenhancement overlaps not only with the notion of treatment, but also with other concepts of prevention, pain relief, and pleasure seeking. The continuity between those concepts makes the issues concerning the prescription of psychotropic drugs subtler. Psychiatrists should explicitly share the continuity with the patients to make a better clinical decision. (shrink)

Morphine is usually preferred to treat moderate or severe pain for late‐stage cancer patients. However, medically unindicated or excessive morphine use may result in respiratory depression and death. This essay contends that a clear distinction between relieving pain and performing active euthanasia in the use of morphine should be made in practice. By drawing on Confucian virtue resources, we construct a Confucian conception of human dignity, including both intrinsic and acquired dignity, to analyze the circumstances (...) of morphine use in current China. We argue that not only the Confucian view of intrinsic dignity but also that of acquired dignity would not support morphine euthanasia. (shrink)

The prelims comprise: Conceptual Issues Arguments concerning AS, E, or TT Doctors and Ending Life Advance Directives Notes References.

... We will turn our attention to the current state of pain relief technology and the ethical questions surrounding the use of advanced technology, otherwise referred to as "high-tech," pain relief. It is obvious that pain may decrease the quality of life for cancer patients. The availability of long-acting narcotics, such as MS Contin or methadone, affords cancer patients long-duration pain relief at minimal cost. The use of adjuvant medications may also be important. (...) Clinical examples of the effective use of adjuvant medications include the addition of a nonsteroidal, anti-inflammatory agent to help patients cope with bone pain and the use of a serotonin blocking agent to reduce the transmission of pain impulses in the spinal cord. Only a small percentage of patients are good candidates for high-tech delivery systems for narcotic administration. In our pain management clinic, all patients are initially placed on oral medications. When the side effects of oral medications become excessive, or the patient becomes unable to take oral medications, high-tech modalities are considered for use. (shrink)

Abstract In order to avoid the occurrence of boar taint, castration of piglets without pain relief is a common practice in pork production. Due to increasing animal welfare concerns, the practice will be banned in organic agriculture from 2012 and alternative methods will have to be implemented. An important factor for the successful implementation of such alternatives is consumers’ acceptance of the methods, as consumers’ daily buying decisions are crucial to the further development of the organic pork sector. (...) Thus, this paper explores organic consumers’ attitudes towards piglet castration without pain relief and three alternative methods and examines which aspects of these alternatives are important to consumers of organic products. The analysis of nine focus group discussions in Germany conducted in fall 2009 and involving a total of 89 participants, shows that castration without pain relief in organic farming was unacceptable for participants. Animal welfare, food safety, taste, and costs were principal aspects that participants used to assess the three alternatives. Participants had mainly favorable attitudes towards castration with anesthesia and analgesia. Although participants had some concerns regarding the fattening of boars (taste), there was openness towards this alternative due to its perceived naturalness. Immunocastration was seen quite critically because participants feared that this alternative might lead to (hormone) residues in meat. Overall, the results suggest that fattening of boars and castration with anesthesia and analgesia could be acceptable alternatives to consumers of organic pork. Content Type Journal Article Category Articles Pages 1-20 DOI 10.1007/s10806-011-9350-2 Authors Astrid Heid, Department of Agricultural and Food Marketing, University of Kassel, Steinstraße 19, 37213 Witzenhausen, Germany Ulrich Hamm, Department of Agricultural and Food Marketing, University of Kassel, Steinstraße 19, 37213 Witzenhausen, Germany Journal Journal of Agricultural and Environmental Ethics Online ISSN 1573-322X Print ISSN 1187-7863. (shrink)

Scholarship has intrinsic value, of course; but when good scholarship can stimulate change for the better in an area as fundamental to human dignity as health care and the relief of suffering, there is a special satisfaction. This has been our experience since 1996, when the first of now four special issues of this journal focused on legal, regulatory, ethical, professional, and financial issues in medical treatment for pain.With the generous and steadfast support of the Mayday Fund, the (...) American Society of Law, Medicine & Ethics has generated a significant body of scholarship published in the Journal of Law, Medicine & Ethics. This research has proven absolutely essential in changing public policy to support better care for those who suffer pain.Over these years, the Mayday Project at ASLME has tackled many of the real and perceived barriers to effective pain relief. In pain management, both real and perceived obstacles can have a powerful negative effect. (shrink)

Scholarship has intrinsic value, of course; but when good scholarship can stimulate change for the better in an area as fundamental to human dignity as health care and the relief of suffering, there is a special satisfaction. This has been our experience since 1996, when the first of now four special issues of this journal focused on legal, regulatory, ethical, professional, and financial issues in medical treatment for pain.With the generous and steadfast support of the Mayday Fund, the (...) American Society of Law, Medicine & Ethics has generated a significant body of scholarship published in the Journal of Law, Medicine & Ethics. This research has proven absolutely essential in changing public policy to support better care for those who suffer pain.Over these years, the Mayday Project at ASLME has tackled many of the real and perceived barriers to effective pain relief. In pain management, both real and perceived obstacles can have a powerful negative effect. (shrink)

As medical technology becomes more sophisticate the ability to manipulate nature and manage disease forces the dilemma of when can becomes ought. Indeed, most bioethical discourse is framed in terms of balancing the values and interests and the benefits and burdens that inform principled decisions about how, when, and whether interventions should occur. Yet, despite advances in science and technology, one caregiver mandate remains as constant and compelling as it was for the earliest shaman—the relief of pain. Even (...) when cure is impossible, the physician's duty of care includes palliation. Moreover, the centrality of this obligation is both unquestioned and universal, transcending time and cultural boundaries.Although universally acknowledged, pain is a complex phenomenon for both the patient and the caregiver, influenced as much by personal values and cultural traditions as by physiological injury and disease. (shrink)

Dr Anne Merriman is the founder of Hospice Africa and Hospice Africa Uganda. She is presently Director of Policy and International Programmes. Here she tells the story of how HAU was founded. Dr Richard Harding is an academic researcher working on palliative care in Sub-Saharan Africa. This paper described Dr Merriman's experience in pioneering palliative care provision. In particular it examines the steps to achieving wider availability of opioids for pain management for those with far advanced disease. Hospice Africa (...) Uganda has been a model facility in achieving high quality clinical care embedded in a strategy of advocacy and education, using a multifaceted approach that has addressed logistical, policy and legislative barriers. Until 1990 control of severe pain in Sub-Saharan Africa was non-existent except in Zimbabwe and S Africa. Oral affordable morphine was brought to Kenya through Nairobi Hospice that year, and to Uganda through Hospice Africa Uganda in 1993. This paper offers an example of a highly effective and cost efficient model of care that has transformed the ability to humanely manage the problems of those with terminal illness, and to offer a culturally appropriate. (shrink)

We can call Thomas Paine-eminent Founder, verbal bomb-thrower, Deist, revolutionary, and rationalist-the spark of the American Revolution. In his influential pamphlets, Paine codified both colonial outrage and the intellectual justification for independence, arguing consistently and convincingly for Enlightenment values and the power of the people. He was a master of political rhetoric, from the sarcastic insult to the diplomatic aperçu. Today, we are living in times that, as Paine said, try men's souls. Whatever your politics, if you're seeking a new (...) Paine-with rhetoric to ignite social and political transformations-where better to start than at the source? This is a work that provides quotes from Thomas Paine's writings. (shrink)

This paper argues that moral thinking is an essential management capability which strengthens organizations and contributes to theirperformance in the marketplace. The paper explains what moral thinking is, and addresses the most common reasons for considering it inappropriate or irrelevant to managerial practice. The argument provides a compelling rationale for the corporate ethics initiatives undertaken in recent years.

This paper examines the inferential framework employed by Palaeolithic cognitive archaeologists, using the work of Wynn and Coolidge as a case study. I begin by distinguishing minimal-capacity inferences from cognitive-transition inferences. Minimal-capacity inferences attempt to infer the cognitive prerequisites required for the production of a technology. Cognitive-transition inferences use transitions in technological complexity to infer transitions in cognitive evolution. I argue that cognitive archaeology has typically used cognitive-transition inferences informed by minimal-capacity inferences, and that this reflects a tendency to favour (...) cognitive explanations for transitions in technological complexity. Next I look at two alternative explanations for transitions in technological complexity: the demographic hypothesis and the environmental hypothesis. This presents us with a dilemma: either reject these alternative explanations or reject traditional cognitive-transition inferences. Rejecting the former is unappealing as there is strong evidence that demographic and environmental influences play some causal role in technological transitions. Rejecting the latter is unappealing as it means abandoning the idea that technological transitions tell us anything about transitions in hominin cognitive evolution. I finish by briefly outlining some conceptual tools from the philosophical literature that might help shed some light on the problem. (shrink)

Acclaimed historian Peter LInebaugh provides an original examination of Paine's works and legacy in the introduction to these two influential arguments for liberty of political thought--including Common Sense, which inspired the American Revolution, and The Rights of Man, a defense of the French Revolution. Original.

The impassioned democratic voice of the Age of Revolution, Paine possessed a gift for stating complex ideas in concise language. This accessible collection of highlights from the social and political philosopher's best-known works includes lengthy selections from Common Sense , The American Crisis , The Rights of Man , and The Age of Reason.

Thomas Paine is one of history's most renowned thinkers and was indispensible to both the American and French revolutions. The three works included, Common Sense, The Rights of Man, and The Age of Reason, are among his most famous publications. Paine is probably best known for his hugely popular pamphlet, Common Sense, which swayed public opinion in favor of American independence from England. The Rights of Man and The Age of Reason further advocated for universal human rights, a republican instead (...) of monarchical government, and truth and reason in politics. The works of this moral visionary, whose ideas are as relevant today as ever, are now available as part of the Word Cloud Classics series, providing a stylish and affordable addition to any library. (shrink)

Collects several works covering a variety of political subjects, including independence from Britain for the American colonies, service in the Continental army, ...

Physician concern about regulatory scrutiny as a barrier to appropriate prescribing for pain management has been identified and studied. A 1991 Pain Research Group survey demonstrated a need to provide updated information about opioids and pain management to state medical board members. Indeed, a national survey even showed a need to provide more education about pain management to oncology Physicians. Two approaches for responding to these concerns have been undertaken in several states by the state medical (...) boards and the pain management community: the development and adoption of administrative policies designed to bring disciplinary standards in line with clinical practice; and the creation of education programs for state medical board members and staffs. Each can have a substantial impact on removing real and perceived regulatory barriers to effective pain relief. (shrink)

Physician concern about regulatory scrutiny as a barrier to appropriate prescribing for pain management has been identified and studied. A 1991 Pain Research Group survey demonstrated a need to provide updated information about opioids and pain management to state medical board members. Indeed, a national survey even showed a need to provide more education about pain management to oncology Physicians. Two approaches for responding to these concerns have been undertaken in several states by the state medical (...) boards and the pain management community: the development and adoption of administrative policies designed to bring disciplinary standards in line with clinical practice; and the creation of education programs for state medical board members and staffs. Each can have a substantial impact on removing real and perceived regulatory barriers to effective pain relief. (shrink)

Pains are unpleasant, universally unpleasant. What seems trivially true has been rejected by various pain scientists because of several phenomena which allegedly show that there can be pain which is not unpleasant. This rejection is partly based on the ambiguity of ‘pain unpleasantness’ which can be avoided by distinguishing between primary and secondary pain affect. As for the alleged counterexamples to the above, I will argue that experiences of episodic analgesia as well as the ‘pain’ (...) experiences of some lobotomized and morphine patients should not be construed as cases in which pain and unpleasantness come apart, but rather as cases in which nociceptive activity and pain dissociate. Regarding the notorious case of pain asymbolia, I will demonstrate that the behaviour of patients with this syndrome suggests that they do feel pain, and that their pain sensations are unpleasant, but much less unpleasant than the pains normal people would have if exposed to the same noxious stimuli. Adopting such an account of these phenomena allows us to retain the widely accepted IASP definition of pain, and thus avoids the issue of integrating non-unpleasant pains into a plausible definition of pain. (shrink)

The ethical concerns of Japanese nurses are compared with those of previously described nurses from the USA. Patient comfort was a primary concern of nurses from both countries. Participants described an ethical imperative to provide adequate pain medication for patients and prevent unnecessary and uncomfortable invasive tests and procedures, especially at the end of life as the focus changed from ‘cure’ to ‘care’. The notion of regard for personhood varied, based on the communication styles and definition of the self (...) inherent in the different cultures of the nurses. A common meaning centred around knowing patients as persons, listening to their needs and preferences, supporting their everyday choices through advocacy, and maintaining their dignity. Despite background cultural differences, there are common ethical concerns between nurses in Japan and the USA. This article invites readers to reflect on everyday nursing practices that exemplify ethical expertise, and the significance of this expertise in uncovering and articulating nursing ethics across cultures. (shrink)

This paper focuses on the possibility of conceiving a form of ontological nihilism, starting from D. M. Armstrong’s combinatorialism. This possibility has been suggested by Efird and Stoneham, by means of proposing an alternative strategy to the ‘subtraction argument’. They claim that it is possible to sustain such nihilism trough the concepts of construction and totality state of affairs. However, this hypothesis will require the acceptance of non-instanciated universals, that is, platonic universals. Yet this is opposite to requirements that are (...) basic for a combinatorial theory, which should uphold that universals exist only in their instantiations. Then, the assumption of platonic universals results in high costs for a combinatorial naturalism, according to which only exists what is located in space and time. (shrink)

This paper focuses on the possibility of conceiving a form of ontological nihilism, starting from D. M. Armstrong’s combinatorialism. This possibility has been suggested by Efird and Stoneham, by means of proposing an alternative strategy to the ‘subtraction argument’. They claim that it is possible to sustain such nihilism trough the concepts of construction and totality state of affairs. However, this hypothesis will require the acceptance of non-instanciated universals, that is, platonic universals. Yet this is opposite to requirements that are (...) basic for a combinatorial theory, which should uphold that universals exist only in their instantiations. Then, the assumption of platonic universals results in high costs for a combinatorial naturalism, according to which only exists what is located in space and time. (shrink)

How do technologies that are too complex for any one individual to produce arise and persist in human populations? Contra prevailing views focusing on social learning, Osiurak and Reynaud argue that the primary driver for cumulative technological culture is our ability for technical reasoning. Whilst sympathetic to their overall position, we argue that two specific aspects of their account are implausible: first, that technical reasoning is unique to humans; and second, that technical reasoning is a necessary condition for the production (...) of cumulative technological culture. We then present our own view, which keeps technical reasoning at the forefront but jettisons these conditions. This produces an account of cumulative technological culture that maintains an important role for technical reasoning, whilst being more evolutionarily plausible. (shrink)

Shaun Gallagher [2019] argues for a ‘non-classical’ conception of nature, which includes subjects as irreducible constituents. As such, first-person phenomenology can be naturalised and at the same time resist reduction to the third-person. In the first part of this paper, I raise three concerns for the claim that nature is irreducibly subject-involving. In the second part of the paper, I suggest that embracing a process ontology could help strengthen Gallagher’s proposal.

Pain management has improved in the past few decades. Opioid analgesics have become the mainstay in the treatment of cancer pain whilst inter-disciplinary pain management programmes are the generally accepted approach to chronic pain of non-malignant origin. Recently some pain specialists have advocated the use of opioids in the long-term management of non-cancer pain. This has raised some fundamental questions about the purpose of pain management. Is it best to opt for maximum (...) class='Hi'>pain relief and comfort, or should one emphasise function and activity as higher priorities? Will the use of opioids create more autonomy for pain sufferers or will this add handicaps to lives which are already limited? Until more clinical outcome data are available we advocate caution in the use of opioid analgesia. Such caution can, and does, raise questions about the rights of the patient and the rights of the prescriber in a context where the facts do not point to a clear course of action. (shrink)

Thomas Paine often declared himself a citizen of the world. This Norton Critical Edition presents Paine and his writing within the transatlantic and global context of the revolutionary ideas and actions of his time. Thomas Paine's loyalties were with universal and self-evident principles rather than with a particular group or nation, and it is this dimension that informed his most important works. This Norton Critical Edition shows how Paine's fury at the British Empire, including its injustices to South Asians and (...) Africans, shaped his first best seller, Common Sense, and how his direct involvement with the French Revolution pushed his ideas toward a unique form of democratic radicalism. Together with his rejection of organized religion, Paine's radicalism resulted in his being one of the most hated men in both monarchial Britain and republican America. This volume includes J. M. Opal's introduction, "Thomas Paine and the Revolutionary Enlightenment, 1770s-90s," which provides essential biographical and historical details across three tumultuous decades. Paine's most important works-from Common Sense (1776) through Agrarian Justice (1796)-are reprinted and are accompanied by explanatory annotations. Supporting materials include a wide range of documents from the turbulent years following the publication of both Common Sense and the Declaration of Independence. These include Pennsylvania's gradual emancipation statute of the 1780s, an ex-slave's impassioned call for revolutionary violence against European imperialists and masters, and a British conservative's witty rejoinder to Paine's vision of a brave new world. Four major interpretations of Paine's work are provided by Nathan R. Perl-Rosenthal, Robert A. Ferguson, Gary Kates, and Gregory Claeys. A Selected Bibliography is also included. (shrink)

Includes the complete texts of Common Sense; Rights of Man, Part the Second; The Age of Reason (part one); Four Letters on Interesting Subjects , published anonymously and just discovered to be Paine’s work; and Letter to the Abbé Raynal, Paine’s first examination of world events; as well as selections from The American Crises In 1776, America was a hotbed of enlightenment and revolution. Thomas Paine not only spurred his fellow Americans to action but soon came to symbolize the spirit (...) of the Revolution. His elegantly persuasive pieces spoke to the hearts and minds of those fighting for freedom. He was later outlawed in Britain, jailed in France, and finally labeled an atheist upon his return to America. (shrink)

This paper focuses on the possibility of conceiving a form of ontological nihilism, starting from D. M. Armstrong’s combinatorialism. This possibility has been suggested by Efird and Stoneham, by means of proposing an alternative strategy to the ‘subtraction argument’. They claim that it is possible to sustain such nihilism trough the concepts of construction and totality state of affairs. However, this hypothesis will require the acceptance of non-instanciated universals, that is, platonic universals. Yet this is opposite to requirements that are (...) basic for a combinatorial theory, which should uphold that universals exist only in their instantiations. Then, the assumption of platonic universals results in high costs for a combinatorial naturalism, according to which only exists what is located in space and time. (shrink)

Over the last fifteen years, an ambitious explanatory framework has been proposed to unify explanations across biology and cognitive science. Active inference, whose most famous tenet is the free energy principle, has inspired excitement and confusion in equal measure. Here, we lay the ground for proper critical analysis of active inference, in three ways. First, we give simplified versions of its core mathematical models. Second, we outline the historical development of active inference and its relationship to other theoretical approaches. Third, (...) we describe three different kinds of claim -- labelled mathematical, empirical and general -- routinely made by proponents of the framework, and suggest dialectical links between them. Overall, we aim to increase philosophical understanding of active inference so that it may be more readily evaluated. -/- This the final submitted version of the Introduction to the Topical Collection "The Free Energy Principle: From Biology to Cognition", forthcoming in Biology & Philosophy. (shrink)

This paper is an introduction to the new field of biorhetorics. Biorhetorics is an applied form of rhetoric that evolved from the study of classical rhetoric, particularly Aristotelian. The author illustrates the stages of development necessary for the creation of a species-specific rhetoric: by (1) formalising rhetoric so as to create a functional rhetoric, (2) then reducing this to a symbolic rhetoric that can be used in conjunction with the collected data of an organism’s Umwelt (including its genome) to form (...) (3) a species-specific rhetoric. The paper draws upon the latest research on bacterial and viral communication to show the possibilities of biorhetorics. In the course of discussing the nature of biorhetorics the author distinguishes it from argumentation theory and rhetoric/s of biology, and positions alongside other fields used in the life sciences such as biosemiotics, information theory, game theory, etc. (shrink)

This paper is an introduction to the new field of biorhetorics. Biorhetorics is an applied form of rhetoric that evolved from the study of classical rhetoric, particularly Aristotelian. The author illustrates the stages of development necessary for the creation of a species-specific rhetoric: by (1) formalising rhetoric so as to create a functional rhetoric, (2) then reducing this to a symbolic rhetoric that can be used in conjunction with the collected data of an organism’s Umwelt (including its genome) to form (...) (3) a species-specific rhetoric. The paper draws upon the latest research on bacterial and viral communication to show the possibilities of biorhetorics. In the course of discussing the nature of biorhetorics the author distinguishes it from argumentation theory and rhetoric/s of biology, and positions alongside other fields used in the life sciences such as biosemiotics, information theory, game theory, etc. (shrink)