A traditional approach to teaching medical ethics aims to provide knowledge about ethics. This is in line with an epistemological view on ethics in which moral expertise is assumed to be located in theoretical knowledge and not in the moral experience of healthcare professionals. The aim of this paper is to present an alternative, contextual approach to teaching ethics, which is grounded in a pragmatic-hermeneutical and dialogical ethics. This approach is called moral case deliberation. Within moral case deliberation, healthcare professionals (...) bring in their actual moral questions during a structured dialogue. The ethicist facilitates the learning process by using various conversation methods in order to find answers to the case and to develop moral competencies. The case deliberations are not unique events, but are a structural part of the professional training on the work floor within healthcare institutions. This article presents the underlying theory on ethics and illustrates this approach with an example of a moral case deliberation project in a Dutch psychiatric hospital. The project was evaluated using the method of responsive evaluation. This method provided us with rich information about the implementation process and effects the research process itself also lent support to the process of implementation. (shrink)

Introduction In 2007, a national review committee was instituted in The Netherlands to review cases of active ending of life for newborns. It was expected that 15–20 cases would be reported. To date, however, only one case has been reported to this committee. Reporting is essential to obtain societal control and transparency; the possible explanations for this lack of reporting were therefore explored. Methods Data on end-of-life decision-making were scrutinised from Dutch nation-wide studies (1995, 2001 and 2005), before institution of (...) the committee. Physicians received a questionnaire about their medical decision-making for stratified samples of deceased infants up to 1 year, drawn from the central death registry. Results In 2005, 58% of all deaths were preceded by an end-of-life decision, compared with 68% in 2001 and 62% in 1995. The use of drugs with a possible life-shortening effect tended to be lower. In 2005, all four cases in the study in which an infants' life was actively ended were preceded by a decision to forego life-prolonging treatment. In three cases, the infant's life expectancy was short; one case involved a longer life expectancy. Discussion The expected number of cases is probably an overestimation due to changes in medical practice such as the tendency to attribute less life-shortening effects to opioids. The lack of reports is probably also associated with requirements in the regulation; it may be difficult to fulfil them due either to time constraints or the nature of the suffering that is addressed. If societal control of active ending of life is considered useful, changes in the regulation may be needed. (shrink)

In this article the Reformer Martin Luther is to be situated against the backdrop of his medieval theological context – considering especially Bernard of Clairvaux. It is well-known that he held in great esteem Bernard and the theology he represented. First of all, Luther's relationship to Bernard is to be investigated by way of a historiographic review of the research that was done in the past 150 years. How did one consider Luther’s attitude toward Bernard, and how did Luther research (...) specifically value this attitude? In this research, denominational positions appear to have played a important role. Secondly, the attempt is made here to sketch Bernard’s place in Luther’s own tradition. Next to the medieval scholastic theology, there were diverse other influences that became important for the young Luther. Bernard’s specific place within the complexity of medieval traditions is to be determined. This is being explained by presenting seven significant texts mainly from Luther’s works, which are added to this article. Finally, the attempt is made to determine more closely Bernard’s place in Luther’s theology between Scholasticism and Mysticism. If one wants to do justice to Bernard in Luther's works, one must take into consideration the way in which Luther has perceived him, namely as a theologian of the Scriptures, a theologian of experience and a preacher of Christ par excellence along the lines of monastic theology. (shrink)

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

The wish to extend the human lifespan has a long tradition in many cultures. Optimistic views of the possibility of achieving this goal through the latest developments in medicine feature increasingly in serious scientific and philosophical discussion. The authors of this paper argue that research with the explicit aim of extending the human lifespan is both undesirable and morally unacceptable. They present three serious objections, relating to justice, the community and the meaning of life.

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown (...) that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life. (shrink)

Much has been written about the rights of health-care professionals to conscientiously object. Ironically, there has been no formal discussion as to whether clinical ethicists have the same right. Given that ethicists routinely deal with the same situations and questions that other health-care professionals find morally discomforting, the question as to whether they have the same right is a critical one. We conclude that ethicists should not have the same right to conscientious objection. The role of an ethicist is to (...) competently manage those situations and cases that cause moral discomfort and confusion. By conscientiously objecting, an ethicist would be failing to fulfil their primary function. The same cannot be said as forcefully about other professionals who object. Moreover, ethicists retain the right to conscientious objection to the joining of the discipline in the first place, and also retain the right to exit if they so choose. (shrink)

The framework of Findlay & Walker's target article provides a first attempt to model the saccadic system at all levels. Their scheme is based on two main principles. These are “parallel processing of saccade timing and metrics” and “competitive inhibition through winner-take-all strategies.” In our opinion, however, both concepts are in their strictest sense at odds with the current knowledge of the saccadic system, and need to be refined to make the scheme more relevant.

The larval arms of echinoid plutei are used for locomotion and feeding. They are composed of internal calcite skeletal rods covered by an ectoderm layer bearing a ciliary band. Skeletogenesis includes an autonomous molecular differentiation program in primary mesenchyme cells (PMCs), initiated when PMCs leave the vegetal plate for the blastocoel, and a patterning of the differentiated skeletal units that requires molecular cues from the overlaying ectoderm. The arms represent a larval feature that arose in the echinoid lineage during the (...) Paleozoic and offers a subject for the study of gene co-option in the evolution of novel larval features. We isolated new molecular markers in two closely related but differently developing species, Heliocidaris tuberculata and Heliocidaris erythrogramma. We report the expression of a larval arm-associated ectoderm gene tetraspanin, as well as two new PMC markers, advillin and carbonic anhydrase. Tetraspanin localizes to the animal half of blastula stage H. tuberculata and then undergoes a restriction into the putative oral ectoderm and future location of the postoral arms, where it continues to be expressed at the leading edge of both the postoral and anterolateral arms. In H. erythrogramma, its expression initiates in the animal half of blastulae and expands over the entire ectoderm from gastrulation onward. Advillin and carbonic anhydrase are upregulated in the PMCs postgastrulation and localized to the leading edge of the growing larval arms of H. tuberculata but do not exhibit coordinated expression in H. erythrogramma larvae. The tight spatiotemporal regulation of these genes in H. tuberculata along with other ontogenetic and phylogenetic evidence suggest that pluteus arms are novel larval organs, distinguishable from the processes of skeletogenesis per se. The dissociation of expression control in H. erythrogramma suggest that coordinate gene expression in H. tuberculata evolved as part of the evolution of pluteus arms, and is not required for larval or adult development. (shrink)

The problem of two relativistically-moving pointlike particles of constant mass is undertaken in an arbitrary Lorentz frame using the classical Lagrangian mechanics of Stückelberg, Horwitz, and Piron. The particles are assumed to interact at events along their world lines at a common “world time,” an invariant dynamical parameter which is not in general synchronous with the particle proper time. The Lorentz-scalar interaction is assumed to be the Coulomb potential (i.e., the inverse square spacetime potential) of the spacetime event separation. The (...) classical orbit equations are found in 1 + 1 spacetime dimensions in the hyperbolic angle coordinates for the reduced problem. The solutions to the reduced motion in these coordinates are the spacetime generalizations of the nonrelativistic Kepler solutions. and they introduce an invariant eccentricity which is a function of other known constants of the motion for the reduced problem. Solutions compatible with physical scattering are obtained by the assumption that the eccentricity is a given function of the ratio of the particle masses. (shrink)

The classical two-body system with Lorentz-invariant Coulomb work function V = -k/ρ is solved in 3+1 dimensions using the manifestly covariant Hamiltonian mechanics of Stückelberg. Particular solutions for the reduced motion are obtained which correspond to bound attractive, unbound attractive, and repulsive scattering motion. A lack of perihelion precession is found in the bound attractive orbit, and the semiclassical hydrogen spectrum subsequently contains no fine structure corrections. It is argued that this prediction is indicative of the correct classical special relativistic (...) two-body theory. (shrink)