Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic’s advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury—particularly (...) its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury. (shrink)

The COVID-19 pandemic swept through New York City swiftly and with devastating effect. The crisis put enormous pressure on all hospital services, including the clinical ethics consultation team. This report describes the recent experience of the ethics consultants and Columbia University Irving Medical Center during the COVID-19 surge and compares the case load and characteristics to the corresponding period in 2019. By reporting this experience, we hope to supplement the growing body of COVID-19 scientific literature and provide details of the (...) human toll the virus took on our hospitals and communities. We also aim to highlight the role of the clinical ethics consultant as well as areas of policy and law that may need to be addressed in order to be better prepared for a future public health crisis. (shrink)

Physicians, philosophers, and theologians consider how to address death and dying for a diverse population in a secularized century.Most of us are generally ill-equipped for dying. Today, we neither see death nor prepare for it. But this has not always been the case. In the early fifteenth century, the Roman Catholic Church published the Ars moriendi texts, which established prayers and practices for an art of dying. In the twenty-first century, physicians rely on procedures and protocols for the efficient management (...) of hospitalized patients. How can we recapture an art of dying that can facilitate our dying well? In this book, physicians, philosophers, and theologians attempt to articulate a bioethical framework for dying well in a secularized, diverse society.Contributors discuss such topics as the acceptance of human finitude; the role of hospice and palliative medicine; spiritual preparation for death; and the relationship between community, and individual autonomy. They also consider special cases, including children, elderly patients with dementia, and death in the early years of the AIDS epidemic, when doctors could do little more than accompany their patients in humble solidarity.These chapters make the case for a robust bioethics—one that could foster both the contemplation of finitude and the cultivation of community that would be necessary for a contemporary art of dying well.ContributorsJeffrey P. Bishop, Lisa Sowle Cahill, Daniel Callahan, Farr A. Curlin, Lydia S. Dugdale, Michelle Harrington, John Lantos, Stephen R. Latham, M. Therese Lysaught, Autumn Alcott Ridenour, Peter A. Selwyn, Daniel Sulmasy. (shrink)

Significant structural, developmental, and financial constraints exist in Scottish soccer that may predicate a different approach to talent identification and development. To our knowledge, no published reports exist evaluating the prevalence of the relative age effect in Scottish soccer players. Consequently, the aim of this study was to investigate the prevalence of the RAE among varied playing levels and ages of male Scottish youth soccer players. Birthdates of male youth players from U10 to U17 age groups and from playing levels: (...) “Amateur”, “Development”, and “Performance”, alongside a group of male Scottish senior professional players were recorded and categorized into quartiles and semesters from the start of the selection year. Birthdates were analyzed for: each playing level and each age group irrespective of playing level. For the varied playing levels examined, an RAE was evident in “Development” and “Performance” playing levels only at youth level. When examining each age group, an RAE was observed in U12–U17 players only. While there was a slight asymmetry favoring Q1 born senior professional players, the RAE was not present within this group of our sample. Results from our study suggest that a bias in selecting individuals born earlier in the selection year may exist within male soccer academy structures, but not at amateur level. The asymmetry favoring chronologically older players at youth but not professional level questions the efficacy of this conscious bias within male Scottish soccer players. (shrink)

We wish to extend the concepts in Ray and Cooper’s (2024) article entitled “The Bioethics of Environmental Injustice: Ethical, Legal, and Clinical Implications of Unhealthy Environments” to palliat...

The scenario is all too common: the elderly woman with end-stage dementia readmitted to the hospital for the fourth time in three months for anorexia, now static cancer progressing despite all proven chemotherapy now pursuing a toxic experimental treatment, or the patient with a rampant infection leading to multiple organ failure who requires machines, medications, and devices to filter the blood, pump the heart, exchange oxygen, facilitate clotting, and provide nutrition. Modern medical science is adept at sustaining life. The field (...) of bioethics has, since its earliest days, debated end-of-life issues; yet American society more broadly remains ill equipped for the experience of dying. This can be .. (shrink)

Moral injury is the trauma caused by violations of deeply held values and beliefs. This paper draws on relational philosophical anthropologies to develop the connection between moral injury and moral identity and to offer implications for moral repair, focusing particularly on healthcare professionals. We expound on the notion of moral identity as the relational and narrative constitution of the self. Moral identity is formed and forged in the context of communities and narrative and is necessary for providing a moral horizon (...) against which to act. We then explore the relationship between moral injury and damaged moral identities. We describe how moral injury ruptures one’s sense of self leading to moral disorientation. The article concludes with implications for moral repair. Since moral identity is relationally formed, moral repair is not primarily an individual task but requires the involvement of others to heal one’s identity. The repair of moral injury requires the transformation of a moral identity in community. (shrink)

At face value, his question seemed sensible. We target cancer with chemotherapy and bone pain with narcotics. Why not also treat the “pathology” of dying? There exists precedent, after all, for the medicalization of less common human traits or conditions: shyness has become social anxiety disorder, and nocturnal leg jerking has become periodic limb movement disorder. We have developed therapies for these. It could follow that Mr. Roberts's dying might become a “life sustenance disorder” for which we could also prescribe (...) therapy. (shrink)

Doctor, just one more thing.” I marvel every time I hear this, nearly always as I reach for the door. It is as though all patients receive copies of the same instructions, perhaps posted somewhere in the waiting room: Wait until your appointment has run over time. Watch until your doctor stands to leave. Ask a question of grave importance that cannot possibly be answered quickly. I released the doorknob. “Yes, sir?” “I was wondering if you had any advice for (...) me on preparing to die. You see, I got a copy of the pathology report and even though my oncologist didn’t tell me the prognosis was bad, I did a little of my own research. I learned that ‘high grade’ and ‘poorly .. (shrink)

Every well-read architect in the English-speaking world will soon be familiar with the name of Uriel Birnbaum. For this he will have to thank a philosopher: a German philosopher, the provocative and prolific Peter Sloterdijk1—author of “the best-selling German book of philosophy since World War II,”2 the Kritik der zynischen Vernunft, or Critique of Cynical Reason. But Sloterdijk’s more recent 1998–2004 magnum opus, the three-volume, 2,573-page Sphären, or Spheres, has not yet been fully translated into English. This itself will prove (...) no insignificant task; the book has been variously described as “expansive,” “majestic,” “epic,” “monumental,” and even “megalomaniac,”3 and thus far only the first volume .. (shrink)

The scenario could not have been more grim. Mrs. Carr had been fitted with a breathing tube for surgery, but the doctors were unable to wean her from the ventilator due to recurrent episodes of life‐threatening infection. She could not eat because of the ventilator, so she received nutrition through a tube in her stomach. At some point, her kidneys shut down and she started dialysis treatments. Between recurrent infection and dialysis, her blood pressure bottomed out, and the medical team (...) frequently jump‐started her heart with intravenous adrenaline‐type medications. Without aggressive support of her lungs, kidneys, nutrition, and cardiovascular system, Mrs. Carr would be dead. “What is going on here?” Anna wondered aloud. “Is this life?” Philosopher and physician Jeffrey Bishop might argue that this is not life. Rather, medicine has created a body in perpetual motion. Contemporary medicine, he contends, has redefined human life as human function; doctors simply replace the broken or dead parts of the human machine with other machines—a ventilator for the lungs, dialysis for the kidneys, and so forth—and the body stays in motion indefinitely. Bishop argues that the discipline of medicine needs to reexamine its metaphysical assumptions—its current approach is detrimental to human flourishing. Should a metaphysics of efficient causation be replaced with a more expansive metaphysics of final causes? (shrink)

Abstract“Sit down,” Mr. R demanded. “I've got something to say to you.” I shot the medical student a querying glance as we simultaneously sunk into our chairs. He continued, “You don't know me, and I got some things to tell you.”I thought I knew Mr. R, and I certainly had some idea of what he was all about. But then he called to me. In his summoning, Mr. R arrested all my preconceived ideas about him. And as the medical student (...) and I began to understand him better, we wanted to know more. We began to engage him more deeply. In the subsequent days, caring for him somehow felt easier, akin to the care one gives a distraught friend rather than a difficult patient. (shrink)

A Yale physician's fascinating and wise exploration of why so many people die poorly and how a medieval bestseller on the art of dying well holds important lessons for today.