Much of the work on the ethics of climate engineering over the last few years has focused on the front-end of the potential timeline for climate intervention. Topics have included the initial taboo on bringing the discussion of climate engineering into the open, guidelines to put in place before commencing research, and governance arrangements before first deployment. While this work is clearly important, the current paper considers what insights can be gleaned from considering the tail-end, that is, by using the (...) requirement for future cessation as a criterion for any acceptable climate engineering strategy. After showing that time-limited interventions are a key part of the rhetoric of leading climate engineering advocates, the paper examines the implications of imposing a 'cessation requirement' on solar radiation management and carbon dioxide removal strategies. Consideration of a cessation requirement turns out to reveal a great deal about what ought to be happening now, before any decision to proceed with climate engineering deployment has been taken. (shrink)

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, as (...) well as the reasons provided for this. A random sample of general practitioners and orthopaedic surgeons as well as members of the general public received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a “recommendation strategy” vis-à-vis smoking cessation prior to surgery rather than a “requirement strategy”. The normative reasons speak in favour of the “recommendation strategy”. (shrink)

Recruiting adolescents into smoking cessation studies is challenging, particularly given institutional review board (IRB) requirements for research conducted with adolescents. This article provides a brief review of the federal regulations that apply to research conducted with adolescents, and describes researchers' experiences of seeking IRB approval for youth cessation research. Twenty-one researchers provided information. The most frequently reported difficulty involved obtaining parental consent. Solutions to commonly reported problems with obtaining IRB approval are also identified. Waivers of parental consent can (...) facilitate recruitment of youths into studies; however, researchers must ensure that their protocols comply with federal regulations when requesting a waiver. (shrink)

Objective: Inhibitory control training has shown promise for improving health behaviours, however, less is known about its mediators of effectiveness. The current paper reports whether ICT reduces smoking-related outcomes such as craving and nicotine dependence, increases motivation to quit and whether reductions in smoking or craving are mediated by response inhibition or a devaluation of smoking stimuli.Method: Adult smokers were randomly allocated to receive 14 days of smoking-specific ICT or active control training. Participants were followed up to 3-months post-intervention. This (...) trial was preregistered.Results: There were no significant differences between ICT and active control training groups. Specifically, participants in both groups showed significant reductions in craving, nicotine dependence, motivation and a devaluation of smoking-stimuli up to 3-months follow-up compared to baseline. Inhibition and devaluation of smoking stimuli did not act as mediators. Devaluation of smoking stimuli was an independent predictor of smoking and craving at follow-up.Conclusion: Inhibitory control training was no more effective at reducing smoking-related outcomes compared to the active control group, however, significant improvements in craving, dependence indicators and evaluation of smoking stimuli were observed across both groups. A return to basic experimental research may be required to understand the most effective ICT approach to support smoking cessation. (shrink)

The predominant approach of public health experts to cigarette smoking might be described as behaviorist, for it aims to eliminate this behavior without attending to human agency and intention. The requirement that physicians address smoking cessation at every patient visit also constitutes physicians as “managers” who focus narrowly on technical means to achieve predetermined ends. In this paper, I contrast such an approach with the Aristotelian tradition, according to which physician and patient ought to develop the virtue of (...) temperance that would allow the patient to quit smoking. Although this model could potentially mitigate medicine’s behaviorist-managerial tendencies, I follow Aristotle to argue that it requires a moral friendship in which participants share a conception of the human good and pursue that good together. Due to the intractable moral pluralism that characterizes contemporary life, physicians and patients are unlikely to achieve this sort of friendship, making Aristotelian medicine impracticable at present. (shrink)

Starting from 2009, national courts of the EU Member States for the first time gained a “real” right to request the EU Court of Justice for preliminary rulings in asylum matters. First judgments of this Court demonstrate equivocal tendencies: some are blaming the Court for incompetence in asylum matters, others believe that the adoption of authoritative decisions at the European level will assist in developing consistent practice of applying asylum law in the European Union, something that failed at international level (...) due to absence of a single authoritative body to provide guidance on interpretation and application of the 1951 Refugee Convention. Considering that the judgments of the EU Court are part of the EU law, the Member States should develop their national asylum law with due regard being taken to those judgments. By the beginning of 2012, the Court has issued eight judgments on the interpretation of various problematic issues of EU asylum law. This Article analyses the jurisprudence of the EU Court in asylum cases, related to the granting of refugee status and subsidiary protection. It also provides a critical evaluation of those judgments. The main objective of the Article is to familiarise the relevant Lithuanian institutions and lawyers with the first judgments of the EU Court in asylum cases and encourage discussions concerning the application of rules established by the Court in the Lithuanian context. Due to limited size, this Article presents the analysis of two EU Court judgments adopted on interpretation of the 2004 Qualification Directive: Elgafaji v. The Netherlands (2009) dealing with granting of subsidiary protection, and Abdulla and others v. Bundesrepublik Deutschland (2010), dealing with cessation of refugee status. The value of those judgments first of all lies in the guidance they provided to the Member States on such concepts as: protection in a situation of an armed conflict, agents of protection, effectiveness of protection; as well as determination of a relationship between refugee status and subsidiary protection, relationship of the Qualification Directive with the European Convention on Human Rights and Fundamental Freedoms (ECHR), also cessation of protection. Elgafaji decision, while quite liberal with regard to persons seeking international protection, is not so liberally applied in the Member States’ practice and does not in itself guarantee positive outcome of the application of a concrete individual fleeing from an armed conflict, or a liberal approach to granting subsidiary protection in the Member States. Based on Elgafaji judgment it is clear that: Art. 15(b) of the Qualification Directive correspond to Art. 3 ECHR, while Art. 15(c) provides additional protection and in that it expands the Member States’ obligations beyond the ECHR to provide protection to persons fleeing in situations of armed conflict. While not every person arriving from an armed conflict situation would automatically fall under the granting of subsidiary protection, in certain exceptional situations indiscriminate violence may amount to individual threat without invoking personal circumstances. The EU Court departed from the individualisation requirement applied by the European Court of Human Rights in Art. 3 cases and did not also rely on international humanitarian law, by introducing a “sliding scale” formula for establishing an individual threat in armed conflict situation instead. This formula addressed the alleged internal discrepancy between “individual threat” and “indiscriminate violence”. The Abdulla decision brought in the human rights and law enforcement perspectives to the interpretation of cessation clauses, however it represents a rather superficial approach in the context of the analysed concepts (e.g. towards effectiveness of protection provided by the multinational armed forces) and is likely to be incompatible with the latest legislative trends in the EU asylum instruments (e.g. determination of refugee status and subsidiary protection by means of a single procedure) and the recent jurisprudence under the ECHR (e.g. failure to ensure a minimum standard of living may violate the ECHR). (shrink)

Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of (...) brain function. The relevant circulation that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act. (shrink)

There are currently two legally established criteria for death: the irreversible cessation of circulation and respiration and the irreversible cessation of neurologic function. Recently, there have been technological developments that could undermine the irreversibility requirement. In this paper, I focus both on whether death should be identified as an irreversible state and on the proper scope of irreversibility in the biological definition of death. In this paper, I tackle the distinction between the commonsense definition of death and (...) the biological definition of death to show that even the commonsense concept of death is specified by biological facts. Resting on this argument, I argue that any definition of death is a posteriori. Thus, irreversibility is part of any definition of death because the actual phenomenon of death is irreversible. In addition, I show that the proper domain of irreversibility in a definition of death is circumscribed by physical possibilities and that irreversibility in the definition of death refers to current possibilities for the reversal of relevant biological processes. I conclude that, despite recent technological advancements, death is still irreversible. (shrink)

Organ donation after cessation of circulation and respiration, both controlled and uncontrolled, has been proposed by the Institute of Medicine as a way to increase opportunities for organ procurement. Despite claims to the contrary, both forms of controlled and uncontrolled donation after cardiac death raise significant ethical and legal issues. Identified causes for concern include absence of agreement on criteria for the declaration of death, nonexistence of universal guidelines for duration before stopping resuscitation efforts and techniques, and assumption of (...) presumed intent to donate for the purpose of initiating temporary organ-preservation interventions when no expressed consent to donate is present. From a legal point of view, not having scientifically valid criteria of cessation of circulation and respiration for declaring death could lead to a conclusion that organ procurement itself is the proximate cause of death. Although the revised Uniform Anatomical Gift Act of 2006 provides broad immunity to those involved in organ-procurement activities, courts have yet to provide an opinion on whether persons can be held liable for injuries arising from the determination of death itself. Preserving organs in uncontrolled donation after cardiac death requires the administration of life-support systems such as extracorporeal membrane oxygenation. These life-support systems can lead to return of signs of life that, in turn, have to be deliberately suppressed by the administration of pharmacological agents. Finally, allowing temporary organ-preservation interventions without expressed consent is inherently a violation of the principle of respect for a person's autonomy. Proponents of organ donation from uncontrolled donation after cardiac death, on the other hand, claim that these nonconsensual interventions enhance respect for autonomy by allowing people, through surrogate decision making, to execute their right to donate organs. However, the lack of transparency and the absence of protection of individual autonomy, for the sake of maximizing procurement opportunities, have placed the current organ-donation system of opting-in in great jeopardy. Equally as important, current policies enabling and enhancing organ procurement practices, pose challenges to the constitutional rights of individuals in a pluralistic society as these policies are founded on flawed medical standards for declaring death. (shrink)

The distinction between the "permanent" (will not reverse) and "irreversible" (cannot reverse) cessation of functions is critical to understand the meaning of a determination of death using circulatory–respiratory tests. Physicians determining death test only for the permanent cessation of circulation and respiration because they know that irreversible cessation follows rapidly and inevitably once circulation no longer will restore itself spontaneously and will not be restored medically. Although most statutes of death stipulate irreversible cessation of circulatory and (...) respiratory functions, the accepted medical standard is their permanent cessation because permanence is a perfect surrogate indicator for irreversibility, and using it permits a more timely declaration. Therefore, patients properly declared dead in donation after circulatory death (DCD) protocols satisfy the requirements of death statutes and do not violate the dead donor rule. The acronym DCD should represent organ "donation after circulatory death" to clarify that the death standard is the permanent cessation of circulation, not heartbeat. Heart donation in DCD does not retroactively negate the donor's death determination because circulation has ceased permanently. (shrink)

In this essay, my aim is to explain Vātsyāyana’s solution to a problem that arises for his theory of liberation. For him and most Nyāya philosophers after him, liberation consists in the absolute cessation of pain. Since this requires freedom from embodied existence, it also results in the absolute cessation of pleasure. How, then, can agents like us be rationally motivated to seek liberation? Vātsyāyana’s solution depends on what I will call the Pain Principle, i.e., the principle that (...) we should treat all aspects of our embodied existence as pain. If we were to follow this advice, we would come to apply the label of pain to all aspects of our embodied existence, including pleasure. This would undermine our attachment to our own embodied existence. I show that this fits with Vātsyāyana’s general theory of motivation. According to this theory, by manipulating the labels using which we think about the world and ourselves, we can induce radical shifts in our patterns of motivation. (shrink)

In 1959 two French neurologists, Pierre Mollaret and Maurice Goullon, coined the term coma dépassé to designate a state beyond coma. In this state, patients are not only permanently unconscious; they lack the endogenous drive to breathe, as well as brainstem reflexes, indicating that most of their brain has ceased to function. Although legally recognized in many countries as a criterion for death, brain death has not been universally accepted by bioethicists, by the medical community, or by the public. I (...) this paper, I defend brain death as a biological concept. I challenge two assumptions in the brain death literature that have shaped the debate and have stood in the way of an argument for brain death as biological. First, I challenge the dualism established in the debate between the body and the brain. Second, I contest the emphasis on consciousness, which prevents the inclusion of psychological phenomena into a biological criterion of death. I propose that the term organism should apply both to the functioning of the body and the brain. I argue that the cessation of the organism as a whole should take into account three elements of integrated function. Those three elements are: 1) the loss of integrated bodily function; 2) the loss of psychophysical integration required for processing of external stimuli and those required for behavior; and, 3) the loss of integrated psychological function, such as memory, learning, attention, and so forth. The loss of those three elements of integrated function is death. (shrink)

Brain death, or the determination of death by neurological criteria, has been described as a legal fiction. Legal fictions are devices by which the law treats two analogous things (in this case, biological death and brain death) in the same way so that the law developed for one can also cover the other. Some scholars argue that brain death should be understood as a fiction for two reasons: the way brain death is determined does not actually satisfy legal criteria requiring (...) the permanent cessation of all brain function, and brain death is not consistent with the biological conception of death as involving the irreversible cessation of the functioning of an organism as a whole. Critics counter that the idea that brain death is a legal fiction is deceptive and undemocratic. I will argue that diagnosing brain death as a hidden legal fiction is a helpful way to understand its historical development and current status. For the legal‐fictions approach to be ethically justifiable, however, the fact that brain death is a legal fiction not aligned with the standard biological conception of death must be acknowledged and made transparent. (shrink)

Critics of organ donation after circulatory death (DCD) argue that, even if donors are past the point of autoresuscitation, they have not satisfied the “irreversibility” requirement in the circulatory and respiratory criteria for determining death, since their circulation and respiration could be artificially restored. Thus, removing their vital organs violates the “dead-donor” rule. I defend DCD donation against this criticism. I argue that practical medical-ethical considerations, including respect for do-not-resuscitate orders, support interpreting “irreversibility” to mean permanent cessation of (...) circulation and respiration. Assuming a consciousness-related formulation of human death, I then argue that the loss of circulation and respiration is significant, because it leads to the permanent loss of consciousness and thus to the death of the human person. The DNR request by an organ donor should thus be interpreted to mean “do not restore to consciousness.” Finally, I respond to an objection that if “irreversibility” has a medical-ethical meaning, it would entail the absurd possibility that one of two individuals in the same physical state could be alive and the other dead—an implication that some think is inconsistent with understanding death as an objective biological state of the organism. I argue that advances in medical technology have created phenomena that challenge the assumption that human death can be understood in strictly biological terms. I argue that ethical and ontological considerations about our nature bear on the definition and determination of death and thus on the permissibility of DCD. (shrink)

Human life is operationally defined by the onset and cessation of organismal function. At postnatal stages of life, organismal integration critically and uniquely requires a functioning brain. In this article, a distinction is drawn between integrated and coordinated biologic activities. While communication between cells can provide a coordinated biologic response to specific signals, it does not support the integrated function that is characteristic of a living human being. Determining the loss of integrated function can be complicated by medical interventions (...) that uncouple elements of the natural biologic hierarchy underlying our intuitive understanding of death. Such medical interventions can allow living human beings who are no longer able to function in an integrated manner to be maintained in a living state. In contrast, medical intervention can also allow the cells and tissues of an individual who has died to be maintained in a living state. To distinguish between a living human being and living human cells, two criteria are proposed: either the persistence of any form of brain function or the persistence of autonomous integration of vital functions. Either of these criteria is sufficient to determine a human being is alive. (shrink)

“Brain death,” the determination of human death by showing the irreversible loss of all clinical functions of the brain, has become a worldwide practice. A biophilosophical account of brain death requires four sequential tasks: agreeing on the paradigm of death, a set of preconditions that frame the discussion; determining the definition of death by making explicit the consensual concept of death; determining the criterion of death that proves the definition has been fulfilled by being both necessary and sufficient for death; (...) and determining the tests of death for physicians to employ at the patient's bedside to demonstrate that the criterion of death has been fulfilled. The best definition of death is “the cessation of functioning of the organism as a whole.” The whole-brain criterion is the only criterion that is both necessary and sufficient for death. Brain death tests are used only in the unusual case in which a patient's ventilation is being supported. Brain death critics have identified weaknesses in its formulation. But despite its shortcomings, the whole-brain death formulation comprises a concept and public policy that make intuitive and practical sense and that has been well accepted by many societies. (shrink)

Description of the biologicalhierarchy of the organism has been extendedhere to included the evolutionary andecological sub-hierarchies with theirrespective levels in order to give a completehierarchical description of life. These newdescriptions include direction of formation,types of constraints, and dual levels. Constraints are produced at the macromolecularlevel of genes/proteins, some of which (a) aredescendent restraints which hold a hierarchytogether and others (b) interact horizontallywith selective agents at corresponding levelsof the niche. The organism is a dual levelconstrained by both the ecologicalsub-hierarchy (survival) and (...) evolutionarysub-hierarchy (fitness) while serving as thehighest level of the specializationsub-hierarchy, therefore, it is unique inbelonging to three sub-hierarchies. Organismsexperience birth, sometimes death, andparticipate in evolution. Birth of an organismis realized when a cell is removed from theconstraints of the organism and assumes itsown organismal constraints. Death occurs withthe cessation of protein synthesis becauseproteins and their products constitutecomponents at high levels of the hierarchy. Selection is of two types, natural selection,involving adaptive traits interacting withfeatures in a niche, and hierarchicalselection, requiring traits to be compatiblewith existing hierarchical constraints. (shrink)

Libet discovered that a substantial duration (> 0.5-1.0 s) of direct electrical stimulation of the surface of the somatosensory cortex at threshold currents is required before human subjects can report that a conscious somatosensory experience had occurred. Using a reaction time method we confirm that a similarly long stimulation duration at threshold currents is required for activation of elementary visual experiences (phosphenes) in human subjects following stimulation of the surface of the striate cortex. However, the reaction times for the subject (...) to respond to the cessation of the visual experience after the end of electrical stimulation could be as brief as 225-242 ms. We also carried out extensive studies in cats under a variety of anesthetic conditions using the same electrodes and parameters of stimulation employed in the human studies to study the patterns of neuronal activity beneath the stimulating surface electrode. Whereas sufficiently strong currents can activate neurons within milliseconds, stimulating currents close to threshold activate sustained neural activity only after at least 350-500 ms. When currents are close to threshold, some neurons are inhibited for several hundreds of millisecond before the balance between inhibition and excitation shifts towards excitation. These results suggest that the prolonged latencies, i.e., latencies beyond 200-250 ms, for the emergence of conscious experience following direct cortical stimulation result from a delay in the sustained activation of underlying cortical neurons at threshold currents rather than being due to any unusually long duration in central processing time. Intracellular records from cortical neurological cells during repetitive electrical stimulation of the surface of the feline striate cortex demonstrate that such stimulation induces a profound depolarizing shift in membrane potential that may persist after each stimulus train. Such a depolarization is evidence that extracellular K+ concentrations have increased during electrical stimulation. Such an increase in extracellular K+ progressively increases cortical excitability until the threshold for sustained activation of cortical neurons is reached and then exceeded. Consequently, the long latency for threshold activation of cortical neurons depends upon a dynamically increasing cortical facilatory process that begins hundreds of milliseconds before there is sustained activation of such neurons. In some cases, this facilatory process must overcome an initial stimulus-induced inhibition before neuronal firing commences. (shrink)

In donation after the circulatory-respiratory determination of death, the dead donor rule requires that the donor be dead before organ procurement can proceed. Under the relevant limb of the Uniform Determination of Death Act 1981, a person is dead when the cessation of circulatory-respiratory function is ‘irreversible’. Critics of current practice in DCDD have argued that the donor is not dead at the time organs are procured, and so the procurement of organs from these donors violates the dead donor (...) rule. We offer a new argument here in defence of current DCDD practice, and, in particular, of the interpretation of the requirement of ‘irreversibility’ as permanence. (shrink)

I investigate Thomas Aquinas's metaphysical account of human death, which is defined in terms of a rational soul separating from its material body. The question at hand concerns what criterion best determines when this separation occurs. Aquinas argues that a body has a rational soul only insofar as it is properly organised to support the soul's vegetative, sensitive, and rational capacities. According to the ‘higher‐brain’ concept of death, when a body can no longer provide the biological foundation necessary for the (...) operation of conscious rational thought and volition, a substantial change occurs in which the rational soul departs and the body left behind is a ‘humanoid animal’ or a mere ‘vegetable.’I argue that the separation of soul and body does not occur until the body ceases to function as a unified, integrated organism. A rational soul is not only the seat of a human being's rational capacities; it is also the principle of the body's sensitive and vegetative capacities. Since Aquinas defines a human being as a composite of soul and body, and not with merely the exercise of rational capacities, the determination of death requires incontrovertible evidence that the body has ceased all the operations that correspond to the soul's proper capacities. The evidence of this is the body's loss of its integrative organic unity and the criterion for determining when this loss occurs is the irreversible cessation of whole‐brain functioning. (shrink)

A combination of emerging life support technologies and entrenched organ donation practices are complicating the physician's task of determining death. On the one hand, technologies that support or replace ventilation and circulation may render the diagnosis of death ambiguous. On the other, transplantation of vital organs requires timely and accurate declaration of death of the donor to keep the organs as healthy as possible. These two factors have led to disagreements among physicians and scholars on the precise moment of death. (...) In this article, I suggest that the debate about exactly when a person dies can benefit from distinguishing the strict biological concept of death from the medical standards for determining human death, and I show how an appreciation of the difference between the permanent and irreversible cessation of circulation is helpful in understanding the reasons for the two approaches to determining when death should be declared. (shrink)

Because complex organs taken from unequivocally dead people are not suitable for transplantation, human death has been redefined so that it can be certified at some earlier stage in the dying process and thereby make viable organs available without legal problems. Redefinitions based on concepts of "brain death" have underpinned transplant practice for many years although those concepts have never found universal philosophical acceptance. Neither is there consensus about the clinical tests which have been held sufficient to diagnose the irreversible (...) cessation of all brain function – or as much of it as is deemed relevant – while the body remains alive. For these reasons, the certification of death for transplant purposes on "brain death" grounds is increasingly questioned and there has been pressure to return to its diagnosis on the basis of cardiac arrest and the consequent cessation of blood circulation throughout the body. While superficially a welcome return to the traditional and universally accepted understanding of human death, examination of the protocols using such criteria for the diagnosis of death prior to organ removal reveals a materially different scenario in which the circulatory arrest is not certainly final and purely nominal periods of arrest are required before surgery begins. Recognizing the probably unresolvable conflict between allowing enough time to pass after truly final circulatory arrest for a safe diagnosis of death and its minimization for the sake of the wanted organs, Verheijde and colleagues follow others in calling for the abandonment of the "dead donor rule" and the enactment of legislation to permit the removal of organs from the dying, without pretence that they are dead before that surgery. While it may be doubted whether such a "paradigm change" in the ethics of organ procurement would be accepted by society, their call for its consideration as a fully and fairly informed basis for organ donation is to be applauded. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Evaluation of Implicit AnthropologiesJochen Fahrenberg (bio) and Marcus Cheetham (bio)Keywordsmind-body, philosophical assumptions, human natureThe three commentaries and the reviewer’s notes contain valuable reflections and expand on number of important points. There is general agreement that surprisingly little is known about psychologists’, psychotherapists’, clinicians’, and other professionals’ philosophical assumptions about human nature. It is conceivable that these implicit anthropologies represent a potential source of bias in research and practice (...) and that further research is therefore justified.Doctor Walach emphasizes the pluralism of world views, which is evident in the questionnaire response patterns. The findings contradict the assumption that monism, immanence, and a scientific worldview are predominant preconceptions. Instead, psychology students mostly favor ontological or methodological dualism, and con-firm that they have spiritual beliefs or indeed some belief in paranormal phenomena. From this, Dr. Walach extends his thought-provoking perspective to folk psychology, as opposed to mainstream psychology, and reflects on the influence of individual beliefs on scientific culture. It is especially from this perspective that the investigation of certain key concepts and belief systems should be given every encouragement.Doctors Wells and Rackley were particularly interested in the implicit anthropologies of clinicians. They are inclined to attribute individual differences in understanding and interaction with patients to “psychological” traits or to momentary experience rather than to philosophical beliefs. The latter view was supported by the majority of students in our investigation. With respect to psychotherapists and clinicians, our article contained only a short reference to the interviews conducted by Wider. The majority of the forty-two professionals taking part in this pilot study assumed that there may be such differential biases in their fields, but they conceded that the momentary clinical condition and pragmatic necessities would often override such biases. An empirical investigation to differentiate psychological, pragmatic–clinical, and philosophical factors and the associated bias would be an ambitious project; very careful interviews and perhaps participant observation would be necessary. But before undertaking such a study, further descriptive studies and the development of testable hypotheses are required.Doctor Brendel referred to the intricacies of the mind–body problem. We agree that many of the recent philosophical writings show nonreductive physicalism to be among the highly favored conceptions. (We do not know whether this discourse represents the majority opinion of philosophers, psychologists, clinicians, or even neuroscientists.) [End Page 213] The inclusion of this specific conception in the multiple-choice item list would require the inclusion of a specific vocabulary and some definitions that are controversial, even among the proponents of nonreductive physicalism. We decided to restrict the wide spectrum of concepts to five categories. Doctor Brendel goes on to voice explicit support for the conceptualization proposed by Horgan, who recommended a pragmatic approach and the use of double vocabularies. He suggests that context-related features in a given instance would suffice for selecting the most appropriate explanation. It is, however, conceivable that close examination of the decision process would reveal criteria containing or stemming from philosophical assumptions.Doctor Walach makes reference to the complementarity principle, which has a certain intellectual appeal when cross-category relationships are considered, and is not restricted to the domain of physics. Compared with a double-language dualism, the complementarity principle postulates that both frames of reference are fundamentally different in categories, exhaustive within their specific explanation scheme, but are essentially incomplete if, for example, brain and consciousness are viewed as a whole.Pertinent methodological aspects were already addressed in the article and endnote. However, the appropriateness of a questionnaire with which to assess philosophical standpoints will continue to be met with concern and require careful consideration. It is clear that there is no other practical method for gathering in a population like first-year students of psychology representative data about ontological beliefs, religious attitudes, or assumptions on human nature.Doctors Wells and Rackley noted discrepancies in the response to two items relating to spiritual existence after death and the cessation of consciousness with biological death. The two statements seem to be contradictory and the observed inconsistencies point to possible misunderstandings, response tendencies, context-dependent effects, or other shortcomings well-known in research using personality questionnaires. However, the assumed postmortal existence... (shrink)

This essay argues that acknowledging the existence of mind-independent facts is a matter of vital importance, in that acquiescence before the layout of the world is something demanded of knowing agents from the most elementary empirical deliverance to the most abstract construct. Building on the idea that normativity requires the presence of more than one option to choose from, the essay shows how the cessation of one's life is the disjunctive alternative of any experiential episode. This much has been (...) missed, it argues, because of a generalized failure to appreciate how even the simplest atomic contents embroil their subjects in acts of assent. Its account thus casts a new light on relativism and skepticism, revealing them to be provisional luxuries supported only by the cognitive labor of others. (shrink)

Experimental vaccines are being developed for the treatment of ‘unhealthy lifestyles’ and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of ‘lifestyle vaccines’ for public health. Based on findings from a qualitative (...) study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The ‘vaccinization’ of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future. (shrink)

Despite the popularity, success, and growth of programs of organ donation after the circulatory determination of death (DCDD), a long‐standing controversy persists over whether the organ donor is truly dead at the moment physicians declare death, usually following five minutes of circulatory and respiratory arrest. Advocates of the prevailing death determination standard claim that the donor is dead when declared because of permanent cessation of respiration and circulation. Critics of this standard argue that while the cessation of respiration (...) and circulation may be permanent, it may not be irreversible at the moment death is declared because, if cardiopulmonary resuscitation were performed, it might succeed. And because irreversibility of cessation of respiration and circulation is required by both the statute and the biological concept of death, the donor must be alive. Who is correct?Making two related distinctions clarifies the cause of the disagreement over whether the DCDD donor is dead and points to a possible resolution. First, in a determination of death, there is an important distinction between the permanent and the irreversible cessation of circulation and respiration—two associated phenomena that are often confounded. Second, there is an important distinction between the medical practice standard for death determination, in which physicians certify the permanent cessation of vital functions as sufficient for death declaration, and the underlying biological concept of death that requires the irreversible cessation of vital functions because death, by definition, is an irreversible event. (shrink)

The problem of moral sunk costs pervades decision-making with respect to war. In the terms of just war theory, it may seem that incurring a large moral cost results in permissiveness: if a just goal may be reached at a small cost beyond that which was deemed proportionate at the outset of war, how can it be reasonable to require cessation? On this view, moral costs already expended could have major implications for the ethics of conflict termination. Discussion of (...) sunk costs in moral theorizing about war has settled into four camps: Quota, Prospect, Addition, and Discount. In this paper, I offer a mathematical model that articulates each of these views. The purpose of the mathematisation is threefold. First, to unify the sunk costs problem. Second, to show that these views differ in the nature of their justifications: some are justified qualitatively and others quantitatively. Third, to clarify the differential force of qualitative and quantitative critiques of these four views. (shrink)

Considerations of objective-value freedom and status freedom do impose constraints on policies that restrict access to cigarettes. As to the objective-value freedom, something of value is lost when anti-alcohol policies lead to pub closures interfering with valued life styles, and a similar, though weaker, argument can be made for cigarettes. As to status freedom, non-arbitrariness requires consultation with vulnerable populations to learn what might aid them with smoking cessation.

In lieu of an abstract, here is a brief excerpt of the content:Diacritics 30.3 (2000) 40-52 [Access article in PDF] Hugo's le Dernier Jour d'un Condamné The End as Contamination Allan Stoekl How does one end a story? What does it mean to end a story? What is the relationship between the end of a story and that which precedes it? These, in many ways, are among the central concerns of nineteenth-century fiction, for this period saw extensive experimentation not only (...) in the areas of narration, point of view, and style, but in the realm of what is often called narrative "closure."This term, one we are all familiar with from television news accounts—everyone wants closure nowadays, whatever that is—is already contested in much of nineteenth-century fiction. The happy certainties of, say, a Sherlock Holmes story are hardly corroborated by the dismal fates of Emma Bovary or Thérèse Raquin. Indeed, one of the goals of much "realism" of the period can be seen as a desire to formulate another type of ending, one that provides not happy consolation—closure in the contemporary sense of the term—but simply an ending as cessation, a hanging-fire that offers only the silence, and emptiness, of the tomb. And even the emptiness of the character: after all, when Charles Bovary is opened up in order to determine the cause of his death, the doctors "find nothing": he was as empty as the ending of his wife's story. Indeed the discovery of that emptiness is the end (such as it is). Charles's emptiness has opened the story, it closes it, and in between there are only episodes that make obvious the end to come: disillusionment in the power of stories, the death-in-life of a life that tries to ape adventures. The end, the end of stories in general, comes to occupy and reconfigure (in its own nonimage) the entire story.As Montaigne put it, there is only a bout rather than a but: an end as mere cessation rather than as goal or conclusion.1 This endlessness of the end—as simple extinction—suffuses all that comes before it: it is not so much that events lead up to an end, but rather that the end casts back on the events that precede it its own void, its fundamental unknowability.Sartre, of course, was eager to continue this Flaubertian critique (as he continued so much else started by Flaubert); in La nausée (Nausea) his hero, Roquentin, refuses any belief in the reality of "adventures"—his own or anyone else's—because they are essentially false: they are stories, with beginnings and endings selected to provide an illuminating or pleasurable experience. They are no more "real" than are the objects [End Page 40] around us, which are fabricated and chosen with a subjective, and selfish, end in view. In lived adventures, as in stories in novels or films, it is the end that gives sense to what comes before it: the economy of narrative, so to speak, requires that everything that figures in a story be of use in contributing to a satisfying and totalizing end (a but). In his diary, Roquentin writes:And in reality you have started at the end. It was there, invisible and present, it is the one which gives to words the pomp and value of a beginning. "I was out walking, I had left the town without realizing it, I was thinking about my money troubles." This sentence, taken simply for what it is, means that the man was absorbed, morose, a hundred leagues from an adventure, exactly in the mood to let things happen without noticing them. But the end is there, transforming everything. For us, the man is already the hero of the story. [...] And the story goes on in reverse: instants have stopped piling themselves up in a lighthearted way one on top of the other, they are snapped up by the end of the story which draws them and each one of them in turn, draws out the preceding instant: "It was night, the street... (shrink)

The Indian philosophers lay emphasis on mind-control. Mind-control is not only negative practice. For, we are not only required to check and curb our evil tendencies but also employ them for a better purpose. The lower constituents of human beings can not be annihilated but can only be tamed and reformed. Cessation of bad tendencies is coupled with cultivation of good tendencies and is followed by good actions. According to Jainism & Buddhism, the path of liberation from sufferings starts (...) with mind-control. The Jainas emphasize on right faith, right knowledge and right conduct which are regarded as Triratnas, three Jewels. Right conduct consists in abstinence from injury, falsehood, stealing, self-indulgence and attachment. According to Buddhism, way to Nirvan (cessation from suffering) consists in eight-fold path which is nothing but self-control. It starts from right views, right determination and right speech and proceeds through right conduct to right livelihood to right effort and to right mindfulness. This process of self-control finally culminates in right concentration. The Upanishadic thinkers and the systems based on Upanishadic traditions have also recognised the importance of self-control. In view of the importance of mind-control in familial, social, moral and spiritual lives we should consistently and constantly make endeavour to practice mind-control and should fight despondency with enthusiasm in the event of some initial failures. (shrink)

Democracy of consideration is a conceptual candidate, next to deliberative democracy. Consideration offers an interesting constellation. If we take the two directions in which consideration leads us, respect and careful examination, these two requirements, to be held together, promise and lead both to a quality of relations between participants of a discussion who feel considered, and to an epistemic quality, from several points of view (constellation), even disciplines and aspects of the issue. It gives rise to a sense of perspective, (...) pluralism, the process of examination, its cessation, and its stabilization “all things considered.” Consideration can be linked to all levels of a deliberative system, to tackle complex problems such as the fight against global warming. Indeed, it goes from individual decisions to international agreements and back again. Solving such a problem requires transitions understood as adjustments (responsiveness) between knowledge, institutions, and individuals, in the course of conversations, all things considered. (shrink)

In this issue of the Report, James L. Bernat proposes an innovative and sophisticated distinction to justify the introduction of permanent cessation as a valid substitute standard for irreversible cessation in death determination. He differentiates two approaches to conceptualizing and determining death: the biological concept and the prevailing medical practice standard. While irreversibility is required by the biological concept, the weaker criterion of permanence, he claims, has always sufficed in the accepted standard medical practice to declare death. Bernat (...) argues that the medical practice standard may be acceptable on the ground that proving circulatory or brain permanence is sufficient to assure complete accuracy for death diagnosis. -/- The topic requires public deliberation: processes to survey people's opinions and mechanisms to channel their opinions into policy-making. What is at stake is the nature of our society. Do we want an expertocracy, in which an enlightened few design policies for the greater good of the majority and exploit the lack of public knowledge to achieve compliance? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Socially Engaged BuddhismBrian KarafinSocially Engaged Buddhism. By Sallie B. King. Honolulu: University of Hawai‘i Press, 2009. 192 pp.In a chapter on the philosophical and ethical foundations of the socially engaged Buddhist movement, Sallie King retells a story from the Burmese liberation struggle against military dictatorship. The story was originally told by Aung San Suu Kyi (b. 1945), the Burmese Buddhist activist who is one of the several representative (...) figures (heroes and heroines) of King’s synoptic account of the modern tradition of Engaged Buddhism. An activist against the dictatorship, Uncle U Kyi Maung, being interrogated by officers of military intelligence as to why he had joined the National League for Democracy, the organization headed by Aung San Suu Kyi, Uncle Maung replied: “For your sake” (p. 32).This story of Buddhist resistance can stand as a representative anecdote for King’s useful history of Engaged Buddhism. The context is one of political oppression and torture, abuse of human rights and repression of democracy, and the attempt to respond to this historical situation from a perspective rooted in the traditional Buddhist spirituality of Asia in a fashion that makes that spirituality relevant to the crises of modernity. The interrogated activist responds to the threat of torture with courage rooted in a Buddhist spiritual practice, and thus is able to assert a political stance grounded in a compassionate recognition of his interdependence with the so-called enemy who is temporarily holding power over him. This constellation of factors illustrates the phenomenon of Engaged Buddhism: It is a form of Buddhist spirituality, not a departure from tradition but an application of traditional ideas—of compassion, interdependence, impermanence, no-self, karma, and others—to the modern period, and specifically to a modern Buddhist Asia riven by war, political oppression, ecological crisis, and capitalist globalization in economics and culture. [End Page 215] This application of Buddhist spirituality to modern Asian (and global, though King’s focus is on Asia) history represents an alternative form of politics, and specifically of political resistance: nonviolent, nonadversarial, rooted in indigenous Asian cultures rather than imported from the West (as would be the case with the various Marxist and liberal political ideologies also at play in the colonial and postcolonial period that saw the development of engaged Buddhism). This is a political resistance, in King’s presentation, grounded in compassion rather than justice, and thereby offering to global observers a significantly different slant on modern politics than the Western ideologies and movements, secular as well as religious.“Engaged Buddhism” as a term, says King, was coined by Thích Nhất Hạnh (b. 1926) in the context of the war in Vietnam. This was to be a form of Buddhism that drew on the traditional sources (wisdom that knows interdependence/emptiness and compassion that acts on that wisdom) but found skillful means to intervene concretely in the multiple crises related to the war: in the form of social service work including education, but also political activism to address the underlying causes of the war. King demonstrates with this example of Thích Nhất Hạnh and Vietnam the combination of traditional Buddhist ideas with modern contexts of practical application that characterize the movement as a whole. The template of the “four noble truths” is foundational to Thích Nhất Hạnh’s thought—suffering, its causes, the cessation of suffering and the path to that cessation. But in a world of war and political oppression the causes of suffering cannot be only located intra-psychically—yes, the afflictive mental states of greed, hatred, and delusion are the ultimate sources, but the deluded collective hatred that issues in war must be seen as a relatively autonomous factor calling for its own analysis and response. If the orphans of a bombed-out village can be said to suffer from afflictive mental states it is really the minds of those carrying out the bombing who must be transformed, and this obviously requires intervention into the political realm, given that the war makers are not themselves usually willing to sit down and explore the causes of their unskillful behavior. Hence, engaged Buddhism is Buddhism in... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Death and Dying in JapanRihito Kimura (bio)A majority of Japanese, at present, feel that the modern biomedical and technological innovations pertaining to human life and death have been forcing a change in our common understanding of what, historically, was simply the natural event and process of death and dying. The meaning of death and the dying process in our lives is changing as have the traditional criteria for determining (...) death, namely, cessation of heartbeat and respiration.An individual’s death should be a personal and private matter as well as a familial, communal, and social matter. It has been regarded as such for many thousands of years in our Japanese society and culture. It is well understood that our traditional socio-cultural understanding of human life positively admits the natural process of death as the final event of life. The ideas expressed in Zen-Buddhist phrases such as “accept death as it is” and “life-death as one phenomenon” have been key motifs totally integrated into our traditional understanding of life (Tomomatsu 1939).However, the traditional perception of death as an acceptable process has [End Page 374] been vanishing as the Japanese have applied modern biomedical technologies more frequently in well-equipped hospital settings. Although the involvement of family members in the process of dying and particularly in the death event continues in a variety of ways, the care of dying patients in Japan is becoming much more similar to that delivered in advanced hospital settings in many countries of the world, than it is different. Now, in Japan, a majority of people end their lives in the hospital, surrounded by high-technology machines. Yet, in a survey by the Yomiuri Shimbun of 15 June 1991, half of the respondents said they would prefer to die at home.In addition, there has been a tradition of not explaining to terminally ill people the true nature of their condition, on the ground that this is most appropriate way to proceed (Kashiwagi 1994, pp. 78–85). However, views on this matter are changing. There is a gradual move toward telling patients the truth, and the notion of informed consent has been widely publicized in the clinical setting (Leflar 1996, pp. 96–107). In the 1991 nationwide opinion poll by the Yomiuri Shimbun, 65 percent of the participants said that they would like to be given full diagnostic information about themselves even if they were terminally ill. Nevertheless, only 22 percent of the people questioned said they themselves would definitely be prepared to disclose such information to a family member.The same survey indicated that 78 percent of people considered palliative care desirable, even though it might shorten life, while 16 percent thought life should be sustained as long as possible, irrespective of the pain that patients might be suffering.Challenges of Care for the DyingA special task force on terminal care, set up by the Ministry of Health and Welfare, issued a report in 1989 that encouraged the disclosure of diagnostic information to patients, provided that consideration was given to patients’ life histories, personalities, relationships with family members, and other factors. The report favored the use of drugs for pain control; it also dealt with matters such as spiritual requirements and the care of the family members.Traditionally, the physician-patient relationship in Japan is based on a complete and unquestioning trust of the physician by the patient, such that the physician acts to make health care decisions on behalf of the patient (Kimura 1991). However, increasingly it is believed that people should not have to accept without question the authority of doctors in the treatment of disease. Responsibility for the care of the dying should be shared between family members and all health professionals, not only physicians. Changes are needed in the mentalities of health care providers, patients, and family members, and it must be recognized that the medical system and institutions are not immutable (Annas and Miller 1994, pp. 374–76). [End Page 375]To complicate matters even further, although a patient’s family is informed of the incurable nature of the disease affecting their family member, the patient, as noted above, usually is not told of... (shrink)

The development and deployment of medical devices, along with most areas of healthcare, has been significantly impacted by the COVID-19 pandemic. This has had variable ethical implications, two of which we will focus on here. First, medical device regulations have been rapidly amended to expedite approvals of devices ranging from face masks to ventilators. Although some regulators have issued cessation dates, there is inadequate discussion of triggers for exiting these crisis standards, and evidence that this may not be feasible. (...) Given the relatively low evidence standards currently required for regulatory approval of devices, this further indefinite reduction in standards raises serious ethical issues. Second, the pandemic has disrupted the usual operations of device representatives in hospitals, providing an opportunity to examine and refine this potentially ethically problematic practice. In this paper we explain and critically analyse the ethical implications of these two pandemic-related impacts on medical devices and propose suggestions for their management. These include an endpoint for pandemic-related adjustments to device regulation or a mechanism for continued refinement over time, together with a review of device research conducted under crisis conditions, support for the removal and replacement of emergency approved devices, and a review of device representative credentialling. (shrink)

In this paper I attempt to understand the implications of a kara's claim that liberation is not an action. If liberation is not an action, how is it up to us and therefore our responsibility? What role do actions have in a life concerned with liberation? The key to understanding a kara's view, I suggest, requires broad reflection on his claim in his commentary on Brahma S tra I.1.4 that cessation of action in accordance with Vedic prohibition is not (...) an action. I will conclude by discussing the implications of this interpretation on the nature of m y in a kara. (shrink)

In a recent paper— The disvalue of death in the global burden of disease 1—we question the commensurability of the two components of the disability-adjusted life year — years lived with disability and years of life lost —and offer a tentative solution to this problem. In an exciting and constructive reply— Is consistency overrated? 2—philosopher S Andrew Schroeder argues that our concern about the DALY may be missing the mark by accepting the DALY as what he refers to as an (...) index reflecting nothing ‘beyond the importance we place in each ’. According to Schroeder, our consistency requirement is then made redundant. Recall our main argument: the DALY is the arithmetical sum of two components, YLDs and YLLs. The YLDs represents the individual disease burden that occurs while we are alive, while YLLs represents the individual disease burden resulting from our death. ‘Death’, in this context, is not the process of dying, which happens within life and which is captured by YLDs, but rather the incidence in which the life of a person has ended. Understood this way, the DALY is the aggregate of life and death, and we argue that these are incommensurables. Why are YLDs and YLLs incommensurables? In our article, we present several reasons for this. Briefly, YLDs measure disease burden that happens to an individual, whether it be painful experiences or loss of function. YLDs have a duration and are usually something we experience, such as pain. YLLs, on the other hand, are instantly generated when the life of that individual has expired. We do not experience YLLs, and they happen where we are not. When YLLs are generated, the life in question has already ended. On a secular account, death is the irreversible cessation of the mind and the senses, and …. (shrink)

Declaration of cardiorespiratory death, as defined by the Uniform Determination of Death Act, requires irreversible cessation of circulatory and respiratory function. A physician’s ability to confidently declare death is paramount because death is both a biological and social construct, and can afford a dying patient the opportunity to be an organ donor via donation after circulatory death. Inconsistencies related to cardiorespiratory death and DCD include the specific language used in the UDDA, specifically the use of the word “irreversible”. Additionally, (...) in DCD there is a large focus on the auto-resuscitative capacity of the heart, however recently some have argued that instead the focus should shift to the brain and a determination of how long it needs to be without circulation to cease functioning prior to declaring death. In this paper, I discuss inconsistencies with cardiorespiratory death as they pertain to organ donation and posit several possible solutions to mitigate these inconsistencies. (shrink)

The current debate regarding the suitability of anencephalics as organ donors is due primarily to misunderstandings. The anatomical and neurophysiological literature shows that the anencephalic lacks a cerebrum because of the failure of neuralplate fusion. However, even the incomplete function of an atrophic brain stem is currently accepted at law in most if not all countries as sufficient for brain life: which is to say, cessation of breathing is currently required in order to make the diagnosis of brain death. (...) Because of the extensive incompleteness of the anencephalic's brain, it is not possible to postpone death significantly by mechanical ventilation and intravenous feeding. It is acceptable to maintain life for a short period of time in order to allow organ transplantation subsequent to the declaration of death at the point of cessation of the capacity for spontaneous respiration. The most important issue is not transplantation, but the issue of brain life raised by the case of anencephalics. Since brain life in any significant sense begins only after the closure of the neural tube on the 30th day after conception, it is reasonable to take this as the point at which brain life begins. Laws should be amended in all countries to allow the abortion of anencephalics at any time, in that they do not at any time possess brain life. Keywords: anencephaly, organ transplantation, beginning of life, brain death, abortion CiteULike Connotea Del.icio.us What's this? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Comment on Hospice of Washington's PolicyJohn A. Robertson (bio)The recent history of medical ethics may accurately be described as a history of coming to terms with personal autonomy and informed consent across the range of medical practice. Nowhere has this recognition been more important than in decisions to withhold or withdraw life-sustaining medical procedures from terminal and chronically ill patients.Despite the widespread acceptance of autonomy in these decisions, many (...) people—physicians, families, and policymakers—have balked at extending it to the withdrawal of artificially supplied fluids and nutrition. The symbolic connotations of food and water have led some persons to perceive cessation of medically-supplied fluids and nutrition to be a cruel, barbarous act, rather than the merciful respect for the dying patient that such withdrawal usually represents.Two recent events might help resolve the controversy, and ensure that decisions about artificial fluid and nutrition are handled like any other medical intervention—according to patient and family choice and patient welfare. One event is the Supreme Court decision in Cruzan (Cruzan v. Director of Missouri Department of Health, 110 S.Ct. 2841, 1990). Although the Supreme Court upheld Missouri's constitutional power to require artificial nutrition for a patient in a persistent vegetative state, its decision was not based on the symbolic importance of artificial fluids and nutrition. No Supreme Court justice saw a significant difference between medically-supplied nutrition and hydration and other medical interventions, thus allowing them to be discontinued either directly or by advance directive on the same basis as other medical interventions.The second event is the publication of the statement of "Philosophy Regarding Medical Intervention to Supply Fluids and Nutrition" by Hospice of Washington (or similar statements by other organizations). This statement is useful and important because it removes the issue of food and water from its symbolic overlay [End Page 139] and places it in the real context of dying hospice patients. It makes clear that the overriding consideration should be benefit to the patient "in accord with the patient's wishes or those of the appropriate surrogate(s) for the patient." Depending on those wishes and their impact on the patient, this position may or may not involve medically-supplied fluids and nutrition.This statement is also helpful in showing the medical complexity of such decisions in terms of their actual effect on dying patients. Rather than an either/or position, it recognizes that fluids may harm a dying patient by increasing discomfort, and that "persons near death do not ordinarily tolerate substantial volumes of enteral feedings." Thus rather than adhere to a symbolically-based position about the meaning of food and water to a dying patient, the important thing is to look to that patient's needs and give fluids or not, as the patient's wishes and situation demand.Fortunately, the law in most jurisdictions will recognize such a position. In those few jurisdictions that have made a fetish of artificial fluids and nutrition, the law should be changed, for the HOW statement makes clear that such a position may actually end up harming dying patients. Patient welfare should be privileged above all else, and patient welfare may often entail that fluids and nutrition not be medically supplied. Even then, however, caregivers will look to patient comfort and remedy dry mouths and lips with lubricants and ice chips.The HOW statement is, in my view, a very useful guideline not only for hospices but for hospitals, too—for any situation in which a patient is terminally ill and soon to die. A somewhat different set of issues arises, however, when the patient is chronically ill and incompetent, and will survive for long periods with medically-supplied fluids and nutrition. Recognition of patient rights in those situation should also permit cessation of fluids and nutrition on the same basis that respirators, antibiotics, and other life-sustaining measures may be withheld. But the withholding of medically-supplied fluids and nutrition from a patient who no longer has interests in surviving in an extremely debilitated condition raises different issues from withholding fluids that could cause such discomfort and nutrition when the patient is imminently dying. In either case, patient... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:The Christian Art of Dying: Learning from Jesus by Allen VerheyMandy Rodgers-GatesThe Christian Art of Dying: Learning from Jesus By Allen Verhey GRAND RAPIDS: WILLIAM B. EERDMANS, 2011. 423 PP. $30.00When Allen Verhey, my former adviser, learned that I would be writing this review, he warned me (with characteristic modesty) that I ought to be careful to critique something about his book, or people might become suspicious. It (...) seems fitting now that this piece is being published after his death, which gives me permission to praise the book without reserve.Over the last few decades, the topic of death and dying has garnered renewed interest among Christian ethicists, and Verhey has been at the center of these conversations. Such conversations have brought into focus the reality that death is not merely the cessation of a life lived well (the “true” subject of ethics) but also that “dying well” is a legitimate subject within ethics. Dying offers unique opportunities for practicing virtues and for loving God, self, and neighbor, and care for the dying and grieving represents an important test of the faithfulness of Christian communities.After beginning with his own assessment of death in the modern West—acknowledging the benefits and triumphs of medicine, along with the pitfalls of medicalized death and the failure of the Church to resist medicalization—Verhey moves to the heart of his book: a retrieval of the Ars Moriendi tradition. Verhey engages a fifteenth-century abridged manual on the art of dying that appeared within the wider genre, one accompanied by wood-block prints (whose images appear alongside Verhey’s text). Placing the little book within its historical context, Verhey describes the view of death presented in it, a “commendacion” of death. He then moves on to the Ars Moriendi’s presentation of temptations faced by the dying person (“Moriens”), the virtues required, and questions, instructions, and prayers for the dying. Along the way, Verhey offers some of his own analysis; but he reserves the bulk of his critique and reformulations for the third section of his book, “Toward a contemporary Ars Moriendi.”Verhey’s articulation of a contemporary Ars Moriendi begins with a “commendacion” of life, in contrast to the medieval commendation of death. He demonstrates how the lens of Jesus’s resurrection serves to illuminate a proper Christian view of death: life is a good—though not the ultimate good—and death and suffering per se ought not to be considered good. At the same time, we need not fear death. Death and suffering are not the greatest evils, and [End Page 191] sometimes they must be risked or accepted “for the sake of God’s cause in the world” (215). Taking its cue from the Ars Moriendi tradition of remembering Jesus, the next chapter traces some of the details of the Passion narratives, including the seven final words of Jesus, and comments on these as they pertain to a modern context of dying. This remembering is then brought to bear on a contemporary retelling of the virtues necessary for dying well—again, relying upon and yet transforming the earlier tradition in nuanced ways. Verhey’s final section, on Christian communities’ care for the dying, includes sustained reflection on the practices of those communities and the resources they offer, focusing particularly on prayer. It offers critiques and additions—for example, recognizing the value of increased silence at funerals, “instead of rushing to fill the silence of death with our words” (348).Verhey’s engagement with the Ars Moriendi literature offers a creative and exemplary use of tradition for a contemporary concern. Our age—one that often refuses to face death—is brought into conversation with another era, when people took their dying seriously. At the same time, Verhey is free with his critique of the tradition and the need to reshape it, primarily on theological grounds. The strength of this book, like all his work, lies in its attention to scripture and its theological nuance and depth. At the same time, he knew and understood people, and that knowledge and pastoral concern are evident throughout. Ultimately, he accomplishes what he expresses in the introduction: “I hope... (shrink)

The current debate regarding the suitability of anencephalics as organ donors is due primarily to misunderstandings. The anatomical and neurophysiological literature shows that the anencephalic lacks a cerebrum because of the failure of neuralplate fusion. However, even the incomplete function of an atrophic brain stem is currently accepted at law in most if not all countries as sufficient for brain life: which is to say, cessation of breathing is currently required in order to make the diagnosis of brain death. (...) Because of the extensive incompleteness of the anencephalic's brain, it is not possible to postpone death significantly by mechanical ventilation and intravenous feeding. It is acceptable to maintain life for a short period of time in order to allow organ transplantation subsequent to the declaration of death at the point of cessation of the capacity for spontaneous respiration. The most important issue is not transplantation, but the issue of brain life raised by the case of anencephalics. Since brain life in any significant sense begins only after the closure of the neural tube on the 30th day after conception, it is reasonable to take this as the point at which brain life begins. Laws should be amended in all countries to allow the abortion of anencephalics at any time, in that they do not at any time possess brain life. (shrink)

There are not many public health issues where views are as extremely polarized as those concerning vaccination policies. Ever since its Fast Track approval by the U.S. Food and Drug Administration in 2006, Merck's human papilloma virus vaccine Gardasil has been sparking controversy. Initially, the criticism has been focused at Merck, due to their overly aggressive marketing strategies and lobbying campaigns. According to a 2007 editorial in Nature Biotechnology, Surrounded by a chorus of disapproval, Merck cracked. As Nature Biotechnology went (...) to press, the company announced a cessation of all efforts to lobby for US state laws requiring compulsory vaccination. Subsequently, questions have been raised whether it was appropriate for vaccine manufacturers to partake in public health policies when their conflicts of interests were so obvious. Some of their advertising campaign slogans, such as cervical cancer kills x women per year and your daughter could become one less life affected by cervical cancer, seemed more designed to promote fear rather than evidence-based decision making about the potential benefits of the vaccine versus any risks. (shrink)

According to the Fine-Tuning Argument, the existence of life in our universe confirms the Multiverse Hypothesis. A standard objection to FTA is that it violates the Requirement of Total Evidence. I argue that RTE should be rejected in favor of the Predesignation Requirement, according to which, in assessing the outcome of a probabilistic process, we should only use evidence characterizable in a manner available before observing the outcome. This produces the right verdicts in some simple cases in which (...) RTE leads us astray, and, when applied to FTA, it shows that our evidence does confirm HM. (shrink)

Constitutivists explicitly emphasize the importance of self-reflection for rational agency. Interestingly enough, there is no clear account of how and why self-reflection plays such an important role for these views. My aim in this paper is to address this underappreciated problem for constitutivist views and to determine whether constitutivist self-reflection is normatively oriented. Understanding its normative features will allow us to evaluate a potential way that constitutivism may meet its purported metaethical promise. I begin by showing why constitutivism, as exemplified (...) by Korsgaard’s and Velleman’s respective views, takes self-reflection to be a constitutive feature of rational agency. Closer examination of this claim suggests three underappreciated problems for the constitutivist’s apparent reliance on self-reflection. First, we have no picture of the specific role that self-reflection plays. Second, it is unclear in what sense it is a requirement for full-fledged agency and, thereby, for self-constitution. Third, it is not clear whether it has any necessary normative features, even given the often cited moral normativity associated with constitutivism. In §1, I will address the first and second questions. §2 will be dedicated to considering the third question. (shrink)

The most recent restatements of stakeholder theory formulate that approach in terms of the distribution of value: “A stakeholder approach to business is about creating as much value as possible for stakeholders, without resorting to tradeoffs” (Freeman et al. 2010: 28). This formulation marks a shift from earlier work, which included a procedural dimension—a requirement that stakeholders participate in organization decision making. The present paper pushes back against this shift: it argues that orienting the stakeholder approach around the participation (...) requirement provides for a different moral logic, one not available to (now) conventional stakeholder theorizing (without that requirement), and one that may be more compelling to many. This argument requires critical re-examination of the moral arguments offered in the most recent restatements of the stakeholder approach. (shrink)

Autonomy is one of the most contested concepts in philosophy and psychology. Much of the disagreement centers on the form of reflexivity that one must have to count as genuinely self-governing. In this essay, we argue that an adequate account of autonomy must include a distinct requirement of accurate self-assessment, which has been largely ignored in the philosophical focus on agents' ability to evaluate the desirability of acting on certain impulses or values. In our view, being autonomous (i.e., self-guiding) (...) involves understanding the extent to which one has the capacities required for one's intended actions. On both clinical grounds (drawn from cases of frontal brain injury) and conceptual grounds, we argue that one's autonomy is diminished to the extent to which one's ability to assess one's capacities is impaired. (shrink)

In Liberalism without Perfection, Jonathan Quong develops what is perhaps the most comprehensive defense of the consensus model of public reason – a model which incorporates both a public-reasons-only requirement and an accessibility requirement framed in terms of shared evaluative standards. While the consensus model arguably predominates amongst public reason liberals, it is criticized by convergence theorists who reject both the public-reasons-only requirement and the accessibility requirement. In this paper, I argue that while we have good (...) reason to reject Quong’s call for a public-reasons-only requirement, all public reason liberals should endorse at least some shared evaluative standards and, hence, an accessibility requirement. (shrink)

The distinction between propositional and doxastic justification is the distinction between having justification to believe P (= propositional justification) versus having a justified belief in P (= doxastic justification). The focus of this paper is on doxastic justification and on what conditions are necessary for having it. In particular, I challenge the basing demand on doxastic justification, i.e., the idea that one can have a doxastically justified belief only if one’s belief is based on an epistemically appropriate reason. This demand (...) has been used to refute versions of coherentism and conservatism about perceptual justification as well as to defend phenomenal “conservatism” and other views besides. In what follows I argue that there is virtually no reason to think there is a basing demand on doxastic justification. I also argue that even if the basing demand were true, it would still fail to serve the dialectical purposes for which it has been employed in arguments concerning coherentism, conservatism, and phenomenal “conservatism”. I conclude by discussing the fact that knowledge has a basing demand and show why this needn’t raise the same sort of problems for coherentism and conservatism that doxastic justification’s basing demand seemed to. (shrink)

A dogma accepted in many ethical, religious, and legal frameworks is that the reasons behind conscientious objection (CO) in healthcare cannot be evaluated or judged by any institution because conscience is individual and autonomous. This paper shows that this background view is mistaken: the requirement to reveal and explain the reasons for conscientious objection in healthcare is ethically justified and legally desirable. Referring to real healthcare cases and legal regulations, this paper argues that these reasons should be evaluated either (...) ex ante or ex post and defends novel conceptual claims that have not been analyzed in the debates on CO. First, a moral threshold requirement: CO is only justified if the reasons behind a refusal are of a moral nature and meet a certain threshold of moral importance. Second, this paper considers the rarely discussed conceptual similarities between CO in healthcare and the legal regulations concerning military refusals that place the burden of proof on conscientious objectors. This paper concludes that conscientious objection in healthcare can be accommodated only in some cases of destroying or killing human organisms. (shrink)