This chapter contains sections titled: Weighing the Value of Meat Stalking the Essence of Hunting Same As It Ever Was The End of Hunting Notes.

Currently in Japan, it is extremely difficult to realize the basic wish of protecting personal dignity at the end of life. A patient’s right to refuse life-sustaining treatment has not been substantially warranted, and advance directives have not been legally enforceable. Unfortunately, it is not until the patient is moribund that all concerned parties start to deliberate on whether or not death with dignity should be pursued. Medical intervention is often perceived as a worthwhile goal to not only preserve life, (...) but also provide psychological benefit to the family, regardless of its effect on the patient. To feel they are doing something, family members tend to act against the imperative “Do not inflict on others what you would not wish done to you,” and permit extraordinary measures they would not want themselves. Another complication in Japanese culture is the necessity of unanimous decisions for end-of-life care. If there is conflict between a patient and his/her family on accepting medical intervention, the view of the latter is more likely to prevail due to different perceptions of human dignity. As a result, incapacitated patients in Japanese clinical settings often suffer through extraneous medical procedures, particularly during end-of-life care. Patient dignity is in danger from a national refusal to accept major bioethical principles such as having respect for patient autonomy, serving the best interests of the patient, doing no harm, and ensuring fairness at the end of life. We argue that more education about human dignity and legislation for death with dignity are necessary. Peace of mind for patients during end-of-life care will never be achieved in this society unless drastic changes take place in medical ethics and law. (shrink)

Modern medicine provides unprecedented opportunities in diagnostics and treatment. However, in some situations at the end of a patient’s life, many physicians refrain from using all possible measures to prolong life. We studied the incidence of different types of treatment withheld or withdrawn in 6 European countries and analyzed the main background characteristics.

Social, legal and health-care changes have created an increasing need for ethical review within end-of-life care. Multiprofessional clinical ethics committees (CECs) are increasingly supporting decision-making in hospitals and hospices. This paper reports findings from an analysis of formal summaries from CEC meetings, of one UK hospice, spanning four years. Using qualitative content analysis, five themes were identified: timeliness of decision-making, holistic care, contextual openness, values diversity and consensual understanding. The elements of an engaged clinical ethics in a hospice context is (...) not generally acknowledged nor its elements articulated. Findings from this study have the potential to explain some of the most challenging ethical problems and to contribute to their resolution. It may also guide future deliberation and raise CEC members' awareness of the recurrent issues and values of their CEC practice. (shrink)

The paper attempts to account for the confusion over the validity of the concept of schizophrenia in terms of two closely related aspects of conceptual indeterminacy. Firstly, it is identified on the basis of a breakdown in intelligibility, but what constitutes such a breakdown is indeterminate. Secondly, the concept sits between the categories of natural disease or illness on the one hand, and character trait or moral failing or gift on the other. This entails an indeterminacy in attempting to define (...) the role that physiological explanation could have. Light may be thrown on the concept by exploring a distinction between a life story in which the schizophrenic condition emerges as the conclusion of the story and a causal process in which the condition is the end result or final consequence. (shrink)

Background In the ethical and clinical literature, cases of parents who want treatment for their child to be withdrawn against the views of the medical team have not received much attention. Yet resolution of such conflicts demands much effort of both the medical team and parents. Objective To discuss who can best protect a child9s interests, which often becomes a central issue, putting considerable pressure on mutual trust and partnership. Methods We describe the case of a 3-year-old boy with acquired (...) brain damage due to autoimmune-mediated encephalitis whose parents wanted to stop treatment. By comparing this case with relevant literature, we systematically explored the pros and cons of sharing end-of-life decisions with parents in cases where treatment is considered futile by parents and not (yet) by physicians. Conclusions Sharing end-of-life decisions with parents is a more important duty for physicians than protecting parents from guilt or doubt. Moreover, a request from parents on behalf of their child to discontinue treatment is, and should be, hard to over-rule in cases with significant prognostic uncertainty and/or in cases with divergent opinions within the medical team. (shrink)

The term “euthanasia” is used in conflicting ways in the bioethical literature, as is the term “assisted suicide,” resulting in definitional confusion, ambiguities, and biases which are counterproductive to ethical and legal discourse. I aim to rectify this problem in two parts. Firstly, I explore a range of conflicting definitions and identify six disputed definitional factors, based on distinctions between (1) killing versus letting die, (2) fully intended versus partially intended versus merely foreseen deaths, (3) voluntary versus nonvoluntary versus involuntary (...) decisions, (4) terminally ill versus non-terminally ill patients, (5) patients who are fully conscious versus those in permanent comas or persistent vegetative states, and (6) patients who are suffering versus those who are not. Secondly, I distil these factors into six “building blocks” and combine them to develop an unambiguous, value-neutral taxonomy of “end-of-life practices.” I hope that this taxonomy provides much-needed clarification and a solid foundation for future ethical and legal discourse. (shrink)

Weberís sociology of inner-worldly mysticism, Almaasí recent synthesis of transpersonal and psychoanalytic object relations theory, and Jungís related metaphorical psychology of alchemy, are brought to bear on the development of Heideggerís evocations of the felt sense of Being between 1927 and 1946, understood as the noetic core of spirituality. In particular, Heideggerís assumption of the Nazi rectorship at Freiburg in 1933ñ34 is seen as a specifically spiritual crisis based on the "metapathological" grandiosity that can result from the miscarriage of self (...) realization in inner-worldly mysticism. In Heideggerís case, as in much contemporary spirituality, this crisis was intensified by pre-existent narcissistic vulnerabilities of character. Heideggerís later writings are considered as expressions of a more genuine spiritual or essential realization, which, while invaluable as a conceptual framework for transpersonal psychology, nonetheless stops short of a balanced personal integration. This analysis constitutes a specific example of how the combination of transpersonal psychology and psychodynamics can be used to understand the emotional conflicts stirred up by transpersonal realization and the resultant potential for distortion in modern spiritual development, as presented by Hunt. (shrink)

Objectives: To discover the current state of opinion and practice among doctors in Victoria, Australia, regarding end-of-life decisions and the legalisation of voluntary euthanasia. Longitudinal comparison with similar 1987 and 1993 studies.Design and participants: Cross-sectional postal survey of doctors in Victoria.Results: 53% of doctors in Victoria support the legalisation of voluntary euthanasia. Of doctors who have experienced requests from patients to hasten death, 35% have administered drugs with the intention of hastening death. There is substantial disagreement among doctors concerning the (...) definition of euthanasia.Conclusions: Disagreement among doctors concerning the meaning of the term euthanasia may contribute to misunderstanding in the debate over voluntary euthanasia. Among doctors in Victoria, support for the legalisation of voluntary euthanasia appears to have weakened slightly over the past 17 years. Opinion on this issue is sharply polarised. (shrink)

Theoretical and empirical research in bioethics frequently focuses on ethical dilemmas or problems. This paper draws on anthropological and phenomenological sources to develop an alternative framework for bioethical enquiry that allows examination of a broader range of how the moral is experienced in the everyday lives of individuals and groups. Our account of moral experience is subjective and hermeneutic. We define moral experience as “Encompassing a person's sense that values that he or she deem important are being realised or thwarted (...) in everyday life. This includes a person's interpretations of a lived encounter, or a set of lived encounters, that fall on spectrums of right-wrong, good-bad or just-unjust”. In our conceptualisation, moral experience is not limited to situations that are heavily freighted with ethically-troubling ramifications or are sources of debate and disagreement. Important aspects of moral experience are played out in mundane and everyday settings. Moral experience provides a research framework, the scope of which extends beyond the evaluation of ethical dilemmas, processes of moral justification and decision-making, and moral distress. This broad research focus is consistent with views expressed by commentators within and beyond bioethics who have called for deeper and more sustained attention in bioethics scholarship to a wider set of concerns, experiences and issues that better captures what is ethically at stake for individuals and communities. In this paper we present our conceptualisation of moral experience, articulate its epistemological and ontological foundations and discuss opportunities for empirical bioethics research using this framework. (shrink)

The use of deception and dishonesty is widely accepted as a fact of life in policing. This paper thus defends a counterintuitive claim: Good faith is a normative foundation for the police as a political institution. Good faith is a core value of contracts, and policing is contractual in nature both broadly (as a matter of social contract theory) and narrowly (in regard to concrete encounters between law enforcement officers and the public). Given the centrality of good faith to policing, (...) dishonesty and deception on par with fraud are justified only as a narrowly circumscribed investigative tool that is constrained by institutional commitments to the fair distribution of security and the rule of law. The practical upshot is the preclusion of most dishonest and deceptive police tactics on par with fraud, leading to an institution that is less proactive and more reactive. (shrink)

While ethical conflicts in the provision of healthcare are common, the current third-party mediator model is limited by a lack of expert ethical mediators, who are often not on site when conflict escalates. In order to improve clinical outcomes in situations such as conflicts at the end of life, we suggest that clinicians—physicians, nurses and social workers—be trained to prevent and deescalate emerging conflicts. This can be achieved using a mediation model framed by a communication-training approach. A case example is (...) presented and the model is discussed. The implication of this preventative/early intervention model for improving clinical outcomes, in particular end-of life conflict, is considered. (shrink)

The thesis of this paper is that Platonic Forms are angels. I make this identification by claiming that Platonic Forms have the characteristics of angels, in particular, that Platonic Forms are alive. I offer four arguments for this claim. First, it seems that engaging in self-directed action is a sufficient condition for being alive. The Forms are, as teleological activities, self-directed actions. Second, bodies receive their being from their Forms, and some bodies are essentially alive. Third, in the Good, all (...) the types of goodness, including life, are identical. The Forms are appearances of the Good. Fourth, since the Good imparts as much goodness as it can, the Forms are alive unless there is some bar to their being alive. There are good reasons to think that there is no such bar. I then show that ethical vices do not give body to human form, but give body to other forms—those that are evil angels. Lastly, I provide a survey of the relationships that various religious traditions posit between ethical vice and the demonic. (shrink)

While pharmaceutical industry involvement in producing, interpreting, and regulating medical knowledge and practice is widely accepted and believed to promote medical innovation, industry-favouring biases may result in prioritizing corporate profit above public health. Using diabetes as our example, we review successive changes over forty years in screening, diagnosis, and treatment guidelines for type 2 diabetes and prediabetes, which have dramatically expanded the population prescribed diabetes drugs, generating a billion-dollar market. We argue that these guideline recommendations have emerged under pervasive industry (...) influence and persisted, despite weak evidence for their health benefits and indications of serious adverse effects associated with many of the drugs they recommend. We consider pharmaceutical industry conflicts of interest in some of the research and publications supporting these revisions, and in related standard-setting committees and oversight panels. We raise concern over the long-term impact of these multifaceted involvements. Rather than accept industry conflicts of interest as normal, needing only to be monitored and managed, we suggest challenging that normalcy, and ask: what are the real costs of tolerating such industry participation? We urge the development of a broader focus to fully understand and curtail the systemic nature of industry’s influence over medical knowledge and practice. (shrink)

Background Making the right decisions, while simultaneously showing respect for patient autonomy, represents a great challenge to nursing home staff in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation to dying patents in end-of-life. Objectives To study how physicians and nurses protect nursing home patients' autonomy in end-of-life decisions, and how they justify their practice. Design A qualitative descriptive design with analysis of the content of transcribed in-depth interviews with physicians and nurses. Participants Nine physicians and ten nurses in (...) 10 nursing homes in Norway. Results and interpretations Assessment of the patient's competence to consent to treatment is almost absent. The physicians build their practice on the principles of beneficence and nonmaleficence. Nurses tend to trust the patients' rejection of life support, even when the patients have difficulty speaking or suffer from dementia. Relatives were, according to the health personnel, included in decision-making processes to a very limited extent. However, futile life support is sometimes provided contrary to the physicians' judgement of what constitutes the patient's best interest on occasions when they are pressurised by next of kin. Conclusions The study reveals a need to improve decision-making routines according to ethical ideals and legislation. Conflicts between relatives and healthcare professionals in the decision-making process deflect the focus from searching for the best possible treatment for the terminal patient. Further discussion is required as to whether the concept of autonomy is applicable in situations in which the patient is impaired and dying. (shrink)

The central claim of this paper is that American states’ use of so-called “triggering conditions” to regulate surrogate decision-making authority in end-of-life care leaves unresolved a number of important ethical and legal considerations regarding the scope of that authority. The paper frames the issue with a case set in a jurisdiction in which surrogate authority to withdraw life-sustaining treatment is triggered by two specific clinical conditions. The case presents a quandary insofar as the clinical facts do not satisfy the triggering (...) conditions, and yet both the appropriate surrogates and the care team agree that withdrawal of life-sustaining treatment is in the best interest of the patient. The paper surveys applicable law across the 50 states and weighs the arguments for and against the inclusion of such triggering conditions in relevant legal regimes. The paper concludes by assessing the various legal and policy options states have for regulating surrogate decision-making authority in light of the moral considerations, and notes the possibility for conflict within ethics teams arising from the potential tension between prudence, risk-aversion, and moral obligation. (shrink)

In the early 1970s, we and others in the economics profession became enamored with the notion of externalties—a cost or benefit imposed on or provided to others but not taken into account by the economic agents who generate the effect. We, and others, seemed to see external effects everywhere. There was polluted water and air, noise, urban blight, traffic congestion, and other features of modern life that seemed to call out for some form of corrective action. As the externalities revolution (...) unfolded, economists and other social scientists overlooked the importance of evolved legal and other institutions that formally and informally establish property and liability rules that cause decision makers to face the cost of their actions, including what otherwise could be external costs imposed on unwilling third parties. While markets seemed always to fail, political institutions were seen systematically as without blemish, or so it seemed. It was this two-pronged failure, 1) a failure to consider and state assumptions about background institutional arrangements and 2) a disregard for special interest politics, that became the Achilles Heel of the otherwise elegant externality arguments. Eventually, it was the modern institutionalists, scholars who focused on laws, regulation, and rules of the marketplace, who attempted to close the lid and drive the nails on the externality coffin. In this paper, we reach back to 1920 and trace the rise and decline of the policy importance of externalities theory. Beginning with A. C. Pigou and Alfred Marshall, our story includes some of the great figures in economic history of thought. But while theory was being built, institutions were overlooked. Pigou continues to be a dominant player in the story until the 1960s and 1970s when externalities theory was challenged by James M. Buchanan, Ronald Coase and other scholars. It is here in the twilight years of the externalities revolution that the prospects of government failure are raised as being more daunting than the likelihood of market failure. Finally, in the late 1970s and beyond, the externalities revolution is replaced by a property rights revolution. (shrink)

Because an increasing number of patients have medical conditions that render them incompetent at making their own medical choices, more and more medical choices are now made by surrogates, often patient family members. However, many studies indicate that surrogates often do not discharge their responsibilities adequately, and in particular, do not choose in accordance with what those patients would have chosen for themselves, especially when it comes to end-of-life medical choices. This chapter argues that a significant part of the explanation (...) of such surrogate failure is that family surrogates are likely to undergo anticipatory grief when making end-of-life decisions. After clarifying both the emotional structure and object of grief, I propose that the pending death of a loved one induces an emotional conflict in surrogates between the care demanded by their responsibility as surrogates and the attachment surrogates feel toward their dying loved one, an attachment surrogates "resolve" in the direction of attachment rather than care. This hypothesis helps to explain both surrogates' general inability to exercise "substituted judgment" on behalf of their loved ones and a wide swath of the particular data regarding this inability (e.g., that surrogates more often err by choosing overtreatment). I conclude by considering possible clinical and philosophical responses to this hypothesis. (shrink)

The ethics of adolescent decision making is a complicated mine­field with laws that vary from state to state. The case of a fourteen-year-old girl, who simultaneously was diagnosed with cancer and discovered she was pregnant, highlights several weaknesses in our current approach to adolescent decision making in the context of pregnancy. In addition, adolescents with life-limiting conditions face similar challenges that can be examined through the framework of Catholic doctrine.

For a little more than a decade, professional organizations and healthcare institutions have attempted to develop guidelines and policies to deal with seemingly intractable conflicts that arise between clinicians and patients (or their proxies) over appropriate use of aggressive life-sustaining therapies in the face of low expectations of medical benefit. This article suggests that, although such efforts at conflict resolution are commendable on many levels, inadequate attention has been given to their potential negative effects upon particular groups of patients/proxies. Based (...) on the well-documented tendency among many African Americans to prefer more aggressive end-of-life medical interventions, it is proposed that the use of institutional policy to break decision making impasse in cases for which aggressive treatment is deemed "medically inappropriate" will fall disproportionately on that group. Finally, it is suggested that the development and application of institutional conflict-resolution policies should be evaluated in the context of historical and current experiences of marginalization and disempowerment, lest such policies exacerbate that experience. (shrink)

Introduction Hundreds of thousands of premature neonates born in low-income countries are implicitly denied treatment each year. Studies from India show that treatment is rationed even for neonates born at 32 gestational age weeks (GAW), and multiple external factors influence treatment decisions. Is withholding of life-saving treatment for children born between 28 and 32 GAW acceptable from an ethical perspective? Method A seven-step impartial ethical analysis, including outcome analysis of four accepted priority criteria: severity of disease, treatment effect, cost effectiveness (...) and evidence for neonates born at 28 and 32 GAW. Results The ethical analysis sketches out two possibilities: (a) It is not ethically permissible to limit treatment to neonates below 32 GAW when assigning high weight to health maximisation and overall health equality. Neonates below 32 GAW score high on severity of disease and efficiency and cost-effectiveness of treatment if one gives full weight to early years of a newborn life. It is in the child's best interest to be treated. (b) It can be considered ethically permissible if high weight is assigned to reducing inequality of welfare and maximising overall welfare and/or not granting full weight to early years of newborns is considered acceptable. From an equity-motivated health and welfare perspective, we would not accept (b), as it relies on accepting the lack of proper welfare policies for the poor and disabled in India. Conclusion Explicit priority processes in India for financing neonatal care are needed. If premature neonates are perceived as worth less than other patient groups, the reasons should be explored among a broad range of stakeholders. (shrink)

The central claim of this paper is that American states’ use of so-called “triggering conditions” to regulate surrogate decision-making authority in end-of-life care leaves unresolved a number of important ethical and legal considerations regarding the scope of that authority. The paper frames the issue with a case set in a jurisdiction in which surrogate authority to withdraw life-sustaining treatment is triggered by two specific clinical conditions. The case presents a quandary insofar as the clinical facts do not satisfy the triggering (...) conditions, and yet both the appropriate surrogates and the care team agree that withdrawal of life-sustaining treatment is in the best interest of the patient. The paper surveys applicable law across the 50 states and weighs the arguments for and against the inclusion of such triggering conditions in relevant legal regimes. The paper concludes by assessing the various legal and policy options states have for regulating surrogate decision-making authority in light of the moral considerations, and notes the possibility for conflict within ethics teams arising from the potential tension between prudence, risk-aversion, and moral obligation. (shrink)

Baumard proposes that life history slowing in populations over time is the principal driver of innovation rates. We show that this is only true of micro-innovation rates, which reflect cognitive and economic specialization as an adaptation to high population density, and not macro-innovation rates, which relate more to a population's level of general intelligence.

In lieu of an abstract, here is a brief excerpt of the content:Thus Spake Howard Roark:Nietzschean Ideas in The FountainheadLester H. HuntIThe position I will be taking here will seem very peculiar to many people. I will be treating a novel as a discussion of the work of a philosopher—namely, Friedrich Nietzsche. Worse yet, I will be treating it as a discussion that is philosophically penetrating and deserves to be taken seriously. Still worse, the novel is Ayn Rand's early novel (...) The Fountainhead. I think it is safe to say that her reputation, among academics who discuss the works of philosophers, is very low. If the reader will only bear with me, though, I think I can make a case that Rand opens a line of inquiry about Nietzsche's ideas and values that is not only quite interesting in itself but one that ought to be pursued further by others.There has always been ample reason to associate Nietzsche with The Fountainhead.1 He is after all, the only philosopher who is more or less directly quoted in the book.2 Beyond that, Rand's novel has many other passages that students of Nietzsche instantly recognize as conscious references to him or deliberate echoes of his style. In addition, she revealed, in an introduction written for the twenty-fifth anniversary edition, that the following quotation from Beyond Good and Evil had originally stood at the head of the book when it was still in manuscript:It is not the works, but the belief which is here decisive and determines the order of rank to—employ once more an old religious formula with a new and deeper meaning—it is some fundamental certainty which a noble soul has about itself, something which is not to be sought, is not [End Page 79] to be found, and perhaps, also, is not to be lost—The noble soul has reverence for itself.—3She said, in the same introduction, that she removed the quotation (evidently, immediately before publication) for philosophical reasons, because of her "profound disagreement with the philosophy of its author." Nietzsche, she says, was fundamentally "a mystic and irrationalist," and even in this quotation, chosen for its content, insinuates a philosophical position that she regards as erroneous (namely, determinism). Even her statement of what she likes about this passage is rather constrained: "as a poet [ie., not as a philosopher], he projects at times (not consistently) a magnificent feeling for man's greatness, expressed in emotional, not intellectual terms."4It is of course true enough that Rand does disagree with Nietzsche, and for more or less the reasons that she suggests here, but it is also true that the passage she has quoted expresses some ethical themes—nobility, order of rank, the "pathos of distance," and (most obviously) the idea of self-reverence as a characteristic of the ethically good—which are at least as important in The Fountainhead as they are in Nietzsche's writings. Though Rand's spirited disclaimer serves to remind us of her deep differences with Nietzsche, the quotation itself suggests that there might be an interesting philosophical, not merely literary or emotional, connection between The Fountainhead and Nietzsche's ideas. What I would like to show here is that this connection merits a much closer look than it has ever been given heretofore. Not only is the presence of Nietzschean themes in Rand's novel deep and pervasive, but the book actually contains a very interesting and powerful internal critique of one of Nietzsche's most characteristic ideas, a criticism based in large part on values and assumptions that he shares. Before I can set out this critique, I will need to explore some of the positive thematic and philosophical connections.IIOne evening, rather late in the novel, Gail Wynand, the corrupt newspaper publisher and financier, surprises his wife, Dominique, with a present: he has had an architect design a house for them. The architect, she realizes with shock as she sees the drawings for the house, is her former lover, Howard Roark, a man with whom she is still in love. None of this is known to her husband, who innocently tells her that [End Page 80] Roark... (shrink)

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding (...) medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed. (shrink)

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

In lieu of an abstract, here is a brief excerpt of the content:Calling Obesity a Disease Is A Terrible DecisionMoose FinklesteinFactsThe medical world struggles to see the difference between health and body weight. It is still mostly combined with the strong belief that there is no way a fat person can be fit and healthy. Despite repeated studies and work to show differently, this prejudice remains. This has become part of what I call “Everyone Knows” pseudoscience, where data that (...) have no scientific basis become “fact” due to constant repetition.Obesity is already the cause of great stigma in our society. Fat people are considered “ugly,” fat jokes are acceptable in everyday life, and being called ‘fat’ is, to many, as big an insult as a racial slur. Fat prejudice can approach the levels of racial prejudice (Puhl, Andreyevea & Brownell, 2008). Fat children are bullied, sometimes to the point of suicide. Some studies have found children as young as five trying to diet for being fat, no matter their actual weight. Fat people are more likely to be unemployed or underemployed, and there are prejudicial beliefs that fat workers are more problematic, despite research saying otherwise (Roehling, Roehling, & Odland, 2008).Obesity is seen by the masses as something people choose. However, science disagrees. There has long been a link between depression and obesity. Mental health is tightly tied to obesity, where those who experience weight discrimination are more likely to gain weight, although unhealthy behaviours such as binge eating and exercise avoidance are sometimes seen as a coping mechanism (Sutin & Teracciano, 2013).It has been reported in a number of journals that 90–95% of the people who lose weight regain the weight within 10 years (Mann et al., 2007; Miller, 1999). “Everyone Knows” claims that this is because people go back to bad habits. Science, however, says that there are complex ways the body wants to regain the weight (Sumithran & Proietto, 2013; Sumithran et al., 2011). Worse, dieting may contribute to obesity. Adolescent girls who diet are at 324% greater risk for obesity than those who do not diet (Stice, Cameron, R. P., Killen, J. D., Hayward, C. & Taylor, C. B. 1999). Weight loss dieting may cause other health problems as well, such as immune system problems (Shade ED, et al. 2004).In the medical world, doctors are encouraged to talk to patients about their weight. Every fat person has heard, “What are we going to do about your weight?” The “we” is supposed encourage the patient to feel that the doctor is on the patient’s side in their battle. Yet what many patients hear is, “I don’t see you as a patient, I see you as fat.” Science says that the higher a patient’s BMI the less respect a doctor has for the patient (Huzinga, Cooper, Bleich, Clark, & Beach, 2009).Horror stories about fat people trying to get decent health care are everywhere. For a good example, see Bruce Taylor Seeman’s piece, “The Perils of Obesity May Include the Doctor” (2006). [End Page E1] There are many blogs and stories on the internet about the way patients are not just shamed for their weight, but actively bullied by medical professionals. One blog, The Well Rounded Mama (wellroundedmama.blogspot.com), discusses the bias of doctors against pregnant fat women, who are told things like, “You cannot have a healthy baby when you are this fat” and encouraged to abort. Tales from people told that their weight is the cause for everything and anything can be found on sites like First Do No Harm (fathealth.wordpress.com). Reading blogs by medical professionals can show the disdain they have for fat people. In one, an emergency room nurse declared that all fat diabetics have poor control, based solely on perceptions from her job. Comments were mostly other nurses agreeing with how “disgusting” fat people are to have to deal with. However, Yale University’s Rudd Center for Food Policy & Obesity not only recognizes the problem but aims to help medical professionals eliminate the bias.If obesity becomes a disease, weight loss surgery (WLS) becomes a bigger gold mine. Medical insurance will be more likely to cover weight loss surgery. WLS is an ever-changing target: there... (shrink)

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but (...) together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Literature 26.2 (2002) 273-295 [Access article in PDF] Billy Budd:Melville's Dilemma Lester H. Hunt I THE CHAIN OF EVENTS NARRATED in Herman Melville's Billy Budd, Sailor (An Inside Narrative)—how Billy is falsely accused of plotting mutiny by his Master-at-Arms, John Claggart, how Billy accidentally kills Claggart and, finally, is executed at the urging of the Captain of the Ship, Edward Fairfax Vere, despite Vere's personal conviction that (...) Billy does not deserve to be killed—is simple enough. The text itself, nonetheless, is troublesomely complex. It is a very difficult work to interpret with both honesty and confidence. Melville unflinchingly represents to us the moral horror of what Captain Vere does to Billy, and yet he also depicts Vere himself with a respect that borders on admiration. The attentive reader experiences a painful cognitive dissonance that can only be soothed by a coherent interpretation, and perhaps by a bit of philosophy.Given the way in which the text of Billy Budd emerged—it was assembled by scholars, long after Melville's death, from a confusing collection of manuscript pages he had left behind when he died—it may well be an unfinished work. It is possible that ill health and death overtook Melville before he had a chance to iron out the inconsistencies that inevitably arise as a book is written, and it is therefore also possible that some of our sense of dissonance is produced by this brute fact. 1 Whether or not this is the case, this book is, according to the view I will present here, at least very close to being coherent. The point of view it represents is actually quite appropriate to an unfinished work, and little damaged by textual indeterminateness. Billy Budd is about the inescapably dilemmatic nature of certain choices. It alleges the impossibility of resolving them in any comfortable way. Melville beckons us to [End Page 273] look through the window of Billy Budd into an abyss of undecidability, and perhaps a text that contains some chaos within itself will better serve as such a window than one that does not.The best way to begin trying to understand how we should take this work is to begin at its very beginning. The very beginning of a story is of course its title, and the title of this story, or more exactly its subtitle, tells quite literally what sort of story it is. It is an "inside" narrative. Of course, this immediately raises the question of what an inside narrative is. Inside what? Are we supposed to contrast it with an outside narrative? And what sort of story would that be?Melville does not leave us entirely without an answer to this question. Billy Budd does contain another story, one that contrasts so sharply with the main narrative that it might well be described as its opposite: it is virtually an inverted version of the book's plot. In an "authorized weekly publication" quoted at some length at the end of the book, the events of Melville's tale are briefly recounted. In this version of the story, apparently the only officially sanctioned one, Billy Budd is depicted as the ringleader of a genuine mutiny, who "vindictively stabbed" Claggart for exposing him. Claggart is motivated only by a "strong patriotic impulse" and Billy Budd by "extreme depravity."This account, Melville tells, us was written "for the most part" sincerely enough, "though the medium, partly rumor, through which the facts must have reached the writer served to deflect and in part falsify them" (1432.27-30). 2 It could be called an "outside" narrative in virtue of the fact that its author was not there and consequently was not in a position to know what actually happened. The most direct way to give literal meaning to the "inside" status of Melville's main narrative is simply to observe that it gives a view from inside the ship, from inside the Bellipotent. It represents things that were known by people who were there, and precisely because they were there.This... (shrink)

End-of-life decisions concerning euthanasia, stopping life-support machines, or handling advance directives are very complex and highly disputed in industrialized, democratic countries. A main controversy is how to balance the patient’s autonomy and right to self-determination with the doctor’s duty to save life and the value of life as such. These EoL dilemmas are closely linked to legal, medical, religious, and bioethical discourses. In this paper, we examine and deconstruct these linkages in Germany and Israel, moving beyond one-dimensional constructions of ethical (...) statements as “social facts” to their conflicting and multifaceted embedding within professional, religious, and cultural perspectives. (shrink)

In this article I attempt to transcend the mainstream conception of health care ethics, including nursing ethics, by bringing into the foreground a tension between a sense of life and an industrial-bureaucratic style of health care, with its emphasis on the systematic and procedural work culture necessary for mass production. I use the concept of ‘a sense of life’ to draw attention to the wisdom, sensitivity and responsibility that is necessary for the authentic care of others to be given a (...) chance in the development of modern health care. I emphasize the mindfulness that the professional requires for genuine care, and how the systematic organization of modern health care, on the whole, ignores, obstructs and even suppresses such mindfulness. (shrink)

The principle of alternate possibilities (PAP), making the ability to do otherwise a necessary condition for moral responsibility, is supposed by Harry Frankfurt, John Fischer, and others to succumb to a peculiar kind of counterexample. The paper reviews the main problems with the counterexample that have surfaced over the years, and shows how most can be addressed within the terms of the current debate. But one problem seems ineliminable: because Frankfurt''s example relies on a counterfactual intervener to preclude alternatives to (...) the person''s action, it is not possible for it to preclude all alternatives (intervention that is contingent upon a trigger cannot bring it about that the trigger never occurred). This makes it possible for the determined PAPist to maintain that some pre-intervention deviation is always available to ground moral responsibility. In reply, the critic of PAP can examine all the candidate deviations and argue their irrelevance to moral responsibility (a daunting prospect); or the critic can dispense with counterfactual intervention altogether. The paper pursues the second of these strategies, developing three examples of noncounterfactual intervention in which (i) the agent has no alternatives (and a fortiori no morally relevant alternatives), yet (ii) there is just as much reason to think that the agent is morally responsible as there was in Frankfurt''s original example. The new counterexamples do suffer from one liability, but this is insufficient in the end to repair PAP''s conceptual connection between moral responsibility and alternate possibilities. (shrink)

Why does institutional police brutality continue so brazenly? Criminologists and other social scientists typically theorize about the causes of such violence, but less attention is given to normative questions regarding the demands of justice. Some philosophers have taken a teleological approach, arguing that social institutions such as the police exist to realize collective ends and goods based upon the idea of collective moral responsibility. Others have approached normative questions in policing from a more explicit social-contract perspective, suggesting that legitimacy is (...) derived by adhering to (limited) authority. This article examines methodologies within political philosophy for analyzing police injustice. The methodological inquiry leads to an account of how justice constrains the police through both special (or positional) moral requirements that officers assume voluntarily, as well as general moral requirements in virtue of a polity’s commitment to moral, political and legal values beyond law enforcement and crime reduction. The upshot is a conception of a police role that is constrained by justice from multiple foundational stances. (shrink)

Background: Hospital nurses are frequently the first care givers to receive a patient’s request for euthanasia or physician-assisted suicide (PAS). In France, there is no consensus over which medical practices should be considered euthanasia, and this lack of consensus blurred the debate about euthanasia and PAS legalisation. This study aimed to investigate French hospital nurses’ opinions towards both legalisations, including personal conceptions of euthanasia and working conditions and organisation. Methods: A phone survey conducted among a random national sample of 1502 (...) French hospital nurses. We studied factors associated with opinions towards euthanasia and PAS, including contextual factors related to hospital units with random-effects logistic models. Results: Overall, 48% of nurses supported legalisation of euthanasia and 29%, of PAS. Religiosity, training in pallative care/pain management and feeling competent in end-of-life care were negatively correlated with support for legalisation of both euthanasia and PAS, while nurses working at night were more prone to support legalisation of both. The support for legalisation of euthanasia and PAS was also weaker in pain treatment/palliative care and intensive care units, and it was stronger in units not benefiting from interventions of charity/religious workers and in units with more nurses. Conclusions: Many French hospital nurses uphold the legalisation of euthanasia and PAS, but these nurses may be the least likely to perform what proponents of legalisation call “good” euthanasia. Improving professional knowledge of palliative care could improve the management of end-of-life situations and help to clarify the debate over euthanasia. (shrink)

Background: Pediatric guidelines recommend that children and adolescents participate in a developmentally appropriate way in end-of-life decision making. Shared decision making in pediatrics is unique because of the triadic relationship of patient, parents, and physician. The involvement of the patient may vary on a continuum from no involvement to being the sole decision maker. However, the effects of child participation have not been thoroughly studied. The aims of this literature review are to identify studies on end-of-life decision making in pediatrics, (...) to explore patient participation, and to assess the effects of such participation. Methods: Five databases—PubMed, PsycInfo, Medline, CINAHL, and Sociological Abstract—were searched for empirical studies on end-of-life decision making in pediatrics. Selected articles fulfilling the criteria were assessed for type of decision, participants’ characteristics, reports on participation of the minor patient, and outcome. Results: Fifty-seven articles on end-of-life decision making in pediatrics were identified. The majority of papers (n = 43, 75%) investigated parents’ and clinicians’ perspectives, while only 14 articles (25%) included perspectives of children and adolescents. Twenty-two articles (39%) reported some details on various forms of children's participation (e.g., receive information, plan care details, consulted before or after a decision was made). Positive (e.g., respect for patient's preferences) and negative (e.g., conflict due to diverging opinions) effects of children's participation in end-of-life decision making were reported. Conclusions: This systematic review highlights the need for research to identify factors that contribute to a favorable participation of minors in decision-making processes, as well as strategies to solve possible conflicts. More research should take into account the dynamics in the triadic process of decision making and emphasize children and adolescents’ perspectives. A better understanding of how to meaningfully involve children and adolescents in end-of-life decision making could facilitate the practice of patient participation in pediatrics. (shrink)

From the celebrated author of When Bad Things Happen to Good People , a profound and practical book about doing well by doing good. For decades now, from the pulpit and through his writing, Harold Kushner has been helping people navigate the rough patches of life: loss, guilt, crises of faith. Now, in this compelling new work, he ad-dresses an equally important issue: our craving for significance, the need to know that our lives and our choices mean something. We sometimes (...) do great things, and sometimes terrible things, to reassure ourselves that we matter to the world. We sometimes confuse fame, power, and wealth with true achievement. But finally we need to think of ourselves as good people, and we are troubled when we compromise our integrity in the pursuit of what we think of as success. Harold Kushner tells us that the path to a truly successful and significant life is through friendship, through family, and through acts of generosity and self-sacrifice. He describes how, in affecting the life of even one person in a positive way, we make a difference in the world, and prove that we do in fact matter. Persuasive and sympathetic, anecdotal and commonsensical, Living a Life That Matters inspires and uplifts. (shrink)

The moral economy of American medicine has been transformed by contentious innovations in organization, administration, regulation, and finance. In many settings old fee-for-service incentives and disincentives have been replaced by those of ``managed care,'' while in other settings they have been diluted or distorted. In the everyday care of patients, old and new may alternate or interact. These innovations may also be having secondary effects on participation in life-sciences research and the development and employment of new technologies, discouraging collective support (...) for preliminary investigation and delaying adoption of improved goods and services until cost-reducing potential has already been realized. This motivational complexity, particularly in its moral dimensions, is hard to address using standard assumptions and methods. I argue for different assumptions, based on the clinical behavior of individual patients rather than the market behavior of aggregated consumers, and I describe a different method, based on an old idea in political economy. I then present a new way to explain the core obligations of clinicians, researchers, and planners and to interpret the policy problems they must now share. (shrink)

Objectives: To assess French district nurses’ opinions towards euthanasia and to study factors associated with these opinions, with emphasis on attitudes towards terminal patients.Design and setting: An anonymous telephone survey carried out in 2005 among a national random sample of French district nurses.Participants: District nurses currently delivering home care who have at least 1 year of professional experience. Of 803 district nurses contacted, 602 agreed to participate .Main outcome measures: Opinion towards the legalisation of euthanasia , attitudes towards terminal patients (...) .Results: Overall, 65% of the 602 nurses favoured legalising euthanasia. Regarding associated factors, this proportion was higher among those who discuss end-of-life issues with terminal patients , who consider competent patients should always be told their prognosis and who value the role of advance directives and surrogates in end-of-life decision-making for incompetent patients . Women and older nurses were less likely to favour legalising euthanasia, as were those who believed in a god who masters their destiny.Conclusions: French nurses are more in favour of legalising euthanasia than French physicians; these two populations contrast greatly in the factors associated with this support. Further research is needed to investigate how and to what extent such attitudes may affect nursing practice and emotional well-being in the specific context of end-of-life home care. (shrink)

Objective—To determine the objectivity, consistency and professional unanimity in the initiation, continuation and withdrawal of life-prolonging procedures in intensive care–to determine methods, time-scale for withdrawal and communication with both staff and relatives–to explore any professional unease about legality, morality or professional defensibility.Design—A structured questionnaire directed at clinical nurse managers for intensive care.Setting—All intensive care units in the Yorkshire region.Results—The survey reported a lack of consistency and objectivity in decision making in this area, with accompanying unease amongst staff.Conclusions—There is a need (...) to work towards more consistent care, both before and during admission, for the protection of the individual patient and to allow rational assessment of intensive care need. Comprehensive audit should lead to objective defensible decisions and facilitate informed choice. More open debate and better communication should minimise this issue as a source of stress amongst staff in intensive care. (shrink)

With armed conflict in the Persian Gulf now upon us, Harvard archaeologist Steven LeBlanc takes a long-term view of the nature and roots of war, presenting a controversial thesis: The notion of the "noble savage" living in peace with one another and in harmony with nature is a fantasy. In Constant Battles: The Myth of the Peaceful, Noble Savage , LeBlanc contends that warfare and violent conflict have existed throughout human history, and that humans have never lived in ecological balance (...) with nature. The start of the second major U.S. military action in the Persian Gulf, combined with regular headlines about spiraling environmental destruction, would tempt anyone to conclude that humankind is fast approaching a catastrophic end. But as LeBlanc brilliantly argues, the archaeological record shows that the warfare and ecological destruction we find today fit into patterns of human behavior that have gone on for millions of years. Constant Battles surveys human history in terms of social organization-from hunter gatherers, to tribal agriculturalists, to more complex societies. LeBlanc takes the reader on his own digs around the world -- from New Guinea to the Southwestern U.S. to Turkey -- to show how he has come to discover warfare everywhere at every time. His own fieldwork combined with his archaeological, ethnographic, and historical research, presents a riveting account of how, throughout human history, people always have outgrown the carrying capacity of their environment, which has led to war. Ultimately, though, LeBlanc's point of view is reassuring and optimistic. As he explains the roots of warfare in human history, he also demonstrates that warfare today has far less impact than it did in the past. He also argues that, as awareness of these patterns and the advantages of modern technology increase, so does our ability to avoid war in the future. (shrink)

In a recent special supplement to the Hastings Center Report entitled “Improving End-of-Life Care—Why Has It Been So Difficult?” Robert Burt wrote the following in an essay ominously entitled “The End of Autonomy”: No one should be socially authorized to engage in conduct that directly, purposefully, and unambiguously inflicts death, whether on another person or on oneself. Decisions that indirectly lead to death should be acted upon only after a consensus is reached among many people. No single individual should be (...) socially authorized to exercise exclusive control over decisions that might lead to death, whether that individual is the dying person, the attending physician, or a family member acting as health care proxy. (shrink)

The objective of this paper is to understand from a sociological perspective how the moral question of euthanasia, framed as the “right to die”, emerges and is dealt with in society. It takes France and Germany as case studies, two countries in which euthanasia is prohibited and which have similar legislation on the issue. I presuppose that, and explore how, each society has its own specificities in terms of practical, social and political norms that affect the ways in which they (...) deal with these issues. The paper thus seeks to understand how requests for the “right to die” emerge in each society, through both the debate (analysis of daily newspapers, medical and philosophical literature, legal texts) and the practices (ethnographic work in three French and two German hospitals) that elucidate the phenomenon. It does so, however, without attempting to solve the moral question of euthanasia. In spite of the differences observed between these two countries, the central issue at stake in their respective debates is the question of the individual’s autonomy to choose the conditions in which he or she wishes to die; these conditions depend, amongst others, on the doctor-patient relationship, the organisation of end-of-life care in hospital settings, and more generally, on the way autonomy is defined and handled in the public debate. (shrink)

Nietzsche and the Origin of Virtue : This book is a discussion of Nietzsche's ethical and political ideas. It is an attempt to be both scholarly and, in a sense, activist. The ultimate point is to see how believers in liberal democracy (like me and most of my readers) should respond to the challenge that Nietzsche represents. As with any profound challenge, one is never the same again after it is overcome. In particular, I suggest that liberals can learn something (...) very important from the ideas that grow out of Nietzsche's early discussion of Homer's notion of agon or Wettkampf (roughly, conflict or competition). (shrink)

INTRODUCTION The Questions of Medical Ethics Call him Andrew. His face is gaunt and unshaven but peaceful. His eyelids are gently closed. ...

This work belongs to what Adam Smith called "the theory of moral sentiments," in particular, it is concerned with the operation of sympathetic affections, which are termed "vicarious affects"; and their rationality and legitimate role in moral theory. Professor Rescher forcefully argues for the thesis that the crucial aspect of vicarious affects lies in their function as motivational factor or reason rather than as a cause of personal conduct. A formal machinery is proposed for the quantitative aspect of the workings (...) of vicarious affects and applied to the problem of the "prisoner’s dilemma." In the latter connection, Rescher shows with insight that there is really nothing paradoxical about the "prisoner’s dilemma." The apparent paradox arises only because the game theorist failed to distinguish sharply rationality and prudence. "It is a travesty... to construe rationality in terms of prudential self-advantage, for there is nothing in any way inherently unreasonable or irrational about a concern for others." "There is no reason why ’self-interest’ should not be construed in an enlightened and widened sense to include the interests of others, through the operation of the vicarious affects." Rescher also points out that there are two alternatives, other than prudence, to the "solution" of conflict interaction situations, i.e., negotiation and impartial arbitration, when both are construed as tacit rather than explicit processes. One chapter is devoted to a fuller analysis and defense of the "impartial arbiter" approach as superior to the negotiation approach, and followed by a sustained critique of utilitarian doctrine of morality. Complex distinctions and arguments are set forth. The fatal weakness of utilitarianism, of various versions, is said to lie in its failure to distinguish de facto utilities and de jure utilities. De jure utilities have rational warrant "exterior to the utilitarian perspective." "An evaluative assessment of the means by which such legitimate human ends as welfare requires the background of a larger vision of the ends of man." The final chapter elaborates this vision as Hegelian in character. While the gap between morality and self-interest is recognized, Rescher postulates as a regulative ideal "a reciprocal coordination of personal and social advantage." But this larger vision includes welfare-transcending considerations, e.g., the various ideals of the quality of life, those "higher" aspirations. "Excellence, dignity, and the sense of worth are its leading themes." In the Primacy of Practice, one finds a fuller discussion of moral excellence, but on the whole Rescher has not offered us a detailed account of this ideal dimension of morality. For the present work, at any rate, Rescher has succeeded in arguing for the significant role of vicarious affects in moral philosophy and its implication for the legitimacy of differential treatments based on personal relationships. It is hoped that, in some future work, Professor Rescher will systematically integrate this role of vicarious affects in an ideal moral theory.—A.S.C. (shrink)

In acute inpatient mental health services, patients commonly demonstrate extreme behaviours. A number of coercive practices, such as locked doors, enforced medication and seclusion, are used in these settings to control such behaviours. The aim of this report is to explore briefly some of the contemporary debates pertaining to seclusion. A perusal of the literature reveals a clarion call to end the practice of seclusion, without consideration of feasible alternatives. It is hoped that this brief report will encourage further evidence-based (...) discussion and research initiatives on this important ethical topic. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Creativity and the Context of NoveltyPete A. Y. GunterAn article might have many virtues: breadth, novel perspective, conceptual background, to name a few. The strongest virtue of Professor Crosby's article is in the sharpening of arguments. In both his book, Novelty, and in the present article, he sharpens arguments which surround the concepts of determinism, novelty, and freedom. The end result is increased clarity; it is also, or so (...) it seems to this writer, the increased plausibility of arguments for novelty and indeterminism.I.It has often been argued that strict determinism (henceforth, determinism) has paradoxical implications. Thus William James protests that it leads inescapably to a "Block Universe": one in which everything is given at once—past, present, and future. In such a world, Crosby points out, nothing can happen at all. But Crosby adds to this a second, crucial point. If determinism is true, he insists, we must give up not only the belief that anything actually happens but also the commonsense belief that cause precedes effect. This result of strict determinism has not been stressed by either its opponents or its proponents.Quite probably, those who have argued for determinism have not reflected on the unpalatable idea that cause does not precede effect. Our ordinary experience exhibits the billiard ball falling into the side pocket after we have hit it with the cue stick. If we dive into a swimming pool, we enter the water dry and then become wet. And, the splash occurs after we separate ourselves from the board. Determinism, however useful in helping us to bring order out of our experience, radically conflicts with fundamental features in nature that lead us to think and examine cause and effect to begin with.There is another respect in which Crosby sharpens our assumptions. Ordinarily [End Page 60] we think of novelty and causality as contradictories. In fact, Crosby insists, they are correlatives. Neither is reducible to the other, nor is either alternative prior to the other. The two together constitute a primordial feature of the universe, such that where in some contexts indeterminism is reduced to a minimum, perhaps an infinitesimal, in others (presumably those in which creativity plays a major role) causality is reduced to a minimum and novelty predominates. Hence philosophy is not saddled with the task of trying to show how novelty can possibly find a place in an exclusively deterministic world. Novelty and determinism are, from the beginning, both present throughout.This viewpoint, if accepted, would obviate any attempt to graft indeterminism into a deterministic universe, so to speak, from without. It would also tend to dissolve the dualisms foisted on us by Descartes and, in another way, by Kant, which radically separate mind (or free will) from matter (or, in Kant's case, "phenomena") on the grounds that the former contains novelty and the latter does not. In Crosby's view some element of novelty is already present in matter. Equally, in his view, "mind" in many, perhaps most, contexts contains a strong element of determinism.There is still a further way of taking Crosby's arguments. It is this. Strict determinists must, he shows, hold that the universe is timeless. Past, present, and future coexist and, literally, nothing happens. It then follows that if one accepts the reality of motion, growth, and dissolution in the world, then in doing so one has decreed the falsehood of strict determinism. It does not (and on Crosby's grounds cannot) follow that there is no determinism in nature. There must, on his grounds, be degrees of causal determinism. But there must also be real novelty. One thus has a transcendental argument, beginning from the simple acceptance of real mobility in the world. That is, "If there is real transformation in the world, then strict determinism must be wrong. There is real transformation in the world. Therefore strict determinism must be wrong." This would make life very hard for the strict determinist, for whom the slightest lapse into a commonsense acceptance of the restless mobility of nature entails the denial of his or her basic thesis.A further argument of Crosby's, however, gives me difficulties. He argues that strict determinism... (shrink)

BackgroundOne of the next frontiers in HIV research is focused on finding a cure. A new priority includes people with HIV (PWH) with non-AIDS terminal illnesses who are willing to donate their bodies at the end-of-life (EOL) to advance the search towards an HIV cure. We endeavored to understand perceptions of this research and to identify ethical and practical considerations relevant to implementing it.MethodsWe conducted 20 in-depth interviews and 3 virtual focus groups among four types of key stakeholders in the (...) United States (PWH, biomedical HIV cure researchers, HIV clinicians, and bioethicists) to obtain triangulated viewpoints because little was known about the ethics of this topic. Each group was queried as to ethical considerations, safeguards, and protections for conducting HIV cure-related research at the EOL to ensure this research remains acceptable.ResultsAll four key stakeholder groups generally supported HIV cure-related research conducted at the EOL because of the history of altruism within the PWH community and the potential for substantial scientific knowledge to be gained. Our informants expressed that: (1) Strong stakeholder and community involvement are integral to the ethical and effective implementation, as well as the social acceptability of this research; (2) PWH approaching the EOL should not inherently be considered a vulnerable class and their autonomy must be respected when choosing to participate in HIV cure-related research at the EOL; (3) Greater diversity among study participants, as well as multi-disciplinary research teams, is necessitated by HIV cure-related research at the EOL; (4) The sensitive nature of this research warrants robust oversight to ensure a favorable risk/benefit balance and to minimize the possibility of therapeutic misconception or undue influence; and (5) Research protocols should remain flexible to accommodate participants’ comfort and needs at the EOL.ConclusionBecause of the ethical issues presented by HIV cure-related research at the EOL, robust ethical safeguards are of utmost importance. The proposed ethical and practical considerations presented herein is a first step in determining the best way to maximize this research’s impact and social value. More much inquiry will need to be directed towards understanding context-specific and cultural considerations for implementing EOL HIV cure research in diverse settings. (shrink)

Background Nurses providing care to patients with end-of-life or terminal illnesses often encounter ethically challenging situations leading to moral distress. However, existing quantitative studies have examined moral distress using instruments that address general clinical situations rather than those specific to end-of-life care. Furthermore, qualitative studies have often been limited to participants from a single unit or those experiencing moral distress-induced circumstances. A comprehensive and integrated understanding of the overarching process of moral distress is vital to discern the unique circumstances surrounding (...) end-of-life care and its consequential impacts. Research objectives To explore the moral distress experiences of nurses who are frequently involved in caring for patients with end-of-life or terminal illnesses and apply it to two existing theories: the model of moral distress and the ecological model. Research design A qualitative descriptive approach was employed. Participants and research context Seven focus group interviews involving 30 nurses were performed. The subsequent transcriptions underwent rigorous content analysis. Ethical considerations We obtained Institutional Review Board approval from a university. Focus group interviews were conducted with nurses who agreed to participate and signed the consent form. Findings The moral distress-inducing factors and nurses’ perceived impact of moral distress were identified and categorized based on moral distress theories and ecological models. A total of 15 categories and 30 subcategories across the following 4 domains were derived: (1) intrapersonal, (2) interpersonal, (3) organizational, and (4) structural factors. Conclusions End-of-life-specific circumstances induced moral distress among nurses, with both negative and positive impacts identified. Effective organizational and policy support is essential to manage conflicts, form a healthy organizational culture, provide training, and prevent unnecessary expenses due to the negative consequences of moral distress. (shrink)

Euthanasia and physician-assisted suicide (PAS) by request and/or based on an advance directive are legal in The Netherlands under strict conditions, thus providing options for patients with Huntington's disease (HD) and other neurodegenerative diseases to stay in control and choose their end of life. HD is an inherited progressive disease characterised by chorea and hypokinesia, psychiatric symptoms and dementia. From a qualitative study based on interviews with 15 physicians experienced in treating HD, several ethical issues emerged. Consideration of these aspects (...) leads to a discussion about the professional role of a physician in relation to the personal autonomy of a patient. Such a discussion can raise awareness that talking about end-of-life wishes with an HD patient is part of the legal, professional and moral responsibility of the physician, and that a letter of intent on behalf of the physician can improve active participation in the process. Discussion of these issues can help to advance the debate on euthanasia and PAS in HD and other neurodegenerative diseases. (shrink)