This chapter contains sections titled: Abortion and Mother‐Fetus Conflict Moral Obligations to the Unborn The Obstetrical Cases: Forced Cesareans Fetal Surgery Conclusion References Further reading.

A capacitated pregnant woman has a nearly unqualified right to refuse a cesarean section. Her right to say “no” takes precedence over clinicians’ preferences and even over clinicians’ concerns about fetal health. Leading medical societies, human rights organizations, and appellate courts have all endorsed this principle. Nevertheless, clinicians continue to limit reproductive liberty by forcing and coercing women to have unwanted cesareans. This “Legal Briefing” reviews recent court cases involving this type of obstetric violence. I have organized these (...) court cases into the following six categories: 1. Epidemic of Unwanted Cesareans2. Court-Ordered Cesareans3. Physician-Coerced Cesareans4. Physician-Ordered Cesareans5. Cesareans for Incapacitated Patients6. Cesareans for Patients in a Vegetative State or Who Are Brain Dead. (shrink)

Definition of the problem. During the last few years obstetricians have become concerned over an increasing rate of cesarean sections, especially an increasing rate of ”section on demand” for non-medical, but personal reasons of pregnant women. For physicians this is a question of risks and benefits for both mother and child. On the other hand, there is the duty to respect women’s autonomy. Arguments. Pregnant women are healthy and the act of giving birth to a child is a physiological one. (...) Thus, the indication has to be proved carefully for surgical intervention instead of vaginal delivery. Cesarean section for non-medical reasons may be helpful for women with an extreme fear of vaginal delivery or previous traumatic experiences. On the other hand the possibility for pregnant women to choose their preferred mode of delivery is combined with the question, whether cesarean section on demand fulfils their demand for a self-determined delivery. Conclusion. With a mode of delivery oriented to the person instead of to the method, self-determination can be realized. Cesarean Section on demand can achieve this in some individual cases. However women’s own ability, activity, and involvement in giving birth to a child may be a stronger manifestation of self-determination. (shrink)

In France between 1780 and 1815, doctors opened a broad correspondence with medical faculties and public officials about foetal anomalies . Institutional and legal reforms forced doctors to encounter monstrous births with greater frequency, and they responded by developing new ideas about heredity and embryology to explain malformations to public officials. Though doctors achieved consensus on pathogenesis, they struggled to apply these ideas in forensic cases, especially with doubtful sex. Medical networks simultaneously allowed doctors to explore obstetrical (...) techniques, as licensing regulations forced practitioners into emotional encounters with child anomalies. Doctors thus developed a new ethics for treating monstrosities, viewing them as pathological specimens, forensic objects, and obstetrical tragedies. (shrink)

Interest in home birth appears to be growing among American women, and most obstetricians can expect to encounter patients who are considering home birth. In 2011, the American College of Obstetricians and Gynecologists (ACOG) issued an opinion statement intended to guide obstetricians in responding to such patients.In this article, I examine the ACOG statement in light of the historical and contemporary clinical realities surrounding home birth in the United States, an examination guided in part by my own experiences as an (...) obstetrician in home-birth-friendly and homebirth-unfriendly medical milieus. Comparison with other guidelines indicates that ACOG treats home birth as an ethical exception: comparable evidence leads to strikingly different recommendations in the case of home birth and the case of trial of labor following a prior cesarean; and ACOG treats other controversial issues that involve similar ethical questions quite differently.By casting the provision of information as not just the primary but the sole ethical responsibility of the obstetrician, ACOG statement obviates obstetricians’ responsibilities to provide appropriate clinical care and to make the safest possible clinical environment for those mothers who choose home birth and for their newborns. What, on its face, seems to be a statement of respect for women’s autonomy, implicitly authorizes behaviors that unethically restrain truly autonomous choices. Obstetricians need not attend home births, I argue. Our ethical duties do, however, oblige us (1) to refer clients to skilled clinicians who will attend home birth, (2) to continue respectful antenatal care for those women choosing home birth, (3) to provide appropriate consultation to home birth attendants, and (4) to ensure that transfers of care are smooth and nonpunitive. (shrink)

Natural disasters in populated areas may result in massive casualties and extensive destruction of infrastructure. Humanitarian aid delegations may have to cope with the complicated issue of patient prioritization under conditions of severe resource scarcity. A triage model, consisting of five principles, is proposed for the prioritization of patients, and it is argued that rational and reasonable agents would agree upon them. The Israel Defense Force's humanitarian mission to Haiti following the 2010 earthquake serves as a case study for the (...) various considerations taken into account when designing the ethical-clinical policy of field hospitals. The discussion focuses on three applications: the decision to include an intensive care unit, the decision to include obstetrics and neonatal units, and the treatment policy for compound fractures. (shrink)

Self-Interest before Adam Smith inquires into the foundations of economic theory. It is generally assumed that the birth of modern economic science, marked by the publication of The Wealth of Nations in 1776, was the triumph of the 'selfish hypothesis'. Yet, as a neo-Epicurean idea, this hypothesis had been a matter of controversy for over a century and Smith opposed it from a neo-Stoic point of view. But how can the Epicurean principles of orthodox economic theory be reconciled with the (...) Stoic principles of Adam Smith's philosophy? Pierre Force shows how Smith's theory refutes the 'selfish hypothesis' and integrates it at the same time. He also explains how Smith appropriated Rousseau's 'republican' critique of modern commercial society, and makes the case that the autonomy of economic science is an unintended consequence of Smith's 'republican' principles. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Day I Touched JesusJeffery L. DealShe deserved better. They all do.I met her early on a morning that promised to be hot and wet, as Sudan tended to be at that time of year. Hot all the time. Hot and wet in the summers. I touched her for the briefest of moments, felt her leg move against my hand and caught a fleeting glimpse of a foot that (...) was barely the size of my fingertip. I was there because a missionary asked me to come, told me stories of conditions in Sudan and convinced me that I could save lives. He was right.Her twin brother was born eight hours earlier, sometime around midnight. The birth attendants managed the delivery as well as anyone could in the same situation. The last time I had attempted to manage such a problem delivery was almost twenty years earlier when I had been a Navy Lieutenant fresh out of my surgical internship on temporary assignment to a Marine Corps battle group in the Philippines. On that deployment, a corpsman brought me to a grass hut where a woman who looked barely more than a child herself labored against a breach delivery. I spent the day examining her while her family brought me things to eat that I do not believe should be eaten. After six hours of no progress, I radioed for a helicopter to take her to Clark Air Force base where they had operating rooms and obstetricians. In South Sudan, we had no such resources.My oldest daughter, a premed student at the time who had worked with me in Sudan on other occasions, sat in the corner with her classmates and watched as I put my hand inside the mother. She was of the Dinka ethnic group and was a large, robust woman who sweated profusely and occasionally caught her breath, but otherwise seemed unmoved by her contractions. Fluids gushed over my gloved hand and the students gasped. I felt the baby's leg retract slightly as if she resented my intrusion.I could not get past the baby's hip—she was wedged tightly in the uterus. I had some medicines that were used to hasten delivery and, not really knowing if it was the right thing to do, I gave the mother some through her IV. Still I could not dislodge the child. I told the students and birth attendants that we would give her one hour while I rounded on the other patients in our remote and poorly equipped clinic. If she did not deliver by that time we would take her to a facility run by a Catholic relief agency several hours drive from us—a drive that due to war, weather, or mechanical problems we could not always complete.I saw the rest of the patients in a hurry while browsing through all of the medical texts and the few books we kept at the clinic. This child's only hope of surviving was for her mother to have a cesarean section, and as quickly as possible. After determining that none of our other patients were in imminent danger, we loaded the mother, the first-born twin, and the grandmother into our vehicle for the long ride. One of the medical students, who at the time of this writing was completing her residency in obstetrics and gynecology, asked me if I shouldn't pray for the woman while we drove. I felt guilty for not praying out loud without being prompted, so I reached back and placed my hand on the mother's abdomen and prayed while I drove. I felt a slight movement. It could have been the rough road or the mother shifting, but I believe to this [End Page 81] day that I felt the child move. I would not feel her again. I drove as fast as the rough, bomb-cratered dirt road allowed.Mother and unborn child were doing well when we finally arrived three hours later. I knew the facility and many of the workers so I drove past the guard and directly to the obstetrics ward. Two nurses rushed out to meet us with... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Montaigne and the Coherence of EclecticismPierre ForceSince the publication of Pierre Hadot's essays on ancient philosophy by Arnold Davidson in 1995,2 Michel Foucault's late work on "the care of the self"3 has appeared in a new light. We now know that Hadot's work was familiar to Foucault as early as the 1950s.4 It is also clear that Foucault's notion of "techniques of the self" is very close to what (...) Hadot calls "spiritual exercises." At the same time, there are important differences between the views of these two philosophers, and Hadot has often expressed his regret that Foucault's untimely death prevented them from exploring these differences.5 One important point of disagreement was the status of eclecticism. In Foucault's interpretation of ancient philosophy, the "constitution of the self" implied a personal choice among disparate philosophical references: "Writing as a personal exercise done by the self and for the self, is an art of disparate truth."6 In a 1989 article Hadot argued from a historical point of view that, so far as Stoicism and Epicureanism were concerned, [End Page 523] eclecticism had no place in a mature practice of philosophy. Foucault's favorite example, Seneca's Letters to Lucilius, in which Stoic arguments were invoked along with Epicurean arguments, was a work for beginners. In a mature practice of Stoicism, one would stick to the arguments of the Stoic school, choose them for their coherence, and instead of trying to forge a spiritual identity for oneself through writing, one would "liberate oneself from one's individuality in order to raise oneself up to universality."7 Hadot added that "it is only in the New Academy—in the person of Cicero, for instance—that a personal choice is made according to what reason considers as most likely at a given moment."8 This discussion of Foucault may give the impression that Hadot was somewhat dismissive of eclecticism. Yet in a 2001 interview Hadot claimed that he had always admired Cicero's intellectual independence, and he proposed a reappraisal "of an attitude that has always had a bad reputation: eclecticism."9Something very similar is a stake in the work of Alexander Nehamas, as Lanier Anderson and Joshua Landy showed in their study of his Art of Living. In the conception of philosophy as a "way of life" (Hadot) or "care of the self" (Foucault) or "self-fashioning" (Nehamas), a central issue is the relationship between theoretical coherence and the coherence of the person who theorizes. Elaborating on Nehamas's chapter on Montaigne, Anderson and Landy argue that there is a move in Montaigne away from doctrinal coherence and towards a coherence of the self. As they put it, "the harmonious whole Montaigne commends [... ] is not a coherent body of fact or theory; it is the unified self of the theorizer."10 Anderson and Landy show that this brings up all kinds of difficulties: can this unified self be other than a fiction? If that is the case, how can philosophy be a way of life? Nehamas's answer is very much in the spirit of the late Foucault: there is a coherence of the self in Montaigne, and this coherence is the product of writing as a philosophical activity. The self is fashioned through writing.Because Montaigne writes in the ancient tradition of philosophy as a way of life, one may recall Hadot's suggestion that Foucault's notion of [End Page 524] "writing the self" is an intriguing but historically inaccurate description of ancient philosophical practice. But perhaps Hadot agrees with Foucault after all, since in his most recent interviews, he speaks favorably of eclecticism, a notion that is central to Foucault's analysis of self-fashioning through writing. The case of Montaigne is particularly interesting for these purposes, not only because the Essays seem to be the prototypical example of "writing the self," but also because eclecticism is both discussed and practiced throughout the Essays. I propose to take a fresh look at this issue by investigating the status of eclecticism in Montaigne's Essays. This must start with an examination of the philosophical tradition most closely associated with... (shrink)

Recalcitrant disputes among health care providers and patients or their families may signal deep cultural differences about what interventions are needed or about clinicians’s professional duties. These issues arose in relation to a mother’s request for hymenoplasty or revirgination for her minor daughter to enable an overseas, forced marriage and protect her from an honor killing. The American College of Obstetrics and Gynecology committee recommends against members performing a hymenoplasty or other female genital cosmetic surgeries due to a lack (...) of data concerning their safety and efficacy. A key issue in such cases is how to determine what is in the minor’s best interest and the scope of health care moral or professional’s duties. The Best Interests Standard can serve as a powerful moral tool for resolving cross-cultural disputes and identifying needed policy. (shrink)

ZusammenfassungDie Diskussion um die steigende Rate an Kaiserschnittentbindungen in der Geburtshilfe erlebt einen neuen Höhepunkt durch das Problem der sog. „Wunschsectio”. Für den Geburtshelfer stellt sich unter Beachtung seiner Fürsorgepflichten die Frage nach der Verantwortbarkeit einer ärztlichen Handlung aufgrund persönlicher Wünsche der Schwangeren, ohne medizinische Indikation, aber mit einem nicht zu vernachlässigenden Risiko. Für die betroffenen Frauen verbindet sich mit der Möglichkeit, die Form der Geburt frei zu wählen, die Frage, ob die Wunschsektio ihre Forderung nach einer selbstbestimmten Geburt erfüllt. (...) In einem „persönlichkeitsspezifischen” Geburtsereignis kann sich Selbstbestimmtheit verwirklichen und die normativ zugrunde liegende Autonomie der Frau gewahrt sein. Eine Wunschsektio kann dies im Einzelfall leisten. Eigene Initiative und Aktivität der Schwangeren dürften jedoch die Selbstbestimmtheit im Erleben der Geburt stärker fördern. (shrink)

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications.We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks (...) makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation.Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging. (shrink)

Once anesthetized, patients are inherently “compliant” with surgical interventions because they can no longer intervene on their own behalf. In their target article, Minkoff et al. (2024) reasonabl...

This article uses the US debate over elective Cesarean section to re-consider some of the more contentious issues raised in feminist debates about childbirth. Three waves of feminist commentary and critique in the United States are analysed in light of the ongoing debate over whether women should be able to choose Cesarean for non-medical reasons. I argue that the alternative birth movement's essentialist and occasionally moralistic rhetoric is problematic, and the idea that some women's preference for high-tech obstetrics is the (...) result of a passive 'socialization' into 'dominant values' is theoretically inadequate. On the other hand, the invocation of women's choice and appreciation of high-tech childbirth serves as a weak foundation for a feminist perspective on childbirth. By limiting their analysis to the rhetorical and discursive nature and functions of 'the medical' and 'the natural', poststructuralist critics of the alternative birth movement obscure the connection of these discourses to practices that have very different consequences for maternal and infant health and, most importantly, for the consumption of health care resources. (shrink)

Since the founding of the University of Limburg (1974), in The Netherlands, an innovative medical curriculum has been guided by educational principles of problem-orientation, continuous assessment, student initiative and attitude development. The teaching of medical ethics was built into the preclinical curriculum from the start. However, the clinical years remained largely unaffected, and only recently has an effort been made to extend the educational philosophy to this more or less traditional part of medical education. Within this context, an experiment of (...) clinical ethics teaching was introduced in the Obstetrics and Gynaecology (Ob/Gyn) clerkships. The objectives, methods and results of this experimental programme are described in this paper. The success of the teaching is based on three features of the programme: 1) its student-centred approach; 2) the programme is designed in a way similar to regular patient conferences; 3) the programme is taught by a team consisting of both clinician and ethicist. Before starting a longitudinal programme of ethics teaching during the clinical years, it proved very helpful to experiment with a well designed and evaluated pilot programme. (shrink)

This paper investigates force shift, a phenomenon in which the canonical discourse conventions, or force, associated with a clause type can be overridden to yield polar questions with the help of additional force-indicating devices. Previous studies attribute force shift to the presence of a complex question force component operating on semantic content. Based on utterance particles and particle clusters in Cantonese, we analyze force shift as resulting from compositional operations on force-bearing expressions. We propose that a simplex force, such as (...) assertion or question, denotes unanchored sentence acts, while a force-shifting particle like Cantonese _ho2_ is an anchoring function anchoring a sentence act to the speaker while querying whether or not the addressee can perform the sentence act. The proposed semantics makes predictions about _ho2_’s interactions with addressee-changing operations and imperatives, as well as about a larger family of force shift phenomena. (shrink)

In September 2020, Project South, along with numerous other organizations, released a report detailing abuses in a Georgia Detention Center – including forced hysterectomies. Whatever other factors are at play, one of them is an intrinsic connection between obstetric violence against pregnant migrants and immigration injustice. It is not incidental that these acts – in US detention centers, along the US‐Mexico border, in Colombian hospitals and clinics – are being perpetrated on immigrant bodies. And it is not accidental or (...) random which immigrant bodies are vulnerable to these violations. Understanding and confronting obstetric violence directed at pregnant migrants, though, requires reconceptualizing the nature of obstetric violence itself. In particular, we must recognize that obstetric violence against pregnant Latin American migrants in the United States and Colombia is a type of immigration injustice, a means to perpetrate immigration injustice, and a product of immigration injustice. As such, bioethicists need to collaborate with immigration scholars to resist it.After providing some background on the nature of obstetric violence and some ways it is perpetuated against pregnant migrants in the United States and Colombia, I will give a brief overview of how I conceptualize immigration justice. From there, I explain how this type of obstetric violence constitutes a type of immigration injustice, a means to perpetrate immigration injustice, and a product of immigration injustice. My hope is that this analysis motivates bioethicists throughout the Americas to engage with immigration scholars and activists to confront the issue more forcefully. (shrink)

Cesarean delivery rates have been steadily increasing worldwide. In response, many countries have introduced target goals to reduce rates. But a focus on target goals fails to address practices embedded in standards of care that encourage, rather than discourage, cesarean sections. Obstetrical standards of care normalize use of technology, creating an imperative to use technology during labor and birth. A technological imperative is implicated in rising cesarean rates if physicians or patients fear refusing use of technology. Reproductive autonomy is (...) at stake since a technological imperative undermines patients’ ability to choose cesareans or refuse use of technology increasing the likelihood of cesareans. To address practices driven by a technological imperative I outline three physician obligations that are attached to respecting patient autonomy. These moral obligations show that a focus on respect for autonomy may prove not only an ideal ethical response but also an achievable practical response to lowering cesarean rates. (shrink)

Is it morally justifiable to force non-consenting pregnant women to submit to caesarean surgery to save their fetus in distress? Even though proponents and opponents largely agree on the interests at stake, such as the health and life of the fetus and the respect for bodily integrity and autonomy of pregnant women, they disagree on which moral weight to attach to these interests. This is why disagreements about the justifiability of forced caesareans tend to be pervasive and intractable. To (...) sidestep this deadlock, we will focus on conditions that give rise to the ‘caesarean dilemma’ in the first place, namely the conflict between inherent norms and values medical professionals are committed to by virtue of being a medical professional. Using the reflective equilibrium, we will test the opponents’ and proponents’ considered judgments about forced caesareans against the norms and values they—as medical professionals—are committed to and determine whether they are coherent. Subsequently we will identify the proponents’ incoherencies between the considered judgments and norms and values they are committed to and conclude that as long as these incoherencies are in place, forced caesareans are morally impermissible. (shrink)

Is it morally justifiable to force non-consenting pregnant women to submit to caesarean surgery to save their fetus in distress? Even though proponents and opponents largely agree on the interests at stake, such as the health and life of the fetus and the respect for bodily integrity and autonomy of pregnant women, they disagree on which moral weight to attach to these interests. This is why disagreements about the justifiability of forced caesareans tend to be pervasive and intractable. To (...) sidestep this deadlock, we will focus on conditions that give rise to the ‘caesarean dilemma’ in the first place, namely the conflict between inherent norms and values medical professionals are committed to by virtue of being a medical professional. Using the reflective equilibrium, we will test the opponents’ and proponents’ considered judgments about forced caesareans against the norms and values they—as medical professionals—are committed to and determine whether they are coherent. Subsequently we will identify the proponents’ incoherencies between the considered judgments and norms and values they are committed to and conclude that as long as these incoherencies are in place, forced caesareans are morally impermissible. (shrink)

Methadone maintenance therapy is a cost-effective, evidence-based treatment for heroin dependence. In the USA, a majority of heroin-dependent offenders are forced to detox from methadone when incarcerated. Recent research published in The Lancet has demonstrated the negative health and economic outcomes associated with such policies. Methadone Continuation Versus Forced Withdrawal on Incarceration in a Combined US Prison and Jail: A Randomised, Open Label Trial. The Lancet, 386, 350–359). This novel evidence raises questions as to the justification for current (...) policies of forced detox in American prisons. Opponents of methadone provision in prisons might offer arguments from retributivism, resource allocation and curative effectiveness to justify their position. This article contends that these arguments do not stand up to ethical scrutiny. In light of this, we hold that American policymakers should reform criminal justice policies to allow the initiation and continuation of methadone treatment in correctional settings. This would be consistent with both international recommendations and the example set by a number of other Western countries. (shrink)

The health of newborns has always been subject to the natural lottery. When in the past a severely disabled baby was born, nature provided the “solution,” and the child did not survive. Medical technology has brought about a change; fetuses who would have died during pregnancy or newborns who once would have had little chance to survive are now kept alive. Although these technological advances do benefit many children, the dark side is that more severely handicapped babies are surviving.When a (...) severely disabled baby is born, all persons concerned are faced with emotional difficulties as well as moral and legal dilemmas. Questions that arise include whether it is acceptable, morally and legally, to allow the severely handicapped newborn to die by forgoing treatment or by direct intervention. (shrink)

The article is dedicated to determine de iure and de facto binding force of the case law of the Court of Justice of the European Union (hereinafter the ECJ) and its place in the system of legal sources in Latvia. The author concludes that the case law of the ECJ consists of legally important statements, which are included in judgements of the ECJ, namely, of an interpretation of legal norms, made by the ECJ, and of judge-made law norms, which the (...) ECJ has found in legal system by use of a further law-making. Therefore, it follows from the above that the case law of the ECJ is regarded as binding independent addition legal source in Latvia. This publication concerns not only Latvia, but also other European Union (hereinafter the EU) member states of the continental Europe or Romano-Germanic legal system. (shrink)

I argue that public officials and health workers ought to respect and protect women’s rights to make risky choices during childbirth. Women’s rights to make treatment decisions ought to be respected even if their decisions expose their unborn children to unnecessary risks, and even if it is wrong to put unborn children at risk. I first defend a presumption of medical autonomy in the context of childbirth. I then draw on women’s birth stories to show that women’s medical autonomy is (...) often ignored during labor. Medical interventions are performed during childbirth without women’s consent. Childbirth is risky and some coercive medical interventions may be understood as attempts to protect children and to prevent mothers from acting impermissibly. However, even if it is wrong to make risky choices during childbirth, women have rights to do wrong in these cases. Therefore, coercive medical interventions are impermissible during childbirth and institutions should adopt specific protections for obstetric autonomy. (shrink)

Thirteen years ago, commenting on the treatment of the human body and its cell lines as patentable commodities, Mary Taylor Danforth wrote:Research with human cells that results in significant economic gain for the researcher and no gain for the patient offends the traditional mores of our society in a manner impossible to quantify Such research tends to treat the human body as a commodity — a means to a profitable end. The dignity and sanctity with which we regard the human (...) whole, body as well as mind and soul, are absent when we allow researchers to further their own interests without the patient's participation by using a patient's cells as the basis for a marketable product.In his insightful article, David Resnik would have us travel further down the path of allowing the patenting of DNA in order to advance scientific research and the welfare of humankind. Dr. Resnik suggests that that the acquisition of such proprietary rights in DNA research must proceed cautiously. (shrink)

In the recent linguistic literature, an increasing attention has been devoted to the role of force dynamics in natural language. The present paper argues that the concept of force plays an important role in the Finnish case system. Translative case in this language is conventionally associated with change of state and the illative and allative cases, with change of location. Unexpectedly under such an approach, these forms are sometimes acceptable in sentences that do not entail a change and superficially (...) seem to be stative. This paper argues that translative, illative and allative are licensed by predicates that entail force exertion. While in many instances, force exertion results in a change, this is not an obligatory configuration, which explains the distribution of the cases under discussion. (shrink)

이 글에서 나는 『사회계약론』 1부 7장에서 자유롭도록 강제됨이라는 구절을 분석하고 이것이 우선은 공유지의 비극에서와 같은 특수의지의 전횡을 막기 위한 강제라고 주장하고자 한다. 이를 이해하기 위해서는 특히 위 구절을 루소 특유의 인간학 및 도덕심리학에 비추어서 이해할 필요가 있다. 자유롭도록 강제함은 루소에게서 최악의 상황 중 하나인 인신적 의존에서 벗어나기 위한 방편으로서 그려진다. 즉 사람에 대한 의존은 대개 해롭기 마련인 것이어서 차라리 사물에 대한 의존, 법에 대한 의존으로 대체되어야 한다는 것이다. 이 점에서 강제는 도덕적으로 문제적인 성격의 그런 강제라기보다는 법 앞에서의 형식적 평등, 그리고 (...) 물질적이고 심리적인 부문에 있어서 실질적 평등의 인위적 창출로 이해되어야 한다. 따라서 내가 여기서 제안해보고 싶은 주장은 자유롭도록 강제됨은 단순히 자유를 위해서는 평등이 요구된다는 것, 다시 말해 루소가 이 문맥에서 강제라고 부르는 모종의 평등 없이는 자유도 불가능함을 의미한다는 것이다. 마지막으로 나는 자유롭도록 강제됨에서 자유가 가리키는 것이 우선은 시민적 자유를 가리키는 것이라는 점, 이는 일반의지가 실현되는 적절한 조건 하에서는 인간이 자신의 참된 주인이 될 수 있는 도덕적 자유까지도 의미할 수 있음을 밝혀볼 것이다. (shrink)

Background: Obstetric labor and childbirth are mostly regarded as a physiological process, whereas social, cultural, psychological and transcendental aspects have received less attention. Labor support has been suggested to promote labor progress. The aim of this study was to investigate whether continuous labor support by a midwife promotes labor progress and vaginal delivery.Material and Methods: A randomized controlled study at a university hospital in Sweden in 2015–17. Primiparous women with singleton pregnancy and spontaneous labor onset were randomized to continuous support (...) or standard care during delivery. The primary outcome was the duration of active labor. Secondary outcomes were delivery mode, women's need of labor analgesia and satisfaction with delivery, maternal cortisol levels, and neonatal morbidity.Results: Continuous support was followed by shorter active labor 11.0 ± 5.7 h compared to 13.7 ± 3.9 h with standard care. Women in the continuous support group tended to have lower cortisol levels and low cortisol during the first and second stages of labor were correlated with shorter active labor. Continuous support was followed by spontaneous delivery in 73%, instrumental delivery in 24% and emergency cesarean section in 3% in contrast to standard care which was followed by spontaneous delivery in 62%, instrumental delivery in 24% and cesarean in 14%. The continuous support group received combined analgesic methods more often. Women's satisfaction with delivery and neonatal morbidity were comparable.Conclusion: Continuous labor support was followed by shorter active labor compared to standard care. Women with continuous support had a high rate of vaginal delivery and tended to have lower cortisol levels during all stages of active labor reflecting a lower stress level. Low cortisol was correlated to shorter active labor. Based on these results, we recommend continuous labor support for all primiparous women during active labor. (shrink)

Thirteen years ago, commenting on the treatment of the human body and its cell lines as patentable commodities, Mary Taylor Danforth wrote:Research with human cells that results in significant economic gain for the researcher and no gain for the patient offends the traditional mores of our society in a manner impossible to quantify Such research tends to treat the human body as a commodity — a means to a profitable end. The dignity and sanctity with which we regard the human (...) whole, body as well as mind and soul, are absent when we allow researchers to further their own interests without the patient's participation by using a patient's cells as the basis for a marketable product.In his insightful article, David Resnik would have us travel further down the path of allowing the patenting of DNA in order to advance scientific research and the welfare of humankind. Dr. Resnik suggests that that the acquisition of such proprietary rights in DNA research must proceed cautiously. (shrink)

By their very nature, overseas medical missions (and even domestic medical charities such as free clinics ) are designed to serve vulnerable populations. If these groups were capable of protecting their own interests, they would not need the help of medical volunteers: their medical needs would be met through existing government health programs or by utilizing their own resources. Medical volunteerism thus seems like an unfettered good: a charitable activity provided by well-meaning doctors and nurses who want to give of (...) their time, skills, and resources to help those who would not otherwise be able to take care of their medical needs. In this article, I argue that if medical volunteerism is to be good, however, it must always meet certain basic ethical requirements. These requirements may be (and perhaps often are) overlooked in the rush to organize and carry out short-term medical missions. I illustrate my point with special reference to short-term medical missions designed to provide surgical repair of obstetric vesico-vaginal fistula, a condition in which the tissues that normally separate the bladder from the vagina are destroyed by obstetric trauma, leading to continuous and unremitting incontinence in the affected woman. (shrink)

The wide and complex range of technologies produced and used in the contemporary societies has challenged the analysis from the different fields of social sciences. In this sense, in order to elaborate a study that aim at understanding the relationship between technological progress and the ongoing institutional changes that mark the capitalist societies, we believe it is necessary to adopt an interdisciplinary approach combining methodologies from Economics and Sociology fields. Therefore, this study proposes the development of an interdisciplinary dialogue between (...) the economic sociology of Pierre Bourdieu and the evolutionary economics developed by authors such as Giovanni Dosi, Sidney Winter, Richard Nelson and Bhaven Sampat. In doing so, we intend to demonstrate that a theory guided by Marx’s historical materialism, as it is the case of evolutionary economics, can be enriched by a materialist theory of symbolic, such as that of Pierre Bourdieu. In searching the comprehension of the complementarity between material and symbolic forces, this study addresses the conflictual process surrounding the formulation of the regulatory institutions to the biotechnology sector in Brazil over the last two decades. More precisely, through a case study, we seek to demonstrate that the convergence of discourses and interests between prestigious scientific organizations and the multinational companies that control the agrobiotechnology industry has been relevant to allow this new technological paradigm to make progress. Finally, we raise some questions concerning this alliance between business and science and the conflicts that revolve around the rapid expansion of the genetically modified crops worldwide. (shrink)

Obstetric violence – psychological and physical violence by medical staff towards women giving birth – has been described as structural violence, specifically as gender violence. Many women are affected by obstetric violence, with awful consequences. The phenomenon has so far been mainly investigated by the health and social sciences, yet fundamental theoretical and conceptual questions have gone unnoticed. Until now, the phenomenon of obstetric violence has been understood as one impeding autonomy and individual agency and control over the body. In (...) this article I will argue that the phenomenon of obstetric violence occurs in a specific state of embodied vulnerability and that might be destructive for subjectivity since it fails to recognize that state and instead disallows support and demolishes relationships and interdependence. This might introduce a conceptual shift and the phenomenon might be reconceptualized as a moment where vulnerability is misrecognized and ambiguity, relations and support are banned. In this case violence is recognized as cutting the original links to our bodies and the world that constitute our phenomenological condition, instead of as hurting the autonomous subject. Obstetric violence, thus, calls to be reflected upon through de Beauvoir’s ideas on ambiguity, the embodied and situated subject and the subject as essentially construed in relations. I believe that de Beauvoir’s conception of the authentic embodied subject as necessarily ambiguous – immanent and transcendent at the same time and ineludibly linked to the world and its others – will be extremely useful for construing this new understanding of how obstetric violence happens and of what precisely constitutes its damage. (shrink)

Acts of civil disobedience, which imply the open violation of a legal directive, often result in the forceful imposition of a choice upon others (e.g. blockades). This is sometimes justifiable, within a democracy, in cases of ‘democratic deficit’, namely, when fundamental rights of an oppressed minority are at stake. In this article, I claim that the use of physical force, in a democracy, may also be justified by the rights of (at least some of) the very people upon whom (...) force is applied. Focusing on the nature of civil disobedience as a ‘form of address’, I argue: (1) using physical force to address others in the democratic arena does not entail infringing upon their status as autonomous agents; (2) using physical force to address others in the democratic arena may contribute to the fulfilment of a positive duty to promote the autonomy of (at least some of) those very people upon whom force is applied. This is not a defence of paternalism: I claim that using force against others, in the democratic arena, may be constitutive of a behaviour that treats others with the respect due to their status as autonomous agents. (shrink)

An episiotomy is ‘an intrapartum procedure that involves an incision to enlarge the vaginal orifice,’1 and is primarily justified as a way to prevent higher degrees of perineal trauma or to facilitate a faster birth in cases of suspected fetal distress. Yet the effectiveness of episiotomies is controversial, and many professional bodies recommend against the routine use of episiotomies. In any case, unconsented episiotomies are alarmingly common, and some care providers in obstetric settings often fail to see consent as (...) necessary in context. In their article, ‘The ethics of consent during labour and birth: episiotomies,’ van der Pijl et al reiterate that consent is necessary for episiotomies. They specify, further, that the antenatal period is crucial for exchanging information, establishing trust between the birthing subject and provider, and exploring the birthing subject’s—rather than the care provider’s—values and preferences regarding episiotomies. They recommend an individualised approach, which would enable birthing subjects to choose how and when they want to give consent. I applaud van der Pijl et al on their practicable recommendations regarding consent for episiotomies. This is certainly a step in the right direction where respect for birthing subjects’ bodily autonomy and integrity is concerned. Still, we must be reminded that consent alone is not coextensive with autonomy. The conditions for securing informed consent in healthcare does not guarantee that one’s decision is truly reflective of their values. After all, even valid consent does not rule out ‘normatively significant external influence’.2 Consent acquisition for obstetric procedures present no …. (shrink)

This article returns to the debate about the relative importance of the productive forces and the relations of production in the feudal mode of production. It argues, using western medieval evidence, that this relation is an empirical one and varies between modes, maybe also inside modes; and that, in the specific case of feudalism, not only were the relations of production the driving force, but developments in the productive forces actually depended upon them.

In this paper I propose three steps to overcome the force-content dichotomy and dispel the Frege point. First, we should ascribe content to force indicators. Through basic assertoric and directive force indicators such as intonation, word order and mood, a subject presents its position of theoretical or practical knowledge of a state of affairs as a fact, as something that is the case, or as a goal, as something to do. Force indicators do not operate on truth- or satisfaction evaluable (...) entities as on the traditional view, but complete and unify them. Second, higher-level acts such as interrogative, logical and fictional acts create higher-level unities that may suspend commitment to the assertions and directions they operate on. But they do not cancel their force, but transfer the meaning of force indicators into the new unities they create. For example, in the context of asking a theoretical or practical question, the assertoric or directive force indicator now presents the kind of knowledge the subject is seeking. Third, the Frege point conflates different varieties of force. We neither need Frege’s assertion sign, nor Hare’s neustic, nor Hanks’s cancellation sign, but only ordinary force indicators and interrogative, logical and fictional markers. Propositions are not forceless contents to which a subject commits by forceful acts, but forceful acts put forward by higher-level acts which may suspend commitment to them. (shrink)

Following decades of maltreatment of women in obstetric care, professional respect for maternal autonomy in obstetric decision making and care have become codified in global and national professional ethical guidelines. Yet, using the example of birth after cesarean, identifiable threats to maternal autonomy in obstetrics continue. This paper focuses on how current scientific knowledge and obstetric practice patterns factor into restricted maternal autonomy as evidenced in three representative maternal accounts obtained prior and subsequent to birth after cesarean. Short- and long-term (...) remedies to improve the current state of restricted maternal autonomy in clinical practice surrounding decision making on birth after cesarean are provided. (shrink)

A growing public concern regarding ethical business conduct has stimulated marketing research in the ethics area. This study is the first empirical research to investigate the relationship between a code of ethics and sales force behavior. The findings present preliminary evidence that a well communicated code of ethics may be related to ethical sales force behavior. Furthermore, it appears that a sales force that is employed in such an environment can be profiled as being relatively high in job performance and (...) receiving equally high satisfaction from their positions. Suggestions are made for future research and recommendations are offered for marketing practitioners. (shrink)

We study the preservation of the property of being a Solovay model under proper projective forcing extensions. We show that every strongly-proper forcing notion preserves this property. This yields that the consistency strength of the absoluteness of under strongly-proper forcing notions is that of the existence of an inaccessible cardinal. Further, the absoluteness of under projective strongly-proper forcing notions is consistent relative to the existence of a -Mahlo cardinal. We also show that the consistency strength of the absoluteness of under (...) forcing extensions with σ-linked forcing notions is exactly that of the existence of a Mahlo cardinal, in contrast with the general ccc case, which requires a weakly-compact cardinal. (shrink)

Traditionally, forces are causes of a special sort. Forces have been conceived to be the direct or immediate causes of things. Other sorts of causes act indirectly by producing forces which are transmitted in various ways to produce various effects. However, forces are supposed to act directly without the mediation of anything else. But forces, so conceived, appear to be occult. They are mysterious, because we have no clear conception of what they are, as opposed to what they are postulated (...) to do; and they seem to be hidden from direct observations. There is, therefore, strong initial motivation for trying to eliminate forces from physics. Furthermore, as we shall explain, powerful arguments can be mounted to show that theories with forces can always be recast as theories without them. Hence it seems that forces should be eliminated, in the interests of simplicity. We argue, however, that forces should not be eliminated--just differently construed. For the effect of elimination is to leave us without any adequate account of the causal relationships forces were postulated to explain. And this would remain the case, even if forces could be identified with some merely dispositional properties of physical systems. In our view, forces are species of the causal relation itself, and as such have a different ontological status from the sorts of entities normally considered to be related as causes to effects. (shrink)

The decline in providers and facilities that will allow a trial of labor after cesarean forces many women to choose a repeat cesarean. The choice is frequently not much of a choice, however, since the full range of options are often not on the table. This limited “choice” violates obstetricians' obligations both to respect patients' autonomy and to offer them good care. There has been a vigorous but so far not very fruitful debate in the last few years about the (...) lack of access to a trial of labor after cesarean. Some recently released documents express concern about the limited access women have to clinicians and facilities willing to offer a trial of labor after cesarean. But access is likely to remain a problem for the foreseeable future. (shrink)

Following Milward and Moravcsik’s injunction that the analysis of European integration requires evidence-based empirical observation, this article focuses on one area of state activity - the armed forces - to illustrate the current trajectory of state transformation in Europe. The article argues that European armed forces are becoming ‘transnational’. They are undergoing a process of concentration and transnationalization. Budgets and resources are focusing on specialist military units, organized into joint rapid reaction forces, which are co-operating at an increasingly lower level (...) with other similarly concentrated units in other states. The article concludes by suggesting that the transnationalization of the armed forces reflects the wider transformation of states; across a range of activities, states are contracting to concentrate on their core functions and co-operating ever more closely with each other to fulfil them. (shrink)

Background Changes in policies and practices related to repeat cesareans and home birth in the U.S. have been influenced by different interpretations of the risk of poor outcomes. Methods This article examines two cases—vaginal birth after cesarean (VBAC) and home birth to illustrate how an emphasis on relative over absolute risk has been used to characterize outcomes associated with these practices. The case studies will rely on reviews of the research literature and examination of data on birth trends (...) and outcomes. Results Childbirth involves some unique challenges in assessing health risks, specifically the issues of: (1) timing of risks (lowering health risk in a current birth can increase it in subsequent births); (2) the potential weighing of risks to the mother’s versus the infant’s health; (3) the fact that birth is a condition of health and many of the feared outcomes (for example, symptomatic uterine rupture) involve very low absolute risk of occurrence; and (4) a malpractice environment that seizes upon those rare poor outcomes in highly publicized lawsuits that receive widespread attention in the clinical community. In the cases of VBAC and home birth, the result has been considerable emphasis on relative risks, typically an adjusted odds ratio, with little consideration of absolute risks. Conclusion Assessments of the safety of interventions in childbirth should involve careful consideration and communication of the multiple dimensions of risk, particularly a balancing of relative and absolute risks of poor health outcomes. (shrink)