Key words: code of ethics; rejected patients; terrorism; terrorist victims; terrorists; values.

Objectives To explore attitudes and reasoning among Swedish physicians and the general public regarding the withdrawal of life-sustaining treatment at a competent patient's request. Design A vignette-based postal questionnaire including 1202 randomly selected individuals in the county of Stockholm and 1200 randomly selected Swedish physicians with various specialities. The vignettes described patients requesting withdrawal of their life-sustaining treatment: (1) a 77-year-old woman on dialysis; (2) a 36-year-old man on dialysis; (3) a 34-year-old ventilator-dependent tetraplegic man. Responders were (...) asked to classify the act of terminating treatment and to prioritise arguments for/against. Results A majority in both groups prioritised arguments in favour of terminating treatment and classified the act as defensible in all vignettes. However, among the general public, 16% classified the act as euthanasia in all vignettes; among physicians this view was most expressed regarding ventilator treatment (26%). Some who classified the act as euthanasia prioritised arguments in favour of terminating treatment: among physicians 18% in vignette 1, 19% in vignette 2 and 34% in vignette 3; among the general public 35% in vignette 1, 20% in vignette 2 and 48% in vignette 3. Conclusion There is a widespread consensus regarding competent patients' right to abstain from life-sustaining treatment. An association between the hastening of death, caused by the withdrawal of life-sustaining treatment and the concept of euthanasia is proposed. The results also suggest that classifying the withdrawal of life-sustaining treatment as ‘euthanasia’ does not necessarily mean that the act is interpreted as ethically unacceptable. (shrink)

Background: There is a shortage of reports on what potential recipients of implantable cardioverter–defibrillators need to be informed about and what role they can and want to play in the decision-making process when it comes to whether or not to implant an ICD.Aims: To explore how patients with heart failure and previous episodes of malignant arrhythmia experience and view their role in the decision to initiate ICD treatment.Patients and methods: A qualitative content analysis of semistructured interviews was used. The (...) study population consisted of 31 outpatients with moderate heart failure at the time of their first ICD implantation.Setting: The study was performed at Sahlgrenska University Hospital, Göteborg, Sweden.Results: None of the respondents had discussed the alternative option of receiving treatment with anti-arrhythmic drugs, the estimated risk of a fatal arrhythmia, or the expected time of survival from heart failure in itself. Even so, very little criticism was directed at the lack of information or the lack of participation in the decision-making process. The respondents felt that they had to rely on the doctors’ recommendation when it comes to such a complex and important decision. None of them regretted implantation of the ICD.Conclusions: The respondents were confronted by a matter of fact. They needed an ICD and were given an offer they could not refuse, simply because life was precious to them. Being able to give well-informed consent seemed to be a matter of less importance for them. (shrink)

Background: Caring for terminally ill patients is a meaningful task, however the patient’s suffering can be a considerable burden and cause of frustration.Objectives: The aim of this study is to describe the experiences of general practitioners in The Netherlands in dealing with a request for euthanasia from a terminally ill patient.Methods: The data, collected through in-depth interviews, were analysed according to the constant comparative method.Results: Having to face a request for euthanasia when attempting to relieve a (...) class='Hi'>patient’s suffering was described as a very demanding experience that GPs generally would like to avoid. Nearly half of the GPs strive to avoid euthanasia or physician assisted suicide because it was against their own personal values or because it was emotional burdening to be confronted with this issue. They explained that by being directed on promoting a peaceful dying process, or the quality of end-of-life of a patient by caring and supporting the patient and the relatives it was mainly possible to shorten patient’s suffering without “intentionally hastening a patient’s death on his request”. The other GPs explained that as sometimes the suffering of a patient could not be lessened they were open to consider a patient’s request for euthanasia or physician assisted suicide. They underlined the importance of a careful decision-making process, based on finding a balance between the necessity to shorten the patient’s suffering through euthanasia and their personal values.Conclusion: Dealing with requests for euthanasia is very challenging for GPs, although they feel committed to alleviate a patient’s suffering and to promote a peaceful death. (shrink)

In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal (...) code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator. (shrink)

The unbridled use of modern medical skills and technology in preserving life at all costs has stimulated interest in expressing a 'right to die' by the legally competent patient who is anxious to protect his autonomy. Some recent decisions by American courts are seen to threaten this 'right to die' of competent patients and imply that legally incompetent patients including children should not have this right under any circumstances, even when expressed on their behalf by guardians, nearest (...) relatives or parents. It is argued that this is contrary to 'natural justice' as viewed by most people. It should be possible to develop procedures which are protective of the basic 'right to life' of the incompetent yet will recognise circumstances where they could be allowed to die. This paper was presented at the 1983 annual conference of the London Medical Group, 'Human Rights in Medicine'. (shrink)

Background Even though the traditional focus in emergency care is on life-threatening medical crisis, ambulance clinicians frequently encounter patients with mental illness, including suicidal ideation. A suicide is preceded by a complex process where most of the suicidal ideation is invisible to others. However, as most patients seek healthcare in the year before suicide, ambulance clinicians could have an important part to play in preventing suicide, as they encounter patients in different phases of the suicidal process. Aim The (...) aim of this study was to describe ambulance clinicians’ conceptions of responsibility when encountering patients in a suicidal process. Research design A qualitative inductive design using a phenomenographic approach was used. Participants and research context Twenty-seven ambulance clinicians from two regions in southern Sweden were interviewed. Ethical considerations The study was approved by the Swedish Ethical Review Authority. Findings Three categories of descriptions captured a movement from responding to a biological being to responding to a social being. Conventional responsibility was perceived as a primary responsibility for emergency care. In conditional responsibility, the patient’s mental illness was given only limited importance and only if certain conditions were met. Ethical responsibility was perceived to have its primary focus on the encounter with the patient and listening to the patient’s life story. Conclusions An ethical responsibility is favourable regarding suicide prevention in ambulance care, and competence development in mental illness and conversation skills could enable ambulance clinicians to have conversations with patients about suicidal ideation. (shrink)

The determination of death by neurological criteria remains controversial scientifically, culturally, and legally, worldwide. In the United Kingdom, although the determination of death by neurological criteria is not legally codified, the Code of Practice of the Academy of Medical Royal Colleges is customarily used for neurological death determination and treatment withdrawal. Unlike some states in the US, however, there are no provisions under the law requiring accommodation of and respect for residents' religious rights and commitments when secular conceptions of (...) death based on medical codes and practices conflict with a traditional concept well-grounded in religious and cultural values and practices. In this article, we analyse the medical, ethical, and legal issues that were generated by the recent judgement of the High Court of England and Wales in Re: A [2015] EWHC 443. Mechanical ventilation was withdrawn in this case despite parental religious objection to a determination of death based on the code of practice. We outline contemporary evidence that has refuted the reliability of tests of brainstem function to ascertain the two conjunctive clinical criteria for the determination of death that are stipulated in the code of practice: irreversible loss of capacity for consciousness and somatic integration of bodily biological functions. We argue that: the tests of brainstem function were not properly undertaken in this case; the two conjunctive clinical criteria set forth in the code of practice cannot be reliably confirmed by these tests in any event; and absent authentication of the clinical criteria of death, the code of practice wrongly invokes a secular definition of death based on the loss of personhood. Consequently, the moral obligation of a pluralistic society to honor and respect diverse religious convictions to the greatest extent possible is being violated. Re A is contrasted with the US case of Jahi McMath in which the court accommodated parental religious objection to the determination of neurological death codified in the Uniform Determination of Death Act. We conclude that the legal system in the United Kingdom should not favour a secular definition of death over a definition of death that is respectful of religious values about the inviolability and sanctity of life. We recommend the legal recognition of religious accommodation in death determination to facilitate cultural sensitivity and compassionate care to patients and families in a pluralistic society. (shrink)

Architecture and Deconstruction Case of Peter Eisenman and Bernard Tschumi -/- Introduction Towards deconstruction in architecture Intensive relations between philosophical deconstruction and architecture, which were present in the late 1980s and early 1990s, belong to the past and therefore may be described from a greater than before distance. Within these relations three basic variations can be distinguished: the first one, in which philosophy of deconstruction deals with architectural terms but does not interfere with real architecture, the second one, in which (...) a collaboration between Jacques Derrida and a group of architects interested in his concepts is commenced, and the third one, in which completed or only designed objects or new concepts of deconstruction created by architects gain their supremacy over philosophy. The following book analyses these three possible ways, first of all with the reference to Peter Eisenman and Bernard Tschumi. -/- Peter Eisenman -/- Misreading… and Other Errors -/- The issue of relations between Peter Eisenman’s work and philosophy of deconstruction may be referred to his activity more than ten years preceding his direct collaboration with Jacques Derrida (in 1985) and organisation of the exhibition Deconstructivist Architecture at Museum of Modern Art in New York (in 1988). As soon as at the stage of designing the first houses (House I-III, 1967-1970), which almost entirely inscribed in formalistic aesthetics of Modernism, the architect analysed the problem of architecture dependence on its assumptions. All his later designs may be treated as consequence of this initial interest in relations between practice and theory, and at the same time as an introduction to manipulations later on led at the level of metaphysics of architecture. Beginning with the issue of presence, considered in comments to House VI (1972), the number of ideas having their analogies in philosophy of deconstruction increased. The text entitled The End of the Classical: The End of the Beginning, The End of the End (1984), in which Eisenman criticised questions of representation in architecture, its delusive strive for truth and comparably unattainable attempts at ultimate definition of elementary rules, should be acclaimed the breaking point. This attitude was extended by numerous strategies disturbing architecture rules defined at metaphysical level in an essay Moving Arrows, Eros, and Other Errors: an Architecture of Absence (1986). The issue of Eisenman’s passage from formalism to deconstruction has already been much discussed in the literature (Rosalind Krauss, Thomas Patin among others), still it should be mentioned that the threads similar to Derrida’s concept included in Eisenman’s writing reveal untranslatability of architecture and philosophy. -/- Choral Works or Separate tricks -/- In 1985-1986 a series of seven disputes between Jacques Derrida and Peter Eisenman took place. The pretext for them were designs concerning Parc de la Villette in Paris. The situation of many months of collaboration between a notable philosopher of the second half of the 20th c. and an architect that already had a huge theoretical oeuvre, ended up with a publication of a large volume entitled Chora L Works and it became at the same time a vast study area for historians of contemporary architecture and philosophers. Derrida’s contribution to concept works were his considerations over the idea of chôra, the properties related to this concept were about to be reflected in shapes of the park. Therefore, Chora L Works became an example of the abilities of contemporary art, both in its capability of translation from philosophical ideas to artistic forms and its resistance to tradition of representing in architecture some phenomena and values originating outside this discipline. In the final period of their collaboration both interlocutors started to polemicise with each other more decidedly, what became a separate part of their thought exchange. The exchange of letters between Derrida and Eisenman at the turn of 1989 ended up the period of their direct contacts, nevertheless, at this time precisely a large group of experts in issues of deconstruction joined the discussion and extended the revealed in the former dispute problems into more than ten years of further considerations and publications. Except for a long text by Jeffrey Kipnis, who had participated in the meetings of the philosopher and the architect, there appeared also comments of researchers of artistic theories (K. Michael Hays, Thomas Patin), philosophers (Andrew Benjamin), and even experts in Greek literature (Maria Theodorou or Ann Bergren). Following these debates a contemporary reflection on architecture has saturated with indeed numerous concepts originating in philosophy of deconstruction. -/- Architecture which imitates mute philosophy -/- The series of Jacques Derrida and Peter Eisenman meetings, which took place in the period of 1985-1987, induced many authors to make comments. Some of them (Jeffrey Kipnis, Ann Bergren, Maria Theodorou) developed the subject of chôra which was introduced to the discussion by Derrida. The problem that was about to be solved was the question of tying up the concept of chôra with architecture, including Eisenman’s architecture and the series of meetings within frames of Chora L Works project. Kipnis on this occasion paid attention to chôra and its character of anachronia which infects any being created within chôra. In other words any event has its counterpart (analogon) in another, earlier event. He demonstrated the similarity of structure of many events and statements from the times of Derrida and Eisenman’s meetings to the almost identical behaviour of figures in Plato’s dialogue Timaeus. The loss of beginning present in this phenomenon was appropriate to both features of chôra and the effects of typical analyses of philosophy of deconstruction. Bergren’s analyses focused on accentuating gender of chôra, which, according to this author, had been neglected hitherto in discussions. She collated chôra descriptions with characteristics of women in myths, early Greek epic and philosophy and she arrived at a conclusion that chôra has features of a single woman and a married one at the same time. And yet Theodorou’s studies showed that in the Homeric epics chôra is not treated as an idea but is related with single things and events. The other part of the comments (represented by Andrew Benjamin and K. Michael Hays’ utterances) concerns Eisenman’s attitude to tradition which was treated as a variety of iteration understood philosophically. Benjamin commenced his considerations at the point of closeness between a definition of tradition and a concept of chôra understood as perpetuation (placement). A problematic issue was for him Eisenman’s complex relation to tradition based on its contest and affirmation at the same time. Overcoming the simple subordination to tradition – according to Benjamin – was based on awareness of the role of repetition in culture not known before. Hays made an attempt to explain the pleasure and torment of repetition with the support of Sigmund Freud and Roland Barthes’ concepts. According to Hays repetitions are attempts of a single being to a certain primal state perceived as free of any tension. In a similar way Rosalind Krauss explained a motif of a grate present in Modernistic art and also exceptionally frequent in Eisenman’s work. -/- Annex Architecture is still writing Balzac novels. Peter Eisenman and literature -/- Architecture’s approach to writing, script or literature, present within Peter Eisenman’s work, is an exceptional phenomenon, furthermore a complex one. The article considers four possible relations. The first one relates to Eisenman’s characteristics as a person extremely gifted with the ability to wordplay, which very ‘play’ reveals skills to create architectural images. In the second approach the attention has been paid to Eisenman’s interests – in the first period of his oeuvre – in linguistic works by Noam Chomsky and his transformational-generative grammar. The third kind of relations applied to overcoming the need for autonomy of architecture (and of modernist aesthetics at the same time) and renew interests in questions of meaning in architecture. The fourth sort of relations occurred when Eisenman started to create reflections of historic or literary narrations in architecture – ‘stone stories’ and architectural fictions of their kind. -/- Bernard Tschumi -/- From perversion to deconstruction In Bernard Tschumi’s writings from the 1970s and 1980s we can find a transposition of important threads of post-structuralist ideas deriving from Georges Bataille, Roland Barthes and Jacques Derrida’s works. The analysis of the architect’s writings also shows roots in Phillippe Sollers, Michel Foucault and Denis Hollier’s works. The analysis of borrowed elements from the beginnings of Tschumi’s theoretical activity may be helpful in explaining the contents of his later writings motre inspired by philosophy of deconstruction. The set of his earliest views was inspired by Marxism, Neo Marxism and French Structuralism, mainly by the writings of Henri Levebre and Guy Debord. From the thought of Levebre Tschumi took interest for city as not only a question of urbanistics but also a political issue. From Debord’s concepts he borrowed a conviction about the role of situational violation for changes in the society structure. Some of these beliefs were preserved in his own concepts of architecture as an event. From this period derived also his will to change conservative elements of social structure not by means of political revolution but of theoretical and creative activity. Tschumi acknowledged that the effective way of the proceedings towards achieving his aims would be accepting the role of both a critical intellectualist and architecture expert who would not hide away his left-wing orientation. The speculations defined by the architect as ‘revolting analyses’ were about to characterise contradictions which tear the society apart, penetrate architecture and constitute the basis of culture. Spreading away of the conscience of false assumptions hidden away in various disciplines could have weakened cohesion of a conservative society and influence the will to change among the elites. This way the beginnings of political revolution were rooted in philosophy of architecture. In 1977 Tschumi published his text entitled The Pleasure of Architecture inspired by Roland Barthes’s The Pleasure of the Text, it also included some concepts derived from Georges Bataille and Jacques Derrida. First of all the author used Barthes’s concept which made an assumption that literary activity is pervaded by the spirit of resistance towards social rules, and Tschudi transferred this remark onto architecture. From the ideas of Bataille, acquainted via Holier’s work, he derived his belief that two concepts of space, a conceptual one (defined as Pyramid) and a sensual one (defined as Labirynth), not losing their distinct features, they join in the concept of experienced space which exceeds contradictions. The exceeding itself was defined as the basic rule of architecture and it was referred to situations in which architecture not only negates social needs, but also disavows its own tradition. Crossing the borders applies not only to political issues or permanent rules of the very discipline but also interfering with other fields (especially literature and film). The fact that architecture is associated with organising events turned Tschumi’s attention to questions of violence that result from upsetting architectural order of a given building by its users and the one hand, and on the other from forcing the users to specific acts imposed by this very order. The analysis of the concepts used by Tschumi in his early writings indicates that they are close to definitions that would occur in his reflection in the following years influenced by philosophy of deconstruction. -/- Approaching deconstruction Tschumi in his theories developed in the 1980s presumed that the current social world had undergone a deep process of decay, and the reaction against which ought to be based on ordering-up actions, and also preserving the main outline of disintegration of the whole and its elements in the state of conflict. The statements concerning the nature of the contemporary to Tschumi social relations were applied by him to the world of architecture, this led him to coming up with designing strategies that took into consideration the destabilised character of conditions in which works of architecture were created. New ways of conduct invented by Tschumi drew their inspiration from literature and research on literature, psychoanalysis, structural linguistics, structuralism and post structuralism, and eventually also deconstruction philosophy. The proposed methods were opposed by their author both to functionalism continuity trends and postmodern architecture. Tschumi’s proposals contradicted any forms of conservatism or traditionalism in political sphere as well as in reference to tendencies in architecture. They were not simple contradictions of social or architectural rules, they intrude them from the inside, weaken or escalate the already existing incongruities, they move the boundaries between the areas. Revolutionary illusions about the possibility of radical changes were replaced with strategies which completed, tainted or test former rules in the series of formal games of permutation and combination. Quite different from avant-garde formalism Tschumi’s games were not about maintaining the autonomy of a given area, but on the contrary – polluting it with other areas’ influences. Tschumi enjoyed demonstrating illusions of architecture concerning simple relations between form and function, or between form and meaning. Making use of Freud, Lacan and Foucault’s research he introduced a category of “madness” into architecture allowing an observation that the recognised norms are nothing but merely ones of many possible principles of behaviour, and their recognised status resulted from unjustified hindering innovativeness which is crucial for architecture. To reborn architecture’s capability of changing Tschumi also made use of Barthes’s discoveries concerning rules of narration and works by writers who applied in their writing knowledge on linguistics. Making a work’s author unclear by various mechanical transformations of its elements was however apparent only, and formal rigours imposed on the process of designing liberated possibilities difficult to obtain in more traditional creative action. Another mode of acting introduced by Tschumi was combining his work of elements deriving from outside architecture; joining space records with notation of motion and events accompanying architectural objects among others. These architectural and extra-architectural elements were not unified, on the contrary their heterogenous and conflictual character was stressed. This is how shock, anxiety and instability, typical for live in great metropolises, infiltrated architecture. Taking some ideas of deconstruction philosophy as a pattern Tschumi also took into critical consideration in his essays traditional in architecture oppositions between form and figuration, or theory and practice. By combining various inspirations he eventually worked out an idea of architectural event, which he understood as a series of actions contesting its own field, redefining its sources, principles and elements. An event, understood in this way, was not so much producing works as rather creating conditions of their production and at the same time designing the society different from a hierarchic one. -/- Park of deconstruction Among numerous philosophical strategies of deconstruction most frequently used was questioning the practice of strong opposition of two reasons. In many cases Bernard Tschumi’s writings just consider functioning of the conflict juxtaposition of the ideas of structure and ornament or theory and practice in history of architecture. Violation of traditional relations between terms of this kind, both old and modern, raised Jacques Derrida’s objections, when he was induced for the first time to co-operate with architects’ milieu. During this long lasting thought exchange the philosopher eventually acknowledged Bernard Tschumi’s arguments for reasoning the encroachment of architecture’s fundamental rules. Deconstruction applied in architecture was not a simple transposition or analogy of practices that had been applied by philosophy of deconstruction. We may even say that considering architectural terms became an important formula of deconstruction. Architecture understood in philosophical way became something beyond the practice and theory of its own discipline, a sort of metaphysics of both philosophy and architecture. The deliberate encroachment of simplicity of dividing architecture into theory and practice, for the first time became a clear aim for Tschumi in his drawings and texts entitled The Manhattan Transcripts. The contents of this series of works was a record of characteristic features of this New York district in such a way that not only objects were the subject of the record but also relations between objects, people and events. The record was about to take into consideration a conflict character of elements of this representation and at the same time to avoid applying to them the rule of mimetism. The record became a form of reflection over the very record by an increased control over the ways of representation. Architecture which was considered in the The Manhattan Transcripts was not directed to fulfill the needs of inhabitation or production, it was rather related with hitherto usually marginalised liminal situations: building ostentatiously big monuments, religious cult, war etc. Architecture operating in these relations focused also the attention on the included in it continuous tendency to overpass its own restrictions, the role of violence as its not recognised factor, or the meaning of excess and shock in its operation. Architecture moving from reason towards madness became even more visible in the design of Parisian Parc de la Villette, whose pavilions were defined as folies (in French it means both small park buildings and follies). The park was supposed to be on the one hand a reflection of traditional society disintegration while on the other it questioned basic rules of producing a work of architecture. The traditional rules of designing, based on ordering up, were replaced with the strategies of dysfunction and dissociation. In Tschumi’s opinion methods of this kind may be equivalent of what Derrida named différance. Instead of aiming at mergence, any diversity, plays or variations were strengthen. Tschumi’s texts, in which he explained his attitude, were completed by Derrida’s extent statement entitled Point de folie – Maintenant l’architecture. Derrida’s article is the most significant of all his statements on architecture as a form of thinking and activity. According to the philosopher, architecture should divide space (in French defined as espacement), what enables both thinking and action – it arranges the space of an event. Tschumi’s buildings, defined as folies, in an essential way destabilise any created order, and at the same time they refresh it. Derrida’s statement suggests that architecture may become both metaphor of an order merging a language or a society but also of inner forces which deconstruct and reconstruct it. Therefore architecture is at the same time a construction, a deconstruction and a reconstruction. Parc de la Villette stands out in this system with its attempt to step beyond the scheme of an easy repetition and its heading for chances of achieving more radical otherness. -/- Conclusion Destruction as construction. Paradoxes of deconstruction in architecture -/- Scepticism about persistence and common importance of fundamental values of human culture evinced in philosophers and writers’ works as early as in Greek antiquity, nevertheless it was not expressed so strongly as in the second half of the 20th century. Especially in Heidegger’s work Being and Time (although originated in 1927, still influential in all later philosophy) the following states were characterised: the state of losing the ground (Abgrund), of being out of sight (Unheimlichkeit) and of being out of dwelling (Un-zuhause-sein) – as the basis of self-confidence of conscious being there (Dasein). The entire criticism of philosophy of home and dwelling draws the inspiration from this early writing of the German philosopher, it combines crisis of basic terms of metaphysics with social conditions which are dictated by living in large metropolis. The crisis of both metaphysical foundation and home appears to be similar to the situation of weakening the relations between a man and his dwelling in extensively expanding cities. Whereas philosophy, as well as many disciplines of social sciences, have diagnosed for a long time the destabilisation of fundamental ideas of Western culture and crucial changes in the ways of dwelling, architecture itself occurred to be “the last fortress of metaphysics” (J. Derrida). Among contemporary architects, Peter Eisenman and Bernard Tschumi were the ones who engaged most decidedly in the issues of critical analysis of architecture foundation and its social role. Both the architects noticed new formulas of contemporary social and individual existence, tremendously different from the entire history, and at the same time they affirmed lack of adequacy of architecture concepts to new situations. Both Eisenman and Tschumi used to describe the existing architecture as a tool for consolidation of highly integrated and hierarchised societies, and also as a discipline extremely uncoincidental with the current character of social life based on ideas of freedom and diversity. The means to transform architecture and make a factor of further social changes out of it, was a concept that accentuated revealing the inner contradictions of this discipline, and considering them in designing strategies. Eisenman’s activity, in regard of what has just been noticed, was focused on questioning the basic rules of traditionally comprehended architecture, especially the rule of purpose. The American architect noticed that the concept of architecture as fulfilment the need of location, hides away the fact that the location has to be constantly reconsidered, and hence it is overtaken by change (dislocation). Therefore new concept of architecture propounded architectural activity to translocate the concept of location – more than before – but also to change its status perpetually. Such comprehended architecture should claim, as its main purpose, the constant revision of this purpose and create itself anew permanently. Even Eisenman’s earliest designs of houses nos. I-IV broke with such values as the sense of safety, closeness and familiarity, and just on the contrary they accentuated senses of strangeness, homelessness and loss of confidence. The contradictions within architecture noticed by Tschumi referred to combination of intellectual and sensual values in architecture, when their non-appropriation was defeated by an additional condition, namely the way of experience based on pleasure of excess, marked by insanity. The features of folly were especially visible in his designs of gardens, where the order of planning was mixed with sensual experience introduced by particular elements (both the ones created by nature, and the buildings defined as folies). Parc de la Villette designed by the French architect in Paris put in question not only the common understanding of purpose in architecture but also the ideas of order and integrity, as its plan was based on the combination of independent layers with records of grids of points, various lines and planes. The architecture that collides inadequate elements with each other was supposed to be a kind of an event with no beginning and no end. The architecture treated as an event became a form of a space weakened articulation that maintains its diversity and lack of accordance of the elements building it up. The analyses of Eisenman and Tschumi’s theoretical writings indicate how much the aims of architecture have actually changed; instead of supporting social persistence, the architecture is rather intensifying contradictions, and instead of providing people with the sense of safety, it sublimes danger. From simple acts of defamiliarisation, increasing the distance to itself and enhancing the role of theory, through discomfort, anxiety, not feeling someone at home, weirdness, excess, shock and violence, architecture reached the edge of stability and uncertainty, only to make an attempt at penetrating what is impossible and unutterable, and recording what cannot become the subject of any records. -/- . (shrink)

continent. 2.2 (2012): 155–158 Michel Serres. Biogea . Trans. Randolph Burks. Minneapolis: Univocal Publishing. 2012. 200 pp. | ISBN 9781937561086 | $22.95 Conveying to potential readers the significance of a book puts me at risk of glad handing. It’s not in my interest to laud the undeserving, especially on the pages of this journal. This is not a sales pitch, but rather an affirmation of a necessary work on very troubled terms: human, earth, nature, and the problematic world we made. (...) It is this world that aspirates the silence (so to speak), and therefore the subject which, along with the development of the “made world” exports the excess augmentation of the cosmically missing, this silence of the natural, et cetera. Had we learned from Locke that lesson of “labor,” to consume what we need… but perhaps we need more than what matters? Serres’ Biogea has several functions on this manner, if it is indeed a book to be consumed. First, readers searching for novelistic entertainment have a place to dwell. Biogea deserves a place in your back pocket; biographical generosity and poetic fluidity should satisfy most textual fetishes. For lay philosophers who want to refresh their acumen, Biogea deserves a place on the book shelf, one already reads a sorely needed postmodern tune-up here. Serres’ style is clearly French; he leaves few cheese crumbs on his words, rather preciseness and breathing in the work give way to a sweeping manner that breaks the narrative line of sight. A circular narrative and anachronistic fragmentation of terms allows an abyssal atmosphere to swell, if only to pump into the book the externality of its broader text. Biogea aspires to a higher standard and the book, at times, is thinking this negentropic problem too. Univocal, the publisher, has crafted a book appropriate for the hands to hold and the translations are an achievement of an otherwise difficult writer to translate. Terms are the conditions of a broader text. It is important to note that Serres’ content is as much a thinking of terminal ports. There is a regard for the transportation technology of the written word. For me, this is the mark of genius, a craftiness that tells of a book device that I may trust. Serres is an accomplished thinker and a necessary voice to check the putative trendiness of anti-postmodernist and market-driven theory of endless cultural liquidation. Offering interventions on subjectivity as an open system we are given a chance to affirm the human, not merely to discard it, but to engage its poetic image emotion, the calibratory silent sense of the analogic world; the terms on which we base our efforts. 1 The human is the center of its own negation, constantly mediating it. Something deeper at stake appears in the work then, and it is quite obvious from the onset. Certainly, a book is an intensification of possible text and those who brought this actual book into existence have captured a rarity in regards to the subject matter and artistic accomplishment. I mentioned terms as conditions, so let us understand Biogea as bio-yea, a yes to bios . An affirmation of living and accepting presence for all of its defiance of images, words, and things temporal. Therefore Serres’ existence and its existants plays parts; out of linearity and still like a porous bone pumping blood it manufactures into the fleshy life it becomes. Starting from a man named silence chaos emerges, or the man “Old Taciturn” takes up a journey anticipating a great flood. In other words, a development akin to the one in Genesis. In dealing with this ancestral occupation, fusing Genesis with contemporary philosophical terms, Serres initiates this anachronistic fragmentation under the forming subjectivity of his own autobiography. This mutation in the open system is precisely one of Serres’ terms. There an abyss is at work, stated, but also measured by heels on the ground—the abyss dispatching earthen tensions, that which plays our tunes, that which we abide by and recognize in volcanoes, rivers, oceans, earthquakes and weaponry in the battles of the world. Set in later stages of the book, such tensions are harnessed through scientific principles in an attempt to unify the terms of natural force if only to terminate the world. Thus the elevation of the earth into the world is clearly set forth. Here already, and few pages in, a resonance is set forth under appellations such as the river Garonne, a subjectivity as much as it is inhuman, the river is the inhuman that makes us human. I get the sense that Serres is taking up a challenge issued by Wallace Stevens; namely, that the great poems of heaven and hell have been written, but that only the poem of the earth has resisted composition. 2 On this level we cannot avoid the killing factor of silence, given that our cognition blocks its pure, radical obliteration. Thus a silence of attunement to the earth is in a novel dialectic of the rithmic and rhythm. A technological world, a triumph of termination is set forth. If a text imposes its will given the reader who authorizes it, it is made to convey or convect a presupposition to a reader or its inhabitant(s). Text is therefore both, in-content, contenting, contentedness, and in reading it, a way to navigate self-destruction (dis-content). Here then would one note that the “inhuman” reveals itself, “an aperiodic rhythm of lovers and beloved…the sea as our friend…but as our enemy…maternal vivifying sea.” The sea is an open book, or vaginal birth canal, where the engagement of text comes forth: “…woman sea, open vulva.” One sees like the sea, but only after it, when the uninhabitable truth of inhabiting it switches the polarity of the sailors soul: “I was seeing like the sea” (9-11). In other words, we are invited to embrace the nonsense of the visible. At this point I am taken to Jean-François Lyotard’s work The Inhuman , specifically the first entry on negentropy that would be congruent with Serres’ thematic. 3 The human being exports, deports, or transplants its relation through text, through the system— and this is its sense or relation to silence, to music. Unaware of Serres’ proximity to this work, the concept of gender interrelation as regards a solar catastrophe runs clear. It would be, on this basis, that Serres references his peers, the other texts that, as mentioned above, are discarded in philosophy today. For students of philosophy what we have here is perhaps a gift, a needed project. If silence and death are at work, there is a political valence to deal with, and here, much like the domain of the text and the dominion of the reader, we confront the world of natural, fluid violence. The anti-postmodernist critique is in part based on a weak idea that the loss of ideology, of a world vision, motivates the “correlationist” project. 4 Serres seems to offer another way to view this when he notes that whereas persons “sometimes kill,” it is clearly “the collective” that “always kills” (17). What is the collective today, if not an organizing function we never see yet acts in its favor in the name of truth? One feels a sense of enigma here, if only to link to what Stevens remarked of communism as a “grubby faith,” providing this applies for capitalism as well, namely any ideology of progress overly interested in absolutes. Here we get the sense that the inhuman, silence, this type of killing, always killing, could not be matched by human-made, political dynamos. Or that if it comes to an equilibrium, a catastrophe is never too far from us to read with our heels. We are left to note that the forces of nature presuppose and permeate political systems, the more these systems obtain force, the more the system takes upon itself the proper name of nature that motivates its dissemination, albeit falsely. This note, that in an age of ecocide and technological captivity (sustainability and transparency) political regimes won’t grow our soul-learning ears any larger than our tongues, stands clear to us. The promise of technological desubjectification is here pushed aside. Regarding politics, Serres illustrates this fact: Where did this corpse come from? Who was it? Who killed it? I don’t know. I won’t try to find out. I refuse to get vengeance for it. And I only see Garonne. For our victims, today, are the rivers, too. Their waters have irrigated my life, enchanted my thought, invigorated my body; I’ve known them to be threatening, untamable, as dangerous as the sea when it rages. Yes, murderous. They decided to control their courses; dams, sometimes senseless, destroying sites and valleys, reduced entire populations to servile displacements; programs for the irrigation of thirsty farmland, often beneficial of course, completed their drying up.(22) Serres enters into his idea concerning the captivity of language from the natural into a world system: For thousands of years, we have been licking things with our tongues, covering and daubing them so as to appropriate things for ourselves. If language boils down to a convention, this convention took place between the speakers without consulting the thing named, become as a result the property of those who covered it in this way with their drawn or voiced productions. Malfeasance analyzes these acts of appropriation. Thus every inert object, every living thing as well, sleeps under the covers of signs, a little in the way that, today, a thousand posters shouting messages and ugly riots of color drown, with their filthy flood, the landscapes, or better, exclude them from perception because the meaning, almost nil, of this false language and these base images forms an irresistible source of attraction to our neurons and eyes. This appropriation covers the world’s beauty with ugliness. (38-39) Technological concealment coming to bear, we begin to get a sense of another commentary on the condition of sensing, driving home the necessity of a text dealing with such subject matter to be what its terms insist. Thus toward new openings: The new opening. As low beneath our feet as you like, the Biogea opens us to another space, high enough for us to be able to acquire a wisdom there, that of redeveloping this same place differently from our fathers, this place that’s still politically cut up by old hatreds, beneath the flood of tears and blood that we call history. Without this soft place, spiritually very old, but newly conceived in this way, without the juridical construction of a common good, opposed to our filthy ownership, I don’t see how our planet, hard, will survive. Hardness that depends on a softness, material belonging that depends on this temporary rented location (51). Serres enters into a summit on the content and the structure of his work. Archimedes is brought in with the concept of three volcanoes. Meaning fire, but as well earth, water, air. For it was Archimedes’ war machines that sought to lift the earth, thus bringing in the question of principles of science: “can a principle be invented while controlling its consequences?” (66-7). May the earth be put in a sentence, terminated by terminology, appellations, gone wild? By means of these element-dominating laws, this old physicist began to tear nature away from the ancient myths; by a strange return, today we’re plunging our successes back into the anxieties and terrors from which that ancient physics was born. Yes, our new history of science and technology is plunging, today, as though in a loop, into the fundamental human myths from which Empedocles’ first laws came. A major progression and a regression on the nether side of the origins. Consequently, the contemporary time requires that we try to return to that unity in which the principles of hate and love are at the same time human, living, inert and global. We will never attain a deontology of our knowledge and actions without thinking the subjective, the objective, the collective, and the cognitive all together simultaneously. Here, hate and love are the result of these four components.(71) Working then on the concept of fire-starting mirrors to the atomic annihilation of the Second War, Serres works into the subjectivity in question on the matter of rhythm—say rithmic— precisely at that point: Knowledge is changing today. The all-political is dying; the monarchy of the sciences said to be hard is coming to a close. The science of the things of the world will have to communicate just as much as the things of the world do, which do it much better than humans do, who don’t always want to do it. Let’s celebrate two changes this morning. The first one strikes a new blow to our narcissism. No, knowledge and the world don’t resemble our analytical enjoyments of refined cutting up, of endless debates and of exclusions full of hate. They, on the contrary, form a bloc and a sum, alliance and alloys. Uniting the fields of knowledge among themselves the way the things are connected among themselves, the second newness puts into place sets united by interlacing, webs and simplexes that combine with the things of the world, themselves combined, the combined knowledge that understands them.(130-1) Biogea closes on its opening flood thematic, approaching the initial telos of Genesis. Here the trees are brought into a position with atmosphere, the opaque abyssal reservoir, the tomb of the sun, sea in the polarity of the earthen heaven and hell. The poem of the earth then is silent but deadly, indeed, as funny as that phrase is, mainly a tomb gas. The meaning of the living and the non-meaning of things converge in the muteness of the world; this meaning and non-meaning plunge there and come out, the ultimate eddy. Mundus patet: through a fissure, through an opening, a fault, a cleft come noises, calls as small as these apertures. I’m listening, attentive, I’m translating, I’m advancing in the scaled-down meaning and science. Mundus patet: should the world open greatly, it will launch me into its silence. The totality remains silent. Knowledge expanded in elation. White origin of meaning, fountain of joy. (198) Final Remarks One test of a review is the long term trajectory the referee thinks the book will have. I see Serres’ text lending greatly into the vision of Biogea . In fact, in the vision of the novel inquiries of Stephen Jay Gould’s work there is something to be thought on the level of the individual and the species; namely, that humanity and its uniqueness is in its deferral, its thinking and naming, a thinking surrounded by silence that filters into everything, that pulls us through the world, the kinetic pulse we recognize, and all of that we cleave away in the base philosophical maxim of difference itself. Unique individuals are spatial creatures: we dwell, and we ought to get good at it. Yet this is an imaginative space that, if you are crazy enough to believe it, de-term-ine the conditions of its own terms. That is why we are not merely creating spaces on the acceleration of time, or so this ignoramus thinks, to accidentally transcend. Imagination already has this insatiable silence that we drink up and fail to manifest. Space is timeless. The imagination itself, shared by humans for themselves, their objects, and the species as a whole, is a non-defined space of relation; a whole human trajectory as part of nature, and part of worlds that are the other side of thinking nature, the consequence of it, at least our attempt to do so. Our survival is based on our deliberation, our caution, our natural deconstructive sense toward this silence that is already part of the song, sung, singing of this century without end. Good books will let us inhabit this space and recognize a form of life. Serres’ text moves toward dwelling, as noted, in masterful and accessible ways. The pitched battles are the falling replays of anemic and dead politics. As soon as we realize there is humanity, we may be able to enjoy the end of it, our inhuman capability of listening to silence. NOTES 1. See Michel Serres. The Parasite . Minneapolis: University of Minnesota Press. 2007. 2. Wallace Stevens, “Imagination as Value” [ca. 1945], in Collected Poetry and Prose . New York: The Library of America. 1997. 724-39. 3. Jean-François Lyotard. The Inhuman: Reflections on Time . Trans. Geoffrey Bennington & Rachel Bowlby. Stanford, CA: Stanford University Press. 1992. 4. See the introduction: Quentin Melliassoux. After Finitude: An Essay on the Necessity of Contingency . Trans. Ray Brassier. New York: Continuum. 2008. EDITOR'S NOTE: This review was updated on August 8, 2012. Substantial edits include block quotes from the book under review as well as the inclusion of comments from the author. (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)

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

In cases of sudden, life-threatening illness where the chance of survival appears negligible to the admitting physician, this opinion is not always revealed during the initial meeting with the patient's relatives. Reasons as to why this withholding of the truth may be acceptable are explored through review of available evidence and personal reflection. Factors identified include: the importance of hope in families' coping mechanisms, and the instinct to preserve it; the fallibility of physicians' perception of poor prognosis (...) in the early phase of illness; the need to avoid large swings in relatives' expectations that occur when patients appear to rally during initial resuscitation; and the adverse effect that an atmosphere of hopelessness can have on the provision of medical care. A strategy for the staged disclosure of information and the confirmation of hopelessness is then described, the aim being to find a compromise between providing a true opinion about a patient's prognosis, and regard for the opposing factors described. (shrink)

The determination of death by neurological criteria remains controversial scientifically, culturally, and legally, worldwide. In the United Kingdom, although the determination of death by neurological criteria is not legally codified, the Code of Practice of the Academy of Medical Royal Colleges is customarily used for neurological death determination and treatment withdrawal. Unlike some states in the US, however, there are no provisions under the law requiring accommodation of and respect for residents' religious rights and commitments when secular conceptions of (...) death based on medical codes and practices conflict with a traditional concept well-grounded in religious and cultural values and practices. In this article, we analyse the medical, ethical, and legal issues that were generated by the recent judgement of the High Court of England and Wales in Re: A [2015] EWHC 443. Mechanical ventilation was withdrawn in this case despite parental religious objection to a determination of death based on the code of practice. We outline contemporary evidence that has refuted the reliability of tests of brainstem function to ascertain the two conjunctive clinical criteria for the determination of death that are stipulated in the code of practice: irreversible loss of capacity for consciousness and somatic integration of bodily biological functions. We argue that: the tests of brainstem function were not properly undertaken in this case; the two conjunctive clinical criteria set forth in the code of practice cannot be reliably confirmed by these tests in any event; and absent authentication of the clinical criteria of death, the code of practice wrongly invokes a secular definition of death based on the loss of personhood. Consequently, the moral obligation of a pluralistic society to honor and respect diverse religious convictions to the greatest extent possible is being violated. Re A is contrasted with the US case of Jahi McMath in which the court accommodated parental religious objection to the determination of neurological death codified in the Uniform Determination of Death Act. We conclude that the legal system in the United Kingdom should not favour a secular definition of death over a definition of death that is respectful of religious values about the inviolability and sanctity of life. We recommend the legal recognition of religious accommodation in death determination to facilitate cultural sensitivity and compassionate care to patients and families in a pluralistic society. (shrink)

BackgroundEach individual’s unique health-related beliefs can greatly impact the patient-clinician relationship. When there is a conflict between the patient’s preferences and recommended medical care, it can create a serious ethical dilemma, especially in an emergency setting, and dramatically alter this important relationship.Case presentationA 56-year-old man, who remained comatose after out-of-hospital cardiac arrest, was rushed to our hospital. The patient was scheduled for emergency coronary angiography when his adolescent daughter reported that she and her father held (...) sincere beliefs against radiation exposure. We were concerned that she did not fully understand the potential consequences if her father did not receive the recommended treatment. A physician provided her with in depth information regarding the risks and benefits of the treatment. While we did not want to disregard her statement, we opted to save the patient’s life due to concerns about the validity of her report.ConclusionsVariations in beliefs regarding medical care force clinicians to incorporate patient beliefs into medical practice. However, an emergency may require a completely different approach. When faced with a patient in a life-threatening condition and unconscious, we should take action to prioritize saving their life, unless we are highly certain about the validity of their advance directives. (shrink)

Background The COVID-19 pandemic has influenced the approach to the health-disease system, raising the question about the principles of bioethics present in physician–patient relations. The principles while widely accepted may not be sufficient for a comprehensive ethical analysis. Therefore, the aim of this study was to explore the perception of these principles and the physician–patient relationship during a hospital stay through a qualitative approach. Method Sixteen semi-structured interviews took place to know the patients’ perception during their 2020 hospitalization (...) for COVID-19. The data was analyzed through the constant comparison method, creating categories and comparing them. In the end, seven categories were established and were grouped in three: bioethical principles (dignity, charity, vulnerability, autonomy), doctor-patient relationship (participant commitment, informed consent, health staff-patient relationship) and the experience of the disease (illness, the role of the family). Results The research found that most patients described a positive experience, with the feeling of having been well cared for with no sense of discrimination or injustice done. The majority also reported that their autonomy was respected in the treatment decisions. The evaluation of these attitudes is an area of opportunity, especially when the patients' vulnerability is at risk. Conclusions The ethics of virtue offers a better reflection of how human beings manifest themselves by emphasizing the development of virtuous character and behaviors that allow them to realize their values in life. Authorized by the Research Ethics Committee with registration: DI/18/105-B/3/308. (shrink)

In some young children brought by their parents for diagnosis of acute life-threatening events investigations suggested imposed apnoea as the cause rather than spontaneous occurrence. Covert video surveillance of the cot in which the baby was monitored allowed confirmation or rebuttal of this diagnosis. That parents were not informed of the video recording was essential for diagnosis and we assert ethically justifiable as the child was the patient to whom a predominant duty of care was owed. The (...) procedure also avoids the risk of separation of child from parent on inadequate information. (shrink)

Background: Recent research demonstrates that people sometimes make different medical decisions for others than they would make for themselves. This finding is particularly relevant to end-of-life decisions, which are often made by surrogates and require a trade-off between prolonging life and maintaining quality of life. We examine the impact of decision role, patient age, decision maker age and multiple individual differences on these treatment decisions. Methods: Participants read a scenario about a terminally ill cancer patient (...) faced with a choice between an aggressive chemotherapy regimen that will extend life by two years and palliative treatments to control discomfort for one remaining month. Participants were randomly assigned to one of three decision roles (patient, physician, or an abstract other) and the scenario randomly varied whether the patient was described as 25 or 65-years old. Results: When deciding for a 65-year old patient, approximately 60% of participants selected aggressive chemotherapy regardless of decision role. When deciding for a 25-year old patient, however, participants were more likely to select chemotherapy for a patient (physician role) or another person (abstract other) than for themselves (70%, 67%, and 59%, respectively). In addition, confidence that powerful others (eg, physicians) control one’s health, as well as respondents’ age and race, consistently predicted treatment choices. Conclusions: Patient age appears to influence medical decisions made for others but not those that we make for ourselves. These findings may help to explain the discord that often occurs when younger cancer patients refuse life-extending treatments. (shrink)

Background: Chronic Pain (CP) has serious medical and social consequences, and leads to economic burden that threatens the sustainability of healthcare services. Thus, optimized management of pain tools to support CP patients in adjusting to their condition and improving quality of life is timely. Although Acceptance and Commitment Therapy (ACT) is considered an evidence-based psychological approach for CP, evidence for the efficacy of online-delivered ACT for CP is still scarce. At the same time, studies suggest that self-compassion mediates (...) the change in disability and psychopathological symptoms in ACT interventions for CP, although self-compassion is not a specific target in ACT. Thus, an explicit focus on self-compassion might increase the efficacy of ACT interventions for CP, although this hypothesis has not been tested. This study aims to develop an eHealth ACT and compassion-based self-management intervention for CP, the iACTwithPain, and to compare its efficacy in improving health outcomes to a similar ACT-only intervention and a waiting list group. Methods: The eHealth platform that will host the interventions will be developed using a flat design identity and will be interactive. The iACTwithPain intervention will comprise 8 weekly self-management sessions, and will be developed taking into consideration the psychological flexibility model applied to CP, with the addition of explicit compassion-based components. To analyse whether the iACTwithPain intervention will present superiority in improving CP’s impact and related health markers over the two other conditions, this study will follow a RCT design with three arms. CP patients will be recruited through direct contact with patient associations and healthcare services and a national press release in Portugal. Outcome measurement will be conducted at baseline, post-intervention and at 3- and 6-months follow-ups. The interventions’ acceptability will also be assessed. Discussion: The iACTwithPain intervention is expected to improve CP patients’ psychosocial functioning, quality of life, and empowerment, by promoting adaptive disease management and regulation of pain-related internal experiences. Results will contribute to a better understanding on the pertinence of adding compassion elements to ACT for CP and to reach an optimized intervention for CP. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:IntroductionStuart J. Youngner (bio), Laura A. Siminoff (bio), and Renie Schapiro (bio)This issue of the Kennedy Institute of Ethics Journal (KIEJ) centers on a piece of empirical research. The motivation behind the study of Laura Siminoff, Christopher Burant, and Stuart Youngner (2004) was to find out more about what the general public understands and believes about when a person is dead. More specifically, the study tried to determine (...) how members of the public define death, especially their acceptance and interpretation of the medical concept of "brain death," and their attitudes toward the so-called "dead donor rule," an informal but powerful social and legal norm insisting that the taking of organs for transplantation not cause the death of the source of those organs.As the demand for organs increases and the waiting list grows, the United States has explored multiple ways to expand the pool of potential donors. One approach has been to gerrymander (coherently or not) the line between life and death to shift patients who are extremely compromised but traditionally considered to be in the living category into the dead category. In this way, the dead donor rule remains technically intact. This reasoning is explicit in the report of the Harvard Medical School Ad Hoc Committee (1968) that "introduced" "brain death" to the American culture. Since then, other efforts to redraw the line have been proposed and rejected.One alternative to gerrymandering is to consider under what conditions, if any, it is morally acceptable to violate the dead donor rule. Some would argue that this alternative is the more "honest" approach. Rather than sidestepping moral problems by calling people dead, it brings the moral problems to the surface where the necessity of sticking to the rule can be considered on its own merits. However, when the Journal of the American Medical Association printed a position paper that proposed making anencepahlic newborns an exception to the dead donor rule, along with arguments about why this was acceptable, the outcry was so great that the proposal was retracted (AMA 1995).Clearly, our society has identified organ transplantation as a priority, although two papers in this volume (those by Courtney Campbell and by Megan Crowley-Matoka and Robert Arnold) take issue with that prioritization. The fact that the donor pool has remained relatively stable (and inadequate) despite massive efforts [End Page 211] to increase it speaks, at least in part, to the cultural and legal resistance to "new" ways to procure more organs. Voluntarism seems to have peaked. Financial incentives clash with the heavily endorsed notion of the "gift of life" and seem to many to violate the dignity of the human body. Presumed consent or eminent domain, in which the community has a greater claim to a person's organs than that person or his/her family, go against the grain of American individual freedom and the ethos of patient autonomy.Abandoning the dead donor rule generally is regarded as an even tougher sell to the American public and its legislators. The study by Siminoff and colleagues attempts, among other things, to gauge just how tough this sell would be. What the data actually demonstrate is a matter of interpretation, and this issue of the KIEJ is devoted to some of those interpretations. The authors, with the exception of Daniel Hausman, came together for a meeting in Cleveland, Ohio, during which the study's methods and data were presented with time for questions, clarifications, and general discussion. The authors then worked with the editors to generate the papers printed in this volume.The issue begins with a presentation of the study conducted by Siminoff and colleagues. The same paper also appears in the journal Social Science and Medicine, where it includes the conclusions of the authors (Siminoff, Burant, and Youngner 2004). In the current volume, we present only the methodology of and data from the study, allowing a number of distinguished commentators to offer their own conclusions and reflections.The first response comes from Tracy Schmidt, Executive Director of Intermountain Donor Services, one of our nation's organ procurement organizations (OPOs). For years, organ procurement professionals have reported anecdotal stories about families who wished to donate organs of... (shrink)

The aim of this study was to gain a deeper understanding of the experience of time when living with severe incurable disease. A phenomenological and philosophical approach of description and deciphering were used. In our modern health care system there is an on-going focus on utilizing and recording the use of time, but less focus on the patient’s experience of time, which highlights the need to explore the patients’ experiences, particularly when life is vulnerable and time (...) is limited. The empirical data consisted of 26 open-ended interviews with 23 participants receiving palliative care at home, in hospital or in a nursing home in Norway. The theoretical frameworks used are mainly based upon K. Martinsens philosophy of care, K. E. Løgstrup phenomenological philosophy, in addition to C. Saunders’ hospice philosophy, L. Feigenberg’s thanatology and U. Qvarnström’s research exploring patient’s reactions to impending death. Experience of time is described as being a movement that moves the individual towards death in the field of opposites, and deciphered to be a universal, but a typical and unique experience emerging through three integrated levels: Sense of time; where time is described as a movement that is proceeding at varying speeds. Relate totime; where the awareness of limited life changes the understanding of time to be more existential. Being in time; where limited time seems to clarify the basic living conditions and phenomena of life. The existence of life when the prospect of death is present is characterized by emotional swings that move within polarizing dimensions which is reflected in the experience of time illustrated as the moves of the pendulum in a grandfather clock. The diversity of the experience of time is oscillating between going fast or slow, being busy or calm, being unpredictable but predictable, safe or unsafe and between being good or bad, depending on the embodied situation of the individual. (shrink)

OBJECTIVES: To ascertain which conditions nurses believe should be in a law allowing active voluntary euthanasia (AVE). DESIGN: Survey questionnaire posted to registered nurses (RNs). SETTING: Australian Capital Territory (ACT) at the end of 1996, when active voluntary euthanasia was legal in the Northern Territory. SURVEY SAMPLE: A random sample of 2,000 RNs, representing 54 per cent of the RN population in the ACT. MAIN MEASURES: Two methods were used to look at nurses' opinions. The first involved four vignettes (...) which varied in terms of critical characteristics of each patient who was requesting help to die. The respondents were asked if the law should be changed to allow any of these requests. There was also a checklist of conditions, most of which have commonly been included in Australian proposed laws on AVE. The respondents chose those which they believed should apply in a law on AVE. RESULTS: The response rate was 61%. Support for a change in the law to allow AVE was 38% for a young man with AIDS, 39% for an elderly man with early stage Alzheimer's disease, 44% for a young woman who had become quadriplegic and 71% for a middle-aged woman with metastases from breast cancer. The conditions most strongly supported in any future AVE law were: "second doctor's opinion", "cooling off period", "unbearable protracted suffering", "patient fully informed about illness and treatment" and "terminally ill". There was only minority support for "not suffering from treatable depression", "administer the fatal dose themselves" and "over a certain age". CONCLUSION: Given the lack of support for some conditions included in proposed AVE laws, there needs to be further debate about the conditions required in any future AVE bills. (shrink)

Aim To study the views of people in a largely Muslim country, Kuwait, of the acceptability of a life-ending action such as physician-assisted suicide (PAS). Method 330 Kuwaiti university students judged the acceptability of PAS in 36 scenarios composed of all combinations of four factors: the patient's age (35, 60 or 85 years); the level of incurability of the illness (completely incurable vs extremely difficult to cure); the type of suffering (extreme physical pain or complete dependence) and the (...) extent to which the patient requests a life-ending procedure, euthanasia or PAS (no request, some form of request, repeated requests). In all scenarios, the patients were women who were receiving the best possible care. The ratings were subjected to cluster analysis and analyses of variance. Results Five clusters were found. For 44%, PAS was always very unacceptable, no matter what the circumstances. For 23%, it was unacceptable, but less so if the patient was older or requested it repeatedly. For 16%, it was unacceptable if the patient was young but was acceptable if the patient was elderly. For 5%, it was unacceptable if the patient had extreme pain but was acceptable if completely dependent. For 11%, it was unacceptable if the patient did not request it but acceptable if she did. Conclusion The majority of the Kuwaiti university students opposed PAS either categorically or with a slight variation according to circumstances. Nonetheless, a minority approved of PAS in some cases, particularly when the patient was elderly. (shrink)

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial (...) nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments. (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)

BackgroundExtremely violent events such as terrorist attacks and mass shootings form a severe risk for the health and wellbeing of affected individuals. In this study based on a public health monitor, we focus on the health impact of the Utrecht tram shooting, which took place in the morning of March 18th 2019. A lone gunman opened fire on passengers within a moving tram. Four people died, and six people were injured in this attack. The attack resulted in nationwide commotion (...) and drew much media attention. Aim of this study was to increase insight into the health effects for the survivors, and whether they received the needed care and support.MethodsSemi-structured interviews with accompanying questionnaires were conducted at six and 18 months post-attack. Overall, 21 survivors participated in the first series of interviews, 15 in the second series. Qualitative data were analyzed using reflexive thematic analysis, quantitative data was only described because of the low sample size.ResultsAt both six and 18 months after the attack many survivors had been able to resume daily life, and most rated their overall health as good or excellent. At the same time, a substantial portion suffered from health problems such as posttraumatic stress symptoms and other complaints, and needed professional care. Furthermore, those in need did not always find their own way to appropriate care through the existing health system: half of the survivors still needed support in finding the right care 18 months later.ConclusionAlthough the design and implementation of this public health monitor were accompanied by multiple challenges, it was possible to track a portion of the survivors and gain insight in the considerable health burden of the attack. Also, it is clear in this study that the health impact of terrorism affects survivors in the long run and requires attention from health authorities and professionals, as survivors were not able to find the right care by themselves. (shrink)

Chest pain is the pain felt in the chest by infants, children and adolescents. In most cases the pain is not associated with the heart. It is mainly recognized by the observance or report of pain by the infant, child or adolescent by reports of distress by parents or care givers. Chest pain is not unusual in children. Lots of children are seen in ambulatory clinics, emergency rooms and hospitals and cardiology clinics. Usually there is a benign cause for the (...) pain for utmost children. Certain patients have conditions that are serious and perhaps life-threatening. Chest pain in pediatric patients needs careful physical examination and a detailed history that would point to the possibility of a serious cause. Researches of pediatric chest pain are scarce. It has been difficult to create evidence-based guidelines for evaluation. In this paper we propose an expert system to help doctors and parents, and care giver in diagnosing chest pain in infants and children. This expert System is design and implemented in SL5 Object language. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:The Cult of Nothingness: The Philosophers and the BuddhaA. J. NicholsonRoger-Pol Droit. The Cult of Nothingness: The Philosophers and the Buddha. Translated by David Streight and Pamela Vohnson. Chapel Hill: University of North Carolina Press, 2003. Pp. xii + 263.Roger-Pol Droit's recently translated study, The Cult of Nothingness: The Philosophers and the Buddha, is not a book about Buddhism per se. Rather, it is a rich and theoretically (...) sophisticated overview of the reception of Buddhism in Europe that deserves shelf space alongside Wilhelm Halbfass' India and Europe and Raymond Schwab's The Oriental Renaissance. But while some of the figures Droit covers may be familiar from these other studies in the history of orientalism, Droit's book has its own unique narrative thread. Specifically, Droit wishes to examine the once widespread notion that Buddhism is a nihilistic religion, a religion that worships nothingness. His central thesis is that this conception of a nihilistic religion really wasn't about Buddhism at all, but "that Europe... was speaking only of herself." Droit sees in the cult of nothingness the subconscious expression of a crisis of foundations among nineteenth-century European intellectuals, as well as a "hidden laboratory for the theoretical development of European nihilism."Along the way to illustrating this thesis, Droit leads a masterful and extremely entertaining tour of the opinions of early Buddhologists and Eastward-looking philosophers, some of whom have seldom been documented elsewhere. He also provides an enormous bibliography of European writings on Buddhism from 1638 to 1890. In the eighteenth and early nineteenth centuries, the Buddha was often identified as one of many gods belonging to an inchoate and primitive world of mythical concordances. Thus, George Stanley Farber wrote in 1816 that "the primeval Buddha... is the same as Vishnu, or Shiva, or Osiris." Writers in this genre were especially fond of identifying the Buddha with the god Mercury. The sole reason, it seems, was simple linguistic confusion-the word for the planet Mercury in Sanskrit is budha, one letter short of buddha. Furthermore, the preeminent Indologist Sir William Jones posited the identity of the Norse god Woden and Buddha; this was later taken up by A. W. Schlegel in his Indische Bibliothek, and eventually influenced the publication of such unforgettable titles as Holmboe's Traces du Buddhisme en Norvège avant l'introduction du Christianisme. Jones elsewhere hinted that the Buddha might have been of Ethiopian, rather than Indian origin, and this set off another wave of speculation. To reconcile theories of a primordial god named Buddha with new evidence that the Buddha had been a man who had lived at a relatively recent date, for a short time a theory of two Buddhas emerged, first suggested by Antione Augustin Giorgi, and later taken up by Jones himself.Droit sees Hegel as the single figure most responsible for establishing the link between Buddhism and nothingness that endured in the nineteenth-century philosophical imagination. Droit painstakingly charts Hegel's changing attitudes toward Buddhism over the course of his lectures from 1822 to 1831. In spite of, or perhaps because of, Hegel's familiarity with all of the most recent secondary works on Buddhism, he had great difficulty in integrating Buddhism into his philosophical grand [End Page 577] narrative. But his most enduring interpretation of Buddhism came in 1827, when he asserted that for Buddhism, "Saintliness consists in man uniting himself with God, with nothingness, with the absolute in this destruction, in this silence.... Man must make himself nothing." Hegel did not get this idea from his contemporaries, but from an earlier stratum of writing on Buddhism, that of seventeenth- and eighteenth-century Jesuit missionaries. After this portrayal of Buddhism became prevalent in European philosophical circles, an extraordinary debate developed. The notion of a religion that worships nothingness was so contrary to common sense that it threatened the Enlightenment conviction that there existed a single, universal human nature. Jules Barthélmy Saint-Hilaire summed it up quite clearly: "In the presence of a phenomenon so curious and so deplorable... one might ask... if, in those climates where life is so horrific and nothingness is worshiped instead of God, human nature is... (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)

Background Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment. Methods We performed an anonymous online survey in a random sample of 1,052 participants recruited (...) via email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%. Results Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients. Conclusion No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Seeing and Being Seen in the Later Medieval World: Optics, Theology, and Religious LifeA. Mark SmithDallas G. Denery, II. Seeing and Being Seen in the Later Medieval World: Optics, Theology, and Religious Life. Cambridge Studies in Medieval Life and Thought (Fourth Series), 63. Cambridge-New York: Cambridge University Press, 2005. Pp. x + 202. Cloth, $75.00.Among the metaphors we live by (to borrow from Lakoff and Johnson), (...) visual metaphors figure prominently in our common discourse about cognition. We are well aware, of course, that in claiming to "see" meanings or "view" ideas in certain lights, we are speaking figuratively. Yet the analogy between thinking and seeing is more than a linguistic artifact. Until the seventeenth century, Western thinkers took it seriously, none more seriously perhaps than the thirteenth-century scholastic community. The upshot was an epistemology based on two cardinal assumptions: first, that the physical world manifests itself to us through species passing from external objects into the soul, and second, that visual perception is providentially designed to yield a faithful conceptual picture of physical reality and its ordering structure.This latter assumption found strong support in Perspectivist optics, which took mature form in the 1260s as an amalgam of Alhacenian visual analysis and species-theory. Hence, by the later thirteenth century it was widely believed not only that vision is essentially cognitive but also that cognition is essentially visual. During the first half of the fourteenth century, this idea was subjected to trenchant criticism and thereby rejected out of hand by several thinkers, among whom Nicolaus of Autrecourt is a particular subject of emphasis in this study.It has become something of a truism lately that theories are neither accepted nor rejected on logical grounds alone. This one, Denery claims, is no exception since there were compelling theological grounds for its adoption. Foremost among these was a new emphasis on self-presentation in the thirteenth century. That emphasis manifested itself at two levels. On the one hand, the clerical orders were encouraged to give the right appearance and to suit the appearance to specific settings. This was especially important among the new preaching orders, whose members had to put on so many public faces that they came to adopt what Denery calls "heuristics of adaptation." On the other hand, new modes of confession and penance required deep introspection on the penitent's part, so that he might "see" himself for the complex of sinful motives and actions he is, as well as experience the contrition-yielding horror such a sight arouses. In both cases, the appearances should reveal the underlying reality: the preacher's spiritual commitment reflected in his mien, the penitent's contrition in the recognition of his vitiated nature.But how can we be sure that what we see in these instances is true? This question is particularly vexing in the case of religious introspection, for, as St. Paul reminds us, our moral vision is distorted by the mirror that darkens it. Enter the analogy between physical vision and cognition. Visual illusions, such as those arising from reflection, were of paramount concern to Perspectivist theorists, who devoted considerable effort to rationalizing them according to unmet normative conditions, such as adequate illumination, appropriate distance, or a healthy eye. Reflected vision is subject to transgressions of these conditions, but adding insult to their injury is that, when seen in mirrors, objects invariably appear displaced and often look distorted in size, shape, and orientation. Fortunately, reason enables us to rectify such illusions according to specific rules that govern visual perception in general and reflection in particular.If the analogy between physical and moral vision holds true, then reason ought to be the corrective in both cases. At first blush, this seems to be Peter of Limoges's position in the Tractatus moralis de oculo (c. 1280), but, as Denery insists, Peter's real point is that our inner, moral vision is so clouded we can rarely tell either how or even that it is distorted. The hoped-for normative circumstances and principles enabling us to rectify it are far too vague and protean to yield certainty from introspection. Given the tight conceptual linkage between... (shrink)

Background Older patients are often vulnerable and highly dependent on healthcare professionals’ assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy. Aim To describe ambulance clinicians’ understanding of older patients’ self-determination when the patient’s decision-making ability (...) is impaired. Research design A qualitative design with an inductive approach, guided by descriptive phenomenology. Participants In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews. Ethical considerations The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority. Findings The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient’s best interests. The clinicians’ interpretations are based on an understanding of the patient’s situation using substitute decision-making in emergency situations and conversations that reveal the patient’s explicit wishes. Sometimes the clinicians collaborate to validate the patient’s implicit will, while they at other times subordinate themselves to others’ opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient’s self-determination. Conclusion The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient’s unique needs based on a holistic perspective and their ability to be autonomous. (shrink)

Objective: To evaluate feasibility of the guidelines of the Groupe Francophone de Réanimation et Urgence Pédiatriques for limitation of treatments in the paediatric intensive care unit .Design: A 2-year prospective survey.Setting: A 12-bed PICU at the Hôpital Jeanne de Flandre, Lille, France.Patients: Were included when limitation of treatments was expected.Results: Of 967 children admitted, 55 were included with a 2-day median delay. They were younger than others , had a higher paediatric risk of mortality score , and a higher (...) paediatric overall performance category score at admission ; all p<0.002. 34 children died. A limitation decision was made without meeting for 7 children who died: 6 received do-not-resuscitate orders and 1 received withholding decision. Decision-making meetings were organised for 31 children, and the following decisions were made: 12 DNROs , 4 withholding , with 14 withdrawing and 1 continuing treatment . After limitation, 21 children died and 10 survived . 13 procedures were interrupted because of death and 11 because of clinical improvement . Parents’ opinions were obtained after 4 family conferences , 3 days after inclusion. The first meeting was planned for 6 days after inclusion and held on the 7th day after inclusion; 80% of parents were immediately informed of the decision, which was implemented after half a day.Conclusions: GFRUPs procedure was applicable in most cases. The main difficulties were anticipating the correct date for the meeting and involving nurses in the procedure. Children for whom the procedure was interrupted because of clinical improvement and who survived in poor condition without a formal decision pointed out the need for medical criteria for questioning, which should systematically lead to a formal decision-making process. (shrink)

An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which (...) the DNR of a terminally ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations :3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail. (shrink)

It is well documented that the higher the socioeconomic status (SES) of patients, the better their health and life expectancy. SES also influences the use of health services—the higher the patients' SES, the more time and specialised health services provided. This leads to the following question: should clinicians give priority to individual patients with low SES in order to enhance health equity? Some argue that equity is best preserved by physicians who remain loyal to ‘ordinary medical fairness’ in non-ideal (...) circumstances when health disparities persist; ie, doctors should allocate care according to needs only and treat everyone with equal regard by being neutral with respect to patients' SES. This paper furthers a discussion of this view by questioning how equitable needs relate to SES. To clarify, it distinguishes between four versions of ‘healthcare need’ and approaches an acceptable conceptualisation of the notion supported by Norman Daniels' theory on health equity. It concludes that doctors should remain neutral to patients' SES in cases in which several patients require the same health care. However, equitable health care requires considerations of the impact of socioeconomic factors (SEF) on patients' capacity to benefit from the care. Remaining neutral towards patients' SES in this respect does not promote equal regard. It follows that priority setting on the basis of SEF is required in fair clinical distribution of care, eg, through allocating more time to patients with low SES. In order to advance equity accurately, the concept of ordinary medical fairness should be amplified according to this clarification. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Christians and Buddhists: Together in HopeCardinal Francis ArinzeDear Buddhist Friends,1. On the occasion of Vesakh, which celebrates important events in the life of Buddha, I wish to express to you, in my capacity as president of the Pontifical Council for Interreligious Dialogue, the best wishes of Catholics throughout the world.2. I am happy to say that ongoing dialogue between Buddhists and Christians is distinguished by efforts to meet (...) at the level of religious experience. Both Buddhism and Christianity emphasize the “contemplative dimension” in their practice of religion. Since 1979, through the “Intermonastic Spiritual Exchange” and the “Monastic Hospitality Programme,” Buddhists and Christians who are committed to a contemplative life through their respective monastic disciplines have engaged in encounters where in-depth dialogue is possible. This effort is truly commendable.3. It is hope of new life that has been at the source of our dialogue, although our understanding of this new life differs. For us Christians, the new life is to be sought and found only in Jesus Christ. Jesus indicated the way when he said: “I am the way, the truth and the life” (John 14:6). He taught us not only not to engage in revenge, but to defeat evil with good. He said: “You have learnt how it was said: Eye for eye and tooth for tooth. But I say this to you: offer the wicked man no resistance. On the contrary, if anyone hits you on the right creek, offer him the other as well” (Matthew 5:38–39). This makes me think of Ven. Maha Ghosananda’s rendering of one of the teachings of Buddha: “When we are wronged, we must set aside all resentment and say, ‘My mind will not be disturbed. Not one angry word will escape from my lips; I will remain kind and friendly, with loving thoughts and no secret malice.’”4. Hope rescues us from discouragement. We are enabled to begin anew by perceiving around us numerous “signs of hope”: the growing solidarity among people in our time, especially with the poor and destitute, the desire for justice and peace, voluntary service, the return of the search for transcendence, an awareness of human dignity and of the rights that flow from it, attention to the environment, and so on. I wish to mention here a particular sign of hope, which Pope John Paul II has underlined—namely, interreligious dialogue.5. People of hope are, at the same time, realists who do not close their eyes to reality with all its positive and negative aspects. We cannot turn a blind eye to the [End Page 199] dramatic crises of our world: the wars between different countries, civil wars, terrorism in all its forms, injustice that is forever widening the gap between rich and poor, hunger, the lack of shelter, unemployment—especially among the youth, globalization without solidarity, the heavy burden of external debt, the problem of drugs, immorality, abortion. The list could be extended. Nevertheless, the small lamp of hope must always remain alight, shining on the paths leading humanity to a better future.6. We Christians and Buddhists, embarked on our respective spiritual paths, can work together to give increased hope to humanity. Yet first we must accept our differences and show each other mutual respect and true love. This will render us more credible, and we shall be for humanity a further sign of hope in addition to those that exist already.7. It is in this spirit that I convey to you once again, dear Buddhist friends, my best wishes for the feast of Vesakh.Cardinal Francis ArinzePontifical Council for Interreligious DialogueCopyright © 1999 The University of Hawai’i Press... (shrink)

In early 2011, news emerged that United States authorities had begun to apply injections of pentobarbital, a substance provided by Danish pharmaceutical company Lundbeck, when executing capital punishments. Lundbeck reported to be appalled by such unintended usage of pentobarbital, which is licensed for treatment of refractory forms of epilepsy and for usage as an anaesthetic.The human rights NGOs Reprieve and Amnesty International urged Lundbeck to ensure that pentobarbital was not made available to U.S. authorities for use in capital punishments. (...) Lundbeck argued that complete halting of provision of pentobarbital would be detrimental to patients suffering from conditions of severe epilepsy for whom the substance was developed and intended for treatment for life-threatening epileptic seizures. Lundbeck’s Danish headquarters also argued that controlling the provision of pentobarbital was out of Danish Lundbeck’s hands because the substance is produced at Lundbeck’s plant in the United States. Eventually, after talks with Amnesty International and Reprieve, Lundbeck in July 2011 announced that it would seek to put a stop to using pentobarbital in capital punishment through the introduction of a “drop-ship” program. (shrink)

One of the most important problems of Muslim societies and humanity is the conflicts and troubles among spouses and between parents and their children in the family. problems. Research is carried out and answers are sought for the solution of these problems, but the dissolution in families cannot be prevented and the divorce rate increases day by day. Besides being a prophet, the Messenger of Allah (pbuh) is a servant of Allah and a human being. It is seen that there (...) were problems in the homes of the Prophet (pbuh), both between him and his wives, and among his wives. Since the creation of human beings has not changed, the Prophet's (pbuh) attitudes and solutions to these problems are important for the solution of family problems happening today. It is seen that the Messenger of Allah (pbuh) reacted to these problems and discussions far above his age and he treated his wives and solved the problems as modern researchers and scientists recommend in the recent world. The purpose of sending the Messenger of Allah (pbuh) is to convey the religion of Allah to people. For this reason, he was given orders regarding the most private matters of his private life when appropriate. Human's happiness in this world and in the hereafter can only be achieved by recognizing this perfect example. This can be achieved by learning about his personality as an individual and his family life as a family. The conflict of values among spouses in the family, life perspective, personality and priority differences are the basis of the problems. In addition, changes in personality especially after marriage, loss of love and respect for each other, and jealousy are the main situations that harm marriage. Many marriages end because of miscommunication. There are many people who try to solve problems by being cold towards their spouse and taking a stand towards him/her. If a man is married to many women, as in the example of the Prophet (pbuh), the main problem he encounters is jealousy and the resulting unrest. In a family, there are joyful and happy moments as well as unhappy moments and times. It is very natural for family members to quarrel with each other and to have disagreements among them. The Prophet's family is not far from it. The wives of the Messenger of Allah (pbuh) are not ordinary people, but women who are either at the forefront of their tribe with their ancestry, intelligence and beauty, or who are one step ahead with their conversion to Islam and their services. According to the laws of God, the same poles repel each other, while the opposite poles attract each other. They are all very precious and it is perfectly natural for a repulsion force to develop between them. It is necessary to think of the Prophet's (pbuh) houses as a school. The state of our mothers when they entered that house is not the same as the degree they reached when the Prophet (pbuh) passed away. Differences of opinion and conflicts between members of the family, deterioration of the balance in relations, and weakening of solidarity are among the events seen in every family. The Prophet (pbuh) was able to have controversies with his wives, even if it was a rarely example. However, in these discussions, it is seen that he does not allow violence and tries to solve the issues patiently and by talking to each other, and sometimes asks for help from his close circle or relatives of his spouses. ʿĀʾIs̲h̲a is the most prominent among the wives of the Messenger of Allah, except for Khadija. She himself knew this and was voicing this claim against the other wives of the Messenger of Allah (pbuh). When the Prophet (pbuh) married Umm Salama, people talked about his beauty. ʿĀʾIs̲h̲a, who heard these praises, was very upset about the new rival who came to her. With Zaynab bt. ḎJ̲aḥs̲h̲ stepping into the house of the prophet, the balances changed and a fierce rivalry began between her and ʿĀʾIs̲h̲a. Just as ʿĀʾIs̲h̲a was proud of her superiority, Zaynab began to brag about her superiority. ʿĀʾIs̲h̲a had a special place among the wives of the Prophet. This was evident from the fact that the Messenger of Allah (pbuh) said at every opportunity that he loved him very much. The Messenger of Allah (pbuh) did not hesitate to express this either. When the Prophet (pbuh) went on an expedition, he would treat his wives fairly and draw lots so that he would not cause hatred or envy among them. When the lottery went out to another wife besides ʿĀʾIs̲h̲a, the dissatisfaction on his face could be felt. Among his other wives, the Prophet tried to protect and watch over his wife, Safiyya, at every opportunity, which he felt was strange because he was later included among them and was of Jewish origin. Although Mariye was a slave, she became one of the envied women among the wives of the Prophet after she gave birth to her son Ibrahim to the Messenger of Allah (pbuh). Undoubtedly, it was ʿĀʾIs̲h̲a who envied him the most. (shrink)

McGovern, Kevin When an unborn child is diagnosed with a life-limiting or life-threatening condition, many people now believe that the best solution is to immediately terminate the pregnancy. This article explores the option of continuing the pregnancy with the support of perinatal palliative care. Many parents have found this alternative fits better with their values, and better honours both their unborn child and their situation as the loving parents of this child. The article also explores (...) the information and support which parents need in order to make a truly informed choice between termination and continuing the pregnancy. (shrink)

Background Patients with unmet medical needs sometimes resort to non-standard treatment options, including the use of unapproved, investigational drugs in the context of clinical trials, compassionate use or named-patient programs. The views and experiences of patients with unmet medical needs regarding unapproved, investigational drugs have not yet been examined empirically. Methods In this qualitative study, exploratory interviews and focus groups were held with patients with chronic or life-threatening diseases, about topics related to non-standard treatment options, such as (...) the search for non-standard treatment options, patients’ views of the moral obligations of doctors, and the conditions under which they would or would not wish to use non-standard treatment options, including expanded access to unapproved, investigational drugs. Results Respondents had very little knowledge about and/or experience with existing opportunities for expanded access to investigational drugs, although some respondents were actively looking for non-standard treatment options. They had high expectations of their treating physicians, assuming them to be aware of non-standard treatment options, including clinical trials elsewhere and expanded access programs, and assuming that they would inform their patients about such options. Respondents carefully weighed the risks and potential benefits of pursuing expanded access, citing concerns related to the scientific evidence of the safety and efficacy of the drug, side effects, drug-drug interactions, and the maintaining of good quality of life. Respondents stressed the importance of education and assertiveness to obtain access to good-quality health care, and were willing to pay out of pocket for investigational drugs. Patients expressed concerns about equal access to new and/or non-standard treatment options. Conclusion When the end of a standard treatment trajectory comes into view, patients may prefer that treating physicians discuss non-standard treatment options with them, including opportunities for expanded access to unapproved, investigational drugs. Although our respondents had varying levels of understanding of expanded access programs, they seemed capable of making well-considered choices with regard to non-standard treatment options and had realistic expectations with regard to the safety and efficacy of such options. Dutch patients might be less likely to fall prey to false hope than often presumed. (shrink)

To carry on reasoning in the face of the implications of skepticism is what Fred Parker calls “sceptical thinking.” Not to be confused with the engineered vacillation leading to a tranquillizing suspense of judgement, it involves the double perspective of someone conducting a life, believing and reasoning as we do, while acutely aware that the whole endeavor is, in a sense, untenable. If, as Sir Philip Sidney famously said, an imaginative writer “nothing affirms, and therefore never lieth,” then the (...) dilemma posed by skepticism might be less embarrassing for that kind of writer than for philosophers. The latter purport to offer tenets valued according to their truth, however variously defined; the former, on the other hand, create “speaking pictures,” or verbal imitations. Skeptically thinking imaginative writers can create speaking pictures of a life in which knowledge is unavailable though people must reason, believe, and act. In a famous letter Keats went so far as to deem a kind of ataraxy to be a condition of the highest art, adducing Shakespeare’s “Negative Capability... of being in uncertainties, Mysteries, doubts, without any irritable reaching after fact & reason”. Parker does not discuss the possibility that negative capability might conduce to the highest flights of literature. He is concerned with the unresolved tensions of skeptical thinking that he sees as complicating key works of literature in the Hanoverian reigns. For their authors and readers, the negativity of skepticism was “disillusioning and destabilizing” if not ameliorated by a humor like Sterne’s or an irony like Hume’s. Humor or irony arises from the oddity that skepticism is put in its place only when we give up and allow nature to reassert itself. Not heroic measures, but backgammon and making merry with friends prevail over doubt. Sometimes, when the confrontation with skepticism gives rise to the precept of following nature, skepticism can result in “a surprising confidence of assertion”. (shrink)

Although prisons provide on-site primary care, the corrections system relies on external hospitals to provide a variety of healthcare services. Compared to the general population, incarcerated patients experience higher rates of chronic medical conditions, mental illness, substance abuse, cancer, traumatic brain injury, assault, and communicable disease. Certain specialties of clinicians are likely to encounter patients who are incarcerated, which makes it important for clinicians to understand how medical decision-making may differ when the patient is a prisoner. The corrections (...) system retains custody of inmates and is responsible for their welfare, including facilitating necessary medical care. However, this does not permit corrections personnel or a warden to automatically assume the role of the patient's medical decision-maker. Except for narrow exceptions, prisoners do not lose their rights to medical decision-making. In some instances, corrections staff or the prison warden have improperly asserted authority to act as the patient's medical decision-maker, such as when the patient lacks decision-making capacity. This violates ethical principles of bodily integrity, respect, and fairness. This paper provides an overview of medical decision-making for incarcerated patients, how surrogate decision-maker hierarchies apply to incarcerated patients without decision-making capacity, and special considerations for this subset of patients. (shrink)

Anesthesiology training programs are tasked with equipping trainees with the skills to become medically and ethically competent in the practice of anesthesia and to be prepared to obtain board certification, yet there is currently no standardized ethics curriculum within anesthesia training programs in the United States. To bridge this gap, and to provide a validated ethics curriculum to meet the aforementioned needs, in July 2021, a survey was sent to anesthesia scholars in the field of biomedical ethics to identify key (...) areas that should be included in such an ethics curriculum. The responses were rated on a Likert scale and ranked. This paper identifies the top ten topics identified as high priority for inclusion in an anesthesiology training program and consequently deemed most relevant to meet the educational needs of graduates of an anesthesiology residency: (1) capacity to consent; (2) capacity to refuse elective versus lifesaving treatment; (3) application of surrogate decisionmaking; (4) approach to do not resuscitate (DNR) status in the operating room; (5) patient autonomy and advance directives; (6) navigating patient beliefs that may impair care; (7) “futility” in end-of-life care: when to withdraw life support; (8) disclosure of medical errors; (9) clinical criteria for “brain death” and consequences of this definition; and (10) the impaired anesthesiologist. (shrink)

Background: Older, frail patients with multimorbidity are at an especially high risk for disease severity and death from COVID-19. The social restrictions proved challenging for the residents, their relatives, and the care staff. While these restrictions clearly impacted daily life in Norwegian nursing homes, knowledge about how the pandemic influenced nursing practice is sparse. Aim: The aim of the study was to illuminate ethical difficult situations experienced by Norwegian nurses working in nursing homes during the COVID-19 pandemic. Research design (...) and participants: The research design involved semistructured individual interviews conducted with 15 nurses working in 8 nursing homes in 3 health regions in Norway, within both urban and rural areas. Ethical considerations: Oral and written information about the study was provided before the participants gave their written consent. The transcribed interviews were de-identified. The study was approved by the Norwegian Centre for Research Data. Findings: Four ethical difficult situations were identified: (a) turning the nursing home into a prison; (b) using medication to maintain peace and order; (c) being left alone with the responsibility; and (d) s. impact on decision-making. Conclusions: The nurses’ ethical challenges were intertwined with external factors, such as national and local guidelines, and the nurses’ own internalized factors, which were connected to their subjective professionality. This duality inflicted emotional distress and gave nurses few opportunities to perform nursing in a professionally sound and safe manner. (shrink)

Patients in a vegetative state/ unresponsive wakefulness syndrome (VS/UWS) pose ethical dilemmas to those involved. Many conflicts occur between professionals and families of these patients. In the Netherlands physicians are supposed to withdraw life sustaining treatment once recovery is not to be expected. Yet these patients have shown to survive sometimes for decades. The role of the families is thought to be important. The aim of this study was to make an inventory of the professional perspective on conflicts in (...) long-term care of patients in VS/UWS. A qualitative study of transcripts on 2 Moral Deliberations (MD’s) in 2 cases of patients in VS/UWS in long-term care facilities. Six themes emerged: 1) Vision on VS/UWS; 2) Treatment and care plan; 3) Impact on relationships; 4) Feelings/attitude; 5) Communication; 6) Organizational aspects. These themes are related to professionals and to what families had expressed to the professionals. We found conflicts as well as contradictory feelings and thoughts to be a general feature in 4 of these themes, both in professionals and families. Conflicts were found in several actors: within families concerning all 6 themes, in nurse teams concerning the theme treatment and care plan, and between physicians concerning all 6 themes. Different visions, different expectations and hope on recovery, deviating goals and contradictory feelings/thoughts in families and professionals can lead to conflicts over a patient with VS/UWS. Key factors to prevent or solve such conflicts are a carefully established diagnosis, clarity upon visions, uniformity in treatment goals and plans, an open and empathic communication, expertise and understanding the importance of contradictory feelings/thoughts. Management should bridge conflicts and support their staff, by developing expertise, by creating stability and by facilitating medical ethical discourses. Shared compassion for the patient might be a key to gain trust and bridge the differences from non-shared to shared decision making. (shrink)

Background: A fair distribution of healthcare services for older patients is an important challenge, but qualitative research exploring clinicians’ consideration in daily clinical prioritisation in healthcare services for the aged is scarce.Objectives: To explore what kind of criteria, values, and other relevant considerations are important in clinical prioritisations in healthcare services for older patients.Design: A semi-structured interview-guide was used to interview 45 clinicians working with older patients. The interviews were analysed qualitatively using hermeneutical content analysis and template organising style.Participants: 20 (...) physicians and 25 nurses working in public hospitals and nursing homes in different parts of Norway.Results and interpretations: Important dilemmas relate to under-provision of community care and comprehensive approaches, and over-utilisation of certain specialised services. Overt ageism is generally not reported, but the healthcare services for the aged seem to be inadequate due to more subtle processes, for example, dominating considerations and ideals and operating conditions that do not pay sufficient attention to older patients’ needs and considerations of justice. Clinical prioritisations are described as being dominated by adapting traditional biomedical approaches to the operating conditions. Many of the clinicians indicate that there is a potential for improving end of life decisions and for reducing exaggerated use of life-prolonging treatment and hospitalisations.Conclusion: The interviews in this study indicate that considerations of justice and patients’ perspectives should be given more attention to strike a balance between specialised medical approaches and more general and comprehensive approaches in healthcare services for older patients. (shrink)

Objectives: to assess physicians’ and patients’ views in Saudi Arabia towards involving the patient versus the family in the process of diagnosis disclosure and decision-making, and to compare them with views from the USA and Japan.Design: A self-completion questionnaire was translated to Arabic and validated.Participants: Physicians from different specialties and ranks and patients in a hospital or attending outpatient clinics from 6 different regions in KSA.Results: In the case of a patient with incurable cancer, 67% of doctors and (...) 51% of patients indicated that they would inform the patient in preference to the family of the diagnosis . Assuming the family already knew, 56% of doctors and 49% of patients would tell the patient even if family objected . However, in the case of HIV infection, 59% of physicians and 81% of patients would inform the family about HIV status without the patient’s consent . With regards to withholding ventilatory support, about 50% of doctors and over 60% of patients supported the use of mechanical ventilation in a patient with advanced cancer, regardless of the wishes of the patient or the family. Finally, the majority of doctors and patients were against assisted suicide.Conclusions: Although there was more recognition for a patient’s autonomy amongst physicians, most patients preferred a family centred model of care. Views towards information disclosure were midway between those of the USA and Japan. Distinctively, however, decisions regarding life prolonging therapy and assisted suicide were not influenced to a great extent by wishes of the patient or family, but more likely by religious beliefs. (shrink)

Introduction: The decision of “do not attempt resuscitation” in the event of cardiopulmonary arrest is usually made when the patients are critically ill and cannot make an informed choice. Although, various professional bodies have published guidelines, little is know about the patients’ own views regarding DNAR discussion.Aim: The aim of this study was to determine patients’ attitudes regarding discussing DNAR before they are critically ill.Methods: A prospective study was performed in a general out patients department. A questionnaire was distributed (...) to consecutive outpatients along with an explanatory leaflet in the adult outpatient clinic.Results: 364 patients completed the questionnaire . 90% of respondents wanted all patients to be asked regarding DNAR decision at some point during a hospital admission. The majority would not find a DNAR discussion distressing. Only 10% would find it upsetting, however, 48% of these still wanted a discussion. 37% of respondents wanted to discuss DNAR decisions on admission; 32% in outpatients; 17% at consent for surgery, 14% when they are critically ill. 87% of respondents would not object to their relatives being involved in making decisions about their resuscitation status. However, only 12% of the subjects in the study had been involved in discussing the resuscitation status of a relative and 21% would not be comfortable to discuss a relative’s resuscitation status. Although 33% of patients preferred their resuscitation status to simply be documented within their clinical notes, 77% wanted it to be more easily accessible.Conclusions: This study suggests that contrary to current practice most patients want to discuss their DNAR status prior to becoming critically ill. This includes half of the small number that find it distressing to discuss. Although most patients are comfortable with relatives being involved in discussing DNAR, a significant proportion do not want their relatives to be asked. Furthermore, once a decision has been made, the majority of patients want it to be more accessible than current practice allows. (shrink)

The September 11th Victims Compensation Fund can only hesitatingly find its place within a comprehensive study of reparation programs. While the origin of the Fund lies in the political exigencies surrounding a perceived threat to the security of the United States, it more accurately reflects the desire by the U.S. Congress to ensure the viability of its nation’s air carriers. Unlike traditional reparations which are closely related to a process of social reintegration of the victim, fostering civic trust and social (...) solidarity, the Fund was not established to bring justice to the victims of the terrorist attacks on September 11, 2001. Also, unlike traditional reparations, the Fund did not seek to serve as a mechanism of corrective or distributive justice as a result of an authoritarian domestic regime or internal conflict. It was initially created out of fear that recourse to the U.S. courts would threaten the precarious financial health of the airline industry. Implicitly, however, such pragmatism reflected a desire by lawmakers that the government be seen as doing all it could to ease the pain of those who suffered so greatly on September 11, 2001. Initial motivations for the program aside, there is no question that the compensation scheme has since taken on a life of its own. Ultimately, the Fund’s contribution to any reparations case-study lies in its cautionary tale about the creation of elaborate administrative schemes that try to individualize recoveries as the mechanisms through which to compensate victims. (shrink)

COVID-19 Pandemic might be considered as a catalyst for transformation in healthcare experience via the use of video consultation as a method for telemedicine. The aim of our qualitative study is to understand the patient perception of video consultations in telemedicine, which has been used by a single pulmonologist in only one university hospital in Turkey since the first three months of the pandemic. Research findings are essential when it comes to a more effective and widespread future use (...) of telemedicine, as it focuses on patient experience about a medical technology that is newly introduced. Totally 30 patients were randomly chosen and interviewed who get healthcare support via telemedicine. A semi-structured questionnaire was used to learn the experiences and opinions of the interviewees. The expressions of the patients highlight some advantages of using telemedicine such as being free from risk of contagion caused by exposure in the hospital, being able to save time and money while reaching to the physician online whenever needed, and success in technical details even though they were experiencing it for the first time. A very few of the patients are feeling discomfort to be in front of the screen. Almost all patients are applicants to suggest to other individuals the system they used, in conditions to be appropriate, and continuity after the pandemic period. Since the pandemic has propagated from one patient, the worldwide implementation of telemedicine might be catalyzed by following in the footsteps of the sporadic examples of decisiveness nourished from patient experiences. (shrink)