Felsefe tarihi, Heidegger’e göre, varlık sorusu etrafında inşa edilmiştir. Büyük filozofların neredeyse tamamı yüzeydeki tüm farklılıklara rağmen esasında bu ontolojik soruyla ilgilenmişlerdir. Bununla birlikte özellikle özgün düşünce geleneğinde bir kırılmanın yaşandığı Platon’la birlikte “varlık sorusu”, gitgide sahihliğinden uzaklaşmış ve Descartes’ın modern felsefenin de başlangıcı olmak bakımından tepe noktasını oluşturduğu bir çizgide, özne ile nesnenin karşılıklı konumlandırılarak yorumlandığı bir epistemolojik soru haline dönüşmüştür. Epistemolojik yaklaşımın öne çıkan özelliği, özne-nesne ilişkisinde bilginin koşullarını belirleyerek öznenin bilme sınırlarını saptamaya çalışmaktır. Bu yaklaşımda nesne özneye (...) aşkındır; dolayısıyla öznenin nesneyi bilmesi ancak kendinden yola çıkmasıyla olanaklıdır; çünkü öznenin kendisine ilişkin bilgisi doğrudan gerçekleşen, içkin bir bilgidir. Dolayısıyla bu yaklaşımdaki temel varsayım, özne ile nesnenin birbirini dışladığı, nesnenin özneye tâbi kılındığı ikili bir dünya varsayımıdır ve bu varsayımda ortaya çıkan karakteristik sorun, dış dünyanın varlığının kanıtlanması/bilinmesi sorunudur. Sonuç olarak bu makalede Heidegger’in bu problemi “varlık sorusu” bağlamında nasıl bir çözüme kavuşturduğu gösterilmeye çalışılacaktır. (shrink)

Bu kitap değerlendirmesinde, Orna Donath’ın annelikten pişman olma durumunu nasıl ele aldığına değinilecek, kitabın güçlü ve zayıf yönleri üzerinde durulacaktır.

Results of a comprehensive simulation study are reported investigating the effects of sample size, test length, number of attributes and base rate of mastery on item parameter recovery and classification accuracy of four DCMs. Effects were evaluated using bias and RMSE computed between true parameters and estimated parameters. Effects of simulated factors on attribute assignment were also evaluated using the percentage of classification accuracy. More precise estimates of item parameters were obtained with larger sample size and longer test length. Recovery (...) of item parameters decreased as the number of attributes increased from three to five but base rate of mastery had a varying effect on the item recovery. Item parameter and classification accuracy were higher for DINA and DINO models. (shrink)

İdrak ve niteliği felsefenin en önemli problemlerinden biridir. İbn Sînâ hissî, hayalî, vehmî ve aklî olmak üzere dört farklı idrak mertebesi dillendirir. Buna göre insan nefsi nesnelerin suretlerini duyu yetileriyle algılar. Daha sonra bu suretleri hayal yetisine teslim eder. Akabinde akıl bu sureti barındırdığı maddî eklentilerden arındırarak aklî suretlerin oluşumu için gerekli zeminleri hazırlar. Daha sonra faal akıl insan nefsine aklî suretleri verir. İnsan zihninde duyularla algılanan bu kavramlardan başka kavramlar da vardır. Bu küllî kavramların yeri nesnel âlem değil öznel (...) âlemdir. İslam felsefesi geleneğinde Fârâbî ilk defa bu ayırımı yapar ve ma‘kūlleri birinci ve ikinci ma‘kūller diye iki kısma ayırır. İbn Sînâ da bu sınıflandırmayı benimser ve konu hakkında yeni açıklamalar getirir. İbn Sînâ, ikinci ma‘kūllerin sonraki dönemlerde yapılan felsefî ve mantıkî ayırımını her ne kadar dillendirmese de eserlerinden bu iki ma‘kūl türünün farklılığına teveccüh eder. Bu çalışmada İbn Sînâ felsefesinde idrak olgusunun gerçekleşme niteliği ele alınacak ve daha sonraki dönemlerde dillendirilen ikinci felsefî ma‘kūl anlamların İbn Sînâ felsefesindeki yeri açıklanacaktır. (shrink)

Kant’s general taxonomy of duties includes substantial claims that normatively and theoretically differentiates it from other moral theories. Basing his moral theory on a conception of Right, he also made a general classification of several duties with their corresponding moral worth. The general aim of this study is to identify the basic principles and criteria that determine Kant’s classification of duties. Another aim is to trace some implications and effects of Kant’s conception of duties in the contemporary discussion of social (...) and economic rights. We argue that the normative basis of the argument against social and economic rights is very similar to that of the principles Kant uses in his classification of duties. However, from the responsibility of the state, Kant imposes legitimate obligations over individuals, albeit indirectly. (shrink)

After a review of terminology, I identify—in addition to Margaret Battin’s list of five primary arguments for and against aid-in-dying—the argument from functional equivalence as another primary argument. I introduce a novel way to approach this argument based on Bernard Lonergan’s generalized empirical method. Then I proceed on the basis of GEM to distinguish palliative sedation, palliative sedation to unconsciousness when prognosis is less than two weeks, and foregoing life-sustaining treatment from aid-in-dying. I conclude that aid-in-dying must be justified on (...) its own merits and not on the basis of these well-established palliative care practices; and that societies must decide, in weighing the merits of aid-in-dying, whether or not to make the judgment that no life is better than life-like-this part of their operative value structure. (shrink)

Slow euthanasia or a good palliative intervention?There are many ways in which doctors influence the circumstances and/or the timing of a patient’s death. Some of these are accepted as normal medical practice—for instance, when a disproportional treatment is forgone, others are considered tolerable only under strict conditions or even intolerable, such as non-voluntary active euthanasia. A relatively new phenomenon in the ethical discussion on end-of-life decisions is terminal sedation. Terminal sedation is used in patients with terminal illnesses where normal medical (...) treatments cannot relieve severe symptoms such as pain and agitation, and no option is left but to take away the perception of these symptoms. Often, the decision to start terminal sedation is accompanied by the decision to forgo the provision of artificial nutrition and hydration in these patients. In The Netherlands, terminal sedation was estimated to be applied in 4–10% of all deaths in 2001.1 The combination of these two decisions have made the moral status of terminal sedation the subject of fierce ethical debates. Is it slow euthanasia2,3 or is it a good palliative intervention that should be sharply distinguished from euthanasia?4,5 One of the characteristics of this debate is that it is a very confused one: people disagree about the meaning of the term, the appropriateness of it and, of course, about the conditions under which it would be morally justified. As a matter of fact, these three discussions are deeply connected: as is often the case, a discussion about terms is a discussion about norms in disguise.The first observation to be made is that many seemingly descriptive definitions of terminal sedation contain normative claims. Examples of this are definitions of terminal sedation in which only …. (shrink)

A distinction is commonly drawn between continuous sedation until death and physician-assisted suicide/euthanasia. Only the latter is found to involve killing, whereas the former eludes such characterization. I argue that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia in that both involve killing. This is established by first defining and clarifying palliative sedation therapies in general and continuous sedation until death in particular. A case study analysis and a look at current practices are provided. This is followed by a (...) defense of arguments in favor of definitions of death centering on higher brain (neocortical) functioning rather than on whole brain or cardiopulmonary functioning. It is then shown that continuous sedation until death simulates higher brain definitions of death by eliminating consciousness. Appeals to reversibility and double effect fail to establish any distinguishing characteristics between the simulation of death that occurs in continuous sedation until death and the death that occurs as a result of physician-assisted suicide/euthanasia. Concluding remarks clarify the moral ramifications of these findings. (shrink)

Continuous sedation until death is an increasingly common practice in end-of-life care. However, it raises numerous medical, ethical, emotional and legal concerns, such as the reducing or removing of consciousness, the withholding of artificial nutrition and hydration, the proportionality of the sedation to the symptoms, its adequacy in actually relieving symptoms rather than simply giving onlookers the impression that the patient is undergoing a painless 'natural' death, and the perception that it may be functionally equivalent to euthanasia. This book brings (...) together contributions from clinicians, ethicists, lawyers and social scientists, and discusses guidelines as well as clinical, emotional and legal aspects of the practice. The chapters shine a critical spotlight on areas of concern and on the validity of the justifications given for the practice, including in particular the doctrine of double effect. (shrink)

Practitioners of palliative medicine frequently encounter patients suffering distress caused by uncontrolled pain or other symptoms. To relieve such distress, palliative medicine clinicians often use measures that result in sedation of the patient. Often such sedation is experienced as a loss by patients and their family members, but sometimes such sedation is sought as the desired outcome. Peace is wanted. Comfort is needed. Sedation appears to bring both. Yet to be sedated is to be cut off existentially from human experience, (...) to be made incapable of engaging self-consciously in any human action. To that extent, it seems that to lose consciousness is to lose something of real value. In this paper, I describe how sedation and the question of intentionally bringing about sedation arise in the care of patients with advanced illness, and I propose heuristics to guide physicians, including Christian physicians, who seek to relieve suffering without contradicting their profession to heal. (shrink)

“Terminal sedation” refers to the use of sedation as palliation in dying patients with a terminal diagnosis. Although terminal sedation has received widespread legal and ethical justification, the practice remains ethically contentious, particularly as some hold that it foreseeably hastens death. It has been proposed that empirical studies show that terminal sedation does not hasten death, or that even if it may hasten death it does not do so in a foreseeable way. Nonetheless, it is clear that providing terminal sedation (...) in combination with the withholding or withdrawing of life-prolonging treatments such as fluid and nutrition can foreseeably hasten death significantly—what is here called early terminal sedation . There are ethical justifications for the use of sedation in palliative care and thus it would seem that ETS is an ethically and legally acceptable practice. However, what emerges from the literature is the repeated assertion that terminal sedation must be restricted to use in imminently dying patients—the “imminence condition”—and that therefore ETS is unacceptable. This restriction has taken on greater significance with the trend of palliative care to include the care of patients who are not imminently dying. This paper proposes to show that although there is widespread intuitive support for the imminence condition, it does not follow from the justifications for sedation as palliation, and that explicit arguments for the imminence condition are needed. (shrink)

In a substantial number of cases, dying patients are brought into a state of lowered consciousness and kept in it until they die in order to prevent or stop severe suffering. Many guidelines and position statements have been published in recent years on sedation until death, as I will call this policy. Some have been published by professional organisations and are meant to be binding for their members, others are the work of task forces and merely aim at providing medical, (...) moral, and legal guidance.1 These guidelines all take the following positions: the patient’s consciousness should not be lowered more than is necessary for preventing her from suffering; it must be impossible to alleviate the suffering in any... (shrink)

ABSTRACT There has been much discussion regarding the acceptable use of sedation for palliation. A particularly contentious practice concerns deep, continuous sedation given to patients who are not imminently dying and given without provision of hydration or nutrition, with the end result that death is hastened. This has been called ‘early terminal sedation’. Early terminal sedation is a practice composed of two legally and ethically accepted treatment options. Under certain conditions, patients have the right to reject hydration and nutrition, even (...) if these are life‐sustaining. Patients are also entitled to sedation as palliation for intolerable, intractable suffering. Though early terminal sedation is thought to be rare at present, the changing nature of palliative medicine suggests its use will increase. Arguments regarding early terminal sedation have failed to recognize early terminal sedation as a distinct legal and ethical entity. It can be seen as both the simple sum of treatment refusal and sedation for palliation, analogous to terminal sedation. It can also be seen as an indivisible palliative treatment, more analogous to assisted suicide or euthanasia. But ultimately, it is wholly analogous neither to terminal sedation given when death is imminent, nor to assisted suicide or euthanasia. This paper contends that early terminal sedation should be considered as a distinct entity. Such a reconception promises to provide a way forward in the debate, practice and policy regarding this contentious area of palliative medicine. (shrink)

The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny the ethical distinctions between euthanasia and palliative sedation, we will critically analyse the guideline's argumentation strategy with which euthanasia is demarcated from palliative sedation. First, we will analyse the guideline's main premise, which entails that palliative sedation is normal medical treatment. After this, we will critically discuss three crucial propositions of (...) the guideline that are used to support this premise: (1) the patient's life expectancy should not exceed 2 weeks; (2) the aim of the physician should be to relieve suffering and (3) expert consultation is optional. We will conclude that, if inherent problematic aspects of palliative sedation are taken seriously, palliative sedation is less normal than it is now depicted in the guideline. (shrink)

Background: In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research design: We (...) reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation. (shrink)

This article discusses the place of sedation in the care of the terminally ill, as used in the practice of palliative care using case studies, clinical pragmatism forms the theoretical framework from which to elucidate the varying part that sedation plays in the overall management of a person facing the end of life. We contend that when used appropriately, sedation is an ethical and legitimate intervention that enhances comfort at the end of life and ought not sedate the person onto (...) “oblivion”. (shrink)

This article focuses on the ethical aspects of medically-induced sedation and pain relief in intensive care medicine. The study results reported are part of a larger investigation of patients’ experiences of being sedated and receiving pain relief, and also families’ experiences of having a close relative under controlled sedation in an intensive care unit. The study is based on qualitative in-depth interviews with nine nurses and six doctors working in intensive care and surgical units in a major Norwegian hospital. The (...) textual data are interpreted according to Kvale’s method for analyzing qualitative data. There are ethical problems regarding how to achieve an acceptable balance between a patient’s subjective well-being and the medical need for reduced sedation. The authors discuss whether some medical reasons for reduced sedation are ethically justifiable, given the actual medical knowledge available. The study also addresses the ethical consequences of reducing medically-induced sedation and the demands it puts on interdisciplinary co-operation and communication, as well as the importance of improving the quality of medical and nursing care. (shrink)

Continuous sedation until death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, often provokes medical-ethical discussions in the opinion sections of medical and nursing journals. A content analysis of opinion pieces in medical and nursing literature was conducted to examine how clinicians define and describe CSD, and how they justify this practice morally. Most publications were written by physicians and published in palliative or general medicine journals. Terminal Sedation and Palliative Sedation are (...) the most frequently used terms to describe CSD. Seventeen definitions with varying content were identified. CSD was found to be morally justified in 73 % of the publications using justifications such as Last Resort, Doctrine of Double Effect, Sanctity of Life, Autonomy, and Proportionality. The debate over CSD in the opinion sections of medical and nursing journals lacks uniform terms and definitions, and is profoundly marked by ‘charged language’, aiming at realizing agreement in attitude towards CSD. Not all of the moral justifications found are equally straightforward. To enable a more effective debate, the terms, definitions and justifications for CSD need to be further clarified. (shrink)

Terminale Sedierung ist unter bestimmten Umständen ethisch rechtfertigbar: Mit dem Wissen um die Begrenztheit des eigenen Lebens ist auch der Sterbeprozess ein bewusst zu gestaltender, dem eigenen Willen unterworfener Bestandteil des Lebens. Das schließt auch die (paradoxe) Möglichkeit ein, bewusst auf das Bewusstsein beim eigenen Sterben zu verzichten. Anhand eigener Studien kann der Autor zeigen, dass sich der Wunsch nach Sterbehilfe bei terminal kranken Menschen als die Folge einer konsequenten Einordnung in das System der Medizin deuten lässt. Infolgedessen begreifen Patienten (...) auch das Sterben als eine Aufgabe des Medizinsystems, so dass sie ärztliche Sterbehilfe als Ausdruck für ein menschenwürdiges Sterben, paradoxerweise sogar als natürlichen Tod auffassen können. In dieser Situation ermöglicht die terminale Sedierung einen Fortschritt: Das Medizinsystem kann der von ihm erwarteten Zuständigkeit für den Prozess des Sterbens nachkommen, ohne direkt und intentional zu töten. Trotzdem bleiben bezüglich der Missbrauchsmöglichkeiten, der Rollenkonfusion der Ärzte und der Grenzen menschlicher Handlungsräume Zweifel. Vor der „Illusion der glatten Lösungen“ (H. Thielicke) wird gewarnt und für den Versuch geworben, das jeweils Beste für die einzelnen Betroffenen zu erreichen. (shrink)

Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress.

Background This paper addresses sedation at the end of life. The use of sedation is often seen as a last resort for patients whose death is imminent and whose symptoms cannot be treated in any other way. This paper asks how to assess constellations, where patients want to hasten their death by refusing (further) life-sustaining treatment, or by voluntarily stopping eating and drinking (VSED), and wish this to be accompanied by sedation. Argument We argue that sedation is ethically and legally (...) permissible not only as a last resort, but in principle. Furthermore, we see a clear obligation to sedate in cases of acute suffering of any kind, while in some other constellations individual physicians’ objections to supposedly premature or unnecessary sedation must be respected. Such possible reservations should, however, be reconsidered in light of the fundamental ethical and legal right to a self-determined death. Conclusion In general, sedation practices should be less restrictive, and existing guidelines should be revised accordingly. (shrink)

This paper is concerned with the moral justification for palliative sedation until death. Palliative sedation involves the intentional lowering of consciousness for the relief of untreatable symptoms. The paper focuses on the moral problems surrounding the intentional lowering of consciousness until death itself, rather than possible adjacent life-shortening effects. Starting from a Kantian perspective on virtue, it is shown that continuous deep sedation until death (CDS) does not conflict with the perfect duty of moral self-preservation because CDS does not destroy (...) capacities for agency. In addition, it is argued that CDS can frustrate the imperfect duty of self-cultivation by reducing consciousness permanently. Nevertheless, there are cases where CDS is morally acceptable, namely, cases where the agent has already permanently lost the possibility for free action in advance of sedation—for example, due to excruciating and ongoing pain. Because the latter can be difficult to diagnose properly, safeguards may be needed in order to prevent the application of CDS for the wrong reasons. (shrink)