Background: Although attention to healthcare ethics in rural areas has increased, specific focus on rural palliative care is still largely under-studied and under-theorized. The purpose of this study was to gain a deeper understanding of the values informing good palliative care from rural individuals' perspectives. Methods: We conducted a qualitative ethnographic study in four rural communities in Western Canada. Each community had a population of 10, 000 or less and was located at least a three hour travelling distance by car (...) from a specialist palliative care treatment centre. Data were collected over a 2-year period and included 95 interviews, 51 days of field work and 74 hours of direct participant observation where the researchers accompanied rural healthcare providers. Data were analyzed inductively to identify the most prevalent thematic values, and then coded using NVivo. Results: This study illuminated the core values of knowing and being known, being present and available, and community and mutuality that provide the foundation for ethically good rural palliative care. These values were congruent across the study communities and across the stakeholders involved in rural palliative care. Although these were highly prized values, each came with a corresponding ethical tension. Being known often resulted in a loss of privacy. Being available and present created a high degree of expectation and potential caregiver strain. The values of community and mutuality created entitlement issues, presenting daunting challenges for coordinated change. Conclusions: The values identified in this study offer the opportunity to better understand common ethical tensions that arise in rural healthcare and key differences between rural and urban palliative care. In particular, these values shed light on problematic health system and health policy changes. When initiatives violate deeply held values and hard won rural capacity to address the needs of their dying members is undermined, there are long lasting negative consequences. The social fabric of rural life is frayed. These findings offer one way to re-conceptualize healthcare decision making through consideration of critical values to support ethically good palliative care in rural settings. (shrink)
Two articles in this issue of the Hastings Center Report explore two sides of the same problematic coin. In “The Limits of Surrogates’ Moral Authority and Physician Professionalism,” Jeffrey Berger discusses the moral problem of a surrogate refusing a treatment, palliative sedation, on behalf of a patient whose suffering is refractory to intensive palliative efforts provided by a multidisciplinary team. In “After the DNR: Surrogates Who Persist in Requesting Cardiopulmonary Resuscitation,” Ellen Robinson and her colleagues analyze data from a (...) study of cases in which physicians wished not to perform cardiopulmonary resuscitation on patients whom they thought it would harm. Both articles begin from the idea of a professional determination about a physician's duty to a patient that conflicted with a surrogate's determination about what should or should not be done for that patient. Berger's argument stops just short of a solution, however, because a physician's professional obligation to help patients, even within guidelines set by other professionals, is insufficient protection for patients. But if Berger's theory is right—that sometimes surrogates lack moral authority to make decisions on behalf of patients—then the Robinson team has developed a careful and public process for attending to that conflict. (shrink)
We apply Carol Gilligan's distinction between a "male" mode of moral reasoning, focussed on justice, and a "female" mode, focussed on caring, to the reading of literature. Martha Nussbaum suggests that certain novels are works of moral philosophy. We argue that what Nussbaum sees as the special ethical contribution of such novels is in fact training in the stereotypically female mode of moral concern. We show this kind of training is appropriate to all readers of these novels, not just to (...) women. Finally, we explore what else is involved in distinctively feminist readings of traditional novels. (shrink)
Debates about moral judgments have raised questions about the roles of reasoning, culture, and conflict. In response, the cognitive prototype model explains that over time, through training, and as a result of cognitive development, people construct notions of blameworthy and praiseworthy behavior by abstracting out salient properties that lead to an ideal representation of each. These properties are the primary features of moral prototypes and include social context interpretation, intentionality, consent, and outcomes. According to this model, when the properties are (...) uniform and coherent, they depict a promoral or immoral prototype, relative to the orientations of the properties. A promoral prototype is represented by an action that is supported by the culture, intentionally benevolent or other-regarding, consensual, and resulting in positive outcomes. An immoral prototype is an action that is condemned by the culture, intentionally malevolent or self-serving, lacking consent, and resulting in negative outcomes. It is hypothesized that moral prototypes will result in a high level of agreement and require effortless processing. Alternatively, when properties conflict or the situation deviates from the prototype, a nonprototype will result. It is hypothesized that nonprototypical situations will act as a source of moral disagreement and may require more effortful processing. (shrink)
This essay argues that making a diagnosis in medicine is essentially a hermeneutic enterprise, one in which interpretation skills play a major part in understanding a disease. The clinical encounter is an event comprised of two voices; one is the voice of science which is grounded in empiricism, the other is that of human experience, which is grounded in story-telling and the interpretation of those stories.Using two voices, one from the Diagnostic and Statistical Manual of Mental Disorders-III-Revised, which describes alcohol (...) abuse and alcohol dependence, and the other, that of Claire, a character in Edward Albee's play, A Delicate Balance, who is conversing with her brother-in-law, Tobias, I apply principles from Hans-Georg Gadamer's hermeneutics to the clinical diagnostic process. The essay will demonstrate that we overlook an enormous amount of information about alcoholism by an overreliance on objective data and that our hope for understanding alcoholics is in listening to their voices, and sharing the interpretation of their experiences with them. (shrink)
A Nietzschean theodicy would claimthat God has created the world exactly the wayit is in order to produce morally autonomousagents in Nietzsche's sense: self-consciousmoral subjectivists. Both atheism and a`Nietzschean theodicy' make the sameprediction: the world will appear to containgratuitous evil. Thus, observation ofapparently gratuitous evil is not evidence foror against either hypothesis. In the absenceof any other evidence for or against theism,the most reasonable position is agnosticism.
Two profound yet incompatible moral imaginations confront each other in the attempt to address Job's experience of turmoil That of the friends is grounded in a deep sense of the moral nature of creation. Job's moral imagination takes shape through an act of witness that attempts to create a community of answerability before God.
_Material Feminisms: New Directions for Education_ provides a range of powerful theoretical and innovative methodological examples to illuminate how new material feminism can be put to work in education to open up new avenues of research design and practice. It poses challenging questions about the nature of knowledge production, the role of the researcher, and the critical endeavour arising from inter- and post-disciplinarity. Working with diffractive methodologies and new materialist ecological epistemologies, the book offers resources for hope which widen the (...) scope for how educational problems are interrogated, and provides a political counter-movement to neo-positivist, outcomes-based approaches within education. Inspired by writers such as Barad, Bennett, and Deleuze and Guattari, the book makes a radical break with cognitive, dualist, and universal conceptions of human subjectivity and intelligence in education. By taking its starting point as the co-consitutiveness of discourse, materiality, corporeality, and place, the book foregrounds educational practices as material enactments of multiple, non-linear, entangled, affective, and relational forces. It offers new insights into how gender, class, and ethnicity are constituted in, and by, material assemblages that are often submerged or ‘unseen’. This book is an essential starting place for those intrigued by what new theoretical accounts of materiality, posthumanism, and affect can offer educational research. Diffractive methodologies challenge readers to take a fuller range of actors into account than in ‘objective’ humanist methodologies, and in so doing to pay closer attention to what data is. It invites researchers to engage with long-standing feminist concerns about power and knowledge production in research processes. This book was originally published as a special issue of _Gender and Education. _. (shrink)
What is the nature of communicative competence? Carol A. Kates addresses this crucial linguistic question, examining and finally rejecting the rationalistic theory proposed by Noam Chomsky and elaborated by Jerrold J. Katz, among others. She sets forth three reasons why the rationalistic model should be rejected: (1) it has not been supported by empirical tests; (2) it cannot accommodate the pragmatic relation between speaker and sign; and (3) the theory of universal grammar carries with it unacceptable metaphysical implications unless it (...) is interpreted in light of empiricism. Kates proposes an empiricist model in place of the rationalistic theory—a model that, in her view, is more consistent with recent findings in linguistics and psycholinguistics. In attempting to clarify the nature of utterance meaning, Kates develops theoretical perspectives on phenomenological empiricism and produces an account of reference and intentionality directly relevant to empirically based theories of speaking and understanding. Among the major topics addressed in the book are transformational-generative and universal grammar, cognitive theories of language acquisition, pragmatic structure, predication and topic-comment structure, and empiricism and the philosophical problem of universals. An innovative and probing work, Pragmatics and Semantics: An Empiricist Theory will be welcomed by philosophers, linguists, and psycholinguists. (shrink)
A serial reaction time experiment tested the hypothesis that there are two independent forms of implicit learning: learning that is linked to making judgments about stimuli, and learning that is linked to motor processing. Participants performed 2, 6, or 12 blocks of single task SRT, dual task SRT, or observation with one of five sequences; each sequence had the same underlying structure. Participants then performed two implicit tests, SRT and pattern judgment, as well as a generation test and an explicit (...) knowledge test. There was a double dissociation of the effect of sequence surface structure on SRT and pattern judgment. SRT and pattern judgment competence developed independently of each other across length of acquisition task. Performance on both implicit tasks did not depend on explicit knowledge. These results indicate that the SRT and pattern judgment measures tap independent forms of implicit learning, which is consistent with the modular nature of memory and cognition. (shrink)
Three experiments investigated whether a motor-linked measure (string typing speed) and an judgment-linked measure (grammatical judgment of strings) accessed the same implicit learning mechanisms in the artificial grammar learning task. Participants first studied grammatical strings through observation or through responding to each letter by typing it and then performed typing and grammatical judgment tests. Grammatical judgment test performance was better after observation than after respond learning, whereas typing test performance on higher order relations was worse after observation than after respond (...) learning (Experiment 1). Participants transferred grammatical knowledge across letter sets on the grammatical judgment test, but not on the typing test (Experiment 2). Typing speed did not differ for hits (grammatical strings classified by participants as grammatical) and misses (grammatical strings classified as nongrammatical, Experiment 3). These results are consistent with typing and grammatical judgment tests tapping independent mechanisms and indicate that implicit learning may consist of many different forms of learning rather than being a unitary learning mechanism. (shrink)
This paper offers a narrative approach to understanding the process of clinical reasoning in complex cases involving medical uncertainty, moral ambiguity, and futility. We describe a clinical encounter in which the pediatric health care team experienced a great deal of conflict and distrust as a result of an ineffective process of interpretation and communication. We propose a systematic method for analyzing the technical, ethical, behavioral, and existential dimensions of the clinical reasoning process, and introduce the Clinical Reasoning Discussion Toolâa dialogical (...) and interpretive device aimed at improving communication, understanding, empathy, and moral deliberation in the clinical setting. (shrink)
We know from the research literature that psychotherapy is effective, but we also know that hundreds of diverse therapies are being practiced that have not been subjected to scientific scrutiny; thus, in some circumstances iatrogenic effects do occur. Therefore, it is crucial that we recognize and implement therapeutic interventions that are evidence based rather than succumb to ethical dilemma, frustration, and complacency. Recommendations for family therapists are discussed, including the need to (a) keep abreast of research findings, (b) translate research (...) findings and developments as they apply to clinical practice, (c) prioritize techniques and intervention models, and (d) reexamine funding priorities and research foci. (shrink)
To illustrate the strength of Bartky's clarity of insight I focus on her discussion of shame found in two essays in Femininity and Domination. I argue that these essays as well as the other in the collection identify and offer a clear analysis of many issues central to feminism and call for Bartky to write a sequel which offers constructive suggestions of ways out.