Background: Due to recent legislations on euthanasia and its current practice in the Netherlands and Belgium, issues of end-of-life medicine have become very vital in many European countries. In 2002, the Ethics Working Group of the German Association for Palliative Medicine (DGP) has conducted a survey among its physician members in order to evaluate their attitudes towards different end-of-life medical practices, such as euthanasia (EUT), physician-assisted suicide (PAS), and terminal sedation (TS). Methods: An anonymous questionnaire (...) was sent to the 411 DGP physicians, consisting of 14 multiple choice questions on positions that might be adopted in different hypothetical scenarios on situations of “intolerable suffering” in end-of-life care. For the sake of clarification, several definitions and legal judgements of different terms used in the German debate on premature termination of life were included. For statistical analysis t-tests and Pearson-correlations were used. Results: The response rate was 61% (n=251). The proportions of the respondents who were opposed to legalizing different forms of premature termination of life were: 90% opposed to EUT, 75% to PAS, 94% to PAS for psychiatric patients. Terminal sedation was accepted by 94% of the members. The main decisional bases drawn on for the answers were personal ethical values, professional experience with palliative care, knowledge of alternative approaches, knowledge of ethical guidelines and of the national legal frame. Conclusions: In sharp contrast to similar surveys conducted in other countries, only a minority of 9.6% of the DGP physicians supported the legalization of EUT. The misuse of medical knowledge for inhumane killing in the Nazi period did not play a relevant role for the respondents’ negative attitude towards EUT. Palliative care needs to be stronger established and promoted within the German health care system in order to improve the quality of end-of-life situations which subsequently is expected to lead to decreasing requests for EUT by terminally ill patients. (shrink)

Objectives To determine the frequencies and types of limitation of medical treatment performed by physician members of the German Society for Palliative Medicine and to analyse the findings with respect to clinical and ethical aspects of end-of-life practices. Design Cross-sectional postal survey. Setting Data collection via the secretary of the German Society for Palliative Medicine using the German language version of the EURELD survey instrument. Subjects All 1645 physician members of the German (...) Society for Palliative Medicine. Main outcome measures Types and frequencies of limitation of treatment and possible determinants. Results 901 physicians participated in the study (response rate 55.8%). Participants reported limitation of treatment in 69.1% of cases. These decisions most often affected artificial nutrition (19%), chemotherapy (14%), antibiotics (11%) and medication other than antibiotics (11%). In the majority of eligible cases, physicians estimated the life-shortening effect of limitation of treatment to be <7 days. However, estimations differ depending on the medical measures in question. Bivariate statistical analysis indicated that withholding of treatment was performed significantly more frequently for patients aged ≥65 years (p=0.019). In addition, there were significant associations between the incidence of limitation of treatment and the different diseases reported by respondents as the underlying cause of death. Conclusion The findings of this study provide information on the current state of an ethically and clinically challenging aspect of clinical practice and can serve as a starting point for further interdisciplinary research on normative and empirical aspects of treatment decision-making at the end of life. (shrink)

In September 1998 the Bundesrztekammer, i.e., the German Medical Association, published new principles concerning terminal medical care. Even before publication, a draft of these principles was very controversial, and prompted intense public debate in the mass media. Despite some of the critics' suspicions that the principles prepared the way for liberalization of active euthanasia, euthanasia is unequivocally rejected in the principles. Physician-assisted suicide is considered to violate professional medical rules. In leaving aside some of the notions customarily used (...) in the euthanasia debate, e.g., passive euthanasia, the principles emphasize the obligation of physicians to offer and the right of patients to receive palliative care. The principles explicitly list modalities of basic treatment that are indispensable in all cases, such as the obligation to satisfy hunger and thirst. This statement is meant to resolve the dispute on nutrition and hydration at the end of life, as it shifts the focus of care from maintaining physiological parameters to satisfying subjective needs. For patients in a persistent vegetative state, artificial feeding is held to be obligatory. Yet, the principles make reference to recent German jurisdiction which permit the stopping of artificial feeding if it is in accordance with the patient's presumed will. Additionally, the wording concerning this issue is found to remain unclear. Patients' autonomy is strengthened by explicitly welcoming advance directives as a means to ascertain patients' wills. The principles mark some changes compared to earlier documents. They deserve careful analysis and should be considered in the international debate on issues concerning the end of life. (shrink)

Some experiences—like the experience of eating cheesecake—are good experiences to have. But when we try to explain why they are good, we encounter a clash of intuitions. First, we have an objectivist intuition: plausibly, the experiences are good because they feel the way that they do. Second, we have a subjectivist intuition: if a person were indifferent to that kind of experience, then it might fail to be good for that person. Third, we have a possibility intuition: for any kind (...) of experience, possibly there is a subject who is indifferent to that kind of experience. The pleasure problem is the problem we face in reconciling these three claims. I explain the problem and argue for a solution. I argue that we ought to reject the most common solutions: rejecting the objectivist or subjectivist intuitions. Instead, we ought to follow Timothy Sprigge in rejecting the possibility claim. We should embrace the view that experiences bear necessary connections to our attitudes. (shrink)

The negotiations of the intergovernmental group known as the ‘IGWG’, undertaken by the Member States of the WHO, were the result of a deadlock in the World Health Assembly held in 2006 where the Member States of the WHO were unable to reach an agreement on what to do with the 60 recommendations in the report on ‘Public Health, Innovation and Intellectual Property Rights submitted to the Assembly in the same year by a group of experts designated by the Director (...) General of the WHO. The result of these negotiations was the ‘Global strategy and plan of action on public health, innovation and intellectual property’ which was approved by the World Health Assembly in 2008. The intention of the Global Strategy and Plan of Action (GSPOA) which was produced by the IGWG was to substantially reform the pharmaceuticals' research and development system in view of the findings that this system, whose purpose is to produce medicines for diseases which affect the greater part of the world population which lives in developing countries, had failed. The intellectual property rights imposed by the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and the recent trade agreements could become one of the main obstacles to access to medicines. The GSPOA makes a critical analysis of this reality, and opens the door to searching for new solutions to this problem. (shrink)

This article studies the unrestraint in beliefs associated with the overemphasizing of our beliefs. The author argues that the intolerance for other points of view appears (among other factors) because of a naively-objectivist understanding of philosophy, one which is based on two assumptions: first, philosophy is considered only as a theory and not an individual practice, not an experience, and second, the truth is considered as identical to a certain ideal-objective content that can be in one’s possession.There are true ideas (...) and proper words. If we learn these ideas, we will definitely seize the truth. The author opposes this understanding the notion of philosophy which is based on the experience of the encounter and upon reflexive comprehension of this experience. It is possible to minimize unrestraint in beliefs if we assume that all the points of view including our own are considered as belonging to the incomprehensible Absolute. (shrink)

These essays, first presented at a conference, “Coping with Sickness,” held in Italy in 1997, address ethical and regulatory medical issues within a historical context. Many of the essays, while addressing interesting topics, combine policy analysis and critical cultural theory. Critical cultural theory can be intellectually engaging at times but is generally irrelevant to public officials concerned with specific policy issues.Coping with Sickness is the third and final volume derived from a series of conferences cosponsored by the European Science Foundation (...) and the Euroconferences Activity of the European Union. The eight essays are organized chronologically and cover a range of disparate topics: medical practitioners and the Spanish Inquisition , the history of autopsy legislation in German since 1800 , the history of “sadism” as a medical term in the nineteenth century , folk medicine in Holland in the late nineteenth century , abortion in Weimar Germany , drug testing in Africa in the early twentieth century , comparative policies toward STDs , and the debate over brain death in Germany . As might be expected in an anthology of this sort, the quality varies considerably. Nonetheless, the subjects addressed in this volume are engaging—much to the credit of the editors.Two pieces in particular represent the range of these collected essays. In “Vacher the Ripper and the Construction of the Nineteenth‐Century Sadist,” Angus McLaren, one of the best historians writing on the history of sexuality today, explores the “discovery” of sadism in the late nineteenth century by focusing on the dramatic trial of Joseph Vacher, who was charged in 1895 for the brutal sexual murder of a woman in Champuis. He later confessed to the murder and the sexual violation of another seven females and four males. Vacher had a long history of mental illness; indeed, he had been institutionalized in July 1893 following a failed attempt at suicide that left a bullet lodged in his head. At the trial the criminologist Alexandre Lacassagne was brought in as an expert witness to testify that Vacher was not insane but an antisocial sadist, as revealed by his dabbling in anarchism, vagabondism, and homosexuality. As a consequence, Vacher was found guilty and given a death sentence.McLaren finds in this trial an example of the social construction of a new medical concept, “sadism.” The emergence of the concept of sadism, he argues, reflected a “gendered notion” of defining appropriate male and female behavior; physicians at the turn of the century believed that “civilized men were most threatened, not by excess passion, but by the enervation spawned by urban life” . The concept of sadism was also employed by doctors to enhance their own authority and to alert the public to the dangers of a male manifesting “feminine traits” and to “beat back” homosexuality.There is much interesting conjecture to McLaren's study, but what policy lessons should be drawn from this remains unclear. If every concept is actually a social construction, reflecting the social anxieties of the age, then is the fashionable concept of social construction itself socially constructed to enhance the authority of the medical historian?More interesting methodologically is Claudia Wiesemann's absorbing essay on the historical debate in Germany over “brain death.” Relying on Ulrich Beck's social theory of simple and reflexive modernization, she shows that, when confronted with complex scientific questions, the public has to decide between competing plausible scientific claims; as a result, political groups make use of scientific expertise and counterexpertise to push their favorite practical and legal solutions. (shrink)

Cuidados paliativos: solución ética acorde con la dignidad humana al final de la vida Cuidados paliativos: solução ética de acordo com a dignidade humana no final da vida It is said that passing laws to legalize euthanasia is absolutely necessary but, in my opinion, it is more pressing to enact a law for the patient to access a universal palliative care service at the end of their life than a law on euthanasia. This article discusses the difference between euthanasia (...) and palliative care. It is affirmed that being in favor of the latter does not mean wanting the patient to be in pain and to suffer, nor extending their life unreasonably. However, opting for palliative care is, on the one hand, what the physician can ethically do as a health worker and, on the other, the only morally acceptable alternative to the natural end of human beings that is appropriate to their dignity. Therefore, palliative care immerses us in an anthropological reflection about our own limitation and fragility, since respect for human life and palliative care dignify the process of dying. Para citar este artículo / To reference this article / Para citar este artigo Zurriaráin RG. Cuidados paliativos: solución ética acorde con la dignidad humana al final de la vida. Pers Bioet. 2019; 23: 180-193. DOI: https://doi.org/10.5294/pebi.2019.23.2.2 Recibido: 08/04/2019 Aceptado: 24/07/2019. (shrink)

The recent surge in land-based investments in the global South has been seen as both an opportunity for rural economic development and as a trend that poses significant social and environmental risks. This study sheds light on this debate through a look at the tobacco industry in Malawi. We employ a case study approach to investigate how rights, property, and authority associated with land and forest resources have shifted in the context of expanded investments in tobacco, and the stakes for (...) both local land users and citizens. Findings point to the need to broaden the metric of risks and trade-offs associated with large-scale land acquisitions, and to engage in a deeper reading of how these are borne out throughout history. (shrink)

Pricing policies and fair-trade practices are critical for sustaining commercial relationships between firms and customers. Nevertheless, in current business practices, fairness has been mistakenly reduced to a minimalistic ethic wherein justice only demands legal and explicit norms to which commercial parties voluntarily agree. Aimed at giving a different explanation of commercial agreements, this paper will introduce a Virtue Ethics (VE) explanation of the relationship between pricing and the common good by taking up classical concepts related to justice in commerce. In (...) particular, we will explore three principles associated with the notion of fairness in commerce as defined in Neo-Aristotelian ethics towards a relationship between a common good and justice in pricing, i.e., proportionality, benevolence and well-being. To exemplify how these criteria of justice apply to decision-making in commercial practices, we will discuss several cases of fair and unfair commercial relationships. (shrink)

Objective—To demonstrate Japanese doctors' and nurses' attitudes towards and practices of voluntary euthanasia (VE) and to compare their attitudes and practices in this regard. Design—Postal survey, conducted between October and December 1999, using a self-administered questionnaire.Participants—All doctor members and nurse members of the Japanese Association of Palliative Medicine.Main outcome measure—Doctors' and nurses' attitude towards and practices of VE.Results—We received 366 completed questionnaires from 642 doctors surveyed (response rate, 58%) and 145 from 217 nurses surveyed (68%). A total (...) of 54% (95% confidence interval (CI): 49-59) of the responding doctors and 53% (CI: 45-61) of the responding nurses had been asked by patients to hasten death, of whom 5% (CI: 2-8) of the former and none of the latter had taken active steps to bring about death. Although 88% (CI: 83-92) of the doctors and 85% (CI: 77-93) of the nurses answered that a patient's request to hasten death can sometimes be rational, only 33% (CI: 28-38) and 23% (CI: 16-30) respectively regarded VE as ethically right and 22% (CI: 18-36) and 15% (CI: 8-20) respectively would practise VE if it were legal. Logistic regression model analysis showed that the respondents' profession was not a statistically independent factor predicting his or her response to any question regarding attitudes towards VE. Conclusions—A minority of responding doctors and nurses thought VE was ethically or legally acceptable. There seems no significant difference in attitudes towards VE between the doctors and nurses. However, only doctors had practised VE. (shrink)

In 2014, the International Association for the Psychology of Religion will have its centennial, and so will its scientific journal, the present Archive for the Psychology of Religion [ Archiv für Religionspsychologie, ARp]. This first article on IAPR's history analyses the fate of the forerunner of ARp, which was published from 1907-1913. When psychology in general began to develop as an empirical, research-based “scientific discipline” since the midst of the 19th century, the psychology of religion became a prominent application (...) of that “new” science of psychology, involving many of the founding fathers of present day psychology. Shortly after evoking these beginnings, the focus of the present article turns to the development of early scientific infrastructure for the psychology of religion. While the psychology of religion was initiated by European scholars such as Fechner and Wundt, it was the organizer of American psychology in general who started the first journal in this field, G. Stanley Hall. Through his European admirer Gustav Vorbrodt, Hall's journal may have been an inspiration to the founding of the first European journal for the psychology of religion, the German-speaking Zeitschrift für Religionspsychologie. Most likely the psychiatrist Johannes Bresler took the initiative to start this journal and had invited pastor Gustav Vorbrodt, who had already repeatedly and vigorously called for psychological study of religion, to join him as editor. Consequently, the subtitle of the journal was ‘Grenzfragen der Theologie und der Medizin [ Boundary Questions in Theology and Medicine].’ The present paper discusses both Vorbrodt's and Bresler's work in the realm of the psychology of religion, as it does the contributions of two further editors; the philosopher-historian of religion Georg Runze, an honorary professor at Berlin University, and Otto Klemm, a collaborator of Wilhelm Wundt and later the director of the latter's psychological laboratory in Leipzig and the first to hold a professorship for applied psychology. Several reasons are discussed to answer the question why the Zeitschrift für Religionspsychologie ceased publishing. Based on empirical-archival research, special attention is given to scholarly disagreements behind the transition of the Zeitschrift für Religionspsychologie to the new Archiv für Religionspsychologie. (shrink)

The problem of inadequate pain management for both terminally ill patients and patients with chronic pain has recently been documented by a number of authors and studies. A 1997 report by the Institute of Medicine, for example, states that “a significant proportion of dying patients and patients with advanced disease experience serious pain, despite the availability of effective pharmacological and other options for relieving most pain.” There are particularly impressive data that pain associated with cancer is not adequately treated.The (...) problem has been attributed to inadequate education of physicians on approaches to pain management and an often misguided belief that prolonged therapy with certain pain medication will lead to addiction; legal obstacles, such as physicians’ fear of criminal prosecution and other disciplinary actions by state licensing boards for overprescribing narcotics; and inadequate insurance coverage as a result of narrow eligibility criteria for hospice care for Medicare beneficiaries, and inadequate reimbursement more generally for pain management and palliative care. (shrink)

The problem of inadequate pain management for both terminally ill patients and patients with chronic pain has recently been documented by a number of authors and studies. A 1997 report by the Institute of Medicine, for example, states that “a significant proportion of dying patients and patients with advanced disease experience serious pain, despite the availability of effective pharmacological and other options for relieving most pain.” There are particularly impressive data that pain associated with cancer is not adequately treated.The (...) problem has been attributed to inadequate education of physicians on approaches to pain management and an often misguided belief that prolonged therapy with certain pain medication will lead to addiction; legal obstacles, such as physicians’ fear of criminal prosecution and other disciplinary actions by state licensing boards for overprescribing narcotics; and inadequate insurance coverage as a result of narrow eligibility criteria for hospice care for Medicare beneficiaries, and inadequate reimbursement more generally for pain management and palliative care. (shrink)

The Joint International Conference on Logic Programming, sponsored by the Association for Logic Programming, is a major forum for presentations of research, applications, and implementations in this important area of computer science. Logic programming is one of the most promising steps toward declarative programming and forms the theoretical basis of the programming language Prolog and its various extensions. Logic programming is also fundamental to work in artificial intelligence, where it has been used for nonmonotonic and commonsense reasoning, expert systems (...) implementation, deductive databases, and applications such as computer-aided manufacturing. Krzysztof R. Apt is project leader at the Centre for Mathematics and Computer Science in Amsterdam and part-time Professor in Computer Science at the University of Amsterdam. Topics covered: Theory Foundations. Programming Languages. Implementation. Programming Methodologies and Tools. Applications. Deductive Databases. Artificial Intelligence. Parallelism. (shrink)

Patients with advanced dementia are less likely than those with other terminal illnesses to receive palliative care. Due to the nature and course of dementia, there may be a failure to recognize the terminal stage of the disease. A possible and under-investigated explanation for this healthcare disparity is the healthcare practitioner who plays a primary role in end-of-life decision-making. Two potential areas that might impact provider decision-making are cognitive biases and moral considerations. In this analysis, we demonstrate how the (...) cognitive biases and moral considerations of practitioners related to clinical decision-making are inherent in clinical practice and may impact on providers’ accuracy related to diagnostic and treatment related decision-making associated with patients with advanced dementia. Anchoring, default, availability, representativeness and framing biases are cognitive biases based on the "Two System Model" that relate to decision-making in end-of-life care. In patients with advanced dementia, those biases may result in a tendency to adhere to traditional mandatory care, involving an aggressive approach to care, which values saving lives at all costs, without taking into account the possible suffering and long-term consequences. Aspects such as moral sensitivity and moral courage play an important role in ethical decision-making related to advanced dementia. Investigations of clinical decision-making that include the cognitive biases and ethical considerations of practitioners might advance the comprehensive understanding of the clinical decision-making process related to care of patients with advanced dementia and promote the quality of care given to this population. (shrink)

Partial proceedings of the 17th World Congress, International Association for Philosophy of Law and Social Philosophy, Bologna, 1995.

Aus dem Inhalt: Views from the North: Hans Petter Graver: Law, Justice and the State: Nordic Perspectives u Jacob Dahl Rendtorff: The Danish Welfare State: Philosophical Ideals and Systemic Reality u Sigri!Dur *orgeirsdottir: Feminist Ethics and Feminist Politics u Kuellike Lengi: The Situation of Human Rights in Estonia u Einar Palsson: Pythagoras and Early Icelandic Law u Law, Discourse and Rationality: Mats Flodin: Internal and External Rationality of Legal Systems u Logi Gunnarsson: A Discourse About Discourse u Hjordi!s Hakonardottir: Legal (...) Language: A Tool of Justice u Ghita Holmstrom-Hintikka: On the Use of Expert Witness in Legal Reasoning and Inquiry u Law, State and Nation: Agust H. Ing*orsson: Democracy, Bureaucracy and Marginalization of the State u Aleksander Peczenik: Law-State, Legal Certainty and Legitimacy of Law u Ove K. Pedersen/Sverre Raffnsoe: Reorganizing Society u Juha Raikka: Mill on National Sentiment u Pall Skulason: Concepts of the State and Classes of Value u Problems of Law and Rights: Britt-Mari Blegvad: How to Cope With Uncertainty: Trust and Law u Jon Wetlesen: Animal Rights or Human Duties?. (shrink)

Two significant, apparently unrelated, trends have emerged in American society and medicine. First, American medicine is reexamining its approach to dying. The Institute of Medicine, the American Medical Association and private funding organizations have recognized that too many dying people suffer from pain and other distress that clinicians can prevent or relieve. Second, this past decade has marked a sharp increase in the number of physicians prosecuted for criminal negligence based on arguably negligent patient care. The (...) case often cited as a watershed is People u. Einaugfer, which involved a New York nursing home patient whose physician was convicted in 1993 of two criminal misdemeanors after he ordered an elderly dialysis patient to be tube fed through a peritoneal dialysis Catheter.How is the growing awareness of dying patients’ pain and the increasing willingness of prosecutors to charge physicians with crimes connected? Pain at the end of life is frequently treated with narcotics, prescription drugs that are closely regulated by state and federal law. That complex web of laws—and a growing fear of legal sanctions—has deterred physicians from prescribing controlled substances. As those legal sanctions move from disciplinary actions to criminal charges, physicians’ fears may expand. (shrink)

Two significant, apparently unrelated, trends have emerged in American society and medicine. First, American medicine is reexamining its approach to dying. The Institute of Medicine, the American Medical Association and private funding organizations have recognized that too many dying people suffer from pain and other distress that clinicians can prevent or relieve. Second, this past decade has marked a sharp increase in the number of physicians prosecuted for criminal negligence based on arguably negligent patient care. The (...) case often cited as a watershed is People u. Einaugfer, which involved a New York nursing home patient whose physician was convicted in 1993 of two criminal misdemeanors after he ordered an elderly dialysis patient to be tube fed through a peritoneal dialysis Catheter.How is the growing awareness of dying patients’ pain and the increasing willingness of prosecutors to charge physicians with crimes connected? Pain at the end of life is frequently treated with narcotics, prescription drugs that are closely regulated by state and federal law. That complex web of laws—and a growing fear of legal sanctions—has deterred physicians from prescribing controlled substances. As those legal sanctions move from disciplinary actions to criminal charges, physicians’ fears may expand. (shrink)

Making particular use of Shale’s analysis, this paper discusses the notion of leadership in the context of palliative medicine. Whilst offering a critical perspective, I build on the philosophy of palliative care offered by Randall and Downie and suggest that the normative structure of this medical speciality has certain distinctive features, particularly when compared to that of medicine more generally. I discuss this in terms of palliative medicine’s distinctive morality or ethos, albeit one that (...) should still be seen in terms of medical morality or the ethos of medicine. I argue that, in the context of multi-disciplinary teamwork, the particular ethos of palliative medicine means that healthcare professionals who work within this speciality are presented with distinct opportunities for leadership and the dissemination of the moral and ethical norms that guide their practice. I expand on the nature of this opportunity by further engaging with Shale’s work on leadership in medicine, and by more fully articulating the notion of moral ethos in medicine and its relation to the more formal notion of medical ethics. Finally, and with reference to the idea of medical education as both on going and as an apprenticeship, I suggest that moral and ethical leadership in palliative medicine may have an inherently educational quality and a distinctively pedagogical dimension. The nature of palliative medicine is such that it often involves caring for patients who are still receiving treatment from other specialists. Whilst this can create tension, it also provides an opportunity for palliative care professionals to disseminate the philosophy that underpins their practice, and to offer leadership with regard to the moral and ethical challenges that arise in the context of End of Life Care. (shrink)

In the clinical practice of palliative medicine, recommended communication models fail to approximate the truth of suffering associated with an impending death. I provide evidence from patients' stories and empiric research alike to support this observation. Rather than attributing this deficiency to inadequate training or communication skills, I examine the epistemological premises of the biomedical language governing the patient-physician communication. I demonstrate that the contemporary biomedicine faces a fundamental aporetic occlusion in attempting to examine death. This review asserts (...) that the occlusion defines, rather than simply complicating, palliative care. Given the defining place of aporia in the care for the dying, I suggest that this finding shape the clinicians' responses to the needs of patients in clinical care and in designing palliative research. Lastly, I briefly signal that a genuinely apophatic voice construing the occlusion as a mystery rather than an aporia may be superior to the present communication and empathy models. (shrink)

In the present paper I try to show that ethical principles of medical activities in general can be adequately applied to medical activities for the patient in his terminal stage. For this objective, I shall argue first what are the principles and rules of medical activities in general, and then show how these can be applied to palliative medicine.

The First International Workshop brings together researchers from the theoretical ends of the logic programming and artificial intelligence communities to discuss their mutual interests. Logic programming deals with the use of models of mathematical logic as a way of programming computers, where theoretical AI deals with abstract issues in modeling and representing human knowledge and beliefs. One common ground is nonmonotonic reasoning, a family of logics that includes room for the kinds of variations that can be found in human reasoning. (...) Topics covered: Stable Semantics. Default Logic. AutoEpistemic Logic. Truth Maintenance Systems. Implementation Issues. Diagnosis. Applications. Inheritance Reasoning. Logics of Belief. Inconsistency and Non-Monotonicity. (shrink)

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary (...) hospital in Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment. (shrink)

This paper explores ethical issues relating to the management of patients who are terminally ill and unable to maintain their own nutrition and hydration. A policy of sedation without hydration or nutrition is used in palliative medicine under certain circumstances. The author argues that this policy is dangerous, medically, ethically and legally, and can be disturbing for relatives. The role of the family in management is discussed. This issue requires wide debate by the public and the profession.

오늘날 발달한 의학기술로 인해 우리는 연명치료와 호스피스 · 완화의료 등 죽음과 관련된 의료, 즉 웰다잉(Well-dying)의 문제에 관심을 가지게 되었다. 웰다잉 문제의 핵심은 임종기 환자의 삶의 질뿐만 아니라 죽음의 질의 문제이다. 이러한 문제들은 우리에게 연명치료 중단 및 호스피스・완화의료의 증대와 관련하여 법적, 제도적 과제와 함께 임종기 환자의 죽음교육의 문제를 제기한다. 이 논문은 연명치료 중단과 호스피스 · 완화의료에서 비종교인에 대한 죽음교육의 문제를 다루고 있다. 비종교인들이 내세 관념 없이도 평안한 죽음을 맞이하기 위해서 해결해야 할 과제는 죽음의 두려움을 어떻게 극복하는가의 문제이다. 이 논문은 비종교인의 죽음에 (...) 대한 두려움을 극복하는 문제를 니체와 에피쿠로스의 철학을 통해 살펴본다. 니체는 “삶을 완성시키는 죽음”, “주인으로서 당당하게 맞이하는 죽음”을 위해 이성적이고 자유로운 죽음을 강조한다. 이러한 니체의 죽음관을 통해 연명치료 중단의 철학적 근거를 살펴보고 ‘죽음의 의료화’에 의해 야기되는 현대인의 소외된 죽음에 대해 니체의 사상을 통해 대안을 제시한다. 또한 내세 관념이 없어도 죽음에 대해 두려워할 근거가 없음을 논거를 통해 제시하는 에피쿠로스의 철학을 살펴본다. 에피쿠로스는 죽음에 대한 두려움으로부터 우리를 해방시켜주고, 니체는 죽음이 삶의 끝이 아니라 삶의 완성임을 일깨워준다. 우리는 이 두 철학자의 가르침을 통해 연명치료 중단과 호스피스 · 완화의료를 선택할 때의 정신적 위안을 얻을 수 있을 것이다. 이러한 철학적 위안이 환자 및 환자 가족에 대한 의미 있는 죽음교육의 근거가 될 것이다. (shrink)

The difficulties of undertaking good quality effectiveness research in palliative medicine are well documented. Much of the ethical literature in this area focuses on the vulnerability of the palliative care population. It is clear that a wider ethical approach will need to be used to justify research in the terminally ill. Some themes of ethical thought are underutilised in considering the ethics of palliative care research. Three arguments to justify the need for effectiveness research in (...) class='Hi'>palliative care should be highlighted: there is evidence of an untapped altruism amongst the population of palliative care patients who would be keen to be involved in such research; traditional Aristotelean and Thomistic virtue ethics would point to the need to gain knowledge in and of itself, but especially in palliative medicine for the benefit of patients: virtue also accrues in the acquisition of a stock of research experience which in turn makes further research feasible; most compellingly, justice would dictate that palliative treatments are effective, that futile or useless treatments are avoided and that patients are not party to “n of 1” trials by default. The current state of the evidence base of effectiveness in palliative care leads us to the uncomfortable position where patients are in precisely the position of being unwitting participants in “n of 1” clinical trials by default, without their explicit consent. (shrink)

ZusammenfassungDieser Beitrag ist Teil des Forums COVID-19: Perspektiven in den Geistes- und Sozialwissenschaften. Die Figur des Pestarztes mit der schnabelförmigen Maske ist heute die am häufigsten zitierte Bildmetapher für die Pest. Es verwundert daher nicht, dass die Pestarztmaske in der Sammlung des Deutschen Medizinhistorischen Museums in Ingolstadt zu den am meisten nachgefragten Objekten und Bildmotiven des Hauses gehört. Der Forumsbeitrag spürt der Figur des Pestarztes auf mehreren Ebenen nach: Zunächst wird anhand zeitgenössischer Text- und Bildquellen diskutiert, welche Art von Schutzkleidung (...) zu Seuchenzeiten empfohlen wurde und welche Rolle das schnabelförmige Maskenattribut dabei spielte. Anschließend wird das Ingolstädter Exemplar unter die Lupe genommen, hinsichtlich seines Materials und seiner Machart auf Authentizität und Praktikabilität hin untersucht und mit dem Exemplar des Deutschen Historischen Museums in Berlin verglichen.Das Ergebnis: Die frühesten Belege für die Verwendung dieser speziellen Art von Schutzkleidung stammen aus Italien und Südfrankreich und datieren aus der Mitte des 17. Jahrhunderts. Für Mitteleuropa gibt es keinerlei Nachweise dafür, dass zu Pestzeiten jemals eine solche Schnabelmaske in Gebrauch gewesen wäre. Und die Pestarztmasken in Ingolstadt und Berlin? Bei kritischer Betrachtung finden sich bei beiden Masken Details, die gegen eine Verwendung als Schutzkleidung sprechen. Ob es sich dabei um ältere, historisierende Nachbauten oder bewusste Fälschungen handelt, muss offen bleiben.This paper is part of Forum COVID-19: Perspectives in the Humanities and Social Sciences. The figure of the plague doctor with the beak mask has become the symbol of the plague par excellence. It’s little wonder that the plague mask in the collection of the German Museum of the History of Medicine in Ingolstadt is one of the museum’s most popular objects and motifs. This forum paper investigates the figure of the plague doctor on several levels: first, it analyses contemporary textual and image sources in regard to protective clothing used in times of plague and the respective role of the beak-like part of the mask. Then it takes a close look at the Ingolstadt specimen. By examining the mask’s materiality and fabrication, questions of its authenticity and practicability are raised. Finally, the Ingolstadt mask is compared with the specimen at the German Historical Museum in Berlin.The conclusion: the beak mask is not mentioned before the mid-seventeenth century, and then only in Italy and Southern France. There is no proof at all of its use during plague outbreaks in Middle Europe. And the specimens in Ingolstadt and Berlin? Both masks present details which suggest that they were not used as protective clothing at all. We do not know, however, if they were produced as replicas for historic reasons or as fakes for the modern art market. (shrink)