Americans who are afraid of living for many years with Alzheimer's might seek a way to end their lives early, when their dementia has just entered the moderate phase. There is no legal process for doing so. In this paper I argue that advance directives, in particular, are not a legal solution for those who prefer to die rather than suffer years of dementia. The problem is that an advance directive only works to hasten death when there (...) is a life-threatening illness for which one can refuse treatment; more often than not, Alzheimer's kills the self long before it kills the body. (shrink)

Research Objective: This study focuses on ADs in the Netherlands and introduces a cross-cultural perspective by comparing it with other countries. Methods: A questionnaire was sent to a panel comprising 1621 people representative of the Dutch population. The response was 86%. Results: 95% of the respondents didn't have an AD, and 24% of these were not familiar with the idea of drawing up an AD. Most of those familiar with ADs knew about the Advanced Euthanasia Directive (AED, 64%). Both (...) low education and the presence of a religious conviction that plays an important role in one's life increase the chance of not wanting to draw up an AD. Also not having experienced a request for euthanasia from someone else, and the inconceivability of asking for euthanasia yourself, increase the chance of not wanting to draw up an AD. Discussion: This study shows that the subjects of palliative care and end-of-life-decision-making were very much dominated by the issue of euthanasia in the Netherlands. The AED was the best known AD; and factors that can be linked to euthanasia play an important role in whether or not people choose to draw up an AD. This differentiates the Netherlands from other countries and, when it comes to ADs, the global differences between countries and cultures are still so large that the highest possible goals, at this moment in time, are observing and possibly learning from other cultural settings. (shrink)

Objectives: After years of public discussion too little is still known about willingness to accept the idea of writing an advance directive among various groups of people in EU countries. We investigated knowledge about and willingness to accept such a directive in cancer patients, healthy controls, physicians, and nursing staff in Germany.Methods: Cancer patients, healthy controls, nursing staff, and physicians were surveyed by means of a structured questionnaire.Results: Only 18% and 19% of the patients and healthy controls (...) respectively, and 10% of the medical staff had written an advance directive. However, 50–81% of those surveyed indicated that they wished to write one. This intention was associated with deteriorating health . Only 29% of the healthy controls and 43% of the patients knew about the possibility of appointing a health care proxy. A majority in all groups believed that advance directives may influence the course of treatment , yet half of those surveyed in all groups fear that patients could be pressurised into writing an advance directive, and 38–65% thought that relatives could abuse such documents.Conclusions: Only a minority of the participants had written an advance directive and knew about the possibility of authorising a health care proxy. Deteriorating health was associated with increasing willingness to make a directive. Despite a majority belief that advance directives may influence treatment at the end of life, other factors limit their employment, such as fear of abuse. (shrink)

The dilemma of whether and how to disclose a diagnosis of cancer or of any other terminal illness continues to be a subject of worldwide interest. We present the case of a 62-year-old Japanese woman afflicted with advanced gall bladder cancer who had previously expressed a preference not to be told a diagnosis of cancer. The treating physician revealed the diagnosis to the family first, and then told the patient: "You don't have any cancer yet, but if we don't treat (...) you, it will progress to a cancer". In our analysis, we examine the role of family consent, communication patterns (including ambiguous disclosure), and advance directives for cancer disclosure in Japan. Finally, we explore the implications for Edmund Pellegrino's proposal of "something close to autonomy" as a universal good. (shrink)

Seeks to provide a new direction for the advancement of political theory. This essay deals with the uneasy relationship between liberty and equality; the nature of democracy and the formation of political consensus; and the weakness of our understanding of class.

Computability theory originated with the seminal work of Gödel, Church, Turing, Kleene and Post in the 1930s. This theory includes a wide spectrum of topics, such as the theory of reducibilities and their degree structures, computably enumerable sets and their automorphisms, and subrecursive hierarchy classifications. Recent work in computability theory has focused on Turing definability and promises to have far-reaching mathematical, scientific, and philosophical consequences. Written by a leading researcher, Computability Theory provides a concise, comprehensive, and authoritative introduction to contemporary (...) computability theory, techniques, and results. The basic concepts and techniques of computability theory are placed in their historical, philosophical and logical context. This presentation is characterized by an unusual breadth of coverage and the inclusion of advanced topics not to be found elsewhere in the literature at this level. The book includes both the standard material for a first course in computability and more advanced looks at degree structures, forcing, priority methods, and determinacy. The final chapter explores a variety of computability applications to mathematics and science. Computability Theory is an invaluable text, reference, and guide to the direction of current research in the field. Nowhere else will you find the techniques and results of this beautiful and basic subject brought alive in such an approachable and lively way. (shrink)

State governments provide preprinted advance directive forms to the general public. However, many adults in the United States (US) lack the skills necessary to read and comprehend health care-related materials. In this study, we sought to determine the readability of state government-sponsored advance directive forms.

The justification for advance directives is grounded in the notion that they extend patient autonomy into future states of incompetency through patient participation in decision making about end-of-life care. Four objections challenge the necessity and sufficiency of individual autonomy, perceived to be a defining feature of liberal philosophical theory, as a basis of advance care planning. These objections are that the liberal concept of autonomy (i) implies a misconception of the individual self, (ii) entails the denial of values (...) of social justice, (iii) does not account for justifiable acts of paternalism, and (iv) does not account for the importance of personal relationships in the advance care planning process. The last objection is especially pertinent in light of recent empirical research highlighting the importance of personal relationships in advance care planning. This article examines these four objections to autonomy, and the liberal theoretical framework with which it is associated, in order to re-evaluate the philosophical basis of advance care planning. We argue that liberal autonomy (i) is not a misconceived concept as critics assume, (ii) does not entail the denial of values of social justice, (iii) can account for justifiable acts of paternalism, though it (iv) is not the best account of the value of personal relationships that arise in advance care planning. In conclusion, we suggest that liberalism is a necessary component of a theoretical framework for advance care planning but that it needs to be supplemented with theories that focus explicitly on the significance of personal relationships. (shrink)

Debates about medical futility first emerged in the scholarly literature during the 1990s after empirical studies showed the widespread use of medical interventions offering no reasonable chance of...

Background Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians’ decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients’ ability to (...) comprehend complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored. Methods Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents’ perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test. Results Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient’s AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to “pass away in peace.” Few (17%) would forgo an AD following a family’s request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD. Conclusions Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient’s initial wishes and preferences expressed by the AD. (shrink)

John Harris is one of the prominent philosophers and bioethicists of our time. He has published tens of books and hundreds of papers throughout his professional life. This paper aims to take a ‘deep-look’ at Harris' works to argue that it is possible to find some principles of Islamic ethics in Harrisian philosophy, namely in his major works, as well as in his personal life. This may be surprising, or thought of as a ‘big’ and ‘groundless’ claim, since John Harris (...) has nothing to do with any religion in his intellectual works. The major features of Harrisian philosophy could be defined as consequentialism or utilitarianism with liberal overtones. Despite some significant and fundamental differences in the application of principles (ie, abortion, euthanasia), the similarities between the major principles in Harrisian philosophy and Islamic ethics are greater at some points than the similarities between Islamic ethics and some other religious ethics (ie, Christian, Judaism). In this study I compare Harrisian teachings with major Islamic principles on ‘Responsibility’, ‘Side-effects and Double-effects’, ‘Equality’, ‘Vicious choice, guilt and innocence’, ‘Organ transplantation and property rights’ and ‘Advance directives’. (shrink)

Advances in life-saving technologies in the past few decades have challenged our traditional understandings of death. Traditionally, death was understood to occur when a person stops breathing, their heart stops beating and they are cold to the touch. Today, physicians determine death by relying on a diagnosis of ‘total brain failure’ or by waiting a short while after circulation stops. Evidence has emerged, however, that the conceptual bases for these approaches to determining death are fundamentally flawed and depart substantially from (...) the established biological conception of death. We argue that the current approach to determining death consists of two different types of unacknowledged legal fictions. These legal fictions were developed for practices that are largely ethically legitimate but need to be reconciled with the law. The considerable debate over the determination of death in the medical and scientific literature has not informed the public that vital organs are being procured from still-living donors and it seems unlikely that this information can remain hidden for long. Given the instability of the status quo and the difficulty of making the substantial legal changes required by complete transparency, we argue for a second-best policy solution: acknowledging the legal fictions involved in determining death to move in the direction of greater transparency. This may someday result in more substantial legal change to directly confront the challenges raised by life-sustaining and life-preserving technologies without the need for fictions. (shrink)

The field of clinical bioethics strongly advocates for the use of advance directives to promote patient autonomy, particularly at the end of life. This paper reports a study of clinical bioethicists’ perceptions of the professional consensus about advance directives, as well as their personal advance care planning practices. We find that clinical bioethicists are often sceptical about the value of advance directives, and their personal choices about advance directives often deviate from what clinical ethicists acknowledge (...) to be their profession’s recommendations. Moreover, our respondents identified a pluralistic set of justifications for completing treatment directives and designating surrogates, even while the consensus view focuses on patient autonomy. Our results suggest important revisions to academic discussion and public-facing advocacy about advance care planning. (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)

After years of failure, in November 2007 primate embryonic stem cells were derived by somatic cellular nuclear transfer, also known as therapeutic cloning. The first embryo transfer for human reproductive cloning purposes was also attempted in 2006, albeit with negative results. These two events force us to think carefully about the possibility of human cloning which is now much closer to becoming a reality. In this paper we tackle this issue from two sides, first summarising what scientists have achieved so (...) far, then discussing some of the ethical arguments in favour and against human cloning which are debated in the context of policy making and public consultation. Therapeutic cloning as a means to improve and save lives has uncontroversial moral value. As to human reproductive cloning, we consider and assess some common objections and failing to see them as conclusive. We do recognise, though, that there will be problems at the level of policy and regulation that might either impair the implementation of human reproductive cloning or make its accessibility restricted in a way that could become difficult to justify on moral grounds. We suggest using the time still available before human reproductive cloning is attempted successfully to create policies and institutions that can offer clear directives on its legitimate applications on the basis of solid arguments, coherent moral principles, and extensive public consultation. (shrink)

It is customary to distinguish experimental from purely observational sciences. The former include physics and molecular biology, the latter astronomy and palaeontology. Experiments involve actively intervening in the course of nature, as opposed to observing events that would have happened anyway. When a molecular biologist inserts viral DNA into a bacterium in his laboratory, this is an experiment; but when an astronomer points his telescope at the heavens, this is an observation. Without the biologist’s handiwork the bacterium would never have (...) contained foreign DNA; but the planets would have continued orbiting the sun whether or not the astronomer had directed his telescope skyward. The observational/experimental distinction would probably be difficult to make precise 1, as the notion of an ‘intervention’ is not easily defined, but it is intuitively fairly clear, and is frequently invoked by scientists and historians of science. Experimentation, or ‘putting questions to nature’, is often cited as a hallmark of the modern scientific method, something that permitted the enormous advances of the last 350 years. And it is sometimes said that the social sciences lag behind the natural because controlled experiments cannot be done so readily in the former. Moreover in certain sciences, e.g. epidemiology, students are explicitly taught that experimental data is preferable to observational data, particularly for doing causal inference. So the distinction between observational and experimental science has quite wide currency, and is often regarded as methodologically significant. Surprisingly, mainstream philosophy of science has had rather little to say about the observational/experimental distinction. 2 For example, discussions of confirmation usually invoke a notion of ‘evidence’, to be contrasted with ‘theory’ or ‘hypothesis’; the aim is to understand how the evidence bears on the hypothesis. But whether this ‘evidence’ comes from observation or experiment generally plays no role in the discussion; this is true …. (shrink)

It has been argued that the inherent risks of advance directives made by healthy people are disproportionate to the potential benefits, particularly if the directive is implementable in cases of reversible mental incapacity. This paper maintains that the evidence for such a position is lacking. Furthermore, respect for the principle of autonomy requires that individuals be permitted to make risky choices about their own lives as long as these do not impinge on others. Even though health professionals have (...) an obligation to try and ensure that patients have appropriate information about possible future treatment options, they cannot predict and describe every eventuality but nor can they disregard firm decisions knowingly made on the basis of incomplete information by competent adults. To attempt to do so would be to reinstate notions of medical paternalism which are contrary to current public expectations. (shrink)

Advances in genetic research and technology can have a profound impact on identity and family dynamics when genetic findings disrupt deeply held assumptions about the nuclear family. Ancestry tracing and paternity testing present parallel risks and opportunities. As these latter uses are now available over the internet directly to the consumer, bypassing the genetic counselor, consumers need adequate warning when making use of these new modalities.

The Dutch law states that a physician may perform euthanasia according to a written advance euthanasia directive when a patient is incompetent as long as all legal criteria of due care are met. This may also hold for patients with advanced dementia. We investigated the differing opinions of physicians and members of the general public on the acceptability of euthanasia in patients with advanced dementia.

Attempts to think anew about philosophical questions from the perspective of breath and breathing. As a physiological or biological matter, breath is mostly considered to be mechanical and thoughtless. By expanding on the insights of many religions and therapeutic practices, which emphasize the cultivation of breath, the contributors argue that breath should be understood as fundamentally and comprehensively intertwined with human life and experience. Various dimensions of the respiratory world are referred to as “atmospheres” that encircle and connect human existence, (...) coexistence, and the world. Drawing from a number of traditions of breathing, including from Indian and East Asian religion and philosophy, the book considers breath in relation to ontological, hermeneutical, phenomenological, ethical, and aesthetic concerns in philosophy. The wide-ranging topics include poetry, theater, environmental issues and health, feminism, and media studies. “Atmospheres of Breathing, the first collection of its kind, explores an emerging ‘respiratory philosophy’ of great consequence for philosophy and other fields. Its rich and diverse essays, many written by the pioneers of this radically new direction, show the deep historical and intercultural roots of such a philosophy, ranging from treatments of forerunners like Zhuangzi and Heraclitus to contemporary theorists of breathing such as Abram and Kleinberg-Levin. Presented here is the vision of innovative ways in which philosophy, on its own or inspired by spiritual practices, can bring breathing into the center of its concern. This is a landmark book that scintillates with brilliant and original insights. If taken as seriously as it deserves, this book has the potential to revolutionize contemporary and future thought.” — Edward S. Casey, author of The World at a Glance and The World on Edge “Air, the misunderstood element, finds ways and means of advancing to places where no one reckons with its presence; and, more significantly, it makes space on its own strength for strange places where there were previously none.” — Peter Sloterdijk. (shrink)

The economic and socio-political impact of multinational corporations (MNCs) on third world countries has been the subject of intense debate and controversy leading to charges of exploitation and colonization on the one hand, and demands for codes of conduct on the other. This article examines the working of one of the most comprehensive of such codes under the most reprehensible political conditions, i.e., the operations of U.S.—based multinational corporations in South Africa under the acgis of the Sullivan Principles. It is (...) argued that despite the best intentions, and considerable social goodwill, the Sullivan Principles were seriously flawed both as to goals and as to means of achieving them. Finally, it suggests a new approach to developing standards of MNC behavior in third world countries which emphasizes those areas of activities that are directly under the control of MNCs, and offers targets of achievement to which MNCs can and should be held accountable.The paper is a revised and expanded version of a keynote speech delivered by the author at the First Biannual Conference on Advances in Management, Orlando, Florida March 25–28, 1992. (shrink)

The question of when we have justification for overriding ordinary, everyday decisions of persons with dementia is considered. It is argued that no single criterion for competent decision-making is able to distinguish reliably between decisions we can legitimately override and decisions we cannot legitimately override.

Ethical decision-making descriptive theoretical models often conflict with each other and typically lack comprehensiveness. To address this deficiency, a revised EDM model is proposed that consolidates and attempts to bridge together the varying and sometimes directly conflicting propositions and perspectives that have been advanced. To do so, the paper is organized as follows. First, a review of the various theoretical models of EDM is provided. These models can generally be divided into rationalist-based ; and non-rationalist-based. Second, the proposed model, called (...) ‘Integrated Ethical Decision Making,’ is introduced in order to fill the gaps and bridge the current divide in EDM theory. The individual and situational factors as well as the process of the proposed model are then described. Third, the academic and managerial implications of the proposed model are discussed. Finally, the limitations of the proposed model are presented. (shrink)

Advance patient directives are various forms of anticipatory medical directives made by competent individuals for the eventuality of future incompetence. They are therefore appropriate instruments for competent patients in the early stage of Alzheimer's disease to document their self-determined will in the advanced stages of dementia. Theoretical objections have been expressed against the concept of advance patient directives (problems of authenticity and identity) which, however, cannot negate the fundamental moral authority of advance patient directives. Therefore, patients, family (...) members, and physicians should make use of the appropriate form of advance directive as part of common treatment and care planning. Advance directives, when utilized intelligently, represent appropriate instruments for shared decision-making by patient, family members and physician. They should be utilized to a greater extent, particularly for the treatment planning of demented patients. (shrink)

_Psychoanalysis Beyond the End of Metaphysics_ offers a new paradigm approach which advocates reengaging the importance of metaphysics in psychoanalytic theorizing. The emergence of the relational trend has witnessed a revitalizing influx of new ideas, reflecting a fundamental commitment to the principle of dialogue. However, the transition towards a more pluralistic discourse remains a work in progress, and those schools of thought not directly associated with the relational shift continue to play only a marginal role. In this book, Robin S. (...) Brown argues that for contemporary psychoanalysis to more adequately reflect a clinical ethos of pluralism, the field must examine the extent to which a theoretical commitment to the notion of relationship can grow restrictive. Suggesting that in the very effort to negotiate theoretical biases, psychoanalytic practice may occlude a more adequate recognition of its own evolving assumptions, Brown proposes that the profession’s advance requires a return to first principles. Arguing for the fundamental role played by faith in supporting the emergence of consciousness, this work situates itself at the crossroads of relational, Jungian, and transpersonal approaches to the psyche. Psychoanalysis Beyond the End of Metaphysics will be of significant interest to all psychodynamically oriented clinicians, alongside scholars of depth psychology and the philosophy of mind. It will also be helpful to advanced and postgraduate students of psychoanalysis seeking to orient themselves in the field at present. (shrink)

The leading art theorist takes on art in the age of the Internet In the early twentieth century, art and its institutions came under critique from a new democratic and egalitarian spirit. The notion of works of art as sacred objects was decried and subsequently they would be understood merely as things. This meant an attack on realism, as well as on the traditional preservative mission of the museum. Acclaimed art theorist Boris Groys argues this led to the development of (...) “direct realism”: an art that would not produce objects, but practices (from performance art to relational aesthetics) that would not survive. But for more than a century now, every advance in this direction has been quickly followed by new means of preserving art’s distinction. In this major new work, Groys charts the paradoxes produced by this tension, and explores art in the age of the thingless medium, the Internet. Groys claims that if the techniques of mechanical reproduction gave us objects without aura, digital production generates aura without objects, transforming all its materials into vanishing markers of the transitory present. (shrink)

The paper analysis the strategies and concepts developed in the world in modern directions: innova- tive economy, digital economy, artificial intelligence, Industry 4.0 and others. The problem is to determine the initial fundamental parameters of order and their prospects in the global world, the definition and principles of artificial intel- ligence systems, its structure and important aspects and principles of future science and technology in analysis and synthesis based on synergetic approaches, innovative, information, converged technologies, taking into account the design (...) of future and viable and safe and sustainable development in the context of Industry 4.0, digital economy and Society 5.0. The general scheme of the integrated model of sustainable and socio-humanitarian development in the global system is proposed, which the authors call the noosphere model of sustainable and safe development as an important fundamental platform for the design and creation of AIS. In the XXI century education, science and innova- tive technologies becomes the «basis» of the spiritual and material reproduction of man, transforming the society of the XXI century into an educational society, ensures compliance with the law of advanced development of human quality, quality of social intelligence and quality of educational systems in society. noosphere evolution. Industry 4.0 is the next stage in the digitalization of production technologies with the accelerated introduction of new developments and cyberphysical systems, which is changing business models. Accordingly, Industry 4.0 as a separate segment of digital manufacturing technologies takes its place among other digital sectors. The analysis of the Strategies and Concepts developed in the world in modern directions: innovative economy, digital economy, artificial intelli- gence, Industry 4.0 and others is carried out in the work. The problem is to determine the initial fundamental para- meters of order and their prospects in the global world, the definition and principles of artificial intelligence systems, its structure and important aspects and principles of future science and technology in analysis and synthesis ba- sed on synergetic approaches, innovative, information, converged technologies, taking into account the design of future and viable and safe and sustainable development in the context of Industry 4.0, DE and Society 5.0. The main scientific and technological factors in the 21st century will be the development of: Artificial Intelligence, Nano Technologies, Bio-Media Technologies, Cognitive Technologies and Socio-Humanitarian Technologies. More specifically – this is the modern development of Innovative Technologies: «NBIC SH». Therefore, it is necessary to note the importance of taking into account the principle of I2K2+SH, ie: Intellectualization, Integration, Convergence, Coevolution and Socio- humanitarian technologies. It is important and necessary to take into account modern principles of designing a su- stainable and secure AIS and solving the problem of Harmonization between 2 worlds: Real and Virtual, especially in their hybridization. Our immediate future is a hybrid nonlinear world. Note that digitalization, artificial intelligence and robotics will be the main drivers of global economic growth by 2030E. An important paradigm and platform is the Integrated System: for Industry 4.0, DE and AI, taking into account the complex principle of I2K2+SH. If the transition of the Ukrainian economy to an innovative one does not take place in the next 3-5 years, Ukraine will remain in the backyard of civilization. (shrink)

This article explores Herodian's History of the Roman Empire alongside Chariton's novel Callirhoe with an eye to how the minds of collective entities are represented and function in the two narratives. It argues that Chariton, unlike Herodian, elaborates on the diversity of emotions that characterizes a specific collective experience and has groups use direct speech throughout. These choices add vividness to the narrative and intensify the fictional sensationalism and dramatic character of the novel. It also shows that, whereas collectives in (...) Chariton's narrative are primarily designed to highlight a specific characteristic of a hero, dramatize an event and enhance suspense, in Herodian's historiography they are an integral part of the plot and central to his historical analysis of contemporary political and social world. This article offers a new analytical tool geared towards the development of a poetics of the collective in ancient narrative as well as a poetics of fictional and factual narration in antiquity, and advances our understanding of the complex relationship between ancient historiography and novelistic writing. (shrink)

Over the last decades, empirical research on subjective well-being in the social sciences has provided a major new stimulation of the discourse on individual happiness. Recently this research has also been linked to economics where reported subjective well-being is often taken as a proxy measure for individual welfare. In our review, we intend to provide an evaluation of where the economic research on happiness stands and of three directions it might develop. First, it offers new ways for testing the basic (...) assumptions of the economic approach and for going about a new understanding of utility. Second, it provides a new possibility for the complementary testing of theories across fields in economics. Third, we inquire how the insights gained from the study of individual happiness in economics affect public policy. (shrink)

Persons with dementia often prefer to participate in decisions about their health care, but may be prevented from doing so because healthcare decision-making law facilitates use of advance directives or surrogate decision makers for persons with decisional impairments such as dementia. Federal and state disability law provide alternative decision-making models that do not prevent persons with mild to moderate dementia from making their own healthcare decisions at the time the decision needs to be made. In order to better promote (...) autonomy and wellbeing, persons with dementia should be accommodated and supported so they can make their own healthcare decisions. (shrink)

In January 2016, Medicare began reimbursing clinicians for time spent engaging in advance care planning with their patients or patients’ surrogates. Such planning involves discussions of the care an individual would want to receive should he or she one day lose the capacity to make health care decisions or have conversations with a surrogate about, for example, end‐of‐life wishes. Clinicians can be reimbursed for face‐to‐face explanation and discussion of care and advance directives and for the completion of (...) class='Hi'>advance care planning forms. Although it seems that political barriers to reimbursement for such planning have largely faded, the Medicare policy's impact on provider billing practices appears to be limited, suggesting other barriers to clinician engagement in advance care planning. Additionally, the effects of this policy on patient behavior and the clinician‐patient relationship are not yet known. (shrink)

BackgroundHospitalized older adults frequently have impaired cognition and must rely on surrogates to make major medical decisions. Ethical standards for surrogate decision making are well delineated, but little is known about what factors surrogates actually consider when making decisions.ObjectivesTo determine factors surrogate decision makers consider when making major medical decisions for hospitalized older adults, and whether or not they adhere to established ethical standards.DesignSemi-structured interview study of the experience and process of decision making.SettingA public safety-net hospital and a tertiary referral (...) hospital in a large city in the Midwest United States.ParticipantsThe study included 35 surrogates with a recent decision-making experience for an inpatient aged 65 or older.MeasurementsThe key factors that surrogates considered when making decisions. Interview transcripts were coded and analyzed using the grounded theory method of qualitative analysis.ResultsSurrogates considered patient-centered factors and surrogate-centered factors. Patient-centered factors included: respecting the patient’s input, using past knowledge of the patient to infer the patient’s wishes, and consider ing what is in the patient’s best interests. Some surrogates expressed a desire for more information about the patient’s prior wishes. Surrogate-centered factors included: surrogate’s wishes as a guide, surrogate’s religious beliefs and/or spirituality, surrogate’s interests, and family consensus.ConclusionOur study indicates that surrogate decision making is more complex than the standard ethical models, which are limited to considerations of the patient’s autonomy and beneficence. Because surrogates also imagine what they would want under the circumstances and consider their own needs and preferences, models of surrogate decision making must account for these additional considerations. Surrogates’ desire for more information about patients’ preferences suggests a need for greater advance care planning. (shrink)

Privacy by Design, a globally accepted framework for personal data management and privacy protection, advances the view that privacy cannot be assured solely by compliance with regulatory frameworks but must become an organisation’s default mode of operation. We are proposing a similar template for the research ethics review process. The Research Ethics by Design framework involves research ethics committees engaging researchers during the design phase of the proposal so that ethical considerations may be directly embedded in the science as opposed (...) to being viewed as addendums after the fact. This collaborative research design proposal results in the establishment of a culture of ethical research rather than research with ethical oversight. Both researchers and research ethics committees come to view the review process as one in which individual protection and collective benefit co-exist in a doubly-enabling positive-sum manner. (shrink)

Advances in science and technology has led to the rise of different issues in relation to human life and security as well as the environment. These issues also paved the way for the field of Bioethics with its principles aiming to uphold moral standards on these issues. This study aimed to test and modify the theoretical models of the factors influencing the conviction schemas of BS Biology Bioethics students of a state university toward bioethical issues. One hundred ten (110) undergraduate (...) students were pre-tested and post-tested for comprehension of Bioethics principles, moral disengagement, and convictions toward bioethical issues. Identified personal factors were also retrieved for testing. Results showed that the Bioethics course has increased the participants’ comprehension of Bioethics principles, moral disengagement, and convictions. Stepwise multiple regression results revealed that anxiety, extraversion, exposure to media, and moral disengagement can predict pre-convictions. On the other hand, only moral disengagement was found to predict post-convictions. Furthermore, moral disengagement can be predicted by convictions before the course while anxiety, openness to change, and convictions were the predictors after the course. The proposed theoretical model was for tested goodness of fit using Structural Equation Modeling (SEM) and acceptance was based on the model fit criteria. Since the proposed model was not found to fit the data, this was revised based on the results of multiple regression and correlation among exogenous variables. Three models were constructed and found to fit the data adequately. These models show the direct and indirect effects of personal factors and moral disengagement on convictions. The mediating effects of moral disengagement and convictions to each other were also shown. Findings further imply that the ability to understand the principles does not influence convictions, but rather moral disengagement has a greater influence on the said factor. Improving moral education by integrating Bioethics to the curriculum is recommended to further strengthen the moral judgement and reasoning of students. (shrink)

While ethical norms for conducting academic research in the United Kingdom are relatively clear, there is little empirical understanding of how university research ethics committees (RECs) themselves operate and whether they are seen to operate well. In this article, we offer insights from a project focused on the Scottish university context. We deployed a three-sided qualitative approach: (i) document analysis; (ii) interviews with REC members, administrators, and managers; and (iii) direct observation of REC meetings. We found that RECs have diverse (...) operation and vary in terms of what members understand to be the remit of their REC and what should constitute the content of ethics review. Overall, though, most participants perceive university RECs as operating well. When asked what they consider to be areas for further improvement, most commented on: implementation of an online system; more experience with how to evaluate various kinds of research projects; best practice exchange and training opportunities; more accurate reflection of the REC role as part of the university’s workload allocation model; and greater recognition of the importance of research ethics governance in the university’s research environment, and, for the members themselves, their career advancement. Based on our findings and subsequent discussions during an end-of-project roundtable with stakeholders, we propose a model of collaboration that can address some of the identified areas that could benefit from further improvement. This model would facilitate a heightened awareness of the importance of supporting REC members in their own effort in assisting students and staff alike in undertaking as ethically robust research as possible. (shrink)

This case compellingly directs us to two challenging issues for the patient's care and treatment: Does evidence of a suicide attempt vitiate the force of an advance directive that refuses life support in the face of progressive, irreversible terminal illness? Does it constitute grounds not to honor an otherwise valid proxy directive and the proxy's decision to withdraw life support?

BackgroundEvaluation of decision-making capacity to consent to medical treatment has proved to be difficult in patients with dementia. Studies showed that physicians are often insufficiently trained in the evaluation of decision-making capacity. In this study, we present findings from a secondary analysis of a qualitative interviews with physicians. These interviews were initially used to assess usability of an instrument for the evaluation of decision-making capacity. By looking at difficult cases of decision-making capacity evaluation in patients with dementia, we provide recommendations (...) for such evaluations in clinical practice.MethodsWe used thematic coding to analyse physicians’ narratives of problematic decision-making capacity evaluations in patients with dementia to uncover challenging issues of decision-making capacity evaluation.ResultsIn this study, decision-making capacity evaluations in patients with dementia were mainly perceived as challenging when they pertained to treatment refusals and treatment unrelated circumstances, such as psychiatric consultation, advance directives, and new living arrangements. Furthermore, the physicians reported training needs regarding situation-independent challenges with decision-making capacity evaluation.ConclusionsUpon further examining self-reported training needs and challenging cases, we have developed recommendations to improve decision-making capacity evaluations in clinical practice. In these recommendations, we argue that being able to evaluate decision-making capacity is an integral part of the informed consent process. (shrink)