Nietzsche argues in the Genealogy of Morality (GM) that key aspects of modern European morality arose as “cures” for widespread human sickness but are ultimately making us sicker (“poisoning” us). This article provides a systematic overview of how Nietzsche believes morality has functioned as a cure and poison for European humanity. Drawing on my own previous work on Nietzsche’s concept of health, I sketch an overview of the (1) sicknesses, (2) treatments, and (3) pathogeneses discussed in each of the three (...) treatises in terms of a single (and plausible) concept of health. The result is a systematic interpretive overview of the core polemical argument in GM. (shrink)

On a postcard to Franz Overbeck from January 4, 1888, Nietzsche makes some illuminating remarks with respect to the three treatises in his book On the Genealogy of Morality.2 Nietzsche says that, ‘for the sake of clarity, it was necessary artificially to isolate the different roots of that complex structure that is called morality. Each of these three treatises expresses a single primum mobile; a fourth and fifth are missing, as is even the most essential (‘the herd instinct’) – for (...) the time being, the latter had to be ignored, as too comprehensive, and the same holds for the ultimate summation of all those different elements and thus a final account of morality.’ Nietzsche also points out that each treatise makes a contribution to the genesis of Christianity and rejects an explanation of Christianity in terms of only one psychological category. The topics of the treatises are ‘good’ and ‘evil’ (first treatise), the ‘bad conscience’ (second), and the ‘ascetic ideal’ (third). The postcard suggests that Nietzsche discusses these topics separately because a joint treatment is too complicated, but that in reality, these ideas are inextricably intertwined, both with each other and with others that Nietzsche omits. Therefore, the three treatises should be regarded as parts of a unified theory and critique of morality. Nietzsche’s remarks on that postcard are important because in the Genealogy itself, he makes little effort to show the unity among the treatises. We shall return to this postcard repeatedly.3 The first treatise has attracted most scholarly attention, but much less work has been done on the second treatise, ‘ “Debts”, “Bad Conscience”, and Related Matters’. This is unfortunate, since it seems that, in Nietzsche’s own view, the central notion of the second treatise, namely, the bad conscience as a feeling of guilt, is a key element of Christian morality. Therefore, understanding Nietzsche’s treatment of this notion is essential to understanding his views on Christianity and the impact of the Christian heritage on non-religious moral philosophy.. (shrink)

This article examines various readings of Nietzsche’s Genealogy of Morality. It treats key issues regarding each of the book’s three essays. The first essay presents slave morality as arising out of ressentiment against masters; Nietzsche thinks that this resentful attitude or affect becomes ingrained and is inherited in later generations. The second essay centers on the phenomenon of “bad conscience.” Nietzsche treats this not just critically, but also as enabling the “artist’s cruelty” which makes possible a new kind of (...) human enhancement. The third essay is about the “ascetic idea,” a “will to transcend” certain essential features of life—such as appearance, change, even willing—from which life suffers. Although Nietzsche finds this ascetic ideal present in the “unconditional will to truth,” this by no means implies that Nietzsche abandons truth as an aim. These three stories should be viewed as “conjectures” and as examples of the kind of thinking needed to understand morality and values. (shrink)

This paper reconstructs Nietzsche’s conception of spiritual illness, especially as exhibited in various forms of the bad conscience, and asks what positive, ennobling potential Nietzsche finds in it. The relevant concept of spirit is arrived at by reconstructing Nietzsche’s conception of life and then considering what reflexive life – life turned back against itself – would look like. It distinguishes four independent features of spiritual illness: the measureless drive to make oneself suffer, self-opacity (or mendaciousness), life-denial, and a self-undermining (...) dynamic in which life exhausts the sources of its own vitality. The paper ends by considering various suggestions as to how these features of spiritual illness might also be preconditions of great spiritual health, including the preconditions for erecting new “ideals.”. (shrink)

ABSTRACT Though the ideas of health and sickness are very much at the heart of Nietzsche’s mature thought, scholars have offered little on what exactly he means by sickness. This is particularly true when Nietzsche presents his conception of sickness in more narrowly physiological terms, as he does explicitly in the Third Essay of On the Genealogy of Morality. In this paper, I present an account of what Nietzsche means by physiological sickliness and sickness, and how these notions are related (...) to asceticism. In particular, I argue that for Nietzsche human beings have been subject through all of history to epidemics of nervous inhibition and exhaustion. In explaining these physiological conditions, I detail the basic understanding of the nervous system in the nineteenth century and show how Nietzsche’s diagnosis of sickness in this system explains many of the mysterious elements of the Third Essay. In my final section, I sketch out the meaning of the ascetic ideal against the backdrop of this nervous sickness. (shrink)

ABSTRACT This article reconstructs Nietzsche's conception of spiritual illness, especially as exhibited in various forms of the bad conscience, and asks what positive, ennobling potential Nietzsche finds in it. The relevant concept of spirit is arrived at by reconstructing Nietzsche's conception of life and then considering what reflexive life—life turned back against itself—would look like. It distinguishes four independent features of spiritual illness: the measureless drive to make oneself suffer, self-opacity, life denial, and a self-undermining dynamic in which life (...) exhausts the sources of its own vitality. The article ends by considering various suggestions as to how these features of spiritual illness might also be preconditions of great spiritual health, including the preconditions for erecting new “ideals.”. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Coward Conscience and Bad Conscience in Shakespeare and NietzscheSandra BonettoGeorge Bernard Shaw once observed that the whole of Nietzsche was expressed in three lines that Shakespeare puts into the mouth of one of his greatest villains, Richard III 1 : "Conscience is but a word that cowards use / Devised at first to keep the strong in awe / Our strong arms be our conscience; (...) swords, our law" (5.6). More specifically, perhaps, these lines invite a comparison between Shakespeare's repeated association of conscience with cowardice in Richard III, 2 and Nietzsche's negative evaluation of bad conscience, notably in On the Genealogy of Morals. 3 The aim of this article is to offer such a comparative analysis in order to demonstrate that Shakespeare's coward conscience anticipates Nietzsche's understanding of the bad conscience (das schlechte Gewissen) as "the consciousness of guilt" (GM, II, p. 67), including its involvement with the notions of debt, sin, punishment, and God.INietzsche devoted the Second Essay of his Genealogy to the discussion of bad conscience, its origins, and related matters, notably guilt (Schuld) and its relation to duty (Pflicht) and debt (Schuld). The German term Schuld denotes both guilt and debt, and both senses are inextricably linked in Nietzsche's analysis. The bad conscience as consciousness of guilt is also [End Page 512] the consciousness of a debt owed—to another individual, society, and above all to the Christian God. The debt owed to God is one that can never be repaid, so that Christian morality necessitates guilt as "eternal punishment" for man's original transgression (see GM, II, pp. 91–92). Thus, Nietzsche argues, the descriptive equivalent of bad conscience, in the language of Christianity, is sin—"this is the priestly name for the... bad conscience" (GM, III, p. 140). In other words, sin is essentially a debt contracted with God. This is evident, for instance, in the substitution of the word "sin" for "debt" (ophéilema) in the formula of the Our Father as found in St. Luke. Even in the more general description, e.g. in the passage of St. Matthew where Jesus is explaining the implications of the petition "Forgive us or debts as we forgive our debtors," where the expressions paràptoma (fault, error) and armatia (aberration, failing, defect in relation to a norm or whole) are the more common terms used to denote sin, the sense of debt is implicit—we only accept our failure in relation to the Christian norm or whole if we accept that we "owe it to God" to live up to that norm in the first place. Moreover, the notion of debt brings with it the debtor's fear of failing to repay the creditor, so that a fear of punishment results from the sense of not living up to the contractual relationship with God.According to Nietzsche, the basis for the bad conscience and guilt, which he further defines as "anger directed against the self" (GM, I, p. 45), is cruelty, a natural human disposition that is displayed unabashedly in punishment. Bad conscience, he argues, is cruelty turned inward and essentially amounts to self-punishment or "psychical cruelty"—a form of subliminal suffering we impose on ourselves. Speaking of the "psychology of conscience," Nietzsche emphasises therefore that conscience "is not 'the voice of God in man'—it is rather the instinct of cruelty that turns back after it can no longer discharge itself externally" (GM, "A Polemic," p. 312). Bad conscience, or sin, is cruelty directed backwards, at oneself. In short, Nietzsche holds that the bad conscience, experienced by us as the "bite" or "sting" of conscience (morsus conscientiae; Gewissensbiss), results from the internalisation of instincts, notably the instincts to cruelty. Rather than acting on natural impulses, man has come to stifle and repress them: "Hostility, cruelty, joy in persecuting, in attacking, in change, in destruction—all this turned against the possessors of such instincts: that is the origin of the "'bad conscience'" (GM, II, p.85).Anticipating Freud's theory of repression and pre-empting his psychological interpretation of conscience as superego (Über-Ich), Nietzsche argues, "all instincts that do not discharge themselves outwardly turn [End Page 513... (shrink)

The current Ebola virus epidemic in Western Africa appears to be spiraling out of control. The worst-case projections suggested that the unchecked spread could result in almost 1.4 million cases by the end of January 2015 with a case fatality rate of at least 50%. The United States and European nations have begun to respond in earnest with promises of supplies, isolation beds, and trained health care personnel in an effort to contain the epidemic and care for the sick. However, (...) there is neither a vaccine nor specific treatment for Ebola infection, and therapy is ideally centered on supportive care. I have previously argued that the provision of palliative care is obligatory during an overwhelming health catastrophe, notably pandemic influenza. Since affected Ebola patients have best outcomes with technologically advanced intensive care—resources in scarce supply in the area—I suggest that the only acceptable approach to large numbers of very sick, dying, and suffering Ebola patients who overwhelm the reso.. (shrink)

What is it like to be a bat? What is it like to be sick? These two questions are much closer to one another than has hitherto been acknowledged. Indeed, both raise a number of related, albeit very complex, philosophical problems. In recent years, the phenomenology of health and disease has become a major topic in bioethics and the philosophy of medicine, owing much to the work of Havi Carel (2007, 2011, 2018). Surprisingly little attention, however, has been given to (...) the phenomenology of animal health and suffering. This omission shall be remedied here, laying the groundwork for the phenomenological evaluation of animal health and suffering. (shrink)

This paper interprets the relation between sovereignty and guilt in Nietzsche's Genealogy. I argue that, contrary to received opinion, Nietzsche was not opposed to the moral concept of guilt. I analyse Nietzsche's account of the emergence of the guilty conscience out of a pre-moral bad conscience. Drawing attention to Nietzsche's references to many different forms of conscience and analogizing to his account of punishment, I propose that we distinguish between the enduring and the fluid elements of a (...) ‘conscience’, defining the enduring element as the practice of forming self-conceptions. I show that for Nietzsche, the moralization of the bad conscience results from mixing it with the material concepts of guilt and duty, a process effected by prehistoric religious institutions by way of the concept of god. This moralization furnishes a new conception of oneself as a responsible agent and holds the promise of sovereignty by giving us a freedom unknown to other creatures, but at the price of our becoming subject to moral guilt. According to Nietzsche, however, the very forces that made it possible have spoiled this promise and, under the pressures of the ascetic ideal, a harmful notion of responsibility understood in terms of sin now dominates our lives. Thus, to fully realize our sovereignty, we must liberate ourselves from this sinful conscience. (shrink)

In this article, I explore Nietzsche’s account of the origins of the ascetic ideal in his Genealogy of Morality. I offer a reading of his claim that this ideal springs from an instinctive response to the sicknesses he describes as “physiological inhibition and exhaustion”, arguing that these sicknesses are primarily nervous conditions found among the priestly class who come up with the ascetic ideal, and periodically among “large masses of people”. The historical frequency of the latter outbreaks accounts (...) for the popularity of the ideal. But the origin story is very much about the ascetic priest, and it is a story Nietzsche tells in bits and pieces over the course of the Genealogy. This article integrates these bits and pieces into one cohesive account. Finally, I consider how the priest’s more innocent ascetic lifestyle suggestions respond to the twin conditions of inhibition and exhaustion. (shrink)

continent. 2.2 (2012): 66–75 ~*~ We’re Doomed. Pessimism is the night-side of thought, a melodrama of the futility of the brain, a poetry written in the graveyard of philosophy. Pessimism is a lyrical failure of philosophical thinking, each attempt at clear and coherent thought, sullen and submerged in the hidden joy of its own futility. The closest pessimism comes to philosophical argument is the droll and laconic “We’ll never make it,” or simply: “We’re doomed.” Every effort doomed to failure, every (...) project doomed to incompletion, every life doomed to be unlived, every thought doomed to be unthought. Pessimism is the lowest form of philosophy, frequently disparaged and dismissed, merely the symptom of a bad attitude. No one ever needs pessimism, in the way that one needs optimism to inspire one to great heights and to pick oneself up, in the way one needs constructive criticism, advice and feedback, inspirational books or a pat on the back. No one needs pessimism, though I like to imagine the idea of a pessimist activism. No one needs pessimism, and yet everyone—without exception—has, at some point in their lives, had to confront pessimism, if not as a philosophy then as a grievance—against one’s self or others, against one’s surroundings or one’s life, against the state of things or the world in general. There is little redemption for pessimism, and no consolation prize. Ultimately, pessimism is weary of everything and of itself. Pessimism is the philosophical form of disenchantment—disenchantment as chanting, a chant, a mantra, a solitary, monophonic voice rendered insignificant by the intimate immensity surrounding it. In pessimism, the first axiom is a long, low, funereal sigh. ~*~ We’re Still Doomed. No one has time for pessimism. After all, there are only so many hours in a day. Whatever our temperament, happy or sad, engaged or disengaged, we know pessimism when we hear it. The pessimist is usually understood as the complainer, forever pointing out what is wrong with the world without ever once offering a solution. But more often than not pessimists are the quietest of philosophers, submerging their own sighs within the lethargy of discontent. What little sound it makes is of interest to no one—“I’ve heard it all before,” “tell me something I don’t know,” sound and fury, signifying nothing. In raising problems without solutions, in posing questions without answers, in retreating to the hermetic, cavernous abode of complaint, pessimism is guilty of that most inexcusable of Occidental crimes—the crime of not pretending it’s for real. Pessimism fails to live up to the most basic tenet of philosophy—the “as if.” Think as if it will be helpful, act as if it will make a difference, speak as if there is something to say, live as if you are not, in fact, being lived by some murmuring non-entity both shadowy and muddied. Had it more self-assurance and better social skills, pessimism would turn its disenchantment into a religion, possibly calling itself The Great Refusal. But there is a negation in pessimism that refuses even such a Refusal, an awareness that, from the start, it has already failed, and that the culmination of all that is, is that all is for naught. Pessimism tries very hard to present itself in the low, sustained tones of a Requiem Mass, or the tectonic rumbling of Tibetan chant. But it frequently lets loose dissonant notes at once plaintive and pathetic. Often, its voice cracks, its weighty words abruptly reduced to mere shards of guttural sound. ~*~ Maybe It’s Not So Bad, After All. If we know pessimism when we hear it, this is because we’ve heard it all before—and we didn’t need to hear it in the first place. Life is hard enough. What you need is a change of attitude, a new outlook, a shift in perspective... a cup of coffee. If we have no ears for pessimism, this is because it is always reducible to something as reliably mutable as a voice. If pessimism is so frequently disparaged, it is because it brings everyone down, determined as it is to view each day as a bad day, if only by virtue of the fact that it is not yet a bad day. For pessimism the world is brimming with negative possibility, the collision of a bad mood with an impassive world. In fact, pessimism is the result of a confusion between the world and a statement about the world, a confusion that also prevents it from fully entering the hallowed halls of philosophy. If pessimism is so often dismissed, this is because it is often impossible to separate a “bad mood” from a philosophical proposition (and do not all philosophies stem from a bad mood?) The very term “pessimism” suggests a school of thought, a movement, even a community. But pessimism always has a membership of one—maybe two. Ideally, of course, it would have a membership of none, with only a scribbled, illegible note left behind by someone long forgotten. But this seems unrealistic, though one can always hope. ~*~ Anatomy of Pessimism. Though it may locate itself at the margins of philosophy, pessimism is as much subject to philosophical analysis as any other form of thought. Pessimism’s lyricism of failure gives it the structure of music. What time is to the music of sorrow, reason is to a philosophy of the worst. Pessimism’s two major keys are moral and metaphysical pessimism, its subjective and objective poles, an attitude towards the world and a claim about the world. For moral pessimism, it is better not to have been born at all; for metaphysical pessimism, this is the worst of all possible worlds. For moral pessimism the problem is the solipsism of human beings, the world made in our own image, a world-for-us. For metaphysical pessimism, the problem is the solipsism of the world, objected and projected as a world-in-itself. Both moral and metaphysical pessimism are compromised philosophically; moral pessimism by its failure to locate the human within a larger context, and metaphysical pessimism by its failure to recognize the complicity in the very claim of realism. This is how pessimism makes its music of the worst, a generalized misanthropy without the anthropos . Pessimism crystallizes around this futility—it is its amor fati , rendered as musical form. ~*~ Melancholy of Anatomy. There is a logic of pessimism that is fundamental to its suspicion of philosophical system. Pessimism involves a statement about a condition . In pessimism each statement boils down to an affirmation or a negation, just as any condition boils down to the best or the worst. With Schopenhauer, that arch-pessimist, the thinker for whom the philosopher and the curmudgeon perfectly overlap, we see a no-saying to the worst, a no-saying that secretly covets a yes-saying (through asceticism, mysticism, quietism), even if this hidden yes-saying is a horizon at the limits of comprehension. With Nietzsche comes the pronouncement of a Dionysian pessimism, a pessimism of strength or joy, a yes-saying to the worst, a yes-saying to this world as it is. And with Cioran yet another variation, futile yet lyrical, a no-saying to the worst, and a further no-saying to the possibility of any other world, in here or out there. With Cioran one approaches, but never reaches, an absolute no-saying, a studied abandonment of pessimism itself. The logic of pessimism moves through three refusals: a no-saying to the worst (refusal of the world-for-us, or Schopenhauer’s tears); a yes-saying to the worst (refusal of the world-in-itself, or Nietzsche’s laughter); and a no-saying to the for-us and the in-itself (a double refusal, or Cioran’s sleep). Crying, laughing, sleeping—what other responses are adequate to a life that is so indifferent? ~*~ Cosmic Pessimism. Both moral and metaphysical pessimism point to another kind, a pessimism that is neither subjective nor objective, neither for-us nor in-itself, and instead a pessimism of the world-without-us. We could call this a cosmic pessimism ... but this sounds too majestic, too full of wonder, too much the bitter aftertaste of the Great Beyond. Words falter. And so do ideas. And so we have a cosmic pessimism, a pessimism that is first and last a pessimism about cosmos , about the necessity and possibility of order. The contours of cosmic pessimism are a drastic scaling-up or scaling-down of the human point of view, the unhuman orientation of deep space and deep time, and all of this shadowed by an impasse, a primordial insignificance, the impossibility of ever adequately accounting for one’s relationship to thought—all that remains of pessimism is the desiderata of affects—agonistic, impassive, defiant, reclusive, filled with sorrow and flailing at that architectonic chess match called philosophy, a flailing that pessimism tries to raise to the level of an art form (though what usually results is slapstick). ~*~ Song of Futility. An ethics of futility pervades pessimism. Futility, however, is different from fatality, and different again from simple failure (though failure is never simple). Failure is a breakage within the heart of relations, a fissure between cause and effect, a fissure hastily covered over by trying and trying again. With failure, there is always plenty of blame to go around; it’s not my fault, it’s a technical difficulty, it’s a miscommunication. For the pessimist, failure is a question of “when,” not “if”—failure as a metaphysical principle. Everything withers and passes into an obscurity blacker than night, everything from the melodramatic decline of a person’s life to the banal flickering moments that constitute each day. Everything that is done undone, everything said or known destined for a kind of stellar oblivion. When scaled up in this way, failure becomes fatality. Fatality is the hermeticism of cause and effect. In fatality, everything you do, whatever you do, always leads to a certain end, and ultimately to the end—though that end, or the means to that end, remain shrouded in obscurity. Nothing you do makes a difference because everything you do makes a difference. Hence the effects of your actions are hidden from you, even as you deceive yourself into thinking that, at last, this time you will outwit the order of things. By having a goal, planning ahead, and thinking things through carefully, we attempt, in a daily Prometheanism, to turn fatality to our advantage, to gain a glimpse of an order that seems buried deeper and deeper in the fabric of the universe. But even fatality has its comforts. The chain of cause and effect may be hidden from us, but that’s just because disorder is the order we don’t yet see; it’s just complex, distributed, and requires advanced mathematics. Fatality still clings to the sufficiency of everything that exists... When fatality relinquishes even this idea, it becomes futility. Futility arises out of the grim suspicion that, behind the shroud of causality we drape over the world, there is only the indifference of what exists or doesn’t exist; whatever you do ultimately leads to no end, an irrevocable chasm between thought and world. Futility transforms the act of thinking into a zero-sum game. ~*~ Song of the Worst. At the center of pessimism lies the term pessimus , “the worst,” a term as relative as it is absolute. The worst is about as bad as it gets, “the worst” as “the best” in disguise, shrouded by the passage of time or the twists and turns of fortune. For the pessimist, “the worst” is the propensity for suffering that gradually occludes each living moment, until it eclipses it entirely, overlapping perfectly in death... which, for the pessimist, is no longer “the worst.” Pessimism is marked by an unwillingness to move beyond “the worst,” something only partially attributable to a lack in motivation. In pessimism “the worst” is the ground that gives way beneath every existent—things could be worse, and , things could be better. “The worst” invariably implies a value judgment, one made based on scant evidence and little experience; in this way, pessimism’s greatest nemesis is its moral orientation. Pessimism’s propositions have all the gravitas of a bad joke. Perhaps this is why the true optimists are the most severe pessimists—they are optimists that have run out of options. They are almost ecstatically inundated by the worst. Such an optimism is the only possible outcome of a prolonged period of suffering, physical or metaphysical, intellectual or spiritual. But does this not also describe all the trials and tribulations of each day—in short, of “life?” It seems that sooner or later we are all doomed to become optimists of this sort (the most depressing of thoughts...) ~*~ Song of Doom. Rather than serving as a cause for despair, gloom and doom are the forms of consolation for any pessimist philosophy. Neither quite affects nor quite concepts, gloom and doom transform pessimism into a mortification of philosophy. Doom is not just the sense that all things will turn out badly, but that all things inevitably come to an end, irrespective of whether or not they really do come to an end. What emerges from doom is a sense of the unhuman as an attractor, a horizon towards which the human is fatally drawn. Doom is humanity given over to unhumanity in an act of crystalline self-abnegation. Gloom is not simply the anxiety that precedes doom. Gloom is literally atmospheric, climate as much as impression, and if people are also gloomy, this is simply the by-product of an anodyne atmosphere that only incidentally involves human beings. Gloom is more climatological than psychological, the stuff of dim, hazy, overcast skies, of ruins and overgrown tombs, of a misty, lethargic fog that moves with the same languorousness as our own crouched and sullen listening to a disinterested world. In a sense, gloom is the counterpoint to doom—what futility is to the former, fatality is to the latter. Doom is marked by temporality—all things precariously drawn to their end—whereas gloom is the austerity of stillness, all things sad, static, and suspended, a meandering smoke hovering over cold lichen stones and damp fir trees. If doom is the terror of temporality and death, then gloom is the horror of a hovering stasis that is life. At times I like to imagine that this realization alone is the thread that connects the charnel ground Aghori and the graveyard poets. ~*~ Song of Spite. There is an intolerance in pessimism that knows no bounds. In pessimism spite begins by fixing on a particular object of spite—someone one hardly knows, or someone one knows too well; a spite for this person or a spite for all of humanity; a spectacular or a banal spite; a spite for a noisy neighbor, a yapping dog, a battalion of strollers, the meandering idiot walking in front of you on their smart phone, large loud celebrations, traumatic injustices anywhere in the world regurgitated as media blitz, spite for the self-absorbed and overly performative people talking way too loud at the table next to you, technical difficulties and troubleshooting, the reduction of everything to branding, spite of the refusal to admit one’s own errors, of self-help books, of people who know absolutely everything and make sure to tell you, of all people, all living beings, all things, the world, the spiteful planet, the inanity of existence... Spite is the motor of pessimism because it is so egalitarian, so expansive, it runs amok, stumbling across intuitions that can only half-heartedly be called philosophical. Spite lacks the confidence and the clarity of hatred, but it also lacks the almost cordial judgment of dislike. For the pessimist, the smallest detail can be an indication of a metaphysical futility so vast and funereal that it eclipses pessimism itself—a spite that pessimism carefully places beyond the horizon of intelligibility, like the experience of dusk, or like the phrase, “it is raining jewels and daggers.” ~*~ Song of Sleep. A paraphrase of Schopenhauer: what death is for the organism, sleep is for the individual. Pessimists sleep not because they are depressed, but because for them sleep is a form of ascetic practice. Sleep is the askesis of pessimism. If, while sleeping, we have a bad dream, we abruptly wake up, and suddenly the horrors of the night vanish. There is no reason to think that the same does not happen with the bad dream we call “life.” ~*~ Song of Sorrow. Nietzsche, commenting on pessimism, once castigated Schopenhauer for taking things too lightly. He writes: ...Schopenhauer, though a pessimist, really —played the flute. Every day, after dinner: one should read his biography on that. And incidentally: a pessimist, one who denies God and the world but comes to a stop before morality—who affirms morality and plays the flute... what? Is that really—a pessimist? We know that Schopenhauer did possess a collection of instruments, and we also know that Nietzsche himself composed music. There is no reason to think that either of them would ever banish music from the Republic of philosophy. But Nietzsche’s jibes at Schopenhauer are as much about music as they are about pessimism. For the pessimist who says no to everything and yet finds comfort in music, the no-saying of pessimism can only be a weak way of saying yes—the weightiest statement undercut by the flightiest of replies. The least that Schopenhauer could’ve done is to play the bass. I’m not a big fan of the flute, or, for that matter, wind instruments generally. But what Nietzsche forgets is the role that the flute has historically played in Greek tragedy. In tragedy, the flute ( aulos ) is not an instrument of levity and joy, but of solitude and sorrow. The Greek aulos not only expresses the grief of tragic loss, but it does so in a way that renders weeping and singing inseparable from each other. The classicist Nicole Loraux calls this the mourning voice . Set apart from the more official civic rituals of funerary mourning, the mourning voice of Greek tragedy constantly threatens to dissolve song into wailing, music into moaning, and the voice into a primordial, disarticulate anti-music. The mourning voice delineates all the forms of suffering—tears, weeping, sobbing, wailing, moaning, and the convulsions of thought reduced to an elemental unintelligibility. In the collapsed space between the voice that speaks and the voice that sings, pessimism discovers its mourning voice. Pessimism: the failure of sound and sense, the disarticulation of phone and logos . Have we rescued Schopenhauer from Nietzsche? Probably not. Perhaps Schopenhauer played the flute to remind himself of the real function of the mourning voice—sorrow, sighs, and moaning rendered indistinguishable from music, the crumbling of the human into the unhuman. Failure par excellence of pessimism. ~*~ Song of Nothing. In Buddhist thought, the First Noble Truth of existence is encapsulated in the Pali term dukkha , conventionally translated as “suffering,” “sorrow,” or “misery.” The Buddhist teachings are clear, however, that this is an objective claim, and not simply one point of view among others. Existence is suffering and sorrow—and yet this is not, the teachings tell us, a pessimistic attitude. It is likely that Schopenhauer, reading the Buddhist texts available to him, recognized some filiation with the concept of dukkha . But dukkha is a multi-faceted term. There is, certainly, dukkha in the usual sense of the suffering, strife, and loss associated with living a life. But this is, in turn, dependent on the finitude and temporality of dukkha , existence as determined by impermanence and imperfection. And this ultimately points to the way in which both suffering and finitude are grounded by the paradoxical groundlessness of dukkha as a metaphysical principle—the insubstantiality and the emptiness of all that is. Beyond what is worse to me, beyond a world ordered for the worst, there is the emptiness of dukkha as an impersonal suffering... the tears of the cosmos. In this context, it is easy to see how Schopenhauer’s pessimism attempts to compress all the aspects of dukkha into a nothingness at the core of existence, a Willlessness coursing through the Will. Though one thing for certain is that with Schopenhauer we do not find the “ever-smiling” countenance of Buddhism—or do we? The texts of the Pali Canon also contain lists of the different types of happiness—including the happiness of renunciation and the strange happiness of detachment. But Buddhism considers even the different types of happiness as part of dukkha , in this final sense of nothingness or emptiness. Perhaps Schopenhauer understood Buddhism better than he is usually given credit for. Thus the experiment of Schopenhauer’s philosophy—the point at which a Western pessimus and an Eastern dukkha overlap or exchange glances. Empty sorrow, a lyricism of indifference. The result is a strange, and ultimately untenable, nocturnal form of Buddhism. ~*~ Cioran once called music a “physics of tears.” If this is true, then perhaps metaphysics is its commentary. Or its apology. ~*~ Pessimism would be more mystical were it not for its defeatism. Mysticism is much too proactive for the pessimist, and pessimism too impassive even for the mystic. At the same time, there is something enviable about mysticism—despite its sufferings. There is a sense in which pessimists are really failed mystics. ~*~ You, the Night, and the Music. In a suggestive passage, Schopenhauer once noted that, “music is the melody to which the world is the text." Given Schopenhauer’s view on life—that life is suffering, that human life is absurd, that the nothingness before my birth is equal to the nothingness after my death—given all this, one wonders what kind of music Schopenhauer had in mind when he described music as the melody to which the world is text—was it opera, a Requiem Mass, a madrigal, or perhaps a drinking song? Or something like Eine kleine Nachtmusik , a little night music for the twilight of thought, a sullen nocturne for the night-side of logic, an era of sad wings sung by a solitary banshee. Perhaps the music Schopenhauer had in mind is music eliminated to non-music. A whisper would suffice. Perhaps a sigh of fatigue or resignation, perhaps a moan of despair or sorrow. Perhaps a sound just articulate enough that it could be heard to dissipate. ~*~ Teach me to laugh through tears. ~*~ Pessimism always falls short of being philosophical. My back aches, my knees hurt, I couldn’t sleep last night, I’m stressed-out, and I think I’m finally coming down with something. Pessimism abjures all pretenses towards system—towards the purity of analysis and the dignity of critique. We didn’t really think we could figure it out, did we? It was just passing time, taking a piss, something to do, a bold gesture put forth in all its fragility, according to rules that we have agreed to forget that we made up in the first place. Every thought marked by a shadowy incomprehension that precedes it, and a futility that undermines it. That pessimism speaks, in whatever voice, is the singing testimony to this futility and this incomprehension—take a chance and step outside, lose some sleep and say you tried... ~*~ Is there a music of pessimism? And would such a music be audible? ~*~ The impact of music on a person compels them to put their experience into words. When this fails, the result is a faltering of thought and language that is itself a kind of music. Cioran writes: “Music is everything. God himself is nothing more than an acoustic hallucination.” ~*~ If a thinker like Schopenhauer has any redeeming qualities, it is that he identified the great lie of Western culture—the preference for existence over non-existence. As he notes: “If we knocked on the graves and asked the dead whether they would like to rise again, they would shake their heads.” In Western cultures it is commonly accepted that one celebrates birth and mourns death. But there must be a mistake here. Wouldn’t it make more sense to mourn birth and celebrate death? Strange though, because the mourning of birth would, presumably, last the entirety of that person’s life, so that mourning and living would the be same thing. ~*~ To the musical idea of the harmony of the universe corresponds the philosophical principle of sufficient reason. Like the music of mourning, pessimism gives voice to the inevitable breakdown of word and song. In this way, music is the overtone of thought. ~*~ The Patron Saints of Pessimism. The patron saints of pessimism watch over suffering. Laconic and sullen, the patron saints of pessimism never seem to do a good job at protecting, interceding, or advocating for those who suffer. Perhaps they need us more than we need them. Lest we forget, there do exist patron saints of philosophy, but their stories are not happy ones. There is, for instance, the fourth century Saint Catherine of Alexandria, or Catherine of the Wheel, named after the torture device used on her. A precocious fourteen year old scholar, Catherine was subject to continual persecution. After all forms of torture failed—including the “breaking wheel”—the emperor finally settled for her decapitation, a violent yet appropriate reminder of the protector of philosophers. There are also patron saints of music and musicians, but theirs too are sad stories. In the second century, Saint Cecilia was also subject to persecution and torture. As she knelt to receive the blade that would separate her head from her body, she ardently sang a song to God. It took three attempts before she was fully decapitated, all the while she continued, perhaps miraculously, to sing. Does pessimism not deserve its own patron saints, even if they are unworthy of martyrdom? But in our search, even the most ardent nay-sayers frequently lapse into brief moments of enthusiasm—Pascal’s love of solitude, Leopardi’s love of poetry, Schopenhauer’s love of music, Nietzsche’s love of Schopenhauer, and so on. Should one then focus on individual works of pessimism? We could include Kierkegaard’s trilogy of horror— Sickness Unto Death , The Concept of Dread , and Fear and Trembling —but all these are undermined by their fabricated and unreliable authors. Besides, how can one separate the pessimist from the optimist in works like Unamuno’s The Tragic Sense of Life , Shestov’s Postetas Clavium , or Edgar Saltus’ under-read The Philosophy of Disenchantment ? Even in cases where the entire corpus of an author is pessimistic, the project always seems incomplete—witness Cioran’s trajectory, from his first book, On the Heights of Despair , to the last unpublished notebooks of acrid and taut aphorisms. And this is to say nothing of literary pessimism, from Goethe’s sorrowful Werther, to Dostoevsky’s underground man, to Pessoa’s disquiet scribbler; Baudelaire’s spleen and ennui, the mystical Satanism of Huysmans and Strindberg, the hauntologies of Mário de Sá-Carniero, Izumi Kyoka, H.P. Lovecraft, grumpy old Beckett... even the great pessimist comedians. All that remains are singular, perhaps anomalous statements of pessimism, a litany of quotes and citations crammed into fortune cookies. Patron saints are traditionally named after a locale, either a place of birth or of a mystical experience. Perhaps the better approach is to focus on the places where pessimists were forced to live out their pessimism—Schopenhauer facing an empty Berlin lecture hall, Nietzsche mute and convalescent at the home of his sister, Wittgenstein the relinquished professor and solitary gardener, Cioran grappling with Alzheimer’s in his tiny writing alcove in the Latin Quarter. ~*~ There’s a ghost that grows inside of me, damaged in the making, and there’s a hunt sprung from necessity, elliptical and drowned. Where the moving quiet of our insomnia offers up each thought, there’s a luminous field of grey inertia, and obsidian dreams burnt all the way down. ~*~ If pessimism has any pedagogical value, it is that the failure of pessimism as a philosophy is inextricably tied to the failure of pessimism as voice. I read the following, from Shestov’s The Apotheosis of Groundlessness : When a person is young he writes because it seems to him he has discovered a new almighty truth which he must make haste to impart to forlorn humankind. Later, becoming more modest, he begins to doubt his truths: and then he tries to convince himself. A few more years go by, and he knows he was mistaken all round, so there is no need to convince himself. Nevertheless he continues to write, because he is not fit for any other work, and to be accounted a superfluous person is so horrible. (shrink)

The current Ebola virus epidemic in Western Africa appears to be spiraling out of control. The worst-case projections suggested that the unchecked spread could result in almost 1.4 million cases by the end of January 2015 with a case fatality rate of at least 50%. The United States and European nations have begun to respond in earnest with promises of supplies, isolation beds, and trained health care personnel in an effort to contain the epidemic and care for the sick. However, (...) there is neither a vaccine nor specific treatment for Ebola infection, and therapy is ideally centered on supportive care. I have previously argued that the provision of palliative care is obligatory during an overwhelming health catastrophe, notably pandemic influenza. Since affected Ebola patients have best outcomes with technologically advanced intensive care—resources in scarce supply in the area—I suggest that the only acceptable approach to large numbers of very sick, dying, and suffering Ebola patients who overwhelm the resources available to successfully manage them is effective palliative care. However, this could hasten death in this vulnerable population and hence, while ethically and medically justifiable, is not without social risk. (shrink)

This paper outlines an interpretation of Ludwig Wittgenstein’s remark in the _Big Typescript_ in which he compares the philosopher bewitched by the workings of language to “the suffering of an ascetic”. The interpretation takes as its starting point Friedrich Nietzsche’s terse account of the philosopher, the history of philosophy, and his diagnosis of ascetic self-misunderstanding, from the Third Essay, “What do ascetic ideals mean?”, in _On the Genealogy of Morality_. In its assumption of an affinity between Wittgenstein’s (...) remark and Nietzsche’s descriptions, and in its analysis, this paper introduces a “method of voice borrowing” to approach the question: “Wittgenstein and Nietzsche?” The juxtaposition of Wittgenstein’s conception of the philosopher’s linguistic self-misunderstanding with Nietzsche’s notion of the ascetic self-misunderstanding leads finally to the question of what is gained by introducing this method, and hence by reading Wittgenstein’s remark on the suffering of an ascetic with the help of Nietzsche’s voice. (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS I. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[i] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[ii] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. II. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[iii] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[iv] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[v] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[vi] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[vii] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[viii] In democratic societies, one must take into consideration community morals and values.[ix] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[x] III. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[xi] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[xii] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[xiii] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[xiv] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. IV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[xv] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[xvi] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[xvii] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[xviii] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[xix] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[xx] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[xxi] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. VI. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[xxii] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[xxiii] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[xxiv] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. VII. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [i] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [ii] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [iii] Moss, p. 1295-1298. [iv] Moss, p. 1296. [v] Moss, p. 1295-1298. [vi] Moss, p. 1295-1298. [vii] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [viii] Cohen, p. 1299-1301. [ix] Moss, p. 1297. [x] Cohen, p. 1300. [xi] Cappelen, p. 478-480. [xii] Cappalen, p. 478-480. [xiii] Cappelen, p.479. [xiv] Cappelen, p. 479. [xv] Cappelen, p. 479 [xvi] Cohen, p. 1301. [xvii] Cappelen, p. 478. [xviii] Cohen, p. 1299-1301. [xix] Cohen, p. 1301. [xx] Cappelen, p. 476-480. [xxi] Cappelen, p. 476-480. [xxii] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [xxiii] Kawachi, p. 18-33. [xxiv] Kawachi, p. 18-33. (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of (...) a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

This paper examines the existential context of physical and mental health. Hans Georg Gadamer and The World Health Organization’s conceptualizations are discussed, and current medicalized and idealized views on health are critically examined. The existential dimension of health is explored in the light of theories of selfhood consisting of different parts, Irvin Yalom’s approach to “ultimate concerns” and Martin Heidegger’s conceptualization of “existentials.” We often become aware of health as an existential concern during times of illness, and health and illness (...) can co-exist. The paper discusses how existential suffering in Western culture is described, to an increasing degree, as disorders or psychological deficits, and perfectionistic health goals easily can become a problem. We seek to avoid suffering rather than relate to it, with all the tension that may create. The paper argues that suffering is an unavoidable aspect of people’s experience of their lives, and actively relating to suffering must be regarded as a fundamental aspect of health. The need and usefulness of a concept of “existential health” is discussed. (shrink)

Although organizational and situational factors have been found to predict burnout, not everyone employed at the same workplace develops it, suggesting that becoming burnt out is a complex, multifaceted phenomenon. The aim of this study was to elucidate perceptions of conscience, stress of conscience, moral sensitivity, social support and resilience among two groups of health care personnel from the same workplaces, one group on sick leave owing to medically assessed burnout (n = 20) and one group who showed (...) no indications of burnout (n = 20). The results showed that higher levels of stress of conscience, a perception of conscience as a burden, having to deaden one’s conscience in order to keep working in health care and perceiving a lack of support characterized the burnout group. Lower levels of stress of conscience, looking on life with forbearance, a perception of conscience as an asset and perceiving support from organizations and those around them (social support) characterized the non-burnout group. (shrink)

Nietzsche's aims and targets -- Reading Nietzsche's preface -- Naturalism and genealogy -- Selflessness : the struggle with Schopenhauer -- Nietzsche and Paul Rée on the origins of moral feelings -- Good and evil : affect, artistry, and revaluation -- Free will, autonomy, and the sovereign individual -- Guilt, bad conscience, and self-punishment -- Will to power in the Genealogy -- Nietzsche's illustration of the art of exegesis -- Disinterestedness and objectivity -- Perspectival knowing and the affects -- The (...) ascetic ideal, meaning, and truth -- Beyond selflessness. (shrink)

The eternal recurrence of the same. Simmel's critique ; Awareness ; Evidence ; Significance ; Coherence -- Demon or god? Deathbed revelation ; Daimonic prophecy ; Dionysian doctrine ; Diagnostic test -- The dwarf and the gateway. The gateway to Hades ; The dwarf's interpretation ; Zarathustra's cross-examination ; The inescapable cycle ; Crossing the gateway ; No time until rebirth ; The ancient memory ; Midnight swan song -- The great noon. Two conclusions ; Tragic end and analeptic satyr (...) play ; Zarathustra's hour ; Noon crucifixion ; Seventh-day convalescence ; Last temptation ; Third-day resurrection -- The laughing lions. Revaluation of values ; Dawn reunion ; Morning consecration ; Call to arms ; Final farewell and last will ; Zarathustra's great destiny -- The shepherd and the serpent. The eternally recurring human ; The future human ; Zarathustra the dragon-slayer ; The decapitation ; The heavy hammer ; No longer shepherd -- Circulus vitiosus deus. Impotence and revenge ; Backward-willing ; Self-redemption ; The third transformation ; The child spirit ; No longer human ; Zarathustra's dying gift -- Post-Zarathustra. Nietzsche and Zarathustra ; Reversing the bad conscience ; Atheism and the death of God ; Countering the ascetic ideal. (shrink)

Two models of the relationship between individual behaviour and health status are examined. On the Freedom Model, the individual is presumed to be capable of free choices including many that have important health consequences. Freedom entails accountability. Thus individuals can be held responsible for health conditions that result from choices they have made. To hold otherwise—to refuse to acknowledge the freedom and responsibilities of individuals—is bad faith. On the Facticity Model, behaviour is a result of facts—genetic and environmental—beyond an individual's (...) control. There is little or no freedom; people are the bodies and roles they inherit. Important among these facts is socio-economic position since it determines much of behaviour and resulting health status. Many people who are poor and lack education also suffer from poor health. To blame their poor health on their behaviour is to blame people already victimised by their circumstances. The relationships of these two models to health promotion are explored. Though conflicting in theory, some justice can be done to each model in the practical world of health promotion by appealing to the freedom in individuals in health education and to the facts that shape individuals in other health promotion and health care contexts. (shrink)

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases ’s 2015 Health Survey, this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual (...) lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies. The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial. (shrink)

Cherie Moraga’s play, Heroes and Saints, and Helena Maria Viramontes’ novel, Under the Feet of Jesus, offer readers perspectives on the lives of migrant farm workers in California that challenge the moral imagination and conscience. Both focus on health hazards of pesticides and on the often prohibitive difficulty of getting health care for those who fall ill as a result of exposure. This paper offers a reflection on the direct political and moral appeal these works present to readers who (...) may not see or acknowledge the sacrifices sustained by those whose undercompensated labors are an integral part of our food systems. (shrink)

ABSTRACT Internalization is an important yet puzzling and undertheorized element in Nietzsche's moral psychology. The aim of this article is to resolve some textual puzzles by way of shedding light on Nietzsche's views on the general nature of internalization, and how it relates to other significant concepts deployed in his thought such as bad conscience, the pathos of distance, the will to power, and the ascetic ideal. I begin by providing a brief interpretation of internalization that is somewhat (...) more perspicuous than exists in the literature. I then make a case for the claim that the consequences of internalization are dependent upon the nature of the attitudes that get redirected inward. This insight allows us to explain why Nietzsche does not give a uniform account of all instances of internalization, and provides resources to give a richer and more satisfying interpretation of his moral psychological and ethical thought. (shrink)

The thesis of this article is that engagement and suffering are essential aspects of responsible caregiving. The sense of medical responsibility engendered by engaged caregiving is referred to herein as clinical phronesis, i.e. practical wisdom in health care, or, simply, practical health care wisdom. The idea of clinical phronesis calls to mind a relational or communicative sense of medical responsibility which can best be understood as a kind of virtue ethics, yet one that is informed by the exigencies of moral (...) discourse and dialogue, as well as by the technical rigors of formal reasoning. The ideal of clinical phronesis is not (necessarily) contrary to the more common understandings of medical responsibility as either beneficence or patient autonomy — except, of course, when these notions are taken in their disengaged form (reflecting the malaise of modern medicine). Clinical phronesis, which gives rise to a deeper, broader, and richer, yet also to a more complex, sense than these other notions connote, holds the promise both of expanding, correcting, and perhaps completing what it currently means to be a fully responsible health care provider. In engaged caregiving, providers appropriately suffer with the patient, that is, they suffer the exigencies of the patient's affliction (though not his or her actual loss) by consenting to its inescapability. In disengaged caregiving — that ruse Katz has described as the silent world of doctor and patient — provides may deny or refuse any given connection with the patient, especially the inevitability of the patient's affliction and suffering (and, by parody of reasoning, the inevitability of their own. When, however, responsibility is construed qualitatively as an evaluative feature of medical rationality, rather than quantitatively as a form of calculative reasoning only, responsibility can be viewed more broadly as not only a matter of science and will, but of language and communication as well — in particular, as the task of responsibly narrating and interpreting the patient's story of illness. In summary, the question is not whether phronesis can save the life of medical ethics — only responsible humans can do that! Instead, the question should be whether phronesis, as an ethical requirement of health care delivery, can prevent the death of medical ethics. (shrink)

BackgroundIn this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored.Research designA qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used.Ethical considerationsApproval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary.FindingsBased on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, (...) coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness.ConclusionMoral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves. (shrink)

A critical discussion of Bernard Reginster's book The Will to Nothingness. The contribution engages with Reginster's interpretation of Nietzschean ressentiment, arguing that it is an essentially interpersonal attitude in two different senses. It is a response to a social situation of structural deprivation, and it involves an element of antagonism toward those who are better off within this social structure. The contribution then discusses Reginster's claim that modern morality restores the sense of power of the masses by adjusting the goals (...) that they aim to pursue. I argue that this interesting interpretation does not do full justice to the themes of hostility or hatred that permeate the Genealogy of Morals, extending from Nietzsche's discussion of the slave revolt to his treatments of the bad conscience and of ascetic ideals. (shrink)

_Beyond Good and Evil_ is Nietzsche's first sustained philosophical treatment of issues important to him. Unlike the expository prose of the essayistic period, the stylized forays and jabs of the aphoristic period, and the lyrical-philosophical rhetoric of the Zarathustra-period, _Beyond Good and Evil_ inscribes itself boldly into the history of philosophy, challenging ancient and modern notions of philosophy's achievements and insisting on a new task for "new philosophers." This is a watershed book for Nietzsche and for philosophy in the modern (...) era. _On the Genealogy of Morality_ applies Nietzsche's celebrated genealogical method, honed in the earlier aphoristic writings, to the problem of morality's influence on the human species. In three treatises that strikingly anticipate insights appearing much later in Freud's _Civilization and Its Discontents_, Nietzsche provides an anthropological psychograph of our species, revealing the origins of the concepts of good and evil, the roles played by guilt and bad conscience, and the persistence of ascetic ideals. Manifesting a hopeful yet unsentimental assessment of the human condition, these books resonated throughout the 20th century and continue to exert broad appeal. (shrink)

“The genealogy of morals” is, most famously, a pair of genealogies: that of the good/evil dichotomy in the First Treatise, and that of the bad conscience in the Second Treatise. But the straightforward presentation of these two narratives is subverted even before it begins. Nietzsche classifies the book not as a treatise or inquiry but as a “polemic”; voices interrupt the narrative to insist that much is left unsaid; the narratives are framed by, of all things, reflections on the (...) scientific conscience; Nietzsche declares the entire enterprise to be a contribution to the critique of “the value of values”; the two genealogies of the first two Treatises overlap and various points and ultimately converge in a discussion of the “meaning” of the “ascetic ideal.” Whatever one makes of these complications, two tentative conclusions can be drawn. Nietzsche is profoundly concerned with the status of his genealogy. And genealogy does not function as reportage, primarily concerned with the accurate depiction of events; rather, it aims to reveal something about the status of “moral values” and the possibility of an alternative to them. (shrink)

Chulpforta, 1862 -- Napoleon III as president -- Saint-just -- Two-poem cycle two kings -- Louis the sixteenth -- Louis the fifteenth -- Agonistic politics, 1871-1874 -- The Greek state, 1871 -- On the future of our educational institutions, third lecture, February 27th, 1872 -- Homer's contest -- Untimely meditations -- David Strauss : the confessor and the writer, 1873 -- Schopenhauer as educator, 1874 -- The free spirit, 1878-1880 -- Human, all too human : a book for free spirits, (...) 1878 -- Miscellaneous maxims and opinions, 1879 -- The wanderer and his shadow, 1880 -- The campaign against morality, 1881-1885 -- Dawn of day thoughts on the prejudices of morality, 1881 -- The joyful wisdom, 1882 -- Thus spoke Zarathustra : a book for everyone and no one, 1883-1885 -- On the new idol -- On the rabble -- On the Tarantulas -- On old and new law tablets -- Conversation with the kings -- Nachlass fragments, 1883-1885 -- Aristocratic radical, 1886-1887 -- Beyond good and evil : prelude to a philosophy of the future, 1886 -- The joyful wisdom, book v, 1887 -- On the genealogy of morals : a polemical tract, 1887 -- First essay, good and evil, good, and bad -- Second essay, guilt, bad conscience, and related matters -- Third essay, what do ascetic ideals mean? -- Nachlass fragments, 1885-1887 -- The antichrist, 1888 -- Twilight of the idols : or how one philosophises with a hammer, 1888 -- Morality as anti-nature -- The improvers of mankind -- What the Germans lack -- Skirmishes of an untimely man -- The antichrist : a curse on Christianity, 1888 -- Ecce homo : how one becomes what one is, 1888 -- Why I am so wise -- Why I write such good books -- The case of Wagner : a musician's problem -- Why I am a destiny -- Nachlass fragments, 1887-1888. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Journal of the History of Philosophy 39.3 (2001) 450-451 [Access article in PDF] Simon May. Nietzsche's Ethics and His War on 'Morality.' New York: Oxford University, The Clarendon Press, 1999. Pp. xi + 212. Cloth, $45.00. When Friedrich Nietzsche reviewed his career during his final year of intellectual activity, he wrote in Ecce Homo (1888) that his "campaign against morality" began with the publication of Daybreak (1880) eight years (...) earlier. With this autobiographical remark in mind, Simon May appropriately develops his study of Nietzsche's ethics, Nietzsche's Ethics and His War on "Morality," by attending to Nietzsche's writings of the 1880's, using the relatively late On the Genealogy of Morals (1887) as his textual keystone.For the sake of his English-speaking readers' convenience, May reiterates Walter Kaufmann's familiar translations of Nietzsche's works in all of his book's citations, and keeps a relatively tight leash on his references to Nietzsche's pre-1880 works and unpublished notebooks. Historical guideposts to authors within Nietzsche's surrounding cultural context are also limited, and the book unfolds around May's reflections on Nietzsche's publications, supplemented by contemporary references to the works of Bernard Williams in matters concerning ethics, and by references to a substantial number of English-speaking Nietzsche scholars in matters concerning Nietzsche's valuation of truth. Such are the book's methodological contours, which are defensible, but which will probably disappoint those who have philosophical sensibilities that are more philologically and historically pronounced.May divides his book in half, the first segment of which reviews a series of familiar Nietzschean thematics, Nietzsche's conception of values, his distinction between master and slave moralities, his analysis of guilt and bad conscience, his conception of life enhancement, and his conception of the ascetic ideal, all with the prospect of suggesting that Nietzsche's ethical ideal is best encapsulated by the phrase, "become what one is." This ideal, as May understands it, is to develop oneself maximally in a life-enhancing way, given the parameters of one's natural capacities. Although one would expect May to associate this prescription with Nietzsche's conception of the "superhuman" (Übermensch), he thought-provokingly sets the ideal of "becoming what one is" directly against Nietzsche's Übermensch, arguing that the latter is, in fact, "unattainable and undesirable." According to May, Nietzsche's discussion of the superhuman type is distractingly unrealistic, chiefly because a perfectly sovereign individual, unlike us, would be an infallible "man-god" (117) and would have nothing left to overcome.The second half of May's study concentrates on Nietzsche's crucial revaluation of the value of truth. May argues that although Nietzsche rejects an unconditional value for truth and its associated ascetic ideal, it is nonetheless consistent to "passionately" value truth and remain a Nietzschean life-enhancer. May respects Nietzsche's perspectivism, but his interpretation clearly runs against the grain of the more extremely relativistic, "anti-truth," readings of Nietzsche.May's short volume contains plenty of food for disagreement. To cite one notable example, May maintains that "with Nietzsche there is not even an attempt to produce a systematic safety net against cruelty... and, to this extent, his philosophy licenses the atrocities of a Hitler" (132). May's fundamental reason is that since unfettered cruelty is consistent with what he understands to be Nietzsche's radically individualist [End Page 450] principle of life-enhancement, the Nietzschean conception of life-enhancement is ethically deficient. Some of Nietzsche's remarks do provoke May's criticism, but common knowledge also tells us that unfettered cruelty often backfires into either physical or spiritual self-destruction. So a wise Nietzschean would not "license" brutality. Neither, however, would such a Nietzschean seek to erect an absolute barrier against unfettered brutality, but would more discriminatingly consider what wisdom dictates in each circumstance, given the interests of life.May's study intends to exclude from the philosophically best interpretation of Nietzsche, what are recognized by most people as ethically undesirable qualities. His study also renders Nietzsche's key ideas workable, accessible, and palatable... (shrink)

Abstract A number of recent studies suggest that income and social inequality (as opposed to poverty itself) have detrimental consequences on people's health. These studies argue that while the poor may suffer the most from inequality, the rich also suffer. On closer inspection, however, it emerges that the basic arguments and evidence that inequality has a causal effect on health are wanting in many respects.

Doctor and patient meet in a circle of feelings determined by suffering. Sensitivity to the suffering is an axis determining the nature of the doctor and patient relationship. The patient's experience of an illness is individual, private, and very often difficult to describe. But the possibility to understand the suffering of another person comes from the fact that suffering is a universal feeling. We propose to enter the world of patient's experience by writing a letter to a doctor, which would (...) reflect their experiences and expectations towards him. This was the task required for 120 students of the second year of medicine and dentistry education. (shrink)

In this edition of two of Nietzsche's late works, Kaufmann has written a short introduction to each work and included indices for each work. There is an appendix to the Genealogy consisting of Kaufmann's translations of the aphorisms from earlier works which Nietzsche alludes to in the Genealogy. Also included is an appendix of discarded drafts of parts of Ecce Homo. In addition to a readable translation, Kaufmann has written a running commentary in the form of short footnotes which become (...) more expansive in one section of the Genealogy which deals with intellectual conscience and with truth. The Genealogy is intended by Nietzsche to be a sequel to and clarification of Beyond Good and Evil. It deals with such themes as master morality as opposed to slave morality, bad conscience, ressentiment, and ascetic ideals. Ecce Homo is Nietzsche's commentary on himself, his books, and his intellectual development. In the introductions, Kaufmann pleas for responsible scholarship when dealing with Nietzsche and rails against what he considers to be a conspiracy of malicious misinterpretations that have sought to discredit Nietzsche. He criticizes views that would disregard Ecce Homo as an insanely disfigured self-portrait. He also rejects interpretations of the Genealogy which suppose that Nietzsche would lump together as evils slave morality, bad conscience, and ascetic ideals. Kaufmann's admiration for Nietzsche is undisguised, and he admits a special fondness for Ecce Homo.—S. O. H. (shrink)

Cet article offre une vue d’ensemble sur les Éléments pour la généalogie de la morale de Nietzsche. La genèse de l’œuvre est d’abord présentée, puis les sources que Nietzsche a exploitées pour ses réflexions sont examinées. Cet examen des sources est suivi d’une analyse de la conception, de la structure et du contenu de l’« écrit polémique » de Nietzsche. Les sections du livre sont présentées et commentées dans leur succession.

A number of health care professionals assert a right to be exempt from performing some actions currently designated as part of their standard professional responsibilities. Most advocates claim that they should be excused from these duties simply by averring that they are conscientiously opposed to performing them. They believe that they need not explain or justify their decisions to anyone; nor should they suffer any undesirable consequences of such refusal. Those who claim this right err by blurring or conflating three (...) issues about the nature and role of conscience, and its significance in determining what other people should permit them to do (or not do). Many who criticize those asserting an exemption conflate the same questions and blur the same distinctions, if not expressly, by failing to acknowledge that sometimes a morally serious agent should not do what she might otherwise be expected to do. Neither side seems to acknowledge that in some cases both claims are true: a conscientious professional should not do her professional duty AND others need not permit or excuse her refusal. I identify these conflations and specify conditions in which a professional might reasonably refuse to do what she is required to do. Then I identify conditions in which the public should exempt a professional from some of her responsibilities. I argue that professionals should refuse far less often than most advocates do . . . and that they should be even less frequently exempt for that failure. Finally, there are compelling reasons why we could not implement a consistent moral policy giving advocates what they want, likely not even in qualified form. (shrink)

Aaron Ridley explores Nietzsche's mature ethical thought as expressed in his masterpiece On the Genealogy of Morals. Taking seriously the use that Nietzsche makes of human types, Ridley arranges his book thematically around the six characters who loom largest in that work—the slave, the priest, the philosopher, the artist, the scientist, and the noble. By elucidating what the Genealogy says about these figures, he achieves a persuasive new assessment of Nietzsche's ethics. Ridley's intellectually supple interpretation reveals Nietzsche's ethical position to (...) be deeper and more interesting than is often supposed: the relation, for instance, between Nietzsche's ideal of the noble and the ascetic or priestly conscience does not emerge as a stark opposition but as a rich interplay between the tensions inherent in each. Equally, he shows that certain under-appreciated confusions in Nietzsche's thought reveal much about the positive aspects of the philosopher's moral vision. The only book devoted entirely to the Genealogy, Nietzsche's Conscience offers a sympathetic but tough-minded critical reading of the philosopher's most important work. Delivered in clear and vigorous language and employing a broadly analytical approach, Ridley's commentary makes Nietzsche's reflections on morality more accessible than they have been hitherto. (shrink)

Individuals diagnosed with conduct disorder (CD) in childhood and adolescence are at risk for increasingly maladaptive and dangerous behaviors, which unchecked, can lead to antisocial personality disorder (ASPD) in adulthood. Children with CD, especially those with the callous unemotional subgroup qualifier (“limited prosocial emotions”/dsm‐5), present with a more severe pattern of delinquency, aggression, and antisocial behavior, all markings of prodrome ASPD. Given this recognized diagnostic trajectory, with a pathological course playing out tragically at the individual, familial, and societal level, and (...) lack of effective remediation via current standards of care, we posit an alternate treatment approach; case‐specific compulsory moral habilitation aimed at rectifying the undeveloped affective domain of adolescents and young adults suffering from these disorders. We begin with a brief historical overview of response to mental illness, review CD and ASPD diagnostic criteria and treatment limitations, and posit a unique neurohabilitative approach that focuses on the absent affective moral development of these populations. Next, we invoke a public health safety argument to justify case‐specific compulsory moral habilitation, discuss neurotechnologies to be considered in treatment, and conclude with ethical considerations and suggestions for further research. (shrink)

Much academic work (in philosophy, economics, law, etc.), as well as common sense, assumes that ill health reduces well-being. It is bad for a person to become sick, injured, disabled, etc. Empirical research, however, shows that people living with health problems report surprisingly high levels of well-being - in some cases as high as the self-reported well-being of healthy people. In this chapter, I explore the relationship between health and well-being. I argue that although we have good reason to believe (...) that health problems causing pain and death typically do reduce well-being, health problems that limit capabilities probably don't reduce well-being nearly as much as most people suppose. I then briefly explore the consequences of this conclusion for political philosophy and ethics. If many health problems don't significantly reduce well-being, why should governments go to great expense to prevent or treat them? Why should parents be obliged to ensure the health of their children? (shrink)

BackgroundPublic Safety Personnel are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury (...) extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger.ObjectiveThis scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers.MethodsA systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers.ResultsThe initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations. Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality.ConclusionPublic safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health. (shrink)

Background: Troubled conscience among nurses and other healthcare workers represents a significant contributor to healthcare worker moral distress, burnout and attrition. While research in this area has examined critical care in hospitals, less knowledge has been obtained from long-term care contexts such as nursing homes, despite widely recognised challenges with regard to vulnerable patients, increasing workload and maintaining workforce sustainability among nurses. Objective: The aim of this study was to illuminate and interpret the meaning of the lived experience of (...) troubled conscience among registered nurses (RNs) working in nursing homes. Research design: This qualitative research employed narrative interviews with eight nurses to obtain essential meanings of their lived experiences of troubled conscience. The interview texts were analysed using a phenomenological hermeneutic approach. Ethical considerations: Participation was voluntary, informed and was conducted with written consent. The Norwegian Centre for Research Data approved the data processing of personal data. Findings: The analysis uncovered two themes: (1) troubled conscience means abandoning ideals, with the subthemes: failing dependent patients; being disloyal to colleagues; being inadequate in the performance of work tasks and (2) troubled conscience means facing realities, with the subthemes: accepting being part of the system; responding to barriers. Discussion: Troubled conscience meant experiencing continuous and simmering tension between one’s ideals and realities and feeling a drive to preserve accountability and one’s moral integrity. Endangered ideals were often under cross-pressure and included humanistic values, professional values, working life values and the values of the organisation. Conclusion: Nurses’ troubled conscience refers to a struggle, but also a force that plays out at various levels and arenas in long-term care. Openness and dialogue about how professional values and the welfare state’s intentions can be realised within the given framework are important for individual nurses’ occupational health as well as the quality of care provided to patients. (shrink)

Nietzsche's harsh attacks on modernity suggest a problem: if the modern age is so diseased, can we overcome it and move on to something higher? Or is the disease too severe? I examine the question by studying Nietzsche's view of spiritual health. Spiritual illness, even in the highest man, is nothing unusual or necessarily debilitating. Even the strongest have been infected since the earliest days of civilization. Indeed, infection with slave morality and bad conscience are requirements for spiritual elevation. (...) And the disease serves life by giving the strong something to struggle against, as well as making possible the spiritual greatness required to revalue all values. The higher man, then, is a mixture of health and disease. The revaluation of values is extraordinarily dangerous, but not impossible. Key Words: great politics • Nietzsche's revaluation of all values • On the Genealogy of Morals • spiritual health. (shrink)

In my ideal academy of healing arts, students of all health-care professions would spend their first semester together, thinking only about suffering. No coursework on bodies, diseases, or basic science. No socialization into distinct professional identities. Just suffering from multiple perspectives: literary, philosophical, spiritual, historical, crosscultural. They would be led to ask what forms of suffering have been responded to in which ways, when, by whom. Whose suffering has been systematically ignored, and what finally led to the recognition of that (...) suffering? They would write about the unresolvable question of what aspects of suffering can be called universal, and what suffering might be local and... (shrink)

The figure of the sovereign individual has stood for about two decades at the center of an exegetical debate concerning its identity and ideality. What is often lost sight of in these debates is the role of the sovereign individual in Nietzsche’s genealogy of guilt and bad conscience in the Genealogy’s second essay. I argue for the following claims. First, that the figure of the sovereign individual is not a singular occurrence in Nietzsche’s published writings but is present in (...) sections from Daybreak and The Gay Science that have not been pursued in this context in the Anglophone literature; sections that shed new light on the sovereign individual. Second, that examination of these texts reveals that the sovereign individual is for Nietzsche embodied by Socrates and the Socratic individual. Third, and most importantly, that with the sovereign individual there emerges individualized conscience – the capacity for self-laceration that concerns one’s misdeeds alone and involves the belief that one’s misdeeds are entirely one’s own individual fault, rather than the fault of the community or the gods. A fourth, rather negative consequence, is that at the end of the day Nietzsche, in the Genealogy, does not manage to provide us with a genealogy of moral guilt. (shrink)

ABSTRACTThe figure of the sovereign individual has stood for about two decades at the center of an exegetical debate concerning its identity and ideality. What is often lost sight of in these debates is the role of the sovereign individual in Nietzsche’s genealogy of guilt and bad conscience in the Genealogy’s second essay. I argue for the following claims. First, that the figure of the sovereign individual is not a singular occurrence in Nietzsche’s published writings but is present in (...) sections from Daybreak and The Gay Science that have not been pursued in this context in the Anglophone literature; sections that shed new light on the sovereign individual. Second, that examination of these texts reveals that the sovereign individual is for Nietzsche embodied by Socrates and the Socratic individual. Third, and most importantly, that with the sovereign individual there emerges individualized conscience – the capacity for self-laceration that concerns one’s misdeeds alone and involves the belief that one’s misdeeds are entirely one’s own individual fault, rather than the fault of the community or the gods. A fourth, rather negative consequence, is that at the end of the day Nietzsche, in the Genealogy, does not manage to provide us with a genealogy of moral guilt. (shrink)

Health care begins as an act of conscience, which urges a response to the sick and holds caregivers accountable to moral standards that public authorities ultimately do not define. Conscience nonetheless expresses itself as a type of dialogue within oneself that is influenced by dialogue with others, especially with society in the form of civil law and professional standards. A well-formed conscience for health care relates the foundations of morality to health care practices and contributes sound moral (...) judgment about them to the common good. Some current health care policies and medical education presume a distorted view of conscience as personal sentiment. These policies circumvent serious discussion and possible resolution of society's most vexing bioethics controversies. (shrink)

Background: Limited knowledge of the experiences of conflicts of conscience found in nursing literature. Objectives: To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta. Research design: Interpretive description was selected to help situate the findings in a meaningful clinical context. Participants and research context: Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta. Ethical consideration: Ethics approval from the Health Research Ethics Board at the University of Alberta. Findings: (...) Three common themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse’s voice, and the unique proximity of nurses. Discussion and conclusion: The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection. (shrink)

In this essay I examine Nietzsche’s shifting understanding of the saintly ideal with an aim to bringing out its philosophical importance, particularly with respect to what I call the problem of ‘cosmodicy’, i.e., the problem of justifying life in the world as worthwhile in light of the prevalent reality of suffering. In his early account Nietzsche understood the saint as embodying the supreme achievement of a self-transcending ‘feeling of oneness and identity with all living things’, while in his later account (...) he viewed the saint as a representative of an unhealthy, life-denying ‘ascetic ideal’. This shift, I contend, is due in large part to Nietzsche’s development of an ‘ethic of power’ as part of his turn against Schopenhauer’s ethic of compassion, which needs to be seen in light of his ongoing effort to articulate and defend an adequate cosmodicy. My ultimate aim in this essay is to read the earlier Nietzsche against the later Nietzsche – with the help of Dostoevsky’s novelistic depiction of the saintly ideal – and to suggest that when properly articulated the saintly ideal is able to provide a more adequate cosmodicy than that which is offered in Nietzsche’s ethic of power. (shrink)

Empirical research shows the significant negative effects inequality has on aspects such as public health, vulnerability to violence, and social trust. While the majority of researchers agree that there exist specific social determinants of health as well as a distinct social gradient in health , there is wide disagreement both over what the exact causal relationship between social inequalities and health is, and what the adequate policy responses especially to the SGH are. For policy-oriented theorists, the question arises which normative (...) implications these empirical findings offer for philosophers working on equality.This paper argues that the first lesson philosophers should take away from the empirical literature is that the issue that needs to be addressed is harmful social inequality, rather than unequal material distributions, or unequal opportunities and starting gates as such. That is to say, inequality with respect to a specific feature X is not—in itself—the problem, but the problem are the negative effects of certain harmful forms of complex social inequalities. For our normative analysis this entails that we should focus on the conceptualization of the ideal of social equality, and the kinds of relationships and institutional arrangements compatible with it. (shrink)

This paper explores the relationship between temporal continuity in nursing and temporal features of sickness. It is based on phenomenological and hermeneutical philosophy, empirical studies of sickness time, and the nursing theories of Nightingale, of Benner and of Benner and Wrubel. In the first part, temporal continuity is defined as distinct from interpersonal continuity. Tensions between temporal continuity and discontinuity are discussed in the contexts of care management, of conceptualisations of disease and of time itself. Temporal limitations to the methodological (...) concept of situation are discussed. The main part of this paper explores nurses' possibilities to relate to their patients' time, and how temporal features of sickness may warrant temporal continuity of nursing. Three temporal characteristics of sickness are discussed: the immediacy of patients' suffering, the basic continuity of life through sickness and health care, and the indeterminism and precariousness of sickness. The timing of nursing acts is discussed. The paper explores how sickness is both part of the continuity of life, and threatens this continuity. It concludes that this tension is implicitly recognised in the temporal continuity of nursing, which allows for discontinuous and continuous aspects of sickness time. Nurses accordingly perceive the sick person's time at several levels of temporality, and distinguish highly complex temporal processes in their patients' trajectory. Temporal continuity provides the time, flexibility, and closeness for nurses to perceive and act into time dimensions of individual sickness. The paper shows that temporal continuity of nursing is grounded in temporal characteristics of severe sickness. It suggests that temporal continuity is an important theoretical concept in nursing. (shrink)