In this article, caring, remembering and sharing memory are presented as moral responses, the case study being Alzheimer’s disease (AD). Memory connects memories and images, while care connects individuals, which is an ethical issue. When a person’s memory is lost, the care of others becomes the only thread connecting them to the world. AD deprives a person of memories, body control, makes it impossible to remember, communicate, move, recognize the environment, and disrupts consciousness. Caring for a patient with a (...) neurodegenerative brain disease requires constant reminding and reiteration; the presence of a caring person reminds of what the patient themselves can no longer remember. Lost memories do not mean that life or relational values have also lost their meaning. The description of the memory movement emphasizes the importance of repetition in the moral act. Highlighting the matter of care, also in scientific work, is the aim of this text. To care is to remember, on behalf of the AD patient, about the patient’s life. Within bioethical research, moral responses are an important point for projects which seek to improve the condition of patients—not only the condition of health but also the comfort of life. This improvement will not be possible without attentive, committed caregivers and their responsible attitude in the face of the phenomenon of memory loss. (shrink)

Abstract:Respect for persons protects patients regarding their own healthcare decisions. Patient informed choice for altruism (PICA) is a proposed means for a fully autonomous patient with decisionmaking capacity to limit his or her own treatment for altruistic reasons. An altruistic decision could bond the patient with others at the end of life. We contend that PICA can also be an advance directive option. The proxy, family, and physicians must be reminded that a patient’s altruistic treatment refusal (...) should be respected. (shrink)

We live in an anxious world, riddled with unpredictable threats to our safety and unexpected hatreds directed toward us. It is easy to obsess on the terrors around us, about which we can do little, and lose perspective on the real and sometimes devastating risks that we encounter in our daily lives. These everyday risks need to be regularly revisited — to remind ourselves that they can be reduced with the application of sharp minds, careful scholarship, and political will.Medical errors (...) in the American health-care system are just such a problem. The risk of death or serious injury at the hands of the American health-care system is not trivial, as we have learned over the past few years as the health-care establishment has acknowledged the level of iatrogenic injury in the system. If, as the Institute of Medicine reported in To Err Is Human, as many as 100,000 people every year are dying in hospitals, clinics, and doctors’ offices as the result of actions or omissions that could have been avoided, then this is a social problem of great magnitude and one that the law must try to correct. (shrink)

We live in an anxious world, riddled with unpredictable threats to our safety and unexpected hatreds directed toward us. It is easy to obsess on the terrors around us, about which we can do little, and lose perspective on the real and sometimes devastating risks that we encounter in our daily lives. These everyday risks need to be regularly revisited — to remind ourselves that they can be reduced with the application of sharp minds, careful scholarship, and political will.Medical errors (...) in the American health-care system are just such a problem. The risk of death or serious injury at the hands of the American health-care system is not trivial, as we have learned over the past few years as the health-care establishment has acknowledged the level of iatrogenic injury in the system. If, as the Institute of Medicine reported in To Err Is Human, as many as 100,000 people every year are dying in hospitals, clinics, and doctors’ offices as the result of actions or omissions that could have been avoided, then this is a social problem of great magnitude and one that the law must try to correct. (shrink)

Patient safety has only recently been subjected to wide-spread systematic study. Healthcare differs from other high risk industries in being more diverse and multi-contextual, and less certain and regulated. Also many patient safety problems are low-frequency events associated with many, varied contributing factors. The subject of this paper is the epistemology of patient safety (the science of the method of finding out about patient safety). Patient safety research is considered here on the background of a (...) risk management framework which requires researchers to: • Understand the context - as a subset of healthcare quality, services and systems research, with technical and human behavioural (cultural) components and a range of external and internal organisational influences, a wide range of research disciplines is necessary • Identify the risks - identify the things that go wrong and the frequency and nature of different types of incidents from sources such as medical record review, observational studies, audit, incident and medico-legal reports • Analyse the risks - deconstruct the things that go wrong, identifying contributing factors and trying to detect trends and patterns in contributing factors, detection, mitigation factors, ameliorating factors and actions taken to reduce risk • Evaluate the risks - decide on priorities, identifying preventive and corrective strategies and judging the risk- and cost-benefit of potential corrective strategies such as standardisation or simplification of a process or device • Manage the risk - evaluate and scope preventive and/or corrective strategies and then implement these, or place the problem on a risk register pending solution, or accept that what is needed is unaffordable • Communicate and consult - use interactive sessions, audit, on-going feedback, reminders and patient mediated prompts • Monitor and review the state of the problem - get baseline trends and patterns so that changes can be tracked and properly attributed to an intervention A hierarchy of levels of evidence has been proposed for clinical research and we argue that insufficient weighting has been given to lower ranked levels of research and to qualitative research, although critical interpretive synthesis is now gaining acceptance in mainstream thinking (e.g. by the Cochrane Collaboration). Fundamental challenges remain including how to grasp the elusive concept of patient safety, how to quantify, characterise and cost the problems, how to judge the extent to which harm can be attributed to errors, violations or system failures, how to identify contributing factors and the extent to which they can be implicated, how to judge whether incidents or their precursors are preventable, how to generate strong evidence to make healthcare safer and how to translate research into practice. Future directions include addressing the mundane as well as rare, dramatic events, and developing further research in non-hospital settings and in developing countries. In summary, a mixture of qualitative and quantitative methods, using information from all available data sources and combining retrospective, real time and prospective study designs, is necessary to address some of the more difficult patient safety problems. (shrink)

When I finally got eye glasses as a teenager, after denying the need for far too long, I was repeatedly surprised by the world that everyone else had been seeing all along. Leaves on the trees, graffiti by the highway—I was astonished, amazed, and suddenly informed. It is easy to assume we are seeing all we need to see, knowing all we need to know, until something jars us from this false comfort and compels us to reconsider. So it is (...) with thinking about the current state of doctor‐patient decisions. The unfocused view has physicians listening to patients and clearly communicating information about illnesses and treatment options, patients making good use of high‐quality data to craft sound decisions, and doctors joining patient preference with provider beneficence to optimize decisions. The reassuring outlook finds physician paternalism defeated, patients empowered, and all right with the world. Peter Ubel cannot let that fiction stand. In Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together, Ubel reminds us that our work in actualizing patient autonomy and fostering patient participation in critical health decisions remains far from over. (shrink)

I’m avoiding Mr. G’s room. I shouldn’t have read the emergency room notes from the other hospital, where this middle‐aged man raised a stink about the wait. What type of person calls the triage nurse a bitch? From the timestamps on the electronic medical record notes, he stormed from that ER and drove his abdominal pain, vomiting, diarrhea, and discontent directly across town to us.I’m reminded of this oft‐quoted aphorism from Sir William Osler: “The good physician treats the disease; the (...) great physician treats the patient who has the disease.” It’s cited by medical educators as an invocation to never forget the humanistic heart at the center of clinical care. But what if the patient is a jerk? That I haven’t met Mr. G, only read briefly about him, doesn’t stop these ugly feelings from surfacing. (shrink)

OBJECTIVE: How outside factors affect physician decision making remains an open question of vital importance. We sought to investigate the importance of various influences on physician decision making when clinical guidelines differ from patient preference. -/- METHODS: An online survey asking 469 primary care providers (PCPs) across four practice sites whether they would order magnetic resonance imaging for a patient with uncomplicated back pain. Participants were randomized to one of four scenarios: a patient's preference for imaging (control), (...) a patient's preference plus a colleague's opinion against imaging (colleague), a patient's preference plus a professional society's recommendation against imaging (profession), or a patient's preference plus an accountable care organization's quality metric that measures physician use of imaging (ACO). Demographic information and the reasoning behind participants' decisions also were obtained. -/- RESULTS: A total of 168 PCPs completed the survey, yielding a 36% completion rate. A majority chose not to pursue imaging: control 68%, colleague 85%, profession 87%, and ACO 78%. Multivariate logistic regression revealed that participants were more likely not to order advanced imaging only when reminded of a professional society recommendation (P = 0.017). Regression also suggested that practice site exerted an effect on the primary outcome. Evidence-based medicine and clinical judgment were the most cited reasons for the decision. -/- CONCLUSIONS: Our results reinforce the potential to leverage professional societies to advance evidence-based medicine and reduce unnecessary testing. At the same time, practice site appeared to exert influence, suggesting that these recommendations must be part of local institutional culture to be effective. (shrink)

Background: Patients prescribed with medication that treats mental health conditions benefit the most compared to those prescribed with other types of medication. However, they are also the most difficult to adhere. The development of mobile health (mHealth) applications (‘apps’) to help patients monitor their adherence is fast growing but with limited evidence on their efficacy. There is no evidence on the content of these apps for patients taking psychotropic medication. The aim of this study is to identify and evaluate the (...) aims and functioning of available apps that are aiming to help and educate patients to adhere to medication that treats mental health conditions. Method: Three platform descriptions (Apple, Google and Microsoft) were searched between October 2015 and February 2016. Included apps need to focus on adherence to medication that treats mental health conditions and use at least a reinforcement strategy. Descriptive information was extracted and apps evaluated on a number of assessment criteria using content analysis. Results: Sixteen apps were identified. All apps included self-monitoring properties like reminders and psycho-educational properties like mood logs. It was unclear how the latter were used or how adherence was measured. Major barriers to medication adherence like patients’ illness and medication beliefs and attitudes were not considered nor where information to patients about mediation side effects. Very few apps were tailored and none was developed based on established theories explaining the processes for successful medication adherence like cognitions and beliefs. Reported information on app development and validation was poor. Discussion: A variety of apps with different properties that tackle both intentional and unintentional non-adherence from a different perspective are identified. An evidence-based approach and co-creation with patients is needed. This will ensure that the apps increase the possibility to impact on non-adherence. Theories like social cognition models can be useful in ensuring that patients’ education, motivation, skills, beliefs and type of adherence are taken into consideration when developing the apps. Findings from this study can help clinicians and patients make informed choices and pursue policy-makers to integrate evidence when developing future apps. Quality-assurance tools are needed to ensure the apps are systematically evaluated. (shrink)

The concept of a digital twin comes from engineering.1 It refers to a digital model of an artefact in the real world, which takes data about the artefact itself, data about other such artefacts, among other things, as inputs. The idea is that the maintenance of artefacts—such as jet engines—can be vastly improved if we work with digital twins that simulate actual objects. Similarly, personalised medicine might benefit from the digital modelling of body parts or even whole human bodies. A (...) medical digital twin could use data about the patient, more general population data, and other inputs to generate predictions about the patient. This could lead to highly personalised interventions and nuanced judgments about the patient’s health. Matthias Braun2 discusses this intriguing prospect, asking how we should think about the way in which a digital twin could represent a patient. I will respond to Braun’s striking suggestion that we can regard a digital twin as an extension of the patient’s body. Notably, Braun does not compare his just-mentioned idea with the extended mind thesis popularised by Andy Clark and David Chalmers.3 But I am sure many readers will be reminded of the extended mind thesis. Accordingly, I will consider this comparison. I cannot discuss this comparison in detail, nor fully evaluate Braun’s suggestion. But I can say something about how we might approach this comparison, and provide some …. (shrink)

A vital and timely reminder that modern life owes as much to outlandish thinking as to dominant ideologies What do the Nag Hammadi library, Dan Brown’s The Da Vinci Code, speculative feminist historiography, Marcus Garvey’s finances, and maps drawn by asylum patients have in common? Jonathan P. Eburne explores this question as never before in Outsider Theory, a timely book about outlandish ideas. Eburne brings readers on an adventure in intellectual history that stresses the urgency of taking seriously—especially in an (...) era of fake news—ideas that might otherwise be discarded or regarded as errant, unfashionable, or even unreasonable. Examining the role of such thinking in contemporary intellectual history, Eburne challenges the categorical demarcation of good ideas from flawed, wild, or bad ones, addressing the surprising extent to which speculative inquiry extends beyond the work of professional intellectuals to include that of nonprofessionals as well, whether amateurs, unfashionable observers, or the clinically insane. Considering the work of a variety of such figures—from popular occult writers and gnostics to so-called outsider artists and pseudoscientists—Eburne argues that an understanding of its circulation and recirculation is indispensable to the history of ideas. He devotes close attention to ideas and texts usually omitted from or marginalized within orthodox histories of literary modernism, critical theory, and continental philosophy, yet which have long garnered the critical attention of specialists in religion, science studies, critical race theory, and the history of the occult. In doing so he not only sheds new light on a fascinating body of creative thought but also proposes new approaches for situating contemporary humanities scholarship within the history of ideas. However important it might be to protect ourselves from “bad” ideas, Outsider Theory shows how crucial it is for us to know how and why such ideas have left their impression on modern-day thinking and continue to shape its evolution. (shrink)

A vital and timely reminder that modern life owes as much to outlandish thinking as to dominant ideologies What do the Nag Hammadi library, Dan Brown's The Da Vinci Code, speculative feminist historiography, Marcus Garvey's finances, and maps drawn by asylum patients have in common? Jonathan P. Eburne explores this question as never before in Outsider Theory, a timely book about outlandish ideas. Eburne brings readers on an adventure in intellectual history that stresses the urgency of taking seriously--especially in an (...) era of fake news--ideas that might otherwise be discarded or regarded as errant, unfashionable, or even unreasonable. Examining the role of such thinking in contemporary intellectual history, Eburne challenges the categorical demarcation of good ideas from flawed, wild, or bad ones, addressing the surprising extent to which speculative inquiry extends beyond the work of professional intellectuals to include that of nonprofessionals as well, whether amateurs, unfashionable observers, or the clinically insane. Considering the work of a variety of such figures--from popular occult writers and gnostics to so-called outsider artists and pseudoscientists--Eburne argues that an understanding of its circulation and recirculation is indispensable to the history of ideas. He devotes close attention to ideas and texts usually omitted from or marginalized within orthodox histories of literary modernism, critical theory, and continental philosophy, yet which have long garnered the critical attention of specialists in religion, science studies, critical race theory, and the history of the occult. In doing so he not only sheds new light on a fascinating body of creative thought but also proposes new approaches for situating contemporary humanities scholarship within the history of ideas. However important it might be to protect ourselves from "bad" ideas, Outsider Theory shows how crucial it is for us to know how and why such ideas have left their impression on modern-day thinking and continue to shape its evolution. (shrink)

This is a review of the biographic drama Love and Mercy. More than a story of the evolution of The Beach Boys, it is the story of the lead Beach Boy, Brian Wilson, and his struggle with substance abuse, mental illness, family stress, emerging love, and a controlling psychologist. Interwoven are many bioethics themes, including the doctor–patient relationship, conflict of interest, autonomy, and patient welfare. For those unaware of the sadness and torment running directly alongside the sunny, bubbly (...) life of The Beach Boys, this film is an eye-opener. It is also a great reminder of the importance of boundaries between clinicians and their patients. (shrink)

The decision of the High Court in Bell v Tavistock has excited considerable discussion about lawful consent for puberty-blocking drug treatment for children with gender dysphoria. The present paper draws attention to a wider question that surfaces through this case: is informed decision-making an adequate practical tool for seeking and obtaining patients’ consent for medical treatment? Informed decision-making engages the premises of the rational choice theory: that people will have well-crystallised health goals; and, if they are provided with sufficient information (...) about medical treatments, then they will be able to choose the treatment that satisfies their goals. Whilst appealing, the informed decision-making paradigm is assailed by various fallacies, which apply not only to children but also to adults. In Bell v Tavistock, the High Court seems to have recognised such fallacies, and it rejected informed decision-making as an adequate tool for consent from children with gender dysphoria. Similar considerations apply to adults in various situations. Thus, Bell v Tavistock can be seen as an attempt to refine the views on the consent that were expressed by the Supreme Court in Montgomery. It can be inferred that the Supreme Court did recognise the limitations of informed decision-making, but it did not develop this point. Further work is required to formulate an adequate model of decision-making, and Bell v Tavistock serves as a useful reminder to rethink informed decision-making as the device for consent. (shrink)

Case 1 reminds us that patients have duties too, while case 2 presents an instance of justified withholding of informationHow refreshing to read these two cases! No conjoined twins, fantastical chimeras, or other incredible scenarios at the fringes of medical reality. Each case highlights the practical and theoretical difficulties that doctors face in their everyday practice.Case 1: In case 1, the patient, who had declined an HIV test, changed his mind and requested an HIV test on the request form (...) without informing the doctor. The pathologist performed the tests and returned the results to the unsuspecting doctor, who duly investigated the matter. The doctor’s anxiety at the situation, as well as the worries of the entire practice and pathology laboratory, must have been deeply unpleasant. Thus the patient, no doubt unintentionally, caused much distress by requesting the HIV test. He was, at the very least, guilty of a lack of foresight and consideration. As a minimum, he should have informed the doctor of his last minute alteration. This would have enabled the doctor to discuss the implications of the test, to organise appropriate counselling, and, most importantly, to receive the results in full knowledge of the situation.As Dr Fraser points out, the experience of case 1 reinforces the importance of taking good medical notes. Even if the patient’s refusal had been documented in the notes, however, this would not have prevented him from requesting the HIV test, and indeed other tests, on the blood form. Pharmacists may still occasionally be faced with situations when they are unsure whether the doctor prescribed 10 capsules of a drug, or 110 capsules, as the patient may have added a “1” in front of the doctor’s original prescription. Similarly, how …. (shrink)

The tremendous toll that COVID-19 has taken on this country’s minority population is the most recent reminder of the health disparities between people of color and people who classify themselves as white. There are many reasons for these disparities, but one that gets less attention than it deserves is the lack of physicians of color available to treat patients of color.

Although most theorists of healthcare rationing argue that rationing, including rationing that takes place in the physician–patient relationship is unavoidable, some health professionals strongly disagree. In a recent essay, Vegard Bruun Wyller argues that bedside rationing is immoral and thoroughly at odds with a sound view of the physician–patient relationship. We take Wyller to be an articulate exponent of the reluctance to participate in rationing found among some clinicians. Our essay attempts to refute the five crucial premises of (...) his argument yet build on his genuine insights. In our analysis, Wyller’s critique of bedside rationing is instructive both for harbouring some very common misconceptions that must be exposed and refuted, but also for offering important words of caution. In particular, bedside rationing must be performed in ways that do not harm the physician–patient relationship. Read irenically, Wyller’s critique is a reminder of what must not be lost in our painful endeavour to update the ethics of medicine to encompass the unavoidability of rationing. (shrink)

Lippert-Rasmussen and Petersen discuss my ‘Moral case for legal age change’ in their article ‘Age change, official age and fairness in health’. They argue that in important healthcare settings (such as distributing vital organs for dying patients), the state should treat people on the basis of their chronological age because chronological age is a better proxy for what matters from the point of view of justice than adjusted official age. While adjusted legal age should not be used in deciding who (...) gets scarce vital organs, I remind the readers that using chronological age as a proxy is problematic as well. Using age as a proxy could give wrong results and it is better, if possible, for states to use the vital information directly than use age as a proxy. (shrink)

In his posthumously published Living Up to Death Paul Ricoeur left an impressive testimony on what it means to live at a high old age with death approaching. In this article I present him as a teacher who reminds us of valuable lessons taught by patients in palliative care and their caretakers who accompany them on their way to death, and also as a guide in our search for a modern ars moriendi, after—what many at least experience as—the breakdown of (...) traditional religious belief in a personal afterlife. These lessons can be summarized in the following theses. ‘Living up to death, one cannot experience one’s own death. Therefore, never consider someone dying as moribund’. ‘Though everybody is alone in dying, nobody should die alone.’ ‘The preparation for death is an affirmation of life’. ‘Life experienced as a gift can be given up’. The plausibility of the last thesis, however, may go beyond the confines of austere philosophical thinking. (shrink)

Drawing chiefly on recent sources, in Part One I sketch an untraditional way of articulating what I claim to be central elements of traditional Catholic morality, treating it as based in virtues, focused on the recipients (“patients”) of our attention and concern, and centered in certain person-to-person role-relationships. I show the limited and derivative places of “natural law,” and therefore of sin, within that framework. I also sketch out some possible implications for medical ethics of this approach to moral theory, (...) and briefly contrast these with the influential alternative offered by the “principlism” of Beauchamp and Childress. In Part Two, I turn to a Catholic understanding of the nature and meaning of human suffering, drawing especially on writings and addresses of the late Pope John Paul II. He reminds us that physical and mental suffering can provide an opportunity to share in Christ's salvific sacrifice, better to see the nature of our earthly vocation, and to reflect on the dependence that inheres in human existence. At various places, and especially in my conclusion, I suggest a few ways in which this can inform bioethical reflection on morally appropriate responses to those afflicted by physical or mental pain, disability, mental impairment, disease, illness, and poor health prospects. My general point is that mercy must be informed by appreciation of the person's dignity and status. Throughout, my approach is philosophical rather than theological. (shrink)

Checklists have been used to improve quality in many industries, including healthcare. The use of checklists, however, has not been extensively evaluated in clinical ethics consultation. This article seeks to fill this gap by exploring the efficacy of using a checklist in ethics consultation, as tested by an empirical investigation of the use of the checklist at a large academic medical system (Cleveland Clinic). The specific aims of this project are as follows: (1) to improve the quality of ethics consultations (...) by providing reminders to ethics consultants about process steps that are important for most patient-centered ethics consultations, (2) to create consistency in the ethics consultation process across the medical system, and (3) to establish an effective educational tool for trainers and trainees in clinical ethics consultation. The checklist was developed after a thorough literature review and an iterative process of revising and testing by a group of experienced ethics consultants. To pilot test the checklist, it was distributed to 46 ethics consultants. After a six-month pilot period in which ethics professionals used the checklist during their clinical activities, a survey was distributed to all of those who used the checklist. The 10-item survey examined consultants’ perceptions regarding the three aims listed above. Of the 25 survey respondents, 11 self-reported as experts in ethics consultation, nine perceived themselves to have mid-level expertise, and five self-reported as novices. The majority (68 percent) of all respondents, regardless of expertise, believed that the checklist could be a “helpful” or “very helpful” tool in the consultation process generally. Novices were more likely than experts to believe that the checklist would be useful in conducting consultations. The limitations of this study include: reduced generalizability given that this project was conducted at one medical system, utilized a small sample size, and used self-reported quality outcome measures. Despite these limitations, to the authors’ knowledge this is the first investigatation of the use of a checklist systematically to improve quality in ethics consultation. Importantly, our findings shed light on ways this checklist can be used to improve ethics consultation, including its use as an educational tool. The authors hope to test the checklist with consultants in other healthcare systems to explore its usefulness in different healthcare environments. (shrink)

This book is a collection of essays by a variety of specialists with a particular interest in palliative care. It contains seven chapters by six different authors. The first chapter Why is the study of ethics important? is by Patricia Webb, a lecturer in palliative care with a background in nursing. She tells us that studying ethics encourages logical reasoned thinking in the face of difficult decisions such as allocation of resources, access to services, best care, clinical research, and rights (...) to life. Webb reminds us that clinical guidelines may not be much help in the face of an ethical dilemma with no clear right or wrong answer. The chapter called Care versus cure by David Jeffrey, a consultant in palliative medicine and writer on medical ethics, reminds us that care is concerned as much with the subjective feelings of the patient as with the physical disease, and aims …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Phenomenological Interviews and Tourette'sThe authors report no conflicts of interest.We appreciate the responses from the two clinicians, Efron and Mathieson. We agree with their reminder about the holistic nature of clinician's engagement (mood, sociality, and work life) and with their emphasis on patient-reported outcome measures, although this is not quite what we did in our interviews. As has recently been recognized in section 24 of the Victorian Mental (...) Health and Well-being Act (to provide a local Australian example), patients and caregivers' "lived experience makes them valuable leaders and active partners in the mental health and wellbeing service system."1In this paper, however, our aim was both more modest and immodest: modest, in that we aimed to work with those "leaders and active partners" to generate a more adequate account of lived experience in concert with behavioral symptomatology; immodest, in that we wondered how the lived experience of Tourette syndrome (TS) aligned (or not) with some of the commonly ascribed features of the condition. Although phenomenology as a discipline does not own lived experience, of course, it is more systematically treated in this tradition, starting with elaborations of Erlebnis.Efron and Mathieson note that older patients are more likely to describe urges or premonitory urges (PUs). This raises the priming question: Has greater exposure to and involvement in medical concepts and treatments transformed the nature of their self-report, or has it provided them with more phenomenological skills, enabling them to pick out discrete parts of experience? Or perhaps they have just been exposed more frequently to the experience over time? We address some related issues below, in our reply to Fernandez, where we outline our interview techniques more fully.They end by noting that the aim of comprehensive behavioral intervention for tics is to become attentive to PUs to better block tics. This is complex and understudied. In principle, becoming aware of something cognitively and experientially can foreground or even perhaps induce that experience. Conversely, from the TS scholarship, we know that attending to urges in certain ways (e.g., via acceptance training) can also reduce perceived urge frequency and intensity (see Gev et al., 2016). We would welcome further work on this link between attention and experience in TS. [End Page 49]Response to FernandezBecause our paper was partly framed around Fernandez' own work on phenomenological psychopathology, we welcome his invitation to provide further "inspiration and guidance" for other phenomenological researchers conducting empirical studies, who may also be dealing with the challenge posed by "narrative habits." When an interviewee uses well-worn medicalized terms to describe their experience, it is not clear whether these descriptions genuinely reveal or rather occlude the experience in question. There are sometimes, perhaps often, second-person phenomenological 'tells' regarding interviewees genuinely re-evoking an experience, but for interviewers it still raises the question of how to prompt alternative and potentially more accurate descriptions of experience.Because of this challenge, we purposely did not use the term "urge" or "premonitory urge" (PU) in our interview questions. Instead, we asked about (and used the broader term of) "experiences" that may occur prior, during, or after ticcing, without assuming that there are such experiences in the first place. We guided interviewees to evoke the memory of a specific, singular tic event (a tic token; see Curtis-Wendlandt 2020, 2023). Once a memory of such an event had been identified, we asked interviewees the following three lead questions:1. What, if anything, did you experience during this tic?2. What, if anything, did you experience before this tic?3. What, if anything did you experience after this tic?The temporal framing of these questions counters common trends and assumptions in the scholarship, which has focused heavily on pre-tic experiences, with little attention given to post-tic experiences (reduced to notions of "relief" and barely investigated), and even less to experiential explorations of the tic itself. Our catalogue of supporting questions sought to elicit fine-grained descriptions of evoked/recalled experiences along sensory and cognitive-affective dimensions:•. Did you see anything before, during, or after this tic? If so, what did you see?•. Did you hear anything... (shrink)

The late Robert Veatch, one of the United States’ founders of bioethics, never tired of reminding us that the paradigm-shifting contribution that bioethics made to patient care was to liberate patients out of the hands of doctors, who were traditionally seen to know best, even when they decidedly did not know best. It seems to us that with the advent of COVID-19, health policy has come full-circle on this. COVID-19 gave rise to a large number of purportedly “ethical” guidance (...) documents aiming to assist health care providers and practitioners with responding to the ethical challenges that might arise in their response to the pandemic. Ethics has two primary functions: provide clear action guidance, and provide clear action justification. The documents in question arguably reflect the ultimate policy triumph of bioethical “principlism”, and, perhaps surprisingly, as a corollary, the ultimate triumph of “doctor-knows-best”. (shrink)

Medicine seeks to overcome one of the most fundamental fragilities of being human, the fragility of good health. No matter how robust our current state of health, we are inevitably susceptible to future illness and disease, while current disease serves to remind us of various frailties inherent in the human condition. This article examines the relationship between fragility and uncertainty with regard to health, and argues that there are reasons to accept rather than deny at least some forms of uncertainty. (...) In situations of current ill health, both patients and doctors seek to manage this fragility through diagnoses that explain suffering and provide some certainty about prognosis as well as treatment. However, both diagnosis and prognosis are inevitably uncertain to some degree, leading to questions about how much uncertainty health professionals should disclose, and how to manage when diagnosis is elusive, leaving patients in uncertainty. We argue that patients can benefit when they are able to acknowledge, and appropriately accept, some uncertainty. Healthy people may seek to protect the fragility of their good health by undertaking preventative measures including various tests and screenings. However, these attempts to secure oneself against the onset of biological fragility can cause harm by creating rather than eliminating uncertainty. Finally, we argue that there are good reasons for accepting the fragility of health, along with the associated uncertainties. (shrink)

This study traces the manner in which the evangelist Mark presents Jesus as a healer. While this is the primary focus, I am also interested, from an identity perspective, in why Mark is keen to present Jesus as the best physician. Healers during the 1st century were varied. Cities had professional healers with great knowledge of the Greek Hippocratic tradition. The entire empire had famous temples of Asclepius and Apollo. Common people had diverse knowledge about various illnesses with remedies varying (...) from herbs to exorcisms. Amidst all this and located in southern Syria in the northern regions of Galilee, Mark presents Jesus as a healer. The study concludes that Mark presents Jesus as an efficient healer with great power and authority. Though Mark is mute regarding other healers such as Asclepius and Apollo, near whose temples patients would sleep for days waiting for healing, he wants to remind the adherents of Jesus’ movement that they are following a great physician. A few selected stories from Mark’s gospel illustrate this argument. (shrink)

“Moral hazard” is a term familiar in economics and business ethics that illuminates why rational parties sometimes choose decisions with bad moral outcomes without necessarily intending to behave selfishly or immorally. The term is not generally used in medical ethics. Decision makers such as parents and physicians generally do not use the concept or the word in evaluating ethical dilemmas. They may not even be aware of the precise nature of the moral hazard problem they are experiencing, beyond a general (...) concern for the patient's seemingly excessive burden. This article brings the language and logic of moral hazard to pediatrics. The concept reminds us that decision makers in this context are often not the primary party affected by their decisions. It appraises the full scope of risk at issue when decision makers decide on behalf of others and leads us to separate, respect, and prioritize the interests of affected parties. (shrink)

The aim of this article is to continue the discussion about factors of importance for an including ethics of care. A further polarization between partiality and impartiality does not seem a relevant approach. What is important is to direct attention both to the other and to the third person, which requires an acknowledgement of responsibility that extends beyond established relationships. Thus, we need to draw attention not only to the vulnerability existing within every seriously ill or injured person, but to (...) factors of importance for marginalization of groups like refugees, people suffering from serious mental illness, and substance misusers, to mention some in the Western world. Marginalized groups are groups experiencing a discrepancy between need of health care and care given. They are not given proper priority in the distribution of resources, and they may experience ignorance when they first meet the healthcare system as patients.Efforts to understand what circumstances can lead to inadequate inclusion indicate that the elements of differentness and extensive losses of life contexts which may be causing feelings of hopelessness and helplessness in the health professionals, are key factors posing challenges to empathy both within and beyond established relationships, besides geographical distance. Groups of people who have suffered extensive loss in their life contexts may be threatening for us, as they reflect our own fears, and remind us of our own vulnerability.I raise the question: How can we contribute to meeting the need for an ethics of care that extends beyond the familiar to the unfamiliar both in established and non‐established relationships? (shrink)

_The Social Work Psychoanalyst's Casebook_ begins with an interview with Dr. Sanville, who reflects on her evolution as a social work analyst, theoretician, writer, teacher, and leader. These reminiscences are followed by accounts of nine analytic treatments, each of which offers an unusual window into what actually transpired between analyst and analysand during the treatment hours. These case studies concern particularly troubled, often traumatized patients-the very "hard to reach" or "difficult to treat" clients with whom social workers have long been (...) familiar. They include a reanalysis by the same analyst of a patient whose first therapy ended in a stalemate; an account of transference and countertransference phenomena during termination; a report on the analysis of a young woman who experienced both chronic and stress-related trauma; and an account of the special issues involved in the treatment of an aging woman. Most of the case studies reflect the influence of Dr. Sanville, whose work has long evinced the therapeutic imagination and disciplined creativity to which all the contributors aspire. Tthe contributors to this volume offer the salutary reminder that analytic work is built on a relationship of respect and empathy and that treatment success follows from the therapist's willingness to accommodate the unique needs of individual patients. In honoring Jean Sanville, _The Social Work Psychoanalyst's Casebook_ speaks to the robustness of a multidisciplinary approach to psychopathology that transcends the bounds of any single profession-an approach in which contemporary psychoanalysis is enlarged by the insights and emphases of social work just as social work is enriched by the clinical wisdom of psychoanalysis. (shrink)

Background: Suicidality is a life-and-death struggle in deep loneliness and psychological pain. There is a lack of knowledge about what could help the suicidal patients’ struggle for continued life. The aim of this study was to develop a deeper understanding of suicidal patients in the aftermath of suicidal attempts. The research question was ‘What resources in the person himself or herself and his or her surroundings are crucial in a suicidal crisis to maintaining the will to live and hope for (...) life’? Methodology: The study has a hermeneutic approach and an explorative design. Data were collected using semi-structured interviews with 10 participants: men and women 21–52 years of age. The context was two emergency psychiatric units and one crisis resolution team. Ethical considerations: The participants signed an informed consent before the interviews were conducted. Findings: This article presents three themes: becoming aware of the desire to live, an experience of connectedness and someone who cares. Discussion: The suicidal person’s awareness of wishes, dreams, hopes and will, but also of their feelings in the aftermath of the suicide attempt, seemed to play a crucial role in a suicidal crisis. Experiences of connectedness remind the person of the responsibility in his or her own life and in the lives of others and seemed to strengthen the urge to go on. Private and professional relationships seem to be crucial in stimulating the desire and hope to go on living. Conclusion: Becoming aware of the desire to live, being connected to others and experiencing someone who cares is necessary for life. Both private and professional networks seemed to be important resources that could remind the suicidal person of his or her own dignity as part of being human. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.4 (2003) 353-355 [Access article in PDF] Emotions and Narrative Selves Valerie Gray Hardcastle In their commentaries, both Phillips (2003) and Woody (2003) agree that the affective side of personhood needs to be better addressed in narrative views of self. In their arguments, they focus mainly on how a patient or a subject is here and now. In contrast, Kennett and Matthews (2003) take (...) a longer view and argue for the importance of a diachronic unity for selfhood. This commentary seeks to integrate these views by discussing how emotions are central to building our personal sense of unified agency. 1Phillips and Woody are right: most philosophical discussions of the narrative view of self are overly cognitive and focus too much attention on our linguistic story-telling abilities and not enough on what it is like to be a person experiencing the world. This is too bad, for it is our affective reactions that drive our personal life narratives. Consider: of all the experiences in the world, we only chose a small subset to become or represent who we are. I regularly eat cold cereal for breakfast before heading off to work, but if you ask me to describe myself, I describe my work or my children, not my breakfast-eating habits. Why is this? I identify with my work, my family life, or my play, but not with my sleeping patterns, the trajectories I chose when I drive, or how I brush my teeth. How is it that I have selected the former activities to highlight in my self-stories, but not the latter?I maintain that I choose the former because I have strong affective ties to them, ties that I do not have to driving routes or personal hygiene. And these ties are what determine what gets into our narratives of self. Actually, my claim is stronger than that. I believe that our emotions not only color what we do but they also allow us to act in the first place (this discussion is greatly expanded in my forthcoming book).Humans delight in pretending that our most prized and most humanly attribute is our forebrain, which houses, we also pretend, our capacity for rational thought. Since Plato at least we have held that subduing our passions to the iron rule of reason is our supreme aspiration; it is the ideal for human cognition. Ironically, we think that the more we are like Star Trek's alien Mr. Spock, the more human we really are.But what would life really be like with an overdeveloped forebrain and without emotion? Let us consider more carefully what it is we really prize about being human. We can rationalize well, it is true, but we do so in the service of personal goals. As Aristotle reminds us, we have practical rationality; we have means-ends reasoning with a point. This is just another way of saying that it is imperative that we identify what is important to us prior to cognizing.Obviously, one might scoff, we need an end to engage in means-ends reasoning. But often, I think, what having an end entails is not well appreciated. These days it is fashionable to believe that our fundamental ends—survival and reproduction—are set by our biology and that all [End Page 353] other ends (or most other ends) derive from them in some fashion. Maybe this story is true, but it obscures how ends—whether they be hardwired in or they come later—function in the human psyche.At a bare minimum, that we have particular ends tells us that we have to tag our abstractions, interpretations, and matched patterns with valances—some things are good, some things are bad, and some are indifferent. Tagging our experiences thus is just what it means to have emotions; we are reacting affectively to our world around us. And it is these reactions that determine which inputs we respond to and which we ignore. We literally cannot move about in our world without emotion. I think, perhaps, that this fact is what Phillips and Woody are... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Anorexia and the MacCAT-T Test for Mental Competence:Validity, Value, and EmotionLouis C. Charland (bio)Keywordsmental competence, decisional capacity, anorexia, value, emotionValidity of the MacCAT-THow does one scientifically verify a psychometric instrument designed to assess the mental competence of medical patients who are asked to consent to medical treatment? Aside from satisfying technical requirements like statistical reliability, results yielded by such a test must conform to at least some accepted pretheoretical (...) desiderata; for example, determinations of competence, as measured by the test, must capture a minimal core of accepted basic intuitions about what competence means and what a theory of competence is supposed to do. The concepts of "face validity" and "content validity" are both important here. Face validity "indicates that an instrument appears to test what it is supposed to and that it is a plausible method for doing so" (Portney and Watkins 2000, 82). Content validity "means that the test contains all the elements that reflect the variable being studied" (Portney and Watkins 2000, 83). An adequate instrument for measuring mental competence must at minimum satisfy both of these requirements.What Tan and her colleagues (2006) have shown is that the MacArthur Competence Assessment Tool—Treatment (MacCAT-T) test for mental competence may not be an empirically valid measure of mental competence for some cases of anorexia. The data they report show that "competence," as measured by the MacCAT-T, does not conform sufficiently well with what is wanted of a clinical medical theory of competence. More specifically, the MacCAT-T is deficient in both face and content validity. This result is extremely significant; previous challenges to the validity of the MacCAT-T have often been largely theoretical in nature. My own objection that the MacCAT is inadequate because it omits the influence of emotion is based on a combination of empirical theory (Charland 1998a) and philosophical argument (Charland 1998b). However, it is entirely theoretical in nature. So is my argument that in ignoring emotion the MacCAT misses a crucial contributing ingredient in competence, namely, value (Charland 2001, see especially 136 note 2). Tan's study provides valuable empirical evidence for the second of these challenges, which deals more specifically with value. On the one hand, the study clearly demonstrates that patients sometimes do [End Page 283] base their treatment decisions on reasons derived from values. And on the other hand, it also nicely illustrates the centrality of values—"utilities" or "preferences"—in the decision-making process generally; a basic assumption of standard decision theory for which, paradoxically, there appears to be no satisfactory counterpart in the MacCAT-T model of reasoning and decision making.Thus, values figure among the reasons that patients actually use in reasoning when they weigh the risks and benefits of proposed treatment options. The MacCAT-T must be amended to incorporate this fact if it is to be a satisfactory clinical medical tool. Without such a correction, the concept of mental competence it measures is empirically invalid. At the root of the problem is a clash of intuitions. Tan's data provide convincing evidence that some of the patients who are deemed to be mentally competent by MacCAT-T standards should not in fact be considered competent. Note that the language in which this clash is expressed—"should not in fact"—involves a combination of descriptive and prescriptive elements, reminding us that the concept of competence is dual in nature: it is both prescriptive and descriptive (Freedman 1981). These problems underscore the need for greater clarity about what pretheoretically we want a clinical theory and test of competence to capture. It is of course reasonable to say that such a test must be consistent with major tenets of the relevant case law (Appelbaum 1998). But a legally valid concept of competence of this sort is too thin and arbitrary a foundation on which to build a clinical medical theory of competence. An empirically valid theory and test of the latter sort must incorporate the role of values if it is be truly helpful in medical practice.Value and the MacCAT-TI agree with Tan and her colleagues that some notion of "pathological value" needs to be... (shrink)

The editorial in the September 1982 issue of this journal and many articles before and since have addressed the problem of informed consent. Is it possible? Is it a useful concept? Is there anything new to be said about it? In this article the basic rationale of the rule (patient autonomy) is explained and the extent of the rule explored. Various exceptions have been offered by the law and an attempt is made to catalogue the chief of these. A (...) number of specially vulnerable groups are then identified, the most important, and vexed, being children. How can informed consent be secured in the case of young patients? Finally, a few problems are mentioned in an attempt to get this subject back to reality. The appeal to the principle primum non nocere may be medical paternalism in disguise. Informed consent is the competing principle that reminds us of the primacy of human autonomy. A pointer is given to the future: even the use of sound recordings to explain medical procedures and to activate informed consent so that it may become a reality and not just a lawyer's myth, should be considered. (shrink)

June 2022 A Revolutionary New Metaphysics, Based on Consciousness, and a Call to All Philosophers We are in a unique moment of our history unlike any previous moment ever. Virtually all human economies are based on the destruction of the Earth, and we are now at a place in our history where we can foresee if we continue on as we are, our own extinction. As I write, the planet is in deep trouble, heat, fires, great storms, and record flooding, (...) weather patterns drastic everywhere. Capitalism has been so successful in supplying us with an endless array of consumer items, that we have never noticed there is a cost. But there is a cost, the cost is the very life of the Earth herself, and now the day of reckoning is here. Days of reckoning are most often days of rath. But I am hoping that this is a day of major Awakening over the entire planet. We have caused a crisis so great for the Earth we can hardly get our minds around it. But I am proposing that deeply embedded in the crisis are ideas, about who and what the Earth is, Ourselves, and what we are here for. I am proposing that this is a call to all philosophy and philosophers to rethink ourselves from the ground up. The human race has never gotten the Earth right and now we must, for the Earth is the true foundation for civilization. We are in deep trouble with the Earth, and it owes to the fact that the great male thinkers never got the Earth right, they could never make the connection between the life of mind and the life of the Earth. I am proposing that deeply embedded in the crisis we are in are ideas. And that in fact the planet is in the grip of a false metaphysics, and scientific image of nature that really comes most recently from Descartes. His conviction that matter, and with it the Earth, are simply the weighable, the measurable the extended in space and time, utterly devoid of any inner life of mind thoughts or Consciousness. This view of matter and the Earth goes back to the very dawn of thought, Descartes is just its most recent and comprehensive version of things. This view of matter is really a false metaphysics that dominates most of the modern world and underpins the whole scientific image of nature itself. I am proposing this is a false metaphysics and offering a new version of things based on Consciousness. If there is a single idea fueling and driving the destruction of the planet, it is the conviction that the Earth is something without Consciousness. When you intend to ravage and savage the planet, turn it into consumer items to be converted into money in the bank, first pretend that all of the bright beings in the natural world are devoid of Consciousness, just “things” you do not have to have any conscious about destroying them. I am proposing that this term Consciousness, that has appeared as term and a problem for modern science, is the key to getting ourselves right with the Earth. I propose this new theory for science will ramify into every other disciplines as well, and the ways we think just about everything. This old paradigm based on a false theory of matter, has run its course, it has brought us to the brink of our own extinction. We need new ideas, and we need them now. You will find my recent work in the Scientific God Journal under the title: Consciousness as the Organizing Principle, and a very complete version of my arguments for this term Consciousness, along with radical reinterpretation of modern science itself, on the Galileo Commission site. It is a radical moment for all of the thinkers among us, take this as my small contribution to rethinking ourselves in new terms, based on my understanding that the true basis for the whole of Being, the Universe, the Cosmos, and with them Ourselves, is this term Consciousness. And unpack it. And I predict that with this term Consciousness every intractable human problem in both science and the modern world will go down like a line of dominos before it. And so, here are a few new ideas I would offer you. These are the times of the Reappearance of the Feminine, a great Awakening as of Springtime after a long dark and lonely Winter. We are leaving behind us an old civilization based on male dominance, fear lies and control, now in decay, disease, and death disintegrating all around us. We are moving into a whole new civilization based on Love and Truth. A new civilization requires new basic terms values and first principles. And so, I return to Descartes. 1. Just over 300 years ago a young man travelling with the army found himself stranded in a foreign town in a bare room lit by a candle with nothing to do but think. And in a couple of nights Descartes laid the entire thought foundations for modern science and most of the modern world. It isn’t clear that modern philosophers with their funding sources of grants, their graduate students, their reputation and all the perks and privileges of academia can do any better. Descartes claimed there are just two principles in the Universe, Matter and Mind. God was pure mind; human beings were mind and matter. And we are the only ones on the planet with mind. Everything else all of the bright array of beings who share the planet with us are simply matter. And matter? The weighable the measurable the extended in space and time utterly devoid of any inner life of thoughts, feelings, or Consciousness This classification was a boon for developing science. Scientists did not have to worry about any inner life in nature, ideas or Consciousness, they could just set about weighing and measuring, as they have until the present day. But it was a disaster for the Earth. Earth was once worshiped as a Goddess. With Descartes she became almost overnight “things.” Simply commodities and resources, an endless of supply of consumer items, to be turned into money in the bank. And now Descartes concept of matter is up for us. If there is a single idea that is enabling and driving the destruction of the Earth, it is the conviction that Earth is something without Consciousness. This whole scientific image of nature as something devoid of Consciousness is driving the destruction of the Earth, and driving us all insane, and it needs to change. Ever since Descartes formulated Dualism, scientists and philosophers have been trying to get rid of it. They have done this by attempting to make matter the fundamental term of reality, and to explain mind or Consciousness in terms of matter. And now, Consciousness has emerged as term and a problem for modern science. 2. The prevailing Universe picture has been mainly based on the belief that Consciousness appears only at the end of evolution in ourselves and some of the higher animals when matter attains “a certain state of complexity” and it is produced by neurons in the brain. But Consciousness is nothing real in itself, the neurons are doing the work, Consciousness is simply a byproduct of neural activity. As William James summed up this position, not his: Consciousness is to the brain as a shadow to the runner, it runs beside him but never influences his stride. And so, the great problem of neuroscience: How do neurons produce Consciousness? So far, no one has been able to say how. All we have is parallelism. Two processes are running in parallel a train of neural events and a train of Consciousness events. And so, which one is primary? The face of neuroscience and much of the modern world is that the neural events are what is really real, Consciousness is secondary. The conviction that Consciousness is something produced by neurons is so deeply held and has been so for so long, that it seems like an obvious fact. It is in fact an assumption and a theory, and it could all well be the other way around. The scientific image of nature as something devoid of Consciousness is now up for us. It has enabled the destruction of the Earth, and we are now at a unique place in our own evolution where we can foresee if we continue on as we are, our own extinction. And so, there are the best reasons for rethinking Descartes concepts of matter. Scientists and philosophers have been trying to escape dualism by making matter the fundamental term. And now, this has not worked. In a nutshell: The mind body problem, the “hard problem of Consciousness” ---how do neurons in the brain, atoms and molecules give rise to ideas thoughts and feelings and who what and where is the “I” who sees them? And then, the near-death experience. I remind you of the truth of the near-death experience. The body in the bed is brain dead eeg flat, but the patient, pure Consciousness is hovering at the ceiling watching the doctors work over the body below, able to read dials he could not have seen from the bed, sometimes able to events in the corridor beyond the room, all subsequently confirmed by the doctors. Evidence as good as it gets that the patient really was out of his body. And so, the patient is able to see without eyes, hear without ears and to think and remember without a brain. There is not a single scientific principle that can account for this. And I am proposing that the near-death experience is a threshold and a key for a much deeper understanding of the Universe. These three problems are so hard they cannot be solved by present scientific principles and therefore call all present principles and ways of thought into question. When your axioms cannot account for the data, it is time to drop them and find better fundamental terms. We have not been able to solve the problems of Consciousness with the assumption that matter is the most basic and fundamental term. And so, if Cartesian dualism is to be overcome at all, we need to try it the other way around. 3. We are in the position of Copernicus. Remember Copernicus? He was making his calculations on the assumption that the Earth was the center of the Universe until they became so unwieldy that he decided to try it all the other way around. To make the sun the center, the Earth revolving around it. And lo, all of his data fell neatly into place. I am proposing a whole new Universe picture. Evolution makes us continuous with every other being, Consciousness would not be in us if it were not in them also, and then, in the atoms and molecules and cells that make up living beings. I propose to make Consciousness the most basic term and see what follows. I am in fact, proposing a new Copernican Revolution, that Consciousness is the true basis for the Universe and the right fundamental term, for science itself all other disciplines as well, and the whole of the modern world. And I predict that every intractable problem in science or the modern world, will go down like a line of dominos before it. In a nutshell: Consciousness and not matter is “first and fundamental” in the Universe, it is there from the very “Beginning” everything has it and all of the true causalities, the explanatory principles belong to it. Not to matter. What then is matter? All matter is an Appearance of something much more real, Consciousness. All matter is an expression of Consciousness, even the least little bit of matter contains Consciousness, and is an expression of Consciousness. And so, we revise the scientific image of nature. Science at present is two termed, matter/energy. It needs to become three termed: Matter/energy/Consciousness, with the recognition that all of the basic principles, the true causalities of events, and of the Universe belong to Consciousness. And now physics. To accommodate this new Universe picture physics needs to alter just one term, energy. All energy contains Consciousness, that idea alone will change our world forever. The animals the trees the plants are just as conscious as we are, as is the Earth herself, a continuum of many forms of Consciousness of which our own is one. The Earth consists of interacting and intersecting forms of Consciousness, Consciousness within Consciousness within Consciousness within Consciousness. A remarkable work has just appeared entitled “Beyond Words What Animals Feel and Think.” Describing in detail how like ourselves all of the animals are. And the more we can see how like us everything else really is, the harder it will be for us to do them all in, in the interest of turning them into consumer items. And so, here is a new principle of understanding, that entails completely new forms of explanation, and a whole new Universe picture to be spelled out in terms of Consciousness and its various properties. This is a Universe that is aware awake and Enspirited throughout. And so, there is only one principle, not two. And so, how does Consciousness work? There is “no mind/body problem.” My Consciousness is aligning the Consciousness of neurons in the brain, that aligns the Consciousness of all other cells in the body, that aligns the Consciousness of molecules and atoms themselves. Mainly from the top down, but also interactive, and not reduction to the purely physical forces. 4. And so, here is a radical new Universe picture, and with it a new way to think about the Universe itself, the Earth, Ourselves, and Spirit. It requires a complete revision of both of the terms of modern science itself. The problem of the modern world owes in deep measure to Descartes concept of matter as something devoid of interior life. But he is only the most powerful and simple expression of a whole tradition of thought that predates him, that goes back to the very dawn of thought itself. It owes to the conviction of both Plato and Aristotle that the Earth was something devoid of reason, or mind, and therefore something to be held in complete contempt. We are emerging from a civilization based on contempt for the Earth, and down the road, it will become contempt for the body, sex, women, the Native people, and people of color everywhere. And so, this entire tradition is now up for us, it has brought us to the brink of our own extinction, and we need to get beyond it. I am proposing that this term Consciousness is the way out. The missing piece of the puzzle and the idea whose time has come. And it will enable us to move into a completely new civilization based on respect for the Earth, women, sex, people of color, that honors everyone and has a place for all. Revolutions in science occur when new data show up that cannot be accounted for by existing paradigms (Thomas Kuhns: The Structure of Scientific Revolutions). Consciousness, and all the properties and problems of Consciousness are just such data, and they compel a new scientific revolution. But we are a scientific age. A new Copernican revolution in science is such as revolution everywhere. And Consciousness is the key to getting every other reality at all levels and depths right as well. It will enable us finally to get the Earth right, get ourselves right with the Earth, and with one another. Archimedes: Give me a place to stand, and I will move the world. I am proposing a new synthesis among our fundamental terms in which this term Consciousness is the new lynchpin. And so, I return once more to Descartes. Descartes in the Mediations was a dualist, they were two realities interacting in the pineal gland mind and body. But Descartes age was high on “Cartesianisms,” on Descartes concept of matter. Animals were simply cleverly wired machines (Hobbes called them automata). Rumor had it that Descartes followers went about kicking dogs reasoning that their howls were not due to any feelings of pain, but simply the wiring of the machine. We have been doing this to the Earth ever since, and now the Earth is not going to stand for it any longer. It is time we all woke up. There is no matter in Descartes sense of it, or in Plato and Aristotle’s sense of it. This old concept of matter is embedded in all of the crisis and catastrophes---fires, drought, pandemics, over population, the disintegrating economies, our ways of life, capitalism and consumerism themselves. All matter is Enspirited, contains Consciousness, and is an expression of Consciousness. Now I tell you something about Descartes you may not know. In the Mediations was a dualist, there are minds and bodies. But by the end of his life, he knew the truth. Descartes guided his whole life by these vivid dreams, and toward the end of his life he had this dream: He saw the Universe as a giant machine and in the heart of the machine propelling the whole, was Consciousness. And so, out of the shades and shadows and into the light of day. Here is a renewed and a new science, a new cosmology. And with it, a revolutionary new metaphysics. The whole of the modern world is in the grip of a false metaphysics, based on Descartes theory of matter. Here is a new, and finally true metaphysics based on the single term, Consciousness. 5. And in all my works, I spell out this new metaphysics based on Consciousness, and what it means for how we think about virtually everything: The Universe, the Earth, Ourselves, and Spirit. Of who, what and where Spirit is, that we may connect with Spirit everywhere. There is only one term for the Universe, and not two, this single term Consciousness, that manifests itself in two modes: Consciousness in Form, Consciousness Formless. And so, here is a sketch of what this new term Consciousness really means. For four great aspects of the real, four new cornerstones for a whole new civilization on Earth, based on Love and Truth. A. For the Universe: New causalities, all matter is an expression of Consciousness, awake and aware, Enspirited throughout, which has a place for the causalities of love ideas intent plan and purpose, what Aristotle called final causality, that for the sake of which. And it has a place for subjectivity, the greatest mystery in the whole of the Universe, knowable only in ourselves, but there in everything else as well, bedrock in the chain of causalities. The buck stops here. Here are two very different Universe pictures. The Cartesian Universe consists of things, pushed, and pulled around by the physical forces that function blind. The true Universe consists of selves and not things. Selves at least in ourselves, are organized and focused about an I, an I am, or a sense of self in everything, ever other being dear to itself. Just one aspect of subjectivity. And so, it is Consciousness all the way down, and subjectivity all the way down. Science proceeds on the basis of the negligible of what it can leave out as unimportant. Subjectivity is the ultimate animating principle of the Universe. What Descartes really did was to strip from nature what is most essential about it, its animating principle Consciousness. And so, we come out of a long history of “clunk.” The great male thinkers have killed creation. First in concepts and now in the lived life. And so, after centuries of fruitless search, not all of it in vain, finally, and just in time the true basic principle for the Universe has shown up in virtually all disciplines, this term Consciousness. B. And so, the Earth: What does this term Consciousness really mean for the Earth? It means that all of the bright array of beings around us have Consciousness. And the more we can realize how like us they are, the harder it will be to do them all in. Is this what it really means to be “made in the image of Spirit?” To destroy ever other living being? The god of Genesis is a creator god who has created billions and billions of living forms. Man, taking himself to be made in the image of Spirit has destroyed virtually all of it. The Earth is not things, not commodities and resources, not an endless array of consumer goods. The Earth consists of conscious living spiritual beings like ourselves, who need to be honored and respected, nurtured and cared for, to be Loved. And if the human race can finally pull it off and bring Love here and start helping the Earth rather than destroying her, even our vast numbers now at 8 billion, may not matter. Deeply embedded in the modern world is a false cosmology based on the hitherto useful but ultimately false metaphysics of Descartes. In particular it owes to Descartes concepts of matter, and of the Earth, as something devoid of Consciousness. And now this concept is up for us. If there is a single idea enabling and driving the destruction of the planet, it is the conviction that the Earth is something devoid of Consciousness. And we all have a vested interest in keeping this false concept in place. When you intend to ravage and savage the Earth, to turn it into consumer items, and money in the bank, first pretend she has no Consciousness that way we need not have any conscious about it. We are in deep trouble with the planet. Virtually all human economies are based on the destruction of the Earth, and we are now at a place in our history where we can foresee if we continue on as we are, our own extinction. And so, here are a few new guiding principles for the planet, based on Consciousness. Consciousness has field properties. The Earth is Consciousness throughout, connected and interconnected throughout, intersecting and interacting fields of Consciousness of which our own is one. To harm one is to harm all. Only this understanding of the Earth can set our destructive technologies, and capitalism, their goals, and their limits. The real problem with capitalism, and with civilization itself is it has no true understanding of the Earth, all the exquisite networks and webworks that connect all beings with one another. Nor it is about to admit that the Earth is our “life support system,” reason gone insane in the modern world. We are destroying our life support system, capitalism is the full expression of the human death wish in the modern world, and it needs to change. And now, let the barriers between ourselves and all other beings go down. C. And so, Ourselves. This new Universe picture based on Consciousness opens into and has a place for new concepts of human identity. In particular, it has a place for reincarnation, a process whereby one Consciousness dons’ bodies again and again and lays them down. This is a process wholly impossible on materialistic theories. This new view of things puts a higher perspective on Freudian determinism, which is a partial knowing in a greater account. We are something more than the victims of genes drives and childhood. We are immortally eternal evolving spiritual beings who take on a cycle of earthly lives in order to achieve certain goals and abilities, and then, our earthly cycle complete, we depart the Earth plane for other areas of the Universe physical or purely spiritual, to continue our evolution elsewhere. The scientific evidence for reincarnation is increasing on all sides, see for example the work of Michael Newton, a mainstream scientist forced to confront the fact of reincarnation. A completely new reincarnational picture is now emerging everywhere. We choose our parents for abilities we could acquire through them. We all come here with reasons for being here, and we all have free will, an original property of Consciousness, and we work out our issues accordingly. We all come here with the same reason for being here. It is to experience the Earth plane and human society at all levels and depths, in every social role, every climate, both sexes male and female and in all races. We are all here to acquire a deep understanding of the Earth plane with all its challenges and all of its present problems. We are not here to devour and consume the Earth, but to honor her for the learning experience she makes available for us. And so, reincarnation is the great equalizer, the fundamental basis for any bill of rights. Many of the problems of the modern world owe to the fact that reincarnation has not been taught in the West. Reincarnation was the center piece of Jesus teachings. It was banned by a fourth century council that decided the populous could best be controlled through fear. They edited all mention of reincarnation from the scriptures, and inserted fear terms instead, a judgmental god, and so on. If reincarnation had been taught, there would have been no suppression of women, but the gift of both sexes would have been honored and developed. And there would have been no reason for contempt for people of color because who they are, we have been or will be. There is no reason to look down on anyone when we know that our own identity includes membership in theirs. The truth of reincarnation needs to be the foundation for getting ourselves right with the Earth, and with one another. D. And so, Spirit. This new Universe picture, based on Consciousness, has a place for Spirit as simply Infinite Consciousness. All universes all worlds are formed out of this Consciousness, divine and sacred throughout. And Spirit is everywhere in the Earth and can be connected everywhere. And the Native North American people had things right. Everything has its own Spirit, and without contradiction is also an expression of Spirit. And what I am really doing in terms of concepts of modern science is presenting the Native North American version of the Real. And this new Universe picture has a place for the essential insight of all religions almost smothered by church tradition: Love. Not an emotion but a great Oneness, that can be found everywhere, even in a busy city street. But especially in the Earth, that is levels and depths of Oneness everywhere. And so, for the first time in their long and bitter antagonistic history, science and religion now share a common base with this term Spirit, the lynchpin in a new conceptual framework. And I offer an interpretation of where we are in our history, this present moment of historical grace, and these tumultuous times in which we live, the return of the Goddess and the Divine Feminine, the Reappearance of the Feminine in history, the Advent of Women, this great Awakening, as of Springtime after a long dark Winter, the Awakening, the Second Coming. And so, stay tuned! (shrink)

BackgroundVascular surgery offers a range of treatments to relieve pain and ulcerations, and to prevent sudden death by rupture of blood vessels. The surgical procedures involve risk of injury and harm, which increases with age and frailty leading to complex decision-making processes that raise ethical questions. However, how vascular surgeons negotiate these questions is scarcely studied. The aim was therefore to explore vascular surgeons’ moral reasoning of what ought to be done for the patient.MethodsQualitative, semi-structured interviews were conducted with (...) 19 vascular surgeons working at three Swedish university hospitals. Data were analysed according to systematic text condensation.ResultsThe surgeons’ moral reasoning about what ought to be done comprised a quest to relieve suffering and avoid harm by exploring what is reasonable to do for the patient. Exploring reasonableness included to shift one´s perspective from the vessels to the whole person, to balance patient’s conflicting needs and to place responsibility for right decision on one´s shoulders. The shift from blood vessels to the whole person implied gaining holistic knowledge in pondering of what is best, struggling with one´s authority for surgery through dialogue, and building relationship for mutual security. To balance patient’s conflicting needs implied weighing the patient’s independence and a sense of being whole against ease of suffering, respecting the patient’s will against protecting life and well-being, and weighing longer life against protecting the present well-being. Finally, to place responsibility on one´s shoulders was conveyed as an urge to remind oneself of the risk of complications, withholding one’s power of proficiency, and managing time during the illness course.ConclusionsThis study contributes to uncovering how moral reasoning is embodied in the vascular surgeons’ everyday clinical discourse as a tangible part of their patient care. The results underpin the significance of moral considerations in the assemblage of medical knowledge and technical skills to further understand vascular surgeons’ clinical practice. The clinical application of these results is the need of forums with sufficient possibilities for articulating these important moral considerations in everyday care. (shrink)

Ben Rich, J.D., Ph.D., presents a scholarly, passionate view of the ethics of the His manuscript is detailed, analytical, and compassionate. No reasonable sensitive person, especially a physician committed to caring for patients, can disagree with the proposal that human beings should have their physical, emotional, and spiritual pain tended to aggressively, meticulously, and compassionately. Similarly, the same individuals advocating for such pain management would agree that no one should go to jail unless he or she is guilty of a (...) serious crime, that decent people should not be robbed or murdered, that children should not be hungry or homeless, and that all citizens of the United States deserve healthcare. Our society attempts to achieve these goals. Laws are written, discussed, and approved by state and federal congresses, voted on by citizens, and theoretically upheld by the courts, churches, and decent individuals. But, unless the world suddenly becomes inhabited by virtuous, ethical humans who can unfailingly differentiate from then, in spite of an abundance of laws and lawyers, doctors, and nurses, this world will continue to have pain and suffering. And, although we want to hold our doctors, politicians, educators, champion athletes, and others to than the average citizen, it is best to remind ourselves frequently that all humans can be weak and are bound to make imprecise judgments, that there is not a homogenous definition of that values and religious beliefs are variable. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Promoting Health and Social Progress by Accepting and Depathologizing Benign Intersex TraitsHida ViloriaI was born with ambiguous genitalia and it was a doctor who, by honoring my bodily integrity and not “fixing” me, gave me the greatest gift I’ve ever received. Because my body and its sexual traits are a positive, fundamental part of my experience and identity as a human being, I know that having my genitals removed (...) or altered according to someone else’s vision would have deeply damaged me, both physically and psychologically.The doctor who protected my autonomy was, unsurprisingly, my father. I say “unsurprisingly” because in my experience parents are typically more protective of their children than doctors are of their patients. Also, doctors do not discuss cases with other doctors in the same way they do with laypeople, as doctors know more about medical issues such as the risks involved in infant genital surgery.Other than having clitoromegaly (a large clitoris), my reproductive anatomy is typically female, and so I was assigned female and raised as such without incident. My parents didn’t discuss my intersex traits with me, and I grew up thinking of myself and being accepted as, a girl.When I began menstruating, my father told me I’d need to take pills to “grow taller.” I thought this unusual, as I wasn’t short, and later overheard my mother arguing with him, saying that the pills were “experimental”. I was reminded of this discussion years later, when she told me that the pills had actually been hormones to make my breasts grow. I never took them though as she convinced my father not to make me.Article 7 of The International Covenant on Civil and Political Rights states that, “No one shall be subjected without his free consent to medical or scientific experimentation,” and I’m grateful to both my parents for protecting my civil rights as they protected my health.Due to my Catholic upbringing and schooling, I had no opportunity to compare my genitals to other girls’, and it wasn’t until the age of twelve that I realized, while perusing magazines with friends, that I have atypical sex anatomy. Contrary to common speculation however, this awareness didn’t make me question being female. I simply assumed there must be some genital variation in humans.I feel my parents made the wisest decision possible by registering me as one of the two accepted, available genders but allowing me to live, physically and behaviorally, as who I am. Despite not having developed a stereotypically curvaceous female figure, I was popular and excelled in typically feminine social activities, as well as sports and academics. For example, I was one of four girls selected out of one hundred twenty–five that competed for a spot on my high school cheerleading [End Page 114] squad when I tried out to help a friend who needed a tryout partner.Other than escaping IGM (Intersex Genital Mutilation) and estrogen therapy, I’ve had only a few experiences pertaining to my medical care around being intersex. These experiences fall into two categories: seeing medical doctors who treated me the same after discovering that I have ambiguous genitalia, and seeing ones who didn’t. I feel incredibly blessed that my experiences in the former category vastly outweigh the latter.My first experience came at the age of twenty, when a gynecologist asked me if my clitoris had always been as large as it is. I responded that it had, and she said, while looking at me disapprovingly, that she’d like to do some tests. When I asked her what they were for though, she wouldn’t respond directly. She said I’d reported having some upper lip hair, and acne, on my intake forms. I replied that neither were above average, and asked if there were health issues I should be concerned about. She reluctantly said no. I asked what reason there was then for undergoing tests because of the size of my clitoris.She finally responded, “It’s just not normal.”Fortunately, I’d had positive reactions to my sex traits from the people I’d dated. For example, the first... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Working with Patience:An Insight into Dealing with Difficult EmotionsDavid VilanovaAs the most trusted professionals in the nation, nurses are expected to care for their patients with empathy and freedom from bias. The reality is that nurses are human, and some form of implicit bias is inevitable. In my own experience, this issue has reared its head on several occasions. My nursing background is prominently in cardiac and intensive care. (...) Seeing patients at their most vulnerable has become a regular part of my practice. Among some of the most challenging cases for me have been when I assume care of a patient withdrawing from alcohol. As an adult child with close alcoholic family members, many instances of abuse and pain stick with me today and these are brought to the surface when I care for patients with alcohol use disorder. In most cases, I easily find a healthy balance between remaining an understanding-and-empathetic provider and protecting my emotional and mental health as I navigate ethical and moral issues. However, with this patient population, walking that fine line is especially challenging. How do I navigate and manage intensely personal emotions and biases while providing the high-quality care I vowed to deliver regardless of my patient's life choices, addictions, and illnesses? How do I maintain an appropriate level of neutrality and clarity as this patient's behavior and attitude spark emotional triggers? In other words, how do I take care of someone I don't like?Mrs. H was a middle-aged Hispanic woman, barely coherent, but speaking clearly enough that I could understand her slurred speech. Immediate dread washed over me as I realized my assignment included a patient withdrawing from alcohol. The patient's affect, incoherence, and aggression were all too reminiscent of a traumatic past I still work to heal from. My coworkers couldn't understand her insults and obscenities and were therefore unphased except for noting her unruly and erratic behavior. On the other hand, I could understand much of what she was yelling at me and any other staff who bravely walked into her room. My immediate thoughts were that this woman clearly did not want our help. My every attempt to enter her room, speak with her, and provide care were met with an all too familiar rejection and denial that she even had a problem. Yet here she was in a hospital room, and I was her nurse. She verbalized denial of drinking too much when told that she was being treated for alcohol withdrawal. She stated this denial more to herself than to the health care providers in the room, and it was reminiscent of the denial I have seen in my loved ones. This was ironic, I always thought, as the need for such self-deception in and of itself points to the fact that something may be wrong and worth addressing.But denial or not, today, this patient—Mrs. H, was entrusted into my care. She refused treatments and medications, and this put me in a complex ethical predicament—treating a patient that I do not like for the personal issues she reminds me of, and the treatment of a patient against their refusal, as she was deemed incapable of making her own decisions. The latter of these two issues was easiest to put aside. Legally, this patient needed to be treated through her alcohol withdrawal. Once her mental status cleared up, she could sign out against medical advice or choose to remain until a safe discharge plan was in place. There was a protocol and legal guidelines for this situation. However, no guidelines [End Page 10] truly exist when it comes to the management of a patient that you simply do not like. The result can be a near-instantaneous dread each time you must answer that patient's bed alarm, call light, or most basic needs. A negative bias takes over, and it would be an understatement to say that this affects the quality of care. Patients in situations like this—with providers who judge them as I have been guilty of—can easily become subject to derogatory remarks, health inequities, and biased labeling... (shrink)

Chaplains often describe their work in health care as “translation” between the world of the patient and the world of hospital medicine. Translators usually work with texts, interpreters with words. However, when chaplains use this metaphor, it describes something other than a discrete task associated with the meaning of words. While medical professionals focus on patients' medical conditions, chaplains seek to read the whole person, asking questions about what people's lives are like outside of the hospital, what they care (...) about most, and where they find joy and support in the world. Chaplains offer a supportive presence that serves to remind patients and caregivers that people are more than just their medical conditions or their current collection of concerns. Some chaplains are skilled at translating patients' experiences and sources of meaning in real time, allowing medical teams to better understand the person they are treating. “Translation” is also defined as metamorphosis. Chaplains provide this sort of translation when they are alone with patients, listening to their deepest concerns, helping them redefine their lives. (shrink)

With attention to the experiences, agency, and rights of tuberculosis patients, this symposium on TB and ethics brings together a range of different voices from the social sciences and humanities. To develop fresh insights and new approaches to TB care and prevention, it is important to incorporate diverse perspectives from outside the strictly biomedical model. In the articles presented in this issue of the Journal of Bioethical Inquiry, clinical experience is married with historical and cultural context, ethical concerns are brought (...) to bear on global health, and structural analyses shed light upon the lived experience of people living with TB. The relational and reciprocal dimensions of care feature strongly in these discussions, which serve as a poignant reminder that behind each of the yearly deaths from TB is a deeply personal story. No single discipline holds a monopoly on how to care for each of these people, but strong cases are made for support from mental health and social workers in addressing the kaleidoscope of needs in TB prevention. As the World Health Organization moves towards the goal of eliminating TB globally by 2050, attending to the needs of TB patients serves global interests to lower disease burden and to develop better integrated communities worldwide. (shrink)

This paper describes adjustments to teaching practice after migrating from the North American to the Australasian higher education sector. Although the particular experience described is individual and personal, the discoveries and adjustments made can be useful to anyone who faces the experience of academic migration, or even to any teacher. Key adjustments recommended include emphasis on inquiry over information, patient attention to the individuality of learners and teachers, and shared practice of the values of sympathetic understanding, fairness and intellectual (...) humility. These recommendations are not new – in fact the paper takes pains to show how ancient they really are – but they can serve as reminders to teachers facing the insecurity of the global higher education environment. (shrink)

Out of the shadows. One of the interesting things about starting a new research project is its uncertainty. You’re not yet sure what you think about the issues you’re about to explore. I was reminded of this recently when, with colleagues here at the Center, I started work on a project on undocumented patients in the U.S. health care system—or rather, in the different systems that make up this fragmented system. There are more than eleven million undocumented residents of the (...) United States. Most are low-income workers, or family members of these workers. Most are also uninsured, with no prospect of obtaining health insurance. Like anyone else who has a body, sometimes an undocumented resident gets sick. What .. (shrink)

Out of the shadows. One of the interesting things about starting a new research project is its uncertainty. You’re not yet sure what you think about the issues you’re about to explore. I was reminded of this recently when, with colleagues here at the Center, I started work on a project on undocumented patients in the U.S. health care system—or rather, in the different systems that make up this fragmented system. There are more than eleven million undocumented residents of the (...) United States. Most are low-income workers, or family members of these workers. Most are also uninsured, with no prospect of obtaining health insurance. Like anyone else who has a body, sometimes an undocumented resident gets sick. What .. (shrink)

A collection celebrating some of the best essays from the Blackwell journals, Bioethics and Developing World Bioethics. Contributors include Helga Kuhse, Michael Selgelid and Baroness Mary Warnock, former Chair of the British Government’s Committee of Inquiry into Human Fertilization and Embryology’s. Traces some of the most important concerns of the 1980s, such as the ethics of euthanasia, reproductive technologies, the allocation of scarce medical resources, surrogate motherhood, through to a range of new issues debated today, particularly in the field of (...) genetics. Includes contributions that are still as hotly debated today as they were 20 years ago and serves as a salutary reminder that free and open discussion is vital to the health of the discipline itself. Includes eight sections comprising some of the journals' best publications in methodological issues, the health care professional-patient relationship, public health ethics, research ethics, genetics, as well as beginning- and end-of-life issues. Will serve the academic bioethicists as well as students of bioethics as an excellent source book. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction:Developing Health Care in Severely Resource-Constrained SettingsPaul Farmer and Sadath SayeedThis symposium of Narrative Inquiry in Bioethics catalogues the experiences of health care providers working in resource-poor settings, with stories written by those on the frontlines of global health. Two commentaries by esteemed scholars Renee Fox and Byron and Mary-Jo Good accompany the narratives, helping situate the lived experiences of global health practitioners within the frameworks of sociology and (...) medical anthropology respectively.The burgeoning interest in global health among students, health science trainees, clinical practitioners, social entrepreneurs, philanthropists, and government officials is often linked with substantial moral claims. People working in global health often start with the rhetorical premise that each and every human being, regardless of economic, social, or political circumstances that lie beyond his or her control, deserves equal access to quality health care services. This is a bold position at risk of trivialization, in part because the sentiment is so commonplace among global health equity activists.Despite this relatively recent global outpouring of solidarity and concern, billions of poor people still lack access to basic health services. All too often, interventions that perpetuate existing trade practices and market economics are promoted, usually to the detriment of the poor. As our good friend and colleague Arthur Kleinman warns:The irrelevance of ethics can be seen when considering universal ethical formulations of justice and equity that do not begin with the local moral conditions of poor people, those experiencing the systematic injustice of higher disease rates and fewer health-care resources because of their positioning at the bottom of local social structures of power.(1999, p.72)If we are serious about reducing health disparities globally, we must be prepared to mobilize resources in Africa just as we would in the United States or in Europe. If we fetishize cost-effective (read: low-cost) interventions for the poor, we must ask whether we use the same metrics in other situations. In other words, we must always strive to address the fundamental structural and social causes of health inequity.We believe that global health must avoid the "iron cage of rationality," to use sociologist Max Weber's words. One unanticipated consequence of the growth of global health as a field is that the "audit culture"—which encourages accountability and effectiveness—can at times reinforce power differentials between donors (whether government agencies or multilateral foundations) and their intended beneficiaries. Agendas are often set not by community members but by global health leaders who rarely demonstrate sustained commitments to a local community. [End Page 73]As the guest editors of this issue, we hope to recapture the soul of global health work through the art of storytelling. Narratives, even when presented as raw and unrefined as many within this issue, remind us of the immense challenges—both programmatic and moral—involved in this work. The profound scarcity of resources available to health providers in poor countries forces ethical questions on doctors, nurses, pharmacists, social workers, and other health care workers, who make difficult choices every day about what to do with the few resources they have. These are the ethical dilemmas of mortal dramas at their most dire. Global health work demands of its practitioners an alternate mode of audit than academic methodologies can provide. Narratives return us to the basic human commitments that led many of us to this work, and they remind us to use words like equality and justice meaningfully.The narratives that follow offer unmitigated perspectives on the working lives of global health practitioners. They highlight the translation of the moral and programmatic challenges of health care delivery into real choices: for example, between a visiting surgeon's desire to treat a patient and his capacity (or really incapacity) to provide follow-up care. They acknowledge the necessity of interdisciplinary cooperation in resource-constrained settings, as well as the difficulties in collaborating across cultures and continents. Most importantly, they make the claim that a newborn in distress in a tent in Port-au-Prince merits the same resources and attention as one in Boston, and that his or her death merits the same indignation. They demonstrate the radical solidarity inherent in the... (shrink)