Upon doing something generous for someone with whom you are close, some kind of reciprocity may be appropriate. But it often seems wrong to actually request reciprocity. This chapter explores the wrongness in making these requests, and why they can nevertheless appear appropriate. After considering several explanations for the wrongness at issue (involving, e.g. distinguishing oughts from obligation, the suberogatory, imperfect duties, and gift-giving norms), a novel proposal is advanced. The requests are disrespectful; they express that their agent (...) insufficiently trusts the hearer to recognize their own reasons to reciprocate, and the close relationship between them morally requires this kind of trust. This proposal is articulated and situated in the recent discussion of the normativity of requests. The chapter concludes by explaining how these requests may appear appropriate. Agents in these relationships often have standing to make requests, though the standing is lacking in these particular cases. (shrink)

I ask you to X. You now have a reason to X. My request gave you a reason. How? One unpopular theory is the epistemic account, according to which requests do not create any new reasons but instead simply reveal information. For instance, my request that you X reveals that I desire that you X, and my desire gives you a reason to X. Peter Schaber has recently attacked both the epistemic account and other theories of the reason-giving force (...) of requests. Schaber defends a new theory of the reason-giving force of requests according to which request give reasons because it is valuable for requesters and requestees that requests have this power. In this paper I argue that Schaber's attack on the epistemic account fails, and that his own theory ought to be rejected because it faces compelling objections. (shrink)

Requests belong to a family of forms of social influence on action that appear problematic when employed in the attempt to directly influence belief. Explaining why this is so is more difficult than it might at first appear. The fact that belief is not directly subject to the will can only be part of the explanation. It must also be the case that requests are incapable of providing epistemic reasons in a way that parallels that in which they (...) provide practical reasons. I propose an account of the nature of requests that is in a position to explain why requests are incapable of doing this. (shrink)

In The Alchemy of Race and Rights Patricia Williams notes that when people of color are asked to understand such practices as racial profiling by putting themselves in the shoes of white people, they are, in effect, being asked to, ‘look into the mirror of frightened white faces for the reality of their undesirability’ (1992, 46). While we often see understanding another as ethically and epistemically virtuous, in this paper I argue that it is wrong in some cases to ask (...) another to attempt to understand certain positions or lines of thought. In developing my argument I draw on the work of María Lugones to argue for a view of agency that is epistemically interdependent. I examine the case described by Patricia Williams to demonstrate specifically how the understanding requested in this case unfairly undermines both epistemic and non-epistemic agency. I distinguish appropriate requests for understanding from inappropriate requests so as to make clear that I am not suggesting that it is wrong to make such requests when the understanding sought after is difficult, painful, or even when it forces one to reconsider the meaning of one’s actions. Finally, I examine an example from Susan Brison to show how strategic refusals to understand may provide a pathway toward new ways of knowing and being in resistance to oppressive regimes. (shrink)

Requests by patients or their families for treatment which the patient's physician considers to be "inappropriate" are becoming more frequent than refusals of treatment which the physician considers appropriate. Such requests are often based on the patient's religious beliefs about the attributes of God (sovereignty, omnipotence), the attributes of persons (sanctity of life), or the individual's personal relationship with God (communication, commands, etc). We present four such cases and discuss some of the basic religious tenets of the three (...) Abrahamic faith traditions as they relate to such requests. We suggest that religious reasons for requesting "inappropriate" treatment are "special" and deserve serious consideration. We offer guidance to assist clinicians and clinical ethicists as they attempt to resolve these conflicts, emphasising the importance of understanding the religious beliefs of the patient/surrogate and suggesting the assistance of a religious interpreter. We suggest open discussion with patients and families of both the clinical situation and the theological basis for these requests. We also suggest that clinicians use additional religious doctrines or principles from patients' own traditions to balance the reasons behind the requests. We conclude that most persistent requests for "inappropriate" treatment should be honoured. (shrink)

In the Netherlands, in 2002, euthanasia became a legitimate medical act, only allowed when the due care criteria and procedural requirements are met. Legally, an Advanced Euthanasia Directive can replace direct communication if a patient can no longer express his own wishes. In the past decade, an exponential number of persons with dementia share a euthanasia request with their physician. The impact this on physicians, and the consequent support needs, remained unknown. Our objective was to gain more insight into the (...) experiences and needs of Dutch general practitioners and elderly care physicians when handling a euthanasia request from a person with dementia. We performed a qualitative interview study. Participants were recruited via purposive sampling. The interviews were transcribed verbatim, and analyzed using the conventional thematic content analysis. Eleven general practitioners and elderly care physicians with a variety of experience and different attitudes towards euthanasia for PWD were included. Euthanasia requests appeared to have a major impact on physicians. Difficulties they experienced were related to timing, workload, pressure from and expectations of relatives, society’s negative view of dementia in combination with the ‘right to die’ view, the interpretation of the law and AEDs, ethical considerations, and communication with PWD and relatives. To deal with these difficulties, participants need support from colleagues and other professionals. Although elderly care physicians appreciated moral deliberation and support by chaplains, this was hardly mentioned by GPs. Euthanasia requests in dementia seem to place an ethically and emotionally heavy burden on Dutch GPs and elderly care physicians. The awareness of, and access to, existing and new support mechanisms needs further exploration. (shrink)

Physicians place significant weight on the distinction between acts and omissions. Most believe that autonomous refusals for procedures, such as blood transfusions and resuscitation, ought to be respected, but they feel no similar obligation to accede to requests for treatment that will, in the physician’s opinion, harm the patient (e.g., assisted death). Thus, there is an asymmetry. In this paper, we challenge the strength of this distinction by arguing that the ordering of values should be the same in both (...) cases. The reason for respecting refusals is that, in such cases, autonomy outweighs well-being. We argue that the same should be true in request cases, which means that requests should not be denied only due to the treatment being too harmful in the physician’s opinion. Our strategy is to consider and reject a number of arguments for the asymmetrical view, including an appeal to the doing–allowing distinction and positive and negative rights. The duty to respect refusals is still greater than the duty to grant requests on our view, but, by arguing that the ordering of values is the same in both cases, we show that there is less of a distinction in healthcare between requests and refusals than many currently believe. (shrink)

Although requests constitute a type of action that have been widely discussed within conversation analysis-oriented work, they have only recently begun to be explored in relation to the situated and multimodal dimensions in which they occur. The contribution of this paper resides in the integration of bodily-visual conduct (gaze and facial expression, gesture and locomotion, object manipulation) into a more grammatical account of requesting. Drawing on video recordings collected in two different hair salons located in the French-speaking part of (...) Switzerland and in France (23 h in total), this paper analyzes clients’ negative requests by exploring how they interface with the participants’ embodied conducts. Contrary to what the literature describes for positively formulated requests, with negative requests clients challenge an expectable next action (or ongoing action) by the hairdresser. One linguistic format constitutes the focus of this article, roughly glossable as ‘You don’t do [action X] too much (huh)’. Our analysis of a consistent collection of such formatted turns will show that clients present them (and hairdressers tend to treat them) in different ways, depending on how they relate to embodied conduct: When these turns are used by the client as instructions, they are accompanied by manipulations of the client’s own hair and tend to occur toward the initial phase of the encounter, at a stage when hairdressers and clients collaboratively negotiate the service in prospect. When uttered as directives, these turns are not accompanied by any touching practices from the client and are typically observable in subsequent phases of the encounter, making relevant an immediate linguistic or/and bodily response from the professional, as shown by the client who is actively pursuing mutual gaze with him/her. Therefore, an action cannot be distinguished from another on the basis of the turn format alone: Its sequential placement and the participants’ co-occurring embodied conduct contribute to its situated and shared understanding. By analyzing the clients’ use of a specific linguistic format conjointly with the deployment of specific embodied resources, this study will advance our understanding of how verbal resources and embodiment operate in concert with each other in the formation and understanding of actions, thereby feeding into new areas of research on the grammar-body interface. (shrink)

Currently, many women who are expecting to give birth have no option but to attempt vaginal delivery, since access to elective planned caesarean sections (PCS) in the absence of what is deemed to constitute ‘clinical need’ is variable. In this paper, we argue that PCS should be routinely offered to women who are expecting to give birth, and that the risks and benefits of PCS as compared with planned vaginal delivery should be discussed with them. Currently, discussions of elective PCS (...) arise in the context of what are called ‘Maternal Request Caesarean Sections’ (MRCS) and there is a good deal of support for the position that women who request PCS without clinical indication should be provided with them. Our argument goes further than support for acceding to requests for MRCS: we submit that healthcare practitioners caring for women with uncomplicated pregnancies have a positive duty to inform them of the option of PCS as opposed to assuming vaginal delivery as a default, and to provide (or arrange for the provision of) PCS if that is the woman's preferred manner of delivery. (shrink)

BackgroundMedical aid in dying was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.MethodsA retrospective chart review of all MAiD requests between December 2015 and June 2017 (...) at two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.ResultsOf 80 patients requesting MAiD, 54% received the intervention. The median number of days between the request for MAiD and the patient’s death was 6 days. The majority of palliative care consults came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 at the time of the MAiD request and 19% were receiving life-prolonging interventions.InterpretationWe highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians’ approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend. (shrink)

On 23 September 2002, the Belgian law on euthanasia came into force. This makes Belgium the second country in the world to have an Act on euthanasia. Even though there is currently legal regulation of euthanasia in Belgium, very little is known about how this legal regulation could be translated into care for patients who request euthanasia.

It has recently been reported that some hospitals in the UK have placed a blanket restriction on the provision of maternal request caesarean sections as a result of the COVID-19 pandemic. Pregnancy and birthing services are obviously facing challenges during the current emergency, but we argue that a blanket ban on MRCS is both inappropriate and disproportionate. In this paper, we highlight the importance of MRCS for pregnant people’s health and autonomy in childbirth and argue that this remains crucial during (...) the current emergency. We consider some potential arguments—based on pregnant people’s health and resource allocation—that might be considered justification for the limitation of such services. We demonstrate, however, that these arguments are not as persuasive as they might appear because there is limited evidence to indicate either that provision of MRCS is always dangerous for pregnant people in the circumstances or would be a substantial burden on a hospital’s ability to respond to the pandemic. Furthermore, we argue that even if MRCS was not a service that hospitals are equipped to offer to all pregnant persons who seek it, the current circumstances cannot justify a blanket ban on an important service and due attention must be paid to individual circumstances. (shrink)

In the Netherlands, consent from relatives is obligatory for post mortal donation. This study explored the perspectives of relatives regarding the request for consent for donation in cases without donor registration. A content analysis of narratives of 24 bereaved relatives of unregistered, eligible, brain-dead donors was performed. Relatives of unregistered, brain-dead patients usually refuse consent for donation, even if they harbour pro-donation attitudes themselves, or knew that the deceased favoured organ donation. Half of those who refused consent for donation mentioned (...) afterwards that it could have been an option. The decision not to consent to donation is attributed to contextual factors, such as feeling overwhelmed by the notification of death immediately followed by the request; not being accustomed to speaking about death; inadequate support from other relatives or healthcare professionals, and lengthy procedures. Healthcare professionals could provide better support to relatives prior to donation requests, address their informational needs and adapt their message to individual circumstances. It is anticipated that the number of consenting families could be enlarged by examining the experience of decoupling and offering the possibility of consent for donation after circulatory death if families refuse consent for donation after brain-death. (shrink)

Research in the fields of pragmatics has highlighted important differences in speech act realisation strategies and the perception of contextual variables across lingua-cultures. This particularly applies for requests, which are potentially face-threating acts and important expressions of cultural behaviour, as their performance is influenced by culturally-embedded perspectives on rights and obligations. Although some languages have been widely investigated in terms of request realisation, such as English, little research has been done on Italian. This study examines request realisation strategies in (...) Italian, in terms of Head Acts and request perspective, and the impact of the sociopragmatic factors of social distance and weight of imposition of the request on strategy choice amongst eight Italian speakers, by means of open-ended roleplays. The data was analysed by using a coding scheme based on Blum-Kulka and Olshtain and revealed that the Italian speakers where more influenced by social distance, which in turn impacted on the choice of request perspective. They were shown to prefer using hearer-orientation, which reflected in the verb conjugation of the Head Acts, since this perspective allows them to do relational work with the hearer, by either addressing the recipient with the familiar tu or with the formal lei. (shrink)

This paper defends the epistemic account of the normativity of requests. The epistemic account says that a request does not create any reasons and thus does not have any special normative power. Rather, a request gives reasons by revealing information which is normatively relevant. I argue that compared to competing accounts of request normativity, especially those of David Enoch and James H.P. Lewis, the epistemic account gives better answers to cases of insincere requests, is simpler, and does a (...) better job incorporating the importance of relationships. I also defend the epistemic account from three objections: that requests are important because they constitute consent, that requests and wishes must be normatively different, and that some requests do not provide any new information. (shrink)

This book addresses the relevance of Timaeus’s cosmology to Socrates’ request for a speech about war. Charles Ives finds relevance in the dialogue’s concern for education apropos of the medical dimensions of Timaeus’ physics, the project of becoming like god, and the philosophical soul responsible for success on the battlefield.

Power provision is coming to be the most important constraint to data center development. The efficient management of power consumption according to the loads of the data center is urgent. As the load for every application hosted in every server node of the data center and corresponding Service Level Agreement requirements can be quite different, it is hard to deploy a power strategy at application. The asynchronies and abruptness characteristics of workload fluctuation make power management policymaking using periodic resource scheduling (...) method invalid. In this article, the design and implementation of the request–response distributed power management scheme is elaborated. Bound by linear time complexity, the method proposed integrates dynamic voltage/frequency scaling, power-on–power-off, and virtual machine migration mechanisms and dynamically optimizes the power consumption of a cloud data center. The significant advantage of the scheme is that it does not need synchronous scheduling between all SNs. Simulation results showed that the scheme could effectively decrease the power consumption of the data center, with a tiny reduction in performance as centralized control methods. (shrink)

Being able to ask others to do things, and thereby giving them reasons to do those things, is a prominent feature of our interpersonal lives. In this paper, I discuss the distinctive normative status of requests – what makes them different from commands and demands. I argue for a theory of this normative phenomenon which explains the sense in which the reasons presented in requests are a matter of discretion. This discretionary quality, I argue, is something that other (...) theories cannot accommodate, though it is a significant aspect of the relations that people stand in to one another, and the kinds of practical reasons that flow from those relations. (shrink)

As obstetric medicine has become more sophisticated, so Caesarean section (CS) has become safer. It is now seen as equally safe or, in some circumstances, safer than vaginal birth. Under the new National Institute for Clinical Excellence (NICE) guidelines on CS that were published in November 2011, requests for CS are to be given more weight. Women requesting CS can no longer be seen as compromising their control over birth. Rather, they are merely exercising their power, with the new (...) guidelines offering them an increasing role in the decision-making process regarding how they give birth. However, these new guidelines also present new problems, bringing the rights of patients and obstetricians into conflict. In order to mediate these tensions, a virtue-based approach to obstetric ethics is needed as a supplement to the rule- and right-based guidance provided by NICE. (shrink)

A request to admit a hospital inpatient with motor neurone disease to the hospice generated unusual unease. Significantly, withdrawal of ventilation had already been planned. The presumption that ventilation would be withdrawn after transfer presented a dilemma. Should the hospice accept the admission? If so, should the hospice staff stop the ventilation, and then when and how? Debate centred on the continuity of best interests and the logistics of withdrawing ventilation. The factors making the request contentious identified competing interests within (...) hospice admission decision making that could detrimentally impact on patient care. (shrink)

This study examines the characteristics of request sequences in Chinese public service calls. The data analysis indicates that a prominent characteristic of Chinese public service calls is the frequent appearance of insert expansions and non-minimal post-expansions, with the latter occurring after both preferred response and dispreferred response. This is closely related to participants’ institutional identities and epistemic asymmetry; operators handling such service calls should pay due attention to this asymmetry to ensure mutual understanding in conversation.

We propose that in addition to children's requests for word names being a reflection of an understanding of the referential nature of words, they may also be requests for adult's teaching. These possible requests for teaching among toddlers, along with other indications, suggest that teaching may be a natural cognition that may be related to the development of theory of mind.

When medical assistance in dying (MAiD) was legalized in Canada in June 2016, the question of allowing decisionally capable persons to make advance requests in anticipation of later incapacity was reserved for further consideration during the mandatory parliamentary review originally scheduled to begin in June 2020 (but since delayed by COVID-19). In its current form the legislation does not permit such requests, since it stipulates that at the time at which the procedure is to be administered the patient (...) must give “express consent” to receiving it. Since express consent presupposes decisional capacity, this requirement rules out administering MAiD to a patient who has lost capacity. Amendments to the legislation passed by Parliament in March 2021 open the door slightly by allowing advance requests by patients after they have been approved for MAiD, if they fear losing capacity before the procedure can be administered. But this provision would apply only to patients whose natural death was deemed to be “reasonably foreseeable”, and would continue to exclude (a) requests made after diagnosis of a “grievous and irremediable medical condition” but in advance of approval for MAiD, and (b) requests made before such a diagnosis. My aim in this paper is twofold: to explore the ethical and legal issues concerning advance requests for MAiD, and to argue for expanding provision for such requests to include both of these further scenarios. (shrink)

This paper analyses video recorded interactions between police officers and drivers in traffic stops in Russia. The interactions were recorded via cameras installed on the drivers’ car dashboards, and subsequently uploaded to YouTube; a practice to which over one million Russian motorists have resorted to counterbalance perceived high levels of bribery and corruption. The analysis focuses on responses to opening requests for identification in five different encounters. These show that the drivers repeatedly engage in potentially interpersonally sensitive activities in (...) which the vulnerability of face, especially that of the police officer, is interactionally manifested by launching counter requests in return. The organisation of the request–counter request sequences highlights how face and identity related concerns are interwoven in the participants’ attempts to contest each other’s authority. (shrink)

Although it seems intuitively clear that acts of requesting are different from acts of commanding, it is not very easy to sate their differences precisely in dynamic terms. In this paper we show that it becomes possible to characterize, at least partially, the effects of acts of requesting and compare them with the effects of acts of commanding by combining dynamified deontic logic with epistemic logic. One interesting result is the following: each act of requesting is appropriately differentiated from an (...) act of commanding with the same content, but for each act of requesting, there is another act of commanding with much more complex content which updates models in exactly the same way as it does. We will also consider an application of our characterization of acts of requesting to acts of asking yes-no questions. It yields a straightforward formalization of the view of acts of asking questions as requests for information. (shrink)

The death of Jesse Gelsinger in 1999 during a gene therapy trial raised many questions about the ethical review of medical research. Here, the author argues that the principle of justice is interpreted too narrowly and receives insufficient emphasis and that what we permit in terms of bodily invasion affects the value we place on individuals. Medical research is a societally supported activity. As such, the author contends that justice requires that invasive medical research demonstrates sufficiently compelling societal benefit. Many (...) consider this societal benefit to be self evident. However, medical research is a complex activity; it yields new treatments but also creates financial rewards and affects health resource allocation. As research evolves into a multibillion pound, multinational enterprise, justice requires a much broader analysis of societal benefit. Without such evaluation we risk undermining the value of bodily integrity and of research participants. (shrink)

Sterilisation requests made by young, childfree adults are frequently denied by doctors, despite sterilisation being legally available to individuals over the age of 18. A commonly given reason for denied requests is that the patient will later regret their decision. In this paper I examine whether the possibility of future regret is a good reason for denying a sterilisation request. I argue that it is not and hence that decision-competent adults who have no desire to have children should (...) have their requests approved. It is a condition of being recognised as autonomous that a person ought to be permitted to make decisions that they might later regret, provided that their decision is justified at the time that it is made. There is also evidence to suggest that sterilisation requests made by men are more likely to be approved than requests made by women, even when age and number of children are factored in. This may indicate that attitudes toward sterilisation are influenced by gender discourses that define women in terms of reproduction and mothering. If this is the case, then it is unjustified and should be addressed. There is no good reason to judge people’s sterilisation requests differently in virtue of their gender. (shrink)

Although the topic has been extensively studied, many issues about understanding of indirect requests in children are still unsolved. Our contribution is to distinguish genuine and ironic hints, focusing on the latter. We examined the understanding of ironic hints and ironic imperatives in 5- to 9-year-old children and in adults, in various situational contexts. The main result of this study was that ironic hints were more difficult to understand than ironic imperatives only when the context was neutral. When the (...) context was ironic, there was no significant difference. Discussion highlights how context enables young children to understand very indirect requests like ironic hints. (shrink)

Although the topic has been extensively studied, many issues about understanding of indirect requests in children are still unsolved. Our contribution is to distinguish genuine and ironic hints, focusing on the latter. We examined the understanding of ironic hints and ironic imperatives in 5- to 9-year-old children and in adults, in various situational contexts. The main result of this study was that ironic hints were more difficult to understand than ironic imperatives only when the context was neutral. When the (...) context was ironic, there was no significant difference. Discussion highlights how context enables young children to understand very indirect requests like ironic hints. (shrink)

While it is recognized that instruction between co-workers is a central component of everyday workplace interaction and learning, this study investigates the ways in which such instructional events are practically initiated in interaction. We analyse recordings of everyday work at a radio station, where journalists prepare and broadcast local news. In our data, a distinction can be made between two interactional contexts from which instructional interactions emerge: searches, where one party is looking for a suitable helper; and established interactions, where (...) the initiation of instruction is prefigured by immediate prior interaction. A further finding is that these two contexts are associated with two different ways of initiating instruction. Direct requests are used in established interactions. In searches, we instead find questions regarding the other person’s procedural knowledge – what we term know-how questions. We finally discuss the ways in which instructional configurations are assembled without reference to institutionally defined instructor/instructed roles. (shrink)

I was asked to evaluate M by her medical oncologist, Dr. T. As a psychiatrist, I was to perform the duties of a mental health specialist in the care of this fifty‐eight‐year‐old woman with metastatic breast cancer who had requested physician aid in dying. Dr. T had no specific concerns, but she was adhering to the letter of the law by referring the patient to me—a “mental health specialist”—because, according to the patient’s medical history, there was “evidence of a mental (...) disorder.” That evidence was comprised of depression treated in the remote past. Some years before California passed its End of Life Options Act in 2015, M had begun talking with Dr. T about the circumstances under which she might no longer want to be alive and might even choose to take active steps to end her life. She had fairly specific and durable criteria for knowing “when the time had come.” In our interview, she asserted very clearly that the time had not come but that, with the law now active, she hoped to have access to a lethal prescription in case it did. (shrink)

In the Laura Ashworth case in 2008, the Human Tissue Authority considered itself bound to overturn a deceased daughter's alleged wish that one of her kidneys should go to her mother, who at the time had end stage kidney failure and was on dialysis. 12 This was so even though Laura's earlier wish to be a living donor would most likely have been authorised, had the formal assessment process begun. The decision provoked much criticism. The recent Department of Health document (...) Requested Allocation of a Deceased Donor Organ, published 29 March 2010, developed by the UK health administrations together with the HTA and NHS Blood and Transplant , which is the main organ allocation body in the UK, seeks to resolve this ethical dilemma by setting out the circumstances in which requests for such deceased donations may be acceptable. 3 The most important conditions appear to be:a. the donation must be unconditional in nature;b. there must be …. (shrink)

At the heart of the debate over assisted suicide is the recognition that not all persons can be healed and not all suffering can be relieved. This article addresses the ethical, professional and legal issues to be considered by the nurses in the United States who are facing patients’ requests for assisted suicide. Both personal and professional risks, and the consequences of an action must be evaluated. Ultimately, a decision is based on some ranking of: patient values; personal values (...) and beliefs; professional codes, standards and other guidelines; and societal laws and regulations. (shrink)

At the heart of the debate over assisted suicide is the recognition that not all persons can be healed and not all suffering can be relieved. This article addresses the ethical, professional and legal issues to be considered by the nurses in the United States who are facing patients’ requests for assisted suicide. Both personal and professional risks, and the consequences of an action must be evaluated. Ultimately, a decision is based on some ranking of: patient values; personal values (...) and beliefs; professional codes, standards and other guidelines; and societal laws and regulations. (shrink)

Objectives—While clinical practice is complicated by many ethical dilemmas, clinicians do not often request ethics consultations. We therefore investigated what triggers clinicians' requests for ethics consultation. Design—Cross-sectional telephone survey.Setting—Internal medicine practices throughout the United States.Participants—Randomly selected physicians practising in internal medicine, oncology and critical care.Main measurements—Socio-demographic characteristics, training in medicine and ethics, and practice characteristics; types of ethical problems that prompt requests for consultation, and factors triggering consultation requests. Results—One hundred and ninety of 344 responding physicians (55%) (...) reported requesting ethics consultations. Physicians most commonly reported requesting ethics consultations for ethical dilemmas related to end-of-life decision making, patient autonomy issues, and conflict. The most common triggers that led to consultation requests were: 1) wanting help resolving a conflict; 2) wanting assistance interacting with a difficult family, patient, or surrogate; 3) wanting help making a decision or planning care, and 4) emotional triggers. Physicians who were ethnically in the minority, practised in communities under 500,000 population, or who were trained in the US were more likely to request consultations prompted by conflict. Conclusions—Conflicts and other emotionally charged concerns trigger consultation requests more commonly than other cognitively based concerns. Ethicists need to be prepared to mediate conflicts and handle sometimes difficult emotional situations when consulting. The data suggest that ethics consultants might serve clinicians well by consulting on a more proactive basis to avoid conflicts and by educating clinicians to develop mediation skills. (shrink)

We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients’ ages ranged from 14 to 85. Continued mechanical ventilation was the focal intervention sought by all families. The ECS’s advice and recommendations generally promoted “reasonable accommodation” of the requests, balancing compassion for grieving families with other ethical (...) and moral concerns such as stewardship of resources, professional integrity, and moral distress. In cases we characterized as finitegoal accommodation, a “reasonable accommodation” strategy proved effective in balancing stakeholders’ interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the “reasonable accommodation” approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases. (shrink)

In this article I intend to describe an issue of the Dutch euthanasia practice that is not common knowledge. After some general introductory descriptions, by way of formulating a frame of reference, I shall describe the effects of this practice on patients, physicians and families, followed by a more philosophical reflection on the significance of these effects for the assessment of the authenticity of a request and the nature of unbearable suffering, two key concepts in the procedure towards euthanasia or (...) physician-assisted suicide. This article does not focus on the arguments for or against euthanasia and the ethical justification of physician-assisted dying. These arguments have been described extensively in Kimsma and Van Leeuwen (Asking to die. Inside the Dutch debate about euthanasia, Kluwer Academic Publishers, Dordrecht, 1998). (shrink)