This chapter contains sections titled: Weighing the Value of Meat Stalking the Essence of Hunting Same As It Ever Was The End of Hunting Notes.

The term “euthanasia” is used in conflicting ways in the bioethical literature, as is the term “assisted suicide,” resulting in definitional confusion, ambiguities, and biases which are counterproductive to ethical and legal discourse. I aim to rectify this problem in two parts. Firstly, I explore a range of conflicting definitions and identify six disputed definitional factors, based on distinctions between (1) killing versus letting die, (2) fully intended versus partially intended versus merely foreseen deaths, (3) voluntary versus nonvoluntary versus involuntary (...) decisions, (4) terminally ill versus non-terminally ill patients, (5) patients who are fully conscious versus those in permanent comas or persistent vegetative states, and (6) patients who are suffering versus those who are not. Secondly, I distil these factors into six “building blocks” and combine them to develop an unambiguous, value-neutral taxonomy of “end-of-life practices.” I hope that this taxonomy provides much-needed clarification and a solid foundation for future ethical and legal discourse. (shrink)

For a little more than a decade, professional organizations and healthcare institutions have attempted to develop guidelines and policies to deal with seemingly intractable conflicts that arise between clinicians and patients (or their proxies) over appropriate use of aggressive life-sustaining therapies in the face of low expectations of medical benefit. This article suggests that, although such efforts at conflict resolution are commendable on many levels, inadequate attention has been given to their potential negative effects upon particular groups of patients/proxies. Based (...) on the well-documented tendency among many African Americans to prefer more aggressive end-of-life medical interventions, it is proposed that the use of institutional policy to break decision making impasse in cases for which aggressive treatment is deemed "medically inappropriate" will fall disproportionately on that group. Finally, it is suggested that the development and application of institutional conflict-resolution policies should be evaluated in the context of historical and current experiences of marginalization and disempowerment, lest such policies exacerbate that experience. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Aquinas on the Beginning and End of Human Life by Fabrizio AmeriniPatrick LeeAquinas on the Beginning and End of Human Life. By Fabrizio Amerini. Translated by Mark Henninger. Cambridge, Mass.: Harvard University Press, 2013. Pp. xxii + 260. $29.95 (cloth). ISBN: 978-0-674-07247-3.This book provides a comprehensive and textually grounded presentation of Thomas Aquinas’s teaching on embryology and an assessment of its bioethical implications. Despite (what I regard as) (...) some mistakes on the application of that teaching to contemporary embryological data, it is an invaluable sourcebook for Aquinas on this issue. At times, Amerini’s “aporetic” style makes for convoluted arguments, but it raises challenging questions and thus will assist anyone working through these issues. (As the title indicates, it also treats the end of life—but only very briefly, in a couple of pages near the end of the book.)The first two chapters examine Aquinas’s general principles regarding matter, form, and substantial generation (the coming to be of a substance), and his positon on the human soul as both subsistent and the substantial form of the human body. Amerini’s treatment is thorough and provides an extensive bibliographical guide to this issue. However, it seems to me that Amerini is less than clear on the distinctiveness of substantial change. Since there are (according to Aquinas and Aristotle) no degrees in the category of substance, generation is not a process but an instantaneous change. Amerini’s frequent use of the term “process of generation,” as well as the position he later proposes on the identity of the embryo, seems to conflict with that point. [End Page 489]Chapters 3 and 4 contain detailed exposition of Aquinas’s basic embryological position, and chapter 4 raises various questions about this position (including doubts that Amerini evidently has about the unicity of the human being’s substantial form). Applying his basic metaphysical principles to what he at the time believed were the embryological facts, Aquinas concluded that the human being with a rational soul is not present until forty days after fertilization for males or ninety days for females. The father and the mother generate the offspring, but the mother provides only the material cause in the form of menstrual blood; the father is the efficient and formal cause, acting through the semen as an instrumental cause. With the power (virtus) of the principal cause in it, the semen gradually organizes the menstrual blood provided by the mother to form, first, a being with a vegetative soul, then an animal, and finally an animal with a body suited to be formed by a rational soul, which God then infuses into it. Aquinas holds that, unlike a sensitive or vegetative soul, a rational soul must be directly created by God, since the rational soul is the source of operations that are independent of matter, that is, performed by the human being but without a bodily organ. Only matter that is suited to a form can receive it. Therefore the matter must be suitably disposed. Just as one can make a knife only with matter capable of supporting its function—and so the matter must be hard and capable of being sharp—so only a body with sense organs, and thus capable of supporting those actions prerequisite to rational operations, can receive a rational soul.Chapter 5 sets out in detail Amerini’s exposition and interpretation of Aquinas on the identity of the embryo. Amerini recognizes, of course, Aquinas’s mistakes and ignorance regarding basic embryological facts—inevitable given the time in which he wrote. Still, Amerini holds that Aquinas’s main conclusion regarding delayed hominization is still valid. He agrees with Aquinas that the general proportionality requirement implies that the embryo/fetus must first possess sensory organs to have a body apt for the reception of a rational soul.On the other hand, Amerini also advances what he believes is a via media between proponents of delayed hominization and proponents of immediate hominization. He argues that although the embryo is not numerically identical with the human being (which comes to be only with the infusion of the rational soul), nevertheless, the embryo from... (shrink)

The central claim of this paper is that American states’ use of so-called “triggering conditions” to regulate surrogate decision-making authority in end-of-life care leaves unresolved a number of important ethical and legal considerations regarding the scope of that authority. The paper frames the issue with a case set in a jurisdiction in which surrogate authority to withdraw life-sustaining treatment is triggered by two specific clinical conditions. The case presents a quandary insofar as the clinical facts do not satisfy the triggering (...) conditions, and yet both the appropriate surrogates and the care team agree that withdrawal of life-sustaining treatment is in the best interest of the patient. The paper surveys applicable law across the 50 states and weighs the arguments for and against the inclusion of such triggering conditions in relevant legal regimes. The paper concludes by assessing the various legal and policy options states have for regulating surrogate decision-making authority in light of the moral considerations, and notes the possibility for conflict within ethics teams arising from the potential tension between prudence, risk-aversion, and moral obligation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Calling Obesity a Disease Is A Terrible DecisionMoose FinklesteinFactsThe medical world struggles to see the difference between health and body weight. It is still mostly combined with the strong belief that there is no way a fat person can be fit and healthy. Despite repeated studies and work to show differently, this prejudice remains. This has become part of what I call “Everyone Knows” pseudoscience, where data that (...) have no scientific basis become “fact” due to constant repetition.Obesity is already the cause of great stigma in our society. Fat people are considered “ugly,” fat jokes are acceptable in everyday life, and being called ‘fat’ is, to many, as big an insult as a racial slur. Fat prejudice can approach the levels of racial prejudice (Puhl, Andreyevea & Brownell, 2008). Fat children are bullied, sometimes to the point of suicide. Some studies have found children as young as five trying to diet for being fat, no matter their actual weight. Fat people are more likely to be unemployed or underemployed, and there are prejudicial beliefs that fat workers are more problematic, despite research saying otherwise (Roehling, Roehling, & Odland, 2008).Obesity is seen by the masses as something people choose. However, science disagrees. There has long been a link between depression and obesity. Mental health is tightly tied to obesity, where those who experience weight discrimination are more likely to gain weight, although unhealthy behaviours such as binge eating and exercise avoidance are sometimes seen as a coping mechanism (Sutin & Teracciano, 2013).It has been reported in a number of journals that 90–95% of the people who lose weight regain the weight within 10 years (Mann et al., 2007; Miller, 1999). “Everyone Knows” claims that this is because people go back to bad habits. Science, however, says that there are complex ways the body wants to regain the weight (Sumithran & Proietto, 2013; Sumithran et al., 2011). Worse, dieting may contribute to obesity. Adolescent girls who diet are at 324% greater risk for obesity than those who do not diet (Stice, Cameron, R. P., Killen, J. D., Hayward, C. & Taylor, C. B. 1999). Weight loss dieting may cause other health problems as well, such as immune system problems (Shade ED, et al. 2004).In the medical world, doctors are encouraged to talk to patients about their weight. Every fat person has heard, “What are we going to do about your weight?” The “we” is supposed encourage the patient to feel that the doctor is on the patient’s side in their battle. Yet what many patients hear is, “I don’t see you as a patient, I see you as fat.” Science says that the higher a patient’s BMI the less respect a doctor has for the patient (Huzinga, Cooper, Bleich, Clark, & Beach, 2009).Horror stories about fat people trying to get decent health care are everywhere. For a good example, see Bruce Taylor Seeman’s piece, “The Perils of Obesity May Include the Doctor” (2006). [End Page E1] There are many blogs and stories on the internet about the way patients are not just shamed for their weight, but actively bullied by medical professionals. One blog, The Well Rounded Mama (wellroundedmama.blogspot.com), discusses the bias of doctors against pregnant fat women, who are told things like, “You cannot have a healthy baby when you are this fat” and encouraged to abort. Tales from people told that their weight is the cause for everything and anything can be found on sites like First Do No Harm (fathealth.wordpress.com). Reading blogs by medical professionals can show the disdain they have for fat people. In one, an emergency room nurse declared that all fat diabetics have poor control, based solely on perceptions from her job. Comments were mostly other nurses agreeing with how “disgusting” fat people are to have to deal with. However, Yale University’s Rudd Center for Food Policy & Obesity not only recognizes the problem but aims to help medical professionals eliminate the bias.If obesity becomes a disease, weight loss surgery (WLS) becomes a bigger gold mine. Medical insurance will be more likely to cover weight loss surgery. WLS is an ever-changing target: there... (shrink)

Background: Pediatric guidelines recommend that children and adolescents participate in a developmentally appropriate way in end-of-life decision making. Shared decision making in pediatrics is unique because of the triadic relationship of patient, parents, and physician. The involvement of the patient may vary on a continuum from no involvement to being the sole decision maker. However, the effects of child participation have not been thoroughly studied. The aims of this literature review are to identify studies on end-of-life decision making in pediatrics, (...) to explore patient participation, and to assess the effects of such participation. Methods: Five databases—PubMed, PsycInfo, Medline, CINAHL, and Sociological Abstract—were searched for empirical studies on end-of-life decision making in pediatrics. Selected articles fulfilling the criteria were assessed for type of decision, participants’ characteristics, reports on participation of the minor patient, and outcome. Results: Fifty-seven articles on end-of-life decision making in pediatrics were identified. The majority of papers (n = 43, 75%) investigated parents’ and clinicians’ perspectives, while only 14 articles (25%) included perspectives of children and adolescents. Twenty-two articles (39%) reported some details on various forms of children's participation (e.g., receive information, plan care details, consulted before or after a decision was made). Positive (e.g., respect for patient's preferences) and negative (e.g., conflict due to diverging opinions) effects of children's participation in end-of-life decision making were reported. Conclusions: This systematic review highlights the need for research to identify factors that contribute to a favorable participation of minors in decision-making processes, as well as strategies to solve possible conflicts. More research should take into account the dynamics in the triadic process of decision making and emphasize children and adolescents’ perspectives. A better understanding of how to meaningfully involve children and adolescents in end-of-life decision making could facilitate the practice of patient participation in pediatrics. (shrink)

The objective of this paper is to understand from a sociological perspective how the moral question of euthanasia, framed as the “right to die”, emerges and is dealt with in society. It takes France and Germany as case studies, two countries in which euthanasia is prohibited and which have similar legislation on the issue. I presuppose that, and explore how, each society has its own specificities in terms of practical, social and political norms that affect the ways in which they (...) deal with these issues. The paper thus seeks to understand how requests for the “right to die” emerge in each society, through both the debate (analysis of daily newspapers, medical and philosophical literature, legal texts) and the practices (ethnographic work in three French and two German hospitals) that elucidate the phenomenon. It does so, however, without attempting to solve the moral question of euthanasia. In spite of the differences observed between these two countries, the central issue at stake in their respective debates is the question of the individual’s autonomy to choose the conditions in which he or she wishes to die; these conditions depend, amongst others, on the doctor-patient relationship, the organisation of end-of-life care in hospital settings, and more generally, on the way autonomy is defined and handled in the public debate. (shrink)

The ethics of adolescent decision making is a complicated mine­field with laws that vary from state to state. The case of a fourteen-year-old girl, who simultaneously was diagnosed with cancer and discovered she was pregnant, highlights several weaknesses in our current approach to adolescent decision making in the context of pregnancy. In addition, adolescents with life-limiting conditions face similar challenges that can be examined through the framework of Catholic doctrine.

While ethical conflicts in the provision of healthcare are common, the current third-party mediator model is limited by a lack of expert ethical mediators, who are often not on site when conflict escalates. In order to improve clinical outcomes in situations such as conflicts at the end of life, we suggest that clinicians—physicians, nurses and social workers—be trained to prevent and deescalate emerging conflicts. This can be achieved using a mediation model framed by a communication-training approach. A case example is (...) presented and the model is discussed. The implication of this preventative/early intervention model for improving clinical outcomes, in particular end-of life conflict, is considered. (shrink)

Background Nurses providing care to patients with end-of-life or terminal illnesses often encounter ethically challenging situations leading to moral distress. However, existing quantitative studies have examined moral distress using instruments that address general clinical situations rather than those specific to end-of-life care. Furthermore, qualitative studies have often been limited to participants from a single unit or those experiencing moral distress-induced circumstances. A comprehensive and integrated understanding of the overarching process of moral distress is vital to discern the unique circumstances surrounding (...) end-of-life care and its consequential impacts. Research objectives To explore the moral distress experiences of nurses who are frequently involved in caring for patients with end-of-life or terminal illnesses and apply it to two existing theories: the model of moral distress and the ecological model. Research design A qualitative descriptive approach was employed. Participants and research context Seven focus group interviews involving 30 nurses were performed. The subsequent transcriptions underwent rigorous content analysis. Ethical considerations We obtained Institutional Review Board approval from a university. Focus group interviews were conducted with nurses who agreed to participate and signed the consent form. Findings The moral distress-inducing factors and nurses’ perceived impact of moral distress were identified and categorized based on moral distress theories and ecological models. A total of 15 categories and 30 subcategories across the following 4 domains were derived: (1) intrapersonal, (2) interpersonal, (3) organizational, and (4) structural factors. Conclusions End-of-life-specific circumstances induced moral distress among nurses, with both negative and positive impacts identified. Effective organizational and policy support is essential to manage conflicts, form a healthy organizational culture, provide training, and prevent unnecessary expenses due to the negative consequences of moral distress. (shrink)

Currently in Japan, it is extremely difficult to realize the basic wish of protecting personal dignity at the end of life. A patient’s right to refuse life-sustaining treatment has not been substantially warranted, and advance directives have not been legally enforceable. Unfortunately, it is not until the patient is moribund that all concerned parties start to deliberate on whether or not death with dignity should be pursued. Medical intervention is often perceived as a worthwhile goal to not only preserve life, (...) but also provide psychological benefit to the family, regardless of its effect on the patient. To feel they are doing something, family members tend to act against the imperative “Do not inflict on others what you would not wish done to you,” and permit extraordinary measures they would not want themselves. Another complication in Japanese culture is the necessity of unanimous decisions for end-of-life care. If there is conflict between a patient and his/her family on accepting medical intervention, the view of the latter is more likely to prevail due to different perceptions of human dignity. As a result, incapacitated patients in Japanese clinical settings often suffer through extraneous medical procedures, particularly during end-of-life care. Patient dignity is in danger from a national refusal to accept major bioethical principles such as having respect for patient autonomy, serving the best interests of the patient, doing no harm, and ensuring fairness at the end of life. We argue that more education about human dignity and legislation for death with dignity are necessary. Peace of mind for patients during end-of-life care will never be achieved in this society unless drastic changes take place in medical ethics and law. (shrink)

From the celebrated author of When Bad Things Happen to Good People , a profound and practical book about doing well by doing good. For decades now, from the pulpit and through his writing, Harold Kushner has been helping people navigate the rough patches of life: loss, guilt, crises of faith. Now, in this compelling new work, he ad-dresses an equally important issue: our craving for significance, the need to know that our lives and our choices mean something. We sometimes (...) do great things, and sometimes terrible things, to reassure ourselves that we matter to the world. We sometimes confuse fame, power, and wealth with true achievement. But finally we need to think of ourselves as good people, and we are troubled when we compromise our integrity in the pursuit of what we think of as success. Harold Kushner tells us that the path to a truly successful and significant life is through friendship, through family, and through acts of generosity and self-sacrifice. He describes how, in affecting the life of even one person in a positive way, we make a difference in the world, and prove that we do in fact matter. Persuasive and sympathetic, anecdotal and commonsensical, Living a Life That Matters inspires and uplifts. (shrink)

BackgroundEthically challenging critical events and decisions are common in nursing homes. This paper presents nursing home doctors’ descriptions of how they include the patient and next of kin in end-of-life decisions.MethodsWe performed ten focus groups with 30 nursing home doctors. Advance care planning; aspects of decisions on life-prolonging treatment, and conflict with next of kin were subject to in-depth analysis and condensation.ResultsThe doctors described large variations in attitudes and practices in all aspects of end-of-life decisions. In conflict situations, many doctors (...) were more concerned about the opinion of next of kin than ensuring the patient’s best interest.ConclusionsMany end-of-life decisions appear arbitrary or influenced by factors independent of the individual patient’s values and interests and are not based on systematic ethical reflections. To protect patient autonomy in nursing homes, stronger emphasis on legal and ethical knowledge among nursing home doctors is needed. (shrink)

End-of-life decisions concerning euthanasia, stopping life-support machines, or handling advance directives are very complex and highly disputed in industrialized, democratic countries. A main controversy is how to balance the patient’s autonomy and right to self-determination with the doctor’s duty to save life and the value of life as such. These EoL dilemmas are closely linked to legal, medical, religious, and bioethical discourses. In this paper, we examine and deconstruct these linkages in Germany and Israel, moving beyond one-dimensional constructions of ethical (...) statements as “social facts” to their conflicting and multifaceted embedding within professional, religious, and cultural perspectives. (shrink)

Research questions and backgroundThis study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians’ uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying process. (...) Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient’s death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient’s life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. Materials and methods An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians’ concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. Results Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. Conclusions The physicians’ knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict. (shrink)

Publication date: 14 June 2017 Source: Author: Sylvester Tabe Arrey This work examines events from Cameroon's life since becoming a nation to foster understanding of the worrisome political situation the country has been traversing since 2016. Bitter and unhappy with their treatment since joining the French-speaking part, many citizens of the minority English-speaking part feel fed up and desire a breakup. I show that apart from constituting an aspect of its pride, Cameroon's history is also a source of tricky challenges (...) the country has been wrestling with since inception. I contend that issues of this kind will always be around if those in the country's cockpit fly it to a destination other than what satisfies and respects the two people – especially the one that moved the English-speaking part to opt for a joint destiny. Instead of toying with truth to score personal political points, authorities should yield to truth, operating in good faith to correct errors and heal hurt hearts so that both people will willingly, not by force, accept to work together. Contrary actions will risk the future. Happiness moves people to look at their history with pride finding things to build while pain stirs frustration and fury, moving them to search for flaws to fix or fight. I hold that both parts face almost the same challenges from unmet needs to emaciating struggles of survival. However, the English-speaking part has unique plaques that ache terribly and have nothing to do with the country’s general cry of lagging development. They touch on its identity and survival, unleashing pain many out of its shoes might fail to feel and so unable to understand the degree of excruciation. I caution that though it has been a show of two regions, the likelihood of someday evolving into a ten-region revolution is certain if wise and inclusive actions are not applied. Apart from groaning in their own pain, many among the other eight are sympathetic to the predicament of the lamenting two, expressing fury, first, against the denial by highly placed authorities of the existence of any problem, and second, in their ruthless and brutal treatment of those who complain or challenge their stance. Anger increased as people's patience waned. Their calm will not last if things stay unchanged. When arguments evolve and accommodate their worries they will get on board pushing the heat to levels officials will have problems containing without facing the temptation of fighting the people they are in office to protect. I end with recommendations the state and activists might find useful. They highlight measures that can help in a heterogeneous society like Cameroon to preserve peace and save it from becoming a scene of mayhem and butchery. (shrink)

Because an increasing number of patients have medical conditions that render them incompetent at making their own medical choices, more and more medical choices are now made by surrogates, often patient family members. However, many studies indicate that surrogates often do not discharge their responsibilities adequately, and in particular, do not choose in accordance with what those patients would have chosen for themselves, especially when it comes to end-of-life medical choices. This chapter argues that a significant part of the explanation (...) of such surrogate failure is that family surrogates are likely to undergo anticipatory grief when making end-of-life decisions. After clarifying both the emotional structure and object of grief, I propose that the pending death of a loved one induces an emotional conflict in surrogates between the care demanded by their responsibility as surrogates and the attachment surrogates feel toward their dying loved one, an attachment surrogates "resolve" in the direction of attachment rather than care. This hypothesis helps to explain both surrogates' general inability to exercise "substituted judgment" on behalf of their loved ones and a wide swath of the particular data regarding this inability (e.g., that surrogates more often err by choosing overtreatment). I conclude by considering possible clinical and philosophical responses to this hypothesis. (shrink)

Although clinical ethics consultation has existed for more than 40 years in the USA and Europe, it was not available in Bulgaria until recently. In introducing clinical ethics consultation into our country, the Modular, Ethical, Treatment, Allocation of resources, Process (METAP) methodology has been preferred because of its potential to be used in resource-poor settings and its strong educational function. This paper presents the results of a METAP evaluation in a hospital palliative care ward in the town of Vratsa. The (...) evaluation was based on Beauchamp and Childress’ four principles of biomedical ethics and involves implementation of specific instruments for clinical ethics decision-making. Research tasks emphasised analyses of ethics meetings in the ward. Data were processed by SPSS v.24 using descriptive statistical analysis. Altogether, 32 ethics meetings of an average duration 20.63 min were conducted on cases involving critically ill patients. Most of the participants (86.0%) expressed satisfaction with the ethics process. The principlist approach supported resolution of conflicts between autonomous patients and their relatives, clarified definitions of “medical benefit” and “social good,” and enabled assessments of the risk of unequal treatment. Even as the specific research tasks were achieved, further participant follow-up is necessary to identify any improvement in healthcare personnel’s ethical competence. METAP worked well in end-of-life care settings. Participants experienced several benefits, including improved team communication, better understanding of patient preferences, and confidence in the correctness of decisions. Despite the significant educational potential of METAP, the need for additional and ongoing ethics training of health professionals should not be underestimated. (shrink)

Conflicts involving end-of-life care between healthcare providers (HCPs) and surrogate decision-makers (SDMs) have received sustained attention for more than a quarter of a century, with early studies demonstrating a frequency of HCP-SDM conflict in ICUs ranging from 32–78% of all admissions (Abbott et al. 2001; Breen et al. 2001; Studdert et al. 2003; Azoulay et al. 2009). More recent studies not only acknowledge the persistence of clinical conflict in end-of-life care (Leland et al. 2017), but they have begun to focus (...) on the ways in which these conflicts escalate to verbal or physical violence in the ICU (Slack et al. 2023; Bass et al. 2024; Berger et al. 2024; Sjöberg et al. 2024). I will argue that part of the explanation for the persistence–and even escalation–of ICU disputes is the incommensurable value systems held by many conflicting HCPs and SDMs. I will argue that a common value system among HCPs can be understood as a “Best Interest Values” (BIV) hierarchy, which I will argue is irreconcilable with the set of “Life-Continuation Values” (LCV) held by a sizable minority of families in the United States. I argue this values-conflict undergirds many ICU disputes. If I am correct that an incommensurable value system underlies many ICU conflicts, then it is not just ineffectual for HCPs to impose their BIV system on LCV families, but also wrong given the American commitment to values pluralism. I conclude that the way to navigate continuous ICU surrogate wars is for BIV-focused healthcare institutions to engage more constructively with LCV stakeholders. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Slaves and the Generals of ArginusaePeter HuntIn the second half of 406 B.C. the Athenians made two shocking decisions. They freed the slaves who had fought in the battle of Arginusae and gave them citizenship, and they condemned to death their victorious generals. I suggest that these two events were related. Specifically, I would like to argue, first, that the competition for rowers to man the huge navies (...) of this period had extended even to slaves. The promise of freedom was intended to motivate the slaves: the grant of Athenian citizenship was an attempt to keep them rowing for Athens rather than deserting and ending up in the enemy's navy. Second, I would like to consider the trial of the generals in the context of this costly, divisive, and controversial policy. A priori considerations, historical parallels, and a few admittedly tenuous pieces of direct evidence suggest that their policy of rewarding the slaves contributed to the generals' unpopularity that made them so vulnerable to prosecution.Slaves to CitizensPassages in Aristophanes' Frogs and a scholiast's quotation of Hellanicus tell us that the slaves who fought in the battle of Arginusae were given freedom and citizenship. Most historians believe that the Athenians freed these slaves,1 but, given Athenian exclusiveness-manifest in Pericles' citizenship law-some doubt that they would have allowed a large group [End Page 359] of slaves to become citizens.2 The evidence, however, indicates that this was exactly what happened.Frogs won first prize at the Lenaean festival of 405-406, about six months after the Athenian naval victory at Arginusae. Early in the play, Dionysus and his slave Xanthias are traveling to Hades. When Dionysus mocks Xanthias for complaining about the load he is carrying, Xanthias exclaims:Dash it all, why wasn't I in that naval battle? Then I could really and truly tell you to go to blazes!(Ar. Ran. 33)3Fighting in the naval battle would have freed Xanthias from carrying Dionysus' baggage and allowed him to tell his master off. A bit later, Charon refuses to ferry Xanthias to Hades:I don't take slaves, unless they fought in the life-or-death naval battle.(190-91)4Again, slaves who have fought in a naval battle are treated differently from other slaves. From these passages alone, one might guess that the slaves who fought in some naval battle-Arginusae being the most recent and probable one-were given their freedom: they did not have to serve their masters and could ride with Charon rather than walking around the lake to get to Hades.Ian Worthington argues against this, the traditional reading of these lines. Xanthias' regret at not serving in the naval battle (33) is not that he would be then be free, but rather that then he would be dead and not forced to serve Dionysus.5 Aristophanes, however, was addressing an [End Page 360] audience many of whom had either fought at Arginusae or had relatives who had. We may associate Arginusae primarily with the deaths of the unrescued crews, but in 405 Arginusae was considered a successful relief mission and a great victory. Aristophanes was addressing the living victors, for whom "to fight at the naval battle" could not serve as shorthand for "to die." Worthington's reading of lines 190-91 is also less convincing than the traditional interpretation. He claims that those who "fought in the life-or-death naval battle" are the men whose drowning after the battle gave rise to the trial of the generals. The text gives no hint or suggestion that Charon is talking about this subset of the sailors who fought in the battle. Rather, Charon refers to another subset of those who fought in the battle, the slaves: "I don't take slaves, unless...." So we should stay with the traditional interpretation and the scholia to Frogs 33, which, although not an independent source, accords with our reading of Aristophanes: ("[I]n the previous year, in the archonship of Antigenes, the Athenians... won a naval battle around Arginusae and freed the slaves who had fought along with them").6Our first evidence for... (shrink)

End-of-life medical decision making presents a major challenge to patients and physicians alike. In order to determine whether it is ethically justifiable to forgo medical treatment in such scenarios, clinical data must be interpreted alongside patient values, as well as in light of the physician's ethical commitments. Though much has been written about this ethical issue from religious perspectives , little work has been done from an Islamic point of view. To fill the gap in the literature around Islamic bioethical (...) perspectives on the matter, we derive a theologically rooted rubric for goals of care. We use the Islamic obligation for Muslims to seek medical treatment as the foundation for determining the clinical conditions under which Muslim physicians have a duty to treat. We next link the theological concept of accountability before God to quality-of-life assessment. Using this construct, we suggest that a Muslim physician is not obligated to maintain or conti.. (shrink)

Background: The demand for autonomy in medical decision making is increasing among Korean people, but it is not well known why some people prefer autonomy in decision making but others do not. Research objectives: The aim of this study was to determine the extent to which Korean adults wished to exercise autonomy in the process of decision making regarding end-of-life treatment and to determine whether economic issues and family functioning, in particular, were associated with preferences for participation in decision making (...) in Korean people. Research design: This study was a cross-sectional correlational study using a survey. Participants and research context: Data were collected using structured questionnaires from 354 patients or their families who visited ambulatory departments at two general hospitals in South Korea, recruited by the proportionate quota sampling method. Data analysis was performed using multinomial logistic regression analyses. Ethical considerations: The study was approved by the hospitals’ directors and the ethics committee of Kyungpook National University Hospital. Written informed consent was given by all participants. Findings: A majority of Korean people wanted to make autonomous decisions regarding treatment at the end of life. Preferences for autonomous decision making regarding end-of-life treatment, rather than relying on family, showed a significant increase in association with poor family functioning and low income. Discussion: Results of this study suggested the necessity for development of alternatives to a dominant traditional “family-centered” approach in Korean people, in order to enhance end-of-life decision making for people who wish to take an active role in the decision-making process. Conclusion: Healthcare providers need to examine not only patients’ preferred decision-making style but also any reasons for their choice, in particular, family conflict and financial burden. (shrink)

With disagreement, doubts, or ambiguous grounds in end–of-life decisions, doctors are advised to involve a clinical ethics committee. However, little has been published on doctors’ experiences with discussing an end-of-life decision in a CEC. As part of the quality assurance of this work, we wanted to find out if clinicians have benefited from discussing end-of-life decisions in CECs and why. We will disseminate some Norwegian doctors’ experiences when discussing end-of-life decisions in CECs, based on semi-structured interviews with fifteen Norwegian physicians (...) who had brought an end-of-life decision case to a CEC. Almost half of the cases involved conflicts with the patients’ relatives. In a majority of the cases, there was uncertainty about what would be the ethically preferable solution. Reasons for referring the case to the CEC were to get broader illumination of the case, to get perspective from people outside the team, to get advice, or to get moral backing on a decision already made. A great majority of the clinicians reported an overall positive experience with the CECs’ discussions. In cases where there was conflict, the clinicians reported less satisfaction with the CECs’ discussions. The study shows that most doctors who have used a CEC in an end-of-life decision find it useful to have ethical and/or legal aspects illuminated, and to have the dilemma scrutinized from a new perspective. A systematic discussion seems to be significant to the clinicians. (shrink)

Don't tell terrible stories—everyone here has enough of their own. Everyone here has a whole bloody sack of terrible stories, and at the bottom of the sack is a hammer the narrator uses to pound you on the skull the instant you dare not believe your ears. Or to pound you when you do believe. Not long ago I saw a tomboyish girl on Khreshchatyk Street demand money of an elderly woman, threatening to bite her and infect her (...) with syphilis. Don't stroll through Volodymyr Hill Park, don't stroll around the botanical garden, and especially don't stroll on Kontraktova Square. Don't stroll anywhere. Don't go to the pavilion with the Golgotha panorama near St. Alexander's Church. Not even the twelve-meter-tall crucified Christ will save you. Don't go outside when it's dark and people turn into shadows a shade darker than dark. Also don't go where you can be seen from far away. Not to imply that people used to be like a bunch of lilies, but now they stink like a cellar of cabbage.The city, which earlier might have had some fun, is now going crazy. It's like a fish in warm water: it doesn't react to anything, swims slowly like it doesn't care if it swallows a hook or not. The excitement and exaltation pass into oppression, just as our necks have sunk into our shoulders, our shoulders into our lumbars, our lumbars into our nether regions. The holiday turns into a funeral, the parades into explosions, depression into mania. Winter passes into summer, people turn into beasts, the hours into ages, and the ages into hours. It's worth simply walking around the city to see a soldier from an unknown army taking a piss near the opera. Farther on is a row of identical old widows selling ball gowns and candelabra. Then there are the aristocrats and manufacturers who throw so much at the prostitutes that they'll soon be richer than their wives.I returned late through the Kyryliv Wood, not heeding all the warnings that I myself have given here. It really is dangerous—the place is famous for it. There's a madhouse nearby, caves where criminals and the sick can hide out. Also, once upon a time, as they say in fairy tales, the great dragon Zmei Gorynich lived here beside the Puchai River. The stench in these places drives away the most committed misanthropes and even one type of philanthrope—that is, perverts. It sounds dumb, but the stench is cleansing. I don't know where it comes from. After the operating theaters and the rooms with amputees, the stench no longer repelled or attracted me; it just was. And this was a great place to think. As I walked, I considered an incident with our patient.The patient, a respectable individual whose name carries too much weight for me to state it directly, one day began to assault people. He nearly strangled a merchant who he believed asked too much for a beaver coat. He likewise wanted to kill his business partner when he didn't say hello loudly enough. But the worst was, he lost all shame of his own nakedness. At first it was the police who took care of it. When our future patient slipped off his pants and undergarments, he was taken to Kyrylivska, which has had means for dealing with such cases dating back to the day when unhinged Cossacks and composers from Kyiv Mohyla Academy were taken there.During the examination we determined that the patient was experiencing a severe breakdown. His wife added that lately, more than once, he had allowed himself strong words in front of the children and often suffered from ennui. Furthermore, she said, the patient had been undergoing treatment for “the French disease” for some years—which was, obviously, where we needed to start.“Syphilis!” Skorsky spat out the matchstick he was chewing on. He was a specialist on the psychological aspects of diseases related to the venereal. “Tertiary syphilis! When poorly treated, over time ‘the French disease’ can destroy the central nervous system. Hence the patient's chicanery. Such theater!”Skorsky and I had not spoken since the incident at Bilinsky's. Meanwhile, something significant had happened to him. The most boring person on earth, Skorsky had simply caught fire. He said hello and kibitzed. I even heard the doctor got drunk alone in his office, then wandered through the forest. Could he be using narcotic substances?“Cocaine!” was the doctor's second proclamation. It was his favorite treatment for the psychological complications of syphilis. Skorsky himself never took what he called “the universal drug”—good for alcoholism and toothaches, neuroses and morphine dependency—though he had read in an article by a respectable Viennese physician, who used cocaine as a panacea, that it was not addictive. That doctor subsequently recanted, but Skorsky paid no attention. He believed the retraction was made under pressure from pharmacologists who had no incentive to cease production of the medications that cocaine might supplant. Their representatives either paid or threatened the Viennese to repent.As the patient was escorted to his room, he assaulted the orderly, Alevtyna. They tried pulling him off her, but, though he released his fingers from her neck, he buried his teeth in her leg. The poor orderly, who had not until then been attacked by a psychotic, nearly died of fear. Later, panic set in over Skorsky's diagnosis. He told her about the consequences of syphilis: grotesque patterns on one's face due to infection of the skin, mucous membranes, cartilage, and bones. He went on about the devastation to the central nervous system, which they had just observed in real life: “The face starts to look like lace some mangy dogs fought over before rolling in the mud.”Alevtyna, who had not yet regained her faculty of speech, straightened up. Ignoring the slavering male orderlies, she bared her leg to get a better look at the wound. She then ran down the hall and out into the garden, where she fell on the ground to rip up grass and small bunches of daisies. Alevtyna ate them along with the soil in their roots.“Minor hysteria. She needs fifteen milligrams of cocaine.”Skorsky took a snuff box out of his pocket and scooped up some white powder with a toothpick made from a goose feather. He gave the order to close Alevtyna's mouth and one of her nostrils, forcing her to snort the medication.We fretted over her so long that evening fell. I decided to walk down, along the ravine, behind the church.It was unlikely there were any large beasts there, but something was rustling. The pits and mounds, ravines, paths, graves of witches whose living sisters flew in the treetops from time to time, the whispers of the forest spirits, the spirits of the nutcases who died in the hospital, the spirits of the monks from the St. Cyril Monastery, Zmei Gorynich and the bogatyrs who wanted to defeat him. The city would be calmer without this forest. I saw the gaps between the trees and went off in the direction of the tram tracks.As I was coming out of the forest, there was a patch of Amanita muscaria that had been trampled into porridge. A bit farther on, the body of Professor Bilinsky lay killed in the blackberry bushes. The way he was lying it looked as though he had not struggled before death. I quickly examined his body but saw nothing out of the ordinary. There were no wounds, no dirt under the fingernails. Animals had not yet smelled the carrion, but swarms of various insects covered him. Oh, why did I have to find the putrid body?The best thing would be to take the tram to his house to inform his relatives. The doors closed, and I noticed my own calm. This death had not evoked any emotions in me other than a feeling of responsibility, the need to tell the family. But also—some alarm at the thought of who the murderer could be. I knew that it was murder.“Your nose is bleeding.” A woman as round as an onion, carrying two baskets full of strawberries, offered me an ironed and starched handkerchief.“Have I dirtied my shirt?”“No, it's as neat as a pin. It's just your nose that's dirty. Wipe it now before you spray blood on my strawberries.”“No one will see the red on red.”“Ah, but it's salty!”“You know why it's not sweet? We'd drink it like syrup.”“Those with Christ in their heart do not talk that way.”“Are your strawberries expensive?”“Why? What?”“I'm checking to see if you have God in your heart.”“Child, if you knew how I have to work for this berry! I have to weed it a hundred times. In a week, the quitch grass grows as high as a horse. And I water it with water I carry from the stream, it kills my arms... ”“How much are the berries?”“They're not for sale. Anyway, soon money won't mean a thing. Soon all money, all these papers made from the skins of sinners on their satanic presses will be annulled. What matters is how we treat each other.”“So if I try your strawberries for free, my ‘thank you’ will be enough?”“Hands off!” she said and thwacked my fingers.I heard loud laughter behind me—same laughter as from the café near the Continental. There was no one sitting near Alina. (This is what fate looks like, remember.) Without asking, I sat next to her, away from the old lady.“Excuse me, but the night before last didn't you, yes, didn't you intrude on my privacy?” She started right away.“I saw it a little differently. Who was that young man with the mustache who paid me for you?”“Are you checking to see if you can flirt?”The tram stopped. People got on and off.“Are you coming back from the hospital?” she asked. “Don't be shocked. My uncle works there. He's told me all about you.”“An uncle by the name of Skorsky?”(Remember: this is what fate looks like.)“Yes. Skorsky's been strange recently—says things that make me wonder if he hasn't lost his mind. Have you noticed anything?”“I don't know.”“You know perfectly well.”“Where are you going?” I tried to change the subject.“I have to send something to my theater friends in Odesa. By the way, they'll be putting on Oedipus Rex soon in Kyiv—in Ukrainian.”“Greek tragedy in Ukrainian! That's a first.”“Exactly. The troupe is rehearsing now in Odesa. The theater where they will perform this fall is being remodeled.”“Wait. Now I remember where I've seen you before—it was at a performance! Vynnychenko's Black Panther and White Bear, at the Bergonier on Fundukleivska.“The same director is doing the Oedipus. He's my friend.”“He's your friend in what sense?”“Again with that tired subject. By the way, I've been thinking about you.”“And I about you.”“That's good. I was thinking not about you, to be precise, but about that elevator you invited me on.”“Who was that man with you?”“Like a broken record! Even if he had been my fiancé, I'm not bought or inherited. I'm not a brooch or a hundred acres of land, and I'm not a house in Kaniv!... Who was with you when you saw Black Panther?“Ah, so.”“Answer!”“That was my mother. She looks very young. She is coming to Kyiv the day after tomorrow. I can introduce you.”“Oh, this is my stop.”I looked out the window and realized that I had long since passed the stop for Bilinsky's.“Can we see each other again?”“We can. But you have only one chance.”Alina the anarchist wrote something on a scrap of paper and handed it to me.Morning, not morning but a thick porridge (I hate porridge). Dew, thick spit, crushed fruits, urine, all on the sparkling cobblestones. The sun, just barely having made its appearance, is already scorching. The human masses scurry and grumble like poorly digested food inside a stomach.I walked diagonally across St. Sofia's Square, then along the perimeter, then one edge, then again diagonally across. I went underground. The basement café of the Continental Hotel was practically empty. I again asked the server to bring the cloth with the embroidered portrait, but I couldn't remember the musician's last name, only that it ended with -sky. The server said that -sky was currently in the southern cities of Yalta and Odesa. I added that Kurbas, the director, Alina's friend, was also in Odesa, rehearsing Oedipus Rex, and that he'd previously put on Black Panther.I was bored, so I walked along Khreshchatyk and then headed down, calling to mind all the Kyiv churches of Podil: there's Birth of Christ, St. Nicholas on the Shore, Intercession, Pyrohoshcha, Holy Presentation, St. Dymytrii Rostovsky, St. Illia's. And also the Epiphany Brotherhood Monastery, Ascension Convent, and St. Katherine's, all these whipped-cream churches on the waffles of our streets. A few of them reminded me of themselves by appearing suddenly out of nowhere.The smells on Kontraktova Plaza where commerce buzzed were like multicolored light bulbs turning on one after another. Here you could catch the aroma of Balabukha jam, which blended with the next smell, English shoe polish at the Raiskys’ shop. Then the crunchy-smelling cabbage from old women standing in a row like herons and spitting out the shells of sunflower seeds. Farther on, the stench of a good-sized rat that crawled under Mrs. Shevchuk's shop where she sells broadcloth. Oh, she can't scream: no, she'll quietly dig that rat out herself so as to not scare off her clients.I bought a paper and two pairs of underwear. I asked two laughing young chambermaids who were secretly puffing in a grape-filled yard for a smoke. I wandered around Podil until evening when I came across a sawmill near the Dnipro that surprisingly smelled pleasantly of mazut fuel oil. The weather was dry, yet in the middle of the road was an enormous puddle, a deep dark black. A forty-year-old woman in a pale pink dress stood near it. The theatricality of it all provoked me to pose her a question,“Ma'am, what should I do?”But she paid me no attention. I shouted,“What should I do?”“What to do, what to do?” she said in Polish. “Jump in the water and swim so far away that you cannot return.”I quickly crossed a section of the forest. The wind brought a mixture of unpleasant air, like a stinky handkerchief held under one's nose. Passing the trees, I saw light in the spaces between them and exited at the hospital.Outside the windows, two orderlies lay in chairs with their heads thrown back. Two others—fools—ran around the yard in different directions, peering out at... something. The lights on the first floor of the hospital were on, and the staff milled about.“You're just in time!” said Ivan, a tall, young orderly.“For what?”“Your patient ran away! We went into his room and he wasn't there.”“What patient?”“The one who bit Alevtyna,” said Danylo, the other orderly, short and middle-aged.“That's Skorsky's patient, not mine.”I had no intention of helping them. This was all history—like my family, Kyiv, and my previous life. I had no intention of thinking about it. I wanted to go to my office, pack up my field surgery kit, and get out. So what? Their psychotic syphilitic ran away—it happened.Of course, that patient could have something to do with Bilinsky's murder. But that was no longer my problem.“What a strange coincidence!” the doctor on duty said. “Comrade doctor, the other one responsible for this patient was just here.”“And where is he now?”“He took off toward the church to look for the patient.”“Didn't the patient escape earlier?”“Don't know.”“How do you not know? You had better call the police, moron, before he kills someone. And get those sleeping orderlies to look for him.”“They can't... ”“Why not? Should I go wake them?”“They're on morphine.”“And you, I can see, have lost your mind. Go, catch your psycho! If it turns out that he killed Bilinsky—and on your watch—you can't imagine what's in store for you.”I adjusted my homburg and set off in the direction of St. Cyril's, that unwelcoming monolithic cube. I glanced around—what if our escaped syphilitic were to jump out of the bushes and bite or strangle me. I looked around because I wasn't sure of my actions, wasn't sure of my choices. Tripping over a clump of clover, I reached the open doors of the church. I couldn't stop myself from going in.The walls and ceiling were covered with frescoes. There was what used to be an angel rolling up the sky on the southern column of the narthex. But also graffiti: people scratched their names on it so as not to be forgotten—their idea of eternity. Prince Volodymyr the Great compared this activity to the desecration of graves. The vandals paid a fine and were beaten with canes. During the raids of Batu Khan, the church was deserted and cracks appeared all over it. Wild martens and feral dogs sought shelter here; insects swarmed under the ceiling with its red mosaics. Birches grew in its midst. Water seeped in the cracks, the water became ice, the ice widened the cracks, more water seeped in the cracks, becoming more ice that further widened the cracks, the wall split and nearly fell over, and then the wall fell over. Yet the angel is still rolling up the sky... When I reached the exit, I heard a rustling behind me. I turned after I stepped outside: in the depths of the church, like a stick in a pot of tar, stood a man with a large bag thrown over his shoulder and a revolver pointed right at me.“Is that you, Doctor?“Don't move!”“What's... Skorsky, what's with you?”“Don't move, I say!”“What are you doing here?”And finally I understood... Skorsky was himself the psycho! (Really, I had known for a while.)“You are the murderer! I knew it! But—why?”“Shut up.”“It was you. You! The stolen cigarettes, the strange behavior, Bilinsky. If I shout, everybody will come running. They've already called the police!”There was heavy breathing behind me. And then a gun rang out.The city is overgrown with new buildings. They encircle everything that was once on the periphery. Kyiv has become an old lady that can no longer restrain herself in the face of pastries. The city climbs farther. It steps over the swamps, turns the old rivers into a series of lakes; the other bodies of water it drives into canals. The grain that falls from the wild wheat is black. When the sun heats it, the grain melts and trickles into the earth. St. Cyril's stands indestructible. No one spackles the small cracks in its walls with either expensive putty or glues, nor with cheap cement and whitewash. One day a small fox appears in the doorway. It runs inside and along the floor of simple gray tiles. The gods watch from the walls, watch and fall into ruin. The fox runs to the iconostasis. Before it is a time-darkened Virgin Mother and Child in oil on sheets of zinc. The fox runs the metal steps that wind up to the second floor. The fox runs past all the vaults, naves, all the frescoes. A buckthorn seed flies in through a broken window. It will be the first. Soon the buckthorn will grow everywhere. A dumb hare will make its nest in the buckthorn bushes and nightingales will settle in the upper branches to sing until the end of the world. The fox runs between the thick rays that penetrate the windows. It catches one of the rays, squints its eyes, and warms itself in the sun.The shot rang out, but I did not fall. I looked around—and on the church threshold was our syphilis patient bearing a rod. His head lay on the rocks by the doorway.“If only he'd been at the stage of nose deformity! Just imagine: a hole instead of a nose plus a hole from the bullet—like an extra pair of eyes!” Skorsky laughed at the corpse.“We need to call the orderlies.”“They heard the shot. They'll run here on their own. You see, Professor Bilinsky believed it would take two or three years to wrap up this patient's case,” Skorsky told me. “But I took care of it much faster!”“Excuse me, but I'm going crazy in this city. I thought that you were Bilinsky's murderer.”“Just so. Why not? I am Bilinsky's murderer.”“Don't tease. You've changed a lot recently, so... ”“Yes, I've started killing people. You might term such a change significant.”“You have the right to irony.”“I am not being ironic.”“Let's call it sarcasm.”“It's the honest-to-God truth.”“And yes, you have the right to mock me.”“Well then, let's be done. To the horses!”“What horses?”“Alina's waiting!”Alina, her uncle Skorsky, a few others I didn't know, and I rode like the wind that ripped off my homburg and carried it back to Kyiv.“There's a fresco in the choir loft at St. Cyril's where Vrubel painted himself and patients from the hospital as the apostles. When I came across it by accident, I really believed they were saints,” Alina said.“I've never been up there. I've only seen the church from below.”“Remember the way back so you can see it sometime.”“The Puchai River used to flow here. You shouldn't trust the landscape,” Skorsky said, reaching for something, perhaps his bag, just when we left the darkness of the trees and saw the endless steppe ahead of us.We rode all night without stopping. Though no one was chasing us. Though we had nowhere to be. We rode like beasts released from a cage. The promises of the horizon turned what we'd left behind into a cage fit for those from whom freedom had been severed, like an anomaly, at birth.The pre-morning sky looked at first like a sack of turnips—filled with something heavy. But with each verst, the sky became lighter. When it was finally light enough to see clearly, we arrived at a knoll at the foot of a stone wall that from a distance had appeared to be a gigantic piece of halva. The exterior ruins of the castle gave no hint of how it was when all was fine here, when people defended themselves successfully from the nomads’ raids. From far off, the wreckage looked like a natural agglomeration of stones—a rocky elevation, no more: a cluster of cliffs. It would rain a few hundred more times, a few hundred more winds from a few hundred directions would blow on this heap, and it would collapse as though nothing had ever been here.A few stalks of wheat grew from one of the rocks. Someone had probably cast a handful of grain here for some birds that forgot to eat it.“Who could this castle belong to?” I asked Skorsky.“I reckon the Swan Princess,” the doctor rejoined, hoping to sound knowledgeable.From behind one of the piles of gray sandstone emerged a young man in a black reptilian coat and a white papakha as lush, bright, and out of place as a dahlia. His name was Artem. The heat was melting our brains, but he was dressed like that, in rooster fashion, which was popular among the otamans. Artem helped Alina dismount her horse and tried to kiss her on the lips, but she offered him a cheek instead.Had she been racing to see this clown?We entered the yard—the ruins had fashioned an internal space that was more or less protected, at least from strangers’ eyes. It turned out that there were even places where it was possible to hide from the rain, and from there the ruins didn't look half bad.In the center of the court was a table, and on it a wooden bucket with pink gladiolas. How romantic! It all looked like it came from outer space. Where on earth, in the middle of the steppe, far from any village or town, did this table, this simple table, come from? And the gladiolas? The steppe hadn't been plowed in so long that any cultivars would have gone wild, degenerated, dried up completely.A campfire crackled nearby—a little preview of what we would soon do to the houses, villages, and cities. Artem the otaman brought over a cezve from the fire and poured the first portion into a small, copper cup for Alina. He also got out a porcelain cup with images of rosy cherubim—but how...?“Who else would like coffee?”Only Skorsky and I responded. The question excited me, even distracted me from the thought of the kiss I had recently witnessed and the Kyiv I had recently left.“It's obvious who the professors here are; cultured people drink coffee. Are you both doctors?”“Uh-huh.”“For wolves of the steppe, like us, doctors are gold, even more precious than gold. Actually, a Hippocrates like you should eat more, because those in your profession will soon be worth your weight in gold. Work on your figures, both of you.”“Who will take pity on the horses that have to carry us?”“We'll find the horses. And very large doctors can be transported on machine-gun carts. We'll need to seat the otamans near you. Only a fool would shoot at a doctor.”“I think we'll find quite enough fools here.”“With your beard, Doctor, you look like Tsar Nicholas II. But even so you won't be shot. You might even be canonized!”“We've only just arrived and you're going on about executions,” Skorsky grumbled and checked to make sure that he still had his bag.“Apologies, apologies, pardonnez-moi. But you are not merely a doctor. A venereologist! Skorsky, you're a specialist! A venereologist is the most important person in wartime. The most valuable! You are the botanists of war. You can't imagine what varieties of flowers grow here, and these beds have long awaited a proper gardener. Or even just a man with a scythe!”“Bite your tongue,” Alina said. “I don't need to listen to this.”“Yes, yes, of course. Excuse me, my r—. ” He almost said “rose.”We rested all day. We went down to a surprisingly close river overgrown with lilies. We rowed the boats left by fishermen. I talked to Skorsky. He took his bag everywhere, refusing even to swim so he wouldn't have to part with it. I asked him what he had in it, but he said it wasn't my damned business.Alina rowed with the otaman to the middle of the river. They were having a loud discussion. She was waving her hands. The current carried their boat downstream slowly and smoothly. What a nuisance, that current!I tried to meet with Alina one-on-one, but she was avoiding me. In the morning I was confused, by lunch I was sad, and after lunch I got angry.In the evening, I lay on the hot grass and drank another cup (I have no idea where they got such good coffee), which had no effect at all on my sleep. I watched the Perseids. Every year, the Earth passes through the tail of Comet Swift-Tuttle. People can see the meteor shower and make a wish. I wished. I counted forty-seven falling stars. All forty-seven of my wishes were for the same thing.Around the campfire, they were sitting, talking. I saw how he tickled her face with a piece of grass and she brushed him off in annoyance. Then they were screaming at each other. Later they again spoke kindly, after which they again quarreled. My joy grew after each tiny mistake that Artem made. I wanted him to show the worst he was capable of.They were screaming at each other, but all I could hear was beautiful opera singing. The stars fell to the sound of their screaming. The stars blessed my joy.Then this happened: Alina kicked the fire, scattered burnt kindling, and burned some of the grass. Artem grabbed her by the arm, but she broke away from him and ran off to the horses.“Go then! I guarantee you'll get to Katerynoslav and return with your tail between your legs.”“I'm going to Huliai-Pole! To Father Makhno!”I jumped up and ran after her.“Where do you think you're going?” Artem shouted.Really—where was I going? I was going after her: to Huliai-Pole, to Katerynoslav, to Rome, to Washington, to Istanbul, to Montevideo... “Go to sleep,” he said. “Come morning, this coquette will be here, right as rain. We've already been through this show. Tomorrow she'll be right here next to my boot!”... No, she won't.In some sort of shape we entered some town. There were some buildings that were some colors, some trees, some streets, some roads, and some signs. Posts, flustered birds’ nests, echoes, colors, shapes—each of some kind. A wedding procession was coming toward us. If you want to make orange, you need to add yellow to red, and then bam—it's black. If you want to salt the soup, shake in a little, and then bam—two handfuls. You want to say a kind word, and then bam—a punch in the face. I was rocked around like a watermelon on a boat and threw up my breakfast straight into the horse's fluffy mane. Sanko found this hilarious, but I said I'd pulverize him. So Sanko sped ahead.No one knew anything about Alina. The daytime sky was like a poorly washed bowl. The sun was a squashed, rotten apricot. The night sky looked like the sole of a boot to me. The moon was a dirty cheap copper coin that had gotten stuck to the sole. Everything seemed spoiled to me, irrelevant, unnecessary. Without her, this journey was a waste of time.“You'd better stay away from everyone,” Artem said. “You'll infect us with your pining, and pining is worse than the clap.”The wedding procession was before us. The young couple, still utter children, walked so calmly it was as if they didn't see us. As if we were made of a light breeze—our bodies, clothes, our horses and their iron shoes—of the lightest gasses. As if we were visible only to ourselves and the coal-black dog that barked, panting and gasping.The wedding was headed straight for us. We were in the middle of the road, and so were they. We approached each other slowly, a wave going toward a wave. Some ten meters before their indifferent faces, I noticed the color of the bride's eyes. And the coral-colored tulips that fell on the road before her. Round goose eggs on meaty stems, the flowers were falling and falling before her. The bride's eyes were almond shaped.“Hey there,” Artem shouted at me. “Wake up!”I came to and saw the whole village, everyone there, not realizing my group had turned left onto a side street away from the procession. The tulips disappeared—where'd they get tulips in the fall? I was sitting alone on my horse in the middle of the road, and the entire wedding procession came to a stop. I moved to the side, and the throng marched on, cutting off our escape route. We rode a few more meters and came across the synagogue.“You know what, you're right,” said the otaman.“Who is?”“Oleksii is the only one here who's right.”“About what?”Artem turned his horse and raced back. Everyone stood still while he ran his horse into the crowd and began firing his revolver. People scattered in all directions. Artem trotted, cackling like an imbecile. The horse kicked an old guy in the mouth. The man fell, spitting out his gold teeth. We rode up to the commotion and formed ranks, but none of us wanted to join the otaman.The bride stopped in the middle of the street. On both sides were buildings and trees, as well as dust, sky, and sun. She stood still, beautiful, as if nothing had happened. Then she adjusted her garland and walked calmly on.“Well, should we get some sugar now?” Artem laughed, looking at the bride, and off he went toward the sugar factory.It was then I noticed that all of the houses had shutters—fuchsia, blue, ocher—and that all the shutters were closed.We flew toward the dirty building, whistling and shouting. If there had been aesthetes among the otamans, they would certainly have razed the abomination in this field after seizing it. They would have spread soil on top and sown buckwheat. Long live buckwheat!, that wonderful crop. Like hunting dogs hot on the trail, we raced to our defenseless victim, with the baying of hundreds of hounds behind us. The field shook beneath us. We became an artist's canvas, evolving from Realism to Romanticism, Romanticism to Expressionism, Expressionism to Suprematism. If we had been painted in black and white, we would have been splotches (until the ink ran, annihilating all remaining patches of white).Two men stood near the gate—unarmed and undressed, in nothing but their undershirts and boots. Our fervor, our kinship with the elements, our entirety, were all for naught.“Jesus Christ! What bores!” Artem exclaimed. “How boring you are!”“Maybe boring for us, but fireworks for them,” Sanko said, dismounting his horse.“The fear of death engenders creativity,” our otaman—a distinguished philosopher of the early twentieth century, that demonic breed—prophesied.He went on, “Excuse me, but with all due respect, we are not going to search you. Just show us right away where the money is. Why are there so few of you? Don't say there's not much money. I want piles and piles of money! If you don't show it to us, we'll print our own on your skin. Believe me, we will.”We entered the factory grounds. There were no workers, only an enormous mountain of sugar beets that looked like a pile of coal from a distance and a pile of dead rats from up close.“So, did you have a good year?” Artem asked a man in an undershirt.“Not really—too dry.”“Nah, that's fine. You wouldn't have been able to gather most of the harvest this year anyway. There's a fire burning across all of Ukraine, all of Russia. The whole world!”While Artem tossed thoughts like well-chewed sunflower seeds into the crowd, the two men quietly stepped aside and then ran fast ahead to the factory's main hall. The gigantic door slammed shut. The gate was locked behind us! The windows were smashed! The factory roared from inside like a cumbersome machine starting up. Bullets whirred through every window.“Bastards! It's a trap! Quick, after me!”Still on horseback, Artem bounded over to a vast window, low to the ground, and smashed it mercilessly. He broke the frame and jumped inside on his horse. I and a few others followed. We broke into their lair, threw open the doors, and let the other warriors inside.Iron vats of hot sugar were steaming, pipes were clattering; machinery groaned.“Parasites!” Artem gritted his teeth. “I'll get you. I'll get you red sons of bitches. Painted whores!”At the word “painted,” his horse fell to the ground. Lying prone, Artem continued fighting, but the red soldiers wouldn't let him stand. Fighting nearby, I rode over to assist but did not know where to aim. Artem got up, ran forward, and brought his sword down on the head of the closest soldier, all the way to the middle of his skull, to the bridge of his nose. It was like butchering a pig. Artem thrust the sword into the buttock of another who was fleeing and cut off his leg at the bend in the knee.“I'll cut off every last one of your asses! Cut off your asses!” Artem bellowed.A half hour later, the dead were lying, the captured sitting, and the victors doing anything they pleased.“Skorsky, are there a lot of casualties?” I asked the doctor, whose hour it was. I hoped not, because I was too tired to help him.“Just a few. The dead are already dead, and the wounded are not ours.”Though Skorsky rarely asked my help, and though I'd become an ordinary soldier, the doctor in me was still present in the most unpleasant attribute—knowledge. Others saw an eviscerated man, pieces of dusty flesh smeared with clay, soil, sand, and straw. I saw a perfectly formed kidney hanging perfectly from the rest of its body like a child's mitten from its coat. You could try this death on for size. Wear it like a sanbenito of the Inquisition.Artem counted the money and then lay on the floor alongside the gigantic sugar mountain in the middle of the room. From time to time, the crystals rustled as they fell.“I didn't think you'd be such a fighter!” the otaman said without turning toward me. “I thought you'd be healing us. You'd keep to the rear and we'd hide you like a girl. But here you are, in the vanguard, like a lion!”“I got excited,” I told him, choosing not to react to the “girl” part.“’Cause Alina said there was no sense counting on you to fight.”“Really?”“Does that sting?”“Why would it? I'm a doctor—not everyone is. It requires a brain. Unlike waving a sword.”“Yeah, yeah. I gave her gladiolas. We were lying in the boat near that castle, doing all manner of things, and she told me all about you. How you met.”“You were lying in that boat talking about me?”“It was the day before you left Kyiv. You agreed to go with the anarchists so quickly!”“Were you surprised? Doctors make fast decisions.”“But you probably had great prospects. Your parents are rich, right?”“And who are your parents?”“Probably all your relatives fled abroad—bourgeois. Why did you stay?”“What the hell's your point?”“Alina, by the way, died a while ago. Probably.”“Don't jinx her.”“Listen here,” he said, staring at the ceiling. “And listen good. If you have designs on her—dead or alive—it's best you castrate yourself now.”“After you.”“If I want to kill somebody, you know, I just do it.”At last he looked at me. I was lying on the floor nearby and looking in his direction, sweaty and relaxed, my appearance complemented by my disdain for his opinion, his authority, his stupid hat. His everything.Artem raised his arm above his head, stuck a finger in the sugar mountain, and licked it. We both got up. Had I anticipated this turn of events, I would have readied a gift for him. Artem held his revolver. Under my hand I found a knife the workers used for gathering beets: it was a deliberately sharpened arc they sank into the swollen brassicas. I jumped up and quickly stepped around the sugar mountain.Artem's bullet hit a pane and broke the glass.“Not man enough for hand-to-hand?”The otaman shot again.“You should've challenged me to a duel, you romantic!”Encrusted with white crystals, I charged Artem from the sugar mountain. We fell in, and the sugar stuck in our hair, mustaches, nostrils, armpits.The gang ran in to get us apart, then backed off because it had nothing to do with them. By now the sugar mountain had burst its banks. Of the once perfect pyramid, a deformed mound remained.Wounded, Artem fell on the sugar mound, turning the white red.I stood before the gang sugar-coated and holding a bloody hook. The old otaman was drawing his last breath. Blood trickled from the corner of Artem's mouth and streamed from the left side of his breast.“What's the commotion?” Old Roman had just come in.“Be quiet,” the boys told him. And a good thing they did.“You killed him? You killed the otaman!”“Shut your mouth,” the boys told him.“You... ”I slugged Roman's stinky herring mouth. How did that son of a bitch find pickled herring in a sugar factory? My fist was now bigger and stronger than ever before, a steel anvil that could split nails and shatter memorial plaques. The unfortunate man's jaw twisted like an upper millstone that had gone off track from the lower.“Let's get out of here and go to Makhno's camp,” I gave my first order.We galloped so fast the grass burned beneath us. The birds and bugs had no time to fly out of the way; hooves trampled the burrows of rodents who didn't dare crawl out of their holes for a long time after. We raced like no one had ever raced before.The steppe, that sly fox, pretended to be an innocent fool. The steppe said, “I'm like Adam: I don't even know my own name.” But its grass harbored the tracks of thousands of armies and the heels of Herodotus, the crunch of Trypillia vessels, and the smell of Scythian hemp, Roman coins, clay figures of wolf people, the chevrons of Denikin's army, glass from the Chekists’ ruby stars, traces of uranium from flying saucers. I threatened it: “Steppe, show me your layers, or I will burn you, plow you under, flood you.” But it just replied: “I'm like Adam: I don't yet know my name.”I lost geography as if it were a silver coin. It fell out of my pocket and rolled through the feather grass that blanketed the steppe in white foam. The open space ahead was so endless that the whole world might as well have been steppe. If people ended up here from somewhere else, they would conclude they were on another planet. The coin fell and became an argentum, became one with the ring on the hand of the princess who had one green eye and one blue, with the twisted candlestick at the monastery on the other side of the steppe, with melted ingots. It broke down into simpler elements, simpler and simpler yet. The horse carried me spreading the seeds of northern plants to the south, just as southern riders had once brought flowers and weeds to the north. And then I turned back. Just as I had no geography, I had no time. Every night I fell asleep with the thought that the next day I would again race. Through all spacelessness, all timelessness. I exchanged one horse for another, got on a train, on a boat, traversed forty versts on foot—in rain that brought the river up to the road, in heat that overturned cattle. The earth I walked on became mine. Mine was the water in the lakes and springs, clean water, dirty water, enlightened water, contaminated with oil, stinking of algae, of fish that died in wells, stinking of the memory of atrocities, water as clean as broken bread. The water did not become Alina.I was doing this for her: I got the basturma out from under my saddle, sodden with the horse's sweat, sliced the throat of a rich man whose daughter I had danced with at a ball, climbed into a vat of beet juice and took a sugar bath, carried out the expropriation of the savings banks, wiped the sweat from my face with my shirt—and the cloth turned red; I didn't know from what. If it was someone else's blood, I didn't care; if it was my own, even less.We mostly came across Reds. We scraped them up like old red paint on a door in order to repaint the boards black. Black looked better. Red is tasteless, but black has style. Healthy men died before us of myocardial rupture like bunnies found in the nest. The ones whose hearts were sewn of steel wire envied the deceased. Seizing estates, banks, distilleries, and prisons reminded us of gathering in the harvest. If you're too lazy to pick an apple, you can shake the tree; some of the fruit gets bruised when it falls. We seized buildings like we were shaking apple trees. No one picked the fruits, we just shook: shook under the beds, under the tables, behind the curtains. No, there was no picking. We just shook until the red juice spurted from the apples.Near the Khorol River with Father Makhno and me in charge, we captured sixteen machine guns and four cannons, as well as five hundred prisoners who immediately came over to our side. The villagers voluntarily gave us bread and cheese, chickens and kvas. People joined us. The front of the machine-gun cart said “You can't run,” and “You won't catch us” at the back. We took factory after factory. Millions of karbovantsi, thousands of poods of sugar, weapons. We smashed the telephone exchanges and captured the telegraphs. We made alliances with some and then with others. Lenin, Wrangel, Frunze, the Germans, Chinese, Australians, Kaiser Wilhelm II, Cleopatra, Maria Theresa Walburga Amalia Christina. We ran the steppe. There were a hundred thousand of us. There were three hundred thousand of them. There were three hundred thousand of us. There were a million of them. There were two million of them. We were all of humanity. We were so many that we were none.The nobles’ estates were long ago forsaken. In the people's deepest trunks lay silks and guipure laces that were once perhaps used only to cover a table. Five steps from the barn in the direction of the pear tree, some silver candlesticks are buried; there's a plaster figure of an angel in the chicken coop, covered with shit and feathers.I was reluctant to be going to my home, but I didn't see any way out. Fate intended me to be a different being from the one I was before.Here my grandfathers and great-grandfathers were born. Here the ones who caused my grandfathers and great-grandfathers to flee had stopped. When we were still far off I noticed that someone was in the house. It was our men—Skorsky had brought them here, about twenty in all. I asked Sanko, whom I had walked with side by side more than once, where the doctor was now. All the men answered that he was around somewhere, but I didn't see him that evening.In 1918, the spirit of my great-grandfather Stepan, along with my mother and uncle, had gotten into a britzka and scrambled off to Paris, to Napoleon, against whom my great-grandfather had fought with the Cossacks, to whom the Russians promised to return self-rule. Following him in the cart went the soul of Grandpa Oleh, who lost a finger when he cut down the old linden near the house; his second finger was blown off by a cannonball near Balaklava, and later his entire hand was cut off by some Turk. Next went the spirit of my father, also Stepan, who did not take part in any war but died of measles at the age of forty. They all got the hell out of here. First, they went to Kyiv, led by my mother, Tamara Makarivna, in order to collect Uncle's family and me, their son. And their son, it turns out, has now come back to rob his own home (I didn't drive my war buddies away, did I?). It's a shame that I didn't know where the bathtub was, or whatever they bathed me in when I was small. It would have been good to walk through the ranks of anarchists with that basin and tell them all to spit into it.Remembering every room, I carried Alina upstairs to my mother's bedchamber. There was no longer furniture or pictures, only bare walls. The bed and mattress remained, but that was enough. Mother hated noise, so she set up her room far away from the running in the halls and the creaks on the stairs. I adjusted the mattress; in a gap, looking like a stalk of wheat, there lay a gold bracelet that she lost in the haste and that the thieves could not find in the mayhem. I tucked it into my pocket.The place could still be saved. It was strong, built under the leadership of my grandfather, who knew how to do it right. He built a sawmill, a gristmill, a dress factory (today it's probably been ransacked, maybe even by our own men).Alina had a complete, displaced break in her right fibula. We needed water first. I went downstairs—the guys were dragging out the piano like an old cow to the slaughter.“What are you doing with that?”“Taking it out.”“Why?”“What's it to you? We want to have fun.”“Can you play?”“We're not your bourgeois lily-handed bitches.”They couldn't play, but they were famous at destruction. “Noise is the music of the new time,” one of the smarter among them might have said. “But noise is the opposite of music. Just as a rose is the opposite of your ugly mugs,” I'd have responded if there was anyone to say it to. I could also have said that this was a Bosendorfer grand piano, that it was very valuable—but do the guys not deserve such a luxury?“Why are you so boring? We're relaxing.”“Then let me play a little first.”“Go ahead, but fast. One-two.”So I played. As before. My fingers ran up and down the black and white keys, which weren't simply keys of these, the simplest, colors. These were the keys that remembered my fingers specifically—achieved by that slovenly German Katerina, our governess. She knew a bundle of languages, could play the piano, and was interested in the latest scientific discoveries. But she had not an ounce of sympathy for anyone who couldn't master anything on the first try. More than once she hit my pinkie against the black key that remembered every one of its four thousand touches. She would pound it on the key and shout, “Si bémol! Si bémol,” and later bang my fingers and translate, “B flach! B flach!”I played. I could not expose myself, so the only thing I could do was believe in miracles. What if these coarse men saw value in this bit of furniture so unintelligible to them? And what if they didn't destroy it, this emblem of my childhood, my land, my air, which I could protect in no other way? My air. My water.“Shchedryk, shchedryk, shchedrivochka,” one of them who recognized the tune began to sing along.“Look at you.” They did not expect music from me, who had until recently been drinking blood like water.They said, “Again, again!”A group of curious men gathered around me. They were ordinary farmers, thieves, and recidivists, peasants and workers, everyone except for Skorsky. They needed this music as they needed baths. The music cleansed them from the inside, perhaps. They had not heard anything besides the whistle of a bullet, the neighing of a horse, or the knocking of a chisel and the whirring of a saw, amputating limbs, for a long time.But it could not go on long. I did not close the piano lid, just stood and went to fetch water for Alina, leaving the unfinished song for later. The well was to the north—that is, at the “Head.” My father once promised to give me a compass if I could learn to identify the ends of the earth by means of the sun. And to make it easier to remember, I gave each one of them a name: the east where the day begins was “Right” (my right hand), the west “Left,” the north “Head,” and the south “Feet.” Back when I could still do whatever I wanted all day long, I would wake in the morning and say: I'm going to the Feet. The mound was at the Feet, Left had the river, Right had the forest. It was only to the Head that I rarely went, because a village was located there. When the villagers saw me, they would speak in whispers and avoid the master's son.... I wiped her brow and her burning, sunken cheeks. I lay down next to her to feel the heat of her skin.When the fire in Alina calmed slightly, I went out into our orchard. My father had once been given a gift from Japan—a tulip tree that blossomed with yellow-green flowers. It had to have grown in the time that I was away. It would have been fatal had it been cut down. I again took the stairs down into the drawing room and came across nobody—they had all disappeared in search of food or were hidden away in their burrows. In the middle of the hall, like an opened rib cage, was the piano, irreparably shattered.B Flach! B Flach!Translation © Ali Kinsella 2022. (shrink)

The paper attempts to account for the confusion over the validity of the concept of schizophrenia in terms of two closely related aspects of conceptual indeterminacy. Firstly, it is identified on the basis of a breakdown in intelligibility, but what constitutes such a breakdown is indeterminate. Secondly, the concept sits between the categories of natural disease or illness on the one hand, and character trait or moral failing or gift on the other. This entails an indeterminacy in attempting to define (...) the role that physiological explanation could have. Light may be thrown on the concept by exploring a distinction between a life story in which the schizophrenic condition emerges as the conclusion of the story and a causal process in which the condition is the end result or final consequence. (shrink)

End-of-life decision making constitutes a major challenge for bioethical deliberation and political governance in modern democracies: On the one hand, it touches upon fundamental convictions about life, death, and the human condition. On the other, it is deeply rooted in religious traditions and historical experiences and thus shows great socio-cultural diversity. The bioethical discussion of such cultural issues oscillates between liberal individualism and cultural stereotyping. Our paper confronts the bioethical expert discourse with public moral attitudes. The paper is based on (...) a qualitative study comprising 12 focus group discussions with religious and secular persons in the USA, Germany, and Israel. Considering the respective socio-political and legal frameworks, the thematic analysis focuses on moral attitudes towards end-of-life decision making and explores the complex interplay between individual preferences, culture, and religion. Our findings draw attention to the variety and complexity of cultural and religious aspects of end-of-life decision making. Although there is local consensus that goes beyond radical individualism, positions are not neatly matched with national cultures or religious denominations. Instead, the relevance of the specific situatedness of religious beliefs and cultural communities becomes visible: Their status and role in individual situations, for example, as consensual or conflicting on the level of personal perspectives, family relationships, or broader social contexts, e.g., as a majority or minority culture within a political system. As the group discussions indicate, there are no clear-cut positions anchored in “nationality,” “culture,” or “religion.” Instead, attitudes are personally decided on as part of a negotiated context representing the political, social and existential situatedness of the individual. Therefore, more complex theoretical and practical approaches to cultural diversity have to be developed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Rhetoric 34.1 (2001) 21-37 [Access article in PDF] Conscience and the Concealments of Metaphor in Hobbes's Leviathan Karen S. Feldman Introduction Conscience is not a topic of terribly heated debate in Hobbes research. 1 Nevertheless, my claim in this article is that conscience in the Leviathan, which Hobbes poses as an example of the dangers of metaphor, is not merely an example of the dangers of metaphor, (...) but rather is the most dangerous metaphor, the metaphor that corrupts knowledge and thereby makes error and deception possible. Hobbes's brief account of conscience, which appears in the chapter of Leviathan on the ends of discourse, tells the story of the insinuation of metaphor into proper nomenclature; however, his example of the metaphorical use of the word conscience turns the story into one in which public knowledge itself is made private and thereby corrupted. Moreover, according to the story, private conscience is itself invented by means of a metaphor; it is in effect metaphorized into being. 2 With the emergence of private conscience, the potential of privatization expands from the privatization of the meaning of words to an entire private sphere of opinion. The metaphorical corruption of conscience invents a new understanding of knowledge as isolated from other witnesses, and the resultant privatization of truth lends itself to the corruption of that truth. Thus, whereas Hobbes characterizes the wrong use of names (of which metaphor is an instance) as a threat to accurate judgment and reason (L 22-23, 34, 161-62), as I will argue in the sections following, Hobbes's demand for the preservation of proper meaning in Leviathan corresponds to an anxiety regarding privacy and its peculiar potential for corrupting truth and knowledge. Hobbes's worries as to the dangers that metaphor poses to the stability of the commonwealth thereby converge with his worries about the dangers of conscience to the principle of public authority (cf. Strong 1993). [End Page 21] Hobbes's condemnations of conscience In Leviathan, conscience is condemned as a source of principles of human decision and action in a commonwealth. The problem with conscience as a principle of action is that it renders each individual inventor of his own rules and judge of his own actions. In brief, individual conscience is incommensurable with the public authority that defines a commonwealth: Another doctrine repugnant to civil society, is, that whatsoever a man does against his conscience, is sin; and it dependeth on the presumption of making himself judge of good and evil. For a man's conscience, and his judgment is the same thing, and as the judgment, so also the conscience may be erroneous. Therefore, though he that is subject to no civil law, sinneth in all he does against his conscience, because he has no other rule to follow but his own reason; yet it is not so with him that lives in a commonwealth; because the law is the public conscience, by which he hath already undertaken to be guided. Otherwise in such diversity, as there is of private consciences, which are but private opinions, the commonwealth must needs be distracted, and no man dare to obey the sovereign power, further than it shall seem good in his own eyes. (L 311) In this account, conscience is not just inferior to civil law as a principle guiding action, but at odds with civil society and the good of the commonwealth. The fact that conscience is private renders it problematic for the commonwealth for several reasons: First, as privately invented, it may be erroneous. Likewise, because it is private, conscience does not possess any binding power outside the individual, private sphere. Each person may be bound by his own conscience, but insofar as consciences differ, standards of action differ, and this leads to the undermining and distraction of the commonwealth. Likewise, private consciences may be divergent from one another, and the conflicts in private judgment produce conflicting actions that disturb the peace of the commonwealth. This rule of privacy is, moreover, associated with primitive life and with the state of nature... (shrink)

For a little more than a decade, professional organizations and healthcare institutions have attempted to develop guidelines and policies to deal with seemingly intractable conflicts that arise between clinicians and patients over appropriate use of aggressive life-sustaining therapies in the face of low expectations of medical benefit. This article suggests that, although such efforts at conflict resolution are commendable on many levels, inadequate attention has been given to their potential negative effects upon particular groups of patients/proxies. Based on the well-documented (...) tendency among many African Americans to prefer more aggressive end-of-life medical interventions, it is proposed that the use of institutional policy to break decision making impasse in cases for which aggressive treatment is deemed “medically inappropriate” will fall disproportionately on that group. Finally, it is suggested that the development and application of institutional conflict-resolution policies should be evaluated in the context of historical and current experiences of marginalization and disempowerment, lest such policies exacerbate that experience. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“Even the Papuan is a Man and not a Beast”: Husserl on Universalism and the Relativity of CulturesDermot Moran (bio)“[A]nd in this broad sense even the Papuan is a man and not a beast.” ([U]nd in diesem weiten Sinne ist auch der Papua Mensch und nicht Tier, Husserl, Crisis, 290/Hua. VI.337–38)1“Reason is the specific characteristic of man, as a being living in personal activities and habitualities.” (Vernunft ist das (...) Spezifische des Menschen, als in personalen Aktivitäten und Habitualitäten lebenden Wesens, Husserl, Crisis, 338/Hua. VI.272)1. Particular Historicities and Universal ReasonIn this paper2 i shall explore—and suggest a way of resolving—the evident tensions to be found in Husserl’s Crisis of European Sciences (and associated texts) [End Page 463] between his commitment to the universality of reason as the goal or telos of European humanity (founded on the ancient Greek “breakthrough” to philosophy and science) and his recognition of the empirical plurality and “relativity” (Relativität) of individual peoples and nations (e.g. Indian, Chinese, Papuan, Bantu) locked into their own particular “socialities” (Sozialitäten), communal worlds, and historical trajectories (what Husserl broadly calls “historicities,” Geschichtlichkeiten, Historizitäten). 3 I shall examine the complex relations and tensions between Husserl’s conception of universality, whereby the same reason functions in every human as animal rationale, “no matter how primitive he is” (“Origin of Geometry,” Crisis, 378/ Hua. VI.385), and his concept of the self-enclosed particularity of individual peoples with their own cultural forms. Indeed, Husserl often emphasizes that the most prominent feature of cultural plurality is precisely its relativity: “relativity belongs to the normal course of life.”4 I shall evaluate Husserl’s response, which defends the project of realizing the ideal of a critical universal rationality, by situating his discussion in terms of the cultural conflict of the time with the rising National Socialist commitment to racial particularism, and by showing Husserl’s commitment to the inherent universality of the one shared life-world.In his research manuscripts of the 1920s and 1930s Husserl frequently discusses the complex relationships that exist between different cultures and traditions; different cultures have their specific historicities (Crisis, 274/Hua. VI.320), dialects, norms, ways of life, and so on. This is simply a matter of fact. There are, furthermore, some well-known and controversial passages in Husserl’s “Vienna Lecture” of May 1935 and also in his Crisis texts (both in the main 1936 published text, Part One [§6] and in the then unpublished Crisis Part Three A §365) where Husserl speaks of the universality inherent in European philosophical culture of the logos and contrasts it with various other communal forms, which are, in his view, merely “empirical-anthropological” types, enclosed in their particular historicities and relativities. Indeed, in this context, Husserl regularly invokes the idea of the “relativity of everything historical” (die Relativität alles Historischen, Crisis, 373/Hua. VI.382). In addition, there are a number of related texts, collected in the Crisis supplementary volume (Hua. XXIX),6 in the Intersubjectivity volumes (especially Hua. XV),7 as well as in the recent volume on the life-world [End Page 464] (Hua. XXXIX),8 which discuss the empirical differences between peoples and also the layers and strata of social groups, nations, and even the idea of larger international collectivities or “supernations” (Übernationen), such as Europe, or the League of Nations. Furthermore, there are—as Husserl indicates in his 1935 letter to the prominent French anthropologist Lucien Lévy-Bruhl—even cultures that are completely “self-enclosed” (abgeschlossene) unities, cut off, some of which know no history. According to Husserl, into this classical world of closed cultures, the ancient Greeks bring a new form of universality, one that leads them, through the grasp of idealization to infinite tasks, to break through the finite horizons of their environing world (Umwelt), which presents itself to them as a “near-world” (Nahwelt, Crisis, 324/Hua. VI.303; Hua. XXVII.228), and to arrive at the highly refined concept of the “true world” or the “scientific world [which] is a purposeful structure (Zweckgebilde) extending to infinity” (Crisis, 382... (shrink)

Research questions and backgroundThis study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians’ uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying process. (...) Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient’s death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient’s life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. Materials and methods An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians’ concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. Results Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. Conclusions The physicians’ knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict. (shrink)

Translated by Drew S. Burk and Anthony Paul Smith. Excerpted from Struggle and Utopia at the End Times of Philosophy , (Minneapolis: Univocal Publishing, 2012). THE END TIMES OF PHILOSOPHY The phrase “end times of philosophy” is not a new version of the “end of philosophy” or the “end of history,” themes which have become quite vulgar and nourish all hopes of revenge and powerlessness. Moreover, philosophy itself does not stop proclaiming its own death, admitting itself to be half dead (...) and doing nothing but providing ammunition for its adversaries. With our sights set on clearing up this nuance, we differentiate philosophy as an institutional entity, and the philosophizability of the World and History, of “thought-world,” which universalizes the narrow concept of philosophy and that of “capital.” We also give an eschatological and apocalyptical cause to this end, of “times” or “ages” rather than those of philosophical practice. Last but not least, it is the Future itself in the performativity of its ultimatum that determines this end times, reversing these times from the Identity the Future accorded to it, withdrawing the thought-world from the lie of its death. Why this style of axioms and oracles, these more or less subtle distinctions, old and debased, with an appeal to the ultimata , to end times and last words? We fight to give, parallel to the concept of Hell, its new theoretical position, for its philosophical return and its non-philosophical transformation. No more so than any other word, Hell is not a metaphor here, just the Principle of Sufficient World. Every man, no doubt, has his “hell” readily available, connivance, control, conformism, domestication, schooling, alienation, extermination, exploitation, oppression, anxiety, etc. We have our little list that the Contemporaries established in the previous century in the same way one used to construct lists of virtues and vices or honors and wealth. They invented it for us without knowing it, for us-the-Futures who have as our responsibility to invent its use. In the Christian and Gnostic tradition, the struggle of the End Times takes place “on earth.” The most sophisticated of believers have it taking place in Heaven as well, above all in Heaven. The various kinds of gnosis imagine infinite falls and vertiginous highs, the vertigo of salvation. On Earth as in Heaven, a hell is available. The Marxists have the law of profit and the control of production, the class struggle Capital imposes on man. The Nietzscheans, the dull grumble of the struggle in the foundations of World and History, the domestication of man, the society of control. The phenomenologists, the capture of being, the most superficial amongst them, the age of suspicion. But all of these “hells” are taken from World, History, Society, and Religion. What we call Hell is no longer of the order of these specific and total intra-worldly generalities, it is both more singular and more universal, no longer being at all of the same order, it is the determinant Identity of these small hells strung out through history but unified here in the name of the last Humaneity. It is even found within the French idiom for hell [ enfer ], en-fer literally means “in-irons.” We are as much “in-irons” as we are “alive” [ en-Vie ]. We believe in Hell but as non-philosophers and it is even because we are non-philosophers that we can believe in it outside of any sort of religion. Hell is less mythological than ideological, it combines philosophizability with universal capital. Under what form? A single term could work for them without being a metaphor or something they would participate in by analogy, a more innovative and conjectural term than control, more universal than profit. It would denote the growing and permanent extortion of a surplus-value of communication, of speed and of urgency in change, in productivity and in work, in the pressure of images and slogans. It would be worse than solicitation, more tenacious than capture, more active and persecutory than control, softer and more insidious than a frontal attack, just as perverse as questioning and accusation, less brutal and offensive than extermination, less ritualized than inquisition, it would be soft and dispersed, instantaneous and vicious, it would be a crime without declared violence. Collusion and conformism, it would be afraid to show itself. Related to rumor, from which it borrows its infinite and tortuous ways. It is harassment. As a modernized form of Hell, perhaps harassment has a long future in front of it, of innocent torture, slow assassination, in short the fall, but radical with no way of recovering and which tolerates only salvation. THE PHILOSOPHICAL PAST OF NON-PHILOSOPHY Non-philosophy is thus Man as the utopian identity of the philosophical form of the World, a utopia destined to transform it. We still have to understand these equations, in particular that of the being-uni-versed from Man, and this book adheres to this by re-exposing non-philosophy in a different way via one of its new possibilities. It uses this opportunity to once again take up formulations that lead to objections answering certain external critics, as well as revisiting diverging interpretations specific to non-philosophers. A portion of this book is devoted to going through these theories via a strict or “lengthy” presentation of non-philosophy, and its defense against more expeditious solutions. This work of rectification is the occasion, merely the occasion, for refocusing non-philosophy on Man (the “Man-in-person,” “Humaneity”), and in a more innovative manner, on its utopian vocation established since the book Future Christ . As for this “occasion,” it is quite obvious. A school of posture, not to say a school of thought, supposes a minimum of closure from the most liberating of knowledge, a heritage, its utilization, and its no less certain dispersal. Within its development, a variety of interpretations will no doubt appear, deviations that are as much normalizations, and a struggle against this multiplication of divergent tendencies. These are perhaps not inevitable evils, especially here, merely a normal development according to the twisting paths of history. But the problem is made worse by the fact that this school of non-philosophers is that of utopia. Not the former attempts devoted to commenting on the worst authoritarian and criminal forms of the past and the present, but utopia as the determinant principle for human life, or to put it another way, of the Future as an irreducible presupposition of (for) thinking the World and History. Non-philosophers are engaged in an aleatory navigation between the respect for the most rigorous utopia, whose rules are not that of the reproductive imagination but those from the Future determining imagination itself, as well as the temptations, diversions, and remorse of history. Little by little, we will begin to understand that the Future as we understand it no longer has any temporal consistency or positive content, without being an empty form or a nothingness, but that it is foreclosed to past and present History, just as it is foreclosed to the place of places, the World, and that it is the only method for establishing the practice of thinking in a non-imaginary instance. Because it is the World and History that are imaginary and have a terrible materiality, it is not necessarily utopia. We will overlap two objectives here: the defense of non-philosophy against the (non-) philosophers that we are, only occasionally, and the introduction of philosophy to a rigorous future. Together they set out to definitively render, without any possible return to philosophical conformism or towards the facilities of the past and present, the non-philosophical enterprise understood as utopia or uchronia. Imagination and speculation, left to themselves and thus undistinguished, are quite good for participating in the grand game of History but have little value or worse for the Future which is unimaginable and unintelligible and must be maintained as such. MAN-IN-PERSON AS SUSPENSION OF THE PHILOSOPHICAL CHORA The point where philosophical resistance is concentrated is without a doubt the invention of the Name-of-Man, first name, oracular as much as axiomatic, of the determining cause for the non-philosophical posture. And that which concentrates the differends is the style of non-philosophy as identity that possesses the dual aspect, of discipline and of the oeuvre, of the theorem and of the oracle. But the real difficulty in understanding the simplicity of non-philosophy is profoundly hidden in the depths of philosophy itself. Because philosophy, from Parmenides to Derrida, even Levinas, continues to be a divided gesture, without a veritable immanence, transforming its thematic contents of transcendence in also forgetting to transform the operative transcendence in the element from which the ontology of surface is established which we will call, in memory of Plato, the chorismos. The general effect of the chora literally gives place to philosophy, demanding binding and sutures to which we will once and for all “oppose” the Man-in-person, his power of cloning, and his future being. All philosophy contains a hinter-philosophy in which it deploys its operations and weaves its tradition like an understudy of a topographical nature and in the best of cases being itself topological. Philosophy as well consists of two levels, its pre-ontological operative conditions on the one hand, and its superficial theme on the other, it too has its presupposed, but is not aware of it or erases it within the unity of appearance named Logos. Rightly, the Logos, and its flash or lightning nature, possesses a “dark precursor,” the chora, which is as much a virtual image, and philosophy, dazzled by its own lightning flash, seems to completely forget about it at the same time it sets itself up within it. Non-philosophy risks taking this same path, of confusing what it believes to be the real with its phantom double, contenting itself to working on the thematic level of philosophy, not its surface objects and its idle chatter (we stopped talking about this a long time ago and in any case they are merely simple materials for inducing a work of transformation), but the transcendence-form of its objects. In the end it risks, through precipitation, taking back up the heritage of philosophy, a heritage of a misunderstood presupposed, even more profound than the play of transcendences. This is what the imperative of the radicality of immanence meant, to treat immanence in an immanent manner, not to make a new object out of it. And from here we get non- (philosophy) and its refusal of the Platonic chorismos , symbol of all abstraction, and thus all transcendental appearance. There are no illusions. The message will leave a heritage in tattered pieces and interpretations. But it was difficult not to dispute the differend to its core. There will be complete confusion of the multiple, possible, and necessary effectuations of non-philosophy with its interpretations. The non-philosophical or human freedom of philosophical effectuation and the philosophical freedom of interpretation. Effectuations demand non-philosophy to return to zero from the point of view of its philosophical material and thus also but within these limits the formulation of its axioms , but in no way providing from the outset divergent interpretations of the aforementioned axioms. They are divergent because they do not take into account the material from which these axioms are derived within non-philosophy, and because they do not see themselves as symptoms of another vision of the World. The utterances of non-philosophy are not mathematical theorems and pure axioms, they merely have a mathematical aspect . They are, by their extraction or origin, mathematical and transcendental. And by their determined function in-Real, within non-philosophy, they are identically in-the-last-Humaneity entities which have an aspect of an axiom and an aspect of interpretation (or an oracular aspect as we say) that attempts (sometimes it is ourselves who provide the occasion) to isolate and transform, in complete freedom of interpretation. There will be an opportunity to complain about the complex character of the language of non-philosophy, an idiom saturated with classical references, sophisticated in a contemporary way. Its freedom of decision up against the whole of philosophy demands these effects of “complication” and “privatization,” as the saying goes. But it also demands fighting against the drift [ dérive ] of the pedagogical-all and the mediatic-all that leads philosophy into the shallow depths of opinion, which is the site of its impossible death. The noble idealism of “pop-philosophy” has been consumed into a “philo-reality;” against this we propose philo-fiction. Parricide, which is at the bottom of these interpretations and which we can judge as being quite fertile, although it has informed tradition, only takes place once or within one lone meaning. In regards to Parmenides, it was possible; Plato introduced the Other as non-being and language, bringing into existence the philosophical system of the World, but is it possible to repeat it again with the same fecundity in regards to non-philosophy, this time in introducing (non) religion or (non) art, still mixing them without taking into account this mixture, alternatively as a philosophical or religious resentment? If philosophy begins via a crime, it is no doubt obliged to continue down similar pathways, to the effect that the crimes of philosophy, once the founding crime has been committed, are a reaction of self-defense. It is undoubtedly from this that we get Marx’s declaration that history begins by tragedy and repeats itself or ends in farce. The preservation of rigor and fecundity is, in every respect, a psychologically difficult task within a theory such as non-philosophy. Having posited an essential objective of liberation in regards to philosophy and its services, one has often understood this objective as an authorization of providing particular interpretations of its axioms and ends up obliterating their scope. This ends up confusing, on one hand, two kinds of freedoms in regards to non-philosophy, the freedom of its interpretations and the freedom of its effectuations. On the other hand, any defense of “principles” against precipitated interpretations is immediately taxed with a will to orthodoxy, a prohibitive objection when we are dealing with, as is the case here, a heretical theory of thought. Nevertheless, it is time to stop confusing heresy as the cause of thought with an ideology of heresies, which is certainly not at all our object, but rather a form of normalization. As for the “disciplinary” aspect, which is not the only aspect, it demands something other than philosophical “answers to objections,” a precision in the definition and use of its procedures in the formation of utterances, since non-philosophy is neither a supplementary doctrine interior to philosophy nor a vision of the world but one whose priority is a “vision of Man,” or rather Man as “vision” that implies a theory and a practice of philosophy. In the end, struggle is only one aspect of non-philosophy, not its whole or telos, struggle coming only from its materiality. In particular, if the discipline of non-philosophy is inseparable from struggle, it is not a question of reducing the monomaniacal obsession of its “marching orders.” This would reduce its complexity and kill its indivisibility, deploying it in a “long march” and a form of Maoization whose philosophical presuppositions no longer have any pertinence here, a case of the One and the Two, which are now cloned and no longer tied together. More generally, non-philosophy is a complex thought composed of a multitude of aspects, which is to say, unilateral interpretations, of a philosophical origin but reduced by their determination in-the-last-instance . The “liberalism” of non-philosophy is merely one of the aspects of which it is capable, not an essence. Similarly, it is only capable of having a “Maoist” aspect. Let us generalize. The weakness of non-philosophy is due to a specific cause, the determination-in-the-last-Humaneity of a subject for the World. Everything that has a right to the philosophical city can be said about it in turn and in a retaliatory mode since Man contributes nothing of himself that Man takes from the World. We can consider non-philosophy as being pretentious, absurd, idealistic, empty, materialistic, formalistic, contradictory, modern, post-modern, Zen, Buddhist, Marxist; it endures or tolerates, perhaps “appeals” to, or at least renders possible, sarcasms, ironies, and insults without even talking about the misunderstandings, partly for the same reason as psychoanalysis. All of this goes beyond simple “deviations.” They are its aspects, which is to say, its “unilateral” philosophical interpretations in both senses of the word, being either sufficient coming from the mouth of philosophers, or reduced to their absolute dimension of sufficiency and totality in the mouths of non-philosophers, and both times due to the weakness and strength of Man-in-person as their determination only in-the-last-instance. The non-philosopher is certainly not a Saint Paul fantasizing about a new Church. The non-philosopher is either a (Saint) Sebastian whose flesh is pierced with as many arrows as there are Churches, or a Christ persecuted by a Saint Paul. What is engaged in here is the practice of retaliation. A negative rule of the non-philosophical ethics of outlawed discussion by way of argumentation (the sufficient is you, the orthodox one is always you, you are the fashionable one, and when a master you are someone else) that is founded on the confusion of effectuations of non-philosophy and of its overall interpretations. Retaliation is the law but as with any too-human law, it must acquire a dimension that displaces it, or rather emplaces it and takes away its authority but not all of its effectiveness. If the non-philosopher is only authorized by himself, which is to say by philosophy but limited by the Real-of-the-last-instance, its critique of other non-philosophers can merely be retaliatory under the same conditions, only by the Real limited in-the last-instance. THE TREE OF PHILOSOPHICAL SAINTLINESS The thematic horizon or material of these debates is in the relationships between philosophy, religion as gnosis, and non-philosophy. It is inevitable, regarding non-philosophers in general (whether they are non-philosophers by name or simply its neighbors) that we often end up evoking Marx’s Holy Family and imagining, arranged on the neighboring branches of the tree of philosophy and annexed, sometimes abusively, to non-philosophy, authors who would quite evidently and quite rightly refuse this label. So it is that we find, for example, a Saint Michel, a Saint Alain, a Saint Gilles 1 without even mentioning the youngest who aspire as well to the freedom of “saintliness” and who make their muted voices heard here. If there is a Holy Family of non-philosophers, it extends completely beyond these three, provided that the sectarian spirit can save us. This book is organized in the following manner: To begin, in order to recall the essential part of the problematic, we have organized a Summary of Non-Philosophy , a vade-mecum of notions and basic problems, in a classical style. Secondly, there is Clarifications On the Three Axioms of Non-Philosophy , designed to posit their proper use as much as to elucidate their meaning. Thirdly, an analysis of Philosophizability and Practicity , both being extreme constituents of philosophical material or the contents of the third axiom. Fourthly, the heart of this work: Let us Make a Tabula Rasa of the Future or of Utopia as Method . Fifthly, we have a theoretical outline of a non-institutional utopia, The International Organization of Non-Philosophy, L’Organisation Non-Philosophique Internationale, (ONPHI) already created in practice but under the conditions of possibility and functioning from which here we put into question “de jure,” thus not without a perplexity concerning “facts,” in any case, without the capability of “getting to the bottom of things.” Sixthly, an essay characterizing The Right and the Left of Non-Philosophy , a brief topology of several philosophizing and normalizing positions of proponents or tenants of this problematic. Seventhly, Rebel in the Soul: A Theory of Future Struggle , a systematic discussion starting from a confrontation of non-philosophical gnosis and non-religious gnosis to the extent that they pose, posed or perhaps still will pose themselves as rivals to non-philosophy in a mixture of fidelity and infidelity. Despite the fact that it can also be read as putting non-philosophy into perspective: it pits against a standard Platonism two contemporary appropriations of Gnosticism. On the basis of the paradigm of Man who never ceases to come as the Future-in-person, each one of these moments strives to reestablish not the “true” non-philosophy and its orthodoxy, but the minimal conditions to respect in order to allow for its maximum fecundity. And in order to bring about one of the last possibilities of its development, making explicit Humaneity as a utopia-for-the-World. In introducing these considerations in the form of a “testament” and “ultimatum,” we want to indicate two things: First, that this is the last time we will intervene in order to caution non-philosophers against the temptation of returning and looking backwards towards philosophy. Only a disillusioned nostalgia for the former World and its traditions barely remain permissible to us.… Secondly, that non-philosophy is also a sort of ultimatum for considering one’s life and transforming one’s thought from the perspective of a uni-version rather than a conversion. Man as future is this ultimatum in action, not an impatient self-proclaimed genius, and philosophy is his testament. It is obviously the ultimatum that determines this testament as “old” with a view towards a life that is, itself, non-testamentary. In and of itself, the “old” can never bear a veritable eschaton. Thus, this book intersects according to the logic of this paradigm, under the sign of the ultimate or “last” as future, philosophy as testament and cautionary note for maintaining the non-philosophical oeuvre as “future” or “utopian.” We will see that between these two dimensions it cradles a theory of struggle. In the end, this book envisions non-philosophers in multiple ways. It inevitably sees them as subjects of knowledge, most often academics insofar as life in the world demands, but above all as close relatives of three great human types. The analyst and political militant are quite obvious, for non-philosophy is close to psychoanalysis and Marxism insofar as it transforms the subject in transforming philosophy. Here again, one must have a sense not of certain nuances but of aspects (of the interpretations, albeit unilateralized) and not in order to construct a simple proletarization or militarization of thought as theory. To be rigorous, rather than authoritarian or spiteful, is its task. And lastly, non-philosophy is a close relative of the spiritual but definitely not the spiritualist. Those who are spiritual are not at all spiritualists, for the spiritual oscillate between fury and tranquil rage, they are great destroyers of the forces of Philosophy and the State, which are united under the name of Conformism. They haunt the margins of philosophy, gnosis, mysticism, science fiction and even religions. Spiritual types are not only abstract mystics and quietists; they are heretics for the World. The task is to bring their heresy to the capacity of utopia, and their utopia to the capacity of the paradigm. NOTES We will recognize allusions, and sometimes references, to closely related or distant themes, but which are related, in the work of Michel Henry, Alain Badiou and via the representative of “non-religious” gnosis of a Platonic origin, in Gilles Grelet. It goes without saying that these discussions are current and local, neither concerning the ensemble of doctrines nor prejudging the eventual evolution of certain amongst them. This concerns defining certain proximities with non-philosophy (rather than adversaries which in some sense they are) and typological and emblematic differends (rather than conflicts with a certain author). (shrink)

In 1968, the Harvard criteria equated irreversible coma and apnea with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism, minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. Brain death does not disrupt somatic (...) integrative unity and coordinated biological functioning of a living organism. Neurological criteria of human death fail to determine the precise moment of an organism’s death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. Brain -based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs. (shrink)

How do the intellect and will remain free while pursuing a life of virtue? This is where the question of prudence comes in. Is the practical wisdom of the prudent man founded upon some kind of innate or acquired instinct, or does it presuppose understanding of intellectually grasped basic principles? And if those principles are presupposed, is reason necessary for applying them in any given instance, or can one solely look to the rightly formed appetites acquired by moral virtue? In (...) answering these questions, Ryan J. Brady looks first and foremost to St. Thomas Aquinas and his ancient and modern interpreters. Brady's way of engaging the question of the interplay between the intellect and reason is by focusing on two apparently conflicting texts of St. Thomas Aquinas, one of which says that synderesis (the habit of the first principles of the practical intellect) appoints the end to the moral virtues and another which says prudence does. The author's conviction is that the correct way of reconciling the two texts not only establishes knowledge not only of the role of conscience, virtue, and natural law in the moral life but also provides insight into the profoundly complementary roles of reason and will within the context of a life of virtue. (shrink)

Social, legal and health-care changes have created an increasing need for ethical review within end-of-life care. Multiprofessional clinical ethics committees (CECs) are increasingly supporting decision-making in hospitals and hospices. This paper reports findings from an analysis of formal summaries from CEC meetings, of one UK hospice, spanning four years. Using qualitative content analysis, five themes were identified: timeliness of decision-making, holistic care, contextual openness, values diversity and consensual understanding. The elements of an engaged clinical ethics in a hospice context is (...) not generally acknowledged nor its elements articulated. Findings from this study have the potential to explain some of the most challenging ethical problems and to contribute to their resolution. It may also guide future deliberation and raise CEC members' awareness of the recurrent issues and values of their CEC practice. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Literature 27.2 (2003) 269-283 [Access article in PDF] To Live a Riddle:The Case of the Binding of Isaac Galia Patt-Shamir MOST OF US BELIEVE we know what a riddle is. Usually it is an obscurity, or a set of obscurities, for which—we assume—an answer can be given, even if one is not yet known. Most of us, moreover, believe we know what a solution to a riddle (...) is; in most cases it is a well-defined explanation of the obscurities inherent in the riddle. But what if these obscurities cannot be defined well inherently? In this case, it may be called "a living riddle." Most of us probably have never given a thought to what a living riddle is, and to what would amount to a response. In this article, I attempt to understand the biblical story of the binding of Isaac (the Akedah), as a riddle of a special type, a riddle whose "solution" is one's life.An underlying assumption here is that obscurities and paradoxical expressions in religious texts reflect real conflicts in life. No one can completely understand a foreign form of life; and moreover, in each form of life the most crucial ideas are couched only in subtle cues. The idea of a living riddle opens a channel between texts and practice; an ability to see the riddle expresses understanding for the form of life it represents.The article opens with a philosophical exposition, followed by a literary illustration regarding the role of riddle in a religious context. In the second part, we offer a methodology, mainly as an implication of the later Wittgenstein's texts; in this part, we will focus on the senses of life as a riddle. The third part focuses on life as the response to the riddle. By applying this method to the biblical story of the Akedah, we will refer to Kierkegaard's Fear and Trembling. In the fourth part, Kierkegaard and Wittgenstein are interwoven to highlight the absurd. [End Page 269] This article ends with a counter-example to the futile attempt to reason with the Akedah, as presented in Kafka's short story "Abraham." I Let us start in reading two passages from Wittgenstein's Culture and Value. Christianity is not a doctrine, not, I mean, a theory about... but a description of something that actually takes place in human life. (p. 28) But in that case why is the scripture so unclear? If we want to warn someone of a terrible danger, do we go about it by telling him a riddle whose solution will be the warning? But who is to say that the scripture is really unclear? Isn't it possible that it was essential in this case to 'tell a riddle'? (p. 31) 1Wittgenstein stresses that first and foremost, the particular case of Christianity refers to a system of practices. In his words Christianity is not a theory about something; it is human life itself. Religious belief can, and has to be, expressed in riddles: telling a riddle is essential for understanding. According to the present view, a riddle is a question in which the answer is inherent. The riddle itself is a hint toward its solution. If, by analogy, a careful detective discovers a clue and shows that it is inherent in the puzzle, we get closer to unraveling the whole.Religion is presented as a riddle of a special kind. Its "solution" is not found in theoretical terms; rather, it is a commitment; "a living riddle." When one takes up this riddle as one's life, one commits every move in life as an expression of the riddle. Even without living it, an ability to see the riddle and its response is an ability for "seeing every problem from a religious point of view," despite seeing oneself as "not a religious person" (as Wittgenstein testifies of himself). 2 The ability to see that it is a living riddle, allows an "outsider" to recognize a certain point about the believer's life not... (shrink)

A research project by the Schools of Theology and Psychology of Australia’s Charles Sturt University surveyed a large sample of Salvation Army officers. This article considers survey responses to two questions relating to end-of-life care: the use of pain medications that may shorten life, and the cessation of fluid and food intake. The results of the analyses are evaluated in terms of Michael Banner’s proposal that moral theology should more assiduously converse with ‘patient ethnographic study’, which the survey instantiates to (...) some extent. Banner’s proposal and the results of the survey are contrasted to Peter Singer’s analytical moral philosophical dictums on end-of-life care. The results are also compared to a metastudy by Andrea Rodríguez-Prat and Evert van Leeuwen of 14 ethnographic studies of those who wish to hasten death at the end of life. We conclude that respondents exemplify a form of moral reasoning that is embedded within Christian spirituality; counters the assumptions of Singer’s approach; contrasts the diminishment of ‘meaning’ at the end of life, as seen in Rodríguez-Prat and van Leeuwen; and deserves further respectful ethnographic study. (shrink)

This article is one of the first sociological explorations of power struggles between intellectuals where matters of life and death are literally at stake. It counters the prevailing tendency within sociology to study intellectuals within confined academic institutions where power struggles are limited to matters of symbolic and institutional recognition. This study explores the conflict between collaborationist and Resistance intellectuals at the end of the Second World War in France, and it focuses in particular on the purge of collaborationist intellectuals (...) which culminated in several high profile trials. This article shows that the arguments and meta-arguments put forward in these trials led to broader intellectual debates outside the courtroom. These debates not only centred on the notion of the writer’s responsibility, but also dealt with anxieties about the disintegrative forces of modern society. Whereas collaborationist intellectuals portrayed their writing as either separate from politics or rescuing a defunct or degenerate nation, Resistance intellectuals such as Jean-Paul Sartre were keen to portray collaborators as outsiders, both socially and sexually, lacking in social integration and subservient to a strong external force. The Resistance intellectuals saw the notion of individual responsibility not as antithetical but as integral to the remaking of the French nation, and this concept would become the cornerstone of the reshaping of the intellectual landscape in the post-war era in France. (shrink)

The way in which medical professionals engage in bioethical issues ultimately reflects the type of care such patients are likely to receive. It is therefore critical for doctors and other health care professionals to have a broad understanding of disability. Our purpose in this paper is to explore ways of teaching bioethical issues to first year medical students by integrating alternative approaches. Such approaches include (a) the use of the narrative format, (b) the inclusion of a disability perspective, and (c) (...) the presentation and facilitation of classes by people with disabilities. We consider how these new kinds of presentations are evaluated by students, faculty, people with disabilities and professional ethicists. We hope new knowledge may provide health care professionals with a greater understanding of the perspectives of patients with disabilities, who are confronted by conflicting ethical values and frameworks for decision-making in their interaction with such professionals. (shrink)

In 1989, Helga Wanglie, 86 years old, broke her hip. This began a medical downhill course that a year later caused her health care providers to conclude that she would not benefit from continued medical treatment. It would be futile, and therefore, should not be provided. Her husband disagreed, and the conflict eventually led to a lawsuit. The Wanglie case touched off an extended debate in the medical and bioethical literature about medical futility: what it means and how useful the (...) concept is in making ethical decisions about starting or stopping treatment. (shrink)

Economic motivations are key drivers of human behavior. Unfortunately, they are largely overlooked in literature related to medical decisionmaking, particularly with regard to end-of-life care. It is widely understood that the directions of a proxy acting in bad faith can be overridden. But what of cases in which the proxy or surrogate appears to be acting in good faith to effectuate the patient’s values, yet doing so directly serves the decision-maker’s financial interests? Such situations are not uncommon. Many patients care (...) as deeply about economic wellbeing of their families as they do for their own lives and health. This brief work examines three scenarios that raise ethical issues regarding the role of pecuniary motives in making critical medical decisions. Each scenario presents a potential financial conflict of interest between an incapacitated patient and a third-party decision-maker and offers a framework for integrating ethical and legal concerns into clinical care. It is our hope that this work prepares physicians for unexpected ethical conflicts of interest and enables them to further the interests of his or her patients. (shrink)

BackgroundOne of the next frontiers in HIV research is focused on finding a cure. A new priority includes people with HIV (PWH) with non-AIDS terminal illnesses who are willing to donate their bodies at the end-of-life (EOL) to advance the search towards an HIV cure. We endeavored to understand perceptions of this research and to identify ethical and practical considerations relevant to implementing it.MethodsWe conducted 20 in-depth interviews and 3 virtual focus groups among four types of key stakeholders in the (...) United States (PWH, biomedical HIV cure researchers, HIV clinicians, and bioethicists) to obtain triangulated viewpoints because little was known about the ethics of this topic. Each group was queried as to ethical considerations, safeguards, and protections for conducting HIV cure-related research at the EOL to ensure this research remains acceptable.ResultsAll four key stakeholder groups generally supported HIV cure-related research conducted at the EOL because of the history of altruism within the PWH community and the potential for substantial scientific knowledge to be gained. Our informants expressed that: (1) Strong stakeholder and community involvement are integral to the ethical and effective implementation, as well as the social acceptability of this research; (2) PWH approaching the EOL should not inherently be considered a vulnerable class and their autonomy must be respected when choosing to participate in HIV cure-related research at the EOL; (3) Greater diversity among study participants, as well as multi-disciplinary research teams, is necessitated by HIV cure-related research at the EOL; (4) The sensitive nature of this research warrants robust oversight to ensure a favorable risk/benefit balance and to minimize the possibility of therapeutic misconception or undue influence; and (5) Research protocols should remain flexible to accommodate participants’ comfort and needs at the EOL.ConclusionBecause of the ethical issues presented by HIV cure-related research at the EOL, robust ethical safeguards are of utmost importance. The proposed ethical and practical considerations presented herein is a first step in determining the best way to maximize this research’s impact and social value. More much inquiry will need to be directed towards understanding context-specific and cultural considerations for implementing EOL HIV cure research in diverse settings. (shrink)

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but (...) together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors. (shrink)

Medical communication in Western-oriented countries is dominated by concepts of shared decision-making and patient autonomy. In interactions with Roma patients, these behavioral patterns rarely seem to be achieved because the culture and ethnicity have often been shown as barriers in establishing an effective and satisfying doctor–patient relationship. The study aims to explore the Roma’s beliefs and experiences related to autonomy and decision-making process in the case of a disease with poor prognosis. Forty-eight Roma people from two Romanian counties participated in (...) semi-structured interviews, conducted by a research team from the University of Medicine and Pharmacy of Iasi. Participants were recruited among the chronically ill patients and caregivers. The Roma community opposes informing the terminal patients about their condition, the “silence conspiracy” being widely practiced. The family fully undertakes the right of decision making, thus minimizing the patient’s autonomy. We identified ethical dilemmas concerning autonomy, lack of patients’ real decision-making power, and paternalistic attitudes exerted firstly by the family and, on demand, by the physician. Instead, the Roma patient benefits from a very active support network, being accompanied at the hospital by numerous relatives. The patient’s right to make autonomous decisions promoted in the Western countries and stipulated by the Romanian law has diminished value in the Roma community. For the Roma, the understanding of dignity is not simply individual and personal, but it is closely related to their cultural particularities. Ignoring their cultural values could create conflicts between healthcare providers and community. (shrink)

This book challenges fundamental doctrines of established medical ethics. It is argued that the routine practice of stopping life support technology causes the death of patients and that donors of vital organs (hearts, liver, lungs, and both kidneys) are not really dead at the time that their organs are removed for life-saving transplantation. Although these practices are ethically legitimate, they are not compatible with traditional medical ethics: they conflict with the norms that doctors must not intentionally cause the death of (...) their patients and that vital organs can be obtained only from dead donors. The aim of this book is to undertake an ethical examination that aims to honestly face the reality of medical practices at the end of life. This involves exposing the misconception that stopping life support merely allows patients to die from their medical conditions, that there is an ethical bright line separating withdrawal of life support from active euthanasia, and that determination of death of hospitalized patients prior to vital organ donation is consistent with the established biological conception of death. A novel ethical justification is required for procuring vital organs from still-living donors. It is contended that in the context of plans to withdraw life support, donors of vital organs are not harmed or wronged by organ procurement prior to death, provided that valid consent is obtained for stopping treatment and organ donation. In view of serious practical difficulties in facing the truth regarding organ donation, an alternative pragmatic account is developed for justifying current practices that relies on the concept of transparent legal fictions. In sum, it is the thesis of this book that to preserve the legitimacy of end-of-life practices, we need to reconstruct medical ethics. (shrink)

Traditionally, physicians and parents made decisions about children’s health care based on western practices. More recently, with legal and ethical development of informed consent and recognition for decision making, children are becoming active participants in their care. The extent to which this is happening is however blurred by lack of clarity about what children — of diverse levels of cognitive development — are capable of understanding. Moreover, when there are multiple surrogate decision makers, parental and professional conflict can arise concerning (...) children’s ‘best interest’. Giving children a voice and offering choice promotes their dignity and quality of life. Nevertheless, it also presents with many challenges. Case studies using pseudonyms and changed situational identities are used in this article to illuminate the complexity of ethical challenges facing nurses in end-of-life care with children and families. (shrink)

Providing versus foregoing enteral nutrition is a central issue in end-of-life care, affecting patients, families, nurses, and other health professionals. The aim of this article is to examine Jewish ethical perspectives on nourishing the dying and to analyze their implications for nursing practice, education, and research. Jewish ethics is based on religious law, called Halacha. Many Halachic scholars perceive withholding nourishment in end of life, even enterally, as hastening death. This reflects the divide they perceive between allowing a fatal disease (...) to naturally run its course until an individual’s vitality (life force or viability) is lost versus withholding nourishment for the vitality that still remains. The latter they maintain introduces a new cause of death. Nevertheless, coercing an individual to accept enteral nourishment is generally considered undignified and counterproductive. A minority of Halachic scholars classify withholding enteral nutrition as refraining from prolonging life, permitted under certain circumstances, especially in situations where nutritional problems flow directly from a fatal pathology. In the very final stages of dying, moreover, there is a general consensus that enteral nourishment may be withheld, providing that this reflects the dying individuals’ wishes. In the event of enteral nourishment becoming a source of overwhelming discomfort, two Halachic ethical mandates would come into conflict: sustaining life by providing nourishment and alleviating suffering. As in all moral conflicts, these would have to be resolved in practice. This article presents the issue of enteral nourishment as it unfolds in Halacha in comparison to secular and other religious perspectives. It is meant to serve as a foundation for nurses to reflect on their own practice and to explore the implications for nursing practice, education, and research. In a world that remains broadly religious, it is important to sensitize health practitioners to the similarities and differences among religions and between secular and religious approaches to ethical issues. (shrink)

The goal of this paper is to review and describe the characteristics and outcomes of ethics consultations on a gastrointestinal oncology service and to identify areas for systems improvement and staff education. This is a retrospective case series derived from a prospectively-maintained database of the ethics consultation service at Memorial Sloan Kettering Cancer Center. The study analyzed all ethics consultations requested for patients on the gastrointestinal medical oncology service from September 2007 to January 2016. A total of 64 patients were (...) identified. The most common primary ethical issue was the DNR order, followed by medical futility. The most common contextual issues were dispute/conflict between staff and family, dispute/conflict intra-family, and cultural/ethnic/religious issues. The majority of ethical issues leading to consultation were resolved ; i.e., the patient, surrogate, and/or healthcare team followed the recommendation of the ethics consultant. 22% had a DNR order prior to the ethics consult and 69% had a DNR order after the consult. In this population of patients on a gastrointestinal oncology service, ethics consultations are most often called regarding patients with advanced cancers and the most common ethical conflicts arose between families and the health care team over goals of care at the end of life, specifically related to the DNR order and perceived futility of continued/escalation of treatment. Ethics consultations assisted with conflict resolution. Conflicts might be reduced with improved communication about prognosis and earlier end of life care planning. (shrink)

The chapter provides a response to Patrick Toner, “Critical Study of Fabrizio Amerini’s Aquinas on the Beginning and End of Human Life,” Oxford Studies in Medieval Philosophy 2, 211–28. The chapter corrects two misrepresentations in Toner’s review. First, it proves that, given Aquinas’ assumptions on substantial form and human soul, Aquinas could not give up his preference for delayed hominization of the embryo even if he were acquainted with contemporary embryology. Aquinas takes as the starting point of his embryology Aristotle’s (...) characterization of the human soul as the act of an organic physical body having life potentially, and this characterization leads him to the conviction that the human soul can enter into the human body only after the principal vital organs are formed. Second, the chapter corrects Toner’s unusual interpretation of the clause “organic” in the Aristotelian characterization of the human soul, by specifying the different senses of potentiality in Aquinas’ embryology. The chapter reaffirms the core idea that establishing when the hominization of the human embryo begins is not decisive for rejecting abortion. The chapter suggests relating the question of abortion to the identity or continuity of the human embryo rather than to the beginning of hominization. (shrink)

BackgroundRespect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients’ preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of ‘relational autonomy’ may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative (...) care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized.Main bodyHere, we develop a relational account of autonomy in end-of-life care, one based on a dialogue between lived reality and conceptual thinking. We first show that the complexities of autonomy as experienced by patients and caregivers in end-of-life practices are inadequately acknowledged. Second, we critically reflect on how engaging a notion of relational autonomy can be an adequate answer to addressing these complexities. Our proposal brings into dialogue different ethical perspectives and incorporates multidimensional, socially embedded, scalar, and temporal aspects of relational theories of autonomy. We start our reflection with a case in end-of-life care, which we use as an illustration throughout our analysis.ConclusionThis article develops a relational account of autonomy, which responds to major shortcomings uncovered in the mainstream interpretation of this principle and which can be applied to end-of-life care practices. (shrink)