In this paper, we explore three separate questions that are relevant to assessing the prudential value of life in infants with severe life-limiting illness. First, what is the value or disvalue of a short life? Is it in the interests of a child to save her life if she will nevertheless die in infancy or very early childhood? Second, how does profound cognitive impairment affect the balance of positives and negatives in a child’s future (...) life? Third, if the life of a child with life-limiting illness is prolonged, how much suffering will she experience and can any of it be alleviated? Is there a risk that negative experiences for such a child will remain despite the provision of palliative care? We argue that both the subjective and objective components of well-being for children could be greatly reduced if they are anticipated to have a short life that is affected by profound cognitive impairment. This does not mean that their overall well-being will be negative, but rather that there may be a higher risk of negative overall well-being if they are expected to experience pain, discomfort, or distress. Furthermore, we point to some of the practical limitations of therapies aimed at relieving suffering, such that there is a risk that suffering will go partially or completely unrelieved. Taken together, these considerations imply that some life-prolonging treatments are not in the best interests of infants with severe life-limiting illness. (shrink)

Volume 20, Issue 4, May 2020, Page 104-105.

This book offers an in-depth analysis of the wide range of issues surrounding "passive euthanasia" and "allow-to-die" decisions. The author develops a comprehensive conceptual model that is highly useful for assessing and dealing with real-life situations. He presents an informative historical overview, an evaluation of the clinical settings in which treatment abatement takes place, and an insightful discussion of relevant legal aspects. The result is a clearly articulated ethical analysis that is medically realistic, philosophically sound, and legally viable.

Given the costs of litigation high-profile court cases about withdrawing life-sustaining medical treatment for seriously ill children in England & Wales tend to be followed by discussion about how to avoid similar cases in future. Whilst two proposals, mediation and replacing the best interests standard with a harm threshold, have received broad attention, a proposal to replace the court by a specialist review committee has not been further investigated. This article analyses the effects of a putative replacement of the (...) courts by a specialist review committee using the process enacted by the futility clauses in the Texas Advance Directives Act (TADA) as a model. Under TADA life-sustaining treatment may legally be withdrawn when a review committee deems it futile and no alternative healthcare provider can be identified. The investigation finds that installing a national review committee with the power to decide whether life-sustaining treatment is futile would have reduced the number of court cases about withdrawal thereof in England & Wales to a handful over the last 3 decades. In addition to shorter procedures and costs savings, a national review committee modelled after TADA would have advantages for both clinicians and parents. Advantages for clinicians are more limited exposure to delivery of clinical care that may cause moral distress and less exposure to adverse press and social media content. Advantages for parents are that the process would establish them as ethical decision makers and offer the possibility of a transfer of the care of the child provided an alternative healthcare provider can be found. As such decisions taken by a specialist review committee may be more acceptable for parents than those of the courts. (shrink)

For those with advanced life-limiting illness, the optimization of quality of life and avoidance of nonbeneficial treatments at the end of life are key ethical concerns. This article evaluates the efficacy of an Interdisciplinary Ethics Panel (IEP) approach to decision making at the end of life for unbefriended nursing home residents who lack decisional capacity and have advanced life-limiting illness, through the use of a ninestep algorithm developed for this purpose. We (...) reviewed the outcomes of three quality-of-care phased initiatives conducted in our facility, a large public nursing home in New York City, between June 2016 and February 2020, which indicated that this IEP approach promoted advance-care planning, as palliative measures were endorsed to optimize quality of life for this vulnerable population at the end of life. We also examined another quality-of-care initiative when this IEP approach was applied to end-of-life decision making for nursing home residents who had a surrogate during the COVID-19 pandemic. This application appeared to be beneficial in adding more residents to our Palliative Care Program while it improved rates of advance-care planning. When all of the above findings are considered, we believe this novel IEP approach and algorithm have the potential to be applied elsewhere after appropriate assessment. (shrink)

Critical care is in an emerging crisis of conflict between what individuals expect and the economic burden society and government are prepared to provide. The goal of critical care support is to prevent suffering and premature death by intensive therapy of reversible illnesses within a reasonable timeframe. Recently, it has become apparent that early support in an intensive care environment can improve patient outcomes. However, life support technology has advanced, allowing physicians to prolong life (and postpone death) in (...) circumstances that were not possible in the recent past. This has been recognized by not only the medical community, but also by society at large. One corollary may be that expectations for recovery from critical illness have also become extremely high. In addition, greater numbers of patients are dying in intensive care units after having receiving prolonged durations of life-sustaining therapy. Herein lies the emerging crisis – critical care therapy must be available in a timely fashion for those who require it urgently, yet its provision is largely dependent on a finite availability of both capital and human resources. Physicians are often placed in a troubling conflict of interest by pressures to use health resources prudently while also promoting the equitable and timely access to critical care therapy. In this commentary, these issues are broadly discussed from the perspective of the individual clinician as well as that of society as a whole. The intent is to generate dialogue on the dynamic between individual clinicians navigating the complexities of how and when to use critical care support in the context of end-of-life issues, the increasing demands placed on finite critical care capacity, and the reasonable expectations of society. (shrink)

What is illness? Is it a physiological dysfunction, a social label, or a way of experiencing the world? How do the physical, social and emotional worlds of a person change when they become ill? And can there be well-being within illness? In this remarkable and thought-provoking book, Havi Carel explores these questions by weaving together the personal story of her own serious illness with insights and reflections drawn from her work as a philosopher. Carel shows how the (...) concepts and language used to describe illness today are inappropriate and misleading. Too often illness is viewed as a localised biological dysfunction while ignoring the actual experience of the ill person, their fears, their hopes, the way they interact with others and, ultimately, experience life. By focusing on the impact of illness on the ill person's life and reflecting on the experience of illness as lived from within, Carel shows how illness is a life-changing process rather than a limited physiological problem. Carel's fresh approach to illness raises some uncomfortable questions about how we all - whether healthcare professionals or not - view the ill and challenges us to become more thoughtful. "Illness" unravels the tension between the universality of illness and its intensely private, often lonely, nature. It offers a new way of looking at a matter that affects every one of us. For those who are ill, it offers insights on our ability to remain happy within the constraints of illness. (shrink)

For a minority of children managed in the NICU, there is a need for more complex technologic assistance in order to sustain life, mitigate a more chronic debilitation from a pervasive life-limiting condition, or provide a bridge from life-sustaining therapy to a more semi-permanent treatment such as organ transplantation. This chapter will address two major types of technology assistance for infants and children—tracheostomy and assisted home ventilation, and dialysis—and the myriad complications and considerations that they raise. (...) Some attention to why clinicians may be so inclined to impose technology as a solution to life-limiting conditions will be noted, as well as why some parents may seem to insist on pursuing technology. (shrink)

The author offers a defense for elective death on utilitarian grounds, but one that is presented specifically from the perspective of someone who: 1) faces a potentially terminal illness and diminishing quality of life; 2) views death as nothing more than a return to prenatal nonbeing; and 3) maintains common humanist ethical commitments. The argument, then, is uniquely situated and limited in scope, rooted both in the particulars of his recent experience with a rheumatic autoimmune illness and (...) non-Hodgkin’s lymphoma as well as in a worldview shaped largely by emerging narratives in the sciences. Drawing upon the work of J.S. Mill and P. Singer, the author begins by assuming that one is generally free to act on a preference for nonbeing so long as others are not unduly harmed or thwarted in pursuing their own aims as a result. But a humanist, he suggests, ideally ought to press beyond this minimum criterion and do one’s best to maximize eudaimonia by carefully weighing how elective death would likely affect others to whom one is currently obligated in significant ways. The focus of one’s ethical reasoning, then, should remain on maximizing well-being and minimizing harm, not on creating a logical flawless and internally coherent defense that may satisfy a set of abstract or universally applicable criteria drawn up by others in an effort to define precisely what might render a given suicide “rational” or “morally permissible.”. (shrink)

People who suffer from eating disorders often have to be treated against their will, perhaps by being detained, perhaps by being forced to eat. In this paper it is argued that whilst forcing compliance is generally acceptable, there may be circumstances under which a sufferer's refusal of consent to treatment should be respected. This argument will hinge upon whether someone in the grip of an eating disorder can actually make competent decisions about their quality of life. If so, then (...) the decision to refuse therapy may be on a par with other decisions to refuse life‐prolonging therapy made by sufferers of debilitating chronic, or acute onset terminal illness. In such cases, palliation might justifiably replace aggressive therapy. The argument will also draw heavily on the distinction between competent refusal of therapy and passive euthanasia, and the distinction between incompetent and irrational decisions. Both distinctions will then be applied to decisions to refuse food. The extent to which sufferers from anorexia nervosa can be categorised as either incompetent or irrational will be examined. It is against this background that it will be argued that at least some of those who suffer from eating disorders should have their refusals respected, even if they may die as a result. (shrink)

Work done within the realm of what is sometimes called ‘descriptive ethics’ brings two questions readily to mind: How can empirical findings, in general, inform normative debates? and How can these empirical findings, in particular, inform the normative debate at hand? Brick et al 1 confront these questions in their novel investigation of public views about lives worth living and the permissibility of withdrawing life-sustaining treatment from critically ill infants. Mindful of the is-ought gap, the authors suggest modestly that (...) their data ‘may be useful when constructing guidelines for clinical practice’. In this commentary, I consider some potential limitations on the generalisability of these data in the context of policy and clinical practice, limitations which may in turn serve as directions for future empirical research. The authors’ study presented participants six case scenarios, five of which involved the possibility of withdrawing life-sustaining treatment from critically ill infants. The results revealed that “[a]lmost all respondents agreed that at some level of quality of life, life may be of no benefit or worse than death for an infant” and that “participants significantly favoured withdrawal of treatment for the most severe cases.” One salient detail in these scenarios …. (shrink)

OBJECTIVES: In treating critically ill neonates, situations occasionally arise in which aggressive medical treatment prolongs the inevitable death rather than prolonging life. Decisions as to limitation of neonatal medical intervention remain controversial and the primary responsibility of the generally unprepared family. This research was designed to study response patterns of expectant mothers towards treatment of critically ill and/or malformed infants. DESIGN/SETTING: Attitudes were studied via comprehensive questionnaires divided into three sections: 1-Sociodemographic data and prior personal experience with perinatal problems; (...) 2-Theoretical philosophical principles used in making medical ethical decisions; and 3-Hypothetical case scenarios with choices of treatment options. SUBJECTS AND RESULTS: Six hundred and fifty pregnant women were studied. Maternal birthplace (p = 0.005) and level of religious observance (p = 0.02) were strongly associated with the desire for maximally aggressive medical intervention in the hypothetical case scenario. Specific personal experiences such as infertility problems, previous children with serious mental or physical problems were not correlated with the selection of different treatment choices. Of the theoretical principles studied, only the desire to preserve life at all costs was significantly associated with the choice for maximal medical treatment (p = 0.003). CONCLUSIONS: Maternal ethnocultural background and philosophical principles more profoundly influenced medical ethical decision-making than did specific personal life experiences. (shrink)

How does the body influence the way we see the world? _Imagination, Illness and Injury_ examines the psychological factors behind perceptual limitations and distortions and links a broad range of somatic manifestations with their resolution. Melanie Starr Costello applies Jungian theory to a variety of cases, attributing psychosomatic phenomena to cognitive processes that are common to us all. She analyses the role of illness in several life narratives, and interprets the appearance of somatic phenomena during important phases (...) of analytic treatment. Together these case narratives present a significant challenge to established views of psychosomatics. Subjects covered include: archetypal constrictions of identity somatic elements of perception the psyche-soma split. _Imagination, Illness and Injury _brings a fresh perspective to the understanding and treatment of the psychotherapy client as a psycho-somatic unity. Jungian analysts, psychoanalysts, and psychotherapists will greatly benefit from the clinical applications of archetypal theory presented here. (shrink)

End-of-life care is the only major reference to systematically explore the unique medical, social, legal, political, and ethical issues to consider while providing care to adults and children with intellectual and developmental disabilities who are facing terminal illness or life-limiting conditions.

Many environmental ills derive from humanity’s unsustainable fondness for meat, a fondness that often pushes (and sometimes breaks) environmental limits and reveals unsustainable patriarchal ideologies. Han Kang’s The Vegetarian and Ang Li’s The Butcher’s Wife each, in very different ways, expose the strands of “meat and gender” enmeshments in Korea and Taiwan respectively, showing the mutual interdependence of carnivorism and patriarchal power. So deeply rooted are the entangled strands of carnivorism and sexism that contesting them (either together or apart) means (...) dismantling the very definition of human corporeality: in The Vegetarian, this means that a woman becomes a plant; in The Butcher’s Wife, it means that a man becomes the very cattle he has spent his life slaughtering; in both, questioning meat is a very dangerous challenge that comes from a woman through a narrative perspective that is clearly feminist. Both novels plainly show deep analogies and correspondences between domestic violence and violence against animals, and yet, in both, there is a taut relationship between vegetable-based histories and a more meat-based modernity. This article argues firstly that the violence of meat-eating in The Vegetarian and The Butcher’s Wife is both physical and psychological. Dreams and madness are involved. Normalcy is male, deviance female. Order is meat, chaos vegetal. And the threat of death will either be fully realized or will hang menacingly in the air. Secondly, this article argues that the novels importantly show that breaking points (psychological and environmental) are often utterly unpredictable and that once breached, the results can also be devastatingly unpredictable. (shrink)

Philip Reed argues that laws that grant people access to euthanasia on the basis of terminal illness are discriminatory. In support of this claim, he offers an argument by analogy: it would be discriminatory to offer a person access to euthanasia because they are women or because they are disabled, as such restricted access would send the message ‘that life as a woman or as a disabled person is (very often) not worth living’.1 And so it must also (...) be discriminatory to offer people access to euthanasia because they are terminally ill. Arguments by analogies are only as good as the analogies on which they are built. Having a terminal illness, I’m going to suggest, is not relevantly similar enough to either being disabled or being a member of an oppressed social group to make Reed’s claim compelling. Let’s explore each branch of the analogy in turn. Why think that terminal illness is relevantly unlike disability, in a way that makes offering access to euthanasia in the latter case discriminatory, but not the former? For one thing, terminal illness is necessarily time-limited. When my father was dying, he found himself in constant …. (shrink)

Three of the most contentious issues in contemporary American society—allocation of medical resources, end of life care, and immigration—converge when undocumented immigrant patients are facing the terminal phase of chronic illness. The lack of consistent, pragmatic policy in each of these spheres leaves us with little guidance for how to advocate for undocumented patients at the end of life. Limited resources and growing need compound the problem. Care for patients in this unfortunate situation should be grounded in (...) clinical and economic reality as well as respect for the dignity of the individual to avoid exacerbating inequalities. (shrink)

The experience of illness raises profound issues concerning the sense or non-sense of human existence as a whole: does life have meaning when it is marked by suffering? And what meaning would it bear, in this case? These questions are asked by both caregivers and recipients of care when they come into contact with limits, pain, and death. In this regard, the existential condition of homo patiens is ambiguous: it can lead either to nihilism and despair or to (...) a higher level of awareness and responsibility. Studies on resilience, post-traumatic growth, and meaning-making processes seem to suggest that in difficult situations the search for meaning comes most clearly to the fore, so that the possibility of finding meaning in life can be a protective factor and a key therapeutic resource, while meaninglessness increases weakness and vulnerability. But what is meant by “meaning” in the illness experience and how may it be integrated into one’s personal life story? This question is answered here in terms of narrative methods that can enhance healthcare practitioners’ capacity to approach their patients with sensitivity and deep understanding and guide them to find meaning in their lives, despite all. (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)

BackgroundAll hospital trusts in Norway have clinical ethics committees. Some of them invite next of kin/patients to be present during the discussion of their case. This study looks closer at how parents of seriously ill children have experienced being involved in CEC discussions.MethodsTen next of kin of six seriously ill children were interviewed. Their cases were discussed in two CECs between April of 2011 and March of 2014. The main ethical dilemma was limitation of life-prolonging treatment. Health care personnel (...) who could elucidate the case were also present in the discussion. The interviewer observed each discussion and then interviewed the next of kin shortly after the meeting, following a structured interview guide.ResultsAll next of kin emphasized that it had been important for them to be present. They stressed the important role of the CEC chair and appreciated that their case was discussed in a systematic way. Some next of kin appreciated that the child’s impending death was discussed openly, and believed that this would facilitate their future grieving. Having had an opportunity to hear all the arguments behind the decision to be made would probably help them to accept the road ahead.All of them felt that they were taken seriously and listened to. They felt that they had added vital information to the discussion. All but one couple did not want any decision-making responsibility, some of them even worried that they might have influenced the discussion too much.ConclusionsNone of the next of kin felt that being present during the CEC discussion had been too heavy a burden. On the contrary, they claimed that their presence in a CEC discussion may add vital information to the discussion and may improve the quality of the decision. It is important that the CEC’s role is explained to them so they are well prepared for what to expect. They need to be followed up after the discussion. (shrink)

The Stoics considered that in order to die well, one must previously have lived (well) and not merely existed, an assertion which will not be contested in this paper. The question raised here is whether an individual whose life expectancy is jeopardized by serious illness or whose life has not been lived to the ‘full’ for whatever reason should have to abandon all hope or, alternately, whether that life could still somehow be saved (in an ethical (...) sense). One clear obstacle to achieving this stems from (bad) moral character, given that moral character is an element which conditions an individual’s moral behaviour, as pointed out by Beauchamp and Childress and particularly Pellegrino and Thomasma. The transformation of moral character requires time and effort but the testimonies of patients who have given their lives a radical new direction upon being diagnosed with a serious illness seem to show the existence of a peculiar phenomenon of moral catharsis. In this paper we attempt to illustrate that this alleged phenomenon is not the result of a kind of cataleptic impression but rather the result of a dialectic and narrative process, during which a first hope of healing is dashed, unveiling a new sense in the illness. Its fulfillment provides the patient with a final hope. (shrink)

On many occasions, care givers are faced with problems in which “drastic” types of treatment seem clearly inappropriate but “lesser” interventions still appear to be advisable, if not indeed mandatory. In the hospital setting, examples are frequent: the demented elderly patient, still very much capable of brief social interactions and still able to enjoy at least limited life, who although clearly not a candidate for coronary bypass surgery is, nevertheless, a patient in whom an intercurrent pneumonia deserves treatment; the (...) severely retarded youngster in whom appendectomy seems clearly warranted but for whom long-term dialysis seems ill-advised. The examples are legion, and their variety defies an easy, stereotypical solution. Why, one may ask, is the treatment of intercurrent pneumonia or operating on an acute appendix “clearly indicated” while coronary bypass and long-term dialysis “clearly” are not? The reactions of care givers in the past have often consisted of attempts to give half-hearted treatment or to treat fully even against their better judgment. The lack of conceptual guidelines that might help sort out such problems has inevitably led either to an inflexible absolutism in which all possible treatment to sustain life or no treatment at all is given or has resulted in a pathetic attempt to act but act minimally with the hope that such actions will be ineffective. (shrink)

Social theory plays an important role in the nursing discipline and nursing inquiry as it helps conceptually embed nursing in the larger picture of the social world. For example, a broad category of critical theory provides a unique lens for uncovering social conditions of inequity and oppression. Among the sociological theories, actor‐network theory (ANT) is an approach to research and analysis that has recently gained interest among nurse philosophers and researchers. Studies guided by ANT seek to understand phenomena of interest (...) as constituted within the relationships between human and nonhuman actors to understand how care practices are co‐created/enacted and how they can be made more humane. In this paper, we describe the benefits of ANT for examining healthcare access for incarcerated individuals with life‐limiting illnesses accessing palliative care and for people using illicit drugs. We argue that attention to the materiality of care practices can contribute to efforts of advancing health equity for these groups. (shrink)

Narrative analysis is well established as a means of examining the subjective experience of those who suffer chronic illness and cancer. In a study of perceptions of the outcomes of treatment of cancer of the colon, we have been struck by the consistency with which patients record three particular observations of their subjective experience: the immediate impact of the cancer diagnosis and a persisting identification as a cancer patient, regardless of the time since treatment and of the presence or (...) absence of persistent or recurrent disease; a state of variable alienation from social familiars, expressed as an inability to communicate the nature of the experience of the illness, its diagnosis and treatment; and a persistent sense of boundedness, an awareness of limits to space, empowerment and available time. These subjectivities were experienced in varying degree by all patients in our study. Individual responses to these experiences were complex and variable. The experiences are best understood under the rubric of a category we call “liminality”. We believe that all cancer patients enter and experience liminality as a process which begins with the first manifestations of their malignancy. An initial acute phase of liminality is marked by disorientation, a sense of loss and of loss of control, and a sense of uncertainty. An adaptive, enduring phase of suspended liminality supervenes, in which each patient constructs and reconstructs meaning for their experience by means of narrative. This phase persists, probably for the rest of the cancer patient’s life. The experience of liminality is firmly grounded in the changing and experiencing body that houses both the disease and the self. Insights into the nature of the experience can be gained from the Existentialist philosophers and from the history of attitudes to death. Understanding liminality helps us to understand what it is that patients with cancer seek from the system to which they turn for help. Its explication should therefore be important for those who provide health care, those who educate health care workers and those concerned to study and use outcomes as administrative and policy making instruments. (shrink)

Malaysia had its first four patients with COVID-19 on 25 January 2020. In the same week, the World Health Organization declared it as a public health emergency of international concern. The pandemic has since challenged the ethics and practice of medicine. There is palpable tension from the conflict of interest between public health initiatives and individual’s rights. Ensuring equitable care and distribution of health resources for patients with and without COVID-19 is a recurring ethical challenge for clinicians. Palliative care aims (...) to mitigate suffering caused by a life-limiting illness, and this crisis has led to the awareness and urgency to ensure it reaches all who needs it. We share here the palliative care perspectives and ethical challenges during the COVID-19 pandemic in Malaysia. (shrink)

We read with interest the extended essay published from Riisfeldt and are encouraged by an empirical ethics article which attempts to ground theory and its claims in the real world. However, such attempts also have real-world consequences. We are concerned to read the paper’s conclusion that clinical evidence weakens the distinction between euthanasia and normal palliative care prescribing. This is important. Globally, the most significant barrier to adequate symptom control in people with life-limiting illness is poor access (...) to opioid analgesia. Opiophobia makes clinicians reluctant to prescribe and their patients reluctant to take opioids that might provide significant improvements in quality of life. We argue that the evidence base for the safety of opioid prescribing is broader than that presented, restricting the search to palliative care literature produces significant bias as safety experience and literature for opioids and sedatives exists in many fields. This is not acknowledged in the synthesis presented. By considering additional evidence, we reject the need for agnosticism and reaffirm that palliative opioid prescribing is safe. Second, palliative sedation in a clinical context is a poorly defined concept covering multiple interventions and treatment intentions. We detail these and show that continuous deep palliative sedation (CDPS) is a specific practice that remains controversial globally and is not considered routine practice. Rejecting agnosticism towards opioids and excluding CDPS from the definition of routine care allows the rejection of Riisfeldt’s headline conclusion. On these grounds, we reaffirm the important distinction between palliative care prescribing and euthanasia in practice. (shrink)

Over three decades, Gillian Howie wrote at the forefront of philosophy and critical theory, before her untimely death in 2013. This interdisciplinary collection uses her writings to explore the productive, yet often resistant, interrelationship between feminism and critical theory, examining the potential of Howie's particular form of materialism. The contributors also bring to this debate a serious engagement with Howie's late turn towards philosophies of mortality, therapy and 'living with dying'. The volume considers how differently embodied subjects are positioned within (...) public institutions, discourses and spaces, and the role of philosophy, art, film, photography, and literature, in facing situations such as sexual oppression and life-limiting illness. (shrink)

Bioethics, and indeed much ethicalwriting generally, makes its point throughnarratives. The religious parable no less thanthe medical teaching case uses a simple storyto describe appropriate action or theapplication of a critical principle. Whilepowerful, the telling story has limits. In thispaper the authors describe a simple teachingcase on ``end-of-life'' decision making that wasill received by its audience. The authors ill-receivedexample, involving the disconnection ofventilation in a patient with ALS (Lou Gherig'sDisease) was critiqued by audience members withlong-term experience as ventilation users. (...) Inthis case, the supposedly simple narrative ofthe presenters conflicted with the lifehistories of the audience. The lessons of thisstory, and the conflict that resulted, speakcritically to the limits of simple teachingcases as well as the strengths of narrativeanalysis as a tool for the exploration ofbioethical case histories. (shrink)

Awareness of illness in schizophrenia reflects complex storied understanding of the impact of the disorder upon one’s life. Individuals may be aware of their illness in different ways and this may be related to their functioning. A total of 76 adults with schizophrenia were assessed for their awareness of illness, neurocognition, social cognition, and social function concurrently and social function was also assessed at three later time points. A cluster analysis revealed 3 groups: generally full awareness, (...) generally limited awareness, and superficial awareness. Comparisons between these profiles revealed the superficial group had poorer executive function, emotion recognition ability, and capacity for social relationships than the full awareness group, yet had better verbal memory and more social contacts than the limited awareness group. These results suggest assessing the narrative qualities of awareness of illness may reveal unique links with cognition and function, and this may have implications for interventions. (shrink)

Stress and mental ill-health carry considerable costs for both individuals and organizations. Although interventions targeting compassion and self-compassion have been shown to reduce stress and benefit mental health, related research in organizational settings is limited. We investigated the effects of a 6-week psychological intervention utilizing compassion training on stress, mental health, and self-compassion. Forty-nine employees of two organizations were randomly assigned to either the intervention or a physical exercise control condition. Multilevel growth models showed that stress and mental ill-health decreased (...) over 3 months in both groups, while self-compassion only increased in the intervention group. There were no significant effects on life satisfaction in any of the groups. The findings show promising results regarding the ability of compassion training within organizations to decrease stress and mental ill-health and increase self-compassion. (shrink)

This article examines the governance of student life in university settings through an examination of discourses of wellness and resilience in the university sector, and in particular at the University of Toronto. Resilience, it is argued, is strategically deployed in ways that enjoin students to think positively about their experiences of university life so as to avert any experience of distress or disability. This is undertaken with the aim of producing a healthy and ‘well’ student body, but does (...) little to address inequalities amongst students, nor how such inequalities might be important in addressing student distress. Focusing on an analysis of the University of Toronto Student Life Programs and Services programs and publications, and in particular pamphlets and newsletters, such as Health & Wellness: Helping Students Make the Most of the University Experience (2009), it seeks to understand the role of resilience in the production of student life and the governance of the university experience. The purpose of this analysis is to examine the possibilities and limits of a new vocabulary of resilience (Seligman, 2009), which posits an expectation of suffering as a resource which can be drawn on in times of stress, and the “positive” disciplinary regimes this vocabulary enforces. This examination is carried out with the overall aim of disrupting unexamined relations to representations of institutional sites and services as resources, and to demonstrate how such representations rely on and reproduce notions of difference, disability and distress as difficulties to be both renounced and exploited. It is also to provoke greater recognition within social justice studies of how university health services texts such as the Health & Wellness pamphlet and newsletters directed at students strategically deploy notions of resilience to govern interpretations of resistance as illness, rather than emancipatory action. (shrink)

Background: End-of-life decision-making for terminally ill neonates raises important legal and ethical issues. In Greece, no recent data on nurses’ attitudes and involvement in end-of-life decisions are available. Research question/aim: To investigate neonatal nurses’ attitudes and involvement in end-of-life decisions and the relation to their socio-demographic and work-related background data. Research design: A survey was carried out in 28 neonatal intensive care units between September 2018 and January 2019. A structured questionnaire was distributed by post. Participants and (...) research context: The questionnaire was answered anonymously by 312 nurses (response rate, 71.1%) and returned to the investigators. Ethical considerations: The study was approved by the Bioethics and Research Committee of Aretaieio Hospital in accordance with the Helsinki Declaration. Findings: Nurses more often reported involvement in various end-of-life decisions, such as continuation of treatment without adding further therapeutic interventions for terminally ill neonates, while less reported were mechanical ventilation withdrawal and drug administration to end life. Nurses with a high attitude score, reflecting a more quality-of-life approach, were more likely to be involved in setting limits to intensive care. α low score was consistent with life preservation. Nurses’ religiousness ( p = 0.097), parenthood ( p = 0.093), involvement in daily practice ( p = 0.03), and position on the existing legal framework ( p < 0.002) influenced their attitude score. Discussion: The likelihood of nurses to support interventions in neonates with poor prognosis in neonatal intensive care units was related to their attitudes. After adjusting for potential confounders, the most important predictors for nurses’ attitudes were parenthood, involvement in daily practice, and position supporting current legislation reform. Conclusion: Variability in involvement in end-of-life decisions among nurses exists on a national level. (shrink)

Background Nurses play an integral role in the care of children hospitalised with a serious illness. Although information about diagnostics, treatments, and prognosis are generally conveyed to parents and caregivers of seriously ill children by physicians, nurses spend a significant amount of time at the child’s bedside and have an acknowledged role in helping patients and families understand the information that they have been given by a doctor. Hence, the ethical role of the nurse in truth disclosure to children (...) is worth exploring. Methods A systematic academic database and grey literature search strategy was conducted using CINAHL, Medline Psych Info, and Google Scholar. Keywords used included truth, children, nurse, disclosure, serious illness, and communication. A total of 17 publications of varying types were included in the final data set. Ethical Considerations As this was a review of the literature, there were no direct human participants. Empirical studies included in the review had received ethics approval. Results Of the 17 articles included in the review, only one directly reported on the experiences of nurses asked to withhold the truth from patients. Empirical studies were limited to HIV-positive children and children diagnosed with cancer and the dying child. Conclusion A paucity of literature exploring the experiences, attitudes, and beliefs of nurses with regard to truth-telling to seriously ill children is evident. Little consideration has been given to the role nurses play in communicating medical information to children in a hospital setting. The 17 articles included in the review focused on cancer, and HIV, diagnosis, and end-of-life care. Further research should be undertaken to explore the experiences and attitudes of nurses to clinical information sharing to children hospitalised with a wide range of serious illnesses and in diverse clinical scenarios. (shrink)

Palliative care seeks to improve the quality of life for patients suffering from the impact of life‐limiting illnesses. Palliative care encompasses but is more than end‐of‐life care, which is defined as care during the final hours/days/weeks of life. Although palliative care policies increasingly require all healthcare professionals to have at least basic or non‐specialist skills in palliative care, international evidence suggests there are difficulties in realising such policies. This study reports on an action research project (...) aimed at developing respiratory nursing practice to address the palliative care needs of patients with advanced chronic obstructive pulmonary disease (COPD). The findings suggest that interlevel dynamics at individual, team, interdepartmental and organisational levels are an important factor in the capacity of respiratory nurses to embed non‐specialist palliative care in their practice. At best, current efforts to embed palliative care in everyday practice may improve end‐of‐life care in the final hours/days/weeks of life. However, embedding palliative care in everyday practice requires a more fundamental shift in the organisation of care. (shrink)

When the clinician and patient are unable to reconcile differences over treatment, does this mean the latter lacks capacity to decide in such matters? Wellesleyet alanalyse the legal judgements in the case of Ms Sudiksha Thirumalesh where, on the particulars, the Court of Protection answered yes, only for the Court of Appeal to disagree. The authors highlight concerns about using isolated false belief as an indicator of incapacity and advise that such matters may be better resolved by greater discussion of (...) the benefits and burdens of treatment, alongside consideration of their costs. Here, I suggest that a disability perspective is also helpful to such cases, recognising that this was a disagreement from which the patient couldn't walk away. Disability means that particular care is required when considering the burdens and benefits of treatment as these may vary widely in the eye of the beholder. Second, the costs of litigation are particularly high when a disabled person, with life-limiting illness, is left feeling they are using precious time and energy arguing for their existence. Third, any such legal judgments ought to make clear what reasonable adjustments have been offered to include the disabled person in proceedings. Fourth, and relatedly, such disputes should be attentive to the significant risk of epistemic injustice, where disabled patients find themselves less believed, in part because the ‘able-bodied’ have not shared their experiences. Together, these considerations (i) add to the call made by Wellesleyet alfor better discussions and (ii) suggest that early involvement of Rehabilitation Medicine, with expertise in disability and related ethics, could offer an important means to reduce the need for such litigation in the future. (shrink)

ABSTRACTThis paper examines how decisions to limit treatment to critically ill patients under uncertainty can be made rationally. Expected utility theory offers one way of making rational decisions under uncertainty. One problem with using this approach is that we may not know the value of each option. One rational course open is to treat until further information becomes available. However, treatment can limit the range of options open. With treatment, a patient may recover such that he no longer requires (...) class='Hi'>life‐supporting treatment. However, his life may be not worth living. If active euthanasia of %on‐terminal’conditions is prohibited, the option of dying will no longer be available. Taking a rational‘wait and see’course may result in being trapped within an unbearable life. On the other hand, sometimes present practice‘lets nature takes its course'. Critically ill patients are allowed to die because it is believed that their lives will be not worth living. It is likely that some patients are allowed to die when there is some objective chance of worthwhile future life. This paper argues that a policy of treating critically ill patients until the nature of future options can be better evaluated, in company with an offer of subsequent euthanasia where appropriate, allows a more rational and humane approach to treatment limitation decisions under uncertainty. (shrink)

Advance care planning (ACP) is a process that seeks to elicit patients’ goals, values, and preferences for future medical care. While most commonly employed in adult patients, pediatric ACP is becoming a standard of practice for adolescent and young adult patients with potentially life-limiting illnesses. The majority of research has focused on patients and their families; little attention has been paid to the perspectives of healthcare providers (HCPs) regarding their perspectives on the process and its potential benefits and (...) limitations. Focus groups were conducted with 15 physicians as part of a larger study of adolescent and young adult ACP in hematopoietic stem cell transplant (HSCT) patients. This study identified two categories important to the utility of ACP in pediatric HSCT patients; (1) the temporal context of ACP and decision making and (2) the limitations of pediatric ACP, with subcategories identified as (a) embodied and witnessed knowing, (b) the impact of clinical cascades—when the treatment of one organ system creates complications in another system that needs to be treated—and a creation of a “new normal” following complications of illness and its treatment in the pediatric intensive care unit (PICU), (c) the balancing of adolescents’ autonomy with their capacity to make informed medical decisions, and (d) the epistemological frames that differ between HCP and patients and their families. These findings support ACP in adolescent and young adult HSCT patients, with a number of implications for practice as this process becomes more common. (shrink)

An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which the DNR of a (...) terminally ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations :3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail. (shrink)

Pediatric palliative care is specialized medical care for children who live with serious and life-limiting illnesses, with the central goal to improve quality of life for both children and their families. Presently, a majority of pediatric palliative care referrals are based on the traditional consultative model, in which primary providers serve as the gatekeepers to palliative care access. It is well-known that racial and ethnic healthcare disparities exist across the continuum of care, fraught with healthcare providers’ biases (...) that impact the care delivered. This includes the referral practices, allocation and utilization of palliative care services, and leaving vulnerable children and families with potentially unmet palliative care needs. We make the moral argument that the establishment of standard referral criteria for pediatric palliative care services is one simple step that must be taken to begin to address and hopefully ameliorate the impact of providers’ biases and disparities that exist within pediatric palliative care. (shrink)

IntroductionHigh healthcare costs make illness precarious for both patients and their families’ economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood.MethodsUsing a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the acceptability (...) of limiting treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection.ResultsGiving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties—the newborn, family members and health worker—cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people’s substantive freedoms.ConclusionIn settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:A Life Worthy of the Gods: The Materialist Psychology of EpicurusKelly E. ArensonDavid Konstan. A Life Worthy of the Gods: The Materialist Psychology of Epicurus. Las Vegas-Zurich-Athens: Parmenides Publishing, 2008. Pp. xx + 176. Paper, $34.00.In this modestly expanded edition of his 1973 book, Some Aspects of Epicurean Psychology (Brill), David Konstan attempts to flesh out the Epicurean explanation of the causes of unhappiness: “empty beliefs” (...) (kenodoxia)—most importantly, the groundless fear of death—and the irrational desires that fuel and are fueled by them. Konstan’s central argument, preserved from the earlier edition, is deceptively simple: empty beliefs, according to Epicureans, are in large part the product of a symbolic association—a “linguistic confusion”—of the afterlife with certain real-life human ills, such as poverty and obscurity.In the first chapter, which is new to this edition, Konstan calls on psychology to flesh out the Epicurean understanding of empty fears and irrational desires—ancient psychology, that is: a science of the soul. Konstan’s reading of the relation between sensation (aisthēseis), the passions (pathē) of pleasure and pain, and belief (doxa) in Epicurean doctrine is unorthodox but thorough. Rather than mapping pathē onto either the soul as a whole or the body, Konstan assigns pathē to the non-rational part of the soul, the seat of sensation. He locates the emotions, which “do not seem to have a special name in Epicurean theory,” in the rational part (11). Crucial to this schema is Konstan’s claim, based on Lucretius’s De Rerum Natura and Diogenes Laertius’s doxography of Epicurus, that Epicureans did not consider emotions such as fear and joy to be pathē at all, since emotions depend on memory and reasoning, whereas pathē do not. The upshot is that fear, as a rational emotion, involves belief and evaluation, and is therefore susceptible to error; whence the psychological roots of pernicious “empty beliefs.”In chapter two, Konstan addresses the Epicurean conundrum of why humans are plagued by fears and anxieties when their needs are so basic. Konstan takes as an explanation of this phenomenon Lucretius’s analysis of irrational desires and their parasitic relationship [End Page 95] with baseless fears. Out of their fear of death—the fear to beat all fears, according to Epicureans—people irrationally desire goods such as wealth, power, and glory that they mistakenly believe will delay their descent into the underworld. Konstan contends that there was a “symbolic association between poverty and death’s antechamber” that was not merely metaphorical (45); to escape poverty is not to cheat something like death, but to cheat death itself, just as to pursue wealth is literally to pursue life. In their vain quest to waylay death, people resort to greediness, crime, deceit—in short, any behavior that could result in material gain. Unfortunately, these unsavory activities serve only to augment rather than assuage fears, since wrongdoers fear being punished for their illicit deeds. The fear of punishment in turn spurs more irrational desires, forming a vicious cycle of mutually reinforcing behavior and states of mind that are incompatible with tranquility.In the final two chapters, Konstan combs Epicurean social theory for the roots of irrational fears and desires and shows how Epicurean epistemology enables the sage to avoid them. Konstan argues that harmful fears and desires emerged when words came to refer not only to visible sensory phenomena, but also to abstract notions whose referents might be phantoms—misleading accounts of the gods and the limits of desire that do not correspond with reality. In addition, laws served to foment fears of divine retribution and death as lawmakers attempted to regulate behavior by disseminating myths about the wrath of the gods and the afterlife. In the final chapter, Konstan is on well-trodden ground when he claims that the Epicurean sage is able to control fears and desires by understanding the nature of reality, pleasure, and human needs.This book will primarily be of interest to scholars of Epicureanism; the sheer number of footnotes and the technical language make it rather inaccessible to the non-specialist. And the specialist may find that Konstan’s treatment of the... (shrink)

In the aftermath of the First World War, the poet Paul Valéry wrote of a "crisis of spirit", brought about by the instrumentalization of knowledge and the destructive subordination of culture to profit. Recent events demonstrate all too clearly that the stock of mind, or spirit, continues to fall. The economy is toxically organized around the pursuit of short-term gain, supported by an infantilizing, dumbed-down media. Advertising technologies make relentless demands on our attention, reducing us to idiotic beasts, no longer (...) capable of living. Spiralling rates of mental illness show that the fragile life of the mind is at breaking point. Underlying these multiple symptoms is consumer capitalism, which systematically immiserates those whom it purports to liberate. Returning to Marxʹs theory, Stiegler argues that consumerism marks a new stage in the history of proletarianization. It is no longer just labour that is exploited, pushed below the limits of subsistence, but the desire that is characteristic of human spirit. The cure to this malaise is to be found in what Stiegler calls a "pharmacology of the spirit". Here, pharmacology has nothing to do with the chemical supplements developed by the pharmaceutical industry. The pharmakon, defined as both cure and poison, refers to the technical objects through which we open ourselves to new futures, and thereby create the spirit that makes us human. By reference to a range of figures, from Socrates, Simondon and Derrida to the child psychoanalyst Donald Winnicott, Stiegler shows that technics are both the cause of our suffering and also what makes life worth living. -- Publisher description. (shrink)

IntroductionDignity therapy is brief psychotherapy targeting psychological and existential suffering among patients with a life-limiting illness. Studies have been conducted on the use of DT by healthcare professionals. In Italy, the current legislation defines that any form of psychotherapy may be performed exclusively by psychotherapists. Consequently, this intervention is unlikely to be used by other healthcare professionals. Herein, we will describe a training on DT not as a psychotherapy intervention but as a narrative intervention for non-psychotherapists health (...) care professionals. Finally, we will explore the potential enablers/barriers as experienced by palliative care physicians and nurses.MethodsThe study was conducted in the Psycho-Oncology Unit within the Cancer Research Hospital of Reggio Emilia. It consisted of an exploratory qualitative case study. Data were collected employing observations and interview data and thematically analyzed.ResultsThe training was attended by six physicians and ten nurses and took place during two-afternoon sessions for 10 h. Two participants put their training into practice and administered DT under the supervision of a psychotherapist. Data analysis highlighted five overarching themes relating to the training experience and direct use of DT, namely, time required, psychological skills, patient’s disease awareness, patient’s life history, and distinguishing DT from Advance Care Planning.ConclusionPalliative care professionals found DT to be a valuable non-pharmacological hospital-based intervention to address the person beyond the patient and his clinical conditions. In our experience, considering that in Italy, psychotherapy is an intervention that psychotherapists can only perform, it can help organize different training on DT for psychotherapists and other healthcare professionals. (shrink)

This article proposes a Social Determinants of Health framework as a counter to the prominence of bio-determinist tropes in understandings of the relationship between concussion and later life neurodegenerative conditions in athletic populations. It is argued that debates about concussion (or repetitive head impacts) causing CTE have been particularly influenced by broader social trends towards neuro-essentialism. This paradigm reduces complex social behaviour to brain matter and continues to dominate the field despite the recent diversification of evidence from autopsy-based studies (...) of neuropathology to epidemiological studies comparing recorded causes of death among former elite athletes. In contrast, this article explores the ‘causes of causes’ of neurodegenerative conditions. It outlines the ways in which the distinct dynamics of: a) employment, b) education, income and wealth, c) health systems and services, and d) social environment and public safety relate to the specific occupational conditions of elite sport and likely negatively shape health outcomes of athletic populations. The article concludes by arguing that to more effectively address these particular health harms we must move beyond narrow, mono-causal models and evoke a cultural change that extends beyond making rule changes and adjusting psychological attitudes and behavioural norms, to redress the social structural parameters of elite sports participation. The continuation of narrower, neuro-centric and reductionist paradigms obscures the causes of the causes of neurodegenerative decline and limits the scope for change. (shrink)

In late December 1998, Renada Daniel-Patterson's father offered to donate a kidney to his daughter and ignited a controversy in the bioethics community. Renada had been born with only one kidney, which began to fail early in her childhood. At age 6, Renada had to receive dialysis three times a week. She was unable to attend school or venture very far from home. This pattern continued until Renada was 13, when Mr. Patterson called from prison to offer her his kidney. (...) Renada was surprised to hear from her father, who was serving 12 years at California State Prison for burglary and drug convictions. Mr. Patterson was determined to be a compatible donor, and the family proceeded with the transplant operation. As a result of this surgery, Renada was able to live the life of a healthy girl for 2 years. Because the medication to prevent rejection of the transplanted organ made her feel ill and bloated and caused her to develop a hump on her back, Renada gradually began to skip doses. As a result, her donated kidney began to fail. It was under these circumstances that David Patterson offered to donate his second kidney to his daughter in 1998. (shrink)

Distinct sources of stress have emerged during the COVID-19 pandemic. Particularly, fear is expected to generate significant psychological burden on individuals and influence on either unsafe behavior that may hinder recovery efforts or virus-mitigating behaviors. However, little is known about the properties of measures to capture them in research and clinical settings. To resolve this gap, we evaluated the psychometric properties of a novel measure of fear of illness and viruses and tested its predictive value for future development of (...) distress. We extracted a random sample of 450 Chilean adult participants from a large cross-sectional survey panel and invited to participate in this intensive longitudinal study for 35 days. Of these, 163 ended up enrolling in the study after the demanding nature of the measurement schedule was clearly explained to them. For this final sample, we calculated different Confirmatory Factor Analyses (CFA) to evaluate the preliminary proposed structure for the instrument. Complementarily, we conducted a content analysis of the items to qualitatively extract its latent structure, which was also subject to empirical test via CFA. Results indicated that the original structure did not fit the data well; however, the new proposed structure based on the content analysis did. Overall, the modified instrument showed good reliability through all subscales both by its internal consistency with Cronbach’s alphas ranging from 0.814 to 0.913, and with test–retest correlations ranging from 0.715 to 0.804. Regarding its convergent validity, individuals who scored higher in fears tended to also score higher in depressive and posttraumatic stress symptoms at baseline. Furthermore, higher fears at baseline predicted a higher score in posttraumatic stress symptomatology 7 days later. These results provide evidence for the validity, reliability, and predictive performance of the scale. As the scale is free and multidimensional potentially not circumscribed to COVID-19, it might work as a step toward understanding the psychological impact of current and future pandemics, or further life-threatening health situations of similar characteristics. Limitations, practical implications, and future directions for research are discussed. (shrink)

his article develops a set of recommendations for the psychiatric and medical community in the treatment of mental disorders in response to the recently published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, that is, DSM-5. We focus primarily on the limitations of the DSM-5 in its individuation of Complicated Grief, which can be diagnosed as Major Depression under its new criteria, and Post-Traumatic Stress Disorder (PTSD). We argue that the hyponarrativity of the descriptions of these disorders (...) in the DSM-5, defined as the abstraction of the illness categories from the particular life contingencies and personal identity of the patient (e.g., age, race, gender, socio-economic status), constrains the DSM-5's usefulness in the development of psychotherapeutic approaches in the treatment of mental disorders. While the DSM-5 is useful in some scientific and administrative contexts, the DSM's hyponarrativity is problematic, we argue, given that the DSMs are designed to be useful guides for not only scientific research, but also for the education of medical practitioners and for treatment development. our goal therefore is to offer suggestions for mental health practitioners in using the DSM-5, so that they can avoid or eliminate the problems that may stem from the limitations of hyponarrativity. When such problems are eliminated, we believe that effective psychotherapeutic strategies can be developed, which would be successful in repairing the very relationships that are strained in mental disorder: the patient's relationship to herself, her physical environment, and her social environment. (shrink)