What makes it the case that a given experience is pleasurable? According to the felt-quality theory, each pleasurable experience is pleasurable because of the way that it feels—its “qualitative character” or “felt-quality”. According to the attitudinal theory, each pleasurable experience is pleasurable because the experiencer takes certain attitudes towards it. These two theories of pleasure are typically framed as rivals, but it could be that they are both partly right. It could be that pleasure is partly a matter of felt-quality, (...) and partly a matter of attitudes. It could be that a hybrid theory is true. In this paper, I aim to advance the cause of hybrid theories of pleasure. I do this in two ways. I begin by examining the challenges which motivate the search for a hybrid theory. I call these the HONEST challenges: Heterogeneity, Oppositeness, Normativity, Euthyphro, Separateness, and Togetherness. The first three challenges—HON—are challenges for the felt-quality theory. The second three challenges—EST—are challenges for the attitudinal theory. Having established the HONEST challenges, I then describe and motivate a particular cluster of hybrid theories which I will call dispositional hybrid theories. According to these theories, pleasurable experiences are all and only those experiences which dispose us to desire them in virtue of feeling the way that they do. The dispositional theories deliver on the promise of hybrid theories: because they appeal to both felt-qualities and attitudes, they have the resources to avoid most, if not all, of the HONEST challenges. (shrink)

I argue that, insofar as we endorse the general idea that desires play an important role in well-being, we ought to believe that their significance for well-being is derived from a pair of more fundamental attitudes: attraction and aversion. Attraction has wholly positive significance for well-being, and aversion has wholly negative significance for well-being. Desire satisfaction and frustration have significance for well-being insofar as the relevant desires involve some combination of attraction and aversion. I defend these claims by illustrating how (...) our desires can be asymmetrical. They can have greater positive than negative significance for well-being, or vice versa. (shrink)

The pessimistic hypothesis is the hypothesis that life is bad for us, in the sense that we are worse off for having come into existence. Suppose this hypothesis turns out to be correct — existence turns out to be more of a burden than a gift. A natural next thought is that we should stop having children. But I contend that this is a mistake; procreation would often be permissible even if the pessimistic hypothesis turned out to be correct. Roughly, (...) this is because we are often in a position to know that future people will approve of having been created, and their approval will not be inappropriate even if they are worse off for having been created. And our respect for the attitudes of future people can permit us to create them. (shrink)

According to a view that goes by “Humeanism,” causal facts supervene on patterns of worldly entities. The simplest form of Humeanism is the constant conjunction theory: a particular type-F thing causes a particular type-G thing iff (i) that type-Fis conjoined with that type-G thing and (ii) all F’s are conjoined with G’s. The constant conjunction theory implies that all causation is extrinsic, in the following sense: for all positive causal facts pertaining to each possible region,it’s extrinsic to that region that (...) those causal facts pertain to it. Actual Humeans don’t accept the constant conjunction theory; they accept more sophisticated versions of Humeanism. But I argue that they, too, are committed to the thesis that all causation is extrinsic. In arguing for this claim,I use a discussion from Brian Weatherson as a springboard. Weatherson argues that on a plausible Humean view, some regions are such that all of their possible duplicates have the same or similar natural laws. I show that this is false. If Humeanism is true, then for every possible region, there are possible duplicates of that region with utterly alien natural laws. As a consequence, no causal facts pertain intrinsically to any region. (shrink)

Some experiences—like the experience of eating cheesecake—are good experiences to have. But when we try to explain why they are good, we encounter a clash of intuitions. First, we have an objectivist intuition: plausibly, the experiences are good because they feel the way that they do. Second, we have a subjectivist intuition: if a person were indifferent to that kind of experience, then it might fail to be good for that person. Third, we have a possibility intuition: for any kind (...) of experience, possibly there is a subject who is indifferent to that kind of experience. The pleasure problem is the problem we face in reconciling these three claims. I explain the problem and argue for a solution. I argue that we ought to reject the most common solutions: rejecting the objectivist or subjectivist intuitions. Instead, we ought to follow Timothy Sprigge in rejecting the possibility claim. We should embrace the view that experiences bear necessary connections to our attitudes. (shrink)

This first part of a two‐part article illustrates how research in evolutionary biology and psychology illuminates questions arising in philosophy—specifically questions about the origins of severe, systemic aggression that arise in the mimetic theory of René Girard. Part I looks at: (i) how old the systemic practice of severe aggression is, (ii) how much results from humanity's mimetic/social and competitive nature and how much from ecological, resource, and cultural conditions, and (iii) if ecological and cultural conditions are important, might we (...) adapt them toward greater cooperativity today? After briefly reviewing mimetic theory, the article looks at evolutionary psychology and biology, including fossil and archeological evidence. Findings suggest that severe, systemic aggression might be relatively recent and that its occurrence depends on ecological/resource/socioeconomic conditions additional to our mimetic/social nature. Thus, distinguishing the conditions that prod aggression from those that support pro‐social behavior might aid us in structuring society today. (shrink)

This article explores current right-wing populism as an ethical position from the perspective of many, though not all, White American evangelicals. The relevant ethics concern not only abortion or gay marriage (which, research finds, are not top vote-motivators) but views of society (who’s in, who’s not) and government (size and role). Building on ideational approaches to studying populism and incorporating historical and religio-cultural material, this article asks: What in White evangelical religious and political history and in present circumstances makes right-wing (...) populism look to be the most ethical stance? In answer, the article explores populism as proposed solutions to the complex intersectionality of economic, way-of-life, and status-loss duress. It investigates how evangelicals, drawing in mediated ways from their religio-political history and beliefs, understand right-populist views of society and government as an ethical solution to these duresses. (shrink)

In virtue of what do we enjoy episodes of pleasure? According to the phenomenological theory of pleasure, we enjoy pleasures in virtue of having certain kinds of phenomenal experiences. According to the attitude theory of pleasure, we enjoy pleasures in virtue of having a certain kind of pro-attitude. In this chapter, we show that the attitude theory faces a dilemma. The attitude that is relevant to pleasure—the desire, liking, or favoring—is either necessarily co-instantiated with certain phenomenology, or not. If the (...) attitude theorist denies that the relevant attitudes are phenomenologically enriched in this sense, then their theory has the problematic implication that pleasure can come radically apart from phenomenology. This leads to a *problem of hedonic inversion*. If the attitude theorist instead affirms that the relevant attitudes are phenomenologically enriched, then they undermine their main objection to the phenomenological theory of pleasure. This is the so-called *heterogeneity problem*, according to which pleasures do not feel alike. Either way, the attitudinal theorist faces a difficult challenge in their ongoing debate with phenomenological theorists. (shrink)

In his edition of this author Buecheler translates the words of Mim. III. 72 πρός σΣ Τñς κοΤΤίδος ψυχñς by ‘per capitale tuum ingenium,’ but affords no explanation as to how he arrived at this sense. May I suggest another interpretation to which Modern Greek seems to me to lead? The equivalent of κοΤΤίς is now πουλί or πουλάκπουλί μου or πουλάκι or simply πουλάκ‘my little birdie,’ i.e. ‘my darling,’ is the most frequent endearing term of the Greeks. See Vlachos's (...) Λεξικòν ‘Eλληογλλικòν ν πουλί 'πουλί μουmon chéri, mon amour, ma poulette.’ Therefore, πρóς σε Τñς κοΤΤíδος ψυχñς I fancy, means, ‘I implore thee by thy darling soul.’ The expression seems to have come down to us intact in sense, and only altered in so far as new words have been substituted for the obsolete ones. Of such a phenomenon I have given several curious examplesin my Notes tn the Gospels. (shrink)

This article explores humanity’s ontology of relationality and telos of the common good as not only inseparable but mutually constitutive, drawing on the work of Thomas Aquinas and looking into the debates between Charles De Koninck and Jacques Maritain.

"Aimée Pallière, Bergson et le Judaïsme" est un ouvrage écrit par Aimée Pallière, une écrivaine et mystique française du XXe siècle. Aimée Pallière était également la belle-sœur du philosophe Henri Bergson. Dans cet ouvrage, Aimée Pallière explore la relation entre Bergson, un important philosophe français, et sa propre compréhension du judaïsme. Elle examine comment les idées philosophiques de Bergson interagissent avec ses racines juives et comment cela influence sa pensée.

No discussion of when an individual is dead is meaningful in the absence of a definition of death. If human death is defined as the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe spontaneously (and hence to maintain a spontaneous heart beat) the death of the brainstem will be seen to be the necessary and sufficient condition for the death of the individual. Such a definition of death is not something radically (...) new. It is merely the reformulation -- in the language of the neurophysiologist -- of much older concepts such as the 'departure of the (conscious) soul from the body' and the 'loss of the breath of life'. All death -- in this perspective -- is, and always has been, brainstem death... (shrink)

My partner loves the experiences she gets from eating olives. I, on the other hand, hate the experiences I get from eating olives. We differ in tastes. But how exactly do we differ? In particular: do our taste experiences differ phenomenologically—that is, do my olive-experiences feel different than my partner’s olive-experiences? Some philosophers have assumed that the answer is “no,” and have advanced important arguments which turn on this assumption. I argue that, contrary to what these philosophers assume, ordinary taste (...) differences do involve differences in phenomenology. My olive-experiences feel different than my partner’s olive-experiences. I argue for this phenomenal thesis in stages. First, I argue that there is a link between our attitudes and our pleasures; second, I argue that there is a link between our pleasures and our phenomenology. Together, my conclusions link our attitudes and phenomenology in a way that vindicates the phenomenal thesis. Along the way, I fend off various worries about what the phenomenal thesis might entail. I show that it does not entail any form if radical subjectivism, nor does it entail that there is a “distinctive feeling of pleasure.” I close by considering how opponents of the phenomenal thesis might retreat to a weaker thesis: one which concerns extraordinary taste differences, as opposed to ordinary taste differences. I argue that there are no obviously sound arguments for even this weaker thesis, which should make us all the more confident in the phenomenal thesis. (shrink)

This Part II of a two‐part article illustrates how research in evolutionary biology, anthropology, archeology, and psychology illuminates questions arising in philosophy—specifically questions about René Girard's theory of aggression. Part I looked at: (i) how old the systemic practice of severe aggression is; (ii) how much of it results from humanity's mimetic/social and competitive nature and how much from ecological, resource, and cultural conditions; and (iii) if ecological, resource, and cultural conditions are important, might we adapt this information toward greater (...) cooperativity today? Part II investigates Girard's theory of ritual sacrifice—especially human sacrifice—as a societal steam valve for the systemic aggression explored in Part I. It draws on theories of play, theater, and art to examine the role and function of such ritual sacrifice. (shrink)

The article examines the role of discourse in organisational sensemaking. By building links between the theorising undertaken within organisational studies and the empirical analysis of multimodal social interaction, it argues for a relational view of sensemaking and investigates how sense is made in and through social interaction in real organisational situations where language use intertwines with embodied actions and the manipulation of artefacts. In particular, the article studies the use of discourse technologies of textual artefacts in sensemaking processes. The data (...) come from training workshops of a Finnish workplace organisation, conducted in order for the employees to delineate the history and future of their organisation with the help of writable papers. The results show how the papers exert agency in the situation by facilitating three specific discursive practices and by enabling and restricting the actions employed in constructing a shared understanding of the organisational reality. (shrink)

ExcerptIn light of the 2008 global financial crisis and its underlying causes, a reassessment of our global market system seems to be afoot, at least in some quarters. If neoliberalism (too much market) yields the Great Recession, if socialist planned markets (not enough market) produce the failed economies of the former Soviet bloc, and if social-market combinations (too much centralization of the market) progress toward the high-cost, centralized programs and slow growth of Western Europe, what are better options? One line (...) of questioning asks, can the dynamism and inventiveness of the market be harnessed not only for corporate and individual…. (shrink)

Despite the acknowledged importance of strategic planning in business and other organizations, there are few studies focusing on strategy texts and the related processes of their production and consumption. In this article, we attempt to partially fill this research gap by examining the institutionalized aspects of strategy discourse: what strategy is as genre. Combining textual analysis and analysis of conversation, the article focuses on the official strategy of the City of Lahti in Finland. Our analysis shows how specific communicative purposes (...) and lexico-grammatical features characterize the genre of strategy and how the actual negotiations over strategy text involve particular kinds of intersubjectivity and intertextuality. (shrink)

This Handbook contains forty essays by an international team of experts on the antecedents, the content, and the reception of the Dionysian corpus, a body of writings falsely ascribed to Dionysius the Areopagite, a convert of St Paul, but actually written about 500 AD. The first section contains discussions of the genesis of the corpus, its Christian antecedents, and its Neoplatonic influences. In the second section, studies on the Syriac reception, the relation of the Syriac to the original Greek, and (...) the editing of the Greek by John of Scythopolis are followed by contributions on the use of the corpus in such Byzantine authors as Maximus the Confessor, John of Damascus, Theodore the Studite, Niketas Stethatos, Gregory Palamas, and Gemistus Pletho. In the third section attention turns to the Western tradition, represented first by the translators John Scotus Eriugena, John Sarracenus, and Robert Grosseteste and then by such readers as the Victorines, the early Franciscans, Albert the Great, Aquinas, Bonaventure, Dante, the English mystics, Nicholas of Cusa, and Marsilio Ficino. The contributors to the final section survey the effect on Western readers of Lorenzo Valla's proof of the inauthenticity of the corpus and the subsequent exposure of its dependence on Proclus by Koch and Stiglmayr. The authors studied in this section include Erasmus, Luther and his followers, Vladimir Lossky, Hans Urs von Balthasar, and Jacques Derrida, as well as modern thinkers of the Greek Church. Essays on Dionysius as a mystic and a political theologian conclude the volume. (shrink)

Palliative care is a recent branch of health care. The doctors, nurses, and other professionals involved in it took their inspiration from the medieval idea of the hospice, but have now extended their expertise to every area of health care: surgeries, nursing homes, acute wards, and the community. This has happened during a period when patients wish to take more control over their own lives and deaths, resources have become scarce, and technology has created controversial life-prolonging treatments. Palliative (...) care is therefore faced with more ethical problems that other areas of health care. This book, by a clinician, teacher, and writer on health care ethics, has been written to provide all those who care for the terminally ill--doctors, nurses, social workers, clergymen, physiotherapists--with the concepts and principles which will assist them with difficult decisions. It challenges many received doctrines of palliative care, but its well-illustrated central theme is that technical expertise must be controlled by humane, non-technical judgments. (shrink)

The task of aligning the philosophical and clinical perspectives on ethics is a challenging one. Clinical practice informs philosophy, not merely by supplying cases, but through shaping and testing philosophical concepts in the reality of the clinical world. In this paper we explore several aspects of the relationship between the philosophical and the clinical within a framework of palliative care for people living with Alzheimer's disease. We suggest that health professionals have a moral obligation to question previous assumptions concerning (...) the quality of life among people with Alzheimer's, and to address the question: does the concept of palliative care properly embrace people with severe dementia? We propose an ethic of palliative care for people with Alzheimer's that is based, not on the traditionally understood principle of autonomy, but on the need to listen to those living with the disease, acknowledging their profound loss of cognitive abilities, with a focus on preventing and relieving suffering, and improving the individual's quality of life. (shrink)

Background: Palliative care is an important part of health services. The individualized care perceptions are is critical for supporting individuality during care and providing quality nursing care. Individualized care not only has, as well as having foundation of the philosophy of nursing but also, is also related to the nurses’ empathic tendencies and professional quality of life of nurses. Aim: This study was conducted to examine the relationships between the empathic tendencies, professional quality of life, and individualized care perceptions (...) of palliative care nurses. Research design: This is a cross-sectional study. Participants and research context: The study was conducted with 141 nurses working in palliative care between December 2023 and February 2024. The data of the study were collected using a “Participant Information Form,” the “Emphatic Tendency Scale (ETS),” the “Professional Quality of Life Scale (ProQOL R-IV),” and the “Individualized Care Scale-Nurse Version A (ICS-Nurse-A).” Ethical considerations: Ethics committee approval was obtained to conduct the study. Individuals who agreed to participate in the study were informed of the purpose of the study, and their written consent was obtained. Findings: The participants had moderate levels of empathic tendencies, compassion satisfaction, and burnout, while their compassion fatigue and individualized care perceptions were high. There was a positive correlation between empathic tendencies and individualized care perceptions ( p <.01). Empathic tendency and compassion satisfaction were significant positive predictors of the individualized care perceptions of the participants and respectively explained 13% and 20% of the total variance in their individualized care perceptions. On the other hand, burnout was a significant negative predictor of their individualized care perceptions and explained 5% of the total variance in their individualized care perceptions. Conclusions: High levels of empathic tendencies and compassion satisfaction had positive effects on the individualized care perceptions of palliative care nurses, whereas high levels of burnout had a negative effect on the same variable. (shrink)

Opponents of legalised assisted dying often assert that palliative care is worse in countries where assisted dying has been legalised, and imply that legalised assisted dying makes palliative care worse. This study considers five versions of this claim: that it is difficulty to access expert palliative care in countries where assisted dying has been legalised, that those countries rank low in their quality of end‐of‐life care; that legalising assisted dying doesn't expand patient choice in respect of (...) class='Hi'>palliative care; that growth in palliative care services has stalled in countries where assisted dying has been legalised; and that legalised assisted dying impedes the growth of palliative care or causes it to decline. In each case, it concludes that neither argumentation nor evidence supports these claims. (shrink)

Background: Nurses are the largest professional group in healthcare and those who make more decisions. In 2014, the Committee on Bioethics of the Council of Europe launched the “Guide on the decision-making process regarding medical treatment in end-of-life situations” (hereinafter, Guide), aiming at improving decision-making processes and empowering professionals in making end-of-life decisions. The Guide does not mention nurses explicitly. Objectives: To analyze the ethical principles most valued by nurses working in palliative care when making end-of-life decisions and investigate (...) if they are consistent with the framework and recommendations of the Guide; to identify what disputed/controversial issues are more frequent in these nurses’ current end-of-life care practices. Design: Qualitative secondary analysis. Participants/context: Three qualitative datasets including 32 interviews from previous studies with nurses working in palliative care in Portugal. Ethical consideration: Ethical approval was obtained from the Ethics Research Lab of the Instituto de Bioética (Ethics Research Lab of the Institute of Bioethics) (Ref.04.2015). Ethical procedures are thoroughly described. Findings: All participant nurses referred to autonomy as an ethical principle paramount in end-of-life decision-making. They were commonly involved in end-of-life decision-making. Palliative sedation and communication were the most mentioned disputed/controversial issues. Discussion: Autonomy was highly valued in end-of-life care and decision-making. Nurses expressed major concerns in assessing patients’ preferences, wishes, and promoting advance care planning. Nurses working in palliative care in Portugal were highly involved in end-of-life decision-making. These processes embraced a collective, inclusive approach. Palliative sedation was the most mentioned disputed issue, which is aligned with previous findings. Communication also emerged as a sensitive ethical issue; it is surprising, however, that only three nurses referred to it. Conclusion: While the Guide does not explicitly mention nurses in its content, this study shows that nurses working in palliative care in Portugal are involved in these processes. Further research is needed on nurses’ involvement and practices in end-of-life decision-making. (shrink)

Background Palliative care is an integral part of health care, which in term has become increasingly technologized in recent decades. Lately, innovative smart sensors combined with artificial intelligence promise better diagnosis and treatment. But to date, it is unclear: how are palliative care concepts and their underlying assumptions about humans challenged by smart sensor technologies (SST) and how can care benefit from SST? -/- Aims The paper aims to identify changes and challenges in palliative care due to (...) the use of SST. In addition, normative guiding criteria for the use of SST are developed. -/- Methods The principle of Total Care used by the European Association for Palliative Care (EAPC) forms the basis for the ethical analysis. Drawing on this, its underlying conceptions of the human and its socio-ethical aspects are examined with a phenomenological focus. In the second step, the advantages, limitations, and socio-ethical challenges of using SST with respect to the Total Care principle are explored. Finally, ethical-normative requirements for the application of SST are derived. -/- Results and Conclusion First, SST are limited in their measurement capabilities. Second, SST have an impact on human agency and autonomy. This concerns both the patient and the caregiver. Third, some aspects of the Total Care principle are likely to be marginalized due to the use of SST. The paper formulates normative requirements for using SST to serve human flourishing. It unfolds three criteria according to which SST must be aligned: (1) evidence and purposefulness, (2) autonomy, and (3) Total Care. (shrink)

Many countries have not considered palliative care a public health problem. With limited resources, disease-oriented therapies and prevention measures take priority. In this paper, I intend to describe the moral framework for considering palliative care as a public health priority in resource-poor countries. A distributive theory of justice for health care should consider integrative palliative care as morally required as it contributes to improving normal functioning and preserving opportunities for the individual. For patients requiring terminal care , (...) we are guided less by principles of justice and more by the duty to relieve suffering and society's commitment to protecting the professional's obligation to uphold principles of beneficence, compassion and non-abandonment. A fair deliberation process is necessary to allow these strong moral commitments to serve as reasons when setting priorities in resource poor countries. (shrink)

Medical assistance in dying (MAiD) and palliative sedation (PS) are both legal options in Canada that may be considered by patients experiencing intolerable and unmanageable suffering. A contentious, lively debate has been ongoing in the literature regarding the similarities and differences between MAiD and PS. The aim of this paper is to explore the propositions that MAiD and PS are essentially similar and conversely that MAiD and PS are distinctly different. The relevance of such a debate is apparent for (...) clinicians and patients alike. Understanding the complex and multi‐faceted nuances between PS and MAiD allows patients and caregivers to make more informed decisions pertaining to end‐of‐life care. It is hoped that this paper will also serve to foster further debate and consideration of the issues associated with PS and MAiD with a view to improve patient care and the quality of both living and dying in Canada. (shrink)

After a review of terminology, I identify—in addition to Margaret Battin’s list of five primary arguments for and against aid-in-dying—the argument from functional equivalence as another primary argument. I introduce a novel way to approach this argument based on Bernard Lonergan’s generalized empirical method. Then I proceed on the basis of GEM to distinguish palliative sedation, palliative sedation to unconsciousness when prognosis is less than two weeks, and foregoing life-sustaining treatment from aid-in-dying. I conclude that aid-in-dying must be (...) justified on its own merits and not on the basis of these well-established palliative care practices; and that societies must decide, in weighing the merits of aid-in-dying, whether or not to make the judgment that no life is better than life-like-this part of their operative value structure. (shrink)

The article explores the underlying reasons for patients’ self‐perception of being a burden (SPB) in family settings, including its impact on relationships when wishes to die (WTD) are expressed. In a prospective, interview‐based study of WTD in patients with advanced cancer and non‐cancer disease (organ failure, degenerative neurological disease, and frailty) SPB was an important emerging theme. In a sub‐analysis we examined (a) the facets of SPB, (b) correlations between SPB and WTD, and (c) SPB as a relational phenomenon. We (...) analyzed 248 interviews with 62 patients, their family caregivers, and professionals using grounded theory and interpretive phenomenological analysis. SPB appeared as important empathic concern in care situations. Patients expressed many sorts of concerns for others, but also perceived an altered self‐understanding that did not meet mutual expectations within relationships. In SPB associated with WTD three constellations were found: (a) WTD to unburden others; (b) patients decided against hastening death to prevent being a further burden to others (in these cases, the SPB counteracted the wish to die); and (c) both wishes for and against dying were sustained by SPB. These patients often felt paralyzed and suffered deeply. Family caregivers felt emotionally touched by SPB and tried to unburden patients by caring and compassion. We concluded that the impact of SPB on a WTD and the various meanings the facets of SPB have in balancing relationships need to be worked out individually. An early palliative and narrative approach is warranted. (shrink)

In September 1998 the Bundesrztekammer, i.e., the German Medical Association, published new principles concerning terminal medical care. Even before publication, a draft of these principles was very controversial, and prompted intense public debate in the mass media. Despite some of the critics' suspicions that the principles prepared the way for liberalization of active euthanasia, euthanasia is unequivocally rejected in the principles. Physician-assisted suicide is considered to violate professional medical rules. In leaving aside some of the notions customarily used in the (...) euthanasia debate, e.g., passive euthanasia, the principles emphasize the obligation of physicians to offer and the right of patients to receive palliative care. The principles explicitly list modalities of basic treatment that are indispensable in all cases, such as the obligation to satisfy hunger and thirst. This statement is meant to resolve the dispute on nutrition and hydration at the end of life, as it shifts the focus of care from maintaining physiological parameters to satisfying subjective needs. For patients in a persistent vegetative state, artificial feeding is held to be obligatory. Yet, the principles make reference to recent German jurisdiction which permit the stopping of artificial feeding if it is in accordance with the patient's presumed will. Additionally, the wording concerning this issue is found to remain unclear. Patients' autonomy is strengthened by explicitly welcoming advance directives as a means to ascertain patients' wills. The principles mark some changes compared to earlier documents. They deserve careful analysis and should be considered in the international debate on issues concerning the end of life. (shrink)

Most models of patient-physician communication take decision-making as a central concept. However, we found that often the treatment course of metastatic cancer patients is not easy to describe in straightforward terms used in decision-making models but is instead frequently more erratic. Our aim was to analyse these processes as trajectories. We used a longitudinal case study of 13 patients with metastatic colorectal and pancreatic cancer for whom palliative chemotherapy was a treatment option, and analysed 65 semi-structured interviews. We analysed (...) three characteristics of the treatment course that contributed to the ‘erraticness’ of the course: (1) The treatment (with or without chemotherapy) contained many options; (2) these options were not stable entities to be decided upon, but changed identity over the course of treatment, and (3) contrary to the closure (option X means no option Y, Z, etc.) a decision implies, the treatment course was a continuous process in which options instead remained open. When the treatment course is characterised by these many and changeable options that do not result in closure, the shared decision-making model should take these into account. More attention needs to be paid to the erratic character of the process in which the doctor has to provide continuous information that is related to the changing situation of the patient; also, flexibility in dealing with protocols is warranted, as is vigilance about the overall direction of the process. (shrink)

The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny the ethical distinctions between euthanasia and palliative sedation, we will critically analyse the guideline's argumentation strategy with which euthanasia is demarcated from palliative sedation. First, we will analyse the guideline's main premise, which entails that palliative sedation is normal medical treatment. After this, we will critically (...) discuss three crucial propositions of the guideline that are used to support this premise: (1) the patient's life expectancy should not exceed 2 weeks; (2) the aim of the physician should be to relieve suffering and (3) expert consultation is optional. We will conclude that, if inherent problematic aspects of palliative sedation are taken seriously, palliative sedation is less normal than it is now depicted in the guideline. (shrink)

The drive for cost-effective use of medical interventions has advantages, but can also be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. However, since it is in the nature of end-of-life palliative care that the benefits it brings to its patients are of short duration, it (...) fares poorly under a policy of QALY-maximization. Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness. The use of QALYs in resource allocation means that palliative care will always compete with alternative uses of the same money. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that investing in palliative care makes more sense not only ethically, but also financially. (shrink)

BackgroundTraditionally, palliative care has focused on patients suffering from life-threatening somatic diseases such as cancer or progressive neurological disorders. In contrast, despite the often chronic, severely disabling, and potentially life-threatening nature of psychiatric disorders, there are neither palliative care units nor clinical guidelines on palliative measures for patients in psychiatry.Main textThis paper contributes to the growing literature on a palliative approach in psychiatry and is based on the assumption that a change of perspective from a curative (...) to a palliative approach could help promote patient-centeredness and increase quality of life for severely ill patients in psychiatry as well as in somatic medicine. To exemplify this, we offer three different clinical scenarios: severe and enduring anorexia nervosa, treatment-refractory schizophrenia, and chronic suicidality and persistent self-injury in borderline personality disorder.ConclusionWe emphasize that many typical interventions for treatment-refractory psychiatric disorders may indeed be of a palliative nature. Furthermore, introducing traditional features of palliative care, e.g. so-called goals of care conversations, could aid even further in ensuring that caregivers, patients, and families agree on which treatment goals are to be prioritized in order to optimize quality of life in spite of severe, persistent mental disorder. (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)