This article constitutes excerpts of a videotaped discussion hosted by the New England Journal of Medicine on January 14, 2008, concerning a range of topics on lethal injection prompted by the United States Supreme Court's January 7 oral arguments in Baze v. Rees. Dr. Atul Gawande moderated the roundtable that included two anesthesiologists - Dr. Robert Truog and Dr. David Waisel - as well as law professor Deborah Denno. The discussion focused on the drugs used in lethal injection (...) executions, whether physicians should participate, potential alternatives, and some of the legal parameters of Baze. (shrink)

By 1999, when Atul Gawande's essay “Whose Body Is It, Anyway?” appeared in The New Yorker, patient autonomy had largely trumped physician paternalism in American medical practice. Gawande uses the stories of actual patients to attempt his counter case for physicians' “talking patients through their decisions.” Toward the end of his essay, Gawande acknowledges that “many ethicists find this line of reasoning disturbing,” but he reassures his readers that “the real task isn't to banish paternalism; the (...) real task is to preserve kindness.”What troubles me, however, is not so much the ethical position Gawande takes but the way he structures his narrative to support his position. “Whose Body Is It, Anyway?” offers an important example for close scrutiny because, in my experience, it so effectively engages readers‐especially medical students‐and persuades them to accept the ethical position it puts forward. Yet Gawande's own reflections about this issue do not stop with this essay. As he has gained clinical experience, he has continued his ethical reflections, and the stories that he tells have changed significantly over the years. I will argue here that close reading and careful narrative scrutiny can alert those who read this essay apart from Gawande's later work to some of the pitfalls in this kind of narrative ethics. (shrink)

Simonet, Emanuel Nicolas Cortes Atul Gawande's book Being Mortal: Illness, Medicine, and What Matters in the End, draws upon both anecdotal stories and literary sources to highlight the importance of honest discussions as the end of life approaches. These discussions are particularly significant for older persons and terminally ill patients. Gawande believes that these discussions could be facilitated by more in-depth and focussed communication between the healthcare professional and the patient. Respecting the patient's values and priorities, and (...) promoting a sense of wellbeing and dignity are critical for quality care. (shrink)

Is it virtuous for someone to try to live to 100? Casting aside questions of intergenerational justice and internal obligations in families, what about the basic desire itself? Discussions of longevity and aging in bioethics are skewed to controversial end‐of‐life decisions, largely avoiding questions of how to age well before such decisions arise. Respected writers such as Atul Gawande, Daniel Callahan, and Ezekiel Emanuel champion accepting a natural life span and not trying to live beyond it. The Stoic (...) Seneca says a desire to live to 100 is foolish because, however long people live, they waste most of their lives, so if they lived a thousand years, they would still waste most of it. Against Seneca and Emanuel, we argue that a functional, not a chronological, view of aging should guide us and that for some seniors, hoping to be centenarians may be neither foolish nor misguided. Using Cicero, we argue that the pleasures of seniors are not necessarily inferior to those of youth and may even surpass them. Finally, we agree with Emanuel that the “symptom burden” of some lives makes living to 100 unpalatable and with Seneca that, given life’s vicissitudes, we should not plan on living to 100, but heeding his wisdom, try to make the most of the time given to us. (shrink)

In this paper, I consider the idea of meaning in life as I believe it has arisen in some discussions of ageing and death. I critically examine and compare the views of Atul Gawande and Ezekiel Emanuel, connecting their views to the idea of meaning in life. I further consider the relation of meaning in life to both the dignity of the person and the reasonableness of continuing or not continuing to live. In considering these issues, I evaluate (...) and draw on Bernard Williams’ distinction between categorical and conditional desires, Susan Wolf's work on meaning in life, and Jeremy Waldron's views on dignity in old age. (shrink)

"Abstract: This book is a philosophical discussion of moral, legal, and medical issues related to aging, dying, and death. It considers different views about whether and why death is bad for the person who dies, and whether these views bear on why it would be bad if there were no more persons at all. The book looks at how the general public is being asked to think about end of life issues, as well, by examining some questionnaires and conversation guides (...) that have been developed for their use. It also considers views about the process of dying and whether it might make sense to not resist death, or even to bring about the end of one's life, given certain views about meaning in life and what things it is worth living on to get and do. Some hold that it is not only serious illness but ordinary aging that may give rise to some of these questions and the book considers various ways in which aging and the distribution of goods and bads in a life could occur. Physician assisted suicide would be one way to end one's life and the book examines arguments about its moral permissibility and whether or not it should be legalized as a matter of public policy. This discussion draws on capital punishment debates concerning State action and also on methods of balancing costs and benefits. The book examines the views of such prominent philosophers, medical doctors, and legal theorists as Shelly Kagan, Susan Wolf, Atul Gawande, Ezekiel Emanuel, Cass Sunstein, and Neil Gorsuch, among others. ". (shrink)

For almost a decade, I have taught an undergraduate course on death and dying and have served as an ethics consultant in an academic medical center where I support patients and families navigating difficult end-of-life decisions. Chapters from Elisabeth Kübler-Ross's On Death and Dying, Sherwin Nuland's How We Die, and Atul Gawande's Being Mortal are required reading in my course because these physician-writers offer detailed, firsthand stories that help readers imagine the places and faces of dying patients and (...) their families. Respectively, these authors teach us about patients' changing perceptions about their own deaths, the physio-cultural shapes of the dying process, and the fraught... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Remixing the Classroom: Toward an Open Philosophy of Music Education by Randall Everett AllsupJuliet HessRandall Everett Allsup, Remixing the Classroom: Toward an Open Philosophy of Music Education (Bloomington, IN: Indiana University Press, 2016).As a leading voice in music education, Randall Allsup works continually to reconceptualize music education toward democratic and socially just praxis.1 He routinely challenges the field to become self-conscious of practices that limit forward movement, providing (...) powerful critiques2 and urging music education toward open possibilities.3 Remixing the Classroom: Toward an Open Philosophy of Music Education is work that will shift our field. His comprehensive philosophy of music education looks, longs, for moral openings4 through which twenty-first-century music education may become a space of possibility. His writing interweaves stories and theory toward what he calls an "open philosophy," drawing upon the ideas of John Dewey, Maxine Greene, and Roland Barthes. Allsup introduces stories of Dapper Dan, Jiro Ono, Kafka, Atul Gawande, and the Orpheus Orchestra in New York City to illustrate powerful points about current and possible paradigms of music education.Chapter 1, "Toward Open Encounters," discusses the making and breaking of the law (tradition) and explores how tradition and the Master-Apprentice model restrict what is possible in music education. Allsup explores the nature of music education and the limitations it places upon its participants. Chapter 2, "Music-Teacher Quality and Expertise," asks fundamental questions of our field and [End Page 100] explores and challenges the "place and purpose of public schooling in a democratic society."5 Allsup speaks to the function of education and critiques music education. Chapter 3, "learning in laboratories," puts forward a Deweyan laboratory model in which a museum is at the center of the school with learning laboratories situated around it. He explores what this structural fluidity might enable and develops notions of lawmaking and lawbreaking, extending possibilities of the open encounter. The final chapter, "looking, Longing, for Moral Openings," calls on music educators to embrace a more open music education paradigm. Allsup draws upon Greene to challenge music education to move "from the predictable to the possible."6 He puts forward the Orpheus Orchestra, a conductorless orchestra, as one possibility.I situate myself as an anti-racist, anti-colonial, feminist scholar rooted in anti-oppression scholarship.7 locating my review through this framework, I elaborate upon what I see as the major strengths and limitations of this work, drawing upon Judith Butler8 and postcolonial theory. significantly, Allsup's book calls upon music education to "give an account of [it]self" and promotes a self-consciousness crucial for our field in the age of high stakes accountability measures. I contend that he provides a music education philosophy for what stuart Hall terms the "postcolonial moment"9 and ultimately positions music education as a space of possibility. Alongside these strengths, I offer a challenge toward what I view as the open possibilities of closed forms and a critique of his "pedagogy of travel and surprise."Judith Butler points to the impossibility of giving an account of oneself. she notes,I speak as an 'I,' but do not make the mistake of thinking that I know precisely all that I am doing when I speak in that way. I find that my very formation implicates the other and me, that my own foreignness to myself is, paradoxically, the source of my ethical connection with others.10Butler notes the subject's "partial opacity to [her]self."11 In Remixing the Classroom, Allsup calls upon music educators to account for the practices and traditions continually reinscribed in the field. He poses challenging but fundamental questions in the work in music education, asking readers to consider what they do unconsciously. Butler asserts we can never fully account for ourselves. Allsup challenges the field to try, pushing music educators to face hard truths and limitations of what music education is and has been. In chapter 1, for example, he argues:To call a studying musician "unmusical" is to extinguish a light; it is to act as if the future is certain and that human potential is somehow fixed. It is to act [End Page 101... (shrink)

Something has changed in America with respect to facing death. As I write this review of When Breath Becomes Air by Paul Kalanithi, it is number one on the New York Times nonfiction bestseller's list; number 10 is Being Mortal by Atul Gawande, on the list for 62 weeks. A few years ago, Christopher Hitchens's Mortality, a remarkable narrative of his living in the face of dying from esophageal cancer, also was a bestseller. While denial of death was (...) thought to be an American characteristic, this may be true no longer; or at least the public shows a strong interest in narratives about mortality.To what extent does the appetite of the reading public signify a changed perspective on mortality?... (shrink)

“It is this distancing of personal relationships, combined with their replacement by written contractual terms and conditions, which make the discussion of ethics within a corporate institutionalised context highly limited and problematic.’ The challenge is to find means of personalising modern corporations so as to encourage ethical behaviour. Atul K. Shah PhD ACA gained his doctorate from the London School of Economics and is Lecturer in the Department of Accounting and Financial Management, at the University of Essex, Wivenhoe Park, (...) Colchester CO4 3SQ; e‐mail ashah@essex.ac.uk. This article was conceived while he was Visiting Assistant Professor at the College of Business, University of Maryland, USA. The author wishes to thank Dan Ostas, Lee Preston and Stephen Loeb for helpful comments on earlier drafts. (shrink)

We examine whether social capital mitigates managerial opportunism around share repurchase announcements. We find that firms headquartered in high social capital states are associated with: (i) higher repurchase completion rates, and more so in environments where governance is weak and the potential for misleading investors is high, (ii) a smaller likelihood of information manipulation such as revealing bad news before repurchases, and (iii) lower completion rates when shares are less undervalued. By documenting that firms’ external social environments help curb managerial (...) opportunism, our study suggests that the location of headquarters facilitates trustworthiness and affects ethical considerations in corporate announcements. (shrink)

This article takes the linguistic space of North India during the nineteenth and twentieth centuries and tries to see how a nationalistic linguistic ideology that was shaping up at that time, creating Hindi and Urdu linguistic communities, used gender as a tool to portray and assert a masculinist vision of language and nation. It involved not just censoring certain representations of women and their cultural spaces, but also using the issue of ‘vulgar’ representations as a premise to marginalize certain languages (...) and their literature. The article looks at the colonial ideology that worked as an enforcer for the nationalists to work towards achieving what they felt as a sanitized and moral form of literature and culture. The linguistic ideology that accompanied these revisions was of projecting Hindi (Khari Boli) as a national language while limiting spaces of other languages, such as Braj, Urdu and Bhojpuri, in the region, by criticizing either their use of sexual imagery or by stereotyping them in a gendered way. This article investigates the arguments of nationalist writers and highlights their masculinist and patriarchal ideas in their bid for the new national language. (shrink)

From the financial year 2014-15, the Indian corporate sector was made to comply with a newly introduced Sect. 135 (5) by the Companies Act of 2013. The rule required select companies to spend 2% of their average net profits on CSR initiatives. This paper tries to find if the companies have complied with the provision based on data for six financial years starting 2014-15. CSR performance of the top thirty companies forming part of the Bombay Stock Exchange (BSE) Sensex was (...) evaluated and a CSR Spend-to-Obligation (CSR SO) Index was calculated comparing the actual spend vis-à-vis the obligatory requirement. A quantitative and a qualitative methodology were used for the analysis. The quantitative method involved computation of the CSR SO index at various levels. The “quality” of the CSR expenditure was also assessed by speaking to twelve experts from the Corporate to find out if the expenditure was in the right direction. The results show that the aggregate average six-year CSR SO index for the 30 Sensex companies is 0.98, suggesting that companies comply with the requirements of mandatory CSR. Moreover, the experts confirm that CSR spending is in the right spirit and direction. It certainly has a long-term orientation and qualifies as quality spending. A novel CSR-SO index is presented that compares CSR performance by comparing actual CSR spending with obligatory requirements. This index can act as a barometer for CSR performance and facilitate objective evaluation. Additionally, the qualitative assessment of CSR spending shows a holistic approach to evaluating CSR. (shrink)

Smartphone acceptance could improve instruction, increase accessibility, and foster student involvement, which is a fundamental element in the development and application of m-learning in the classroom. This process reflects continuing advancements and versions in educational methods. The effect of mobile technology adoption in classrooms is examined in this study, focusing on its effects on student engagement, educational outcomes, and the associated infrastructure and support. The study comprised qualitative and quantitative data collected from 300 students using a mixed-method approach. Five key (...) variables related to mobile technology use were integrated, and SPSS software was employed for analysis. Descriptive statistics were used to compute an adoption index, highlighting positive student feedback and assessing technological integration, despite, to assess variations in student satisfaction and academic achievement; a one-sample t-test was used. Results revealed significant positive impacts on engagement and outcomes, though challenges in infrastructure and cost price. The findings highlight how mobile technology could transform education, but they also highlight how much additional resources and encouragement are required to ensure that it is as sustainable and effective as possible. (shrink)

The development of cultural heritage tourism (CHT) frequently encounters obstacles pertaining to community support, as the attitudes of the local populace typically dictate the outcome of tourism endeavors. The community's influence on these perceptions has been undervalued in traditional approaches, which has resulted in low levels of engagement and support for cultural preservation. This study aims to bridge this gap by investigating how different degrees of community involvement impact local perceptions of the advantages of tourism, the preservation of culture, and (...) general satisfaction with the results. Data was gathered from 300 participants who were actively involved in many heritages sites' tourism planning. The connections between perceptions of the advantages of tourism and community involvement (CI) were evaluatedby utilizing Partial Least Squares Structural Equation Modeling (PLS-SEM). The results demonstrated that the perceptions of economic benefits (PEB), perceptions of cultural preservation (PCP), and community satisfaction (CS) are all positively impacted by greater CI. The aforementioned results underscore the significance of adopting participatory methodologies, implying that cultivating community engagement is vital for the sustainable growth of CHT. (shrink)

Background and rationale Clinicians often encounter a variety of ethical challenges in their routine clinical practice, and it varies across healthcare and cultural settings of their practice. Despite of this, there are no clear-cut available guidelines concerning the right course of action in a given ethically challenging situation. A validated instrument that could capture the health care providers’ (HCP’s) viewpoints in this regard is lacking from Indian settings. Thus, the current study aimed at developing an instrument to assess the HCP’s (...) perspective regarding different ethically challenging situations encountered in the Indian settings. Methods The questionnaire was developed by involving 15 medical experts. A mixed-method approach, Delphi-technique, and online survey were used for item generation and validation. Results The questionnaire comprised of 11 items (accounts 57% variance; having an α = 0.68) representing four factors: health-resource constraints, medical responsibility of the HCP, obtaining patients/family members’ consent for the treatment, and treatment beyond the standard protocol. The gender and clinical disciplines of the participants were related to their level of endorsement for various domains of the ECCS-Q. Conclusions Ethical challenges in the clinical practice fall in different clusters. The clinicians’ course of action in such situations have many socio-demographic and professional determinants. Future studies are warranted to investigate these phenomena. (shrink)

According to Gawande, Lazaroff “chose badly.” Gawande suggests that physicians may be permitted to intervene in choices of this kind. What makes the temptation to intervene paternalistically in this and similar cases especially strong is that the patient’s choice contradicts his professed values. Paternalism appears less problematic in such cases because, in contradicting his values, the patient seems to sidestep his own autonomy. This chapter addresses the dangers of overextending this interpretation. I argue that it is not so (...) easy to judge when a person is not genuinely exercising autonomy, and that choosing contrary to one’s own values does not necessarily amount to sidestepping one’s autonomy. The key insight is to recognize the importance of the attitude of caring as an integral part of some expressions of autonomy. This will allow us to develop an alternative picture of minimal autonomy, according to which it is possible to choose against one’s values while genuinely exercising autonomy. For practical purposes, in medicine and elsewhere, this means that, in cases like Lazaroff’s, those tempted toward paternalism must exercise particular caution before they deem a choice to be disen- gaged from autonomy: even if a choice contradicts the person’s own values, it might be rooted in caring, and then, despite initial appearances to the contrary, it may still command the highest level of protection against paternalism. (shrink)

Review of Arul Gawande's best seller about preparing for death.

Cunningham and Kavic [1] rightly note that standard accounts of surgical complications—ours included—have focused on postoperative events [2, 3]. As they point out, this postoperative focus leaves open the question of how we should categorize adverse intraoperative events. They argue that we should distinguish between two types of adverse intraoperative events: those that introduce additional risk of postoperative complications and those that do not. On their account, adverse intraoperative events that introduce additional risk of postoperative complications are intraoperative complications, whereas (...) those that do not are simple errors. Cunningham and Kavic say little about why we might want to make this distinction. We take it that the underlying purpose is to focus attention on the importance of diligence in surgical performance. Gawande defines diligence as ‘‘the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles’’ [4, p. 8]. It is clear that diligence in surgery requires us to attend not just to those adverse intraoperative events that lead to postoperative complications but also to adverse intraoperative events that increase the risk of postoperative complications. We wholeheartedly agree about the importance of diligence in surgery, both in the intraoperative and the.. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Democratizing Psychiatric ResearchRecognizing the Potential and the Limits of Experiential ExpertiseThe author reports no conflict of interests.First, I want to express my gratitude for such thoughtful and generative responses to the manuscript "Why Democratize Psychiatric Research?," which has been in development for several years and is the product of much reflection that has taken place in academic, advocacy, and interpersonal contexts. I am delighted to see such insightful engagement (...) with the piece and to have a chance to respond to both Drs. David Crepaz-Keay and Sam Fellowes here. Given that the authors raise such different questions within their commentaries, I consider each in turn.In his illuminating commentary, Crepaz-Keay makes three important points in response to the epistemic and ethical reasons I lay out as justifications for democratizing efforts in mental health research. First of all, Crepaz-Keay warns that there is "more subjectivity across much of medicine" than in the picture I've painted, and that we might do better to focus on this shared territory, taking up the goal of democratization across all of medicine, rather than risk "othering" psychiatry as uniquely subjective. In this way, Crepaz-Keay emphasizes, mental health service user researchers might "become leaders in progressive medical thinking."I appreciate this call to emphasize the ways in which the importance of subjective experiences cuts across all of medicine and to learn broad lessons from the pioneering participatory work that has been accomplished in the domain of mental health. I agree that much of medicine suffers from a focus on the objective to the neglect of the subjective, and wonder if this focus can sometimes create a distinct kind of worry in territories in which objective measures are widely available. Consider the focus on reducing the size of a tumor at all costs that can sometimes obscure important considerations related to what a good end of life might look like (Gawande, 2014). Particularly [End Page 143] within the process of determining what is worth measuring within research (and what is worth treating within clinical contexts), patient voices are essential to making an informed and beneficial decision. I agree with Crepaz-Keay here—this point applies to all realms of medicine.In contrast, I think other kinds of risks arise in domains in which objective measures are not widely available and therefore subjective reports of patients make up an essential part of any diagnosis or assessment. Another area I often think about is placebo studies, and in this space, stereotypes related to 'real' suffering and 'real' healing circulate widely (Friesen, 2019b). Largely, these stereotypes tend to support the importance and reality of that which occurs at the level of the physical or biological and take much less seriously suffering or healing which is thought to be located 'all in the head' (Friesen & Dionne, 2022). These biases also cut across medicine, influencing which patients are seen as trustworthy, dramatic, or worthy of one's compassion. I would argue that they show up especially in the setting of mental health care and research, in part because of the lack of objective measures and physiological explanations. A psychiatrized patient often has nothing physical or objective to point to with regard to their suffering, and so may be at the whim of a provider in relation to whether they are likely to be believed or discredited. As such, we must be especially alert to the unique risks that arise when evidence for suffering comes in a subjective form, and how efforts toward democratization might help reduce such risks.Second, Crepaz-Keay offers an essential intervention in relation to the importance of anti-racism within participatory practices in psychiatry. Although I do make mention of the lack of representation of racialized communities in participatory psychiatric research in discussing the important role that values play in the development of psychiatric knowledge, Crepaz-Keay accurately points out that this point related to representation is cross-cutting, and highly relevant to several of the other reasons I offer for why psychiatry research ought to be democratized. I am grateful for this invitation to look more broadly at how the exclusion of some voices from participatory efforts might apply across... (shrink)

An implicit rationale for ethics in medical schools is that there is a perceived need to teach students how not to think and how not to act, if they are to avoid a lawsuit or being struck off by the GMC. However, the imperative to keep within the law and professional guidance focuses attention on risks to patients that can land a doctor in trouble, rather than what it means to treat a patient humanely or well. In this paper I (...) explore the gap between learning how not to think and act as a doctor, and learning to be reflective and responsive to patients as fellow human beings. This gap is exposed by the difference between a GMC web resource for doctors, and a detailed ethical discussion by Gawande in his book Complications. The latter raises fundamental questions of meaning, and exemplifies an approach to ethical thinking as the appropriate management of doubt that, according to the argument of this paper, is of utmost importance for doctors. (shrink)