In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Acts of Enjoyment: Rhetoric, Žižek, and the Return of the SubjectJames J. Brown Jr. and Joshua GunnActs of Enjoyment: Rhetoric, Žižek, and the Return of the Subject by Thomas Rickert. Pittsburgh: University of Pittsburgh Press, 2007. Pp. x + 252. $24.95, hardcover.Thomas Rickert had a falling-out with his brother, and this distresses him so much that his disrupted relation is described as “traumatic.” Rickert reports that while (...) listening to a portable CD player during a run on an unexpectedly warm winter day, a song by the now defunct jazz/rock band Morphine reminded him of a happy time at a pool hall with his brother (24). Mediated—or better, medicated—by music, the homological happiness of running in the sun and a positive past memory also resurfaced a painful relational rupture, the reason of which Rickert omits to underscore that mysterious, “little detail or object” of the Real that marks his singular finitude as a writing subject (216 n. 11). We’ll want to come back to this curiously deliberate omission, but for the present we note Rickert is not simply an undead author but a human being with relations and feelings. He is not just a gifted scholar or a bundle of reflections, but a nexus of body and movement and words and affect. If there is anything that Rickert’s study can be said to work through with brilliance, humor, and grace, it is the reality of complex personhood.Rickert’s brotherly confession comes in Chapter 1 as a way to introduce a psychoanalytic understanding of subjectivity, and more specifically, to help illustrate how trauma works itself out as an afterwardness or “belatedness” ( Nachträglichkeit ): traumatic events from the past are not reckoned with or worked-through until some coincidence or reminder, such as a similar [End Page 183] sensory experience, reintroduces the event in doubled re-presentation (18–27). This implies the “subject” (a paradigm person) is a kind of timedelay, a self-conscious temporal moving that becomes this way through re-presentation. The rhetorical subject is analogously a retrojected reckoning with events past (not all traumatic) that Rickert identifies as a scene of writing, a locus that has important implications for rhetorical studies in general and writing pedagogy in particular. Rickert’s logic is as follows: if we agree that the subject is a belated one in the psychoanalytic sense, then how we teach rhetoric needs to change. Rickert opens the book with the observation that his students are producing excellent cultural critiques but that such critiques do not lead the students to change their actions (1–7), perhaps evidence enough that something is not quite right in a classroom grounded by “cultural studies pedagogy” and ideology critique—or at the very least, proof that something has changed. The opening gambit is simply that a “postpedagogy” premised on an understanding of rhetorical subjectivity as belatedness is better than a status quo rooted in the rational subject of the Enlightenment.Mostly through a Žižek-filtered, Lacanian lens, Acts of Enjoyment then undertakes a retake of the rhetorical field, frequently scanning from the traumatic ontology of the rhetorical subject to that domain of knowledge that we hold dear, the subject of rhetoric. In Chapter 2, the (primal) scene thus shifts from the slo-mo subject to rhetorical studies, initially through a reassessment of Kinneavy’s “communications triangle,” but ultimately in response to the shock treatment of poststructuralism. The initial theoretical traumas introduced by Victor Vitanza, Diane Davis, Sharon Crowley, and others discussed in Chapter 1 are threaded into an account of “poststructural” redress in Chapter 2: as is true of all forms of trauma, the initial poststructural jolt delivered to the concept of subjectivity was deadened; poststructural theory was eventually used to “shore up rather than challenge Kinneavy’s triangle” (37). To truly work-through our traumatized subject in both senses, we need a second trauma: Lacanian psychoanalysis. Presumably, “poststructuralist thought” is to be opposed because it has no account of the subject (21–24); “Lacan,” after all, “is not a poststructuralist” (48). The remainder of the chapter is then used to deploy Lacan’s conceptual lexicon.Just as... (shrink)

Ethics consultants’ grasp of ethical principles is ever improving. Yet, what still remains and will remain lacking is their ability to access factors that lie outside their conscious awareness and thus still effect suboptimal outcomes. This article will explore several ways in which these poor outcomes may occur. This discussion will include clinicians’ implicit biases, well-intentioned but nonetheless intrusive violations of patients’ privacy, and clinicians’ unwittingly connoting to patients and families that clinicians regard their moral values and conclusions as superior. (...) I shall suggest several ways in which clinicians may seek to reduce these sources of bad outcomes or at least to do better when they occur. (shrink)

As we go to press, the threat of biological or chemical warfare in the Persian Gulf is no longer imminent. Yet the questions raised by the proposed use of “investigational drugs,” without informed consent, to protect U.S. troops remain. The article by Edmund G. Howe and Edward D. Martin presents the arguments that informed the Pentagon's thinking on the subject. It and the commentaries, by George J. Annas and Michael A. Grodin, and Robert J. Levine, explore, among others, issues (...) of informed consent, of distinguishing ‘research’ and ‘treatment,’ and of the nature and extent of the autonomy of military personnel.—B‐JC, HLN. (shrink)

One of the most important and difficult tasks in medicine is to determine when patients have the capacity to make decisions for themselves. This determination may determine a patient’s life or death. This article presents criteria and approaches now used to make this assessment and discusses how these approaches are presently applied in five common disorders that can serve as paradigms for approaches in other disorders. I propose that since there are new diagnoses and treatments, reconsidering our current practices is (...) warranted. The possibilities that clinicians can nudge patients to make better choices for themselves and, above all, that clinicians can maintain and maximize positive patient/careprovider relationships during and after these assessments, are emphasized. (shrink)

This introduction to The Journal of Clinical Ethics highlights and expands four articles within this issue that propose somewhat new and radical innovations to help and further the interests of patients and families worst off. One article urges us to enable historically marginalized groups to participate more than they have in research; a second urges us to allocate limited resources that can be divided, such as vaccines and even ventilators, in a different way; a third urges us to help families (...) find greater meaning when their loved ones are dying; and a fourth urges us to treat patients who illegally use drugs as caringly as is possible, though there may be limits to what providers can do. This piece also addresses the importance of providers bonding with patients, recognizing that some providers may be better at eliciting patients’ trust than others, and thus the importance of connecting these patients with these providers since this may be the sole way these patients can optimally respond and do well. Finally, providers taking time away from their patients to oppose and reduce social stigma is considered. (shrink)

In this article I will discuss how clinicians might best treat adolescents who may die. I initially discuss these patients’ cognition, emotional tendencies, and sensitivity to interpersonal cues. I next discuss their parents’ feelings of loss and guilt and their clinicians’ risk of imposing their own moral views without knowing this. I then address the practical concerns of helping these patients gain or regain resilience and to identify strengths they have had in the past. I finally explore who, among staff, (...) might be best able to do this. I highlight as the main goal that patients, their parents, and ideally also their clinicians are able to come to agree on the best course the patients should take. (shrink)

Physicians who are impaired, engage in unprofessional behavior, or violate laws may be barred from further practice. Likewise, medical students may be dismissed from medical school for many infractions, large and small. The welfare of patients and the general public must be our first priority, but when we assess physicians and students who have erred, we should seek to respond as caringly and fairly as possible. This piece will explore how we may do this at all stages of the proceedings (...) physicians and students may encounter. This may include helping them to resume their medical careers if and when this would be sufficiently safe and beneficial for patients. (shrink)

The primary task of ethics consultants is to work with patients—and sometimes also their families—to discern and then meet patients’ and families’ needs and wants to the extent possible. That is primarily a cognitive endeavor. Yet the feelings of patients and ethics consultants may determine what they can work together to accomplish. This article considers their feelings. It looks at sources of distrust and their hopedfor resolution, specific means to enhance patients’ decision making in their relationship with ethics consultants, and (...) a new, highly different approach that may enhance their relationships more than most commonly used ways of relating. (shrink)

After COVID-19 first began to spread in the United States, dentists developed new guidelines that limited whom they could treat under these emergency conditions. Patients who faced greater limits to accessing treatment included children. Using a case of a child who was not able to access treatment, I discuss how careproviders might best seek to maintain their emotional bonding with patients and their loved ones, even if they must turn them down for an intervention.I also address whether and when to (...) give patients and their loved ones warning that access to treatment could be limited, using illness caused by COVID-19 as an example of how careproviders may better anticipate patients’ needs at all times.Finally, I discuss careproviders’ needs. I suggest that medical professionals’ culture should make it as easy as possible for them to acknowledge their feelings of vulnerability, so that they may better determine, in times of disaster, whether they should treat or triage patients. Careproviders who triage may choose to share with patients and loved ones that they also feel pain when they deny patients an intervention. (shrink)

How can clinical ethics consultants best assist patients and their family members when patients may be dying? In this introduction, I consider this concern in light of four articles that appear in this issue of The Journal of Clinical Ethics, by Jeffrey T. Berger; Mary T. White; Linying Hu, Xiuyun Yin, Xiaolei Bao, and Jin-Bao Nie; and Thaddeus Mason Pope and Melinda Hexum.Patients and family members experience extreme stress at the end of life, a high-stakes situation in which few of (...) us have extensive experience. This stress can make us less able to process new information, cripple decision making, and even lead to long-term harm.I provide a number of practical approaches that clinical ethics consultants can use to help patients and family members in these situations, so that their decisions may reflect more what they really want and so that, after this stress has diminished, they may then do better. (shrink)

Stress can make the comprehension of complex information more difficult, yet patients and their family members often must receive, process, and make decisions based on new, complex information presented in unfamiliar and stressful clinical environments such as the intensive care unit. Families may be asked to make decisions regarding the donation of organs and genetic tissue soon after the death of a loved one, based on new, complex information, under tight time limits. How can we assist patients and families to (...) better process complex information while under stress, and make better decisions for themselves or a loved one? (shrink)

Patients’ and families’ greatest need is often to do what for them is most meaningful. This may be, for example, their religion, their family, or their doing good for others. This piece will explore ways in which care providers may help maximize these ends. Paradigms offered will include Jehovah’s Witness patients needing kidney transplants, a transgender adolescent wanting his sperm preserved, care providers’ deciding whether to disclose that a deceased organ donor had HIV, and care providers seeking to do good (...) for children profoundly impaired and adults who feel shame for just existing. (shrink)

This piece discusses ways in which clinicians may go beyond their usual practices. These include exploring the limits of old laws, consulting with colleagues and ethics committees earlier and more often, and giving patients’ family members new choices they didn’t have previously. This could include asking patients and family members whether clinicians should prioritize staying in the single, unconflicted role of serving patients and families, even when this might preclude simultaneously serving another interest, for example, that of a hospital.

This article discusses how careproviders of all types can help people with differences of sexual development (DSD): people with ambiguous genitalia, who used to be referred to as intersexed. Careproviders may be in a unique position to benefit these people by offering to discuss difficult issues that concern them, even when the discussions are brief. Specific interventions include learning about people with DSD, whether through the literature or in the clinic; treating them with optimal respect; raising difficult topics such as (...) sex, fertility, and social stigma; encouraging them and helping them to meet others with DSD; and sharing the strengths that we can see that they have. We have come far, but have a long way to go. (shrink)

Clinical ethics consultants (CECs) must know key moral principles and have adequate psychosocial skills. This is, though, not enough. They must also have and hone “between-the-lines” skills that will change over time. This article discusses seven of these skills that CECs need before, during, and after consultations. They have in common the unusual primary goal of maximizing CECs’ ability to bond with the patients and families with whom they consult. A focus on relationships, rather than on ethical outcomes, may paradoxically (...) enhance the possibility of achieving an ethical outcome. (shrink)

In this issue of The Journal of Clinical Ethics, Emily Bell and Eric Racine are guest editors of a special section focusing on the use of deep brain stimulation (DBS) to treat Parkinson’s disease. In “Deep Brain Stimulation, Ethics, and Society,” Bell and Racine report that DBS already has been used to treat more than 50,000 patients. The ethical issues raised in this special section are important not only in regard to Parkinson’s disease and DBS, but in many areas of (...) medicine.The articles discuss sound, state-of-the-art ethical approaches. This introduction to the issue presents approaches that are adjunctive and intended to increase careproviders’ options, that should increase careproviders’ ability to individualize the care that they provide to their patients. (shrink)

In this piece I discuss when care providers should not contact suicidal patients’ families to get collateral information from them or hospitalize patients over their objections. I suggest that when these patients are chronically suicidal, overriding these wants may be best in the short run but increase their net risk in the longer run. I also discuss in this regard how contacted families may become overprotective and how hospitalization can be traumatic. I present an alternative approach that can increase these (...) patients’ safety over the longer run and relate three practical approaches care providers may find useful: explaining their decisions to patients, monitoring their own fear, and instilling hope. (shrink)

The author describes an alternative approach that careproviders may want to consider when caring for patients who request interventions that careproviders see as futile. This approach is based, in part, on findings of recent neuroimaging research. The author also provides several examples of seemingly justifiable “paternalistic omissions,” taken from articles in this issue of The Journal of Clinical Ethics (JCE). The author suggests that while careproviders should always give patients and their loved ones all potentially relevant information regarding “futile” decisions, (...) careproviders may wish to consider, paradoxically, not giving advice in these situations, when the advice is based mostly or wholly on their own moral views, based on this same, ethical rationale. (shrink)

We provide a new wrinkle to the Argument from Unfair Advantage, a rather popular one in the ethics of doping in sports discussions. But we add a new argument that we believe places the moral burden on those who favor doping in sports. We also defend our position against some important concerns that might be raised against it. In the end, we argue that for the time being, doping in sports ought to be banned until it can be demonstrated that (...) our concerns can be satisfied. (shrink)

This article reviews careproviders’ most difficult emotional challenges during disasters and provides approaches for responding optimally to them. It describes key approaches that careproviders may pursue to best help patients and others during a catastrophe. It raises unanswered questions regarding when, if ever, careproviders should provide active euthanasia to patients who are incompetent, and when, if ever, careproviders should give their own food and water to patients or others who may otherwise soon die without them.