In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate (who may or may not hold the power of attorney ), and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The evermore common (...) aversion of best interest judgments entails a risk that health care providers withdraw from the decision-making process, abandoning patients (or their family members) to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit. (shrink)

abstract Many people assume that invasive research on animals is justified because of its supposed benefits and because of the supposed mental inferiority of animals. However probably most people would be unwilling to sign a living will which consigns themselves to live biomed‐ical experimentation if they ever, through misfortune, end up with a mental capacity equivalent to a laboratory animal. The benefits would be greater by far for medical science if living will signatories were to be (...) used, and also the mental superiority boast would no longer apply. Ultimately, it is argued that invasive biomedical experiments would be unacceptable in a democratic society whose members are philosophically self‐consistent. (shrink)

Volume 20, Issue 8, August 2020, Page 85-87.

Significant criticisms have been raised regarding the ethical and psychological basis of living wills. Various solutions to address these criticisms have been advanced, such as the use of surrogate decision makers alone or data science‐driven algorithms. These proposals share a fundamental weakness: they focus on resolving the problems of living wills, and, in the process, lose sight of the underlying ethical principle of advance care planning, autonomy. By suggesting that the same sweeping solutions, without opportunities for choice, be (...) applied to all, individual patients are treated as population‐level groups—as a theoretical patient who represents a population, not the specific patient crafting his or her individualized future care plans. Instead, advance care planning can be improved through a multimodal approach that both mitigates cognitive biases and allows for customization of the decision‐making process by allowing for the incorporation of a variety of methods of advance care planning. (shrink)

The world population aged significantly over the twentieth century, leading to an increase in the number of individuals presenting progressive, incapacitating, incurable chronic-degenerative diseases. Advances in medicine to prolong life prompted the establishment of instruments to ensure their self-determination, namely the living will, which allows for an informed person to refuse a type of treatment considered unacceptable according to their set of values. From the knowledge on the progression of Alzheimer disease, it is possible to plan the medical (...) care, even though there is still no treatment available. Irreversible cognitive incapacity underlines the unrelenting loss of autonomy of the demented individual. Such a loss requires the provision of specific and permanent care. Major ethical issues are at stake in the physician–patient–family relationship, even when dementia is still at an early stage. The authors suggest that for an adequate health care planning in Alzheimer disease the living will can be presented to the patient in the early days of their geriatric care, as soon as the clinical, metabolic or even genetic diagnosis is accomplished. They also suggest that the appointment of a health care proxy should be done when the person is still in full enjoyment of his cognitive ability, and that the existence and scope of advance directives should be conveyed to any patient in the early stages of the disease. It follows that ethical guidelines should exist so that neurologists as well as other physicians that deal with these patients should discuss these issues as soon as possible after a diagnosis is reached. (shrink)

Following the first enactment of living will legislation in California in 1976 the majority of the states of the USA have now passed similar laws. However, flaws have been identified in the way they work in practice and many states are considering reviewing their legislation. In Britain there is no legislation but the subject is currently commanding considerable interest. This paper assesses the future prospects for living wills in both the USA and Britain, analysing the different options (...) available and comparing the two countries. If patients who become permanently incompetent are to have their previous autonomous decision-making respected, there is general agreement that advance directives for health care must be introduced. The difficulty is in deciding how to implement them, and especially whether this should be by statutory or non-statutory means, the traditions in the two countries being very different in this respect. It is concluded that whichever route is taken, promoting respect for patient autonomy is as much a matter for education and persuasion of doctors as of the adoption of particular instruments. Doctors should therefore be trained in what constitutes good medical practice in this area and, to ensure that it can be carried out properly, the general level of medical facilities for these patients must also be protected and promoted. (shrink)

Advance directives such as living wills are attractive in that they give us a sense of control over our futures. But they also tend to obscure conflicts between a patient's competent wishes and later, incompetent interests. They allow caregivers to avoid evaluating quality of life in assessing the best interests of incompetent patients.

Pulitzer Prize-winning author Will Durant chronicles the lives and ideas of key philosophers throughout history in this informative yet eminently readable text. Beginning with Socrates and Plato and concluding with Friedrich Nietzsche, Durant builds a history of philosophy by showing how each thinker's ideas informed and influenced the next generation.

In the final pages of On What Matters, Volume II, Derek Parfit comments: ‘We live during the hinge of history... If we act wisely in the next few centuries, humanity will survive its most dangerous and decisive period... What now matters most is that we avoid ending human history.’ This passage echoes Parfit's comment, in Reasons and Persons, that ‘the next few centuries will be the most important in human history’. -/- But is the claim that we live (...) at the hinge of history true? The argument of this paper is that it is not. The paper first suggests a way of making the hinge of history claim precise and action-relevant in the context of the question of whether altruists should try to do good now, or invest their resources in order to have more of an impact later on. Given this understanding, there are two worldviews - the Time of Perils and Value Lock-in views - on which we are indeed living during, or about to enter, the hinge of history. -/- This paper then presents two arguments against the hinge of history claim: first, that it is a priori extremely unlikely to be true, and that the evidence in its favour is not strong enough to overcome this a priori unlikelihood; second, an inductive argument that our ability to influence events has been increasing over time, and we should expect that trend to continue into the future. The paper concludes by considering two additional arguments in favour of the claim, and suggests that though they have some merit, they are not sufficient for us to think that the present time is the most important time in the history of civilisation. GPI Working Paper No. 12-2020. (shrink)

In pursuit of the dream that patients' exercise of autonomy could extend beyond their span of competence, living wills have passed from controversy to conventional wisdom, to widely promoted policy. But the policy has not produced results, and should be abandoned.

A culture in crisis -- The rise of the living will -- Empirical and ethical problems with living wills -- Living wills don't make decisions : human beings do -- The barbaric life of the ICU -- Life after the ICU -- Reform : the current state of the art -- Healing the intensive care unit.

What I wish to do in this paper is to look at a part of John Stuart Mill's ‘one very simple principle’ for determining the limits of state intervention. This principle is, you will remember, that ‘the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.’.

Caring for unrepresented patients encompasses legal, ethical, and moral challenges regarding decision-making, consent, the patient’s values, wishes, best interest, and the healthcare team’s professional integrity and autonomy. In this article, I consider the impact of the aging population and the effects of the social determinants of health and suggest that without preventive intervention, the number of unrepresented patients will continue to increase. The health, social, and legal risk factors for becoming unrepresented require a multidisciplinary response. Medical-Legal Partnerships (MLPs) bring (...) healthcare and legal professionals together to address risk factors and health-harming legal needs. The article discusses the role of MLPs in identifying at-risk individuals, providing preventive interventions, and providing support. I make recommendations and conclude that proactive MLPs offer a sustainable approach to the ethical challenges in caring for unrepresented patients by providing interventions to prevent individuals from becoming unrepresented. (shrink)

Examines the history of speculative thought by focusing on such dominant personalities as Plato, Bacon, Spinoza, Kant, Schopenhauer, and Nietzsche.

For centuries, Augustine of Hippo's writings have moved and fascinated readers. With the fresh, keen eye of a writer whose own intellectual analysis has won him a Pulitzer Prize, Garry Wills examines this famed fourth-century bishop and seminal thinker whose grounding in classical philosophy informed his influential interpretation of the Christian doctrines of mind and body, wisdom and God.Saint Augustine explores both the great ruminator on the human condition and the everyday man who set pen to parchment. It challenges many (...) misconceptions - among them those regarding his early sexual excesses. Here, for students, Christians, and voyagers into the new millennium, is a lively and incisive portrait of one who helped to shape our thought. (shrink)

Historically, the sociology of emotion has been relatively long on theory and short on methods. This collection of articles seeks to remedy this by introducing new ways to capture the four factors of emotion, as articulated by Thoits (1989): meaning, expression, label, and physiology. As a group, these studies reify existing dichotomies in the literature—that is, emotional experience versus emotional expression—and seek to reconcile them. Additionally, they all champion the use of mixed methods—either simultaneously or sequentially—adopting some combination of direct (...) or indirect observation, subjective understanding/experience, and physiological change. Using examples drawn for their own research, the authors provide new ways to capture emotion that will carry emotion scholars into the next four decades of research. (shrink)

A concise survey of the culture and civilization of mankind, The Lessons of History is the result of a lifetime of research from Pulitzer Prize–winning historians Will and Ariel Durant. With their accessible compendium of philosophy and social progress, the Durants take us on a journey through history, exploring the possibilities and limitations of humanity over time. Juxtaposing the great lives, ideas, and accomplishments with cycles of war and conquest, the Durants reveal the towering themes of history and give (...) meaning to our own. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Hegel’s Theory of Self-Conscious Life by Guido SeddoneWill DesmondSEDDONE, Guido. Hegel’s Theory of Self-Conscious Life. Leiden: Brill, 2023. 155 pp. Cloth, $138.00Guido Seddone’s monograph explores an ensemble of issues centering on what he terms Hegelian “naturalism.” He argues that “Hegel’s philosophy represents a novel version of naturalism since it stresses the mutual dependence between nature and spirit, rather than just conceiving of spirit as a substance emerging and (...) separating from bodily natural requisites.” Seddone avoids scholarly exegeses to address instead “theoretical and systematic aspects of the Hegelian philosophy.” He focusses on “life” and “self-consciousness” as the conceptual keys to those parts of Hegel that remain compelling for relevant contemporary debates. “This book is, therefore, based on the dialogue between Hegel [End Page 361] and contemporary thinkers and strives to enhance our understanding of theoretical and practical issues and to widen the grammar of the philosophical thought.” The book’s chapters proceed from the more abstract to the more concrete—essentially from issues of logic, epistemology, and psychology to morality, society, and history.Chapter 1 (“Science of Logic: The Logical Premises of Hegel’s Naturalism”) argues that the categories of “Teleology” and “Life” in Hegel’s Science of Logic mark the critical transition in his naturalism from the sciences of physics (“Mechanism”) and chemistry (“Chemism”) to biology, as well as from external nature to inner self-consciousness and cognition. Seddone helpfully points to Hegel’s revisions of Kant’s subordination of teleological language (merely heuristic) to mechanical explanation. Most promising is the comparison of the “self-referring negativity” of Hegelian “life” to discussions by Evan Thompson and Francisco Varela of the cell—whose permeable membrane enables it to be more than its merely chemical environment.Chapter 2 (“Self-Consciousness”) takes a rather bird’s-eye approach to the Phenomenology of Spirit, offering a basic reading of Hegelian self-consciousness and Geist in relation to the Cartesian cogito and Kantian unity of apperception. Scattered remarks about animal desire and the master–slave relation could be clarified to better explore a naturalistic basis of the Hegelian conception of mind. One is struck by the dearth of specific texts from the section “Self-Consciousness”: Seddone seems content with some well-known quotations (for example, Geist as an “I that is We and We that is I”) punctuating large generalizations.Chapter 3 does not quite live up to its title (“The Hegelian Theory about the (Human) Biological Organism”) in that it focuses primarily on Hegel’s “treatise about habits” in the Encyclopaedia of the Philosophical Sciences. Here habit is construed as a second nature, and hence a further step toward self-conscious, relational mind: Habits are “universal ways of the soul, i.e. ways in which individual soul [sic] incorporates feelings by evolving general rules and practices.”The last section of chapter 4 (“Extended and Embodied Mind”) reverts to habits as moments of the feeling soul but dissociates Hegel’s notion of Verleiblichung from contemporary discussions of embodied mind. By contrast, Seddone argues for retranslating Hegelian Geist as “common mind” and juxtaposes this with the related concept of mind (in, for example, Philip Pettit) as “extended” through social entities, with the result that Hegel’s approach is praised as “the state-of-the-art of this topic.”Chapter 5 (“Natural and Self-conscious Agency”) is perhaps the clearest chapter as it presents the dialectic of the abstractly universal will in the initial sections of Philosophy of Right, links this and the Hegelian conception of free agency to his logical category of “actuality,” and proceeds to an illuminating contrast of the Hobbesian and Hegelian visions of society and state. [End Page 362]In tackling attempts to reconcile “Normativity and Freedom,” chapter 6 spends over six pages rehearsing the basics of Kantian autonomy before turning to Hegel’s Phenomenology of Spirit, specifically the master–slave dialectic (again) as the critical moment in the evolution of social norms. “My thesis is that self-conscious life needs recognition in order to achieve the higher form of independence created by social acknowledgement and justification, what [sic] fosters the condition for an authoritative reason that can be socially... (shrink)

Context: A growing number of Japanese people have completed advance directives, especially living wills, even though there is no legislation recognising such documents and little empirical research on their impact on clinical care at the end of life in Japan.Objectives: To investigate physicians’ attitudes about living wills and their experiences with patients who had completed a living will and later died.Design: Self administered survey and qualitative study using open question and content analysis.Setting: Japan.Participants: Physicians known to (...) have cared for a patient who had presented a living will prior to death.Measurements: The physician’s response to receiving a living will, communication about the living will, the impact of the living will on clinical care, demographics, and their opinion on advance directives, especially living wills.Main results: Fifty five per cent of respondents approved of advance directives in general, and 34% had more opportunities to communicate with a patient and his/her family after receiving the living will. Sixty nine per cent of the physicians who received a living will did not, however, change their course of therapy as a consequence of receiving the living wills. Based on the analysis, we identified three areas of concern in the comments on living wills: concerns relative to patients, physicians, and families; social context, and clinical and administrative concerns. The physicians raised various topics for discussion; they tended to describe the issues from a clinical perspective.Conclusions: Our identified areas of concern should prove helpful in better understanding the clinical and ethical implications of living wills in Japan. (shrink)

Can interests survive dementia, permanent unconsciousness--even death? If not, what kills them off? Perhaps lack of attention (one could almost say "lack of interest"), if having the interest requires believing that you have it, caring about its object, and in some sense investing in that object. Thus, once you no longer care about the object, the investment--and the interest--is gone. If an interest disappears when you stop caring about its object, will it disappear when you are mentally incompetent and (...) unable to care about it? If so, then it seems such interests cannot survive the onset of incompetence (let alone death). -/- This issue arises with living wills and other ways to decide the medical care you will receive when you become mentally incapacitated and unable to decide for yourself. Such decisions are made to protect certain kinds of interest. For example, you may want to avoid expensive end-of-life care in order to protect your family's inheritance, thereby protecting your interest in your family's welfare. Or you might have a religious commitment to the sanctity of life, and therefore an interest in keeping your biological life going as long as possible, even when you are permanently unconscious. We use living wills and similar forms of advance medical decision making to protect our such interests when we anticipate being unable to protect those interests by acting autonomously at the time of treatment. If, however, those interests do not survive incompetence, then the moral authority of living wills is severely undermined, for the interests they are meant to protect do not exist. It will be argued that some interests can survive a permanent loss of mental capacity, for sometimes, as strange as it sounds, you can be disposed to care about a thing even when you will never be conscious again. (shrink)

Watching a dramatic musical television episode reminded me of my own meltdown and reconstruction during the collection of my dissertation research. This stir of memory led me to write down my story. Seeking meaning in the experience of the studio teacher in an early childhood school, I co-participated in events that led me through a dramatic and transformative experience that deepened my awareness and understanding of what it means to teach and learn in the wondrous space of the atelier, otherwise (...) called the early childhood studio. We engaged in the meaning making process of our studio endeavours through keeping field notes and a journal, informally interviewing and engaging in collaboration sessions with the studio teachers, and reviewing the dissertation manuscript for authenticity. Through active listening and engagement, I collided with predicament. I learnt that the only way to move through the crisis-point is to ‘keep on living’. In the end, I came to a new sense of how to live and work in an early childhood studio and I also came to understand that life eats entropy. My experience in the studio became about the beauty of courage, time, and deep listening, as examined through the experiences of fear of the new and of my reconstruction into something more. (shrink)

After falling from a roof, an older man lost neurological function below his face. In two days, the patient regained consciousness, but it was unclear whether he could communicate his preferences, whether due to injuries or difficulties with language. His family believed he could communicate with them, and that he was capable of making treatment decisions. The staff did not think to contact the hospital’s largely inactive ethics consultation service for assistance, and instead looked to the patient’s living (...) class='Hi'>will for guidance, even though the patient was not terminally ill, and his lack of capacity had not been determined. (shrink)

_A penetrating study of the images, symbols, pageants, and creative performances ambitious Elizabethans used to secure political power_ Shakespeare’s plays abound with kings and leaders who crave a public stage and seize every opportunity to make their lives a performance: Antony, Cleopatra, Richard III, Othello, and many others. Such self-dramatizing characters appear in the work of other playwrights of the era as well, Marlowe’s Edward II and Tamburlaine among them. But Elizabethan playwrights were not alone in realizing that a sense (...) of theater was essential to the exercise of power. Real rulers knew it, too, and none better than Queen Elizabeth. In this fascinating study of political stagecraft in the Elizabethan era, Garry Wills explores a period of vast cultural and political change during which the power of make-believe to make power real was not just a theory but an essential truth. Wills examines English culture as Catholic Christianity’s rituals were being overturned and a Protestant queen took the throne. New iconographies of power were necessary for the new Renaissance liturgy to displace the medieval church-state. The author illuminates the extensive imaginative constructions that went into Elizabeth’s reign and the explosion of great Tudor and Stuart drama that provided the imaginative power to support her long and successful rule. (shrink)

"Since at least 1980 Godard’s cinema has been explicitly looking for (its) music, as if for its outside. In Sauve qui peut (la vie) Paul Godard hears, and asks about it, coming through the hotel room wall, and it follows him down to the lobby, but remains “off,” like Marguerite Duras’s voice, in spite of his questions, until the final sequence. At that moment, at the end of the section entitled “Music,” the protagonist is at the same time struck by (...) a car and struck by the entrance of the music into the diegetic present of the film, as the camera pans past an orchestra playing on the sidewalk while Paul fades off under the quizzical gaze of his daughter. By 2004, with Notre musique , it would seem to have taken over the whole text, for the film was announced as being about the collaboration between Godard and German record label ECM. In the context of that film it is difficult to determine both what that music is and who we are, although this discussion will try to advance a hypothesis in that regard. In fact, my main contention will be that music in Godard’s films functions as something like the absent image ( s ), not those it has lost but rather its cinema to come, what remains to be discovered and live within it, the survival of it. Not a cinema that cannot be seen, rather the image that can perhaps only be heard; and not the romantic or psychedelic dream of a synaesthetic apotheosis either, rather the technological coincidence of sonimage that has also been the precise direction of Godard’s cinematic research for more than thirty years. For the argument I will be making here is inscribed within my own investigation of what I call “technological life,” the means by which, in “prosthetic” symbiosis, or “dorsal” umbrality, a form lives beyond the simplistic opposition of animate and inanimate, or against the reductive presuppositions of autokinetic ipseity...". (shrink)

Washington eludes us, even in the city named for him. Other leaders are accessible there—Lincoln brooding in square-toed rectitude at his monument, a Mathew Brady image frozen in white, throned yet approachable; Jefferson democratically exposed in John Pope’s aristocratic birdcage. Majestic, each, but graspable.Washington’s faceless monument tapers off from us however we come at it—visible everywhere, and perfect; but impersonal, uncompelling. Yet we should remember that this monument, unlike the other two, was launched by private efforts. When government energies were (...) stalled, in the 1830s, subscriptions kept the project alive. Even when Congress took over the project, stones were added by the citizenry, those memorial blocks one can study while descending the long inner stairway. The classical control of the exterior hides a varied and spontaneous interior—an image of the puzzle that faces us, the early popularity of someone lifted so high above the populace. The man we can hardly find was the icon our ancestors turned to most easily and often. We are distanced from him by their generosity, their willingness to see in him something more than human.The larger they made Washington, the less they left us to admire—until, in Horatio Greenough’s George Washington, he becomes invisible by sheer vastness. Greenough took for his model what the neoclassical period believed was the greatest statue ever created, by the greatest sculptor who ever lived—the Elean Zeus of Phidias. Since that chryselephantine wonder was no longer extant, artists had to rely on the description given by Pausanias in the Description of Greece, and on coins of Elis that celebrated the work. Here is what Pausanias had to say.The seated god is himself fashioned from gold and ivory; the garland on his head appears to be real olive shoots. In his right hand he holds a Victory, also of gold and ivory, offering a ribbon, a garland on her head. In the god’s left hand there is a scepter, encrusted with every kind of metal, and the bird on the tip is an eagle.1 1. Pausanias Description of Greece 5. 11. Garry Wills, a prize-winning author and journalist, is Henry R. Luce Professor of American Culture and Public Policy at Northwestern University. Among his many books are Nixon Agonistes , Inventing America , and The Kennedy Imprisonment . His forthcoming book, Cincinnatus: George Washington in the Englightenment, will appear in June 1984. His previous contribution to Critical Inquiry was “Critical Inquiry in Clausewitz”. (shrink)