Two experiments employed experience sampling to examine the factors associated with a prospective and retrospective focus during mind wandering. Experiment One explored the contribution of working memory and indicated that participants generally prospect when the task does not require continuous monitoring. Experiment Two demonstrated that in the context of reading, interest in what was read suppressed both past and future-related task-unrelated-thought. Moreover, in disinterested individuals the temporal focus during mind wandering depended on the amount of experience with the topic matter—less (...) experienced individuals tended to prospect, while more experienced individuals tended to retrospect. Together these results suggest that during mind wandering participants’ are inclined to prospect as long as the task does not require their undivided attention and raise the intriguing possibility that autobiographical associations with the current task environment have the potential to cue the disinterested mind. (shrink)

The Logic of Human Personality shows how the ancient definition of person remains useful today, and explains how it happened to fall into disuse. The method of using the categories of Aristotle is illustrated by showing how action, relation, and time as well as the fundamental category of substance, can help us understand what it is to be a person. The Logic of Human Personality agrues, against Mill and others who have found Aristotle's categories unsatisfactory, that in fact they are (...) useful for much psychological and anthropological research today, particularly in the intercultural field. (shrink)

ABSTRACT In this article the Irish harp tradition is re-configured as a space consisting of visual and sonic dimensions. The visual dimension of the Irish harp space incorporates the employment of the instrument in contemporary iconography; the sonic dimension includes the employment of the instrument as a metaphor in contemporary literature and songs. By employing Bloch’s concept of surplus and tracing the path of the Irish harp from its earliest employment in Christian iconography, its prominence as an icon of colonial (...) and Ascendancy rule, and finally its utilisation as an utopian tool to inspire members of the Volunteer and United Irish movements in the late eighteenth century, I identify how the accumulation of centuries of utopian surplus resulted in the creation of an utopian icon that had the capacity to inspire a generation of Irish men and women to critique the prevailing social and political order in the eighteenth century. (shrink)

The dire implications of navigating the overwhelming whiteness of the education system for Black women is foregrounded by the author’s autoethnography about her educational journey and experiences. Within it, the author illustrates the key role of her Black identity - despite being immersed in whiteness– to provide a strong sense of self, pride and resilience, which ultimately leads to her survival in the unequal spaces of the education system. By way of her own educational experiences, the author shares how she (...) becomes motivated to embark upon a PhD as a way to centre and affirm Black identities and in order to make palatable spaces within the hostility of whiteness. Drawing on her PhD research, which is framed by Black feminist epistemology, Critical Race Theory and Bourdieu’s theory of practice, her findings, based on the semi-structured interviewing of 25 other Black British women graduates, illustrates that the participants share similar educational experiences and responses. The paper concludes by asserting that the attainment of Black girls and young women often does not reflect their strong commitment to education- which evidences one consequence of journeying into the ‘heart of whiteness'. Therefore, the author argues for the necessity of more research and support for this diverse group. (shrink)

Mentoring relationships occur across a range of nursing contexts and are shown to have multiple, favourable personal and professional outcomes. Specifically, mentoring has been associated with the development of nurse leaders. This study describes features that are integral to initiating mentoring relationships that focus on nursing leader development. These significant features are addressed in relation to the nursing literature. Thirteen nurse leaders from eastern states of Australia were interviewed during 2005 and 2006 about their understanding and experiences of mentoring for (...) leadership. Their narratives were analysed using a hermeneutic phenomenological methodology. Mentoring relationships for nurse leadership were revealed as developing from esteemed connections between two people. Mentors were shown to unconditionally champion their mentee’s careers, and mentees were shown to possess a leadership vision for nursing. The findings of this study have implications for establishing mentoring relationships for nurse leader development. Consideration should be given to the specific focus and context of these relationships to ensure that the full potential of the mentoring process is realised. It is also important to better understand the key aspects that contribute to the phases of mentoring relationships for nurse leader development because they are shown to influence the dynamic and function of these relationships over time. (shrink)

Research using explicit measures has linked decreased positive future thinking, but not increased negative future thinking, with clinical depression. However, individuals may be unable or unwilling to express thoughts about the future, and can be unaware of implicit beliefs that can influence their behavior. Implicit measures of cognition may shed light on the role of future thinking in depression. To our knowledge, the current study presents the first implicit measure of positive and negative future thinking. A sample of 71 volunteers (...) completed both implicit and explicit measures of positive and negative future thinking. The findings indicate differences in the evaluation of both positive and negative future events between the two groups. However, group differences were more pronounced on the implicit measure. These findings point to the potential utility of an implicit measure of future thinking in mental health research and clinical practice. (shrink)

The Republic of Ireland has some of the most restrictive abortion legislation in the world which grants to the ‘unborn’ an equal right to life to that of the pregnant woman. This article outlines recent developments in the public discourse on abortion in Ireland and explains the particular cultural and religious context that informs the ethical case for access to abortion services. Our perspective rests on respect for two very familiar moral principles – autonomy and justice – which are at (...) the centre of social and democratic societies around the world. This article explains the context for the deployment of these concepts in order to support the claim that the current legislation and its operationalisation in clinical practice poses serious risks to the health, lives and well-being of pregnant women, tramples on their autonomy rights and requires of them a self-sacrifice that is unreasonable and unjust. (shrink)

Mentorship, often viewed as a central capacity of leadership, is acknowledged as influential in growing nurse leaders. Mentoring relationships are perceived as empowering connections offering a dynamic guided experience to promote growth and development in personal and professional life. A hermeneutic phenomenological approach informed by Heidegger and Gadamer was used to explore understandings and experiences of mentorship for nurse leadership by 13 Australian nurse leaders. We found that learning and transformation associated with becoming a nurse leader mentor was experienced as (...) an enduring evolutionary process. Participants' life journeys provided experiences that developed their understandings and established their personal identity as a leader and mentor. We considered the journey motif in terms of its inextricable connection with lived time and used Heidegger's ecstasies of temporality as a lens to understand how the temporal dimensions of past, present and future influenced and shaped the development of nurse leader mentors. We found that our temporal existence influences interpretation of ourselves and the world. Individuals can benefit from multiple separate mentoring interludes, with different mentors, over a lifetime. For some nurses, becoming a leader and mentor is a lifelong transformative process that grows from diverse experience and influential role modelling rather than formal instruction. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Dispelling the Myth of the Non-Singer:Embracing Two Aesthetics for SingingLouise M. PascaleI entered the Music Workshop course with trepidation. Of all the courses in my Master's program, I feared this one the most. My experiences with music have always been negative ones. As I entered the classroom, memories surfaced of the time I was told to mouth the words so I would not throw the rest of the class (...) off key and when I was laughed off the stage after a friend and I attempted a rendition of "Rolling O'er the Billows." After that, I was convinced I should not sing.1Maxine Greene reminds us how easy it is to get caught in the "main text of life," one that is "negotiated mostly by convention, routine, habit, duty and one we have very little choice in."2 Our long-held acceptance of the "singer" and "non-singer" provides a perfect example of Greene's metaphor. The traditional meaning of "singing" is created out of convention and habit, perpetuated by the "main text" (white, middle class) values of American society.Singing, as it is understood in today's educational settings, settled into its role in American music education as a result of a number of significant decisions made as early as the 1600s by prominent leaders of the church.3 Each of these decisions added to the growth and strength of the view of singing that became [End Page 165] what I refer to as a "taproot"4 in music education. This taproot continued to settle comfortably into the groundwork of music education and has had major and long-lasting effects on how we generally perceive and experience singing.The Western perspective of singing is wedded to a multitude of assumptions and beliefs and, over a period of time, has taken on complex meaning. It is associated with subtle nuances, such as valuing the high, lilting soprano voice over the alto. It is connected to various philosophies and strongly held convictions, such as improving vocal performance through the mastery of musical literacy, and even exclusionary practices, such as selecting out the "better singers" and suggesting that others refrain from singing at all.Perhaps the most profound consequence of this entrenched taproot is that it has left American society with a very limited perception of "singing." This singular, well-supported root, albeit strong, impenetrable, and closely connected with a number of cultural and societal assumptions, effectively narrows the scope of our perceptions, our language, our philosophy, and our teaching practices in the domain of singing in education. Illustration of the powerful ways music relates to and directly expresses the social attitudes and cognitive processes of a culture are found in the work of John Blacking and John Miller Chernoff.5 Their work provides an opportunity to reflect on the cultural and societal influences of the "taproot" philosophy of music education and the ways these have created limitations on who expresses themselves musically, why, how, and for whom.One of the most critical of those limitations is that we have classroom teachers who rarely, if ever, sing with their students. The gap between those in education who sing and offer musical activities to their students and those who do not is greater than ever. The "non-singer" mentality persists in educational communities and is not being addressed in music education circles. Singing continues to be considered, by most educators, to be a complicated skill that must be learned and requires training in breathing, vocal technique, and diction, and a basic knowledge of note reading.Many have strong feelings about singing; it is not a neutral subject. When the topic of singing is brought up, some involved in the conversation are likely to personalize it and be eager to share stories about their singing ability and to express their opinions about whether or not they qualify as a "singer." Sometimes the reactions can be extreme. Some people shy completely away from singing, to the point of running from the room at the mere suggestion that they might be asked to participate in singing in public. Others have an opposite reaction and experience singing as an enjoyable activity... (shrink)

From Harry and Louise through the McCaughey septuplets, this book explains stories and issues in health care ethics that have appeared in the news media.

The year 2018 was the 40th anniversary of the birth of Louise Joy Brown, marking four decades of clinical in vitro fertilization and embryo transfer. Though this milestone, reached first by Steptoe and Edwards in the United Kingdom, is well acknowledged through Nobel accolade, the achievement was not entirely celebrated at the time. Global contention was not just moral, but political and legislative. In the United States, the achievement led in 1978 to the freezing of federal funds by the (...) National Institute of Health for research on human embryos and oocytes.A report published on May 4, 1979, by the Ethics Advisory Board of the Department of Health... (shrink)

Louise Weiss (1893 – 1983) percorre, em múltiplas viagens, o Ocidente europeu, a América, as longínquas paragens do Oriente, o continente africano. A sua obra, em particular as Mémoires d’une Européenne, revela-se um testemunho eloquente de sua força anímica e do olhar atento e crítico das décadas vividas no século XX. É no espaço e no tempo das suas múltiplas viagens que Weiss diagnostica e espelha a relação de Alteridade Ocidente / Oriente, entre a Europa e o Outro. A (...) vida e a acção militante no curso de sua longa vida centrou-se em três pólos nucleares: combate pela paz, combate pelo voto feminino e combate pela construção da Europa.É nesta luta incessante que Louise Weiss – a Europeia cumpria o lema que a norteava – partic­ipar na aventura do seu século. (shrink)

Feminist Theory: A Philosophical Anthology addresses seven philosophically significant questions regarding feminism, its central concepts of sex and gender, and the project of centering women’s experience. Topics include the nature of sexist oppression, the sex/gender distinction, how gender-based norms influence conceptions of rationality, knowledge, and scientific objectivity, feminist ethics, feminst perspectives on self and autonomy, whether there exist distinct feminine moral perspectives, and what would comprise true liberation. Features an introductory overview illustrating the development of feminism as a philosophical movement (...) Contains both classic and contemporary sources of feminist thought, including selections by Mary Wollstonecraft, John Stuart Mill, Simone de Beauvior, Kate Millett, bell hooks, Marilyn Frye, Martha Nussbaum, Louise Antony, Sally Haslanger, Helen Longino, Marilyn Friedman, Catharine MacKinnon, and Drucilla Cornell. (shrink)

This book addresses the relative absence of the voices and ideas of African women in philosophy. Most of the authors (who are mostly African men) bemoan the fact that many voices are missing. Each contributes what they can to highlight the importance of the gap or to address the gap. The co-editors suggest that from its start, African philosophy intended to be egalitarian, emancipatory, and revolutionary, and so the current marginalization of African women should be a prominent concern. The review (...) addresses the chapter's themes in three broad categories. In the first category are five of the women contributors and two of the men, who all write with a focus on the overlooked contributions of African women. Their goal is to encourage appreciation for the contributions already made by women scholars, or to emphasize women's prominent role in society. A second category includes all men, and in these five articles the issue of women's marginalization in African philosophy departments is the central topic. The men bemoan the lack of participation of more women in the field and they speculate as to the cause of their absence. A third, smaller category includes two articles that address current specific situations of women's suffering in Africa, that is, widowhood and rape victims. The book holds out hope that if changes take place, women will feel more comfortable and appreciated in the profession of philosophy. (shrink)

O Parmênides de Platão é um diálogo notoriamente desafiador. Para apresentar uma interpretação completamente satisfatória dele, cada argumento precisa ser reconstruído em seus próprios termos e se todas as reconstruções forem acuradas, as interconexões lógicas entre os argumentos de ambas as partes do diálogo devem revelar a mensagem geral do Parmênides. Aqui gostaria de resumir minha interpretação e considerar algumas importantes objeções e alternativas a ela, particularmente como estas aparecem nos trabalhos de Constance Meinwald e Mary Louise Gill. Quero (...) explicar por que a interpretação de Meinwald é significativamente menos convincente do que a minha e, como Gill e eu chegamos a conclusões semelhantes, quero destacar as diferenças importantes entre nossas interpretações. (shrink)

I love books for many things, but I despise them for introducing a physical limit to the free circulation of knowledge (compared to the Internet). At least, that's what I had always thought. continent. is an online journal aiming at, among other things, breaking with the established paradigms of how academic work has to be published in order to be respected among relevant peers. I'm the engineer behind the current version of continent. , making it work and keeping it running (...) since began in 2010. We provide an online platform for knowledge to circulate, beyond the limitations of institutional attachment or distribution of physical volumes. And regardless of not having a physical publication ourselves, and being a trans-national endeavour with core members spread across three continents, we had the honour to join the Publish Or Be Damned fair and conference of Northern European independent book publishers at Index Art Foundation in Stockholm, Sweden. The place was bursting with exceptional volumes made by some of the most interesting publishers in the European north. The encounter changed the way I think about such books: these editions are designed, engineered and crafted to a level of sophistication that they begin to hold more than just their informational value printed. They convey and communicate a form of tactile knowledge and pleasure, and this completely changed my perspective on the matter. Because continent. had not materialised yet and only appeared in the form of social events (such as those in Basel, Boston, New York, or Zürich), we could not offer any such tactile pleasures to those visiting our booth. Given this, my solution was to turn continent. 's participation into a spectacle of simulation. With so many important figures of the independent publishing world present, we staged a series of imaginary book-launch moments for the camera. Presenting a first quasi-materialisation of continent. in the form of a book, or rather, the hypothetical extrapolation of our red square shape from our logo into a red 30x30 cm slate. Thanks to all those that participated. Your presences allowed continent. to visualise what it would be like if we had a book, and had been published within the honorable circle of these fine publishers. Soon the day will come where this will become reality. Thanks to all who joined the fun and didn't mind me showing these to the rest of the world. I'll publish them here, for them not to perish, even if I shall be damned. Ida Marie Hede Bertelsen ( Pork Salad Press ) Abdul Dube ( sideprojects ) René Sørensen ( sideprojects ) Anders ( OEI Editör ) Brett Bloom ( Half Letter Press ) Anni Puolakkaby ( OK Do ) Kit Hammonds, Kate Phillimore, Louise O'Hare ( Publish and Be Damned ) Ingvar Högni ( Útúrdúr ) Fredrik Ehlin, Andjeas Ejksson, Oscar Mangione ( Geist Magazine ) Klara Källström, Thobias Fäldt ( B-B-B Books ) Laura Hatfield ( Witnas editors ) Chris Johnsen ( WITNAS editors ) Matthew Rana ( Witnas editors ) Ola Ståhl & Carl Lindh ( In Edit Mode Press ) Staffan Lundgren ( Axl Books ) Tuuka Kaila ( NAPA Books ) Vebjørn Guttormsgaard Møllberg + Ingrid Forlang ( Kuk et Parfyme ) Diana Baldon, Joanna Nowotny and Egle Kulbokaite ( Index Foundation ). (shrink)

Louise Chardon écrit à l'automne 1901 son autobiographie ; elle a 25 ans mais Louise n'est pas une demoiselle : elle a quitté l'école à onze ans pour entrer comme apprentie chez une échantillonneuse ; abusée sexuellement par un parent de son employeuse, placée dans diverses maison de refuge prostestantes, Louise a sombré dans la marginalité ; arrêtée plusieurs fois pour vagabondage, elle est recueillie par son oncle et sa femme, M. et Mme Joly, à Saint-Etienne ; (...) mais devenue l'amante de son o... (shrink)

This volume marks a phase of accomplishment in the work of the World Phenomenology Institute in unfolding a dialogue between Occidental phenomenology and the Oriental/Chinese classic philosophy. Going beyond the stage of reception, the Oriental scholars show in this collection of studies their perspicacity and philosophical skills in comparing the concepts, ideas, the vision of classic phenomenology and Chinese philosophy toward uncovering their common intuitions. This in-depth probing aims at reviving Occidental thinking, reaching to its intuitive sources, as well as (...) providing Chinese thinking with a precise apparatus of expression toward its rejuvenation in a new significance. Studies by Korean and Chinese phenomenologists: Nam-In Lee, Inhui Park, Benjamin I. Schwartz, Anna-Teresa Tymieniecka, Sitansu Ray, Zhang Xian, Zhang Qingxiong, Tsung-I Dow, Ashok K. Gangadean, Yushiro Takei, Louise Sunderarajan, Gregory Tropea, James Sellmann, Tyong Bok Rhie, Sang-Ki Kim, Daniel Zelinski, Qingjie Wang, Calvin O. Schrag, Jung-Sun Han. (shrink)

This article examines the nature and structure of witness and defendant narrative accounts in the evidential portions of courtroom trials, using the O.J. Simpson, Oklahoma Bombers and Louise Woodward trials as a database. The article proposes a means of distinguishing narrative from non-narrative accounts, using Labov's definition of the `minimal narrative' as a starting point, and puts forward a modified model of narrative structure. A range of narrative structures are explored, and the model is used to analyse a series (...) of representative example narratives taken from the trial data. Different types of narrative fragmentation produced by multiple tellers of the same narrative are also examined, along with the frequent disjunction between `tellers' and `knowers'. Lastly, the article explores the relationship between narrative structures and narrative fragmentation and the discourse strategies used by lawyers in direct and cross-examination. (shrink)

Deliberative democracy entails a commitment to deciding political questions on their merits. To that end, people engage in an exchange of reasons in a shared endeavour to arrive at the right answer or the best judgement they can make in the circumstances. Of course, in practice a shared judgement may be impossible to reach. Yet while compromise may seem a natural way of dealing with the disagreement that deliberation leaves unresolved – for example, some deliberative theorists argue that a willingness (...) to compromise manifests respect for the considered views of others, even as we continue to disagree with them – the relationship between deliberation and compromise is not as straightforward as one might think. To explain why, this paper contrasts conflicts of judgement with conflicts of preference, interest and value to show why greater attention needs to be paid to the character of the decision to be made. (shrink)

Arguing About Human Nature covers recent debates--arising from biology, philosophy, psychology, and physical anthropology--that together systematically examine what it means to be human. Thirty-five essays--several of them appearing here for the first time in print--were carefully selected to offer competing perspectives on 12 different topics related to human nature. The context and main threads of the debates are highlighted and explained by the editors in a short, clear introduction to each of the 12 topics. Authors include Louise Anthony, Patrick (...) Bateson, David Buller, John Dupre, Paul Griffiths, Sally Haslanger, Richard Lewontin, Ron Mallon, and E.O. Wilson. Contributors Rachel Cooper, Nancy Holmstrom, Kim Sterelny, and Elizabeth Cashdan provide brand new chapters in these debates. Suggested Reading lists offer curious readers new resources for exploring these debates further. A rguing About Human Nature is the first volume of its kind, designed to introduce to an interdisciplinary student audience some of the most important arguments on the subject generated by scientific research and philosophical reflection. (shrink)

What is Japanese philosophy? This paper will address this question, not by giving a survey of the works of Japanese philosophers or a definition of the subject matter of Japanese philosophy, but by attempting to present how it emerged as a distinct philosophical tradition—by sketching the controversies that gave rise to its formation; the social, intellectual, and historical factors that paved the way to its development; and the revolution of thought which finally gave it the title “Japanese philosophy.” I will (...) argue that Japanese philosophy was born not because Japanese thinkers desperately wanted a philosophy that they could call their own, but because, first and foremost, they were thinking of ways to articulate the ever changing and paradoxical nature of reality. Formed by their religion and informed by the Chinese and Japanese classics, they used the language learned from the West and tried to answer the most fundamental questions of existence. A unique way of philosophizing thus emerged and became a true locus of dialogue between Eastern and Western thought.An Inquiry into the Historical Development of Philosophy in Japan. (shrink)

This article suggests that there is a relationship between successfully maintaining integrity in nursing and the practical provision of opportunities for shared reflection offered by good clinical supervision. In order to establish this case, I will first give some definitions and then proceed to consider how these ideas relate conceptually. The article makes no attempt to offer empirical research as confirmation, but provides a conceptual and moral argument making use of anecdotes for puposes of clarification and illumination. It is the (...) author’s belief that, if it is understood and implemented properly, clinical supervision offers a radical challenge to nursing’s existing culture. If nurses are interested in the survival of the profession, it is perhaps a challenge that has to be addressed. (shrink)

If the discourse of manners and customs aspires to a stable fixing of subjects and systems of differences, however, its project is not and never can be complete. This is true if only for the seemingly trivial reason that manners-and-customs descriptions seldom occur on their own as discrete texts. They usually appear embedded in or appended to a superordinate genre, whether a narrative, as in travel books and much ethnography, or an assemblage, as in anthologies and magazines.6 In the case (...) of travel writing, which is the main focus of this essay, manners-and-customs description is always in play with other sorts of representation that also bespeak difference and position subjects in their own ways. Sometimes these other positioning complement the ideological project of normalizing description, and sometime they do not.In what follows, I propose to examine this interplay of discourses in some nineteenth-century travel writing chiefly about Africa. While Barrow’s work is not prominent on anybody’s mental bookshelves these days, readers will recognize such names as David Livingstone, John Speke, James Grant, Richard Burton, Mungo Park, or Paul Du Chaillu. During the co-called opening up of central and southern Africa to European capitalism in the first half of the nineteenth century, such explorer-writers were the principal producers of Africa for European imaginations—producers, that is, of ideology in connection with the European expansionist project there. What I hope to underscore in these writings is not their tendency towards single, fixed subject positions or single, fixed systems of difference. Rather, I wish to emphasize the multiplicity of ways of codifying the Other, the variety of fixed positions and the variety of given sets of differences that they posit. European penetration and appropriation is semanticized in numerous ways that can be quite distinct, even mutually contradictory. In the course of examining discursive polyphony in these travel writings, I hope to stress the need to consider ideology not only in terms of reductive simplification but also in terms of the proliferation of meanings. 6. Ethnographies would seem to be a counterexample to this claim, but in fact one can fairly easily show that ethnographic writing is inextricably tied to personal narrative. Indeed this tie is a symptom of a serious contradiction between ethnographic methods and ethnographic discourse. See my “Fieldwork in Common Places,” in Writing Culture: The Poetics and Politics of Ethnography, ed. James Clifford and George Marcus . Mary Louise Pratt is an associate professor in the Department of Spanish and Portuguese and the Program in Comparative Literature at Stanford University. She is author of Toward a Speech-Act Theory of Literary Discourse and is a member of the editorial boards of Poetics, Signs Tabloid, and Cultural Anthropology. (shrink)

ABSTRACT In this commentary I evaluate what McGowan’s project would conclude with respect to the treatment of professional Australian Football League player Adam Goodes, who was incessantly ‘booed’ by crowds for the final two years of his career. Analysing Goodes’ case in light of McGowan’s argument leads me to two observations. First, McGowan’s norm-enactment approach is incredibly useful because it explains how words like ‘boo’ (with unstable meaning) can constitute actionable discrimination. Second, however, I wonder if a narrow focus on (...) whether such speech is legally actionable might encourage an overestimation of the power of laws to shepherd new g-norms into social practices. (shrink)

This research project investigated manifestations of critical thinking in pupils 10 to 12 years of age during their group discussions held in the context of Philosophy for Children Adapted to Mathematics. The objective of the research project was to examine, through the pupils' discussions, the development of dialogical critical thinking processes. The research was conducted during an entire school year. The research method was based on the Grounded Theory approach; the material used consisted of transcripts of verbal exchanges among the (...) pupils. Analysis of the transcripts revealed that: critical thinking appears to the extent that a 'dia-logue' is established among pupils; on the cognitive level, dialogical critical thinking is comprised of four thinking modes: logical, creative, responsible and meta-cognitive; and on the epistemological level, dialogical critical thinking is only manifested in a context where egocentricity of perspective and relativism of beliefs are transcended. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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