In the three target articles, Ellen Fox et al. present data from their seminal study on ethics consultation in US general hospitals (Fox, Danis, et al. 2022, Fox and Duke 2022, Fox, Tarzian, et al....

In this paper we introduce narrative and hermeneutical perspectives to clinical ethics support services (CESS). We propose a threefold consideration of ‘theory’ and show how it is interwoven with ‘practice’ as we go along. First, we look at theory in its foundational role: in our case ‘narrative ethics’ and ‘philosophical hermeneutics’ provide a theoretical base for clinical ethics by focusing on human identities entangled in stories and on moral understanding as a dialogical process. Second, we consider the role of theoretical (...) notions in helping practitioners to understand their situation in clinical ethics practice, by using notions like ‘story’, ‘responsibility’, or ‘vulnerability’ to make explicit and explain their practical experience. Such theoretical notions help us to interpret clinical situations from an ethical perspective and to foster moral awareness of practitioners. And, thirdly, we examine how new theoretical concepts are developed by interpreting practice, using practice to form and improve our ethical theory. In this paper, we discuss this threefold use of theory in clinical ethics support services by reflecting on our own theoretical assumptions, methodological steps and practical experiences as ethicists, and by providing examples from our daily work. In doing so, we illustrate that theory and practice are interwoven, as theoretical understanding is dependent upon practical experience, and vice-versa. (shrink)

In today’s pluralistic society, clinical ethics consultation cannot count on a pre-given set of rules and principles to be applied to a specific situation, because such an approach would deny the existence of different and divergent backgrounds by imposing a dogmatic and transcultural morality. Clinical ethics support (CES) needs to overcome this lack of foundations and conjugate the respect for the difference at stake with the necessity to find shared and workable solutions for ethical issues encountered in clinical practice. We (...) argue that a pragmatist approach to CES, based on the philosophical theories of William James, John Dewey, and Charles Sanders Peirce, can help to achieve the goal of reaching practical solutions for moral problems in the context of today’s clinical environment, characterized by ethical pluralism. In this article, we outline a pragmatist theoretical framework for CES. Furthermore, we will show that moral case deliberation, making use of the dilemma method, can be regarded an example of a pragmatist approach to CES. (shrink)

Care Ethics ist eine ethische Theorie, Pflegeethik ein Disziplinbegriff. Aber gerade in der Disziplin der Pflegethik kann die Care Ethics ein wichtiges gedankliches Werkezeug darstellen. In der Care Ethics wird nicht der Prinzipienbezug in den Vordergrund gestellt, sondern das Anerkennen von Kontext, moralischer Verantwortung und Beziehungen. In diesem Denkparadigma spielt es für die Reflexion auch eine Rolle, wer man selbst ist, und mit welcher Perspektive man sich einer ethischen Problemsituation nähert.

Predictive genetic testing may confront those affected with difficult life situations that they have not experienced before. These life situations may be interpreted as ‘absurd’. In this paper we present a case study of a predictive test situation, showing the perspective of a woman going through the process of deciding for or against taking the test, and struggling with feelings of alienation. To interpret her experiences, we refer to the concept of absurdity, developed by the French Philosopher Albert Camus. Camus' (...) writings on absurdity appear to resonate with patients' stories when they talk about their body and experiences of illness. In this paper we draw on Camus' philosophical essay ‘The Myth of Sisyphus’, and compare the absurd experiences of Sisyphus with the interviewee's story. This comparison opens up a field of ethical reflection. We demonstrate that Camus' concept of absurdity offers a new and promising approach to understanding the fragility of patients' situations, especially in the field of predictive testing. We show that people affected might find new meaning through narratives that help them to reconstruct the absurd without totally overcoming it. In conclusion, we will draw out some normative consequences of our narrative approach. (shrink)

ABSTRACT The part played by time in ethics is often taken for granted, yet time is essential to moral decision making. This paper looks at time in ethical decisions about having a genetic test. We use a patient‐centred approach, combining empirical research methods with normative ethical analysis to investigate the patients' experience of time in (i) prenatal testing of a foetus for a genetic condition, (ii) predictive or diagnostic testing for breast and colon cancer, or (iii) testing for Huntington's disease (...) (HD). We found that participants often manipulated their experience of time, either using a stepwise process of microdecisions to extend it or, under the time pressure of pregnancy, changing their temporal ‘depth of field’. We discuss the implications of these strategies for normative concepts of moral agency, and for clinical ethics. (shrink)

The current process towards formalization within evaluation research, in particular the use of pre-set standards and the focus on predefined outcomes, implies a shift of ownership from the people who are actually involved in real clinical ethics support services in a specific context to external stakeholders who increasingly gain a say in what ‘good CESS’ should look like. The question is whether this does justice to the insights and needs of those who are directly involved in actual CESS practices, be (...) it as receivers or providers. We maintain that those actually involved in concrete CESS practices should also be involved in its evaluation, not only as respondents, but also in setting the agenda of the evaluation process and in articulating the criteria by which CESS is evaluated. Therefore, we propose a participatory approach to CESS evaluation. It focuses on the concrete contexts in which CESS takes place, reflective and dialogical learning processes, and how to be democratic and inclusive. In particular, this approach to CESS evaluation is akin to realist evaluation, dialogical evaluation, and responsive evaluation. An example of a participatory approach to evaluating CESS is presented and some critical issues concerning this approach are discussed. (shrink)

The moral status of the human embryo has gained much attention in debates over the acceptability, or otherwise, of human embryonic stem cell research. Far less attention has been paid to the suppliers of those embryos: people who have undergone IVF treatment to produce embryos to assist them to have a baby. It is sociologically and ethically important to understand their views and experiences of being asked to donate embryos for research if we are to fully understand the wider social (...) and regulatory aspects of hESC science. This paper reports on parallel studies investigating these issues in the UK and in Switzerland. The studies reveal the inextricable entangling of the social and moral status of embryos. Since donors participate in different discursive domains and contexts (public, clinic, family) that shape their perception of “what” an embryo is, their views of embryos embody conflicting ideas and ambivalences. (shrink)

Philosophical anthropologies that emphasise the role of the emotions can be used to expand existing notions of moral agency and learning in situations of great moral complexity. In this article we tell the story of one patient facing the tough decision of whether to be tested for Huntington’s disease or not. We then interpret her story from two different but compatible philosophical entry points: Aristotle’s conception of Greek tragedy and Karl Jaspers’ notion of Grenzsituationen (boundary situations). We continue by indicating (...) some ways in which these two positions may be used for reflecting upon different perspectives involved in clinical decision-making, those of patients, clinicians and bioethicists. We conclude that the ideas we introduce can be used as hermeneutic tools for situating learning and dialogue within a broader cultural field in which literature and art may also play important roles. (shrink)

Gerade im Gesundheitswesen ist die Frage nach (Gestaltungs-)Macht heikel. Aber wer anderen Gutes tun möchte, der muss wirksam tätig werden können. Dies beinhaltet immer auch soziale Gestaltungsmacht. Wie gehen Pflegende mit der ihnen übertragenen bzw. auferlegten Macht um? Wie viel Macht ist im Kontext von Medizin, Pflege und Gesundheitssorge nötig? Und wie nehmen die Patientinnen und Patienten sie wahr? *Oft fühlen sich Menschen, die unter einer akuten Krankheit leiden, ohnmächtig. Und so wirkt der Begriff der Macht, den wir oft genug (...) mit Herrschaft und Gewalt verbinden, in einem Bereich, in dem es um Fürsorge und Behandlung geht, merkwürdig fehl am Platz. Gleichwohl bringen Ressourcen wie Wissen und finanzielle Mittel automatisch die Frage nach Macht in der Fürsorge aufs Tapet. Das Buch fragt nach der moralischen Bedeutung von Gestaltungsmacht und sucht das prekäre Verhältnis von Macht und Fürsorge ethisch auszuloten. (shrink)

This paper is based on linked qualitative studies of the donation of human embryos to stem cell research carried out in the United Kingdom, Switzerland, and China. All three studies used semi-structured interview protocols to allow an in-depth examination of donors’ and non-donors’ rationales for their donation decisions, with the aim of gaining information on contextual and other factors that play a role in donor decisions and identifying how these relate to factors that are more usually included in evaluations made (...) by theoretical ethics. Our findings have implications for one factor that has previously been suggested as being of ethical concern: the role of gratitude. Our empirical work shows no evidence that interpersonal gratitude is an important factor, but it does support the existence of a solidarity-based desire to “give something back” to medical research. Thus, we use empirical data to expand and refine the conceptual basis of bioethically theorizing the IVF–stem cell interface. (shrink)

BackgroundThe need for an ethical debate about the use of coercion in intensive care units (ICU) may not be as obvious as in other areas of medicine, such as psychiatry. Coercive measures are often necessary to treat critically ill patients in the ICU. It is nevertheless important to keep these measures to a minimum in order to respect the dignity of patients and the cohesion of the clinical team. A deeper understanding of what patients and their relatives perceive during their (...) ICU stay will shed different light on intensive care management. Patients' experiences of loss of control, dependency and abandonment may lead to a new approach towards a broader approach to the concept of coercion in intensive care. The aim of our research is to explore the experiences of patients and relatives in the ICU and to determine when it might be possible to reduce feelings and memories of coercion.MethodsWe conducted and analysed 29 semi-structured interviews with patients and relatives who had been in the ICU a few months previously. Following a coding and categorisation process in MAXQDA™, a rigorous qualitative methodology was used to identify themes relevant to our research.ResultsFive main themes emerged: memory issues; interviewees’ experiences of restricting measures and coercive treatment; patients’ negative perception of situational and relational dependency with the risk of informal coercion; patients’ perceptions of good care in a context of perceived dependency; progression from perception of coercion and dependency to respect for the person. All patients were grateful to have survived. However, coercion in the form of restraint, restriction of movement, and coercive treatment in the ICU was also acknowledged by patients and relatives. These included elements of informal coercion beyond restraints, such as a perceived negative sense of dependence, surrender, and asymmetrical interaction between the patient and health providers.ConclusionsTo capture the full range of patients' experiences of coercion, it is necessary to expand the concept of coercion to include less obvious forms of informal coercion that may occur in dependency situations. This will help identify solutions to avoid or reduce negative recollections that may persist long after discharge and negatively affect the patients' quality of life. (shrink)

The aim of this paper is to analyze an Intensive Care Unit case that required ethics consultation at a University Hospital in Northern Italy. After the case was resolved, a retrospective ethical analysis was performed by four clinical ethicists who work in different healthcare contexts. Each ethicist used a different method to analyze the case; the four general approaches provide insight into how these ethicists conduct ethics consultations at their respective hospitals. Concluding remarks examine the similarities and differences among the (...) various approaches and offer a reflection concerning the possibility of a shared resolution to the case. The authors’ efforts to come to a tentative consensus may serve as an example for professionals working in medical contexts that reflect an increasing pluralism of values. This article aims to respond to some of these concerns by illustrating how different methods in clinical ethics would be used when considering a real case. The goal is not to establish the best model on a theoretical level, but to learn from actual practice in order to see if there are common elements in the different methods, and to validate their pertinence to clinical ethics consultation. (shrink)

Background The COVID-19 pandemic posed many unprecedented challenges to health care systems and public health efforts worldwide. Policy making and science were deeply intertwined, in particular with regard to the justification of health policy measures. In this context, ethical considerations were often at the core of decision-making trade-offs. However, not much is known about the actual ethical challenges encountered by policy makers and scientists involved in policy advice. With this study, we therefore aim to explore the ethical challenges during COVID-19-related (...) political decision-making in Switzerland as perceived by policy makers and scientists involved in policy making. We also explore the role ethics advice had during the pandemic response and what can be learned for future public health crises. Methods We conducted thirteen qualitative expert interviews with policy makers and scientists involved in decision-making on COVID-19 policy responses in Switzerland on the regional and national level. We used inductive content analysis to analyse the interviews. Results Among the multitude of ethical challenges highlighted, interviewees perceived making trade-offs between the common good vs. the individual good and between economic welfare vs. health of the population, as well as proportionality of the policy measures, and the capacity of the public to accept uncertainty as central. Interviewees had diverging opinions on whether ethical considerations were sufficiently raised and discussed on the Swiss policy level during the COVID-19 pandemic. Among the reasons why ethics was not sufficiently discussed, they mentioned a lack of time in the fast-paced dynamic of the pandemic, ethics as a complex subject area, the interconnectedness between ethics and law, too much focus on few topics (mostly on vaccination-related ethical questions), and power relationships, such as dominance of medical professionals over ethicists. They evaluated ethics support to have been adequately present in the decision-making process, but wished for ethics training, involvement of the public in the discourse and for accompanying communication to build trust among the population for the future. Conclusions The study provides empirical insights into the ethical considerations of COVID-19 policy making in practice in Switzerland. It can help to develop ethics assistance for future crises and inform ethical health policy and decision-making not only in Switzerland, but also in other countries. (shrink)

Are there universal values of right and wrong, good and bad, shared by virtually every human? The tradition of natural law argues that there is. Drawing on the work of psychoanalyst Melanie Klein, whose analyses have touched upon issues related to original sin, trespass, guilt, and salvation through reparation, in this 2006 book C. Fred Alford adds an extra dimension to this argument: we know natural law to be true because we have hated before we have loved and have wished (...) to destroy before we have wanted to create. Natural law is built upon the desire to make reparation for the goodness we have destroyed, or have longed to destroy. Through reparation, we earn salvation from the most hateful part of ourselves, that which would destroy what we know to be good. (shrink)

La réception tardive de l'oeuvre de Ernst Troeltsch en France nous a privés d'une analyse du christianisme originale et féconde. Elle nuance et enrichit ce que nous savons, au travers de la réflexion wébérienne notamment, des relations de la religion chrétienne à la modernité. Contre les interprétations usuelles qui datent l'émergence de cette dernière de la Renaissance et de la Réforme, Troeltsch insiste sur la centralité des Lumières comme marquant la fin de la civilisation ecclésiastique ; c'es l'évanouissement de la (...) référence structurante à l'ordre divin qui inau­gure selon lui l'entrée dans le monde moderne. Sur la base de ce constat, il s'agit pour Troeltsch de trouver une définition du christianisme qui soit en adéquation avec les conditions de l'existence moderne. Dans son ouvrage datant de 1912, « Les doctrines sociales des Églises et groupes chrétiens », il examine les types « Église », « secte » et « mystique » pré­sents depuis les origines évangéliques, circonscrivant trois modes socio­logiques et éthiques qu'il confronte à la modernité. Aucun n'est seul adéquat. Pour durer, le christianisme devra, selon Troeltsch, renoncer à la réalisation d'un programme éthique d'essence religieuse au sein du monde et accepter le cantonnement de la foi dans l'intimité des cons­ciences, tout en s'articulant à des réalités socio-culturelles à l'échelle de tous dont les formes et les transformations internes sont toujours à repenser.The delayed reception of the work of Ernst Troeltsch in France deprived us of an analysis of an original and fertile Christianity. It nuances and enriches what we know, especially through a Weberian reflection, about the relations of the Christian religion and modernity. Against the customary interpretations that date the emergence of the latter from the Renaissance and the Reformation, Troeltsch insists on the centrality of the Enlightenment as marking the end of an ecclesiastical civilization. It is the disappearance of the structuring reference to the divine order that inaugurated, according to him, the entrance to the modern world. On the basis of this observation, Troeltsch is interested in finding a definition of Christianity that would be in harmony with the conditions of modern existence. In his work dating from 1912, "The social doctrines of the Churches and Christian groups ", he examines the categories "Church", "sect", and "mystic" that were present evangelical times, circumscribing three sociological and ethical modes, which he confronts with modernity. No single one is adequate. In order to endure, Christian­ity should, according to Troeltsch, renounce the attempt to set up an ethical program of a religious essence in the heart of the world and accept the establishment of a faith in the intimacy of consciences, all the while adapting its« to socia-cultural realities applicable to everyone, of which the forms and internal transformations are always to be re-thought. (shrink)

Stiff Person Syndrome is a rare autoimmune disorder associated with antibodies against glutamic acid decarboxylase, the key enzyme in γ -aminobutyric acid synthesis. In order to investigate the role of cerebral benzodiazepinereceptor binding in SPS, we performed [ 11 C]flumazenil positron emission tomography in a female patient with SPS compared to nine healthy controls. FMZ is a radioligand to the postsynaptic central benzodiazepine receptor which is co-localized with the GABA-A receptor. In the SPS patient, we found a global reduction of (...) cortical FMZ binding. In addition, distinct local clusters of reduced radiotracer binding were observed. These data provide first in vivo evidence for a reduced postsynaptic GABA-A receptor availability which may reflect the loss of GABAergic neuronal inhibition in SPS. (shrink)

Rev. ed. of: Analytical psychology: notes of the seminar given in 1925 / by C.G. Jung; edited by William McGuire. c1989.

The model of DNA-histones has the following elements: The hydrogen bonds between the complementary nucleotide bases function as informational gates. When the electrons π of one nucleotide base are excited, an exchange of protons is produced between the two complementary bases. The result is the displacement of the conjugated double bonds which facilitates the inter-molecular transmission of the electronic wave of excitation by electro-magnetic coupling. Each triplet of nucleotide bases of DNA fixes one definite amino acid . Between the nucleotide (...) bases and the amino acids there are constituted informational gates, which ensure the circulation of the electronic wave of excitation. An input signal molecule arrives at the receiver gene and unleashes the activity of the enzymes which introduce in the DNA-histones system the electronic wave of excitation. The electronic wave of excitation arises as a result of the break of the high-energy bonds of ATP. Then, the electronic excitation is transmitted to the productor gene where it represents the signal for starting the synthesis of the mRNA.Le modèle de système ADN-Histone a les éléments suivants: Les liaisons d'hydrogène entre les bases nucléotidiques complémentaires fonctionnent comme des portes informationnelles. Quand les électrons π d'une base nucléotidique sont excités, il se produit un échange de protons entre les bases complémentaires. Le résultat est un déplacement des doubles liaisons conjugées qui facilite la transmission de l'onde d'excitation électronique par un couplage électromagnétique. Chaque triplet de bases nucléotidiques de l'ADN fixe un certain amino-acide . Entre les bases nucléodiques et les amino-acides se constituent des portes informationnelles qui assurent la circulation de l'onde d'excitation dlectronique. Une molécule signal d'entrée arrive au gène récepteur et déclenche l'activité des enzymes qui introduisent dans le système ADN-histone l'excitation électronique. L'excitation électronique apparait comme résultat de la rupture des liaisons de haute énergie del' ATP. l'Onde d'excitation électronique est transmise au gène producteur, où elle rdprésente le signal pour faire commencer la synthèse de l'ARNm.Das Modell des DNS-Histonen Systems weist folgende Elemente auf: Die Wasserstoffbindungen zwischen den komplementäaren Nukleotidbasen funktionieren wie informationale Pforten. Wenn die π Elektronen einer Nukleotidbase erregt werden, ensteht ein Protonenwechsel zwischen den Komplementären Basen. Das Ergebnis ist eine Verschiebung der konjugierten Doppelbindungen, die die Weiterleitung der elektronischen Erregungswelle durch eine elektromagnetische Kupplung erleichtert. Jedes Nukleotidbasentriplett der DNS fixiert eine bestimmte Aminosäure . Zwischen den Nukelotidbasen und den Aminosäuren entstehen Informationspforten, welche den Umlauf der elektronischen Erregungswelle sichern. Ein Eintrittsignal Moleküul gelangt zur Rezeptorgen und löst die Aktivität von Enzymen aus, welche die elektronische Erregungswelle in das DNS-Histonen System einführen werden. Die elektronische Erregungswelle erscheint als Ergebnis der Spaltung der hochenergetischen Bindungen des ATP-s. Die elektronische Erregungswelle wird alsdann zur Produktorgen weitergeleitet, wo sie das Signal zum Beginn der Synthese der mRNS darstellt. (shrink)

This a special issue of the Journal of Logic Language and Information that I edited.

This essay argues that retrieving insights from the ancient Stoic philosophers for Christian ethics is much more difficult than is often assumed and, further, that the "ethics of retrieval" is itself something worth prolonged reflection. The central problem is that in their ancient sense both Christianity and Stoicism are practically dense patterns of reasoning and mutually incompatible forms of life. Coming to see this clearly requires the realization that the encounter between Stoicism and Christianity is a conflict of lived traditions. (...) Precisely because we cannot simply extract Stoic insights from the lives in which they belong, the task of determining how Stoicism is useful for Christianity is exceptionally challenging. Indeed, doing justice to the Stoics has more to do with facing an alternative to Christianity than it does with appropriating insights for our own use. These points are developed in conversation with Elizabeth Agnew Cochran's recent article on the Stoic influence upon Jonathan Edwards. This essay is a response to C. Kavin Rowe's critique of my 2011 argument that certain dimensions of Roman Stoic ethics are at work in Jonathan Edwards's moral thought. Rowe raises questions about the act of selectively retrieving ideas from a philosophical tradition to support constructive work in another tradition. I argue for the importance of acknowledging how Christian thought has been shaped by what Jeffrey Stout describes as moral bricolage, the selective retrieval of ideas from various traditions, and I contend that this bricolage can continue to be a fruitful means through which Christian ethics engages external traditions. Moreover, the importance of Stoicism's retrieval in early modern philosophy makes the work of eighteenth-century theologians such as Edwards a particularly valuable resource for exploring the plausibility of Christian engagement with the Stoics. (shrink)