Through a focus on one child’s extended stay in a Pediatric Intensive Care Unit, I raise four general questions about pediatric medicine: How should physicians communicate with parents of very sick children? How should physicians involve parents of very sick children in treatment decisions? How should care be coordinated when a child is being treated by different medical teams with rotating personnel? Should the guidelines for making judgments of medical futility and discontinuation of treatment (...) differ when the patient is a child rather than an adult? (shrink)

Durante su desarrollo el niño se enfrenta a eventos que plantean demandas difíciles de satisfacer como la enfermedad y la hospitalización. La Organización Mundial de Salud define la salud como un estado de completo bienestar físico, mental y social, pero no existe consenso en la literatura sobre el término bienestar. El objetivo del artículo es realizar una revisión bibliográfica acerca del concepto bienestar en niños, asociado al proceso salud - enfermedad y a la hospitalización. Los niños experimentan bienestar cuando predominan (...) sus emociones positivas, estas favorecen la salud, las negativas, pueden provocar estados patológicos y son frecuentes en la hospitalización. Esa realidad amerita ser transformada. El bienestar en niños hospitalizados constituye un reto para las ciencias médicas para penetrar las bases del nivel secundario de atención. Throughout their development, children face events that pose hard-to-satisfy demands for them such as illness and hospitalization. The World Health Organization defines health as a state of complete physical, mental, or social well-being; however, there is no consensus in literature about the term "well-being". The objective of the article is to do a bibliographic review on the concept of children well-being associated to the health-illness process and to hospitalization. Children experience the state of well-being when positive emotions, which favor health, prevail. Negative feelings, on the other hand, can cause pathological states and they are common in hospitalization. That reality merits transformation. Hospitalized children's well-being presents a challenge for medical sciences in order to get inside the basis of secondary health care attention. (shrink)

SummaryMalaria is a major cause of under-five mortality in Mali and many other developing countries. Malaria control programmes rely on households to identify sick children and either care for them in the home or seek treatment at a health facility in the case of severe illness. This study examines the involvement of mothers and other household members in identifying and treating severely ill children through case studies of 25 rural Malian households. A wide range of intra-household (...) responses to severe illness were observed among household members, both exemplifying and contravening stated social norms about household roles. Given their close contact with children, mothers were frequently the first to identify illness symptoms. However, decisions about care-seeking were often taken by fathers and senior members of the household. As stewards of the family resources, fathers usually paid for care and thus significantly determined when and where treatment was sought. Grandparents were frequently involved in diagnosing illnesses and directing care towards traditional healers or health facilities. Relationships between household members during the illness episode were found to vary from highly collaborative to highly conflictive, with critical effects on how quickly and from where treatment for sick children was sought. These findings have implications for the design and targeting of malaria and child survival programming in the greater West African region. (shrink)

In most other nations, insurance for medical care is called sickness insurance, and it covers sick people. In the United States, we have “health insurance,” and its major carriers — commercial insurers, large employers, and increasingly government programs — strive to avoid sick people and cover only the healthy. This perverse logic at the heart of the American health insurance system is the key to reform debates.Focusing on sick people versus healthy people might seem a strange (...) way to view the coverage issue. Most discussions of insurance categorize people into other groupings: the insured versus the uninsured; Caucasian whites versus other racial and ethnic groups; men versus women; poor and low-income people versus everybody else; children, adults, and the elderly; or citizens versus immigrants and undocumented aliens. More recently, health researchers have begun talking about “vulnerable populations,” using most of the same demographic groupings and adding other illness-inducing factors such as social isolation, stress, and impoverished neighborhoods. But as I will show, insurance plans now use premiums, cost-sharing, and other design features in ways that indirectly divide each of these groups into the sick and the healthy, to the detriment of the sick. By shifting the costs of illness onto people who use medical care — that is, sick people — market-oriented reforms of the last few decades have eroded insurance in the name of strengthening it. (shrink)

The paediatric intensive care unit (PICU) is a high-stress environment for parents, families and health care professionals (HCPs) alike. Family members experiencing stress or grief related to the admission of their sick child may at times exhibit challenging behaviours; these exist on a continuum from those that are anticipated in context, through to unacceptable aggression. Rare, extreme behaviours include threats, verbal or even physical abuse. Both extreme and recurrent ‘subthreshold’ behaviours can cause significant staff distress, impede optimal (...) clinical care and compromise patient outcomes. The unique PICU environment and model of care may magnify stressors for both families and staff and the family-centred approach to care (FCC) central to paediatric practice, may also contribute to contextual challenges. Pervasive conflict in paediatric healthcare is harmful for patients, families, PICU staff and the institution more broadly. We propose that caring for children and caring for staff are inseparable goals and the latter has been inadvertently but detrimentally deprioritised as FCC has become a primary focus. A transparent and graded hierarchy of responses to variable levels of challenging behaviour is necessary to ensure that families are supported, while HCPs remain protected in the workplace. This requires establishing firm limits supported by all teams and levels of the institution. As such, we aim to identify and clarify the context and impact of challenging parent and family behaviour in the PICU and to offer potential, proactive mitigation strategies, based on reflections and stakeholder discussion following recent clinical challenges and experiences in our unit. (shrink)

Philosophy has long been concerned with ‘moral status’. Discussions about the moral status of children, however, seem often to promote confusion rather than clarity. Using the creation of ‘savior siblings’ as an example, this paper provides a philosophical critique of the moral status of children and the moral relevance of parenting and the role that formative experience, regret and relational autonomy play in parental decisions. We suggest that parents make moral decisions that are guided by the moral significance (...) they attach to children, to sick children and most importantly, to a specific sick child (theirs). This moral valorization is rarely made explicit and has generally been ignored by both philosophers and clinicians in previous critiques. Recognizing this, however, may transform not only the focus of bioethical discourse but also the policies and practices surrounding the care of children requiring bone marrow or cord blood transplantation by better understanding the values at stake behind parental decision making. (shrink)

There have been ongoing debates as to how, or even whether, we should clinically classify gender diversity in children through clinical classification manuals. So‐called ‘depathologizing’ is argued as being vital to address the stigma that these children are somehow disordered or sick. Yet one argument in favour of continued clinical classification for transgender and gender non‐conforming children is that it better facilitates access to specialist psychological support. I argue that whilst continued clinical classification offers a seemingly (...) pragmatic solution to ensuring access, it does in fact obscure our understanding of the individual needs of these children. In this paper I address fundamental issues that aim to better our understanding of need and thus why a child may benefit from specialist support. I do so by critiquing a paper I nearly wrote, which argued for the ongoing continued classification of gender incongruence in children. Ultimately, I argue that specialist psychological support and care should be driven by the needs of the individual child, as determined by the child and those involved with their care. By bettering our understanding as to why specialist psychological support may be beneficial for some, we move past the focus of such specialist support being provided because of the child’s gender diversity. Methodologically the paper may be unusual, in comparison to traditional normative counter‐argumentative bioethical position papers, but by presenting an argument for depathologization of gender diversity of children in this way there is also an alternative insight into the methods of bioethics. (shrink)

The future will be controlled by those nations which most intelligently allocate their resources. Our nation's capital is the stored flexibility needed by our children to meet the future. How we allocate our nation's limited resources and capital will dictate the kind of lives our children will lead. We are not correctly or intelligently allocating our nation's health care resources. There are serious internal contradictions in a society that no longer produces the radios, televisions, or video recorders (...) it invented, yet pays for all patients receiving lung transplants and artificial hearts. While moving our basic value-producing industries - steel and automobiles - abroad, we continue to manufacture MX missiles and artificial hearts. We give heart transplants to smokers, but we close our steel mills. We spend freely on military and medicine, yet we refuse to spend enough to succeed in international trade. We overtreat sick people but undertreat our sick economy. Like the fading southern family in William Faulkner novels that "takes sick," as a nation we are treating our illnesses at the expense of our livelihoods. (shrink)

Films provide many memorable scenes of care that both shape and reinforce ideas about who deserves care, how carers should behave, and what kinds of people appear ‘naturally’ suited to the labors of caring for children, the sick, the elderly and the disabled (namely women). My specific interest here is in films about migrant domestic workers in Hong Kong and Singapore. from the Philippines and Indonesia, who take up live-in housekeeping positions. The films about their lives (...) range from documentary to popular, low-budget horror to independent art cinema. While surveying the strengths and limitations of a handful of these films, I offer strategies for how to frame each film in terms of its director, production methods, distribution, and target audience. How and when might different genres be best used to engage students in critical thinking about care work and migrant labor? What stereotypes exist about migrant workers and what blind spots emerge in understanding paid care work? How can we promote dialogue about the often ambivalent relationship between caregiver and cared-for? (shrink)

Motherhood, as it is practiced, constitutes an obstacle to gender equality in political participation. Several options are available as a potential solution to this problem. One is to advice women not to become mothers, or if they do, to devote less time and energy to caring for their children. However this will have negative repercussions for those who need to be cared for, whether children, sick people or the elderly. A second solution is to reject the view (...) that political participation is an important or necessary part of human flourishing, and allow that those who engage in caring activities can live good lives without having a say in how they are ruled. This has negative consequences for the carers who find themselves in a position, if not of direct oppression, of being dominated, and therefore susceptible of being oppressed. The solution I propose, inspired by the writings of Sophie de Grouchy, is that we look for a form of republicanism that regards caring activities as a form of political participation. (shrink)

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural areas (...) were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their children’s care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Grieving One More TimeNeethi Pinto"The deeper sorrow carves into your being, the more joy you can contain."—Kahlil GibranI take care of very sick children in the pediatric intensive care unit (PICU). When a child dies, grief strikes in three distinct waves. First, I grieve for the child we couldn't heal, the unfairness, and the complete and utter sadness of a life cut too short. Then, (...) I grieve for the survivors—the families whose lives will be changed forever and who must find the strength to go on. It's not until later, in solitude, that I am able to grieve a third time—this time by and for myself.As clinicians, we are also survivors. Yet, our culture in medicine rarely affords us the permission or the grace to unpack the depth of the sorrow and grief we regularly witness and suffer. Instead, we must summon up the fortitude to take care of the child in the next room before we can pause and process our grief. As a field, we have been more intentional about having "hot" (soon after the event) and "cold" (days to weeks later) debriefings, but these short conversations about our shared experience are limited. The sheer reality of our day-to-day lives in the PICU is that the next critically ill patient is waiting.My processing of grief happens when I replay the events leading up to the patient's death over and over and over again. Was there something I missed? Could I have done better? In fact, I teach my medical students, pediatric residents, and PICU fellows that this very questioning makes us better physicians—as long as we don't let our second-guessing or fear of making a mistake paralyze our actions in the future.Little did I know I would grieve a fourth time …"How would you feel if this was your daughter?" These words were harshly spoken by my patient's father, a former police officer, the day his daughter died of respiratory failure. I had cared for her on many occasions during her prolonged admission, including that very sad last day. Undoubtedly, he was grieving, but I could feel his anger when he interrogated me. I wondered if he remembered how he profusely thanked me for caring for his daughter when we first met or the many times our team had resuscitated her, saving her life. I spent countless hours at her bedside, during the day, in the middle of the night, away from my own young family. Sure, these hours—nights, weekends, and holidays—are "part of the job," but I chose a career in pediatric critical care because of a commitment to caring for the most medically vulnerable children—the sickest of the sick—despite these hours. As pediatric intensivists, we have a unique opportunity to help children and their families at the most harrowing times in their lives—when they face the possibility of death. Although we know at the outset that some children will not survive, the grief we experience when a child dies still runs deep. It hurts every single time. In this case, my profound grief was exacerbated by the father's hostility. One year later, my sorrow deepened when I answered my doorbell at home to find a police officer handing me a subpoena for a malpractice lawsuit regarding this child's death—a delivery intended to intimidate me. I found myself grieving a fourth time—grieving for the loss of joy—joy that had been central to my identity as a physician. [End Page 72]Then, the feeling of shame crept in and haunted me. I always understood that I entered a high-risk/high-stakes field where children die because of the severity of their illness despite state-of-the-art medicine and technology. Over the years, I've learned that not only is it rewarding to help a child survive critical illness but it is incredibly moving to forge an intense human connection with families when their children are dying. So, my shame was not due to a sense of failure in preventing this child's death but rather due to the... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:How was Haiti?Sadath Sayeed"She smelled of milk and urine. Chacko marveled at how someone so small and undefined, so vague in her resemblances, could so completely command the attention, the love, the sanity of a grown man."—Arundhati Roy from The God of Small ThingsFather and SonTwenty minutes before I was to be taxied to the airport in Port-au-Prince, the baby boy handed to me did not breathe continuously. He (...) didn't breathe at all. Born a few hours earlier at home—probably in one of the hundreds of make-shift tent cities. I did ask if the baby cried after he came out of mom. Yes. He didn't suckle well and stopped crying. Dad decided to get help. Climbed onto a moped with his baby wrapped in a blanket. Must have tucked him under one arm and rode between piles of rubble to the closest health care facility.People at this other place tried to help his baby boy breathe. They pushed air into his mouth like you are doing. After a few minutes, they said that they couldn't help anymore."Go to the University hospital."From a shirt sleeve pocket, he pulled a crumpled white piece of paper with some writing scribbled on it. I gathered it documented this last visit. They took the time to hand him a note before they sent him on his way.What did Dad think? Thanks for the note. Okay, now what? Swaddle my baby. Tuck him under one arm. Hop on my moped.Strained ResourcesL'Université d'État d'Haïti has been the main teaching hospital for all of the country for decades. Many, if not most, formally trained Haitian health care providers have spent some time in Port-au-Prince at this institution. As important as it is, it has suffered from neglect over many, many years. The earthquake made matters exponentially worse. [End Page 98]Dad must have been directed to the pediatric service when he arrived. There, a few Haitian pediatric residents and nurses were doing what they did every morning. Tending to an overcrowded patient population of babies, children, and parents. The pediatrics building was left uninhabitable. All inpatient and outpatient care took place on a street where the tents had been erected.In the ICU, tent twenty beds filled a space probably meant for ten military style cots. Metal cribs and full adult hospital beds were jammed next to one another to fill every possible nook. Parents slept on the adult beds with their sick children or underneath the cribs. Siblings too. Outside, hundreds of parents would line up starting at six a.m. and stand in line for hours so that they could get their children seen in a couple of smaller tents that were used to run the outpatient clinics. Moms would fan their kids under the shade of trees on the side of the road. Feed them some milk or juice while they waited. Smile at us passers-by. They seemed to possess a bottomless well of patience.Power cords with extension wires littered the street-hospital floor under the canopy.When it rained, we were only modestly concerned about electrocution. A single 1950's style metal desk with two worn out chairs greeted visitors to the entry way and was usually occupied by some of the medical staff. A single, large metal fan that had collected enough dust and soot in its circular cage to look bearded hummed a breeze toward the desk.A bottomless well of patience and resiliency. In the popular media, this last word has been thrown around a lot to describe the character of the Haitian people. It is insufficient. Their adversity is truly absurd. Sense cannot be made of the scene in the pediatrics tents months after the earthquake struck, nor elsewhere on that campus, let alone outside its walls.The local medical staff hadn't been paid a dime in many months even prior to the earthquake. They suffered unimaginable losses during the earthquake. They still came to work."We love our children. They love us too."What so many of us think of as charity... (shrink)

The allocation of critical care resources and triaging patients garnered a great deal of attention during the COVID-19 pandemic, but there is a paucity of guidance regarding the ethical aspects of resource allocation and patient prioritization in ‘normal’ circumstances for Canadian healthcare systems. One context where allocation and prioritization decisions are required are surgical waitlists, which have been globally exacerbated due to the COVID-19 pandemic. In this paper, we detail the process used to develop an ethics framework to support (...) prioritization for elective surgery at The Hospital for Sick Children, Toronto, a tertiary pediatric hospital. Our goal was to provide guidance for the more value-laden aspects of prioritization, particularly when clinical urgency alone is insufficient to dictate priority. With this goal in mind, we worked to capture familial, relational, and equity considerations. As part of our institution’s concerted efforts to ethically and effectively address our surgical backlog, an ethics working group was formed comprising clinicians from surgery, anesthesiology, intensive care, a hospital bioethicist, a parent advisor, and an academic bioethics researcher. A reflective equilibrium process was used to develop an ethics framework. To this end, the same methodology was used to create a support for patient prioritization that identifies clinically and morally relevant factors for prioritization among medically similar surgical cases, with a substantive goal being to identify and redress health inequities in surgical prioritization, inasmuch as this is possible. While further steps are needed to validate several aspects of the framework, our research suggests that an ethics framework grounded in the practical realities of hospital operations provides consistency, transparency, and needed support for decisions that are often left to individual clinicians, as well as an opportunity to reflect upon the presence of health inequities in all domains of healthcare delivery. (shrink)

This article provides a discussion of the limits of both narrative and culture based on a close textual analysis of the short story, “People Like That Are the Only People Here: Canonical Babbling in Peed Onk,” by Lorrie Moore. In this story, a mother describes her experiences on a pediatric oncology ward when her infant son develops Wilms' tumor. The authors examine how the story satirically portrays the spurious claims of language, story, and culture to protect us from an unjust (...) universe and then exposes their false promises. The various personal, professional, and genre-specific narratives we use to create order and coherence from the terror of serious illness are ultimately ineffective. Similarly, the superficially comforting culture of the hospital ward cares more about creating the illusion of control than it does about the suffering of sick children. Language and culture cannot make sense of human anguish, the article concludes, yet they are all we have to hold back the chaos. Mystery and uncertainty, as part of the human condition, must become part of our stories and part of our culture. (shrink)

The Hippocratic oath is such an enduring icon of medical morality that physicians in Nazi Germany invoked it to protest _Euthanasie_, the systematized killing of weak or sick children, people with incurable diseases, hospitalized criminals (a category applicable to gays), geriatric patients, long-term patients, patients not of German blood (Jews and Romani), and people with disabilities. Several expert witnesses at the 1945 Nuremberg Medical Trial also cited the oath to condemn Nazi physicians' abuse of human research subjects. Noting (...) these invocations, in 1947 the physicians who founded the World Medical Association modernized the Hippocratic oath to convey to future medical students its foundational precepts: benefitting the sick, not harming them, not breaching confidentiality, and not treating patients unjustly, irrespective of their gender or social status. This article presents a historically accurate reading of the oath's strange-seeming passages to show that it does not prohibit abortion, euthanasia (medical aid in dying), or surgery. The article also contends that oath-swearing remains an important asset in teaching clinicians their role responsibilities, and that its ethics supports women's rights to reproductive health care and can valorize challenges to venture-capitalist and for-profit managements that prioritize profitability over providing quality health care for patients. (shrink)

Background: Paediatric nurses often face complex situations requiring decisions that sometimes clash with their own values and beliefs, or with the needs of the children they care for and their families. Paediatric nurses often use new technology that changes the way they provide care, but also reduces their direct interaction with the child. This may generate ethical issues, which nurses should be able to address in the full respect of the child. Research question and objectives: The purpose (...) of this review is to describe the main ethical dimensions of paediatric nursing. Our research question was, ‘What are the most common ethical dimensions and competences related to paediatric nursing?’ Research design: A rapid evidence assessment. Method: According to the principles of the rapid evidence assessment, we searched the PubMed, SCOPUS and CINAHL databases for papers published between January 2001 and March 2015. These papers were then independently read by two researchers and analysed according to the inclusion criteria. Ethical considerations: Since this was a rapid evidence assessment, no approval from the ethics committee was required. Findings: Ten papers met our inclusion criteria. Ethical issues in paediatric nursing were grouped into three areas: (a) ethical issues in paediatric care, (b) social responsibility and (c) decision-making process. Conclusion: Few studies investigate the ethical dimensions and aspects of paediatric nursing, and they are mainly qualitative studies conducted in critical care settings based on nurses’ perceptions and experiences. Paediatric nurses require specific educational interventions to help them resolve ethical issues, contribute to the decision-making process and fulfil their role as advocates of a vulnerable population (i.e. sick children and their families). Further research is needed to investigate how paediatric nurses can improve the involvement of children and their families in decision-making processes related to their care plan. (shrink)

The phenomenon of ‘sharenting’, whereby a parent shares news and images of their child on social media, is of growing popularity in contemporary society. There is emerging research into children’s attitudes regarding sharenting and their associated concerns regarding privacy; however, this research most often involves young people who are approaching adulthood and are competent to participate. As a result, children who experience illness or disability are largely absent from current research, and as such, the moral permissibility of a (...) parent sharing their child’s illness journey on a public social media platform is largely unexplored. In this essay, I explore this issue by using the United NationsConvention on the Rights of the Childand Joel Feinberg’s principle of the child’s right to an open future as the basis of my argument: that children with illness and disability have the same rights as healthy children to privacy, identity and an open future and that publication of their illness on a social media platform violates these rights. I conclude that parents, as surrogate decision makers for their children, have the same responsibilities in protecting their child’s privacy as they do in making medical decisions on behalf of their children. As children of the social media generation approach adulthood, it is important to consider the rights of those who cannot speak for themselves and the ethical consequences of sharenting for children with illness and disability. (shrink)

This article describes a study carried out among 14-18-year-old nursing students in Hungary. The students were asked to consider an ethical problem. The parents of a sick child ask that she should not be told of a forthcoming operation. Are the nurses to agree to this demand or not? The author concluded from this study that nurses need more training in ethical decision-making, that they need to know about the rights of children in hospital, and that nursing training (...) should start when students are older. (shrink)

Several charters of rights have been issued in Europe to solemnly proclaim the rights of children during their hospital stay. However, notwithstanding such general declarations, the actual implementation of hospitalized children’s rights is unclear. The purpose of this study was to understand to which extent such rights, as established by the two main existing charters of rights, are actually implemented and respected in Italian pediatric hospitals and the pediatric units of Italian general hospitals, as perceived by the nurses (...) working in them. (shrink)

For many people the idea that children are autonomous agents whose autonomy the parents should respect and the state should protect is laughable. For them, such an idea is the offspring of idle academics who never had, or at least never seriously interacted with, children. Autonomy is the province of full fledged rational adults, not immature children. It is easy to see why many people embrace this view. Very young children do not have the experience or (...) knowledge to make informed decisions about matters of momentous significance. However, from this fact many people infer (or talk as if they infer) that all children are helpless moppets, wholly incapable of making any informed decisions. (shrink)

The world of the Na'vi is much more feminine. Na'vi women are equal partners with their men and are just as capable as their male counterparts. And as the tsahìk (spiritual leader) of the Omaticaya clan, Neytiri's mother Mo'at exercises an unrivalled degree of power and influence due to her ability to interpret the will of Eywa, the Na'vi's female deity. Historically, women are the ones who have had the most intimate experience of care, since they have traditionally been (...) the ones tasked with providing it for children, the sick, the disabled, and the elderly. The philosopher Sara Ruddick (1935–2011), one of the pioneers of care ethics, identified three activities at the core of what she calls “maternal work”: preserving the life of the child, fostering the growth of the child, and training the child for social acceptability. (shrink)

Spirituality in Nursing: Standing on Holy Ground addresses the relationship between spirituality and nursing practice across a variety of settings and broad perspectives related to caring for the ill and infirm, from care of special population like children, families and older adults to spiritual care during disaster situations. The current edition examines both historical and contemporary issues pertaining to the spiritual needs and care of the sick and includes topical discussions of areas such as the (...) nurse's role in spiritual care, the nurse-patient relationship, spiritual needs of special populations, and spiritual needs in areas such as mass casualty disasters and parish leadership. The author brings her considerable experience as a parish nurse to each discussion, lending a unique perspective to each of the issues addressed in this text. (shrink)

BackgroundAs the number of randomised controlled trials of medicines for children increases, it becomes progressively more important to understand the experiences of parents who are asked to enrol their child in a trial. This paper presents a narrative review of research evidence on parents' experiences of trial recruitment focussing on qualitative research, which allows them to articulate their views in their own words.DiscussionParents want to do their best for their children, and socially and legally their role is to (...) care for and protect them yet the complexities of the medical and research context can challenge their fulfilment of this role. Parents are simultaneously responsible for their child and cherish this role yet they are dependent on others when their child becomes sick. They are keen to exercise responsibility for deciding to enter a child in a trial yet can be fearful of making the 'wrong' decision. They make judgements about the threat of the child's condition as well as the risks of the trial yet their interpretations often differ from those of medical and research experts. Individual parents will experience these and other complexities to a greater or lesser degree depending on their personal experiences and values, the medical situation of their child and the nature of the trial. Interactions at the time of trial recruitment offer scope for negotiating these complexities if practitioners have the flexibility to tailor discussions to the needs and situation of individual parents. In this way, parents may be helped to retain a sense that they have acted as good parents to their child whatever decision they make.SummaryDiscussing randomised controlled trials and gaining and providing informed consent is challenging. The unique position of parents in giving proxy consent for their child adds to this challenge. Recognition of the complexities parents face in making decisions about trials suggests lines for future research on the conduct of trials, and ultimately, may help improve the experience of trial recruitment for all parties. (shrink)

Volume 24, Issue 12, December 2024, Page 48-51.

Photo ID 222412412 © US Navy Medicine | Dreamstime.com ABSTRACT In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. INTRODUCTION Medical resources in an austere environment without quick recourse for resupply or casualty evacuation are often (...) limited. The shortage extends not only to supplies like blood products and drugs, but physicians and other medical personnel. In the midst of a mass casualty scenario, such as a battle that includes intense ground fighting, the medical staff will stretch scarce resources and triage casualties according to specific criteria. Typically, they proceed by providing care for the most severely wounded first, referred to here as conventional triage. At times, though, the staff may reverse the triage so that soldiers with minor wounds can return to the fight. In a mass casualty situation, when medical personnel apply conventional triage and treat casualties from opposing forces, a dilemma may arise. We argue that it can be permissible for military physicians to prioritize their own soldiers over enemy combatants in a mass casualty triage, where reverse triage does not apply. The case we will focus on is as follows: Battlefield Triage: During combat operations on a remote island in the Pacific Ocean, a compatriot soldier and an enemy combatant arrive at the compatriot soldier country’s medical treatment facility. Both have similar gunshot wounds to the abdomen, and they arrive with similar conditions. Both have low oxygen saturation and excessive blood loss. The sole physician only has enough time to stabilize one person. The scenario is brief, and we are aware that medical rules of eligibility will most often dictate how the physician proceeds,[1] but this scenario is useful in setting up the question we focus on in this paper: would it be wrong to favor the stabilization of a soldier just because the soldier is the physician’s compatriot? In other words, can nationality serve as an ethically justified tiebreaker in a situation such as Battlefield Triage?[2] In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. The AMA’s Code of Medical Ethics asserts that physicians have “ethical obligations to place patients’ welfare above their self-interest and above obligations to other groups.”[3] The World Medical Association’s Declaration of Tokyo affirms that “no motive, whether personal, collective or political, shall prevail against this higher purpose” of alleviating distress.[4] Physicians are taught early on that triage decisions must be medically indicated and made without consideration of factors such as race, ethnicity, religion, social status, and nationality. They are taught that public trust and obligations of justice grounded in equality demand that only medical indications be considered. But military physicians in a military setting are beholden to obligations, duties, and responsibilities as members of the military, and when these obligations, duties, and responsibilities conflict, as they do in Battlefield Triage, which loyalties win out and why?[5] Critics of partiality on national grounds argue that partiality undermines public trust in medicine and justice because everyone should be treated equally regardless of nationality.[6] Proponents of partiality argue that military obligations supersede equality and that justice requires partiality in such cases.[7] Despite the critics’ disagreement, both agree that there is a morally right, perhaps even blameless, course of action. Drawing on insights from virtue ethics, we argue that Battlefield Triage is a moral tragedy in which justice is unattainable and there is no action without moral cost. The assumption that there is a morally right choice is flawed. We argue that while no decision in this scenario is free from moral blame, there are reasons to favor treating one’s soldiers over enemy combatants. I. The Case Against Partiality There is a common assumption that there is a morally right or just decision in Battlefield Triage. A number of organizations and scholars claim that it is wrong for military physicians to favor their own soldiers on the grounds of nationality or some form of ‘group membership.’ (In a conflict involving service members from multiple nations working as a coalition, a soldier from an allied country may receive the same priority as the US service member due to ‘group membership.’) The World Medical Association’s WMA Declaration of Lisbon on the Rights of the Patient, which was reaffirmed in 2015, posits that, “[i]n circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.”[8] This echoes what was set forth in Article 12 of the Geneva Conventions, which states that “[o]nly urgent medical reasons will authorize priority in the order of treatment to be administered.”[9] The argument for impartiality in Battlefield Triage is that every person is morally equal, and equality entails that medical distribution is, “based on a combination of medical need and urgency.”[10] This is in keeping with the bioethical principles that are generally applied.[11] II. The Case for Partiality On the other side, there are arguments that favoritism is the ethically right decision in Battlefield Triage.[12] The argument asserts that members of the military form a morally significant community of friends and participation in these relationships demands partiality. Just as parents have strong ethical duties to their children and not just any children, military personnel have ethical duties to their group, a group that involves an affirmation of mutual aid and support. Some have termed these ‘associative duties. According to Michael Gross, obligations of friendship, care, and solidarity “leave very little room for generally applicable principles of justice that would obligate a medic to treat enemy or non-compatriot wounded ahead of their compatriots.”[13] This is true in Battlefield Triage, but it may also be true even if the enemy’s soldier were more seriously wounded: “the ethics of small group cohesion, largely an ethics of care, mostly replaces the demands of impartial justice.”[14] In a more recent article, Gross explains that preferential treatment is ethically justified based on fighting capability and “the special obligations people owe friends, family, and, no less, comrades-in-arms.”[15] To not show partiality to the US soldier would be morally wrong on the grounds of friendship and mutual care.[16] III. The Moral Tragedy of Battlefield Triage Defenders and critics of Battlefield Triage favoritism based on nationality both frame their position as just or fair. For example, Justin List argues that physicians are “bound to practice medical neutrality,”[17] Marcus Adams denies that physicians “possess special ethical obligations” to enemy combatants because of their profession.[18] These perspectives assume that there is a morally right decision and that justice is attainable. The assumption that there is or can be a morally right Battlefield Triage decision, and we need to put our heads together to figure it out, remains strongly entrenched. However, the facts of the situation should give us pause; there are too many people and too few resources, and this demands a decision-making process that determines who will receive scarce resources. By its very nature, a battlefield triage decision has to be made based on some characteristic or value, a characteristic or value that will inevitably favor some at the expense of others. This is precisely why competing analyses “in the military context struggle to resolve these conflicts satisfactorily.”[19] Drawing on the insights of virtue ethics, we suggest that Battlefield Triage is a moral tragedy. Virtue ethics suggests that morality is about acting virtuously, which is to say that we should do what a virtuous person would do in the situation. Ethics is about figuring out how a just, wise, compassionate, loving, and fair person would act, and then doing that, as one grows in virtue. But life is not always clear cut, and it is possible that virtuous people may find themselves in a moral tragedy, a situation in which, through no fault of one’s own, a person must make a morally objectionable decision. After the action the virtuous person “emerges having done a terrible thing, the very sort of thing that the callous, dishonest, unjust, or in general vicious agent would characteristically do.”[20] Stated differently, a moral tragedy presents a virtuous person with two or more courses of action, all of which have a moral cost.[21] In Battlefield Triage, no matter how the physician goes about deciding, there is going to be defensible concern from those not saved. The fact that there are more people than can be helped fosters competing values in battlefield triage: maximize lives saved, treat people equally, treat the worse off, and support the war effort. Treating people equally may create tension between treating the worse off, maximizing lives saved, and supporting the war effort. Reverse triage is a case in point, as supporting the war effort conflicts with treating the worse off first, as is a fair lottery system since deploying a lottery may not maximize lives saved or support the war effort. There can be reasons why one person is selected over another, to be sure. Yet, there are reasons for making a decision, and that the decision is subject to legitimate moral concern is another. To recognize the moral tragedy of Battlefield Triage is to recognize the impossibility of acting blamelessly in the situation. In this situation, the virtuous military physician is going to have to sacrifice important values such as justice, compassion, and respect for others, even with a defensible criterion in hand. The physician will grieve this sacrifice accordingly. The physician may find her decision difficult or stressful, and rightly so, because of what her circumstances require of her. This kind of moral tragedy results “in actions which betray and violate the rights of persons to whom there may be a strong duty of care. When this happens, it properly triggers an appropriate moral emotion since our moral integrity has been violated and this affects how we think of ourselves and what we have become.”[22] Rather than view her triage decision as the morally superior choice, the virtuous military physician will view her decisions in these circumstances in a different light: it is the least bad option in a terrible situation, and she did something ethically problematic, something that is contrary to her moral character. She deeply regrets the circumstances in which she had to act. IV. Virtue Ethics A virtue ethicist has insight into how one should go about deciding what to do in a moral tragedy, although virtue ethics may not be as helpful as one may hope. The goal of the virtuous military physician in Battlefield Triage is to adopt the best course of action or the action that she feels she ought to do, all things considered. This does not make her choice devoid of serious wrongdoing—a decision must be made, but that does not make it just. The virtuous military physician will approach the situation with courage, responsibility, and insight. She will think about the decision carefully, wisely, and conscientiously; she will weigh the goods and harms of the choices before her, in conjunction with a proper conception of the good life, human worth, and understanding of her obligations to others—including chain of command, fellow soldiers, and the medical community. She is attuned to the value of human life and has a reasonable idea of the various ways her decisions will affect others. She recognizes that she is in this non-ideal situation through no fault of her own: she is not the one fighting in battles; she is serving her country as a physician, whose job it is to save lives, treat everyone justly, and promote military objectives. She regrets the decision she is forced to make in battlefield triage, acting “with immense regret and pain,” Hursthouse explains, “instead of indifferently or gladly.”[23] This is because, no matter what decision is made, the virtuous military physician “does something terrible or horrible,” something she otherwise would not do and is contrary to her values.[24] V. A Resolvable Moral Tragedy Instead of asking whether there is a morally right decision, in which a decision is morally blameless and above reproach, the virtue ethicist asks whether there is a decision with a convincing rationale, knowing that a decision can have a clear rationale but still be morally tragic. It is perfectly reasonable to think that different virtuous persons will arrive at different courses of action: “two virtuous agents, in the same situation,” Hursthouse writes, “may act differently” in irresolvable moral tragedies, in cases in which there is no clear course of action.[25] Because a person must act in a moral tragedy, one goal is to identify reasons for choosing the chosen action. Some decisions are clearly indefensible—treating neither the compatriot soldier nor the enemy combatant in Battlefield Triage would be wrong—and some decisions are more problematic than others. If the military physician selects to treat the soldier because she does not like the enemy combatant’s skin color, such a reason would be deeply problematic. But much of the debate over how to act in a moral tragedy is not over clearly indefensible or problematic criteria. Instead, the literature is largely about different standards or implementations of justice. Some scholars defend nation-impartial triage as right, while others defend nation-aware triage as right, and each argues that the other side is promoting an unjust or otherwise wrong solution to Battlefield Triage. We suggest that Battlefield Triage is a resolvable moral tragedy and that virtue ethics offers convincing reasons to prefer the treatment of the compatriot soldier rather than the enemy combatant on the grounds of national identity. Virtues are integral to living a good life, a flourishing life, but as Aristotle observed long ago, human beings are inherently social, interdependent and interconnected in profound ways.[26] This goes beyond the obvious fact that we need each other to survive day to day (one person makes clothes, another farms, and another makes tools); the claim is that a good or flourishing life depends in large part on one’s social network or community. This is why many of Aristotle’s moral virtues are other facing: justice, friendship, generosity, and magnanimity, to name a few. Courage, a typically self-facing virtue, is understood by Aristotle to be the virtue that regards one’s fear of death in battle, a battle fought on behalf of one’s city.[27] All of this remains true today. Namely, there is an important sense in which our community matters to our lives: it is easier to live a good, flourishing life if one is part of a good, flourishing community. Our community is made up of smaller groups, and it is more accurate to say that we are simultaneous members of different groups within a broader community. A person may be part of a family, friend group, research team, large state university, city, state, and nation. Groups can function well or not, as we all have experienced, and this suggests that there are virtues or excellences that groups can instantiate. Good groups are unified in purpose, with each member doing their duty alongside others for the attainment of that purpose. Good groups manifest solidarity among their members. Although Aristotle does not list solidarity as a virtue, a number of modern-day virtue ethicists have begun examining how group solidarity can be a virtue that contributes to a good or flourishing life.[28] Solidarity is not conceptualized as an individual virtue, a virtue possessed by a person in isolation of others; instead, it is a collective virtue, a virtue that is shared among members of a defined group with particular ends.[29] “A group has solidarity to the extent that its members are disposed to: (1) share values, aims, or goals; (2) care about those values, aims, or goals; (3) act in accordance with those values, aims, or goals; (4) trust the testimony of other group members with respect to those values, aims, and goals; and (5) feel a sense of belonging to the group.”[30] The virtue of collective or group solidarity involves individuals having special concern for each other, shared aims and values, trust, loyalty, and a sense of belonging with these specific others. There is a oneness to the group in the pursuit of a definite goal or purpose, involving mutual support and affirmation of each member. As such, the group has ends and goods above and beyond the good of each individual person. Sometimes solidarity requires personal sacrifice for the collective (for example, a father sacrificing food so his child can eat). The virtue of collective or group solidarity is important to the military and medical community at every level, and for clear reasons. In the military, there is a clear hierarchy of command, unity of purpose and end, mutual trust and support in complex settings, and so on. Soldiers need to know they can count on one another, and solidarity grounds a soldier’s ability to trust others and be assured of mutual aid. In medicine, solidarity maintains self-regulation of the profession, shared values and goals, as well as public support, not to mention that day-to-day operations require physician trust, engagement, and effort toward the ends of clinical care. Physicians need to work together, along with others, in pursuit of health, and disunity is sowed when there is mistrust, selfishness, or disengagement among the healthcare team and organization. Importantly, just as we are all members of various groups and hence may manifest group solidarity in different settings, the virtuous military physician instantiates collective solidarity with both the medical profession and the military. Her dual loyalty contributes to the moral difficulty of acting in Battlefield Triage. The military physician has competing obligations to distinct groups and cannot satisfy all obligations in Battlefield Triage. Solidarity with the military supports the consideration of favoring the soldier for reasons of national identity, whereas solidarity with the medical community does not. Something has to give, which is why it is a moral tragedy. The virtuous military physician, therefore, must weigh the costs of each course of action. To fulfill her obligations to the medical community would require that she does not use nationality and other non-medical considerations in Battlefield Triage. Since the soldier and enemy combatant are equally injured, justice would demand a random process, perhaps a flip of the coin. Although this may satisfy obligations the military physician has to the medical community, this would be costly to the physician’s military group. If word gets out that the physician decides who to treat based on a coin toss, soldiers, families, and citizens may become frustrated and angry. Soldier morale may go down if it becomes known that a coin flip led to the preventable death of a soldier and the saving of an enemy combatant who had killed (or attempted to kill) other soldiers. As Gross highlights, military solidarity involves a mutual aid promise that military personnel promise to help one another.[31] A military physician is part of the military and, as such, is part of the mutual aid promise, which would appear to be violated if the physician flips a coin. Treating a member of one’s own team may be psychologically more beneficial than treating an enemy combatant and may lead to less moral distress.[32] Finally, treating soldiers rather than enemy combatants promotes broader military and social aims, including returning soldiers to health, maintaining unity of purpose, and minimizing community suffering from a soldier’s death. Favoring members of one’s group, that is, triage based on nationality in Battlefield Triage, would fulfill obligations of military group loyalty, which is contrary to the values and duties of medicine. It does not seem as though showing favoritism in this particular situation is very costly to the medical community or general public, but this is because there is recognition that the physician is in the military. Medicine is impartial to non-medical indications partly because of fairness and to promote public trust in medicine. However, Battlefield Triage is unique, as medicine is being practiced in a non-public, wartime setting. In ordinary circumstances, a patient’s identity is irrelevant, and physicians ought not play favorites. Since Battlefield Triage is not an ordinary circumstance, decisions based on patient identity may not undermine public trust in medicine. In addition, it is contestable that fairness in Battlefield Triage requires that no consideration be paid to one’s nationality. Fairness is about giving each person their due, what is owed to them, and the case can be made that soldiers who place themselves in danger for the sake of the common good or a just cause are owed special attention when they suffer harm in the line of duty. In other words, soldiers voluntarily undergo risk to themselves for the greater good, and society owes them for this sacrifice. This plausibly includes preferential treatment in a situation such as Battlefield Triage. So, while the medical community affirms justice demands non-preferential treatment, the military community can affirm the opposite. The demands of fairness are unclear at best or in conflict in this situation: demands of physician justice decry favoritism, while demands of military justice support favoritism. Triage not based on nationality is arguably unfair and triage based on nationality may not undermine public trust, after all. All things considered, there is a clear rationale for favoring nationality-based preferential treatment in Battlefield Triage. Adopting a nationality-based preference in this situation is more defensible than not. This does not make such a decision ethically right or just. Preference based on nationality is the least bad decision, but it is not morally blameless. It involves one in a serious moral wrong, a wrong otherwise avoided and contrary to one’s character. The virtuous military physician is in a situation in which obligations conflict, and we disagree with Gross, who posits that care of fellow soldiers “is important to the near exclusion of all else.”[33] Gross fails to appreciate the collective virtue of solidarity as applied to those in medicine. The military physician has duties to fellow soldiers but also to fellow physicians, to the medical community, and humanity. To favor a soldier on grounds of nationality violates her duties and responsibilities to this latter group. She is involved in a moral tragedy and can only seek the most just action given the circumstances, yet, at least in virtue ethics, the action remains far from blameless. CONCLUSION We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. As such, the virtuous military physician incurs a moral cost to acting as she does—there is a moral residue. However, despite being a moral tragedy, there are clear reasons to act in favor of treating one’s own, considering group solidarity. As such, these kinds of tragedies are resolvable: virtuous military physicians should favor treatment of their own, although they would do so with sorrow. - [1] Militaries set forth medical rules of eligibility or guidelines used to determine whether a person qualifies for specific medical interventions or treatments in certain circumstances, and these guidelines are binding for a military physician. For example, despite opposition from medical organizations, militaries have adopted reverse triage guidelines for military physicians to follow. For ethical discussion, see Falzone, Elisabeth, P. Pasquier, C. Hoffmann, O. Barbier, M. Boutonnet, A. Salvadori, A. Jarrassier, J. Renner, B. Malgras, and S. Mérat. "Triage in military settings." Anaesthesia Critical Care & Pain Medicine 36, no. 1 (2017): 43-51. https://doi.org/10.1016/j.accpm.2016.05.004 [2] There are issues that are related to this, including the triage of civilians and allied soldiers. We set related issues aside for purposes of this paper [3] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [4] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [5] This is termed the “dual loyalty” dilemma in military medicine and has been described at length elsewhere: Institute of Medicine (US) Board on Health Sciences Policy. Military Medical Ethics: Issues regarding Dual Loyalties: Workshop Summary. Washington (DC): National Academies Press (US); 2008. Toward a Framework for Resolving Dual Loyalties. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214853/ [6] See Kenneth G. Swan and K.G. Swan, Jr., “Triage: The Past Revisited,” Military Medicine 161:8 (1996): 448–452. https://doi.org/10.1093/milmed/161.8.448; Jerome A. Singh, “American Physicians and dual loyalty obligations in the ‘war on terror,’” BMC Medical Ethics 4.4 (2003): 1–10. https://doi.org/10.1186/1472-6939-4-4; Beam, Thomas E. "Medical Ethics on the Battlefield." Military Medical Ethics: Sect. IV. Medical ethics in the military. Medical ethics on the battlefield: the crucible of military medical ethics 2 (2003): 369-402; Hereth, Blake. "Health justice for unjust combatants." Journal of Military Ethics 20, no. 1 (2021): 67-81. https://doi.org/10.1080/15027570.2021.1949782. [7] See Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. Gross, Michael L. "Comradery, community, and care in military medical ethics." Theoretical medicine and bioethics 32 (2011): 337-350. https://doi.org/10.1007/s11017-011-9189-6. Gross, Michael L. "The limits of impartial medical treatment during armed conflict." In Military medical ethics for the 21st century, pp. 71-84. Routledge, 2016. [8] World Medical Association, WMA Declaration of Lisbon on the Rights of the Patient. 5 December 2022, https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ [9] Geneva Convention for the Amelioration of the Condition of Wounded, Sick in Armed Forces in the Field. 12 August 1949. https://www.un.org/en/genocideprevention/documents/atrocity-crimes/Doc.30_GC-I-EN.pdf. [10] List, Justin M. "Medical neutrality and political activism: physicians' roles in conflict situations." In Physicians at war: The dual-loyalties challenge, pp. 237-253. Dordrecht: Springer Netherlands, 2008. 240 [11] Beauchamp, T., and J. Childress. 2013. Principles of Biomedical Ethics, 7th ed. Oxford, United Kingdom: Oxford University Press. [12] Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. [13] Gross, "Comradery, community, and care in military medical ethics," 347. [14] Gross, “Comradery, community, and care in military medical ethics,” 349. [15] Gross, Michael L. "When medical ethics and military ethics collide." Narrative inquiry in bioethics 13, no. 3 (2023): 199-204. 202 https://dx.doi.org/10.1353/nib.2023.a924191 [16] Our argument draws on virtue ethics, from which care ethics derives, and it is worth clarifying how our argument relates to Gross’s. We do not think that the virtue of friendship grounds triage decisions, for we think it is unlikely that the physician and wounded soldier are friends. Instead, as explained below, we think the collective virtue of group solidarity better captures the moral significance of group loyalty and that Gross would agree with us. But since military physicians are part of distinct groups, with competing obligations, the military physician will be forced to sacrifice a value in battlefield triage cases. In other words, we think Gross downplays the dual group membership of a military physician. [17] List,”Medical neutrality and political activism,” 250. [18] Adams,”Triage priorities and military physicians,” 235. [19] London, Leslie, Leonard S. Rubenstein, Laurel Baldwin-Ragaven, and Adriaan Van Es. "Dual loyalty among military health professionals: human rights and ethics in times of armed conflict." Cambridge Quarterly of Healthcare Ethics 15, no. 4 (2006): 381-391. 383. [20] Hursthouse, R. On Virtue Ethics. OUP 1999. 74 [21] Nussbaum, Martha C. "The costs of tragedy: Some moral limits of cost-benefit analysis." The Journal of Legal Studies 29, no. S2 (2000): 1005-1036, 1007. [22] De Wijze, S. (2005). Tragic-remorse–the anguish of dirty hands. Ethical theory and moral practice, 7(5), 453-471, 457. https://doi.org/10.1007/s10677-005-6836-x [23] Hursthouse, 73 [24] Hursthouse, 81 [25] Hursthouse, 72 [26] Aristotle, Politics 1253a8. Reeve, C. D. C., Indianapolis: Hackett Publishing Co., 2017 [27] Aristotle, Nicomachean Ethics. III.6.114a, 34-35. 2002, Nicomachean Ethics, Christopher Rowe (trans.), Oxford: Oxford University Press [28] Byerly, T. Ryan, and Meghan Byerly. "Collective virtue." The Journal of Value Inquiry 50, no. 1 (2016): 33-50. https://doi.org/10.1007/s10790-015-9484-y; Federico, Veronica. "Conclusion: solidarity as a public virtue." Solidarity as a Public Virtue (2018): 495-542. https://doi.org/10.5771/9783845290058. Rehg, William. "Solidarity and the common good: An analytic framework." Journal of Social Philosophy 38, no. 1 (2007): 7-21. https://doi.org/10.1111/j.1467-9833.2007.00363.x [29] Byerly and Byerly. "Collective virtue." 43 [30] Battaly, Heather. "Solidarity: Virtue or vice?." In Social virtue epistemology, pp. 303-324. Routledge, 2022. 304 [31] Ibid., 2011: 341 [32] It might be thought that displaying altruism by helping an enemy combatant at the expense of one’s fellow soldier may be psychologically satisfiying. For evidence that military physicians find it difficult to treat enemy combatants, see Lundberg, Kristina, Sofia Kjellström, Anders Jonsson, and Lars Sandman. "Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties." Military medicine 179, no. 8 (2014): 821-826. https://doi.org/10.7205/MILMED-D-14-00038. Lamblin, Antoine, Clément Derkenne, Marion Trousselard, and Marie-Ange Einaudi. "Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study." BMC Medical Ethics 22 (2021): 1-13. https://doi.org/10.1186/s12910-021-00723-2 [33] Ibid., 2011: 344. (shrink)

When physicians in training enter their clinical years and first begin to become involved in clinical decision making, they soon find that more than the technical data they had so carefully learned is involved. Prior to that time, of course, they were aware that more than technology was involved in practicing medicine, but here, for the first time, the reality is forcefully brought home. It may be on the medical ward, when a patient or a patient's relatives ask that no (...) further treatment be given and that the patient be allowed to die; it may be in ob/gyn, when a 4- or 5-month pregnant lady with two other children and just deserted by her husband pleads for an abortion; it may be in the outpatient setting, where patients unable to afford enough to eat cannot afford to buy antibiotics for their sick child or provide him or her with the recom mended diet. Whatever the setting, students soon find themselv. es con fronted with problems in which an answer is not given by the technical possibilities alone; indeed, students may have to face situations in which, all things considered, the use of these technical possibilities seems ill-advised. But choices need to be made. Some of us may choose to hide behind a mastery of technology. (shrink)

Newborn screening for genetic diseases has developed rapidly in Western countries. These biopolitics raise the question of birth as a sociological “knot” insofar as it is the threshold between the child and the fetus. The question therefore addressed in this text, based on a field study of newborn screening for cystic fibrosis in France, is that of the link between the quest for good health and the elimination of poor health. Do they reinforce each other or, on the contrary, are (...) they contradictory? I analyze the positions of both mothers of screened children and clinicians regarding the following three points: prenatal diagnosis to preclude sets of sick siblings, identification of heterozygous individuals, and generalized prenatal screening. This study shows how increasingly attentive patient care and an increasingly demanding approach to prenatal diagnosis reinforce one another. It also analyzes the role of taking action early on and evaluating the lives of sick or disabled people in this process. In conclusion, I engage a more general discussion about what I suggest calling a “quality life.”. (shrink)

The following is excerpted from Sean Gurd’s translation of Euripides’ Hippolytus published with Uitgeverij this year. Though he was judged “most tragic” in the generation after his death, though more copies and fragments of his plays have survived than of any other tragedian, and though his Orestes became the most widely performed tragedy in Greco-Roman Antiquity, during his lifetime his success was only moderate, and to him his career may have felt more like a failure. He was regularly selected to (...) have his plays performed in the annual festival of Dionysus at Athens. But the plays were performed in a competition, and in the competitions he lost and lost, winning first place only five times in a career that spanned more than forty years. His corpus reads like the remains of a life spent trying to get a few things right and never being quite satisfied: scenes and schematized combinations of elements recur again and again, each time slightly changed. Hippolytus itself is an example: it contains two scenes in which a sick or dying character lies on a couch or a stretcher and is surrounded by silence and grief; he had experimented with such scenes in Alcestis, and would work with them again in Herakles and Orestes. Nor, judging from appearances, was he immune to the desire to score a hit, or to satisfy the audiences and the judges at the competition. Hippolytus is a rewrite of another Hippolytus, performed several years earlier, which scandalized the audience and certainly did not take first place. In that earlier Hippolytus (called by later writers Hippolytus Veiled), Euripides fashioned a Phaedra who was neither ashamed of loving her stepson nor incapable of taking steps to satisfy her desire. The forwardness of her approach to Hippolytus so outraged him that he covered his head with a robe (hence the play’s later title). Euripides liked to write energetic and self-confident women like this. He staged his Medea in 431, just three years before he revised Hippolytus, and in it the jilted title character murders her children in revenge for Jason’s new marriage to a more politically advantageous wife. Another flop: the play came in third of three. Evidently the judges did not like their women showing agency, especially when the consequences were transgressive. “The ornament of women,” wrote another great Athenian a little earlier, “is silence.”i Euripides’ Medea and his first Phaedra had other decorations. So three years after Medea crashed and burned and some time after the first Hippolytus suffered the same fate, he produced another Hippolytus play with a different setting and story. How could this one not have been a reaction to the failure of the first? “Second thoughts are always better,” he has one of his characters say, as though he were offering an apology for his first thoughts on the same story. In this new version, Phaedra is suicidally ashamed of her love, choosing to die rather than have it discovered, and willing to bring down her beloved Hippolytus in the service of the same end. Now it is Phaedra herself who covers her head in shock and horror at her desire. Only an intermediary, a slave of the house and an old crone with her fingers in all sorts of illicit pots, communicates Phaedra’s secret – against orders – and in consequence brings about the demise of two resolutely moral figures. It worked. For his tale of two well-born nobles with an unswerving commitment to moral action, destroyed by the meddling of a slave (and by the hostility of some particularly uncaring divinities), the judges crowned Euripides winner. It was the first time he had won, after almost thirty years of work. *** What Hippolytus wants more than anything else, as he protests with outrage just before leaving Trozen for the last time, is the benefit of due process – oaths, witnesses, an investigation that would reveal who really lusted after whom. Ironic, given that in the first Hippolytus, as far as we can make out, he did get a trial – but too late, and Theseus’ successful processing of Hippolytus failed to prevent his death. I cannot help hearing in the second Hippolytus’ complaints the anger of his authorial semblable who lost year after year by a process of judging that might have seemed brutal to him. Judges took no cognizance of how he worked, how long or hard or why; they just voted, and Euripides lost. But then I hear, in the fate of the first Hippolytus, an even grimmer commentary. Processed or not, we lose. We run aground. At the very least, this might cast a darker shadow on the business of watching or reading a play: in that twilight, things move too fast to make a fair assessment and, in any case, the reasonably high definition of what you see and hear belies the truth of indistinction, the multiplicities just below the surface. Watching is a constrained activity, a form of captivity, but reading is plastic. This translation was begun to supply the script for an audio version of the play, recorded in the spring of 2012, and here and there it sacrifices literalness for sayability and the voices and passions of the actors on that occasion. But it was finished to be read, and engineered to create a reading caught between the poles of specificity and non-specificity that the play itself conjures and relies on at its generative core. Thus two texts: the one clear, perhaps overprecise, respectably modern in its presentation, and the other ancient, a reasonable approximation of the classical reading process, and indistinct in vital ways. Like early modern dramatic texts, the exact provenance and original function of the scripts that have made it down to us are unknown. We do know that the ultimate survival of Hippolytus was thanks to its wide-spread use as a school text. But its relation to the first performance in 428 BCE is a matter only of speculation. Euripides presumably had a fair copy before production began; it was probably modified during rehearsals. The actors may have had copies, too (probably the young men who served in the chorus did not). The chor?gos, a wealthy Athenian who paid for the production, might have been presented with or just made sure to get his hands on a high-quality text, to commemorate the play’s success. Fans might have been able to buy copies. Any one of these sources might have provided the ultimate progenitor of our text. Several of them might have, in fact, if later editors compared and conflated traditions. The plays toured extensively in the Greek-speaking world, and were restaged as repertoire for centuries afterwards. In the process they were subjected to enough modifications by producers and actors that in the later fourth century the Athenian statesman Lycurgus had a law passed prohibiting performances at Athens from deviating from the official “city” text of the tragedies (which he had commissioned). It is unlikely that the city text was the last word; but it marks an important moment in Athens’ role in their dissemination, since after this the major sites of textual curatorship moved overseas, to Alexandria, Pergamum, Rome, Antioch, Constantinople. Any single text of any single play is thus no more than a moment of clarity and stability, crossed and subtended by multiple vectors of change, including that of textual flux (from Euripides’ first drafts to the latest printed text) and that of Euripides’ life work as a writer, in the light of which the Hippolytus is just one attempt to produce something exactly right, to win the prize or finally satisfy himself or prove to himself that all this longing for perfection was a waste of time. I am intrigued by the possibility that a single text might somehow serve as a lens onto this wider zone of indistinction, representing a small region clearly but nonetheless containing a blurred image of the whole, like a Leibnizian monad. After all, no text is a witness: it is, rather, a perception and a performance, and what every Hippolytus must perform is the awkward overlay of singular and plural, social practise and subliminal drive, that structures the tragedy. Modern critical editions can do this by juxtaposing a (relatively) clean and simple text with a textual apparatus reporting variants and theorizing the relationship between textual instantiations. A translation lacks the resolution to catch the fine variations which feed into the construction of an apparatus. But there are other means to hand. Guessing at the exact words of the original text is always just that – guessing – though Hippolytus is less problematic than plays like Iphigenia at Aulis. But we can make a pretty secure guess at what such a text looked like. Texts read by fifth-century readers were fundamentally different from what is presented in the best medieval MSS and printed in modern publications. The texts of Euripides’ time and for many centuries afterwards did not indicate word division with spaces (or by any other means) and were extremely sparing in punctuation, often avoiding it altogether. There was only one “case” of letters – what we call “capitals.” Musical sections were inscribed as though they were prose, without line endings to reflect their rhythm or their rhetorical structure. There was no indication of the speakers within a dramatic text, either. The earliest surviving dramatic texts, which come from over a century after Euripides’ death and a time which was much more elaborate and precise in its textual culture, indicated speaker-change with a little line or paragraphos below the line and a double-point [:] at its end. This convention almost certainly does not date back to Euripides’ own time; it may not even date to Lycurgus. In any case, such indications were understood to be readers’ marks: they did not have the same authority as the text and they were subject to readers’ revisions. At least ideationally, if not in concrete and distinguishable fact, a dramatic text was understood as containing no indication of speaker-change (and certainly none of who was saying what). The reader had to figure that out for him-/herself. The clear, legible, easy texts we are accustomed to reading are the fabrications of medieval and modern reading cultures. The first text, then, presents the translation as the text would have been in the mid-fourth century, perhaps decades after Euripides’ death. The second text processes Hippolytus, makes sense of it and makes it “readable.” That is: too distinct, dangerously so. It gets in your way, conjures fantoms, tries to make you see. Fragments of the Hippolytus Veiled, otherwise almost entirely lost, are juxtaposed with similar passages in the text – not to suggest a reconstruction, but a dialogue and a complex set of reassessments. I have not tried to represent the full variety of textual variants, but I have signalled where, for one reason or another, the text is soft and different editions propose excisions or changes. The two texts must be read together: you, reader, form the bridge between the distinctly seen and the indistinct invisible. You, in the end, will be its mask. *** illsandhateddiseaseswhatcanidoforyouwhatshouldinotdohereisthelightandthebrightairyoursickbedisnowout s idethehouseyoureverywordwastocomeherebutyouwillrushbacktoyourbedroomagainyoufadequicklyyoudelig htinnothingyoudislikewhatyouhaveyoulovewhatyoudontitsbettertobesickthantendthesickthefirstissimpleto the secondattachesheartspainandhandsworkeveryhumanlifeispainfulthereisnoendtotoildarknesshidesbehindclo udswhateverisdearerthanlifeweproveunhappyloversofwhatshineshereforlackofknowledgeofanotherlifethere isnoproofforthingsbeneaththeearthonlystoriessustainus liftmybodystraightenmyheadthebondsofmylimbsareloosenedtakemyhandsandmypalearmsthishatistooheavy formyheadtoweartakeitoffspreadmyhairovermyshoulders couragechilddonttossandturnsoviolentlyyouwillbearyoursicknessmoreeasilywithpeaceandanoblemindallmort alssuffer aiaiiwanttodrinkpurewaterfromadewyspringiwanttoliebackandrestunderthetreesinsomegrassymeadowchildw hycrydontsaythesethingsnearthecrowdhurlingwordsmountedonmadness sendmetothemountainiwillgototheforestwherebeastkillingdogspressthespotteddeergodsilongtoshouttothedo gstoshootthethessalianjavelinpastmyblondhairtoholdthebarbeddartinmyhandwhythisanxietychildwhatdoyouc areabouthuntingwhydoyoulustforflowingspringstheresahillwithwaterjustnexttothetowerwecangetyouadrinkt h ereartemismistressofthesaltlakeandthecoursethunderingwithhorseshoovesiwishiwereonyourplainsbreakings t uds whythrowthesefrenziedwordsaboutjustnowyouweresettingoutforthemountaintohuntandnowyoulongforhorses onthewavelesssand thesethingsneedanoracletotellwhichgodreinsyouinanddrivesyoufromyoursenseschild whathaveidonehowfarhaveibeendrivenfromgoodthoughtsiwascrazyiwascursedbysomepowerpheupheualasn ursecovermyheadagainimashamedofwhativesaidcovermeatearmovesdownfrommyeyeanditembarrassesm eithurtstostraightenourmindanditisterribletobeinsanebesttodiebeforeyoubecomelucidagain illcoveryoubutwhenwilldeathcovermeimoldivelearnedalotmortalsshoulddrinkoffriendshipmoderatelynotfrom th edeepestmarrowofthesoulamindslovecharmsshouldbeeasytoundoorthrustawayortiemoretightlyitisaverydiffic ultweightforonesoultolaborovertwopeopleasiamwrackedbypainforhertoomuchdisciplinecausesmoreharmthan pleasureandwarswithhealthipraisetoomuchlessthannothinginexcessandthewiseagreewithme *** Scene 1 Enter Phaedra and the Nurse; the former is recumbent on a couch while the latter bustles about her with gestures that might be those of a caregiver or a guard. NURSE Ills and hated diseases! What can I do for you? What should I not do? Here is the light, and the bright air; your sick bed is now outside the house. Your every word was to come here, but you will rush back to your bedroom again. You fade quickly. You delight in nothing. You dislike what you have. You love what you don’t. It’s better to be sick than tend the sick – the first is simple. To the second attaches heart’s pain and hand’s work. Every human life is painful. There is no end to toil. Darkness hides behind clouds whatever is dearer than life. We prove unhappy lovers of what shines here for lack of knowledge of another life. There is no proof for things beneath the earth. Only stories sustain us. PHAEDRA Lift my body, straighten my head: the bonds of my limbs are loosened. Take my hands and my pale arms. This hat is too heavy for my head to wear. Take it off, spread my hair over my shoulders. NURSE Courage, child; don’t toss and turn so violently. You will bear your sickness more easily with peace and a noble mind. All mortals suffer. PHAEDRA Aiai. I want to drink pure water from a dewy spring. I want to lie back and rest under the trees in some grassy meadow. NURSE Child, why cry? Don’t say these things near the crowd, hurling words mounted on madness. PHAEDRA Send me to the mountain. I will go to the forest where beast-killing dogs press the spotted deer. Gods! I long to shout to the dogs, to shoot the Thessalian javelin past my blond hair, to hold the barbed dart in my hand. NURSE Why this anxiety, child? What do you care about hunting? Why do you lust for flowing springs? There’s a hill with water just next to the tower; we can get you a drink there. PHAEDRA Artemis, mistress of the salt lake and the course thundering with horse’s hooves: I wish I were on your plains breaking studs! NURSE Why throw these frenzied words about? Just now you were setting out for the mountain to hunt – and now you long for horses on the waveless sand. These things need an oracle to tell which god reins you in and drives you from your senses, child. PHAEDRA What have I done? How far have I been driven from good thoughts? I was crazy, I was cursed by some power. Pheu pheu. Alas. Nurse, cover my head again. I’m ashamed of what I’ve said. Cover me – a tear moves down from my eye and it embarrasses me. It hurts to straighten your mind and it is terrible to be insane. Best to die before you become lucid again. NURSE I’ll cover you. But when will death cover me? I’m old; I’ve learned a lot. Mortals should drink of friendship moderately, not from the deepest marrow of the soul. A mind’s love-charms should be easy to undo, or thrust away, or tie more tightly. It is a very difficult weight for one soul to labor over two people, as I am wracked by pain for her. Too much discipline causes more harm than pleasure and wars with health. I praise “too much” less than “nothing in excess,” and the wise agree with me. ***. (shrink)

One of the theological disagreements in Christianity is the legitimacy of infant baptism. It was not discussed in the early period of Christianity. Nevertheless, it is one of the problems that have been debated especially since the post-reform period. Debates about infant baptism create differences in Christianity. Churches accepting infant baptism, espe¬cially the Catholic Church, acknowledge it as a tradition that has been practiced for thou¬sands of years. According to them, children were baptized by Jesus and the Church Fathers (...) kept doing this ritual. However, most of the Protestant Churches, like Anabaptists, criticize infant baptism as it does not happen based on free will. They claim that such people should get baptized again. According to them, Jesus did not baptize infants and the biblical texts, which are shown as a source of infant baptism, indicate that either Jesus blessed babies or baptized adults. Therefore, theological debates about infant baptism have continued in Christianity. The article discusses the historical process of infant baptism and the arguments presented by different groups about this discussion. The main framework of the article is the discussions between groups about biblical texts and religious identification, especially the post-reform period. Infant baptism is an important issue because it includes modern discussions about differences among churches, Bible interpretation, will, and mind. Since there is no specific study on infant baptism in our country, we can say that the article will contribute to the studies of the history of religions.Summary: The sacrament is one of the controversial topics among Christian churches. It has been discussed structure of the sacraments as well as the legitimacy of these practices throughout the history. Infant baptism is another example over legitimacy debate about the sacraments. Infant baptism is a key topic because it involves fundamental doctrines like salvation, faith, and original sin and conflicts among churches.This study addresses the historical process of infant baptism and the arguments presented by different groups regarding the debates of its legitimacy. It aims to shed light on one of the current debates of various groups in the post-reform period, especially among the Protestants. Initially, we discuss the value of baptism in Christian theology, then the histori¬cal process of infant baptism, and finally the arguments of groups that accept and do not accept infant baptism. Although there are various studies about baptism in our country, there is no specific study assessing infant baptism. Therefore, we think that this paper will augment the existing literature in the field.Baptism is the most meaningful sacrament in Christianity as it is an indicator of being a Christian and the first step of the way to salvation for Christians. It is also a unifying sacra¬ment because it is accepted by the Roman Catholic, Eastern Orthodox, and Protestant Churches. Catholics and Orthodox Churches agree on the seven sacraments (baptism, con¬firmation, Eucharist, penance, anointing of the sick, marriage, and holy orders) with a few exceptions. However, since the Protestants adopt an understanding of religion based upon the Bible, they only accept the baptism and Eucharist mentioned in the Bible as a sacrament. Although the Protestants agree on baptism, they have opposing views about infant baptism. The only source between the Protestant Churches about infant baptism is the Bible. These groups accept only Biblical texts as a legitimate source, not the Church fathers. However, the debate on whether the references in the Bible refer to the baptism of babies or the baptism of adults has reached to today. Since adults were baptized during the spread of Christianity, there was no significant debate about infant baptism in the early period. Generally, Church Fathers did not state infant bap¬tism as a systematic sacrament, but rather as a spiritual blessing. Therefore, baptism was accepted as a ritual that involves the infant, adult, and patient baptism in Christian litera¬ture. However, with the emergence of some heretic groups against infant baptism, the meaning of infant baptism and adult baptism has been used differently by Christians. As a result of the first discussions between heretic groups and the Church Fathers, some defense attempts of infant baptism have started in the Christian world. On the one hand, theologians struggled against those who are against infant baptism; on the other hand, the Church de¬cided to support infant baptism in councils. It was accepted that babies should be baptized even if they cannot speak during the sacrament and cannot answer questions about faith. It became widespread after Christianity was accepted as an official religion by Rome, and it was officially accepted by the Catholic church in the 13th century. Infant baptism discus¬sions have increased again after the Reform. While Catholic, Orthodox, Anglican, Lutheran, Methodist, Presbyterian, and Congressional churches accept infant baptism; groups such as Baptists, Pentecostalists, Anabaptists, Seventh-Day Adventists, Jehovah's Witnesses, and Last-Day Saints are against infant baptism.According to churches practicing infant baptism, babies should be baptized as soon as pos¬sible for God's divine grace and salvation. However, the churches that oppose infant baptism claim that this is a meaningless reason. According to them, baptism was only performed at Easter and Pentecost in the early period and even a candidate who wanted to be Christian was tested for a length of time. This practice reveals the connection of baptism with wisdom and faith. They claim that baptism is a meaningful and dogmatic action, not an ordinary practiceç Therefore, infant baptism, which is not based on reason, weakens faith. These churches point out that this ritual is deceptive, and it will lose children's faith over time since it is not supported by faith. They also criticize the idea that this baptism will make the person a member of the public. In this regard, they emphasize that members of the current society no longer live in villages and do not consist of groups recognizing each other. Thereby, It is clear that the membership of the current society has lost its sociological meaning in the modern society.Criticisms of these churches refusing infant baptismhave become more noteworthy in the recent period by the contributions of authors, Karl Barth (b. 1966) and Emil Brunner (d. 1966). All these criticisms focus on the fact that infant baptism is not based on the essential references of religion, but rather on the practices of church fathers. Therefore, they argue that families, who believe but not investigate, baptized babies only for the tradition. In other words, people care about society, not religious beliefs, but according to these groups, this is meaningless anxiety. These discussions reveal infant baptism is not only theological debate, but also socio-cultural.In our opinion, most of the references in the texts shown as evidence for infant baptism point to the inseparable bond between God and children, like in the Old Testament. We think that claim of these groups that faith requires a level of consciousness is a consistent criticism. In this context, it can be stated that the criticisms of the infant baptism in the post-reform period are effective and that groups who believe in this baptism could not respond to these criticisms through sacred texts and rational proofs. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:In Search of FaithKate RowlandSometimes I’m jealous of my patients’ faith. As a former happily religious person I miss the benefits I used to get from an active faith. I know that some of my patients must struggle with their faith, and I know the struggle probably affects their well–being. For those who simply believe or those who simply don’t believe, it’s easy. And for those who do believe, (...) there can be so much serenity and so much reward.As a doctor, I spend a lot of time reading science, weighing evidence, and making recommendations. Religion has been a respite from this. Faith, for me, has never been a series of decisions based on the best available evidence. I could analyze it as much as I wanted, peel its layers apart, question it, but in the end, it was just faith, not a hypothesis. It has always been something that I believe (or don’t), and practicing my faith had always been a relatively pleasant decision of figuring out what kind of community I want to share in.My faith life has been in shambles for the past several years. I feel distant from and unwelcome in the church where I was raised, and I haven’t found anywhere else to land. I cannot decide how to raise my own small children. I want them to have grounding in God, but I can’t decide how much I believe in God anymore, and I am fixated on the idea that I don’t want to be hypocritical or lie to [End Page 210] them. I don’t want them to see me worshipping in a way that is not really authentic to me.My husband is agnostic—literally—on the issue. He is open to introducing a loving, kind, forgiving God, but unsure about a God incarnate. We both worry about the identity with a particular religion usurping the actual relationship with God: I am [religion], therefore I believe [this], therefore my God does [this] or is [this].And so all of these fears and doubts have led us to live with no religion, and no outward faith. Our children attend a parochial nursery school run by a religion other than one where we were raised, and they have an apparently happy but neutral opinion of religion and God. They understand ceremonies. At age four, they have a more active faith life than I do, since they attend weekly services at school. But then, they have fewer choices than I do. They do what the teachers tell them. They would do what I told them to do, if I could ever decide what I believed in.I spend so many hours a week with my patients that they have become my main source of demonstration of active, living faith. I know that they share mostly good parts with me. I see so much of the good because I mostly see patients who get to choose how to practice their own religions; they don’t feel oppressed by religious or culturo–religious demands or expectations. It’s interesting that I see the positive sides of their faith, not the struggle, because I otherwise see a lot of the struggling parts of their lives. I see the flinty, edgy woman, the patient who has spent more time in the hospital in the past month than I have, the woman who is sick of her low platelet count that keeps her from living a normal life. And every day she has some message of faith: she tells our medical team what Bible passage is keeping her strong, she tells us how God watches over her when we tell her that her counts are better, she tells us to have a blessed day. Sometimes she curses at the hospital or her condition or at her medications, sometimes at us. So far her faith is unshaken.I take care of a woman who has burning mouth syndrome, a chronic condition that causes her lips, her tongue, and her palate to feel as though they are on fire. Eating makes it worse, drinking makes it worse, breathing makes it worse... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Everyday Utopia: What 2,000 Years of Wild Experiments Can Teach Us About the Good Life by Kristen R. GhodseeMark A. AllisonKristen R. Ghodsee. Everyday Utopia: What 2,000 Years of Wild Experiments Can Teach Us About the Good Life. New York: Simon & Schuster, 2023. 352 pp., hardcover, $29.99. ISBN 9781982190217.Kristen R. Ghodsee has written a wide-ranging, highly readable, and commendably radical vindication of utopian thought and experimentation. Everyday (...) Utopia is aimed at the educated lay reader—itself, perhaps, a utopian projection—rather than specialists. Nevertheless, all but the most erudite and cosmopolitan of scholars will encounter unfamiliar and compelling utopiana within its pages. While her earlier book, Why Women Have Better Sex Under Socialism: And Other Arguments for Economic Independence (2018), concentrated on "state-sponsored solutions" to the deprivations of capitalism and patriarchy, the present volume sets its sights squarely on the private sphere, and utopian visions "for rearranging our domestic lives" (17).Ghodsee situates this turn to the domestic in two contexts. The first is the COVID-19 pandemic, which revealed the frangibility of the international commitment to gender equality. "Women around the globe woke up and realized that decades of feminism had done little to reverse the social expectation that mothers, sisters, wives, and daughters should provide care for young children, elderly parents, and sick relatives, as well as perform the emotional labors that hold families together in times of crisis," she laments (xii). Everyday Utopia's second context is the spate of recent works of "popular neo-utopianism," including Rutger Bregman's Utopia for Realists (2017), Aaron Bastani's Fully Automated Luxury Communism (2019), and Peter Diamandis and Steven Kotler's Abundance: The Future is Better Than You Think (2012) (14). What Ghodsee finds wanting in this discourse is its myopic focus on the public sphere, and its unspoken presupposition that our private and domestic lives have no such need of utopian renovation. But it is just this presupposition [End Page 285] that the COVID-19 lockdown discredited, although many other indicators (runaway housing and childcare costs, the environmental crisis, the epidemic of loneliness) already suggested as much. Ghodsee rightly insists that "where we reside, how we raise and educate our children, our personal relationship to things, and the quality of our connections to friends, families, and partners impact us as much as tax policies, the price of energy, or the way we organize formal employment" (14). As utopian thinkers from Plato forward have understood, moreover, it is short-sighted to suppose that sweeping economic and political transformations are possible without a concomitant rethinking of the "intimate worlds" that subtend these public domains (15).Accordingly, Everyday Utopia devotes its succeeding chapters to examining alternatives to the dominant institutions of the contemporary private sphere, including the single-family household, the monogamous couple paradigm of childrearing and mating, and the institution of private property. In each case, Ghodsee plumbs the past and limns the present to highlight utopian alternatives to contemporary norms. Among this book's greatest strengths is its consistently international range of examples and admirably sustained commitment to feature "experiments that have received relatively less attention" in the extant literature (xv).Take, for example, the chapter on communal alternatives to single-family homes. Ghodsee includes many of the usual (and eminently worthy) suspects: Buddhist and Christian cenobite monasteries, Fourierist phalansteries, Israeli kibbutzim, and the Corbusier-inspired "microdistricts" of the former Eastern bloc (47). But we also learn of less canonical phenomena, such as the Neolithic proto-city of Çatalhöyük, "one of the first major settlements in the world," where as many as eight thousand people lived in an essentially contiguous structure, in highly egalitarian and likely non-consanguineous households (32). Or consider the Beguine nuns, a lay order founded in 1190 that survived, albeit in attenuated form, into the twentieth century. The Beguine lived communally in urban areas, enjoying liberties unthinkable not only to their cloistered counterparts, but to virtually all their female contemporaries: they brewed beer, made lace, taught school—and traversed the streets unchaperoned. The chapter concludes with a discussion of contemporary cohousing. In Denmark, roughly one percent of the population was living in co... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Standing UpEmily QuinnA 10–year old and her mother walk into a male gynecologist’s office. That sounds like the beginning of a sick joke, right? Imagine how it must have felt to actually be that 10–year–old. I walked into the Salt Lake City ob–gyn office, terrified out of my mind. It was the year 1999 and due to the recent accessibility of the Internet, there was a surprising amount (...) of information about complete androgen insensitivity syndrome (CAIS) available. There was also an active and prominent support group for women with CAIS and other similar conditions. Despite all of this, I was standing in the office of a doctor who knew nothing about my body. He did not direct me to any actual support, and for the next twelve years I went from doctor to doctor, none of them really knowing what to do with me. For as much as I was in and out of the doctor’s office, I never seemed to receive any “care.”It was really difficult to have doctors who knew nothing about my condition. It was scary to be a kid with hundreds of questions but without an adult who had the answers. So many doctors were excited to look at me, to talk to me, to get the chance to meet me. As a child it made me feel like a freak. I felt alone, and scared, like I was on parade for all of these people who didn’t know anything about me except that I was “special.”I was savvy enough to turn to the Internet for help, but searching for “sex disorders” online was a terrifying thing to do back then. Even now, it’s not a safe space for a pre–teen looking for answers. I was so scared and ashamed of my body, and I desperately wanted someone to talk to about it. I found articles about celebrities who were rumored to be like me, and I saw the word “hermaphrodite” thrown around as carelessly as it had been used in my doctor’s office. I wished desperately that one of those celebrities would admit to having a body like mine. Because if any of them were like me, maybe I wouldn’t be the freak that the adults made me feel like I was. Maybe then I wouldn’t be so alone.As hard as all of this was, in a way my doctor’s lack of knowledge turned out to be both a blessing and a curse. I felt cursed and ashamed of this different, “broken” body that couldn’t be “fixed.” I felt like a problem that nobody had the solution to. I was told so many lies—that I would definitely get cancer, that I could never have sex, that I needed surgery immediately. Not once was I ever told the truth—that there were hundreds of others out there I could talk to, that I didn’t do anything wrong, that I was going to be okay. My doctors didn’t point me in the direction of a support group or a therapist who could help me work through what it all meant. In Utah, the most important thing a woman can do is to have children, and it was devastating to learn I would not to be able to conceive. I wish any of my doctors had pointed me in the direction of a professional I could talk to about it.It wasn’t until I was older that I discovered the blessing amongst all of this pain. As it turns out, my doctors were so entirely ignorant about my condition that they didn’t know how to remove or even find my internal testes. I’ve managed to make it 25 years without surgery. Now, when I speak to medical students, many of them balk at this idea that surgery is something I’ve “escaped.” But I know how many affected individuals see it as I do. It’s incredibly lucky that somebody with CAIS is surgically untouched, and I fully believe that rarity to be the saddest thing. It shouldn’t be the norm to... (shrink)

Children in the pediatric intensive care unit are indisputably in a vulnerable position, dependent on nurses to acknowledge their needs. It is assumed that children should be approached from a holistic perspective in the caring situation to meet their caring needs. The aim of the study was to unfold the meaning of nursing care through nurses’ concerns when caring for children in the pediatric intensive care unit. To investigate the qualitative aspects of practice embedded (...) in the caring situation, the interpretive phenomenological approach was adopted for the study. The findings revealed three patterns: medically oriented nursing—here, the nurses attend to just the medical needs, and nursing care is at its minimum, leaving the children’s needs unmet; parent-oriented nursing care—here, the nursing care emphasizes the parents’ needs in the situation, and the children are viewed as a part of the parent and not as an individual child with specific caring needs; and smooth operating nursing care orientation—here, the nursing care is focused on the child as a whole human being, adding value to the nursing care. The conclusion drawn suggests that nursing care does not always respond to the needs of the child, jeopardizing the well-being of the child and leaving them at risk for experiencing pain and suffering. The concerns present in nursing care has been shown to be the divider of the meaning of nursing care and need to become elucidated in order to improve the cultural influence of what can be seen as good nursing care within the pediatric intensive care unit. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Sophocles’s Enemy Sisters: Antigone and IsmeneWm. Blake Tyrrell (bio) and Larry J. BennettAt the core of the Oedipus myth, as Sophocles presents it, is the proposition that all masculine relationships are based on reciprocal acts of violence. Laius, taking his cue from the oracle, violently rejects Oedipus out of fear that his son will seize his throne and invade his conjugal bed. Oedipus, taking his cue from the oracle, (...) does away with Laius, violently rebuffs the sphinx, then takes their places—as king and “scourge of the city,” respectively. Again, Oedipus, taking his cue from the oracle, plots the death of that unknown figure who may be seeking to usurp his own position. Oedipus, Creon, and Tiresias, each taking his cue from the oracle, seek one another’s downfall.All these acts of violence gradually wear away the differences that exist not only in the same family but throughout the community.—René Girard, Violence and the SacredRené Girard does not include feminine relationships in his assessment of the Oedipus myth, yet the same redundancy that characterizes the males marks the females.1 Jocasta conjoins in one person multiple and redundant social roles: she is the mother and wife of the same person, for which she [End Page 1] hangs herself, leaving for Oedipus “many pains that a mother’s furies fulfilled” (Homer Odyssey 11.279–80). Her daughters, their father’s sisters, manifest kinship redundancy in two persons. Incest produces circularly, reverting to a sibling of the parent rather than moving forward with a descendant. The absence of linear progression from one generation to the next creates a sameness and equilibrium that thwart separation and individuality. Oedipus’s brothers/sons fail in their adult roles, because neither can overcome the other’s right to the throne of Thebes and the mastery of its royal household. They are enemy brothers locked in reciprocal violence.2 Antigone and Ismene have escaped notice not only as enemy sisters but even as products of the same incest. Audiences for Sophocles’s Antigone have viewed them as “normal” women and cooperated with his characters in emphasizing the differences between them. They have assumed from Antigone’s betrothal to Haemon and resistance to Creon that she is the elder, more mature sister.3 They tend to accept without question that Antigone engages in burial rituals with Polyneices’s corpse (241–58) and returns to it (442–35).4 Bernard M. W. Knox’s critically powerful concept of the “Sophoclean hero” has bolstered this view of Antigone while reducing Ismene to a foil, and abetted the tendency of modern producers of the play to cast an older or more famous actress in the role of Antigone.5 Naturalistic readings like that of C. M. Bowra—“seeing that Ismene is her only close relative in the world, Antigone is remarkably cold to her”6—have masked the source and hence the vehemence of Antigone’s fury.That the reciprocity of the violence between Ismene and Antigone has gone unnoticed is understandable in view of the familiarity of the conflict between their brothers. Males in Greek society pursued difference by striving to excel as aristoi (best) in competition for prestige, wealth, and power.7 Whenever Eteocles and Polyneices came together, each asserted a right to Oedipus’s household and throne that was equally matched, and violence ensued from the equilibrium. On the other hand, Greek women were not supposed to compete with one another for distinction. They wove wool for clothes, maintained the household, and cared for the children, the sick, and the dead, activities that required cooperation away from public view.8 Proximity to other women was the norm and desideratum. Moreover, lawgivers like Solon based their funeral legislation on the premise that every woman wanted to participate in mourning.9 For the sake of public tranquillity, legislators tried to limit the numbers of women participants by imposing restrictions according to degrees of kinship, for instance, to children of fifth cousins. In this context, women were interchangeable, and the places they held during birth, coming of age in wedding ceremonies, and death, [End Page 2] were open to more than one woman. Closeness and... (shrink)

Chronic kidney failure is a serious somatic disease. Addressing the issue of living with a chronic disease means fully considering the patients’ entourage, their families, and those close to them, especially their children and spouses.Objectives: The present paper focuses on the couple’s psychological experience when one of them suffers from a chronic disease, in this instance kidney disease. In particular, how is the spouse affected by the treatment provided? The aim is not only to see how care for (...) sick people can be improved, but also, more specifically, how relatives and especially partners can receive attention.Methodology: A qualitative approach is not only adopted, being based on the psychotherapeutic follow-up of the partners of patients with chronic kidney disease, but also of the patients themselves, addressing the matter of their life as a couple. Three couples were considered, and two case studies are presented here. The issues that cut across these different situations are examined.Results and Discussion: Some couples show considerable resourcefulness. However, over the years, that capacity for adaptation and inventiveness can also be interrupted by the periods of greater suffering and even despair, especially when the somatic pathology becomes chronic. Many spouses talk about how living with a sick partner weighs down on them, causing severe fatigue. Some aspects of the illness can also become traumatic. The disease regularly disrupts the daily life of the couple and the family. This leads to a reworking of family relations. Each couple has its own history with the condition. As it emerges, it can disrupt the bonds of filiation, especially when the illness is hereditary. Making psychological care more accessible to the partners involved constitutes a major challenge for our hospital care systems. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Moral Responsibility in a Context of Scarcity:the Journey of a Haitian PhysicianPaul PierreAlmost all Haitian physicians have been involved in some sort of "social movement" at one point in their professional life. In a country characterized by a natural inclination to question authority, fighting the status quo of the ineffective, corrupt and disorganized [End Page 89] Haitian health system often appears to be the right thing to do.In 2002, (...) I played an active role in a large protest movement for better working conditions at the largest health facility in Port-au-Prince: the General Hospital (GH). Port-au-Prince is the capital and economic center of Haiti. It is home to close to a third of Haiti's ten million people. At that time, the situation at the GH facility was dire. All of the 400 beds at the GH were dirty. The staff was underpaid and unhappy. Drug and medical supply stock-outs were routine. Medical equipment was rarely maintained and only one of the six operating theatres in the surgery block was working. Unsupervised physicians in training (like me) were the main health care providers. Attending physicians were busy running their own private clinics, and most of them would come to the hospital solely to "recruit" the less poor patients for their clinics. As physicians-in-training, we had the responsibility of caring for the poor, but we had no means. We grew frustrated and angry witnessing our powerless patients losing legs, arms and their lives for lack of care. On many occasions, I had the parents of my patients buy the gloves that I would use to examine their sick relatives. I've seen patients fighting for the inheritance of medications left by others who had just passed away. There was no way for this hospital to fulfill its mission, and no way for its staff to deliver anything other than mediocre care. We could not accept that situation at such an early stage in our medical development, and so we refused to continue to work. We went on a strike, which completely paralyzed the delivery of care at the hospital for nearly two months. After intense negotiation, the strike ended with a signed agreement with the Minister of Health that addressed, more or less, the reasons of our movement. However, the implementation of the agreement was permanently delayed by other competing "state emergencies" including a general insurrection.At the time of our movement, I thought we were making history. After witnessing 11 "social movements" that similarly paralyzed the GH in the following decade for reasons identical to ours, I am now convinced that we were not. We were temporary actors performing in the cynical play of scarcity on permanent display in Port-au-Prince. The social movement that we started ended up hurting the very same people that we were trying to help.Extending access to heath care to poor people seemed to me at that time to be too complicated and too expensive for an unorganized state like Haiti. I realized that local protests could, at best, influence the allocation of local resources. But so-called local resources are so limited in "resource-limited" countries. Haiti spends only $40 U.S. dollars per capita for health care. This is not enough for good care. The options we were provided were not real ones—since all of them would end in more suffering. The case of providing health care to poor people needed to be approached differently.I was born in Port-au-Prince at the same general hospital in which I would later work. I am the third of four children, and the first male child in my family. My father made me understand very clearly that my first responsibility was for my siblings. My sisters made me understand equally clearly that I had no authority over any of them. I ended up with a lot of responsibility but with very little authority. The few of us who completed school, entered university, studied abroad and "emerged" were considered, to some extent, responsible for the others—the ones who couldn't go to school, university, or abroad, the ones who had "sunk... (shrink)

The ArgumentPain has important biomedical socioanthropological, semiotic, and other facets. In this contribution pain and the experssion of pain are looked at from the perspective of evolutionary biology, utilizing, among others, cross-cultural data from field work in Melanesia.No other being cares for sick and suffering conspecifics in the way humans do. Notwithstanding aggression and neglect, common in all cultures, human societies can be characterized as empathic, comforting, and promoting the health and well-being of their members. One important stimulus triggering (...) this caring response in others is the expression of pain. The nonverbal channel of communication, particularly certain universal — i.e., culture-independent facial expressions, gestures, and body postures, convey much of the message from the painstricken person to the group.These behaviors signal the person's physical and psychical pain, sadness, grief, and despair in ways very similar to the signs given by infants and small children: the body loses tonus and sinks or drops to the ground, the gestures are those of helplessness. Pain and grief may be so strong that control is lost not only over the body's posture but also over the mind's awareness. In such cases the afflicted person may carry out actions endangering himself or others. In general, these behavior patterns resemble those of infants in situations of distress and danger, and it is not surprising that the response of the members of the group is basically parental: taking care, assisting and consoling.Perceptive and behavioral patterns which developed in the course of avian and mammalian phylogeny to serve the well-being of the young have proven, as was shown by Eibl-Eibesfeldt, to be powerful building blocks for actions in other spheres of human interaction. Love is one such field, the reactions to a conspecific suffering pain is another. (shrink)

The study of the cultural activity of the Spiritual missions of the Russian Orthodox Church in various regions of Russia is one of the urgent tasks in the context of the problematic field of the theory of regionalism, cultural studies and socio-philosophical knowledge. Russian settlements on the territory of the Yenisei River basin and the entry of ethnic groups and territories of Yakutia and Buryatia into the Russian Empire has become one of the most important stages of the integration of (...) the ethnic groups of Siberia into a single statehood. The Irkutsk Spiritual Mission received a more perfect organization, institutionalized by increasing the number of missionary camps, which for successful Christian activities carried out among pagans allowed the formation of school educational institutions for the education and upbringing of a new Buryat generation of children in the doctrinal Orthodox canons, and Russian cultural traditions. In this regard, one of the key tasks of the missionaries was to establish a rational view of further life in new Christian-type formations, which was realized in socio-cultural activities: providing medical care to sick representatives of other ethnic groups, a friendly attitude to people of a different faith and a sincere desire to guide them on the path of righteousness, etc. It should be noted that the largest share of foreigners in this territory belonged to Buddhists, which was reflected in the influence of lamas on doctrinal issues, including economic ones. Since Buddhism in the Russian Empire belonged to the section of tolerant religions, direct (administrative) pressure on it was impossible. There remained funds of an exclusively spiritual nature, to which Orthodox missionary work was directed. Today in the Russian Federation, Buddhism, as well as Islam, Catholicism and Protestantism, as well as some other faiths belong to the category of traditional religions, which organizationally operate within the framework of the modern Russian Constitution. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Navigating Hard Situations that Medical School Cannot Prepare You ForJenna BennettI imagined my first experience with grief as a medical student would be peaceful and measured, prompted by the quiet and peaceful [End Page 88] passing of an elderly individual who lived a long life, surrounded by loving family members comforting each other and reminiscing. Of course, I knew things would get harder—I just didn't expect it to be (...) during my first clinical experience as a medical student.My vision for my first experience with grief as a medical student was idealistic, but I was not unfamiliar with grief on a professional or personal basis. Prior to medical school, I was an aide at a long-term care facility. Many patients were on hospice, so end-of-life care and conversations took place daily without fear or shame. Deaths in this setting had happened as I envisioned—a natural course after a long life. Most of the time, the patients and their families were prepared and accepting. It was, of course, a somber occasion no matter how prepared everyone was, but death was almost never unexpected or met with anything other than tearful acceptance. As an aide, I felt honored to provide care at the end of one's life.In my personal life, I had similarly lost elderly family members. Although it was upsetting to have my loved ones pass away, no matter how much time we had to prepare, my family and I were never blind-sided and had time to discuss final wishes and cherish time together; however, for my family, there was one exception to this. When I was young, my father unexpectedly passed away from a heroin overdose. He was alone when he died, not even 30 years old.For a long time, I was ashamed of my father's death. I was very young, and I didn't understand the nature of addiction. I was angry, confused, and embarrassed. As a result, I created my own version that I thought was more palatable, for years telling everyone he had passed away surrounded by a loving family after a long battle with lung cancer.Over the years, I came to terms with my father's death. I learned that substance use is a disease, not a choice. I forgave my dad, along with eventually also forgiving myself for my years of denial and shame. His struggles and death ended up being a large motivation to pursue a career in the medical field, along with being a key part of my identity that I no longer hesitate to share. Despite having matured in this way long before starting medical school, I now recognize I still had some lingering rejection of the wide reality of tragedies that exist in our world.My first clinical experience as a medical student was a 3-week rotation with pediatric hospitalists. By the halfway point of this rotation, I was having a great time and was excited to finally be working with patients after months of sitting in lecture halls and late nights in the library. Of course, all the children we saw were sick, which was hard to see, but all the patients either had viral infections or chronic, but usually non-life-threatening, conditions. Therefore, everyone in our service rapidly improved with minimal interventions, and almost everyone was able to go home after just a few days. I was also encouraged by how loving and knowledgeable all of the family members of the patients were. Even when family members were upset and occasionally took frustrations out on the physicians I was working with, I was not shaken and empathized entirely, as I knew the families' reactions resulted from love and concern for their children. Overall, these initial experiences with patients and their families maintained my optimism that things wouldn't get emotionally hard for me anytime soon, but life, and subsequently medicine, do not wait for you to be ready.I was chatting with my attending one morning toward the latter half of this rotation. Another care team came into our small workroom, which was not unusual, but I could immediately tell something was different... (shrink)

This pastoral-theology-based reflection on hospital chaplaincy, set within the horizon of the pastoral situation of Germany in the post-secular (!) age, introduces the perspective of a consolation-oriented ministry, as this was developed by Ignatius of Loyola. Such a pastoral care for the sick, as integrated into the basic offices of the church, presents a graded model for action: while human accompaniment is offered to all, spiritual ministry is restricted, but realized in an ecumenically encompassing sense. Spiritual and ritual (...) care for members of other religions, while these members are to be addressed according to the principles laid down by Vatican II, is severely limited for reasons of identity and alterity. In all cases, however, Christianity is presented as “therapeutic religion”. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Pains And Gains Of Rural Health Practice:Lessons Books Never TaughtSridevi Seetharam, Bindu Balasubramaniam, G. S. Kumar, and M. R. SeetharamHow The Journey BeganIn the early 1980s, as fresh graduates from Mysore Medical College in southern India, we were brimming with a zeal to "cure the sick" and "change the world." We had an ideal of evidence-based, rational, ethical and equitable health care and set out to serve (...) rural and under-served communities which included displaced forest-based tribes. In the initial years, with the naivety of the inexperienced, we believed that by correcting the dehydration of the doe-eyed six-year-old Mare and giving her a free course of antibiotics, we had made health care accessible to her. Much to our dismay, within a month, Mare was back in the outpatient clinic, with diarrhea all over again and looking thinner than ever. We realized that it was a losing battle to keep her healthy as long as she continued to drink water from the same contaminated stream, live in unhygienic surroundings, and eat only the paltry meals that her family could barely afford. We gradually began to connect these living examples to what our preventive medicine text books had stressed all along—there are many social determinants of health which, if left unaddressed, do not permit realization of the vision of health for all.Such instances continually pulled us out of the hospital building and into the villages and tribal hamlets. We discovered that our textbook of Preventive and Social Medicine (Park, 1986) (P&SM as we used to call it), was our most valuable possession. [End Page 106] We devoured the descriptions of national health programs, sanitation procedures, water treatment protocols, and maintenance of cold chain for vaccines with a completely new perspective. We discovered the Manual of Basic Techniques for a Health Laboratory, (World Health Organization, 1980) detailing how to set up a laboratory with low cost, reliable and simple methods. We learned to drive a jeep to haul supplies and patients. To step up the level of clinical care, some of us pursued post-graduate programs and equipped ourselves to provide more specialized care too. It has been over two decades since we embarked on this journey. We have encountered a variety of perplexing dilemmas with no clear solutions. We have sometimes been compelled to adopt health practices that were not really evidence-based, seemingly irrational, inequitable and even downright unethical. This narration describes only a few of our thousands of cases, and hopefully conveys our periods of self-doubt, despair and hope, as well as, the challenges we face to reconcile with the difficult choices we are forced to make every day.Unforeseen Challenges in Saving Mothers and ChildrenHigh maternal and child mortality rates have been one of the most disturbing aspects of the health care scenario in rural India. To ensure immunization of all children, health workers with vaccine carriers go from village to village and hamlet to hamlet to reach those infants that would have missed visits to the immunization clinics. Our grass-root workers facilitate these visits by identifying households with such children. Occasionally, they encounter families who spirit away the infant into the adjoining woods as soon as the health worker is seen approaching, and blandly proclaim that the child is not at home. Despite reassurance and counseling about the safety and necessity of the vaccine, their apprehensions and misconceptions are insurmountable. What is the extent of the responsibility of the health worker? Is it ethical to hunt down the child and force the administration of the vaccine in view of the public health gains, besides the child's welfare?A few months ago, a pre-term neonate was admitted to our hospital, but worsened and needed referral to a higher centre in the city. The family refused to go despite repeated persuasion and detailed explanation about the technical limitations of care at our centre. From the family's perspective, the variety of social, cultural, and monetary challenges they would face in the city were themselves limitations for care. We were compelled to retain the baby and continue giving the best care we could.Two... (shrink)

In response to cancer, patients may be thrown into precarious processes of remaking their purpose, identity, and connections to the world around them. Thoughtful and thorough responses to these issues can be supported by person-centered phenomenological approaches to caring for patients. The importance of perspectives on illness offered by theoretical phenomenology will become apparent through the example of the experience of nausea, or perhaps more accurately put—chemo sickness. The focus here is on how chemo sickness alters one's way of relating (...) to the world. I will examine the phenomenon of nausea through the lens of the phenomenological concept of mood—an existential feeling that engenders a diffused tone permeating through one's world and shapes the envisioned possibilities on one's horizon. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:If You’re Not Part of the Solution...Sarah GilesI worked on an island that lured people to their deaths. I have come to realize that there are certain resources that every population must have in order to continue to exist. Health care providers are needed if a group is to continue to reside in one place. Without nurses and doctors, people tend to refuse to go to a location (...) or choose not to stay. Perhaps if doctors like me refused to work in places where people have their basic human rights ignored, those places would cease to exist. It’s wishful thinking, but it’s the only way I can imagine the events of December 15th, 2010, could have been prevented. [End Page E11]Australia has a large offshore detention center on Christmas Island, a tiny dot in the middle of the Indian Ocean. Housed in a collection of prison–like facilities are men, women, and children who have come to an Australian Island claiming they are refugees. They have paid an average of $10,000 (U.S. dollars) to be smuggled by boat from nearby Indonesia and are then, usually, intercepted by the Australian navy or coast guard, and brought to the island to await processing. This processing can take two to four years and, even then, it can end with deportation. The asylum seekers spend years in a massively overcrowded and unstimulating purgatory.To say that I was not familiar with the political situation on the island would be a farcical under-statement. As a Canadian family doctor, I went to work on Christmas Island because of its exotic location and reputation for world–class SCUBA diving. It sounded like a dreamy place to do a locum. The little research I had done told me that there was a detention center on the island, but I had been told that I would only deal with those patients if they were sick enough to come into hospital. I didn’t imagine that I would end up feeling culpable for the deaths of 48 people who dreamed of restarting their lives in Australia.On December 15th, 2010, a rickety boat carrying approximately 100 asylum seekers somehow slipped past the navy and coast guard into the water just off of Christmas Island. The weather was foreboding and the waves were massive. As the boat approached the island, it lost power and, horrifically, smashed into the cliffs, leaving an estimated 48 men, women, and children to drown and an almost equal number in need of rescue and medical attention. My name was on the call schedule that day. All survivors were brought to the hospital. Our worlds collided.At the time, I thought it was good luck there was an extra doctor on the island that day. I was relieved that we were able to cope with the mass casualty situation and that only few survivors were sick or injured enough to require evacuation to the main land. Three years later, I wonder if the accident would have happened at all had we not been there.I had felt smug providing care in the public hospital, believing it was morally superior to working as a mercenary at the detention center. But I now realize that all of the health care providers had a role in allowing the tragedy to occur. What would have happened if all of the doctors refused to work with people held under those conditions? If that critical infrastructure of health care were not available on the island, the detention center could not be there. If the detention center weren’t there, the government would stop processing people there and perhaps desperate people would stop risking their lives to get to Christmas Island. Maybe the women and men who lost their children or the children who lost their parents would never have gotten on that boat. Maybe.Parts of that awful day stay with me. My job as a doctor prevented me from offering the compassionate care I wanted to provide and forced me to turn into a medical conveyor belt. When a young patient was laid in front of me, I assessed her, started... (shrink)