This paper deals with the moral issues relevant to medical decisions to terminate the life of a human organism. The expression “termination of life” will be used to cover both (1) active intervention to bring about a state of an Organism that will cause its death, and (2) a failure to intervene in causal processes that will otherwise result in the death of an organism. I shall attempt to distinguish the different cases in which the decision to terminate (...) life is morally justified and to isolate the considerations that are morally relevant to such decisions. -/- Decisions to terminate life: some possibly relevant considerations -/- There are a number of considerations that different people think relevant to medical decisions to terminate life and that are taken into account in actual medical practice. The following questions capture, I hope, the main ones: 1. Can the Organism in question be characterized as a person? 2. If the Organism is not a person, is it at least a potential person; that is such as will develop into a person? 3. If the Organism is a person, does he or she desire his or her own death, and if so is that desire a rational one? 4. If the Organism is a potential person, will this potential person express a rational desire to die once it becomes capable of expressing such a desire? 5. What quality of life will this person enjoy 6. What quality of life will this potential person enjoy? 7. What is the cost of maintaining the life of this person? 8. What is the cost of allowing this potential person to become a person, and then of maintaining his or her life? 9. Are we dealing with an unconscious person whom it is technologically impossible to restore to consciousness? 10. Is the termination of life a matter of active intervention or only a matter of refraining from saving the life of the organism? 11. Are we dealing with the case of “direct” killing or only one of “indirect” killing? 12 Does it require “ extraordinary” or only “ordinary” means to keep the person alive? 13. Is the individual suffering from a fatal illness? There are two ways in which each of these considerations might be relevant to a decision to terminate life. First, it might bear upon the question of whether it is morally permissible to terminate life. Secondly, if termination of life is morally permissible it may be relevant to the question of whether there is any positive reason for terminating life. (shrink)

Fertility treatment enables involuntary childless people to have genetically related children, something that, for many, is a valuable life project. In this paper, I respond to two sets of objections that have been raised against expanding state-funded fertility treatment provision for existing treatments, such as in vitro fertilisation (IVF), and against funding new treatments, such as uterine transplantation (UTx). Following McTernan, I refer to the first set of objections as the ‘one good among many’ objection. It purports that it (...) is unjustifiable for the state to prioritise the funding of the life project of becoming a parent through fertility treatment provision over the funding of other life projects that people might have. Following Lotz, I refer to the second set of objections as the ‘norm-legitimation’ objection. It maintains that the provision of costly forms of fertility treatment, such as UTx, would legitimise problematic social norms concerning genetic relatedness, reproduction and parenting, and that states should not engage in such a legitimation. In response to these objections, I defend the view that (reproductive) preferences ought to be taken more seriously when discussing fertility treatment provision and parental projects, and that not doing so can be costly, especially for women. The approach defended in this paper seeks to avoid disregarding and policing preferences and to reconcile their fulfilment with political projects aimed at improving the material and social conditions of sub-fertile people: people who, for social or biological reasons (or an intersection of the two), are unable to reproduce unassisted. (shrink)

Cryonic suspension is a relatively new technology that offers those who can afford it the chance to be 'frozen' for future revival when they reach the ends of their lives. This paper will examine the ethical status of this technology and whether its use can be justified. Among the arguments against using this technology are: it is 'against nature', and would change the very concept of death; no friends or family of the 'freezee' will be left alive when he is (...) revived; the considerable expense involved for the freezee and the future society that will revive him; the environmental cost of maintaining suspension; those who wish to use cryonics might not live life to the full because they would economize in order to afford suspension; and cryonics could lead to premature euthanasia in order to maximize chances of success. Furthermore, science might not advance enough to ever permit revival, and reanimation might not take place due to socio-political or catastrophic reasons. Arguments advanced by proponents of cryonics include: the potential benefit to society; the ability to cheat death for at least a few more years; the prospect of immortality if revival is successful; and all the associated benefits that delaying or avoiding dying would bring. It emerges that it might be imprudent not to use the technology, given the relatively minor expense involved and the potential payoff. An adapted and more persuasive version of Pascal's Wager is presented and offered as a conclusive argument in favour of utilizing cryonic suspension. (shrink)

This paper defends two main claims. First: although it is easy to lose sight of this, what cost-benefit analysis really demands, in order to approve of a prospective policy, is that it be possible for those who would gain through the policy change to compensate those who would lose through it. And second: in cases where a policy change does, or can reasonably be expected to, lead to someone's death, the demand of compensability is much harder to satisfy than (...) economists typically think. More specifically, their standard move—maintaining that compensability should be judged ex ante, and that it is thus really just risk of death, not death itself, that must be (and often is) compensable—is unsuccessful. Then, the implications of these claims are briefly explored. (shrink)

Background and objectivesIn Bahrain, maintaining life support at all costs is a cultural value considered to be embedded in the Islamic religion. We explore end-of-life decision making for brain dead patients in an Arab country where medical cultures are dominated by Western ideas and the lay culture is Eastern.MethodsIn-depth interviews were conducted from February to April 2018 with 12 Western-educated Bahraini doctors whose medical practice often included end-of-life decision making. Discussions were about who should make withdrawal (...) of life support decisions, how decisions are made and the context for decision making. To develop results, we used the inductive method of thematic analysis.ResultsInformants considered it difficult to engage non-medical people in end-of-life decisions because of people’s reluctance to talk about death and no legal clarity about medical responsibilities. There was disagreement about doctors’ roles with some saying that end-of-life decisions were purely medical or purely religious but most maintaining that such decisions need to be collectively owned by medicine, patients, families, religious advisors and society. Informants practised in a legal vacuum that made their ethics interpretations and clinical decision making idiosyncratic regarding end-of-life care for brain dead patients. Participants referred to contrasts between their current practice and previous work in other countries, recognising the influences of religious and cultural dimensions on their practice in Bahrain.ConclusionsEnd-of-life decisions challenge Western-trained doctors in Bahrain as they grapple with aligning respect for local culture with their training in the ethical practice of Western medicine. (shrink)

Previous research has indicated older adults value listening to music as a leisure activity. Yet, recent research into listening practices broadly has often focused on younger adults and the use of newer, digital listening technologies. Nonetheless, the radio, which is familiar to older people who grew up with it at the forefront of family life, is important to consider with regard to listening practices and the potential associated well-being benefits. This research investigated older adults’ everyday radio listening practices, in (...) order to begin to understand how the radio fits into their daily lives and how it might influence their sense of well-being. Twenty-five Australian residents (aged 66–87; 56% female, 44% male) participated in semi-structured, one-to-one interviews. The results of a qualitative thematic analysis revealed themes concerning listening preferences, listening routines, access, and motivations/outcomes. While personal preferences (concerning content, stations, and presenters) were diverse, individuals clearly communicated these as well as their established listening routines and habits. Listener motivations varied: some people focused on the enjoyment that listening to the radio creates while some noted benefits to their well-being, such as relaxation, modifying their mood, and feelings of comfort and community. Radio listening practices can be defined in terms of differing engagement styles, as characterized using continua ranging from passive to active, or focused, listening as well as generalized or specific listening. Based on participants’ experiences, a proposed engagement space model links how people engage with the radio to the possible outcomes mentioned. Importantly, benefits to well-being can result from varied engagement styles. The findings presented provide an in-depth understanding of how the radio fits into older adults’ everyday life, with implications for considering how the radio might be used as a widely accessed, low-cost tool for maintaining and enhancing quality of later life. (shrink)

Nick Dyer-Witheford and Greig de Peuter. Games of Empire: Global Capitalism and Video Games . Minneapolis: University of Minnesota Press. 2009. 320pp. pbk. $19.95 ISBN-13: 978-0816666119. In Games of Empire , Nick Dyer-Witheford and Greig de Peuter expand an earlier study of “the video game industry as an aspect of an emerging postindustrial, post-Fordist capitalism” (xxix) to argue that videogames are “exemplary media of Empire” (xxix). Their notion of “Empire” is based on Michael Hardt and Antonio Negri’s Empire (2000), which (...) characterizes the contemporary world order as a decentralized system of global economic, political, and economic power that transcends national boundaries. In the view of the authors, Hardt and Negri’s account sets itself apart from other analyses of international politics by offering a “comprehensive account of conditions of work, forms of subjectivity, and types of struggle in contemporary capital” (xx). Dyer-Witheford and de Peuter thus divide Games of Empire into three sections to reflect each of these aspects of Empire ’s argument, seeing their work as the first account to explore “virtual games within a system of global ownership, privatized property, coercive class relations, military operations, and radical struggle” (xxix). Books in the University of Minnesota Press’s Electronic Mediations series “explore the humanistic and social implications” of new technologies that spark “significant changes in society and culture, politics and economics, thinking and being.” That’s an abstract goal, and one that Games of Empire surely meets. Yet at times it can be difficult to understand exactly which specific intervention this book seeks to make. It is unclear whether the authors of Games of Empire see their work as an indictment of game scholars’ lack of attention to political economy, or whether it’s a work of political theory hoping to show that other disciplines should be paying more attention to the production and play of videogames. Because Dyer-Witheford and de Peuter don’t directly criticize previous political critiques of gaming—such as Edward Castronova’s exploration of the “porous membrane” allowing two-way traffic between virtual economies and those of the real world, or Alexander Galloway’s unraveling of control protocols in algorithmic design, or Ian Bogost’s idea of political procedural rhetoric—they sometimes leave the reader wondering how to situate the book in the broader discourse on games and politics, either separately or together. Thus, Games of Empire might best be seen as an introduction to the writings of Hardt and Negri for game players and designers, rather than as a text for communicating the basic concepts of game studies and design. It is neither a truly new theory of games or digital media, nor is it a new theory of Empire—and that’s not a criticism. It is instead an introduction to Empire through popular culture, as Zizek does for Lacan in Looking Awry . If one were teaching an introductory course on contemporary political theory, this book would offer obvious inroads into Negri and Hardt’s thinking for a number of reasons. Despite its radical ideological bent, the book isn’t off-putting to readers who don’t necessarily share the authors’ politics. It synthesizes complex ideas from difficult thinkers like Marx, Foucault, and Guattari while integrating modifications and critiques of Empire theory itself. And although the book is dense, sometimes feeling longer than it actually is (just over 200 pages), Games of Empire maintains a breezy readability by tightly coupling core concepts of Empire theory to well-known games and widely-publicized conflicts within the videogame industry. The first section of the book focuses on immaterial labor, the accumulation of “cognitive capital,” and the global process of manufacturing videogame consoles. It is significant for the authors that videogames began as hacker experiments within research institutes of the military industrial complex, programmed on stolen time, before becoming a commodity (7). This is the first in a string of examples showing how creative dissidence and conflict fuel the continuing evolution of Empire’s control. Dyer-Witheford and de Peuter explain that the videogame industry now constitutes an international production apparatus dominating both creative work in developed nations and manual labor in developing ones. Because game industries in the United States, Western Europe, and Japan are predominately non-unionized, they serve as an exemplary system for analyzing how global capital exploits contemporary intellectual work—including an excellent analysis of the “EA Spouse” scandal of 2004. On the side of the consumer, the authors argue that rabid “console races” that drive the industry forward from a technological perspective serve to structure gamer identity and combat piracy; later in the book, these machines offer a window into the worlds of Congolese coltan mining and electronic waste (222-224). In the second section, Dyer-Witheford and de Peuter move on to deep case studies of individual games to show how the most popular game genres embed imperial assumptions about conflict, exchange, and urban life. First they argue that military training games such as Full Spectrum Warrior —co-developed by university researchers, industry developers, and military contractors—contribute to the “banalization” of war, a subjective state wherein perpetual preparedness for war is accepted as a part of everyday life (100). Chapter five covers Michel Foucalt’s notion of “biopower,” the extension of capital accumulation to life itself. The authors argue that virtual worlds such as World of Warcraft , which take market capitalism as a given and force players into essentialist roles and racial antagonisms, are organized to maximize control and profit (often on the backs of virtual currency “farmers” in China and southeast Asia). Finally, they criticize the naïve assumption that humor and cynicism in the popular sandbox game franchise Grand Theft Auto offer any remedy to its racialized, violent content. Instead, such games indulge and normalize the fantasy of getting rich at any cost by keeping the realities of contemporary urban life and corporate greed at a safe distance (181). Part three of Games of Empire focuses on “games of multitude,” a preliminary attempt to escape from Empire’s order through alternate modes of videogame development and play. Multitude is defined dialectically, as “the engine and the enemy” of Empire (187). This is the most important, yet also most contradictory section of the text. It lays bare the process by which Empire and its media feed our creative and intellectual development to overabundance. At a certain point, the force of the multitude reaches such a level that it threatens the stability of Empire; however, instead of following Hardt and Negri’s utopian assumptions about the radical potential of the multitude, the authors here follow Paolo Virno’s warning that Empire is “very good at adopting apparently iconoclastic practices and utopian ideas as management techniques and revenue sources” (188). At every turn, advances in player configurative power provide new sources of revenue and advertising angles for the game industry. A disappointing shortcoming of these latter pages is the lack of truly new examples for radical resistance within game development. Instead, it turns out that the radical left seems satisfied with the same mild successes that the left-of-center also has celebrated: artist’s mods, virtual world activism, and critical counterplay within strategy- and wargames. Having been frequently cited by many authors before Dyer-Witheford and de Peuter, this idea of subversion or resistance through play feels tired and unpersuasive. It is unclear if the authors believe it is possible to embrace game design itself as a way of pursuing what they call “exodus” from Empire, or if an all-too-fashionable subversion is the only workable strategy. While the book does explore how the earliest independent game studios were eventually subverted and incorporated into the game industry proper, it doesn’t affirm or critique more recent non-commercial, DIY game development projects such as Klik-of-the-Month Club and Ludum Dare. Dyer-Witheford and de Peuter’s analysis of so-called “tactical games,” including the editorial works of La Molleindustria, leads to an even more ambivalent take on the contemporary design ecology. At the conclusion of his essay on “Countergaming,” Galloway asserts that avant-garde videogame artists “should create new grammars of action […] should create alternative algorithms” (Galloway 125). Yet Dyer-Witheford and de Peuter characterize works such as McDonald’s Video Game and Oiligarchy as didactic, suggesting that the role of radical political games might be “limited to that of agitprop” (199). They are concerned that games like those of Molleindustria rigidly structure the activities of their players in order to prove a point. Yet, despite their repeated assertion that the equation of greater interactivity with democratic digital liberation is flawed, the authors see potential in policy simulators that “allow players to edit or tweak” (202) their parameters in response to what Bogost has called simulation fever , the simultaneous drive toward and fear of simulation (Bogost 108). The possibility of practicing radical design is bucked, and early attempts at critical game development like those of Molleindustria’s seem to be relegated to the status of exceptions that prove the rule for player-centered exodus. Overall, there is one glaring question Games of Empire leaves unanswered: how exactly are videogames the “exemplary media” of Empire, and what are the implications of videogames being exemplary in this way? Presumably Dyer-Witheford and de Peuter want to avoid essentialist claims, so they’re not keen on following Wark’s desire to mark “the game’s difference from [legacy media] as something that speaks to changes in the overall structure of social and technical relations” (Wark 225). It is also unclear how the production apparatuses, labor standards, and subjectivizing processes involved in the creation and use of other any other kind of digital media would fail to justify their equally exemplary status. Even the book’s concluding paragraph holds that virtual games “are one molecular component of this undecidable collective mutation” (Dyer-Witheford and de Peuter 229) of intellect, labor, and daily life. In the end, the authors seem to back away from their focus on games as exemplary to bring their work in line with broader theories of the gradual digitization of the everyday, in line with Galloway and Manovich. Despite these flaws, there is an undeniable elegance to Games of Empire ’s contrasting of gaming’s overwhelmingly imperial content with its multitudinous form . And its ambivalence about the potential of independent or political game development might be seen by scholars of Empire as a strength rather than a weakness, an acceptance that every new expression of multitude offers another opportunity for the expansion of Empire. The book also functions as a strong, all-encompassing call to greater responsibility on the part of mainstream game developers to be more conscious of the ideologies they embed in their work, of the way their intellectual property is used and manipulated by those who employ them, and of the material impact their industry has on the world at large. For players it offers a toolbox of concepts for radical examinations of their own play activities, asking them to be more cognizant of the consequences of their consumption of digital media and the ways in which their virtual lives interface with the real. REFERENCES Bogost, Ian. Unit Operations: An Approach to Videogame Criticism . Cambridge, Mass.: MIT Press, 2006. Castranova, Edward. Synthetic Worlds: The Business and Culture of Online Games . Chicago, Illinois: University of Chicago Press, 2006. Dyer-Witheford, Nick and de Peuter, Greig. Games of Empire: Global Capitalism and Video Games . Minneapolis, Minnesota: University of Minnesota Press, 2009. Galloway, Alexander. Gaming: Essays on Algorithmic Culture . Minneapolis, Minnesota: University of Minnesota Press, 2006). Wark, McKenzie. Gamer Theory . Cambridge, Mass.: Harvard University Press, 2007. (shrink)

The increase in life expectancy in developed countries has lead to an increase in the number of elderly people cared for in nursing homes. Given the physical frailty and deterioration of mental capacities in many of these residents, questions arise as to their autonomy and to their protection from harm. In 2005, one of the highest German courts, the Bundesgerichtshof issued a seminal judgement that dealt with the obligations of nursing homes and with the preserving of autonomy and privacy (...) in nursing home residents. An elderly woman had sustained a fracture of the neck of the femur during a fall. The health insurance company held that the nursing home had breached its obligations to protect her from falling and sued the home for the hospital costs of her treatment. However, the BGH maintained that the case of the health insurance was not justified. It held that obligations of nursing homes have to be limited to normal arrangements within reasonable financial and personal effort, and that the autonomy of residents had to be protected from unnecessary interference. Permanent control or even restraining measures to reduce each risk would deprive the patient fully of her autonomy, and must therefore be hindered. Other judgments of other courts have emphasised the “protectionist” approach. The article deals with these different approaches and comments on both rationales. It will be shown that both approaches must be differentiated to establish fully autonomy and protection for nursing home residents. (shrink)

Available from UMI in association with The British Library. Requires signed TDF. ;Belief in God is a belief about a matter of fact and existence . I assume that BG is meaningful, coherent and neither probably true or probably false . ;The evidentialist objection to BG presupposes that we have obligations in respect of those beliefs that we accept, this being a voluntary form of assent to propositions . EO claims that acceptance of BG without sufficient evidence in its support (...) is irrational. But we cannot have evidence for all our beliefs; the need to avoid an infinite regress of justification typically leads EO to endorse some form of foundationalism . This allows certain beliefs to be basic ; EO must defend a criterion of proper basicality which excludes BG from that status. Typically, this restricts properly basic beliefs to those that are either self-evident, evident to the senses or incorrigible . ;Plantinga argues that this criterion is self-referentially incoherent and implausible , and claims that BG can be properly basic. This does not commit him to allowing just any belief to be properly basic, because basic beliefs have justifying conditions which allow him to point to differences between BG and obviously irrational beliefs . Criteria for proper basicality are to be arrived at inductively, from sample-sets of the beliefs we do in fact hold as basic . ;However, this procedure can be used to defend the restriction of proper basicality for matter of fact beliefs to those formed, justified and defeated on the basis of sense-experience, and so allows EO to be maintained . BG cannot be formed directly on the basis of religious experience, for this procedure shows none of the features of reliable, and some of the features of unreliable, epistemic practices . Nor is BG related to our trust in epistemic practices as are our fundamental beliefs about matters of fact . ;'Wittgensteinian basicalism' sees BG as an unjustified and unjustifiable cognitive claim constitutive of the religious language-game and form of life . But a Wittgensteinian epistemology rejects metaphysics as illusion, and grants BG rationality only at the cost of sacrificing its objectivity . Attempts to show that BG is presupposed in the assumption that the universe is intelligible fail because scepticism is not self-refuting; we cannot know that the universe is in fact intelligible . ;BG is not analogous to those beliefs we hold without evidence but which are clearly rational. It must be supported by evidence in order to secure acceptance. (shrink)

Across the world, healthcare providers must wrestle with the twin ogres of finite resources and infinite demand. Successful healthcare delivery creates its own legacy of need. For example, a renal failure patient may now be given a greatly extended life by means of dialysis or organ transplantation. In the process, the healthcare provider has created a permanent demand for services during that extended life. It has been estimated that the recurrent cost of maintaining a patient on (...) hemodialysis for 1 year in the United Kingdom is in the region of £20,000. (shrink)

The foundation of the Australian colonial project lies within an ‘originary violence’, in which the state retains a vested interest in maintaining the founding order of things. Inequalities and iniquities are maintained for the purpose of sustaining the life and continuity of the state. The Australian state, founder of a violent order is called upon by the international community to conform and uphold ‘human rights’, but what does this call to conformity require, particularly when the call comes from (...) states which are also founded upon colonial violence? This article argumes that very little is required beyond the masquerade that ‘equality’ for Aboriginal peoples is an on-going project of the state. So for what purpose does the masquerade continue? (shrink)

A first-person account of some victims of the virus, the author puts faces and circumstances to the tragedy of the Covid-19 pandemic. Told from a chaplain’s point of view, these narratives will take the reader beyond the numbers and ask questions like: What is the cost of keeping families separated at the end of life, and, if patient/family centered care is so central to healthcare these days, why was it immediately discarded? Is potentially saving human lives worth the (...) risk of damaging them beyond repair? (shrink)

The cost of health care at the end of life accounts for a high proportion of total health care costs in the United States. The percentage of Medicare payments attributable to patients in their last year of life was 28.3% in 1978 and has remained substantially the same at 25.1% in 2006. This indicates how little progress has been made in containing these costs, though doing so will be important to promote a financially sustainable health care system. (...) These expenditures also highlight the prospect that efforts to reduce health care costs overall are likely to disproportionately affect the care patients receive at the end of life. (shrink)

Most Act-Utilitarians, including Singer are Permissivists who claim that their theory usually permits abortion. In contrast, a minority, including Hare and Tännsjö, are Restrictionists who assert that Act-Utilitarianism usually limits abortion. I argue that both Permissivists and Restrictionists have misunderstood AU’s radical implications for abortion: AU entails that abortion is, in most cases in the economically developed world, morally obligatory. According to AU, it is morally obligatory for A to do F in circumstances C if and only if A’s doing (...) F in C produces at least as much total net value as any other action that A could do in C. As mentioned above, AU has generally been seen to be fairly permissive about abortion. A little more exactly, AU is usually thought to hold that abortion is morally permissible in most cases, even during the second and third trimester. But not all AUs are Permissivists. Restrictionists maintain that the value of the future good that the fetus will experience over an entire life is likely to often outweigh the value of the good that its female parent will lose if the fetus is not aborted. Neither Permissivists nor Restrictionists have understood AU’s implications for abortion, at least as it concerns those living in economically developed countries today. First, Restrictionists have failed to recognize the marginal costs that a person in the developed world incurs on future people. One life lived now in the developed world consumes more resources than a life lived in the developing world, and in the process makes the prospects of future people considerably worse. Restrictionists ignore these costs when they claim that it is often morally impermissible to abort fetuses. Second, Permissivists have not gone far enough when they have claimed that abortion is morally permissible. Singer and others have argued that we in the developed world ought to redirect much of our wealth to the underdeveloped world because its marginal value is much higher there than here. But the average cost of raising a child in the United States is almost $13,000 per year. Hence, by forgoing a child one can save and maintain, on average, between 6 and 65 people per year. Thus, AU entails that almost everyone in the developed world who is financially capable of supporting a child should not do so, even if that means aborting a fetus. (shrink)

Pulmonary rehabilitation has demonstrated patients’ physiological and psychosocial improvements, symptoms reduction and health-economic benefits whilst enhances the ability of the whole family to adjust to illness. However, PR remains highly inaccessible due to lack of awareness of its benefits, poor referral and availability mostly in hospitals. Novel models of PR delivery are needed to enhance its implementation while maintaining cost-efficiency. We aim to implement an innovative community-based PR programme and assess its cost-benefit. A 12-week community-based PR will (...) be implemented in primary healthcare centres where programmes are not available. Healthcare professionals will be trained. 73 patients with CRD and their caregivers will compose the experimental group. The control group will include dyads age- and disease-matched willing to collaborate in data collection but not in PR. Patients/family-centred outcomes will be dyspnoea, fatigue, cough and sputum, impact of the disease, emotional state, number of exacerbations, healthcare utilisation, health-related quality of life and family adaptability/cohesion. Other clinical outcomes will be peripheral and respiratory muscle strength, muscle thickness and cross sectional area, exercise capacity, balance and physical activity. Data will be collected at baseline, at 12 weeks, at 3- and 6-months post-PR. Changes in the outcome measures will be compared between groups, after multivariate adjustment for possible confounders, and effect sizes will be calculated. A cost-benefit analysis will be conducted. This study will enhance patients access to PR, by training healthcare professionals in the local primary healthcare centres to conduct such programmes and actively involving caregivers. The cost-benefit analysis of this intervention will provide an evidence-based insight into the economic benefit of community-based PR in chronic respiratory diseases. The trial was registered in the ClinicalTrials. gov U.S. National Library of Medicine, on 10th January, 2019. (shrink)

We all now know that the novel coronavirus is anything but a common cold. The pandemic has created many new obligations for all of us, several of which come with serious costs to our quality of life. But in some cases, the guidance and the law are open to a degree of interpretation, leaving us to decide what is the ethical course of action. Because of the high cost of some of the obligations, a conflict of interest can (...) arise between what we want to do and what it is right to do. And so, some people choose to respect only the letter of the law, but not the spirit, or not to respect even the spirit of the guidelines. This paper identifies and describes the new obligations imposed on us all by the pandemic, considers their costs in terms of the good life, and provides an ethical analysis of two personal and two public cases in terms of the letter and spirit of the guidance and legislation. (shrink)

Technological dystopias incarnate transhumanist dreams of a this-worldly blissful immortality. Underlying these and others is a globalized technocratic paradigm, the loss of an overarching cosmic world view, rise in consumerism, a gnostic repudiation of the body, and a neo-pelagian aspiration to individualistic self-sufficiency. One response to these transhumanist dreams is to remind ourselves of how nature actually works, its origins, constrains, and future. Our relationship with nature spills over to how we feel standing face-to-face with pain and suffering. In this (...) article I reframe cancer as a journey of maintaining harmony with nature instead of a war against death that we are destined to lose. I argue that understanding the limits and constraints of the natural world help us come to peace with the reality of cancer, and perhaps find meaning in suffering. Instead of avoiding the inevitable at all costs, vulnerability and suffering have their own lessons. In contrast to trans humanist dreams, being human presents an opportunity to welcome the reality of imperfection, to be liberated from our addiction to control and excessive technological manipulation of nature, to draw together as a community, and to live the lessons of each stage of our finite life to its fullest. I hope this reflection, grounded in scientific literature and engaging with richly embodied medical humanities readings, can help us all change how we relate to cancer, from books to bench to biotech to bedside. (shrink)

The focus of this study is to explore the impact of transformation from living as a community and perceiving cooperation as a responsibility to meet each other’s needs to individualized society of the modern life due to the capitalist market system on religious obligations with economic implications through emerging institution in the modern period. This study will first analyze how the proxy-embeddedness has led to a transformation in the society from the perspective of Islamic economics under four categories: (1) (...) the weakening of Muslims’ relations with their relatives and neighbours; (2) Equalization of worship for different purposes on a common denominator; (3) Lack of social awareness due to deprivation of the experience of performing worship personally; and (4) the prioritization of those capable of being productive over unproductive people in terms of being beneficiaries of zakat or other types of benefits. Worships such as zakāt and sacrifice are among the acts of worshipping that enable wealthy Muslims to help those in need financially. Although the transfer of material resources to the needy people through modern institutions ensures the fulfilment of worship, through which principles and objectives this transfer is carried out are also important. Significant transformations are observed in the way these worships are performed compared to the pre-modern period, as institutions that carry out zakāt and sacrificial meat collection and distribution activities in line with capitalist principles such as low transaction costs and efficiency. First, it is expected from a Muslim to be aware of the social environment he/she is in, be aware of the needy, and maintain social relations within this awareness. All kinds of charity and financial aid at the level of individual relations, especially zakāt and sacrifice, ensure the continuation of this awareness. If Muslims perform these worships and charity activities through institutions, the awareness of one’s environment will weaken. A second transformation is to make these worships indistinguishable from each other by equating them to the common denominator of paying money. This situation leads to the equalization of worship at the material level and causes the differences to be invisible for Muslims who perform the worship. A third transformation is that the realization of worship by institutions through the proxy system causes Muslims to be deprived of the experience of performing worship individually. While these prayers are performed through institutions in an efficient and low-cost way, the only thing expected from Muslims is to make the necessary payment through the bank. In this case, the spiritual contributions expected to be realized during the fulfilment of the worship decrease. Finally, we see that some institutions utilize capitalist principles and goals to decide who should receive financial aid. For this reason, people who can become a productive factor due to the help they receive are prioritized over others. There is a rational choice behind this decision mechanism: It is aimed to reduce the number of needy people in society by transforming zakat recipients into zakāt payers. On the other hand, Islamic sources do not consider such a priority among those who deserve to receive zakāt. Moreover, this situation will lead to the permanent postponement of people who are not included as a productive factor in the capitalist system but in need. In the second part of the study, an analysis of the agency (vekalet) system, which allows individuals to transfer some of their responsibilities to private institutions to spend time more efficiently, is conducted through the example of nursing houses. Another example of the fulfilment of zakat and sacrifice through the proxies given to institutions is that Muslims fulfil their responsibilities towards their relatives through institutions such as nursing houses. The reason for such a need arises from the fact that people, who take place as human capital in the capitalist system, are required to spend their time to improve themselves, get new education and gain more experience, instead of spending their time taking care of their relatives so that the production process can continue to grow. Although this type of service contract is formally valid in terms of Islamic law when evaluated in terms of the bond that Islamic morality envisages to be established between Muslims and their relatives and the protection of this bond, institutions such as nursing houses can lead to the commodification of family ties due to the transfer of responsibilities to relatives in return for a service fee. (shrink)

The aims of this study were to examine the effectiveness of a range of smartphone apps for managing symptoms of anxiety and depression and to assess the utility of a single-case research design for enhancing the evidence base for this mode of treatment delivery. The study was serendipitously impacted by the COVID-19 pandemic, which allowed for effectiveness to be additionally observed in the context of significant community distress. A pilot study was initially conducted using theSuperBetter app to evaluate the proposed (...) methodology, which proved successful with the four finishing participants. In the main study, 39 participants commenced, with 29 finishing the intervention phase and completing post-intervention measures. At 6-month follow-up, a further three participants could not be contacted. This study used a digitally enhanced, multiple baseline across-individuals single-case research design. Participants were randomly assigned to the following apps:SuperBetter,Smiling Mind,MoodMission,MindShift, andDestressify. Symptomatology and life functioning were measured at five different time points: pre-baseline/screening, baseline, intervention, 3-week post-intervention, and 6-month follow-up. Detailed individual perceptions and subjective ratings of the apps were also obtained from participants following the study’s completion. Data were analyzed using visual inspection, time-series analysis, and methods of statistical and clinical significance. Positive results were observed for all apps. Overall, more favorable outcomes were achieved by younger participants, those concurrently undertaking psychotherapy and/or psychotropic medication, those with anxiety and mixed anxiety and depression rather than stand-alone depression, and those with a shorter history of mental illness. Outcomes were generally maintained at 6-month follow-up. It was concluded that a diverse range of evidence-based therapies offered via apps can be effective in managing mental health and improving life functioning even during times of significant global unrest and, like all psychotherapies, are influenced by client features. Additionally, this single-case research design is a low-cost/high value means of assessing the effectiveness of mental health apps.Clinical Trial Registration: The study is registered with the Australian and New Zealand Clinical Trials Registry, which is a primary registry in the World Health Organization Registry Network, registration number ACTRN12619001302145p. (shrink)

Autonomy, an individual's right to make personal decisions regarding his/her own health, represents one of the major ethical principles of medicine. While there are many examples citing the benefits this right provides for the individual, the impact that personal healthcare decisions have on others is often neglected. Here, evidence from end-stage renal disease is reviewed to hypothesise the creation of a universal kidney donation programme that although provides unparalleled benefits to its citizens, relies on the participation of a large proportion (...) of the society. Given that this essay also addresses the public's major concerns regarding kidney donation, one of the only remaining implementation barriers is the individuals' right not to participate. Therefore, irrespective of the humane and complex emotionally laden reasons for not enrolling in such programmes, this essay provides some estimates of the significant resource and quality of life costs associated with autonomy. Assuming humans are competent to make informed personal healthcare choices, similar to recent efforts to increase awareness about the negative impact of certain lifestyle choices on global warming, citizens should also be better informed about the medical costs their autonomy has on society. (shrink)

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)

Background:Policemen all over the world are tasked with the heavy work of maintaining social security. With the imbalance in mentality brought about by high population density and social transformation, the work of the Chinese police is particularly hard. As the window of demographic dividend is closing and the number of newborns is insufficient, China has started to adjust its established fertility policy to encourage a family to have two children. However, the results have not met the expectations of the (...) policy adjustment. It is generally believed that factors such as high work pressure, high parenting costs, and low levels of happiness may be the main reasons for low fertility intentions. Studying this typical population of police officers may explore the relationship between work stress, happiness, and reproductive concerns, and provide evidence of Chinese sample.Objectives:To explore the relations between job burnout, subjective well-being, and generativity concern in Chinese police officers.Methods:The study used a cross-sectional survey to collect data from 494 police officers from H city in China. The participants completed the Maslach Burnout Inventory (MBI), the Family Adaptability and Cohesion Scale (FACESII), the Loyola Generativity Scale (LGS), and the Satisfaction with life scale (SWLS). Moderated mediation effect models assessed the association between job burnout, subjective well-being, and generativity concern.Results:Job burnout had a significant negative predictive effect on both subjective well-being and generativity concern, and subjective well-being played a mediating role between job burnout and generativity concern. In addition, family intimacy and adaptability had a significant negative moderating effect between subjective well-being and generativity concern. In a conclusion, there is a moderated mediating effect between job burnout and generativity concern.Conclusion:Subjective well-being played a mediating role between job burnout and generativity concern. (shrink)

In the article the divergent-convergent approach to managing software development industrial company, which is based on the spiral model of the project life cycle, each stage of which is identified by the developed system of performance indicators performed work plan and wasted resources. Unlike the existing proposed approach allows time to determine the need for expansion of security or its abbreviation, which explains the calculation of expediency maintain software development projects output on the market or not. Other advantages of (...) the proposed approach include the following: the possibility of analyzing the effectiveness of the project development and the impact of its resources to ensure the defined time intervals; conduct comparative analysis of the efficiency and effectiveness of the project life cycle stages of development; the possibility of determining the moment of transition from divergence processes to ensure convergence contributes to providing the rational use of resources, transparency in government; spiral lifecycle model development project combines a gradual transition from stage to stage and iterative, allowing time to reduce risk on the effectiveness of the project development and its security. Along with the advantages in using divergent-convergent model of project development of industrial enterprises, the main problem is the definition of a spiral cycle time of transition to the next stage of implementation of the selected project. As the promotion and twisting spiral must enter the time limits for each stage of the life cycle and impact indicators of costs incurred for the organization of work of each stage. Special attention will be paid to the moment of inflection in the presented model when changing divergence convergence process management software development project Overall approach facilitates finding and developing ways to increase the efficiency of project implementation of enterprise software and processes at each stage of the life cycle. (shrink)

Background: Dignity, an abstract and complex concept, is an essential part of humanity and an underlying guiding principle in healthcare. Previous literature indicates dignity is compromised in people with dementia (PwD), but those PwD maintain the capacity to live with dignity with appropriate external support. Alzheimer’s disease and related dementias (ADRDs) lead to progressive functional decline and increased vulnerability and dependence, leading to heightened risks of PwD receiving inappropriate or insufficient care that diminishes dignity. Considering the increased disease prevalence and (...) the continuously escalating costs of dementia care, establishing a productive value-based guideline may prevent suffering, maximize dignity, and thus promote quality of life (QoL). Aim: The goal of this project is to identify actionable targets for integrating dignity harmoniously and practically into care planning and management for PwD. Research Design: We conducted a concept analysis using Walker and Avant’s eight-step process. A comprehensive literature search was conducted (PubMed and CINAHL) with the keywords “dignity,” “dementia,” “Alzheimer’s disease,” and “dementia care.” Results: A total of 42 out of 4910 publications were included. The concept of dignity in PwD is operationalized as the promotion of worthiness and the accordance of respect that allows the presence and expression of a person’s sense of self, regardless of physical, mental, or cognitive health. The concept has two subdimensions: absolute dignity which encompasses the inherent self and relative dignity characterized by its dynamic reflective nature. Worthiness and respect are the two main attributes, while autonomy is an underlying component of dignity. Specific antecedents of dignity in PwD are empowerment, non-maleficence, and adaptive environmental scaffolding. As a consequence of facilitating dignity in PwD, QoL may be enhanced. Conclusion: As a foundational and necessary humanistic value, incorporating dignity into dementia care can lead to efficient and effective care that optimizes QoL in PwD throughout their disease progression. (shrink)

Intensified and extensive data production and data storage are characteristics of contemporary western societies. Health data sharing is increasing with the growth of Information and Communication Technology platforms devoted to the collection of personal health and genomic data. However, the sensitive and personal nature of health data poses ethical challenges when data is disclosed and shared even if for scientific research purposes. With this in mind, the Science and Values Working Group of the COST Action CHIP ME ‘Citizen's Health (...) through public-private Initiatives: Public health, Market and Ethical perspectives’ identified six core values they considered to be essential for the ethical sharing of health data using ICT platforms. We believe that using this ethical framework will promote respectful scientific practices in order to maintain individuals’ trust in research. We use these values to analyse five ICT platforms and explore how emerging data sharing platforms are reconfiguring the data sharing experience from a range of perspectives. We discuss which types of values, rights and responsibilities they entail and enshrine within their philosophy or outlook on what it means to share personal health information. Through this discussion we address issues of the design and the development process of personal health data and patient-oriented infrastructures, as well as new forms of technologically-mediated empowerment. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Literature 30.1 (2006) 174-189 [Access article in PDF] Sophie's Choice: Letting Chance Decide Suzanne Dovi University of Arizona When, if ever, should individuals facing a genuine moral dilemma adopt a random decision procedure to determine the outcome of that dilemma? Or to put the question more metaphorically, is it ever morally preferable to determine the outcome of a moral dilemma by flipping a coin? In this paper, (...) I will argue that sometimes it is. To make this argument, I consider a particularly agonizing moral dilemma—the one found in William Styron's Sophie's Choice. Drawing on this famous example of a moral dilemma, I identify three salient features of a moral dilemma that make it morally permissible, and even morally preferable, for an agent to adopt a random decision procedure to determine its outcome. By 'morally preferable,' I do not mean to imply that an agent is morally required to adopt a random decision procedure to determine the outcome of a moral dilemma. As will be seen, I disagree with the view that humans must always pursue the most morally preferable course of action. Nevertheless, I contend that agents should adopt a random decision procedure when faced with a moral dilemma that possesses three salient features. These three features are: (1) when there is clearly no "better" outcome from the range of choices available to the agent; (2) when particular kinds of moral burdens (guilt burdens) can be alleviated by that agent adopting a random decision procedure; and (3) when the alternatives were given to, and not made by, the agent. The first two salient features are necessary for it to be morally permissible [End Page 174] to decide a moral dilemma using a random decision procedure. The third feature is not necessary since a person could, due to her morally permissible decisions, face a moral dilemma whose outcome could be legitimately determined by a random decision procedure. However, I maintain that all three features are jointly sufficient for determining when it is morally preferable to adopt a random decision procedure to decide the outcome of a moral dilemma. I Hard choices are decisions that require us to choose among conflicting goals, purposes, values, or goods that are very important to us. Such choices pervade our lives. According to David Schmidtz, to face such a hard choice can be "the price of the richness and complexity of a life well-lived. To have both ideals and loved ones is to run the risk of having to make decisions under unresolved conflicts of value."1 Although hard choices are often ordinary, some hard choices can also be genuine moral dilemmas.2For my purposes, hard choices become genuine moral dilemmas when an agent cannot avoid violating his or her deeply held moral beliefs. Moreover, genuine moral dilemmas are dilemmas that have no "right" answer. So, for example, genuine moral dilemmas occur when an agent faces a decision between outcomes that are, as far as the agent can reasonably determine, equally bad or incommensurable. Indeed, some genuine moral dilemmas can involve choices between such horrible outcomes that it does not make sense to use moral language to justify their decisions—that is, to provide reasons for thinking that one outcome is preferable to another. In these cases, genuine moral dilemmas do not offer any possibility for moral redemption: the agent cannot morally justify choosing one outcome over another. Thus, genuine moral dilemmas can impose serious (and potentially devastating) moral costs on the decision-maker.William Styron's Sophie's Choice presents an example of such a genuine moral dilemma. Sophie Zawistowska has been asked to choose which of her two children, Eva or Jan, will be sent to the gas chamber in Auschwitz. An SS doctor, Fritz Jemand von Niemand, will grant a dispensation to only one of Sophie's children. If she does not choose which one should live, Dr. von Niemand will send both to their death. Sophie chooses her daughter Eva to go to the gas chamber. Her son, Jan, is sent to the Children's Camp and she... (shrink)

Today, Catholic health care involves complex medical professional organizations, incredible technological and scientific accomplishments, prohibitive costs, and interfering governmental participation. Notwithstanding the challenges presented by the structural transformation of Catholic hospitals in recent years, Pope Francis’s instruction revives the duty of health care professionals to act as missionaries. This essay explores why Francis maintains the importance of building Catholic health care during these changing circumstances. Confronting the penchant of our modern medical culture to marginalize the weakest members of our society, (...) Francis addresses the perils that follow when health care professionals are no longer seen as servants to the dignity of all life. National Catholic Bioethics Quarterly 14.3 : 421–428. (shrink)

This article presents estimates of the global cost of collective and interpersonal violence for the period of one year. This includes war, terrorism, homicides, assaults and domestic violence against women and children. The cost of conventionally defined interpersonal violence, that is, homicides and assault, are about 7.5 times higher than the cost due to war and terrorism. I also estimate the costs of non-fatal domestic violence against children and women and suggest that these costs are much higher (...) than the combined costs of homicide, assault, terrorism and war. The main reason is that the prevalence of these types of violence is very high: possibly as many as 16 per cent of all children are punished using violent methods and about 12 per cent of all women experience intimate partner violence. Richer societies have lower levels of violence, and there is evidence that prevalence rates have been declining over time. However, it is often unclear why this is the case. Much of the evidence from violence red... (shrink)

This paper discusses the ethical implications of racism and some of the various costs associated with racism occurring at the institutional level. We argue that, in many ways, the laws, social structures, and institutions in Western society have operated to perpetuate the continuation of historical legacies of racial inequities with or without the intention of individuals and groups in society. By merely maintaining existing structures, laws, and social norms, society can impose social, economic, and health costs on racial minorities (...) that impinge on their well-being and human dignity. Based on a review of multidisciplinary research on racism, particularly focusing on healthcare, we demonstrate how institutional racism leads to social and economic inequalities in society. By positing institutional racism as the inherent cause of avoidable disparities in healthcare, this paper draws attention to the ethical significance of racism, which remains a relatively neglected issue in bioethics research. (shrink)

Given the long-standing controversy about whether the brain-dead should be considered alive in an irreversible coma or dead despite displaying apparent signs of life, the ethical and policy issues posed when family members insist on continued treatment are not as simple as commentators have claimed. In this article, we consider the kind of policy that should be adopted to manage a family's insistence that their brain-dead loved one continues to receive supportive care. We argue that while it would be (...) ethically inappropriate to continue to devote scarce acute care resources to such patients in a hospital setting, it may not be ethically inappropriate for patients to receive these resources in certain other settings. Thus, if a family insists on continuing to care for their brain-dead loved at their home, we should not, from a policy perspective, interfere with the family's wishes. We also argue that healthcare professionals should make some effort to facilitate the transfer of brain-dead patients to these other settings when families insist on continued treatment despite being informed about the lack of any potential for recovery of consciousness. Our arguments are strengthened by the fact that patients in a persistent vegetative state, who, when correctly diagnosed, also have no potential for recovery of consciousness, are routinely transferred from hospitals to nursing homes or long-term care facilities where they continue to be ventilated, tube fed and to receive other supportive care. We also briefly explore the question of who should be responsible for the costs of such treatment at the long-term care facility. (shrink)

COVID-19 lockdown presented a novel opportunity to study the experiences of people attempting to maintain friendships in the context of worldwide, government-enforced physical distancing and lockdown. Here we report on an experiential, idiographic qualitative project with a purposive sample of Scottish students. Data was collected via one-to-one on-line interviews with nine student participants. Data was transcribed and analyzed using Interpretative Phenomenological Analysis. Analysis highlighted three group-level experiential themes and associated subthemes. Participants’ shared experiences of maintaining friendships were reflected in (...) a dynamic process by which ‘changes to communication’ were associated with experiences of ‘effort and balance’ across friendships. Participants reported becoming particularly aware of the psychological processes involved in maintaining friendships, in turn, this was associated with ‘reflection and growth.’ These experiential findings resonate well with several longstanding classic theories; however, they also speak to the particularities of the context in which the study was conducted. They suggest the need for a pandemic psychology that moves beyond the typical focus on the direct impacts of infectious disease to address the wider psychosocial impacts with equal vigor. (shrink)

This newly revised edition of Bonhoeffer's classic statement of the Christian life contains the full text of Bonhoeffer's Nachfolge.--F. E. B.

Just Ecological Integrity presents a collection of revised and expanded essays originating from the international conference 'Connecting Environmental Ethics, Ecological Integrity, and Health in the New Millennium' held in San Jose, Costa Rica in June 2000. It is a cooperative venture of the Global Ecological Integrity Project and the Earth Charter Initiative.

John Lachs tells us in the short “Preface” to his latest book that in an earlier work, “Intermediate Man, a book I wrote some years ago,” (1981) he “presented similar ideas. But this book is significantly different from the earlier. It covers more topics and makes, I hope, a more compelling case for my analysis” (p. vii). He goes on to state that in The Cost of Comfort one can find his analysis of contemporary life a “testable form,” (...) given over to an invitation to experiment (similar to anoth... (shrink)

BackgroundThis essay provides an ethical and conceptual argument for the use of informed consent prior to the diagnosis of brain death. It is meant to enable the family to make critical end-of-life decisions, particularly withdrawal of life support system and organ donation, before brain death is diagnosed, as opposed to the current practice of making such decisions after the diagnosis of death. The recent tragic case of a 13-year-old brain-dead patient in California who was maintained on a ventilator (...) for over 2 years illustrates how such a consent would have made a crucial difference.MethodsConceptual, philosophical, and ethical analysis.ResultsI first consider a conceptual justification for the use of consent for certain non-beneficial and unwanted medical diagnoses. I suggest that the diagnosis of brain death falls into this category for some patients. Because the diagnostic process of brain death lacks the transparency of traditional death determination, has a unique epistemic structure and a complex risk-benefit profile which differs markedly from case to case, and presents conflicts of interest for physicians and society, I argue that pre-diagnostic counseling and informed consent should be part of the diagnostic process. This approach can be termed as “allow cardiac death”, whose parallel logic with “allow natural death” is discussed. I also discuss potential negative impacts on organ donation and health care cost from this proposal and offer possible mitigation. I show that the pre-diagnostic counseling can improve the possibility for well-thought-out decisions regarding organ donation and terminating life-support system in cases of hopeless prognosis. This approach differs conceptually from the pluralism of the definition of death, such as those in New Jersey and Japan, and it upholds the Uniform Determination of Death Act.ConclusionsMy intention is not to provide an instant panacea for the ongoing impasse of the brain death debate, but to point to a novel conceptual ground for a more pragmatic, and more patient- and family-centered approach. By enabling the family to consent to or decline the diagnostic process of brain death, but not to choose the definition of death, it upholds the current legal definition of death. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Decolonizing MemoryLaurence J. Kirmayer*, MD (bio)In this far-reaching essay, Emily Walsh explores the significance of memory for coming to grips with the enduring legacy of colonialism in psychiatry. She argues that "for reasons of self-preservation, racialized individuals should reject collective memories underwritten by colonialism." Psychiatry can enable this process or collude with the structures of domination to silence and disable those who bear the brunt of the colonialist history (...) of violence and its current global incarnations. In this brief commentary, I want to underscore the importance of Walsh's argument, link it to contemporary work in cognitive and social science on the dynamics of memory, and point to some resources for implementing these insights in health services and clinical practice.Memory as Psychological Process, Social Practice and Cultural InstitutionMemory is not simply an individual psychological process of accessing images, stories, and knowledge of the past, but a reconstructive process of building a narrative (Kirmayer, 1996). This narrative is profoundly shaped by available templates, metaphors and models that are provided by the tacit, normative and official histories of society (Hirst, Yamashiro & Coman, 2018). But memory is also shaped by cultural affordances that guide attention and by narrative practices, which depend on other people (Ramstead, Veissière, & Kirmayer, 2017). In effect, remembering is not a matter of reaching down into one's memory archive or sedimented experience, but an embodied and enactive process of thinking with and through others (Laanes & Meretoja, 2021; Veissière, Constant, Ramstead, Friston, & Kirmayer, 2020). Memory then depends on community and on a shared understanding of history and of possible futures through which one can anchor and elaborate one's individual story.A direct consequence is that disconnecting a person from others, disembedding them from their social milieu, will lead to disruptions in memory and in the continuity of self. When the environment is toxic, this severance may sometimes be (partly) beneficial—but it always comes at a cost. Figuring out those costs, making them explicit, and ensuring that those whose history is being suppressed or overwritten by others have a chance to reclaim and write their own, is an ethical and pragmatic imperative.The denial of vital memories (recent or remote, personal or collective) causes fractures in the self that may disorganize the individual, install false consciousness, and cement the exclusionary and disvalued position of colonized, racialized, and [End Page 243] marginalized subjects. This process is not only—or even primarily—about memory. It is part of the structure of everyday life, inscribed in institutions and practices where colonial histories, racism, and economic exploitation are deeply entangled. Representations of the past are part of the way we construe the present and anticipate the future—but not every interpretive frame is a memory; there are structures in and of the moment that condition how we think about ourselves in health and illness and these too convey interests and biases disguised as "just the way things are."Fanon's Politics of Postcolonial Memory and IdentityWalsh offers a reading of aspects of Fanon's philosophy to reveal the workings of colonialism in and through memory. She is concerned with specific subsets of collective memories that are affectively charged and related to the identity of a group (Wertsch & Roediger, 2008). These memories are collective not simply they are shared by or distributed among the members of a group but because they define or constitute the collective itself.History is written largely by the powerful who create dominant or 'master' narratives that serve their own projects of legitimation and self-mystification (Trouillot, 2015; Lindqvist, 2021). But the creation of dominant narratives is not solely the province of those in power. There are many kinds of self-serving collective memory (Baumeister & Hastings, 2013)—from those related to the creation of nation states, which may ignore not only colonized peoples, but all ethnicities, religions or linguistic groups subordinated to the ideals of the dominant group (Anderson, 2006; Gunew, 2013; van Alphen & Carretero, 2015), to other forms of collective identity, even to those created by liberatory movements. These are maintained by institutionalization, ceremonial repetition and reenactment... (shrink)

Given the long‐standing controversy about whether the brain‐dead should be considered alive in an irreversible coma or dead despite displaying apparent signs of life, the ethical and policy issues posed when family members insist on continued treatment are not as simple as commentators have claimed. In this article, we consider the kind of policy that should be adopted to manage a family's insistence that their brain‐dead loved one continues to receive supportive care. We argue that while it would be (...) ethically inappropriate to continue to devote scarce acute care resources to such patients in a hospital setting, it may not be ethically inappropriate for patients to receive these resources in certain other settings. Thus, if a family insists on continuing to care for their brain‐dead loved at their home, we should not, from a policy perspective, interfere with the family's wishes. We also argue that healthcare professionals should make some effort to facilitate the transfer of brain‐dead patients to these other settings when families insist on continued treatment despite being informed about the lack of any potential for recovery of consciousness. Our arguments are strengthened by the fact that patients in a persistent vegetative state, who, when correctly diagnosed, also have no potential for recovery of consciousness, are routinely transferred from hospitals to nursing homes or long‐term care facilities where they continue to be ventilated, tube fed and to receive other supportive care. We also briefly explore the question of who should be responsible for the costs of such treatment at the long‐term care facility. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:SACRIFICE AND THE PUBLIC SPHERE Colin Jager University ofMichigan The Inscription on the Memorial to Irish Freedom in Parnell Square, Dublin, reads: "O generations of freedom, remember us, the generations of the vision." The irony, of course, is that the generations of freedom to whom the inscription is addressed have yet to be born. Or rather: they/we are partly a generation of freedom, while remaining also and of necessity (...) a generation of vision. Freedom—always partial and imperfect where it exists at all—remains bound up with vision. And violence (so the memorial tells us) is never far from vision. Is itpossible to conceive ofa public sphere free from violence? This is the question I address here with the help ofHannah Arendt. I begin by describing Arendt's distinction between the public and private realms and summarizing Seyla Benhabib's interpretation ofthese categories. Arendt, ofcourse, valued the public sphere ofcontestation that she associated with the Greek world; for her, the private realm of the household should remain completely separate from public life—the private was a place ofmere necessity, devoted solely to maintaining the physical body. According to Benhabib, we can follow Arendt in thinking of the public sphere as a place of contestation and hence of potential pain, or we can allow the concerns of the private into the public realm, and thus work to create a public sphere based on association and potential solidarity. Working out of the communicative theories of Jürgen Habermas, Benhabib tries to pull Arendt toward Habermas by emphasizing what she calls Arendt's "reluctant modernism": those elements ofher thought that move away from a sharp distinction between public and private and tend toward association and solidarity. And yet—this is the conviction that motivates this essay—history tells us that we cannot simply exchange one for the other. The poignancy ofmy epigraph springs, I think, precisely from our 58Colin Jager realization that vision never modulates easily into freedom. The monument's inscription, the very fact of its existence, links vision indissolubly with bloodshed and sacrifice, while imagining freedom as a peaceful realm beyond violence, a place ofharmony and solidarity for which the "generations ofthe vision" were willing to sacrifice themselves. Yet we are not that generation of freedom. We have not shed the burden of vision and history, for history is never simply behind us. What the eighty bloody years since the Easter uprising have taught us, if anything, is that the coming offreedom is always delayed and that the hopes for a peaceful transition from vision to freedom, agon to association, revolution to democracy, are forever marred by the reality ofa world where there is more than one vision and where continued sacrifices in the name ofvision seem to bring us no closer to peace, or to freedom. Who is the monument for, then? We must conclude that it is for us who remain somewhere between vision and freedom, forced by our own monuments to acknowledge that history that continues to infect our present. If agon and association, vision and freedom, inevitably bleed into each other, then we cannot talk realistically about one simply replacing the other. In this regard Arendt's work is crucial because it teaches us that movement from an agonistic Greek public to an associative modern public is accomplished only at the cost of displacing the distributive violence of the Greek world onto a figure ofsuffering. The necessity ofsuch suffering is the element that Benhabib, with her emphasis on the ideal communicative community, misses. Therefore, highlighting suffering helps us to understand Arendt: the suffering figures scattered through her work are the only way to make sense of her crucial notions of storytelling and forgiveness. More generally, highlighting suffering helps us understand what is at stake in any Utopian theory of the public sphere: envisioning the transition from an agonistic public sphere, defined by its relationship to violence, to a nonviolent associative public sphere of peace and communicative ethics is impossible wiüiout acknowledging those who pay the price for such a passage. Freedom, ifit does come, comes at a terrific cost—and there is no guarantee that it will still be here tomorrow. 1. Agonism and Associationism... (shrink)

Ecological Immunology assumes that immunological defenses must be minimized in terms of cost (energy expenditure). To reach this goal, a complex and still largely unexplored strategy has evolved to assure survival. From invertebrates to vertebrates, an integrated immune–neuroendocrine response appears to be crucial for the hierarchical redistribution of resources within the body according to the specific ecological demands. Thus, on the basis of experimental data on the intimate relationship between stress and immune responses that has been maintained during evolution, (...) we argue that a broader perspective based on the integration of immune and neuroendocrine responses should be adopted to describe the comprehensive strategy that the body utilizes to adapt to dynamic environmental conditions. We discuss the hypothesis that a bow‐tie architecture might be suitable to describe the variety of immune–neuroendocrine inputs that continuously target cells and organs while, at the same time, fulfilling the basic requirement of minimizing the cost of immune–neuroendocrine responses. Bow‐tie architectures are able to convert a variety of stimuli (fan in) into a wide range of fine‐tuned responses (fan out) by passing through the integrating activity of a core (knot) constituted by a limited number of elements. Finally, we argue that the ecologically negotiated immune–neuroendocrine strategies may have deleterious effects in the post‐reproductive period of life when, at least in humans, chronic, low‐grade, systemic inflammation develops, in accordance with the antagonistic pleiotropy theory of aging. BioEssays 30:868–874, 2008. © 2008 Wiley Periodicals, Inc. (shrink)

This research explores the harmful effects of negative workplace gossip (NWG) on targets and organizations, including its impacts on helping behavior and knowledge hiding. The mediating role of guanxi closeness and the moderating role of need for affiliation are also examined. The study, based on conservation of resources theory, collected data from 526 employees in the hospitality industry in China, using a three-wave survey design. Hierarchical multiple regression analysis was employed to test the hypotheses. The empirical results showed that NWG (...) was a strong predictor of reduced helping behavior and increased knowledge hiding; and that guanxi closeness mediated both the negative relationship between NWG and helping behavior, and the positive relationship between NWG and knowledge hiding. Additionally, need for affiliation was shown to act as a moderator between NWG and guanxi closeness: high need for affiliation amplified the negative impact of NWG on guanxi closeness, and then further affected employees’ helping behavior and knowledge hiding. This study therefore offers an important new perspective for interpreting the detrimental effects of negative gossip in organizations, providing not just theoretical advances but practical ways in which managers can proactively reduce these impacts. (shrink)