In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Acts of Enjoyment: Rhetoric, Žižek, and the Return of the SubjectJames J. Brown Jr. and Joshua GunnActs of Enjoyment: Rhetoric, Žižek, and the Return of the Subject by Thomas Rickert. Pittsburgh: University of Pittsburgh Press, 2007. Pp. x + 252. $24.95, hardcover.Thomas Rickert had a falling-out with his brother, and this distresses him so much that his disrupted relation is described as “traumatic.” Rickert reports that while (...) listening to a portable CD player during a run on an unexpectedly warm winter day, a song by the now defunct jazz/rock band Morphine reminded him of a happy time at a pool hall with his brother (24). Mediated—or better, medicated—by music, the homological happiness of running in the sun and a positive past memory also resurfaced a painful relational rupture, the reason of which Rickert omits to underscore that mysterious, “little detail or object” of the Real that marks his singular finitude as a writing subject (216 n. 11). We’ll want to come back to this curiously deliberate omission, but for the present we note Rickert is not simply an undead author but a human being with relations and feelings. He is not just a gifted scholar or a bundle of reflections, but a nexus of body and movement and words and affect. If there is anything that Rickert’s study can be said to work through with brilliance, humor, and grace, it is the reality of complex personhood.Rickert’s brotherly confession comes in Chapter 1 as a way to introduce a psychoanalytic understanding of subjectivity, and more specifically, to help illustrate how trauma works itself out as an afterwardness or “belatedness” ( Nachträglichkeit ): traumatic events from the past are not reckoned with or worked-through until some coincidence or reminder, such as a similar [End Page 183] sensory experience, reintroduces the event in doubled re-presentation (18–27). This implies the “subject” (a paradigm person) is a kind of timedelay, a self-conscious temporal moving that becomes this way through re-presentation. The rhetorical subject is analogously a retrojected reckoning with events past (not all traumatic) that Rickert identifies as a scene of writing, a locus that has important implications for rhetorical studies in general and writing pedagogy in particular. Rickert’s logic is as follows: if we agree that the subject is a belated one in the psychoanalytic sense, then how we teach rhetoric needs to change. Rickert opens the book with the observation that his students are producing excellent cultural critiques but that such critiques do not lead the students to change their actions (1–7), perhaps evidence enough that something is not quite right in a classroom grounded by “cultural studies pedagogy” and ideology critique—or at the very least, proof that something has changed. The opening gambit is simply that a “postpedagogy” premised on an understanding of rhetorical subjectivity as belatedness is better than a status quo rooted in the rational subject of the Enlightenment.Mostly through a Žižek-filtered, Lacanian lens, Acts of Enjoyment then undertakes a retake of the rhetorical field, frequently scanning from the traumatic ontology of the rhetorical subject to that domain of knowledge that we hold dear, the subject of rhetoric. In Chapter 2, the (primal) scene thus shifts from the slo-mo subject to rhetorical studies, initially through a reassessment of Kinneavy’s “communications triangle,” but ultimately in response to the shock treatment of poststructuralism. The initial theoretical traumas introduced by Victor Vitanza, Diane Davis, Sharon Crowley, and others discussed in Chapter 1 are threaded into an account of “poststructural” redress in Chapter 2: as is true of all forms of trauma, the initial poststructural jolt delivered to the concept of subjectivity was deadened; poststructural theory was eventually used to “shore up rather than challenge Kinneavy’s triangle” (37). To truly work-through our traumatized subject in both senses, we need a second trauma: Lacanian psychoanalysis. Presumably, “poststructuralist thought” is to be opposed because it has no account of the subject (21–24); “Lacan,” after all, “is not a poststructuralist” (48). The remainder of the chapter is then used to deploy Lacan’s conceptual lexicon.Just as... (shrink)

We provide a new wrinkle to the Argument from Unfair Advantage, a rather popular one in the ethics of doping in sports discussions. But we add a new argument that we believe places the moral burden on those who favor doping in sports. We also defend our position against some important concerns that might be raised against it. In the end, we argue that for the time being, doping in sports ought to be banned until it can be demonstrated that (...) our concerns can be satisfied. (shrink)

I suggest that we may want to strive, over time, to change our present professional-cultural view, from one that sees an expression of moral distress as a threat, to a professional-cultural view that welcomes these challenges. Such an effort to better medicine would not only include dissenting clinicians, but patients (and their loved ones) as well.

Shared decision making (SDM) is the state of the art for clinicians’ communication with patients and surrogate decision makers. SDM involves give and take, in which all parties interact to maximize the autonomy of patients. In this article I summarize the core steps of SDM and explore ways to use it to benefit patients to the greatest extent. I review three articles included in this issue of The Journal of Clinical Ethics that highlight additional approaches we can use to help (...) patients and parents to see what may be in their own or their child’s best interest. I describe how these approaches can be used in most other medical fields. I explore ways to share information with patients that are outside the usual scope of SDM. Finally, I discuss how we might look, together with patients, at what all parties are feeling before we begin the process of SDM. (shrink)

In this article I will discuss how clinicians might best treat adolescents who may die. I initially discuss these patients’ cognition, emotional tendencies, and sensitivity to interpersonal cues. I next discuss their parents’ feelings of loss and guilt and their clinicians’ risk of imposing their own moral views without knowing this. I then address the practical concerns of helping these patients gain or regain resilience and to identify strengths they have had in the past. I finally explore who, among staff, (...) might be best able to do this. I highlight as the main goal that patients, their parents, and ideally also their clinicians are able to come to agree on the best course the patients should take. (shrink)

Physicians who are impaired, engage in unprofessional behavior, or violate laws may be barred from further practice. Likewise, medical students may be dismissed from medical school for many infractions, large and small. The welfare of patients and the general public must be our first priority, but when we assess physicians and students who have erred, we should seek to respond as caringly and fairly as possible. This piece will explore how we may do this at all stages of the proceedings (...) physicians and students may encounter. This may include helping them to resume their medical careers if and when this would be sufficiently safe and beneficial for patients. (shrink)

As we go to press, the threat of biological or chemical warfare in the Persian Gulf is no longer imminent. Yet the questions raised by the proposed use of “investigational drugs,” without informed consent, to protect U.S. troops remain. The article by Edmund G. Howe and Edward D. Martin presents the arguments that informed the Pentagon's thinking on the subject. It and the commentaries, by George J. Annas and Michael A. Grodin, and Robert J. Levine, explore, among others, issues (...) of informed consent, of distinguishing ‘research’ and ‘treatment,’ and of the nature and extent of the autonomy of military personnel.—B‐JC, HLN. (shrink)

In this special issue of The Journal of Clinical Ethics, different views on both the ethical desirability of women delivering in hospitals or at home with midwives are discussed. What careproviders, including midwives, should recommend to mothers in regard to the place of giving birth is considered. Emotional concerns likely to be of importance to mothers, fathers, midwives, and doctors are also presented. Finally, possible optimal approaches at the levels of both policy and the bedside are suggested.

Attention to the ethical concerns of healthcare aides can provide important information about patients’ needs to careproviders, improve the ethical environment of an institution, and benefit aides who suffer from bearing ethical concerns alone. All persons benefit from sharing their ethical concerns with others. Among other benefits, ethics consultation offers careproviders, caregivers, healthcare aides, patients, and patients’ loved ones an opportunity to have their concerns heard.John Fletcher tried to follow every ethics consultation with a debriefing for all participants, including patients (...) and family members, to increase the possibility for continued healing after the conclusion of the consultation, and there are good reasons to follow this practice. (shrink)

The author describes an alternative approach that careproviders may want to consider when caring for patients who request interventions that careproviders see as futile. This approach is based, in part, on findings of recent neuroimaging research. The author also provides several examples of seemingly justifiable “paternalistic omissions,” taken from articles in this issue of The Journal of Clinical Ethics (JCE). The author suggests that while careproviders should always give patients and their loved ones all potentially relevant information regarding “futile” decisions, (...) careproviders may wish to consider, paradoxically, not giving advice in these situations, when the advice is based mostly or wholly on their own moral views, based on this same, ethical rationale. (shrink)

This article discusses a case in this issue of The Journal of Clinical Ethics by McCrary and colleagues, “Elective Delivery Before 39 Weeks’ Gestation Reconciling Maternal, Fetal, and Family Circumstances,” in which parents asked the medical team to deliver their fetus “early.” The author discusses (1) the importance that parents have to a child when they are able to love the child, and how important it is for decision makers to consider this; (2) exceptional approaches that may enable parents to (...) “change their minds”; and (3) substantive and procedural innovations that may help to prevent clinicians’ views from playing too big a role and/or being arbitrary. The author concludes by describing how he felt when reading the case and uses this to illustrate how clinicians may benefit by assessing their feelings. (shrink)

Should people with exceptionally profound disabilities be given an equal chance of surviving a pandemic, even when their care might require a greater use of limited medical resources? How might an ethics of care be used to shape a policy regarding these patients?

In this issue of JCE, Baum-Baicker and Sisti present senior psychoanalysts’ views of wisdom.Although views on wisdom differ widely, there is agreement that when ethical conflicts arise, wisdom may be critical in bringing about an optimal result. Here I will present recent empirical findings on wisdom and the ways careproviders may acquire and apply it, especially in ethical conflicts. The findings are not well-known and may seem counterintuitive; I selected them, in large part, for those reasons. A core challenge may (...) be to decide when to give patients standard care and when to make exceptions. In this issue of JCE, Baum-Baicker and Sisti discuss exceptions and Bursztajn and colleagues consider how these exceptions may be further validated as evidence-based treatments. (shrink)

This article reviews careproviders’ most difficult emotional challenges during disasters and provides approaches for responding optimally to them. It describes key approaches that careproviders may pursue to best help patients and others during a catastrophe. It raises unanswered questions regarding when, if ever, careproviders should provide active euthanasia to patients who are incompetent, and when, if ever, careproviders should give their own food and water to patients or others who may otherwise soon die without them.

Clinical ethics consultants (CECs) must know key moral principles and have adequate psychosocial skills. This is, though, not enough. They must also have and hone “between-the-lines” skills that will change over time. This article discusses seven of these skills that CECs need before, during, and after consultations. They have in common the unusual primary goal of maximizing CECs’ ability to bond with the patients and families with whom they consult. A focus on relationships, rather than on ethical outcomes, may paradoxically (...) enhance the possibility of achieving an ethical outcome. (shrink)

Stress can make the comprehension of complex information more difficult, yet patients and their family members often must receive, process, and make decisions based on new, complex information presented in unfamiliar and stressful clinical environments such as the intensive care unit. Families may be asked to make decisions regarding the donation of organs and genetic tissue soon after the death of a loved one, based on new, complex information, under tight time limits. How can we assist patients and families to (...) better process complex information while under stress, and make better decisions for themselves or a loved one? (shrink)

A recently enacted law permits patients to see their electronic medical record (EMR) immediately after their careprovider writes in it. In this article I discuss a proposal that authors make in this issue of The Journal of Clinical Ethics, that ethics consultants (ECs) keep their notes in a separate section of the EMR that patients cannot access when their ethics notes may be troubling to patients, to avoid unduly harming them.I discuss this concern and three more widely applicable clinical goals: (...) to help patients feel safe; to gain patients’ trust; and to provide hope to patients, when possible. These goals apply to careproviders and ECs who seek to help patients and families resolve ethical conflicts. I explain why these goals are singularly important and how careproviders may pursue them, using as an example informing patients about temporal framing to help them find hope. (shrink)

In this issue of The Journal of Clinical Ethics, Emily Bell and Eric Racine are guest editors of a special section focusing on the use of deep brain stimulation (DBS) to treat Parkinson’s disease. In “Deep Brain Stimulation, Ethics, and Society,” Bell and Racine report that DBS already has been used to treat more than 50,000 patients. The ethical issues raised in this special section are important not only in regard to Parkinson’s disease and DBS, but in many areas of (...) medicine.The articles discuss sound, state-of-the-art ethical approaches. This introduction to the issue presents approaches that are adjunctive and intended to increase careproviders’ options, that should increase careproviders’ ability to individualize the care that they provide to their patients. (shrink)