Considering the organization’s ethical context as a framework to investigate workplace phenomena, this field study of military reserve personnel examines the relationships among perceptions of psychosocial group variables, such as cohesiveness, helping behavior and peer leadership, employee job attitudes, and the likelihood of individuals’ withholding on-the-job effort, a form of organizational misbehavior. Hypotheses were tested with a sample of 290 individuals using structural equation modeling, and support for negative relationships between perceptions of positive group context and withholding (...) effort by individual employees was found. In addition, individual effort-performance expectancy and individual job satisfaction were negatively related to withholding effort. The findings provide evidence that individual perceptions of positive group context play a key role in the presence of misbehavior at work. The results indicate that positive group context might be an important element of ethical climate that should be managed to temper occurrence of such adverse work behavior. (shrink)

In the world of human resource management employees who deliberately “withhold effort” on the job are called “production deviants.” The implication is that workers are under a duty to perform as best they can, but why should we accept this? Three answers are presented and interrogated. The first says that employees who withhold effort are guilty of “time-banditry” or theft from their employers. The second says that withholding effort harms one’s colleagues or co-workers. The third suggests (...) that employees owe their employers a debt of gratitude, whose discharge requires that they be as productive as they reasonably can be. (shrink)

The nocebo effect, a phenomenon whereby learning about the possible side effects of a medical treatment increases the likelihood that one will suffer these side effects, continues to challenge physicians and ethicists. If a physician fully informs her patient as to the potential side effects of a medicine that may produce nocebogenic effects, which is usually conceived of as being a requirement associated with the duty to respect autonomy, she risks increasing the likelihood that her patient will experience these side (...) effects and therefore suffer (unnecessary) harm, a violation of the duty of nonmaleficence. If, on the other hand, she intentionally withholds side effect information in an effort to protect her patient from suffering unnecessary harm from side effects, which is consistent with the duty of nonmaleficence, she violates the duty to respect patient autonomy. In this paper, the author discusses several previous attempts to deal with the nocebo effect and explains their weaknesses. He then proposes a means of managing the nocebo effect and argues that it does not share the weaknesses found in previous approaches. He concludes with a discussion of a simple, yet practical tool that might help clinicians manage the tension resulting from the nocebo effect. (shrink)

However, the barriers and facilitators of such changes - law reform perspectives - have been virtually ignored. Why do so many attempts to change the law fail but others are successful? International Perspectives on End-of-Life Law Reform aims to address this question by drawing on ten case studies of end-of-life law reform from the United Kingdom, the United States, Canada, the Netherlands, Belgium and Australia. Written by leading end-of-life scholars, the book's chapters blend perspectives from law, medicine, bioethics and sociology (...) to examine sustained reform efforts to permit assisted dying and change the law about withholding and withdrawing life-sustaining treatment. Findings from this book not only shed light on changing end-of-life law but also provide insight more generally into how and why law reform succeeds in complex and controversial social policy areas. (shrink)

Evidence suggests that psychedelics bring about their therapeutic outcomes in part through the subjective or qualitative effects they engender and how the individual interprets the resulting experiences. However, psychedelics are contraindicated for individuals who have been diagnosed with certain mental illnesses, on the grounds that these subjective effects may be disturbing or otherwise counter-therapeutic. Substantial resources are therefore currently being devoted to creating psychedelic substances that produce many of the same biological changes as psychedelics, but without their characteristic subjective effects. (...) In this article, we consider ethical issues arising from the prospect of such potential “nonsubjective” psychedelics. We are broadly supportive of efforts to produce such substances for both scientific and clinical reasons. However, we argue that such nonsubjective psychedelics should be reserved for those special cases in which the subjective effects of psychedelics are specifically contraindicated, whereas classic psychedelics that affect subjective experience should be considered the default and standard of care. After reviewing evidence regarding the subjective effects of psychedelics, we raise a number of ethical concerns around the prospect of withholding such typically positive, meaningful, and therapeutic experiences from most patients. (shrink)

The COVID-19 pandemic has been accompanied by an “infodemic” of misinformation and conspiracy theory. This article points to three explanatory factors: the challenge of forming accurate beliefs when overwhelmed with information, an implausibly individualistic conception of epistemic virtue, and an adversarial information environment that suborns epistemic dependence. Normally we cope with the problems of informational excess by relying on other people, including sociotechnical systems that mediate testimony and evidence. But when we attempt to engage in epistemic “superheroics” - withholding (...) trust from others and trying to figure it all out for ourselves – these can malfunction in ways that make us vulnerable to forming irrational beliefs. Some epistemic systems are prone to coalescing audiences around false conspiracy theories. This analysis affords a new perspective on philosophical efforts to understand conspiracy theories and other epistemic projects prone to collective irrationality. (shrink)

There is a curious asymmetry in cases where the use of religious language involves a breakdown in communication and leads to a seemingly intractable dispute. Why does the use of religious language in such cases almost always arise on the side of patients and their families, rather than on the side of clinicians or others who work in healthcare settings? I suggest that the intractable disputes arise when patients and their families use religious language to frame their problem and the (...) possibilities of solution. Unlike clinicians, they are not bilingual and thus lack the capacity to understand and negotiate differences in terms that are responsive to those who work in healthcare settings. After considering a representative case, I explore whether an ethics consultant or chaplain can function as a translator and suggest that, at best, such efforts at mediation depend on contingent aspects of a case and will only be partially successful. To appreciate limits on the role for bilingual translators, I consider a futility dispute where a parent using religious language demands that everything be done for a permanently unconscious child. I challenge the traditional interpretation that says the parent values “mere duration of biological life irrespective of quality.” From a religious perspective, human life is never “merely biological.” This effort to slot the dispute into standard philosophical schemas misses what is crucial in the dispute. I suggest that a better interpretation views the dispute at a meta-level as one about whether withholding and withdrawing care is morally distinguishable from killing. Curiously, this interpretation makes the advocate of futile care into an ally of those “quality of life” advocates who also challenge this distinction. The crux of their dispute now rests on the normative ethics of killing. While I think my interpretation comes much closer to the views of many who demand ‘futile care,’ I suggest that it still falls short because of the way it reconstructs the religious concerns in nonreligious terms. I close by considering an analogy between the language of suffering and the language of faith, suggesting that both require a much richer understanding of the narratives that orient the lives of patients and their families. (shrink)

Vaccines are a powerful measure to protect the health of individuals and to combat outbreaks such as the COVID-19 pandemic. An ethical dilemma arises when one effective vaccine has been successfully developed against an epidemic disease and researchers seek to test the efficacy of another vaccine for the same pathogen in clinical trials involving human subjects. On the one hand, there are compelling reasons why it would be unethical to trial a novel vaccine when an effective product exists already. First, (...) it is a firm principle of medical ethics that an effective treatment or vaccine should not be withheld from patients if their life may depend on it. Second, since epidemic outbreaks often emerge in settings with less-resourced health systems, there is a pronounced risk that any trial withholding an effective vaccine would disproportionately affect the vulnerable populations that historically have been exploited for biomedical research. Third, clinical trials for novel vaccines may be at odds with efforts to control active outbreaks. On the other hand, it may be justified to conduct a trial for a candidate vaccine if it is expected to have certain advantages compared with the existing product. This essay discusses key factors for comparing vaccines against epidemic pathogens, including immunological, logistical and economic considerations. Alongside a case study of the development of vaccines for Ebola, the essay seeks to establish a general framework that should be expanded and populated by immunologists, epidemiologists, economists and bioethicists, and ultimately could be applied to the case of COVID-19 vaccines. (shrink)

The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant observation on a (...) surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting. (shrink)

In the last 25 years writing in bioethics, particularly in medical ethics, has generally claimed that action is ethically acceptable only if it receives informed consent from those affected. However, informed consent provides only limited justification, and may provide even less as new information technologies are used to store and handle personal data, including personal genetic data. The central philosophical weakness of relying on informed consent procedures for ethical justification is that consent is a propositional attitude, so referentially opaque: consent (...) is given to specific propositions describing limited aspects of a situation, and does not transfer even to closely related propositions. Assembling genetic data in databases creates additional difficulties for ethical justification. This is not because genetic information is intrinsically exceptional, but because the merger of genetic and information technologies make it possible to assemble massive quantities of complex information that defeat individuals' best efforts to grasp what is at stake, or to give or withhold informed consent. The future agenda for bioethics will need to take account of both these limitations of appeals to informed consent. (shrink)

Background Moral sensitivity and academic integrity discernment hold paramount importance for healthcare professionals. Owing to distinct undergraduate educational backgrounds, nurses and physicians may exhibit divergent moral perspectives, academic integrity cognisance, and moral sensitivity within clinical environments. A limited number of studies have investigated the disparities and congruencies pertaining to moral sensitivity and academic ethical awareness among nursing and medical students. Objective The study compares moral sensitivity and academic ethical awareness of undergraduate nursing and medical students with and without clinical exposure. (...) Research design A self-administered cross-sectional survey conducted from January to February 2022 was used to collect data from a medical school in Hong Kong. Participants and research context A total of 545 respondents, including 137 nursing students and 408 medical students, completed the questionnaire. Ethical consideration Ethics approval of the study was obtained. Written consent was waived to maintain anonymity because completing the questionnaire was considered implied consent. Findings Both groups of undergraduates demonstrated a high level of bioethics knowledge. In terms of academic integrity, medical students were found to have a less concerned attitude towards punctuality, attendance, and skipping classes. Regarding moral sensitivity, senior medical students with clinical experience put less emphasis on decision-making involving patient participation, while senior nursing students were more hesitant in withholding treatment for incompetent patients who refused treatment. Both nursing and medical students showed decreased moral sensitivity in the ‘conflicts’ domain with increased clinical exposure. Conclusion Study findings contribute to the discussion comparing the ethical attitudes of nursing and medical students. More effort should be made in nursing and medical education to promote practices in line with high academic integrity and to develop the ability to be morally sensitive in professional settings. (shrink)

Against the Manichees, Augustine argued that sin must involve a free exercise of will. Otherwise it will not count as the agent's own act for which the agent is morally responsible. In the 390's, however, Augustine became convinced that only the first humans sinned by free exercise of will. This view faced him with the question: how is it that unambiguously good agents come to will the evil? Augustine found no satisfactory solution, and the first evil will appears, on his (...) reckoning, to be either a random outcome or due to a withholding of grace. Despite his best efforts, his account of moral agency in evil remains flawed. (shrink)

Research shows that the physician’s personal attributes and social characteristics have a strong association with their end-of-life decision making. Despite efforts to increase patient, family and surrogate input into EOL decision making, research shows the physician’s input to be dominant. Our research finds that physician’s social values, independent of religiosity, have a significant association with physician’s tendency to withhold or withdraw life sustaining, EOL treatments. It is suggested that physicians employ personal social values in their EOL medical coping, because they (...) have to cope with existential dilemmas posed by the mystery of death, and left unresolved by medical decision making mechanisms such as advanced directives and hospital ethics committees. (shrink)

Children's autonomy includes, as far as possible, self-determination, bodily integrity and the right to influence outcomes. Limits to bodily integrity, which involves no touching without the child's consent or tacit agreement, are discussed. The clinical, legal and ethics literature tends to agree that children may give valid consent to major recommended treatment from around 12 years but may not refuse it until they are legal adults. Research shows that young children are more aware of their bodily integrity and autonomy, of (...) morality and decision making, than was assumed in the past. Adults therefore need to inform children and respect their initially instinctive efforts to protect their bodily integrity. Unlike assent, consent involves patients being adequately informed and being able to accept or refuse proposed treatment. Reasons are given for adults’ need to consult with children when determining their best interests. Beyond words, giving or withholding consent also involves emotions of fear, trust and courage, besides embodied reactions of cooperating with treatment or resisting it, in which young children actively engage. Some clinicians work with the informed cooperation of young children who need lifesaving treatment, and at times accept their refusal. Reasons for differences between mainstream experts’ views and clinical practices are considered. (shrink)

The hereafter, one of the main pillars of Islam, has been discussed by both theologians and Ṣūfīs from various angles and interpreted in many different ways. Although there is consensus on the main subjects, there are a lot of controversies in details. One of the Ṣūfīs who authored on diverse problems over the hereafter is ʿAlāʾ al-Dawla al-Simnānī (d. 736/1336). He was a Kubrawī shaykh during the Īlkhānid era. He inclined towards the Ṣūfī path after serving the Buddhist ruler Arghun (...) (r. 1284-1291) for ten years, thanks to a spiritual experience he had. He met with Nūr al-dīn ʿAbd al-Raḥmān al-Isfarāyīnī (d. 717/1317), a Kubrawī shaykh based in Baghdad, and became a disciple of him, granted ijāza (a certificate of authority) from him. Upon his shaykh’s order, he turned back to his hometown and spent his life until his death, in his Ṣūfī lodge raising disciples and writing works. He had contributed greatly both to his own order and to the literature of Ṣūfism with his disciples and written works. As regards to the hereafter, his opinions on the reality of this world and its position against the next, death, the doomsday and its kinds, the existence of the paradise and the hell today and their present location are remarkable. In this article, his views over those problems are discussed in the context of his understanding of mystical training.Summary: ʿAlāʾ al-Dawla al-Simnānī (d. 736/1336) lived between the second half of the seventh century (h.) and the first half of the eighth century, in today’s Iran, during reign of the Īlkhānid’s. Thanks to the connection of his family to the Īlkhānid court, his father and uncle’s administrative positions at the court and his will and efforts, he started to serve Arghun (r. 1284-1291) around the age of fifteen and gained his personal intimacy. After serving him for ten years, he experienced a spiritual transformation and inclined towards a mystical life. He left Arghun for his hometown Simnān, on the pretext of his disease that courtier doctors could not treated, but under the condition that he would turn back after he recovered from the disease. He got better just after a while but did not return. He arrived Simnān at the beginning of a holy month of Ramadan, took off his formal clothes and began to mystical training himself based on Abū Ṭālib al-Makkī’s Qūt al-qulūb. After a while, he met with one of the disciples of Nūr al-dīn ʿAbd al-Raḥmān al-Isfarāyīnī (d. 717/1317) and wondered about him. Then left Simnān for Baghdad with the intention of visiting him. However, Arghun was informed about this and prevented him from going to Baghdad, withholding him for some time. After a while, Simnānī escaped from Arghun and returned to Simnān and wrote a letter to al-Isfarāyīnī on this incident. In response, al-Isfarāyīnī said that he does not need to visit Baghdad, al-Isfarāyīnī would be with him spiritually and ordered him to start his training. Simnānī kept his connection alive with his shaykh during this period via letters and spiritual meetings but he could not meet with him face to face. Afterwards, he could meet him twice and granted ijāza from him.After that, upon his shaykh’s order, he turned back to Simnān and engaged with disciples’ mystical trainings and authoring books. He gained an eminent position in both his order and history of the Ṣūfism, upbringing too many disciples and writing around ninety works. His importance in the Kubraviyya rooted firstly in the fact that the extant sub-branches of the order have him in their silsila (spiritual genealogy). In this regard Simnānī is a key actor within his order. Besides, it is significant that he had great impact on the founders of two branches of the Kubraviyya, i.e. Sayyid ʿAlī Hamadānī (d. 786/1385) and Muhammad Nurbakhsh (d. 869/1464) that indicating his influence among the order itself. When examined from the angel of the history of the Ṣūfism, the most apparent and distinctive point regarding Simnānī is his criticism against Ibn ʿArabī (d. 637/1240) on the problem of being. Notwithstanding, his supreme contribution to the Ṣūfism is his doctrine of latāif, which particularly influenced Pārsā (d. 822/1240), a leading disciple of the founder of the Naqshbandiyya. Likewise his mystical experiences and thoughts on rijāl al-ghāib had also influenced subsequent Ṣūfīs. His thoughts on the problem of khawātir, which is crucial component of Kubravī path, and detailed information given in his books regarding the lights (anwār) and the truth of nūr as well as his explanations about the situations experienced during the manifestation of God can be listed among his contributions to the history of the Ṣūfism.Simnānī who wrote on various problems of Ṣūfism, dealt with the problem of the Hereafter in the context of his understanding of initiation. For the world cannot be disunited from the Hereafter, as his understanding of the Hereafter is examined, his view of the world is studied as well. With reference to the presupposition that there are three distinct dimensions of the world, Simnānī says that man’s relationship with the world should be differentiated according to following three aspects: the world’s being a plantation for the hereafter, the world’s being a place that should be abandoned and the world does not have a reality. According to him the hereafter is a continuous moment, whereas the worldly life is bound by the past and the future. Since the past and the future do not have a real being, hence the world as well does not have real being. Simnānī embraces the death and the Doomsday in an intertwined fashion in the context of his own understanding of mystical training. Approvingly the consensus of the Ṣūfis, he divides the death into two: necessary and voluntary. And he divides the Doomsday into three: big, middle and small. According to this, the wayfarer who has weakened his soul’s evil attributes via the voluntary death observes the situations of the small doomsday. Thereby the wayfarer who observed everything that is depicted in the Quran that will be experienced after the necessary death, gains time to take necessary precautions before the necessary death, which is irremediable. Another issue that Simnānī raises regarding the Doomsday is the sorts of the Doomsday. Based on the different names of the Doomsday, he says that there are different doomsdays each of which is related with one of the latāif situated among human faculties. Ultimately salvation from those doomsdays is possible with a different good deed. Another point that Simnānī comes up with is the problem of existence of the paradise and the hell today. He thinks that the paradise and the hell both exist today, with reference to his own kashf. He relates this narrating the verses and the traditions, which support his view. Besides, he accepts that there are two paradises and hells, one is inside the human nature and the other is out there. According to Simnānī, entering the outer paradise without observing one’s inner paradise is nonsense. This is possible only through a spiritual journey from one’s external being into his/her internal being. In the end, this can only be accomplished via the voluntary death. (shrink)

Plato inaugurated the Western tradition of political philosophy in his effort to vindicate the memory of Socrates and prevent future persecutions of philosophy. To attain this double objective, Plato embedded teachings and distributed themes with a view to appropriately revealing and withholding insights. The ultimate crucible for heuristically testing this Platonic method is Plato's distribution of themes of eros and force. Eros and force parallel the two cardinal features of the erotic Socrates who was suspected of guiding ambitious (...) youths to demagogic careers. Plato's metaphysics, dominated by his theory of Forms or Ideas, similarly originated in indignation at Socrates' legal murder and anguish about the future of philosophy. By positing fixed, eternal, and immutable standards, Plato seeks to preempt the litigious excesses, oratorical shenanigans and legalistic leeway that once made it possible to charge and convict Socrates. The reference of what is actual to a transcendent standard of truth served also to usher in the western tradition of textual embeddedness of meanings. This means that original political philosophy, understood as Platonic philosophy, is a relationship between form and content---between "how" something is articulated in writing and "what" is written. After the onslaught of the diagnostic critique of western thought, unleashed mainly by Nietzsche and Heidegger, the revival of esotericism in our century has been useful in unlocking Platonic interpretation and in showing Plato's text to be dependent on an inextricable interweaving between form and content. (shrink)

A lot of Indian research is replicative in nature. This is because originality is at a premium here and mediocrity is in great demand. But replication has its merit as well because it helps in corroboration. And that is the bedrock on which many a fancied scientific hypothesis or theory stands, or falls. However, to go from replicative to original research will involve a massive effort to restructure the Indian psyche and an all round effort from numerous quarters. (...) The second part of this paper deals with the essence of scientific temper, which need not have any basic friendship, or animosity, with religion, faith, superstition and other such entities. A true scientist follows two cardinal rules. He is never unwilling to accept the worth of evidence, howsoever damning to the most favourite of his theories. Second, and perhaps more important, for want of evidence, he withholds comment. He says neither yes nor no. Where will Science ultimately lead Man is the third part of this essay. One argument is that the conflict between Man and Science will continue till either of them is exhausted or wiped out. The other believes that it is Science which has to be harnessed for Man and not Man used for Science. And with the numerous checks and balances in place, Science will remain an effective tool for man's progress. The essential value-neutrality of Science will have to be supplemented by the values that man has upheld for centuries as fundamental, and which religious thought and moral philosophy have continuously professed. (shrink)

Is discomfort intrinsic to wonder? The author pursues this question by showing how early visitors to the Niagara Falls found that efforts to improve the view eliminated the difficulty that made viewing the falls rewarding in the first place. Visitors’ experiences accord with eighteenth-century accounts that suggest that wonder thrives on difficulty and desire thrives on inaccessibility. This aesthetic effect finds expression in The Arabian Nights and other texts that both represent and enact narrative withholding, and also in the (...) visual form of the arabesque, which beguiles the eye with movement but does not go anywhere. The essay concludes by connecting these insights into aesthetic difficulty to present-day concerns that attempts to bring the humanities to a broader audience may “dumb down” art. I conclude that such concerns miss the point that aesthetic experiences depend upon a tension between legibility and illegibility that artworks continue to generate in new and unforeseen ways. (shrink)

Is discomfort intrinsic to wonder? The author pursues this question by showing how early visitors to the Niagara Falls found that efforts to improve the view eliminated the difficulty that made viewing the falls rewarding in the first place. Visitors’ experiences accord with eighteenth-century accounts that suggest that wonder thrives on difficulty and desire thrives on inaccessibility. This aesthetic effect finds expression in The Arabian Nights and other texts that both represent and enact narrative withholding, and also in the (...) visual form of the arabesque, which beguiles the eye with movement but does not go anywhere. The essay concludes by connecting these insights into aesthetic difficulty to present-day concerns that attempts to bring the humanities to a broader audience may “dumb down” art. I conclude that such concerns miss the point that aesthetic experiences depend upon a tension between legibility and illegibility that artworks continue to generate in new and unforeseen ways. (shrink)

Health care reform is being assaulted from all sides. In January, the House of Representatives voted to repeal The Patient Protection and Affordable Care Act (the "Affordable Care Act"). For now, that effort will not succeed, owing to Democratic control of the Senate and the presidential veto. But conservative lawmakers in the House threaten to withhold key funding for implementation, and we can expect ongoing efforts to enact various partial amendments.Meanwhile, a core component of the reform law is running (...) the gauntlet of constitutional challenges in dozens of courts.1 So far, two federal district judges—in Richmond, Virginia, and Pensacola, Florida—have declared the individual mandate unconstitutional, as .. (shrink)

The futility debate may be considered as an effort to provide a clear and justified borderline between physician and patient decision–making authority. In this paper we argue that the search for a definition of futility that provides physicians with a final argument in discussions about life–prolonging treatment, is misplaced. An acceptable and meaningful criterion of futility that satisfies this effort seems impossible. As a consequence, we reject a dichotomous domain of decision–making power as the starting point for definitions (...) of futility. A good decision about withholding life–sustaining treatment should be justified from the perspectives of both physician and patient. In this light, a range of definitions of futility is still useful as it can clarify intuitions that a treatment is inappropriate. (shrink)

In the summer of 1941, Harald Sverdrup, the Norwegian-born Director of the Scripps Institution of Oceanography (SIO) in La Jolla, California, was denied security clearance to work on Navy-sponsored research in underwater acoustics applied to anti-submarine warfare. The clearance denial embarrassed the world renown oceanographer and Arctic explorer, who repeatedly offered his services to the U.S. government only to see scientists of far lesser reputation called upon to aid the war effort. The official story of Sverdrup's denial was the (...) risk of blackmail over relatives in occupied Norway. Declassified documents tell a different story. Although Sverdrup's integrity was defended on the highest levels of U.S. science, doubt was cast upon him by members of his own institution, who accused him of being a Nazi sympathiser. Personal distrust, rooted in scientific and intellectual disagreement, spilled over into questions about Sverdrup's loyalty and judgement. These doubts were considered sufficient grounds for withholding clearance, until Roger Revelle, a former student of Sverdrup now working within the Navy, was able to obtain a limited clearance for Sverdrup to develop techniques to forecast surf conditions during amphibious assaults. After the war, this work was credited with saving many lives, but at the time it placed Sverdrup out of the mainstream of Navy-sponsored oceanographic research. In being denied access to major areas of scientific work, Sverdrup's position as a leader of American oceanography was undermined.The loyalty case of Harald Sverdrup illustrates the emergence of an institutional apparatus through which the U.S. military began to control and shape the organisation of American science in the twentieth century. Military sponsorship of scientific research, begun during the open conflicts of World War II and continuing into the simmering tensions of the Cold War, involved explicit control by the U.S. military of who had access to critical information. This in turn meant who could do science in conjunction with the military. As the U.S. Navy became the principal sponsor of oceanography in the post-war years, clearance to do military work became to a great extent clearance to do oceanography. Choices about who could be trusted were also choices about who would do science, and what kind of science they would do. (shrink)

The concept of futility in medicine refers to the incapability of an intervention to achieve its goal. Futility determinations form the basis for withholding and withdrawing life-sustaining interventions. Criticisms of attempted futility definitions relate to inconstant probability and value judgements concerning the goal pursued. This variability frustrates efforts to define futility. Language modifications and procedural approaches, both important ancillary measures, inherently lack the ability to resolve this difficulty. Beneath the notion of futility lie foundational factors whose revised understanding is (...) required to advance a definition. These factors include autonomy, death and the goals of medicine. Reconsidering the essence and influence of foundational factors is necessary to move beyond a seemingly irresolvable problem. In this essay, I assert that defining futility is not pointless but rather possible, necessary and unavoidable. With this assertion, I respond to the criticisms of futility. These responses together with a corrective understanding of foundational factors lead to a definition of futility. This definition balances respect for patients’ autonomy whilst allowing for interventions that do not undermine the essence of medicine and integrity of those practising it. Defining futility is an exercise in necessity requiring renewed perceptual foundations. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Too Expensive to Treat? Finitude, Tragedy, and the Neonatal ICU by Charles C. CamosyAutumn Alcott RidenourReview of Too Expensive to Treat? Finitude, Tragedy, and the Neonatal ICU CHARLES C. CAMOSY Grand Rapids, MI: Eerdmans, 2010. 208 pp. $18.00In Too Expensive to Treat? Charles Camosy makes an important contribution to bioethics and Christian ethics by making the case for the need to consider social factors when treating imperiled newborns. (...) Arguing for both the full moral status of newborns and Roman Catholic social teaching’s emphasis on the just allocation of resources, Camosy calls the medical community, bioethicists, and [End Page 209] Christian ethicists to account for current practices that disproportionately favor exorbitant costs for imperiled infants over other even more basic medical needs within the US health care system. Written before the adoption of the Affordable Care Act under the Obama administration, Camosy’s argument has only increased in significance given the national need to prioritize resources in view of the government’s expansion of health care coverage.Born within twenty-two to twenty-four weeks of gestation and weighing between 500 and 850 grams, some imperiled infants absorb hundreds of thousands of dollars in short-term care that may extend into millions of dollars given long-term costs (146, 171–93). Recognizing the tragic reality in which “we have virtually unlimited health care needs” coupled with “limited health care resources,” Camosy contends that current Medicaid funds that privilege the NICU (neonatal intensive care unit) should be reevaluated (1–3). In an effort to temper the “autonomous,” patient-driven principle with “justice,” Camosy poses a challenging philosophical, theological, and practical proposal for what he identifies as the “gray area” of the NICU.Maintaining a twofold commitment to human dignity that values the moral worth of the infant, on the one hand, and the common good that privileges a preferential option for the poor, on the other, Camosy develops his argument in four major steps. First, he validates the moral status of newborn infants and rejects social quality of life models that dismiss their intrinsic status as “persons.” Second, he dismisses arguments that emphasize personal dignity at the expense of considering the social quality of life, pointing out that such arguments disregard Catholic social teaching’s emphasis on the link between relational anthropology and human personhood (100). Third, he contends that “weak” social quality of life models that privilege the patient or individual over social considerations do not take seriously either Catholic social teaching’s emphasis on the common good or the potentially overwhelming economic and practical burdens they might place on families and society as a whole. Finally, Camosy presents a constructive proposal for limiting NICU resources that seeks to counter a culture of overtreatment that idolizes technology and is at the mercy of an unrestrained free market (162). Emphasizing the need for a just allocation of resources, he supports withholding and withdrawing life-sustaining treatment in some cases, thus foreseeing the possible death of some infants. Although he does not accept the direct killing of these infants, he does maintain that Catholic social teaching would allow for the withdrawal of life-sustaining treatment based on certain criteria.Camosy raises a host of important considerations relevant to decisions about imperiled infants. Yet a few questions remain. First, from a Christian point of view, does he not fall into a kind of soft utilitarianism, even though he himself desires to avoid the pitfalls of utilitarianism? Second, how might Camosy envision Christian practices that care for “exposed” infants left without life-sustaining treatment? Finally, what about the difficult emotions that accompany [End Page 210] the death of an infant or child? Do certain kinds of grief complicate our rationing choices that appear to pit the old against the young? While perhaps unanswerable, these questions merit further discussion.Autumn Alcott RidenourMerrimack CollegeCopyright © 2015 Society of Christian Ethics... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:258 HISTORY OF PHILOSOPHY and diversity"-- ("it is useless to deny or even minimize the incongruities and the contradictions" in Rousseau's statements, as Burgelin says in another book). Instead he puts the finger on the one trait that sets this piece of rationalism (or anti-rationalism, as some would say) apart from all others: not sentiment verging on the mystical, but egocentrism, existentially founded and unique. Rousseau, taking a stand (...) outside the battling parties, outside his own religion, becomes more and more "une existence solitaire en face d'une autre existence, qui le regarde," that "other existence" which he calls God. Alas, the descent from such existential heights is swift. Soon the solitary thinker will be enmeshed again in unsolitary speculations about those very issues he had left behind in his flight into the self. Where will this strange pilgrim's progress end? In 1769, seven years before his death and feeling the cold breath of old age upon him, Jean-Jacques wrote: "In my childhood I believed by authority, in my youth by feeling, in my mature age by reason; now I believe because I have always believed." Burgelin cites this as proof that Rousseau never ceased to believe. Maybe so. But is this the point? What the passage defines is the pilgrim's irreversible religious itinerary. On cannot but ask what the next inevitable stop on the road would have been. Waiting for Godot? "Whoever makes an effort to find in Rousseau's work an explicit philosophy... runs into a very peculiar difficulty, for a philosophy is defined above all by its coherence, and [Rousseau] himself warns us against his own methods." With these words Pierre Burgelin opened his monumental work, La philosophic de l'existence de ].-]. Rousseau (1952). It is in the several pertinent chapters of this earlier work that the reader will find what the present book withholds: a philosophical analysis as rigorous as it is profound and comprehensive, the best analysis we have to Rousseau's religious thought. Professor Burgelin's new book merely proves that not even he can do justice to Jean-Jacques without explaining him. GREGORSEBBA Emory University l~mile ou de l'dducation. Par Jean-Jacques Rousseau. Introduction, bibliographic, notes, et index analytique par Francois et Pierre Richard. gdition illustr~e. (Paris: ~ditions Garnier Fr~res, 1962. Pp. 1 + 664 [1].) While the new Pldiade edition of Rousseau, a model of contemporary French scholarship, makes its slow, stately way towards completion, the well-known yellow Classiques Garnier keep coming out in new editions or simply in new dress. This 12mile is a handsomely produced, very readable BOOK REVIEWS 259 reissue of the 1939 Garnier edition, with reproductions of eighteenthcentury engravings on themes of Rousseau. They add rich period flavor to this strange work in which a hypermodern intelligence talks the language of three centuries ago. There are useful notes, the detailed subject index is exceptionally well laid out, the spacious bibliography is ample for Rousseau 's sources and influence, but its meager twentieth-century section should have been reworked and brought up to date. The Introduction, too, can still be read with much profit, even though its critical standpoint is now antiquated, eloquent proof of the effectiveness of Rousseau scholarship in the last two decades. For its price this is a very handy, serviceable edition to have until the Biblioth~que de la PMiade catches up with Garnier Fr~res. Emory University GREGOR SEBBA Kant's Theory o[ Knowledge. By Graham Bird. (New York: The Humanities Press, 1962. Pp. x + 210. ~5.50.) In the Preface the author states that he has two main objectives in his book: To pursue one central argument through the Critique of Pure Reason and to discuss Kant's views in terms of a modern philosophical idiom. Bird follows this programme out through most of the book, departing from it on only one occasion, in Chapter 11 (pp. 181-188) in which he discusses and criticizes Strawson's theory of personality (as presented in his book Individuals, chap. 3). The space given to Strawson does not, however, constitute a serious digression from the main argument because it comes at the end of a chapter devoted... (shrink)

The treatment of persons who frequently present to the healthcare system following repetitive foreign body ingestion has been addressed in the psychiatric literature. However, there has been little exploration of the ethical considerations regarding the treatment of these patients. The complexity of their medical and psychiatric presentation raises fundamental ethical questions regarding the duty to treat, patient autonomy, justice, and futility. Careful ethical analysis is particularly important in this context, since the frustration that medical professionals may feel in response may (...) lead to false assumptions that can negatively impact patient care. A careful exploration of these questions can increase awareness and understanding, which in turn can lead to improved treatment of patients who repetitively ingest foreign bodies. Care for patients who inflict self-harm, particularly by repetitive foreign body ingestion, is not futile. The patients have a right to treatment and are entitled to resources. Efforts should be made to provide a more comprehensive treatment approach to these patients. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:258 HISTORY OF PHILOSOPHY and diversity"-- ("it is useless to deny or even minimize the incongruities and the contradictions" in Rousseau's statements, as Burgelin says in another book). Instead he puts the finger on the one trait that sets this piece of rationalism (or anti-rationalism, as some would say) apart from all others: not sentiment verging on the mystical, but egocentrism, existentially founded and unique. Rousseau, taking a stand (...) outside the battling parties, outside his own religion, becomes more and more "une existence solitaire en face d'une autre existence, qui le regarde," that "other existence" which he calls God. Alas, the descent from such existential heights is swift. Soon the solitary thinker will be enmeshed again in unsolitary speculations about those very issues he had left behind in his flight into the self. Where will this strange pilgrim's progress end? In 1769, seven years before his death and feeling the cold breath of old age upon him, Jean-Jacques wrote: "In my childhood I believed by authority, in my youth by feeling, in my mature age by reason; now I believe because I have always believed." Burgelin cites this as proof that Rousseau never ceased to believe. Maybe so. But is this the point? What the passage defines is the pilgrim's irreversible religious itinerary. On cannot but ask what the next inevitable stop on the road would have been. Waiting for Godot? "Whoever makes an effort to find in Rousseau's work an explicit philosophy... runs into a very peculiar difficulty, for a philosophy is defined above all by its coherence, and [Rousseau] himself warns us against his own methods." With these words Pierre Burgelin opened his monumental work, La philosophic de l'existence de ].-]. Rousseau (1952). It is in the several pertinent chapters of this earlier work that the reader will find what the present book withholds: a philosophical analysis as rigorous as it is profound and comprehensive, the best analysis we have to Rousseau's religious thought. Professor Burgelin's new book merely proves that not even he can do justice to Jean-Jacques without explaining him. GREGORSEBBA Emory University l~mile ou de l'dducation. Par Jean-Jacques Rousseau. Introduction, bibliographic, notes, et index analytique par Francois et Pierre Richard. gdition illustr~e. (Paris: ~ditions Garnier Fr~res, 1962. Pp. 1 + 664 [1].) While the new Pldiade edition of Rousseau, a model of contemporary French scholarship, makes its slow, stately way towards completion, the well-known yellow Classiques Garnier keep coming out in new editions or simply in new dress. This 12mile is a handsomely produced, very readable BOOK REVIEWS 259 reissue of the 1939 Garnier edition, with reproductions of eighteenthcentury engravings on themes of Rousseau. They add rich period flavor to this strange work in which a hypermodern intelligence talks the language of three centuries ago. There are useful notes, the detailed subject index is exceptionally well laid out, the spacious bibliography is ample for Rousseau 's sources and influence, but its meager twentieth-century section should have been reworked and brought up to date. The Introduction, too, can still be read with much profit, even though its critical standpoint is now antiquated, eloquent proof of the effectiveness of Rousseau scholarship in the last two decades. For its price this is a very handy, serviceable edition to have until the Biblioth~que de la PMiade catches up with Garnier Fr~res. Emory University GREGOR SEBBA Kant's Theory o[ Knowledge. By Graham Bird. (New York: The Humanities Press, 1962. Pp. x + 210. ~5.50.) In the Preface the author states that he has two main objectives in his book: To pursue one central argument through the Critique of Pure Reason and to discuss Kant's views in terms of a modern philosophical idiom. Bird follows this programme out through most of the book, departing from it on only one occasion, in Chapter 11 (pp. 181-188) in which he discusses and criticizes Strawson's theory of personality (as presented in his book Individuals, chap. 3). The space given to Strawson does not, however, constitute a serious digression from the main argument because it comes at the end of a chapter devoted... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:258 HISTORY OF PHILOSOPHY and diversity"-- ("it is useless to deny or even minimize the incongruities and the contradictions" in Rousseau's statements, as Burgelin says in another book). Instead he puts the finger on the one trait that sets this piece of rationalism (or anti-rationalism, as some would say) apart from all others: not sentiment verging on the mystical, but egocentrism, existentially founded and unique. Rousseau, taking a stand (...) outside the battling parties, outside his own religion, becomes more and more "une existence solitaire en face d'une autre existence, qui le regarde," that "other existence" which he calls God. Alas, the descent from such existential heights is swift. Soon the solitary thinker will be enmeshed again in unsolitary speculations about those very issues he had left behind in his flight into the self. Where will this strange pilgrim's progress end? In 1769, seven years before his death and feeling the cold breath of old age upon him, Jean-Jacques wrote: "In my childhood I believed by authority, in my youth by feeling, in my mature age by reason; now I believe because I have always believed." Burgelin cites this as proof that Rousseau never ceased to believe. Maybe so. But is this the point? What the passage defines is the pilgrim's irreversible religious itinerary. On cannot but ask what the next inevitable stop on the road would have been. Waiting for Godot? "Whoever makes an effort to find in Rousseau's work an explicit philosophy... runs into a very peculiar difficulty, for a philosophy is defined above all by its coherence, and [Rousseau] himself warns us against his own methods." With these words Pierre Burgelin opened his monumental work, La philosophic de l'existence de ].-]. Rousseau (1952). It is in the several pertinent chapters of this earlier work that the reader will find what the present book withholds: a philosophical analysis as rigorous as it is profound and comprehensive, the best analysis we have to Rousseau's religious thought. Professor Burgelin's new book merely proves that not even he can do justice to Jean-Jacques without explaining him. GREGORSEBBA Emory University l~mile ou de l'dducation. Par Jean-Jacques Rousseau. Introduction, bibliographic, notes, et index analytique par Francois et Pierre Richard. gdition illustr~e. (Paris: ~ditions Garnier Fr~res, 1962. Pp. 1 + 664 [1].) While the new Pldiade edition of Rousseau, a model of contemporary French scholarship, makes its slow, stately way towards completion, the well-known yellow Classiques Garnier keep coming out in new editions or simply in new dress. This 12mile is a handsomely produced, very readable BOOK REVIEWS 259 reissue of the 1939 Garnier edition, with reproductions of eighteenthcentury engravings on themes of Rousseau. They add rich period flavor to this strange work in which a hypermodern intelligence talks the language of three centuries ago. There are useful notes, the detailed subject index is exceptionally well laid out, the spacious bibliography is ample for Rousseau 's sources and influence, but its meager twentieth-century section should have been reworked and brought up to date. The Introduction, too, can still be read with much profit, even though its critical standpoint is now antiquated, eloquent proof of the effectiveness of Rousseau scholarship in the last two decades. For its price this is a very handy, serviceable edition to have until the Biblioth~que de la PMiade catches up with Garnier Fr~res. Emory University GREGOR SEBBA Kant's Theory o[ Knowledge. By Graham Bird. (New York: The Humanities Press, 1962. Pp. x + 210. ~5.50.) In the Preface the author states that he has two main objectives in his book: To pursue one central argument through the Critique of Pure Reason and to discuss Kant's views in terms of a modern philosophical idiom. Bird follows this programme out through most of the book, departing from it on only one occasion, in Chapter 11 (pp. 181-188) in which he discusses and criticizes Strawson's theory of personality (as presented in his book Individuals, chap. 3). The space given to Strawson does not, however, constitute a serious digression from the main argument because it comes at the end of a chapter devoted... (shrink)

Withholding and withdrawing treatment are widely regarded as ethically equivalent in medical guidelines and ethics literature. Health care personnel, however, widely perceive moral differences between withholding and withdrawing. The proponents of equivalence argue that any perceived difference can be explained in terms of cognitive biases and flawed reasoning. Thus, policymakers should clear away any resistance to accept the equivalence stance by moral education. To embark on such a campaign of changing attitudes, we need to be convinced that the (...) ethical analysis is correct. Is it? In this article, I take a closer look at the moral relation between withholding and withdrawing. My conclusion is that withholding and withdrawing are not in general ethically equivalent. Thus, medical guidelines should be rewritten, and rather than being “educated” away from their sound judgments, medical professionals and patients should have nuanced medico-ethical discussions regarding withholding and withdrawing treatment. (shrink)

It may seem that epistemic and practical rationality weigh reasons differently, because ties in practical rationality tend to generate permissions and ties in epistemic rationality tend to generate a requirement to withhold judgment. I argue that epistemic and practical rationality weigh reasons in the same way, but they have different "default biases". Practical rationality is biased toward every option being permissible whereas epistemic rationality is biased toward withholding judgment's being required.

Several authors have recently endorsed the thesis that there is what has been called pragmatic encroachment on knowledge—in other words, that two people who are in the same situation with respect to truth-related factors may differ in whether they know something, due to a difference in their practical circumstances. This paper aims not to defend this thesis, but to explore how it could be true. What I aim to do, is to show how practical factors could play a role in (...) defeating knowledge by defeating epistemic rationality—the very kind of rationality that is entailed by knowledge, and in which Pascalian considerations do not play any role—even though epistemic rationality consists in having adequate evidence. (shrink)

In healthcare priority settings, early access to treatment before reimbursement decisions gives rise to problems of whether negative decisions for cost‐effectiveness reasons should result in withdrawing treatment, already accessed by patients. Among professionals there seems to be a strong attitude to distinguish between withdrawing and withholding treatment, viewing the former as ethically worse. In this article the distinction between withdrawing and withholding treatment for reasons of cost effectiveness is explored by analysing the doing/allowing distinction, different theories of justice, (...) consequentialist and virtue perspectives. The authors do not find any strong reasons for an intrinsic difference, but do find some reasons for a consequentialist difference, given present attitudes. However, overall, such a difference does not, all things considered, provide a convincing reason against withdrawal, given the greater consequentialist gain of using cost‐effective treatment. As a result, patients should be properly informed when given early access to treatment, that such treatment can be later withdrawn following a negative reimbursement decision. (shrink)

In “Postponed Withholding: Balanced Decision-Making at the Margins of Viability,” Syltern et al. (2022) propose a novel approach to life-and-death decision making for extremely preterm infants in t...

Many medical ethicists accept the thesis that there is no moral difference between withholding and withdrawing life-sustaining therapy. In this paper, we offer an interesting counterexample which shows that this thesis is not always true. Withholding is distinguished from withdrawing by the simple fact that therapy must have already been initiated in order to speak coherently about withdrawal. Provided that there is a genuine need and that therapy is biomedically effective, the historical fact that therapy has been initiated (...) entails a claim to continue therapy that cannot be attributed to patients who have not yet received therapy. This intrinsic difference between withholding and withdrawing therapy is of moral importance. In many instances, patients will waive this claim. But when one considers withdrawing therapy from one patient to help another in a setting of scarce resources, this intrinsic moral difference comes into sharp focus. In an era of shrinking medical resources, this difference cannot be ignored. (shrink)

The right to refuse medical intervention is well established, but it remains unclear how best to respect and exercise this right in life support. Contemporary ethical guidelines for critical care give ambiguous advice, largely because they focus on the moral equivalence of withdrawing and withholding care without confronting the very real differences regarding who is aware and informed of intervention options and how patient values are communicated and enacted. In withholding care, doctors typically withhold information about interventions judged (...) too futile to offer. They thus retain greater decision-making burden and face weaker obligations to secure consent from patients or proxies. In withdrawing care, there is a clearer imperative for the doctor to include patients in decisions, share information and secure consent, even when continued life support is deemed futile. How decisions to withhold and withdraw life support differ ethically in their implications for positive versus negative interpretations of patient autonomy, imperatives for consent, definitions of futility and the subjective evaluation of benefits and burdens of life support in critical care settings are explored. Professional reflection is required to respond to trends favouring a more positive interpretation of patient autonomy in the context of life support decisions in critical care. Both the bioethics and critical care communities should investigate the possibilities and limits of growing pressure for doctors to disclose their reasoning or seek patient consent when decisions to withhold life support are made. (shrink)

This paper presents a puzzle about justification and withholding. The puzzle arises in a special case where experts advise us to not withhold judgment. My main thesis is simply that the puzzle is genuinely a puzzle, and so leads us to rethink some common assumptions in epistemology, specifically assumptions about the nature of justification and doxastic attitudes. Section 1 introduces the common assumptions. Section 2 presents the puzzle case. Section 3 assesses the puzzle case. Section 4 explains the choice (...) we're faced with. Sections 5 and 6 consider and reject some proposed solutions, and in the process refine and clarify the choice we're faced with. Section 7 considers and rejects a miscellany of different proposed solutions. (shrink)

Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support int...

This paper argues that Sulmasy and Sugarman have not succeeded in showing a moral difference between withholding and withdrawing treatment. In particular, they have misunderstood historical entitlement theory, which does not automatically prefer a first occupant by just acquisition.

In the twenty-first century, decisions to withhold or withdraw life-supporting measures commonly precede death in the neonatal intensive care unit without major ethical controversy. However, caregivers often feel much greater turmoil with regard to stopping medical hydration and nutrition than they do when considering discontinuation of mechanical ventilation or circulatory support. Nevertheless, forgoing medical fluids and food represents a morally acceptable option as part of a carefully developed palliative care plan considering the infant’s prognosis and the burdens of continued treatment. (...) Decisions to stop any form of life support should focus on the clinical circumstances, not the means used to sustain life. (shrink)

Background Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments. The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units. Methods A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, (...) legal and religious leaders. Results Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of. Most respondents were between 30 and 49 years old, Catholic Christians, anesthesiologists, working in Beirut. Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect”. The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary, involving the family, and the patient, or his advance directives or his surrogate and the nurses. The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices. Conclusion Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country. (shrink)

This paper explores ethical issues relating to the management of patients who are terminally ill and unable to maintain their own nutrition and hydration. A policy of sedation without hydration or nutrition is used in palliative medicine under certain circumstances. The author argues that this policy is dangerous, medically, ethically and legally, and can be disturbing for relatives. The role of the family in management is discussed. This issue requires wide debate by the public and the profession.

Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating (...) suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed. (shrink)

PurposeScarce evidence exists regarding end-of-life decision (EOLD) in neurocritically ill patients. We investigated the factors associated with EOLD making, including the group and individual characteristics of involved healthcare professionals, in a multiprofessional neurointensive care unit (NICU) setting.Materials and methodsA prospective, observational pilot study was conducted between 2013 and 2014 in a 10-bed NICU. Factors associated with EOLD in long-term neurocritically ill patients were evaluated using an anonymised survey based on a standardised questionnaire.Results8 (25%) physicians and 24 (75%) nurses participated in (...) the study by providing their ‘treatment decisions’ for 14 patients at several time points. EOLD was ‘made’ 44 (31%) times, while maintenance of life support 98 (69%) times. EOLD patterns were not significantly different between professional groups. The individual characteristics of the professionals (age, gender, religion, personal experience with death of family member and NICU experience) had no significant impact on decisions to forgo or maintain life-sustaining therapy. EOLD was patient-specific (intraclass correlation coefficient: 0.861), with the presence of acute life-threatening disease (OR (95% CI): 18.199 (1.721 to 192.405), p=0.038) and low expected patient quality of life (OR (95% CI): 9.276 (1.131 to 76.099), p=0.016) being significant and independent determinants for withholding or withdrawing life-sustaining treatment.ConclusionsOur findings suggest that EOLD in NICU relies mainly on patient prognosis and not on the characteristics of the healthcare professionals. (shrink)

The American Journal of Bioethics, Volume 11, Issue 12, Page 70-72, December 2011.

The topic of withholding the Heimlich maneuver as part of a do-not-attempt-to-resuscitate (DNAR) order or an advance directive has not been widely discussed in the clinical ethics literature. This discussion addresses a request by family members to withhold the Heimlich maneuver from a patient in a long-term care facility. A request to forgo the Heimlich maneuver seems to have prima facie categorical similarities to justifications for withholding lifesaving treatments such as cardiopulmonary resuscitation (CPR). Further examination reveals significant distinctions. (...) Such distinctions call into question the ethical appropriateness of including the Heimlich maneuver among interventions to be withheld as part of end-of-life care planning, and encourages a broader discussion of an increasingly uncritical deference to autonomy in end-of-life decision making. Most notably, the Heimlich maneuver is the only intervention known to effectively relieve the distressing symptoms of accidental choking. The Heimlich maneuver serves a palliative function and is the standard of care for accidental choking. The Heimlich maneuver should not be conflated with other life-prolonging interventions that may be withheld as part of end-of-life care planning. (shrink)

Withholding and pursuit are well-documented phenomena in talk between adults and in talk with children. They have been described as working to perform various functions that emerge locally between speakers in a variety of interactional contexts both in ordinary conversation and in institutional talk.In this paper I explore further the actions of pursuit and withholding in interaction between parents and their very young children, first described in Filipi (2003, 2009) by going beyond description and by examining how these (...) features might be implicated in learning. Longitudinal change is thus a focus of the analysis. Examples of talk are drawn from one child aged from 11 to 24 months interacting with members of her family.Applying the microanalytic approach of Conversation Analysis, the study reports four contexts in which pursuit emerges as an important resource. They are pursuit relevant to sequence structure, linguistic pursuit, pursuit of understanding and pursuit of a particular response token. Analysis shows that while the adults orient to the need to move the action forward, particularly observable in the Summons/Response adjacency pair, withholding of completion can occur at any time in order for parent and child to work on particular skills. Finally, I argue that the micro details of the actions of withholding and pursuit provide a particularly useful lens with which to observe the dynamic qualities of asymmetry. Keywords: parent child interaction; Conversation Analysis; language development; asymmetry; withholding; pursuit. (shrink)

Withholding and pursuit are well-documented phenomena in talk between adults and in talk with children. They have been described as working to perform various functions that emerge locally between speakers in a variety of interactional contexts both in ordinary conversation and in institutional talk.In this paper I explore further the actions of pursuit and withholding in interaction between parents and their very young children, first described in Filipi by going beyond description and by examining how these features might (...) be implicated in learning. Longitudinal change is thus a focus of the analysis. Examples of talk are drawn from one child aged from 11 to 24 months interacting with members of her family.Applying the microanalytic approach of Conversation Analysis, the study reports four contexts in which pursuit emerges as an important resource. They are pursuit relevant to sequence structure, linguistic pursuit, pursuit of understanding and pursuit of a particular response token. Analysis shows that while the adults orient to the need to move the action forward, particularly observable in the Summons/Response adjacency pair, withholding of completion can occur at any time in order for parent and child to work on particular skills. Finally, I argue that the micro details of the actions of withholding and pursuit provide a particularly useful lens with which to observe the dynamic qualities of asymmetry. Keywords: parent child interaction; Conversation Analysis; language development; asymmetry; withholding; pursuit. (shrink)