This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called (...) early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care. (shrink)

BackgroundHuntington’s disease has a poor prognosis. For HD patients in the Netherlands, one way of dealing with their poor prognosis is by drawing up an advance euthanasia directive. Little is known about the perspectives of HD patients on their AED.AimTo gain insight into patients’ views on and attitudes towards their AED, and changes over time.MethodsA longitudinal qualitative interview study using 1 to 6 semi-structured interviews over a period of maximum three years. Nine HD patients who either had an AED or (...) were thinking about drawing it up participated in this study.ResultsWe identified two themes that characterize patients’ perspectives on their AEDs: general character of the AED; uncertainty around their AED. Ad The conditions that the participants described in their AED were generally not very specific for the person. Mostly they were general notions of unbearable suffering. Familiarity with HD in the family could play a role in drawing up an AED. Ad Participants generally were aware of the tentative character of their AED and could have doubts concerning their own willingness or the willingness of others in the future. Sometimes these doubts were so great, that it prevented them from drawing up an AED. However, patients did not alter their AED during the follow-up period or changed in their view or attitude on their AED.ConclusionHD patients that draw up an AED usually describe general conditions for euthanasia and recognize that these conditions may change as the disease progresses. An AED or the wish to draw one up may be a good conversation starter for conversations about goals and preferences for future care. (shrink)

The majority of Dutch physicians feel pressure when dealing with a request for euthanasia or physician-assisted suicide. This study aimed to explore the content of this pressure as experienced by general practitioners. We conducted semistructured in-depth interviews with 15 Dutch GPs, focusing on actual cases. The interviews were transcribed and analysed with use of the framework method. Six categories of pressure GPs experienced in dealing with EAS requests were revealed: emotional blackmail, control and direction by others, doubts about fulfilling the (...) criteria, counterpressure by patient’s relatives, time pressure around referred patients and organisational pressure. We conclude that the pressure can be attributable to the patient–physician relationship and/or the relationship between the physician and the patient’s relative, the inherent complexity of the decision itself and the circumstances under which the decision has to be made. To prevent physicians to cross their personal boundaries in dealing with EAS request all these different sources of pressure will have to be taken into account. (shrink)

Background As our society is ageing, nursing homes are finding it increasingly difficult to deal with an expanding population of patients with dementia and a decreasing workforce. A potential answer to this problem might lie in the use of technology. However, the use and application of surveillance technology in dementia care has led to considerable ethical debate among healthcare professionals and ethicists, with no clear consensus to date. Aim To explore how surveillance technology is viewed by care professionals and ethicists (...) working in the field, by investigating the ideal application of surveillance technology in the residential care of people with dementia. Methods Use was made of the concept mapping method, a computer-assisted procedure consisting of five steps: brainstorming, prioritising, clustering, processing by the computer and analysis. Various participants (ranging from ethicists to physicians and nurses) were invited on the basis of their professional background. Results The views generated are grouped into six categories ranging from the need for a right balance between freedom and security, to be beneficial and tailored to the resident, and clearly defined procedures to competent and caring personnel, active monitoring and clear normative guidance. The results are presented in the form of a graphic chart. Conclusions There appears to be an inherent duality in the views on using surveillance technology which is rooted in the moral conflict between safety and freedom. Elaboration of this ethical issue has proved to be very difficult. (shrink)

Introduction Families of patients with dementia may need support in difficult end-of-life decision making. Such guidance may be culturally sensitive. Methods To support families in Canada, a booklet was developed to aid decision making on palliative care issues. For reasons of cost effectiveness and promising effects, we prepared for its implementation in Italy, the Netherlands and Japan. Local teams translated and adapted the booklet to local ethical, legal and medical standards where needed, retaining guidance on palliative care. Using qualitative content (...) analyses, we grouped and compared adaptations to understand culturally sensitive aspects. Results Three themes emerged: (1) relationships among patient, physician and other professionals—the authority of the physician was more explicit in adapted versions; (2) patient rights and family position—adding detail about local regulations; and (3) typology of treatments and decisions. Considerations underlying palliative care decisions were detailed (Dutch and Italian versions), and the Japanese version frequently referred to professional and legal standards, and life-prolongation was a competing goal. Text on artificial feeding or fluids and euthanasia was revised extensively. Conclusions Providing artificial feeding and fluids and discussing euthanasia may be particularly sensitive topics, and guidance on these subjects needs careful consideration of ethical aspects and possible adaptations to local standards and practice. The findings may promote cross-national debate on sensitive, core issues regarding end-of-life care in dementia. (shrink)

Background:Surveillance technology such as tag and tracking systems and video surveillance could increase the freedom of movement and consequently autonomy of clients in long-term residential care settings, but is also perceived as an intrusion on autonomy including privacy.Objective:To explore how clients in residential care experience surveillance technology in order to assess how surveillance technology might influence autonomy.Setting:Two long-term residential care facilities: a nursing home for people with dementia and a care facility for people with intellectual disabilities.Methods:Ethnographic field study.Ethical considerations:The boards (...) representing clients and relatives/proxies of the clients were informed of the study and gave their written consent. The clients’ assent was sought through a special information leaflet. At any time clients and/or proxy were given the option to withdraw from the study. The research protocol was also reviewed by a medical ethics committee.Findings:Our findings show a pattern of two themes: (1) coping with new spaces which entailed clients: wandering around, getting lost, being triggered, and retreating to new spaces and (2) resisting the surveillance technology measure because clients feel stigmatized, missed the company, and do not like being “watched.”Conclusion:Client experiences of surveillance technology appear to entail a certain ambivalence. This is in part due to the variety in surveillance technology devices, with each device bringing its own connotations and experiences. But it also lies in the devices’ presupposition of an ideal user, which is at odds with the actual user who is inherently vulnerable. Surveillance technology can contribute to the autonomy of clients in long-term care, but only if it is set in a truly person-centered approach. (shrink)

Recent evaluation of the practice of euthanasia and related medical decisions at the end of life in the Netherlands has shown a slight decrease in the frequency of physician-assisted death since the enactment of the Euthanasia Law in 2002. This paper focuses on the absence of euthanasia cases concerning patients with dementia and a written advance euthanasia directive, despite the fact that the only real innovation of the Euthanasia Law consisted precisely in allowing physicians to act upon such directives. The (...) author discusses two principal reasons for this absence. One relates to the uncertainty about whether patients with advanced dementia truly experience the suffering they formerly feared. There is reason to assume that they don’t, as a consequence of psychological adaptation and progressive unawareness (anosognosia). The second, more fundamental reason touches upon the ethical relevance of shared understanding and reciprocity. The author argues that, next to autonomy and mercifulness, “reciprocity” is a condition sine qua non for euthanasia. The absence thereof in advanced dementia renders euthanasia morally inconceivable, even if there are signs of suffering and notwithstanding the presence of an advance euthanasia directive. This does not mean, however, that advance euthanasia directives of patients with dementia are worthless. They might very well have a role in the earlier stages of certain subtypes of the disease. To illustrate this point the author presents a case in which the advance directive helped to create a window of opportunity for reciprocity and shared decision-making. (shrink)

This article introduces a new hybrid intake procedure developed for posttraumatic stress disorder (PTSD) screening, which combines an automated textual assessment of respondents’ self-narratives and item-based measures that are administered consequently. Text mining technique and item response modeling were used to analyze long constructed response (i.e., self-narratives) and responses to standardized questionnaires (i.e., multiple choices), respectively. The whole procedure is combined in a Bayesian framework where the textual assessment functions as prior information for the estimation of the PTSD latent trait. (...) The purpose of this study is twofold: first, to investigate whether the combination model of textual analysis and item-based scaling could enhance the classification accuracy of PTSD, and second, to examine whether the standard error of estimates could be reduced through the use of the narrative as a sort of routing test. With the sample at hand, the combination model resulted in a reduction in the misclassification rate, as well as a decrease of standard error of latent trait estimation. These findings highlight the benefits of combining textual assessment and item-based measures in a psychiatric screening process. We conclude that the hybrid test design is a promising approach to increase test efficiency and is expected to be applicable in a broader scope of educational and psychological measurement in the future. (shrink)

Women who had had breast cancer and had been enrolled in a large genetic breast cancer epidemiological study were interviewed about their experience of participation in the study, their attitudes to the confidentiality of data, and the feedback of personal and general research results. Collection of family history information seemed more salient in indicating the genetic nature of the study than the enrolment information sheet. There were no concerns about confidentiality.While participants would have welcomed general feedback about the results of (...) the study and were critical that this had not been provided, the feedback of personal information proved complicated and, sometimes, difficult. It is suggested that individual feedback of genetic test information in epidemiological studies should be undertaken only when there are specific reasons. (shrink)

A collection of essays, six of which appear in English for the first time, focusing on various problems of positivistic philosophy, this book treats such issues as the adaption of natural science methodology to sociology, the problem of generalization in the social sciences, and the implications of science for social values. These essays are argumentative in tone, and often interrelated; the editor has provided a well balanced selection of spokesmen for the diverse points of view represented. Professor Giddens’ introduction is (...) itself a valuable essay. He offers both an historical introduction to the articles and an interesting explanation of the common themes that required their inclusion in the collection. Basically, he appears to be concerned with an attempt "to impose some order upon the flux of differing usages" of the term "positivism." He sees the positivistic attitude in sociology as including certain methodological, analytical, and technical presuppositions. The collection is intended to explicate these presuppositions. (shrink)

The author here presents a series of significant, thoughtful, and well-written essays which are united by their common concern with man and his social world. The book is subtitled "Essays on the Coherence and Deformation of Social Reality." The essays, particularly in Part One, offer an introduction to and a defense of the phenomenological approach to philosophy, though Natanson does tend to slant his reading in an existentialist direction. He strongly objects to recent attempts to bridge the gap between the (...) "empirical-positivistic" and the "conceptual-phenomenological" modes of analysis by the oversimplification of the latter’s methodological postulates. Though this position may solidify differences between the two schools, Natanson’s concern for the integrity of the phenomenological method is noteworthy. (shrink)

This is a timely critique of contemporary Marxist theory, its implications for social structure, and its practical dilemmas. Three themes appear throughout: the mythologizing of Marx, the rationale of Revolution, and the significance of history for social philosophy. Contrary to the approach of many commentators, Hook emphasizes the tremendous differences between the "early" and "late" Marx. He insists that "to judge Marx’s meaning by his own intent, we must go to the published works for which Marx took public responsibility." In (...) the course of the discussion, the author criticizes contemporary Marxist theory. It has itself become an "ideology," a mythology with an uncritical belief in the seemingly universal solution to human ills offered by the socialization of the means of production through revolution. Hook emphasizes that the tone of later Marxist writings, particularly Capital, had gradually shifted away from any belief in the inevitability of violent revolution. From this perspective the author traces the ambiguities of Marx’s writings that afforded the opportunity for Leninist-Stalinist revisionism on this and other issues. Hook is suspicious of the facile and selective exegesis of Marx’s writings used to support the political bias of many commentators. Revolution itself has become a symbol, which, in the author’s view, is often taken up uncritically to support a myth of society. In this context Hook has an enlightening discussion of the putative "right" to revolution. It is essentially an extralegal power, legitimate only where the context of the historical events makes intralegal change absolutely impossible. The author is therefore disturbed by the "cult of revolution" which uses a mythologized Marx to support a program of deliberate, episodic violence as a strategy of social change. The significance of historical experience is evident throughout these later chapters, particularly where Hook undertakes a reevaluation of the Bolshevik Revolution. The historical and philosophical misconceptions underlying ideologies of violence are the most frequent subjects of his criticism. These ideologies have sought to draw moral support from legitimizing examples of history, as well as from the mythologized Marx. Hook goes to great lengths to deny them any such support. Hook concludes with an examination of the emerging scheme of human rights, insisting that they must be understood in their historical context, and that democratic principles are the key to their full realization. (shrink)

Professor Grünfeld’s book puts forward the thesis that the hard and fast lines that have been drawn between philosophy and science, as well as between the hard and soft sciences, are inaccurate and possibly illusory. He contends that values, as a function of philosophy, are related to science in various complex ways. In a sense, his approach involves a collapsing of metascientific and scientific disciplines into one another. This thesis is applied to the analysis of historical method, language, and philosophy (...) of science. The author covers a wide range of topics in a thorough and well documented fashion. His examination of Popper’s approach to history and scientific method, though by no means elementary, serves as an excellent introduction to that particular area of philosophy of science. A considerable portion of the book is devoted to a linguistic analysis of interrelated problems of logic, methodological models, and metaphysics. On the basis of that discussion, the author presents two thoughtful chapters on the implications of his thesis for philosophy of science, one concerning the concept of "self-evidence" in science, the other examining the relation between observation and theory. (shrink)

This work is a defense of positivism in social theory: Addis is committed to the view that the substantive concerns of physical and social science are essentially the same. Indeed, he states that an adequate philosophy of society presupposes an adequate philosophy of science. He therefore begins with an analysis of various themes from the latter: causation, the notions of process and closed systems, and determinism. It is in fact a basic presumption of the book that some refined theory of (...) determinism is true. The author argues that all "social objects," such as those posited by Durkheim, are no more than properties of, or relations between, individual social beings. In the course of this argument, he develops a detailed treatment of reduction of the social into the physical sciences. It is his belief that logical analysis of the notion of reduction is essential to an understanding of social theory. Reduction is examined in two phases. First, he elaborates on his contention that social objects reduce to individual human beings. Second, he examines the reduction of socio-historical explanations to psycho-physical laws. He then proceeds to apply the preceding discussions to problems of philosophy of history, the relation of ideas to historical process, freedom and purpose in history, and a critique of "Marxism.". (shrink)

Lodge’s thoughtful study is a mixture of political science, history, and economics drawn together by a central philosophical theme. The author seeks to explore the issue of the legitimacy of social institutions, and he raises certain questions concerning the nature of man in society as well as the relationship between ideology and social values. In his view, the dominant social institutions that grew with the United States were founded upon a "Lockean" ideology. At the core of this ideology was the (...) concept of man as an atomistic unit. Reflecting this concept, the traditional American ideology stressed five components: first, individualism as the basic social value; second, property as the guarantee of human rights; third, competition as the dynamic of social interaction; fourth, the limited state; fifth, scientific/technological specialization. Lodge reviews the development of this ideology and argues that it has led to an ever-increasing fragmentation of society and a frustration of social purpose. As the Lockean paradigm proved itself inadequate to resolve problems in a world of interdependent and interwoven social wholes, the need for a new American ideology became apparent. (shrink)

Writing from a scientifically and philosophically informed perspective, the authors provide a critical overview of the conceptual difficulties encountered in many current neuroscientific and psychological theories.

In offering his analysis of the concepts of the good and the just, the author combines certain techniques of social science with a philosophical reflection upon certain fundamental issues. It is the objective of this book to establish a balanced approach differing from relativism and historicism on the one hand, and normative absolutism on the other. The task is not an easy one; many may view the attempt here to be less than conclusive, though it is certainly challenging. Essentially the (...) book argues for a concept of human nature that is "dispositional," and defined contextually, but in some sense not bound to circumstances in the way in which the historicist would have it. Kaplan utilizes the principles of "systems analysis," explained in detail in the first chapter of the book, to reach this contextual understanding of human nature. It is by identification of social systems as homeostatic that the argument is advanced that units of social and political analysis cannot be treated in the abstract, nor can they be understood without acknowledging contextual rules that are in some sense objective. (shrink)

Unger has written a thoughtful but problematic study of the shortcomings of liberal political theory. The specific method of the critique is his own, but it is well-structured and readable. The problem is that the precise nature of the "liberal psychology" and "liberal political theory" under attack is never very clear. This lack of clarity stands in marked contrast to the general tone of the work. One can assume with some justification that the author sees the classic core of the (...) liberal doctrine "in the work of Thomas Hobbes, of his contemporaries, and of his successors...." Nevertheless, the doctrine addressed by the author appears to be of much wider scope; Hobbes, Locke, Hume, Spinoza, Rousseau, and Kant are all called in "to illustrate rather than to prove their adherence to the doctrines that are the subject of the critique." It is with reservations concerning the subject under attack that one must approach this study. (shrink)

The strength of this book is not a novelty of analysis, but rather its clarity and readability. The author intends it to be a useful teaching tool, "a genuine introduction, presupposing neither background in philosophy nor familiarity with the issues...." It is well arranged and quite successful as an introductory commentary. The book would appear to work best as a secondary source, supplementing more extensive philosophical texts. It need not be limited to courses specifically dealing with social and political philosophy. (...) The first chapter offers an elementary explanation of the nature of philosophical discourse in general; chapters three, "Freedom," and five "Utilitarianism and Justice," would be useful in a course on ethics. (shrink)

We analyse the effect of the regulatory T cells (Tregs) in the local control of the immune responses by T cells. We obtain an explicit formula for the level of antigenic stimulation of T cells as a function of the concentration of T cells and the parameters of the model. The relation between the concentration of the T cells and the antigenic stimulation of T cells is an hysteresis, that is unfold for some parameter values. We study the appearance of (...) autoimmunity from cross-reactivity between a pathogen and a self antigen or from bystander proliferation. We also study an asymmetry in the death rates. With this asymmetry we show that the antigenic stimulation of the Tregs is able to control locally the population size of Tregs. Other effects of this asymmetry are a faster immune response and an improvement in the simulations of the bystander proliferation. The rate of variation of the levels of antigenic stimulation determines if the outcome is an immune response or if Tregs are able to maintain control due to the presence of a transcritical bifurcation for some tuning between the antigenic stimuli of T cells and Tregs. This behavior is explained by the presence of a transcritical bifurcation. (shrink)

This is the second volume of analytical commentary on Wittgenstein's masterpiece, the Philosophical Investigations. Like the first, it consists of philosophical essays and critical exegesis. The six essays deal comprehensively with various themes in Wittgenstein''s philosophy: the relationship between his mathematics and his philosophy of mind; his conception of grammar and rules of grammar; the relation between a rule and what accords with a rule; the characterization of rule-following as mastery of a technique manifest in practice; his notion of a (...) form of life, and of agreement in definitions and judgements; a comprehensive investigation into his account of logical and mathematical necessity and other topics. (shrink)

This fourth and final volume of the monumental commentary on Wittgenstein's _Philosophical Investigations_ covers pp 428-693 of the book. Like the previous volumes, it consists of philosophical essays and exegesis.

This major new study by one of the most penetrating and persistent critics of philosophical and scientific orthodoxy, returns to Aristotle in order to examine the salient categories in terms of which we think about ourselves and our nature, and the distinctive forms of explanation we invoke to render ourselves intelligible to ourselves. The culmination of 40 years of thought on the philosophy of mind and the nature of the mankind Written by one of the world’s leading philosophers, the co-author (...) of the monumental 4 volume _Analytical Commentary on the Philosophical Investigations_ Uses broad categories, such as substance, causation, agency and power to examine how we think about ourselves and our nature Platonic and Aristotelian conceptions of human nature are sketched and contrasted Individual chapters clarify and provide an historical overview of a specific concept, then link the concept to ideas contained in other chapters. (shrink)