This chapter contains sections titled: Introduction Doubts About Libertarianism Obligations Conclusions References Further reading.

The suffering of non-human animals is great and omnipresent. This is because animals are vulnerable to disease, disfigurement, injury, predation, age-related physical decline and death, and—today—it is also because human beings are subjecting animals to unprecedented violence in two different domains. Human activities and their byproducts are devastating wild animal habitats at such a fantastic rate that we are obliged to speak of a “sixth mass extinction”, and, while the crisis is typically measured in terms of the loss (...) of entire species, it plays itself out concretely on the bodies ofindividuals. At the same time, industrialized societies now objectify and “process” animals on a massive scale in a variety of settings, for instance—to mention but the numerically most significant—in CAFOs, industrial slaughterhouses and aquafarms, where each year the whole lifecycles of hundreds of billions of land and sea creatures are controlled without any consideration for their pain or terror except insofar as it threatens the economically efficient growth and harvesting of their edible tissues. How should we best respond to the awfulness, and the enormity, of animal suffering? (shrink)

An argument is advanced to show that affluent and moderately affluent people, like you and me, are morally obligated: (O1) To provide modest financial support for famine relief organizations and/or other humanitanan organizations working to reduce the amount of unnecessary suffering and death in the world, and (O2) To refrain from squandering food that could be fed to humans in situations of food scarcity. Unlike other ethical arguments for the obligation to assist the world’s absolutely poor, my argument (...) is not predicated on any highly contentious ethical theory that you likely reject. Rather, it is predicated on your beliefs. The argument shows that the things you currently believe already commit you to the obligatoriness of helping to reduce malnutrition and famine-related diseases by sending a nominal percentage of your income to famine relief organizations and by not squandering food that could be fed to them. Consistency with your own beliefs implies that to do any less is to be profoundly immoral. (shrink)

In teasing out the diverse origins of our “modern, ecological understanding of epidemic disease” Greater than the parts: holism in biomedicine, 1920–1950, Oxford University Press, Oxford, 1998), historians have downplayed the importance of parasitology in the development of a natural history perspective on disease. The present article reassesses the significance of parasitology for the “invention” of medical ecology in post-war France. Focussing on the works of microbiologist Charles Nicolle and on that of physician and zoologist Hervé Harant, I argue that (...) French “medical ecology” was not professionally insulated from some major trends in parasitology, especially in Tunis where disciplinary borders in the medical sciences collapsed. This argument supports the claim that ecological perspectives of disease developed in colonial context but I show that parasitologists such as Harant built on the works of medical geographers who had called attention to the dynamic and complex biological relations between health and environment in fashioning the field of medical ecology in the mid-1950s. As the network of scientists who contributed to the global emergence of “disease ecology” is widening, both medical geography and parasitology stand out as relevant sites of inquiries for a broader historical understanding of the multiple “ecological visions” in twentieth-century biomedical sciences. (shrink)

According to standard comparativist views, death is bad insofar as it deprives someone of goods she would otherwise have had. In The Ethics of Killing, Jeff McMahan argues against such views and in favor of a gradualist account according to which how bad it is to die is a function of both the future goods of which the decedent is deprived and her cognitive development when she dies. Comparativists and gradualists therefore disagree about how bad it is to die (...) at different ages. In this paper I examine two prominent criticisms of gradualism and show that both misconstrue McMahan. I develop a related criticism that seems to show that a gradualist cannot coherently relate morbidity and mortality. This criticism also fails, but has an instructive implication for how policy-makers setting priorities for health care investments should regard choices between life-saving interventions and interventions against non-fatal diseases in the very young. (shrink)

As previous pandemics, the coronavirus disease 2019 (COVID-19) has direct and indirect effects on mental health and well-being. The purpose of the current study was to examine whether meaning in life mediated the association between coronavirus suffering and satisfaction with life and whether stress-related growth moderated the mediating effect of meaning in life on the association between these variables. Stress-Related Growth Measure (SGM) was also conducted for the purpose of this study. The participants were 402 (66% women) young adults (...) who completed the Suffering Measure During COVID-19, Meaningful Living Measure, Satisfaction With Life Scale, and SGM. The results indicated that the SGM has adequate psychometric properties with unidimensional structure of stress-related growth in the face of adversity. Moderated mediation analysis revealed that coronavirus suffering directly influenced satisfaction with life as well as indirectly by its effect on meaning in life. Additionally, stress-related growth was found as a moderator in the relationship between coronavirus suffering–meaning in life and coronavirus suffering–satisfaction with life. These results suggest that meaning in life mitigates the effect of coronavirus suffering on satisfaction with life, and this mediating effect is moderated by stress-related growth in young adults. While meaning in life helps explain the relationship between coronavirus suffering and satisfaction with life, the stress-related growth functions as a protective factor against the adverse effect of coronavirus experiences. (shrink)

Here is a thoroughly updated edition of a classic in palliative medicine. Two new chapters have been added to the 1991 edition, along with a new preface summarizing where progress has been made and where it has not in the area of pain management. This book addresses the timely issue of doctor-patient relationships arguing that the patient, not the disease, should be the central focus of medicine. Included are a number of compelling patient narratives. Praise for the first edition "Well (...) written. . .should be read by everyone in medical practice or considering a career in medicine."---JAMA. "Memorable passages, important ideas, and critical analysis. This is a book that clinicians and educators should read."---New England Journal of Medicine. (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)

Abstract: I argue that Orientalism continues to construct Arabs as subjects that cannot suffer violence, particularly the violence of torture. Beginning with Edward Said’s observation that Orientalists constructed ‘Arabs’ in the nineteenth -century as inorganic, metallic, and mineralized beings, I trace these themes through various sites in and around Guantanamo Bay. One finds the tropes of Orientalism in the Bybee memo as well as in the diary of Mohamedou Ould Slahi. Through these three distinct but related moments, one finds that (...) Orientalism continues to produce Arabs as inorganic entities beyond death and thereby immune to violence and specifically the violence of torture. Insofar as imperialism has co-opted the language of non-violence by constructing its enemies as inviolable, one must recognize the Orientalized Arab as a receptor of limitless ‘non - violent’ hostilities. (shrink)

It is often accepted that we may legitimately speak about voluntary euthanasia only in cases of persons who are suffering because they are incurably injured or have an incurable disease. This article argues that when we consider the moral acceptability of voluntary euthanasia, we have no good reason to concentrate only on persons who are ill or injured and suffering.

Fear of cancer is mostly related to cancer recurrence, metastasis, additional cancer, and diagnostic tests. Its legacy as a lethal disease has raised fear of approaching death. Currently, cancer’s total suffering and the worsening phenomena have raised fear, especially among female patients. Family caregivers (FCGs) who are responsible for the day-to-day cancer care at home need to help the patients deal with this fear frequently. Due to the limited care competencies, they need supportive care from healthcare professionals in (...) cancer fear management. This study aims to assess how types of demanded healthcare information affect the FCG’s role in reducing the fear of female cancer patients. The mindsponge theory was used in conceptual development and interpretation. Bayesian Mindsponge Framework (BMF) analytics were used for statistical analysis on a dataset of 48 spouses (husbands) and 12 other family members in five congested communities of Surabaya, Indonesia. Results showed that among the six types of healthcare information, FCGs with higher demand on cancer-specific information and information on cancer physical needs were more likely to need support in reducing the fear of female cancer patients. Meanwhile, FCGs with a higher demand for information on support services were less likely to need support to reduce cancer patients’ fear. Other types of healthcare information have ambiguous effects on the need for support in reducing cancer-induced fear. This study reveals that the demanded cancer-specific information, e.g., cancer’s prognosis or likely outcome and information on cancer physical needs, need to be met in priority to assist FCG’s role in cancer fear management. (shrink)

"Get a behind-the-scenes glimpse of what it takes to change the world in this comprehensive biography that tells the complete life story of internationally renowned peacemaker Nelson Mandela. Civil rights activist. World leader. Writer. Throughout his life, Nelson Mandela took on many roles, all in the pursuit of peace. Born in 1918 in South Africa, he grew up in a culture of government-enforced racism and became involved in the anti-apartheid movement at a young age. Deeply committed to nonviolent activism, Mandela (...) directed a peaceful campaign against the racist policies of his South African government, and spent twenty-seven years in prison as a result. In the years following his emergence as a free man, he continued his efforts to dismantle the country's apartheid system and was awarded the Nobel Peace Prize alongside South African President F.W. de Klerk. In 1994 he was inaugurated as South Africa's first black president and served until his retirement from active politics in 1999 at the age of eighty-one. He continued to promote global peace until his death in 2013, and his legacy lives on. From Nelson Mandela's childhood to his monumental impact on race relations and nonviolent activism, this comprehensive biography shares the truth about the man behind the iconic smile: his struggles, his triumphs, and the sacrifices along the way"--. (shrink)

Mitochondrial DNA (mtDNA) diseases are a group of neuromuscular diseases that often cause suffering and premature death. New mitochondrial replacement techniques (MRTs) may offer women with mtDNA diseases the opportunity to have healthy offspring to whom they are genetically related. MRTs will likely be ready to license for clinical use in the near future and a discussion of the ethics of the clinical introduction ofMRTs is needed. This paper begins by evaluating three concerns about the safety of MRTs (...) for clinical use on humans: (1) Is it ethical to use MRTs if safe alternatives exist? (2) Would persons with three genetic contributors be at risk of suffering? and (3) Can society trust that MRTs will be made available for humans only once adequate safety testing has taken place, and that MRTs will only be licensed for clinical use in a way that minimises risks? It is then argued that the ethics debate about MRTs should be reoriented towards recommendingways to reduce the possible risks of MRT use on humans. Two recommendations are made: (1) licensed clinical access to MRTs should only be granted to prospective parents if they intend to tell their children about their MRT conception by adulthood; and (2) sex selection should be used in conjunction with the clinical use ofMRTs, in order to reduce transgenerational health risks. (shrink)

Abortion and euthanasia are among the most controversial topics in society today. Abortion is simply any action that intentionally causes the death and removal from the womb of an unborn child. Likewise, Euthanasia is the act of intentionally ending the life of a person who is elderly, terminally ill, or suffering from some incurable injury or disease. In this book, Dr. Wayne Grudem attempts to give an accurate summary of biblical teachings related to abortion and euthanasia, and also (...) to represent fairly the arguments of people who disagree with his positions. (shrink)

A portrait of Australian flying fox life in the Anthropocene illuminates startlingly familiar stories. These animals are participants in most of the major catastrophic events, as well as contestations about rescue, of contemporary life on Earth: warfare, man-made mass death, famine, urbanisation, emerging diseases, climate change, biosecurity, conservation, and local/international NGO aid. They are endangered, and are involved in all four of the major factors causing extinctions: habitat loss, overexploitation, introduced species, and extinction cascades. My account of flying foxes (...) in Australia rests on the understanding of species articulated both vigorously and eloquently by Donna Haraway : we and others are entangled in knots of species who are co-shaping each other in layers of reciprocating complexity. I seek to engage both the living, warm-blooded beings whose lives are threatened, and the excruciatingly dynamic deathscape that is surrounding them/us. Positioned, like much of life on Earth today, in zones of increasing conflict and terror, the lives and deaths of flying foxes tell us that in the Anthropocene there is no way out of entanglements within multispecies communities. Rather than seeking to erect more impenetrable barriers against others, relational ethics for living and dying in the Anthropocene urge us to assume ever greater mutuality and accountability as intradependent members of the suffering family of life on Earth. (shrink)

Don't tell terrible stories—everyone here has enough of their own. Everyone here has a whole bloody sack of terrible stories, and at the bottom of the sack is a hammer the narrator uses to pound you on the skull the instant you dare not believe your ears. Or to pound you when you do believe. Not long ago I saw a tomboyish girl on Khreshchatyk Street demand money of an elderly woman, threatening to bite her and infect her with syphilis. (...) Don't stroll through Volodymyr Hill Park, don't stroll around the botanical garden, and especially don't stroll on Kontraktova Square. Don't stroll anywhere. Don't go to the pavilion with the Golgotha panorama near St. Alexander's Church. Not even the twelve-meter-tall crucified Christ will save you. Don't go outside when it's dark and people turn into shadows a shade darker than dark. Also don't go where you can be seen from far away. Not to imply that people used to be like a bunch of lilies, but now they stink like a cellar of cabbage.The city, which earlier might have had some fun, is now going crazy. It's like a fish in warm water: it doesn't react to anything, swims slowly like it doesn't care if it swallows a hook or not. The excitement and exaltation pass into oppression, just as our necks have sunk into our shoulders, our shoulders into our lumbars, our lumbars into our nether regions. The holiday turns into a funeral, the parades into explosions, depression into mania. Winter passes into summer, people turn into beasts, the hours into ages, and the ages into hours. It's worth simply walking around the city to see a soldier from an unknown army taking a piss near the opera. Farther on is a row of identical old widows selling ball gowns and candelabra. Then there are the aristocrats and manufacturers who throw so much at the prostitutes that they'll soon be richer than their wives.I returned late through the Kyryliv Wood, not heeding all the warnings that I myself have given here. It really is dangerous—the place is famous for it. There's a madhouse nearby, caves where criminals and the sick can hide out. Also, once upon a time, as they say in fairy tales, the great dragon Zmei Gorynich lived here beside the Puchai River. The stench in these places drives away the most committed misanthropes and even one type of philanthrope—that is, perverts. It sounds dumb, but the stench is cleansing. I don't know where it comes from. After the operating theaters and the rooms with amputees, the stench no longer repelled or attracted me; it just was. And this was a great place to think. As I walked, I considered an incident with our patient.The patient, a respectable individual whose name carries too much weight for me to state it directly, one day began to assault people. He nearly strangled a merchant who he believed asked too much for a beaver coat. He likewise wanted to kill his business partner when he didn't say hello loudly enough. But the worst was, he lost all shame of his own nakedness. At first it was the police who took care of it. When our future patient slipped off his pants and undergarments, he was taken to Kyrylivska, which has had means for dealing with such cases dating back to the day when unhinged Cossacks and composers from Kyiv Mohyla Academy were taken there.During the examination we determined that the patient was experiencing a severe breakdown. His wife added that lately, more than once, he had allowed himself strong words in front of the children and often suffered from ennui. Furthermore, she said, the patient had been undergoing treatment for “the French disease” for some years—which was, obviously, where we needed to start.“Syphilis!” Skorsky spat out the matchstick he was chewing on. He was a specialist on the psychological aspects of diseases related to the venereal. “Tertiary syphilis! When poorly treated, over time ‘the French disease’ can destroy the central nervous system. Hence the patient's chicanery. Such theater!”Skorsky and I had not spoken since the incident at Bilinsky's. Meanwhile, something significant had happened to him. The most boring person on earth, Skorsky had simply caught fire. He said hello and kibitzed. I even heard the doctor got drunk alone in his office, then wandered through the forest. Could he be using narcotic substances?“Cocaine!” was the doctor's second proclamation. It was his favorite treatment for the psychological complications of syphilis. Skorsky himself never took what he called “the universal drug”—good for alcoholism and toothaches, neuroses and morphine dependency—though he had read in an article by a respectable Viennese physician, who used cocaine as a panacea, that it was not addictive. That doctor subsequently recanted, but Skorsky paid no attention. He believed the retraction was made under pressure from pharmacologists who had no incentive to cease production of the medications that cocaine might supplant. Their representatives either paid or threatened the Viennese to repent.As the patient was escorted to his room, he assaulted the orderly, Alevtyna. They tried pulling him off her, but, though he released his fingers from her neck, he buried his teeth in her leg. The poor orderly, who had not until then been attacked by a psychotic, nearly died of fear. Later, panic set in over Skorsky's diagnosis. He told her about the consequences of syphilis: grotesque patterns on one's face due to infection of the skin, mucous membranes, cartilage, and bones. He went on about the devastation to the central nervous system, which they had just observed in real life: “The face starts to look like lace some mangy dogs fought over before rolling in the mud.”Alevtyna, who had not yet regained her faculty of speech, straightened up. Ignoring the slavering male orderlies, she bared her leg to get a better look at the wound. She then ran down the hall and out into the garden, where she fell on the ground to rip up grass and small bunches of daisies. Alevtyna ate them along with the soil in their roots.“Minor hysteria. She needs fifteen milligrams of cocaine.”Skorsky took a snuff box out of his pocket and scooped up some white powder with a toothpick made from a goose feather. He gave the order to close Alevtyna's mouth and one of her nostrils, forcing her to snort the medication.We fretted over her so long that evening fell. I decided to walk down, along the ravine, behind the church.It was unlikely there were any large beasts there, but something was rustling. The pits and mounds, ravines, paths, graves of witches whose living sisters flew in the treetops from time to time, the whispers of the forest spirits, the spirits of the nutcases who died in the hospital, the spirits of the monks from the St. Cyril Monastery, Zmei Gorynich and the bogatyrs who wanted to defeat him. The city would be calmer without this forest. I saw the gaps between the trees and went off in the direction of the tram tracks.As I was coming out of the forest, there was a patch of Amanita muscaria that had been trampled into porridge. A bit farther on, the body of Professor Bilinsky lay killed in the blackberry bushes. The way he was lying it looked as though he had not struggled before death. I quickly examined his body but saw nothing out of the ordinary. There were no wounds, no dirt under the fingernails. Animals had not yet smelled the carrion, but swarms of various insects covered him. Oh, why did I have to find the putrid body?The best thing would be to take the tram to his house to inform his relatives. The doors closed, and I noticed my own calm. This death had not evoked any emotions in me other than a feeling of responsibility, the need to tell the family. But also—some alarm at the thought of who the murderer could be. I knew that it was murder.“Your nose is bleeding.” A woman as round as an onion, carrying two baskets full of strawberries, offered me an ironed and starched handkerchief.“Have I dirtied my shirt?”“No, it's as neat as a pin. It's just your nose that's dirty. Wipe it now before you spray blood on my strawberries.”“No one will see the red on red.”“Ah, but it's salty!”“You know why it's not sweet? We'd drink it like syrup.”“Those with Christ in their heart do not talk that way.”“Are your strawberries expensive?”“Why? What?”“I'm checking to see if you have God in your heart.”“Child, if you knew how I have to work for this berry! I have to weed it a hundred times. In a week, the quitch grass grows as high as a horse. And I water it with water I carry from the stream, it kills my arms... ”“How much are the berries?”“They're not for sale. Anyway, soon money won't mean a thing. Soon all money, all these papers made from the skins of sinners on their satanic presses will be annulled. What matters is how we treat each other.”“So if I try your strawberries for free, my ‘thank you’ will be enough?”“Hands off!” she said and thwacked my fingers.I heard loud laughter behind me—same laughter as from the café near the Continental. There was no one sitting near Alina. (This is what fate looks like, remember.) Without asking, I sat next to her, away from the old lady.“Excuse me, but the night before last didn't you, yes, didn't you intrude on my privacy?” She started right away.“I saw it a little differently. Who was that young man with the mustache who paid me for you?”“Are you checking to see if you can flirt?”The tram stopped. People got on and off.“Are you coming back from the hospital?” she asked. “Don't be shocked. My uncle works there. He's told me all about you.”“An uncle by the name of Skorsky?”(Remember: this is what fate looks like.)“Yes. Skorsky's been strange recently—says things that make me wonder if he hasn't lost his mind. Have you noticed anything?”“I don't know.”“You know perfectly well.”“Where are you going?” I tried to change the subject.“I have to send something to my theater friends in Odesa. By the way, they'll be putting on Oedipus Rex soon in Kyiv—in Ukrainian.”“Greek tragedy in Ukrainian! That's a first.”“Exactly. The troupe is rehearsing now in Odesa. The theater where they will perform this fall is being remodeled.”“Wait. Now I remember where I've seen you before—it was at a performance! Vynnychenko's Black Panther and White Bear, at the Bergonier on Fundukleivska.“The same director is doing the Oedipus. He's my friend.”“He's your friend in what sense?”“Again with that tired subject. By the way, I've been thinking about you.”“And I about you.”“That's good. I was thinking not about you, to be precise, but about that elevator you invited me on.”“Who was that man with you?”“Like a broken record! Even if he had been my fiancé, I'm not bought or inherited. I'm not a brooch or a hundred acres of land, and I'm not a house in Kaniv!... Who was with you when you saw Black Panther?“Ah, so.”“Answer!”“That was my mother. She looks very young. She is coming to Kyiv the day after tomorrow. I can introduce you.”“Oh, this is my stop.”I looked out the window and realized that I had long since passed the stop for Bilinsky's.“Can we see each other again?”“We can. But you have only one chance.”Alina the anarchist wrote something on a scrap of paper and handed it to me.Morning, not morning but a thick porridge (I hate porridge). Dew, thick spit, crushed fruits, urine, all on the sparkling cobblestones. The sun, just barely having made its appearance, is already scorching. The human masses scurry and grumble like poorly digested food inside a stomach.I walked diagonally across St. Sofia's Square, then along the perimeter, then one edge, then again diagonally across. I went underground. The basement café of the Continental Hotel was practically empty. I again asked the server to bring the cloth with the embroidered portrait, but I couldn't remember the musician's last name, only that it ended with -sky. The server said that -sky was currently in the southern cities of Yalta and Odesa. I added that Kurbas, the director, Alina's friend, was also in Odesa, rehearsing Oedipus Rex, and that he'd previously put on Black Panther.I was bored, so I walked along Khreshchatyk and then headed down, calling to mind all the Kyiv churches of Podil: there's Birth of Christ, St. Nicholas on the Shore, Intercession, Pyrohoshcha, Holy Presentation, St. Dymytrii Rostovsky, St. Illia's. And also the Epiphany Brotherhood Monastery, Ascension Convent, and St. Katherine's, all these whipped-cream churches on the waffles of our streets. A few of them reminded me of themselves by appearing suddenly out of nowhere.The smells on Kontraktova Plaza where commerce buzzed were like multicolored light bulbs turning on one after another. Here you could catch the aroma of Balabukha jam, which blended with the next smell, English shoe polish at the Raiskys’ shop. Then the crunchy-smelling cabbage from old women standing in a row like herons and spitting out the shells of sunflower seeds. Farther on, the stench of a good-sized rat that crawled under Mrs. Shevchuk's shop where she sells broadcloth. Oh, she can't scream: no, she'll quietly dig that rat out herself so as to not scare off her clients.I bought a paper and two pairs of underwear. I asked two laughing young chambermaids who were secretly puffing in a grape-filled yard for a smoke. I wandered around Podil until evening when I came across a sawmill near the Dnipro that surprisingly smelled pleasantly of mazut fuel oil. The weather was dry, yet in the middle of the road was an enormous puddle, a deep dark black. A forty-year-old woman in a pale pink dress stood near it. The theatricality of it all provoked me to pose her a question,“Ma'am, what should I do?”But she paid me no attention. I shouted,“What should I do?”“What to do, what to do?” she said in Polish. “Jump in the water and swim so far away that you cannot return.”I quickly crossed a section of the forest. The wind brought a mixture of unpleasant air, like a stinky handkerchief held under one's nose. Passing the trees, I saw light in the spaces between them and exited at the hospital.Outside the windows, two orderlies lay in chairs with their heads thrown back. Two others—fools—ran around the yard in different directions, peering out at... something. The lights on the first floor of the hospital were on, and the staff milled about.“You're just in time!” said Ivan, a tall, young orderly.“For what?”“Your patient ran away! We went into his room and he wasn't there.”“What patient?”“The one who bit Alevtyna,” said Danylo, the other orderly, short and middle-aged.“That's Skorsky's patient, not mine.”I had no intention of helping them. This was all history—like my family, Kyiv, and my previous life. I had no intention of thinking about it. I wanted to go to my office, pack up my field surgery kit, and get out. So what? Their psychotic syphilitic ran away—it happened.Of course, that patient could have something to do with Bilinsky's murder. But that was no longer my problem.“What a strange coincidence!” the doctor on duty said. “Comrade doctor, the other one responsible for this patient was just here.”“And where is he now?”“He took off toward the church to look for the patient.”“Didn't the patient escape earlier?”“Don't know.”“How do you not know? You had better call the police, moron, before he kills someone. And get those sleeping orderlies to look for him.”“They can't... ”“Why not? Should I go wake them?”“They're on morphine.”“And you, I can see, have lost your mind. Go, catch your psycho! If it turns out that he killed Bilinsky—and on your watch—you can't imagine what's in store for you.”I adjusted my homburg and set off in the direction of St. Cyril's, that unwelcoming monolithic cube. I glanced around—what if our escaped syphilitic were to jump out of the bushes and bite or strangle me. I looked around because I wasn't sure of my actions, wasn't sure of my choices. Tripping over a clump of clover, I reached the open doors of the church. I couldn't stop myself from going in.The walls and ceiling were covered with frescoes. There was what used to be an angel rolling up the sky on the southern column of the narthex. But also graffiti: people scratched their names on it so as not to be forgotten—their idea of eternity. Prince Volodymyr the Great compared this activity to the desecration of graves. The vandals paid a fine and were beaten with canes. During the raids of Batu Khan, the church was deserted and cracks appeared all over it. Wild martens and feral dogs sought shelter here; insects swarmed under the ceiling with its red mosaics. Birches grew in its midst. Water seeped in the cracks, the water became ice, the ice widened the cracks, more water seeped in the cracks, becoming more ice that further widened the cracks, the wall split and nearly fell over, and then the wall fell over. Yet the angel is still rolling up the sky... When I reached the exit, I heard a rustling behind me. I turned after I stepped outside: in the depths of the church, like a stick in a pot of tar, stood a man with a large bag thrown over his shoulder and a revolver pointed right at me.“Is that you, Doctor?“Don't move!”“What's... Skorsky, what's with you?”“Don't move, I say!”“What are you doing here?”And finally I understood... Skorsky was himself the psycho! (Really, I had known for a while.)“You are the murderer! I knew it! But—why?”“Shut up.”“It was you. You! The stolen cigarettes, the strange behavior, Bilinsky. If I shout, everybody will come running. They've already called the police!”There was heavy breathing behind me. And then a gun rang out.The city is overgrown with new buildings. They encircle everything that was once on the periphery. Kyiv has become an old lady that can no longer restrain herself in the face of pastries. The city climbs farther. It steps over the swamps, turns the old rivers into a series of lakes; the other bodies of water it drives into canals. The grain that falls from the wild wheat is black. When the sun heats it, the grain melts and trickles into the earth. St. Cyril's stands indestructible. No one spackles the small cracks in its walls with either expensive putty or glues, nor with cheap cement and whitewash. One day a small fox appears in the doorway. It runs inside and along the floor of simple gray tiles. The gods watch from the walls, watch and fall into ruin. The fox runs to the iconostasis. Before it is a time-darkened Virgin Mother and Child in oil on sheets of zinc. The fox runs the metal steps that wind up to the second floor. The fox runs past all the vaults, naves, all the frescoes. A buckthorn seed flies in through a broken window. It will be the first. Soon the buckthorn will grow everywhere. A dumb hare will make its nest in the buckthorn bushes and nightingales will settle in the upper branches to sing until the end of the world. The fox runs between the thick rays that penetrate the windows. It catches one of the rays, squints its eyes, and warms itself in the sun.The shot rang out, but I did not fall. I looked around—and on the church threshold was our syphilis patient bearing a rod. His head lay on the rocks by the doorway.“If only he'd been at the stage of nose deformity! Just imagine: a hole instead of a nose plus a hole from the bullet—like an extra pair of eyes!” Skorsky laughed at the corpse.“We need to call the orderlies.”“They heard the shot. They'll run here on their own. You see, Professor Bilinsky believed it would take two or three years to wrap up this patient's case,” Skorsky told me. “But I took care of it much faster!”“Excuse me, but I'm going crazy in this city. I thought that you were Bilinsky's murderer.”“Just so. Why not? I am Bilinsky's murderer.”“Don't tease. You've changed a lot recently, so... ”“Yes, I've started killing people. You might term such a change significant.”“You have the right to irony.”“I am not being ironic.”“Let's call it sarcasm.”“It's the honest-to-God truth.”“And yes, you have the right to mock me.”“Well then, let's be done. To the horses!”“What horses?”“Alina's waiting!”Alina, her uncle Skorsky, a few others I didn't know, and I rode like the wind that ripped off my homburg and carried it back to Kyiv.“There's a fresco in the choir loft at St. Cyril's where Vrubel painted himself and patients from the hospital as the apostles. When I came across it by accident, I really believed they were saints,” Alina said.“I've never been up there. I've only seen the church from below.”“Remember the way back so you can see it sometime.”“The Puchai River used to flow here. You shouldn't trust the landscape,” Skorsky said, reaching for something, perhaps his bag, just when we left the darkness of the trees and saw the endless steppe ahead of us.We rode all night without stopping. Though no one was chasing us. Though we had nowhere to be. We rode like beasts released from a cage. The promises of the horizon turned what we'd left behind into a cage fit for those from whom freedom had been severed, like an anomaly, at birth.The pre-morning sky looked at first like a sack of turnips—filled with something heavy. But with each verst, the sky became lighter. When it was finally light enough to see clearly, we arrived at a knoll at the foot of a stone wall that from a distance had appeared to be a gigantic piece of halva. The exterior ruins of the castle gave no hint of how it was when all was fine here, when people defended themselves successfully from the nomads’ raids. From far off, the wreckage looked like a natural agglomeration of stones—a rocky elevation, no more: a cluster of cliffs. It would rain a few hundred more times, a few hundred more winds from a few hundred directions would blow on this heap, and it would collapse as though nothing had ever been here.A few stalks of wheat grew from one of the rocks. Someone had probably cast a handful of grain here for some birds that forgot to eat it.“Who could this castle belong to?” I asked Skorsky.“I reckon the Swan Princess,” the doctor rejoined, hoping to sound knowledgeable.From behind one of the piles of gray sandstone emerged a young man in a black reptilian coat and a white papakha as lush, bright, and out of place as a dahlia. His name was Artem. The heat was melting our brains, but he was dressed like that, in rooster fashion, which was popular among the otamans. Artem helped Alina dismount her horse and tried to kiss her on the lips, but she offered him a cheek instead.Had she been racing to see this clown?We entered the yard—the ruins had fashioned an internal space that was more or less protected, at least from strangers’ eyes. It turned out that there were even places where it was possible to hide from the rain, and from there the ruins didn't look half bad.In the center of the court was a table, and on it a wooden bucket with pink gladiolas. How romantic! It all looked like it came from outer space. Where on earth, in the middle of the steppe, far from any village or town, did this table, this simple table, come from? And the gladiolas? The steppe hadn't been plowed in so long that any cultivars would have gone wild, degenerated, dried up completely.A campfire crackled nearby—a little preview of what we would soon do to the houses, villages, and cities. Artem the otaman brought over a cezve from the fire and poured the first portion into a small, copper cup for Alina. He also got out a porcelain cup with images of rosy cherubim—but how...?“Who else would like coffee?”Only Skorsky and I responded. The question excited me, even distracted me from the thought of the kiss I had recently witnessed and the Kyiv I had recently left.“It's obvious who the professors here are; cultured people drink coffee. Are you both doctors?”“Uh-huh.”“For wolves of the steppe, like us, doctors are gold, even more precious than gold. Actually, a Hippocrates like you should eat more, because those in your profession will soon be worth your weight in gold. Work on your figures, both of you.”“Who will take pity on the horses that have to carry us?”“We'll find the horses. And very large doctors can be transported on machine-gun carts. We'll need to seat the otamans near you. Only a fool would shoot at a doctor.”“I think we'll find quite enough fools here.”“With your beard, Doctor, you look like Tsar Nicholas II. But even so you won't be shot. You might even be canonized!”“We've only just arrived and you're going on about executions,” Skorsky grumbled and checked to make sure that he still had his bag.“Apologies, apologies, pardonnez-moi. But you are not merely a doctor. A venereologist! Skorsky, you're a specialist! A venereologist is the most important person in wartime. The most valuable! You are the botanists of war. You can't imagine what varieties of flowers grow here, and these beds have long awaited a proper gardener. Or even just a man with a scythe!”“Bite your tongue,” Alina said. “I don't need to listen to this.”“Yes, yes, of course. Excuse me, my r—. ” He almost said “rose.”We rested all day. We went down to a surprisingly close river overgrown with lilies. We rowed the boats left by fishermen. I talked to Skorsky. He took his bag everywhere, refusing even to swim so he wouldn't have to part with it. I asked him what he had in it, but he said it wasn't my damned business.Alina rowed with the otaman to the middle of the river. They were having a loud discussion. She was waving her hands. The current carried their boat downstream slowly and smoothly. What a nuisance, that current!I tried to meet with Alina one-on-one, but she was avoiding me. In the morning I was confused, by lunch I was sad, and after lunch I got angry.In the evening, I lay on the hot grass and drank another cup (I have no idea where they got such good coffee), which had no effect at all on my sleep. I watched the Perseids. Every year, the Earth passes through the tail of Comet Swift-Tuttle. People can see the meteor shower and make a wish. I wished. I counted forty-seven falling stars. All forty-seven of my wishes were for the same thing.Around the campfire, they were sitting, talking. I saw how he tickled her face with a piece of grass and she brushed him off in annoyance. Then they were screaming at each other. Later they again spoke kindly, after which they again quarreled. My joy grew after each tiny mistake that Artem made. I wanted him to show the worst he was capable of.They were screaming at each other, but all I could hear was beautiful opera singing. The stars fell to the sound of their screaming. The stars blessed my joy.Then this happened: Alina kicked the fire, scattered burnt kindling, and burned some of the grass. Artem grabbed her by the arm, but she broke away from him and ran off to the horses.“Go then! I guarantee you'll get to Katerynoslav and return with your tail between your legs.”“I'm going to Huliai-Pole! To Father Makhno!”I jumped up and ran after her.“Where do you think you're going?” Artem shouted.Really—where was I going? I was going after her: to Huliai-Pole, to Katerynoslav, to Rome, to Washington, to Istanbul, to Montevideo... “Go to sleep,” he said. “Come morning, this coquette will be here, right as rain. We've already been through this show. Tomorrow she'll be right here next to my boot!”... No, she won't.In some sort of shape we entered some town. There were some buildings that were some colors, some trees, some streets, some roads, and some signs. Posts, flustered birds’ nests, echoes, colors, shapes—each of some kind. A wedding procession was coming toward us. If you want to make orange, you need to add yellow to red, and then bam—it's black. If you want to salt the soup, shake in a little, and then bam—two handfuls. You want to say a kind word, and then bam—a punch in the face. I was rocked around like a watermelon on a boat and threw up my breakfast straight into the horse's fluffy mane. Sanko found this hilarious, but I said I'd pulverize him. So Sanko sped ahead.No one knew anything about Alina. The daytime sky was like a poorly washed bowl. The sun was a squashed, rotten apricot. The night sky looked like the sole of a boot to me. The moon was a dirty cheap copper coin that had gotten stuck to the sole. Everything seemed spoiled to me, irrelevant, unnecessary. Without her, this journey was a waste of time.“You'd better stay away from everyone,” Artem said. “You'll infect us with your pining, and pining is worse than the clap.”The wedding procession was before us. The young couple, still utter children, walked so calmly it was as if they didn't see us. As if we were made of a light breeze—our bodies, clothes, our horses and their iron shoes—of the lightest gasses. As if we were visible only to ourselves and the coal-black dog that barked, panting and gasping.The wedding was headed straight for us. We were in the middle of the road, and so were they. We approached each other slowly, a wave going toward a wave. Some ten meters before their indifferent faces, I noticed the color of the bride's eyes. And the coral-colored tulips that fell on the road before her. Round goose eggs on meaty stems, the flowers were falling and falling before her. The bride's eyes were almond shaped.“Hey there,” Artem shouted at me. “Wake up!”I came to and saw the whole village, everyone there, not realizing my group had turned left onto a side street away from the procession. The tulips disappeared—where'd they get tulips in the fall? I was sitting alone on my horse in the middle of the road, and the entire wedding procession came to a stop. I moved to the side, and the throng marched on, cutting off our escape route. We rode a few more meters and came across the synagogue.“You know what, you're right,” said the otaman.“Who is?”“Oleksii is the only one here who's right.”“About what?”Artem turned his horse and raced back. Everyone stood still while he ran his horse into the crowd and began firing his revolver. People scattered in all directions. Artem trotted, cackling like an imbecile. The horse kicked an old guy in the mouth. The man fell, spitting out his gold teeth. We rode up to the commotion and formed ranks, but none of us wanted to join the otaman.The bride stopped in the middle of the street. On both sides were buildings and trees, as well as dust, sky, and sun. She stood still, beautiful, as if nothing had happened. Then she adjusted her garland and walked calmly on.“Well, should we get some sugar now?” Artem laughed, looking at the bride, and off he went toward the sugar factory.It was then I noticed that all of the houses had shutters—fuchsia, blue, ocher—and that all the shutters were closed.We flew toward the dirty building, whistling and shouting. If there had been aesthetes among the otamans, they would certainly have razed the abomination in this field after seizing it. They would have spread soil on top and sown buckwheat. Long live buckwheat!, that wonderful crop. Like hunting dogs hot on the trail, we raced to our defenseless victim, with the baying of hundreds of hounds behind us. The field shook beneath us. We became an artist's canvas, evolving from Realism to Romanticism, Romanticism to Expressionism, Expressionism to Suprematism. If we had been painted in black and white, we would have been splotches (until the ink ran, annihilating all remaining patches of white).Two men stood near the gate—unarmed and undressed, in nothing but their undershirts and boots. Our fervor, our kinship with the elements, our entirety, were all for naught.“Jesus Christ! What bores!” Artem exclaimed. “How boring you are!”“Maybe boring for us, but fireworks for them,” Sanko said, dismounting his horse.“The fear of death engenders creativity,” our otaman—a distinguished philosopher of the early twentieth century, that demonic breed—prophesied.He went on, “Excuse me, but with all due respect, we are not going to search you. Just show us right away where the money is. Why are there so few of you? Don't say there's not much money. I want piles and piles of money! If you don't show it to us, we'll print our own on your skin. Believe me, we will.”We entered the factory grounds. There were no workers, only an enormous mountain of sugar beets that looked like a pile of coal from a distance and a pile of dead rats from up close.“So, did you have a good year?” Artem asked a man in an undershirt.“Not really—too dry.”“Nah, that's fine. You wouldn't have been able to gather most of the harvest this year anyway. There's a fire burning across all of Ukraine, all of Russia. The whole world!”While Artem tossed thoughts like well-chewed sunflower seeds into the crowd, the two men quietly stepped aside and then ran fast ahead to the factory's main hall. The gigantic door slammed shut. The gate was locked behind us! The windows were smashed! The factory roared from inside like a cumbersome machine starting up. Bullets whirred through every window.“Bastards! It's a trap! Quick, after me!”Still on horseback, Artem bounded over to a vast window, low to the ground, and smashed it mercilessly. He broke the frame and jumped inside on his horse. I and a few others followed. We broke into their lair, threw open the doors, and let the other warriors inside.Iron vats of hot sugar were steaming, pipes were clattering; machinery groaned.“Parasites!” Artem gritted his teeth. “I'll get you. I'll get you red sons of bitches. Painted whores!”At the word “painted,” his horse fell to the ground. Lying prone, Artem continued fighting, but the red soldiers wouldn't let him stand. Fighting nearby, I rode over to assist but did not know where to aim. Artem got up, ran forward, and brought his sword down on the head of the closest soldier, all the way to the middle of his skull, to the bridge of his nose. It was like butchering a pig. Artem thrust the sword into the buttock of another who was fleeing and cut off his leg at the bend in the knee.“I'll cut off every last one of your asses! Cut off your asses!” Artem bellowed.A half hour later, the dead were lying, the captured sitting, and the victors doing anything they pleased.“Skorsky, are there a lot of casualties?” I asked the doctor, whose hour it was. I hoped not, because I was too tired to help him.“Just a few. The dead are already dead, and the wounded are not ours.”Though Skorsky rarely asked my help, and though I'd become an ordinary soldier, the doctor in me was still present in the most unpleasant attribute—knowledge. Others saw an eviscerated man, pieces of dusty flesh smeared with clay, soil, sand, and straw. I saw a perfectly formed kidney hanging perfectly from the rest of its body like a child's mitten from its coat. You could try this death on for size. Wear it like a sanbenito of the Inquisition.Artem counted the money and then lay on the floor alongside the gigantic sugar mountain in the middle of the room. From time to time, the crystals rustled as they fell.“I didn't think you'd be such a fighter!” the otaman said without turning toward me. “I thought you'd be healing us. You'd keep to the rear and we'd hide you like a girl. But here you are, in the vanguard, like a lion!”“I got excited,” I told him, choosing not to react to the “girl” part.“’Cause Alina said there was no sense counting on you to fight.”“Really?”“Does that sting?”“Why would it? I'm a doctor—not everyone is. It requires a brain. Unlike waving a sword.”“Yeah, yeah. I gave her gladiolas. We were lying in the boat near that castle, doing all manner of things, and she told me all about you. How you met.”“You were lying in that boat talking about me?”“It was the day before you left Kyiv. You agreed to go with the anarchists so quickly!”“Were you surprised? Doctors make fast decisions.”“But you probably had great prospects. Your parents are rich, right?”“And who are your parents?”“Probably all your relatives fled abroad—bourgeois. Why did you stay?”“What the hell's your point?”“Alina, by the way, died a while ago. Probably.”“Don't jinx her.”“Listen here,” he said, staring at the ceiling. “And listen good. If you have designs on her—dead or alive—it's best you castrate yourself now.”“After you.”“If I want to kill somebody, you know, I just do it.”At last he looked at me. I was lying on the floor nearby and looking in his direction, sweaty and relaxed, my appearance complemented by my disdain for his opinion, his authority, his stupid hat. His everything.Artem raised his arm above his head, stuck a finger in the sugar mountain, and licked it. We both got up. Had I anticipated this turn of events, I would have readied a gift for him. Artem held his revolver. Under my hand I found a knife the workers used for gathering beets: it was a deliberately sharpened arc they sank into the swollen brassicas. I jumped up and quickly stepped around the sugar mountain.Artem's bullet hit a pane and broke the glass.“Not man enough for hand-to-hand?”The otaman shot again.“You should've challenged me to a duel, you romantic!”Encrusted with white crystals, I charged Artem from the sugar mountain. We fell in, and the sugar stuck in our hair, mustaches, nostrils, armpits.The gang ran in to get us apart, then backed off because it had nothing to do with them. By now the sugar mountain had burst its banks. Of the once perfect pyramid, a deformed mound remained.Wounded, Artem fell on the sugar mound, turning the white red.I stood before the gang sugar-coated and holding a bloody hook. The old otaman was drawing his last breath. Blood trickled from the corner of Artem's mouth and streamed from the left side of his breast.“What's the commotion?” Old Roman had just come in.“Be quiet,” the boys told him. And a good thing they did.“You killed him? You killed the otaman!”“Shut your mouth,” the boys told him.“You... ”I slugged Roman's stinky herring mouth. How did that son of a bitch find pickled herring in a sugar factory? My fist was now bigger and stronger than ever before, a steel anvil that could split nails and shatter memorial plaques. The unfortunate man's jaw twisted like an upper millstone that had gone off track from the lower.“Let's get out of here and go to Makhno's camp,” I gave my first order.We galloped so fast the grass burned beneath us. The birds and bugs had no time to fly out of the way; hooves trampled the burrows of rodents who didn't dare crawl out of their holes for a long time after. We raced like no one had ever raced before.The steppe, that sly fox, pretended to be an innocent fool. The steppe said, “I'm like Adam: I don't even know my own name.” But its grass harbored the tracks of thousands of armies and the heels of Herodotus, the crunch of Trypillia vessels, and the smell of Scythian hemp, Roman coins, clay figures of wolf people, the chevrons of Denikin's army, glass from the Chekists’ ruby stars, traces of uranium from flying saucers. I threatened it: “Steppe, show me your layers, or I will burn you, plow you under, flood you.” But it just replied: “I'm like Adam: I don't yet know my name.”I lost geography as if it were a silver coin. It fell out of my pocket and rolled through the feather grass that blanketed the steppe in white foam. The open space ahead was so endless that the whole world might as well have been steppe. If people ended up here from somewhere else, they would conclude they were on another planet. The coin fell and became an argentum, became one with the ring on the hand of the princess who had one green eye and one blue, with the twisted candlestick at the monastery on the other side of the steppe, with melted ingots. It broke down into simpler elements, simpler and simpler yet. The horse carried me spreading the seeds of northern plants to the south, just as southern riders had once brought flowers and weeds to the north. And then I turned back. Just as I had no geography, I had no time. Every night I fell asleep with the thought that the next day I would again race. Through all spacelessness, all timelessness. I exchanged one horse for another, got on a train, on a boat, traversed forty versts on foot—in rain that brought the river up to the road, in heat that overturned cattle. The earth I walked on became mine. Mine was the water in the lakes and springs, clean water, dirty water, enlightened water, contaminated with oil, stinking of algae, of fish that died in wells, stinking of the memory of atrocities, water as clean as broken bread. The water did not become Alina.I was doing this for her: I got the basturma out from under my saddle, sodden with the horse's sweat, sliced the throat of a rich man whose daughter I had danced with at a ball, climbed into a vat of beet juice and took a sugar bath, carried out the expropriation of the savings banks, wiped the sweat from my face with my shirt—and the cloth turned red; I didn't know from what. If it was someone else's blood, I didn't care; if it was my own, even less.We mostly came across Reds. We scraped them up like old red paint on a door in order to repaint the boards black. Black looked better. Red is tasteless, but black has style. Healthy men died before us of myocardial rupture like bunnies found in the nest. The ones whose hearts were sewn of steel wire envied the deceased. Seizing estates, banks, distilleries, and prisons reminded us of gathering in the harvest. If you're too lazy to pick an apple, you can shake the tree; some of the fruit gets bruised when it falls. We seized buildings like we were shaking apple trees. No one picked the fruits, we just shook: shook under the beds, under the tables, behind the curtains. No, there was no picking. We just shook until the red juice spurted from the apples.Near the Khorol River with Father Makhno and me in charge, we captured sixteen machine guns and four cannons, as well as five hundred prisoners who immediately came over to our side. The villagers voluntarily gave us bread and cheese, chickens and kvas. People joined us. The front of the machine-gun cart said “You can't run,” and “You won't catch us” at the back. We took factory after factory. Millions of karbovantsi, thousands of poods of sugar, weapons. We smashed the telephone exchanges and captured the telegraphs. We made alliances with some and then with others. Lenin, Wrangel, Frunze, the Germans, Chinese, Australians, Kaiser Wilhelm II, Cleopatra, Maria Theresa Walburga Amalia Christina. We ran the steppe. There were a hundred thousand of us. There were three hundred thousand of them. There were three hundred thousand of us. There were a million of them. There were two million of them. We were all of humanity. We were so many that we were none.The nobles’ estates were long ago forsaken. In the people's deepest trunks lay silks and guipure laces that were once perhaps used only to cover a table. Five steps from the barn in the direction of the pear tree, some silver candlesticks are buried; there's a plaster figure of an angel in the chicken coop, covered with shit and feathers.I was reluctant to be going to my home, but I didn't see any way out. Fate intended me to be a different being from the one I was before.Here my grandfathers and great-grandfathers were born. Here the ones who caused my grandfathers and great-grandfathers to flee had stopped. When we were still far off I noticed that someone was in the house. It was our men—Skorsky had brought them here, about twenty in all. I asked Sanko, whom I had walked with side by side more than once, where the doctor was now. All the men answered that he was around somewhere, but I didn't see him that evening.In 1918, the spirit of my great-grandfather Stepan, along with my mother and uncle, had gotten into a britzka and scrambled off to Paris, to Napoleon, against whom my great-grandfather had fought with the Cossacks, to whom the Russians promised to return self-rule. Following him in the cart went the soul of Grandpa Oleh, who lost a finger when he cut down the old linden near the house; his second finger was blown off by a cannonball near Balaklava, and later his entire hand was cut off by some Turk. Next went the spirit of my father, also Stepan, who did not take part in any war but died of measles at the age of forty. They all got the hell out of here. First, they went to Kyiv, led by my mother, Tamara Makarivna, in order to collect Uncle's family and me, their son. And their son, it turns out, has now come back to rob his own home (I didn't drive my war buddies away, did I?). It's a shame that I didn't know where the bathtub was, or whatever they bathed me in when I was small. It would have been good to walk through the ranks of anarchists with that basin and tell them all to spit into it.Remembering every room, I carried Alina upstairs to my mother's bedchamber. There was no longer furniture or pictures, only bare walls. The bed and mattress remained, but that was enough. Mother hated noise, so she set up her room far away from the running in the halls and the creaks on the stairs. I adjusted the mattress; in a gap, looking like a stalk of wheat, there lay a gold bracelet that she lost in the haste and that the thieves could not find in the mayhem. I tucked it into my pocket.The place could still be saved. It was strong, built under the leadership of my grandfather, who knew how to do it right. He built a sawmill, a gristmill, a dress factory (today it's probably been ransacked, maybe even by our own men).Alina had a complete, displaced break in her right fibula. We needed water first. I went downstairs—the guys were dragging out the piano like an old cow to the slaughter.“What are you doing with that?”“Taking it out.”“Why?”“What's it to you? We want to have fun.”“Can you play?”“We're not your bourgeois lily-handed bitches.”They couldn't play, but they were famous at destruction. “Noise is the music of the new time,” one of the smarter among them might have said. “But noise is the opposite of music. Just as a rose is the opposite of your ugly mugs,” I'd have responded if there was anyone to say it to. I could also have said that this was a Bosendorfer grand piano, that it was very valuable—but do the guys not deserve such a luxury?“Why are you so boring? We're relaxing.”“Then let me play a little first.”“Go ahead, but fast. One-two.”So I played. As before. My fingers ran up and down the black and white keys, which weren't simply keys of these, the simplest, colors. These were the keys that remembered my fingers specifically—achieved by that slovenly German Katerina, our governess. She knew a bundle of languages, could play the piano, and was interested in the latest scientific discoveries. But she had not an ounce of sympathy for anyone who couldn't master anything on the first try. More than once she hit my pinkie against the black key that remembered every one of its four thousand touches. She would pound it on the key and shout, “Si bémol! Si bémol,” and later bang my fingers and translate, “B flach! B flach!”I played. I could not expose myself, so the only thing I could do was believe in miracles. What if these coarse men saw value in this bit of furniture so unintelligible to them? And what if they didn't destroy it, this emblem of my childhood, my land, my air, which I could protect in no other way? My air. My water.“Shchedryk, shchedryk, shchedrivochka,” one of them who recognized the tune began to sing along.“Look at you.” They did not expect music from me, who had until recently been drinking blood like water.They said, “Again, again!”A group of curious men gathered around me. They were ordinary farmers, thieves, and recidivists, peasants and workers, everyone except for Skorsky. They needed this music as they needed baths. The music cleansed them from the inside, perhaps. They had not heard anything besides the whistle of a bullet, the neighing of a horse, or the knocking of a chisel and the whirring of a saw, amputating limbs, for a long time.But it could not go on long. I did not close the piano lid, just stood and went to fetch water for Alina, leaving the unfinished song for later. The well was to the north—that is, at the “Head.” My father once promised to give me a compass if I could learn to identify the ends of the earth by means of the sun. And to make it easier to remember, I gave each one of them a name: the east where the day begins was “Right” (my right hand), the west “Left,” the north “Head,” and the south “Feet.” Back when I could still do whatever I wanted all day long, I would wake in the morning and say: I'm going to the Feet. The mound was at the Feet, Left had the river, Right had the forest. It was only to the Head that I rarely went, because a village was located there. When the villagers saw me, they would speak in whispers and avoid the master's son.... I wiped her brow and her burning, sunken cheeks. I lay down next to her to feel the heat of her skin.When the fire in Alina calmed slightly, I went out into our orchard. My father had once been given a gift from Japan—a tulip tree that blossomed with yellow-green flowers. It had to have grown in the time that I was away. It would have been fatal had it been cut down. I again took the stairs down into the drawing room and came across nobody—they had all disappeared in search of food or were hidden away in their burrows. In the middle of the hall, like an opened rib cage, was the piano, irreparably shattered.B Flach! B Flach!Translation © Ali Kinsella 2022. (shrink)

Organ transplantation has increased worldwide while the number of organ donors have not increased similarly. Consequently, the waiting period for transplant candidates is prolonged. Patient narratives have uncovered physical and psychosocial suffering in the transplantation process. However, relatively few studies have explored patients’ experiences in the actual waiting period. This qualitative study was conducted in Norway and aimed to describe patients’ experiences of being accepted as recipients of a new liver and their waiting following this decision. A sample of (...) 21 patients with end‐stage liver disease, placed on the ordinary waiting list for a liver transplant, were interviewed in the hospital before they went home to wait for a compatible liver. Uncertainty related to life and death was a major issue, both in the waiting period and as a response to being put on the waiting list. Another central issue was their overwhelming lack of energy. Patients inferred a linear relationship between lack of energy, physical limitations and mental distress. Despite major advances in medical treatment, little follow‐up was given during the waiting period and most of the patients seemed resigned to the inevitability of their suffering. This raises issues of health personnel responsibility and a need to heighten awareness about patient suffering during the waiting period. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Institute of Medicine’s Report on Non-Heart-Beating Organ TransplantationRoger Herdman (bio), Tom L. Beauchamp (bio), and John T. Potts Jr. (bio)In December 1997, the Institute of Medicine (IOM) released a report on medical and ethical issues in the procurement of non-heart-beating organ donors. This report had been requested in May 1997 by the Department of Health and Human Services (DHHS). We will here describe the genesis of the IOM (...) report, the medical and moral concerns that led the DHHS to sponsor it, the process of producing it, and its conclusions. The analyses, findings, and recommendations of the report are also reviewed, in particular the central issues that led to suggestions for policy changes.Transplantation BackgroundAs a first step, some background in the relevant aspects of organ transplantation will prove useful. For the purposes of this analysis, “transplantation” involves the transfer of cells, tissues, or solid organs from one human to another to replace the structure or function of comparable body components that, through injury or disease, are defective or of inadequate function. The IOM report deals with solid organs, primarily kidneys and livers, whose blood supply is reconnected in the organ recipient, in contrast to cells, like bone marrow, and tissues, like corneas. A variety of donor types exists for organ transplantation, each with particular medical and scientific conditions.Living donors are healthy (and usually genetically related) individuals who volunteer to provide either a whole, paired organ such as a kidney or a section of an organ such as a liver. Cadaver donors are individuals who have died and from whom a full array of organs can be taken. “Heart-beating” cadaver donors are individuals who have suffered “brain death,” that is, irreversible cessation of function of the whole brain including the brain stem; and “non-heart-beating” donors (NHBDs) are individuals who are ill or injured, but not “brain dead,” and who have suffered cardiopulmonary death, that is, irreversible cessation of cardiac and respiratory function. NHBDs can be “controlled,” which means that [End Page 83] they can be sustained by artificial life support systems until a medical and family decision is made to terminate futile life support. This can be done at a scheduled time and in a controlled manner, and organs can then be recovered for transplantation. NHBDs can also be “uncontrolled,” which means that their hearts and breathing have stopped through disease or injury at an unexpected time or in an uncontrolled manner, and they cannot be resuscitated; the organs of some individuals of this description can be recovered for transplantation. The IOM report focused on both controlled and uncontrolled NHBDs and on problems specific to them.The questions that were asked and addressed in the IOM report became current and salient beginning in 1992 with the establishment of the University of Pittsburgh “Policy for the Management of Terminally Ill Patients Who May Become Organ Donors After Death.” This policy addressed controlled NHBDs and the ethical questions raised by their use; much of the discussion was reported in the June 1993 special issue of the Kennedy Institute of Ethics Journal. Public notice and anxiety about some of these concerns were sharpened and refocused by national and local media allegations of improper treatment of donors at the Cleveland Clinic in 1997, specifically premature—i.e., antemortem—recovery of organs and administration of drugs that allegedly might hasten donor death.The DHHS Request for StudyIt is not surprising that several federal actions would be taken in response to these events. Some, such as the results of a transplantation task force, remain largely internal to DHHS at this writing. Others are public, such as the IOM study of the NHBD situation. In May 1997, the DHHS initiated contacts with the IOM with the goal of exploring federal concerns about the medical and ethical treatment of NHBDs, in particular the allegations directed at the Cleveland Clinic.The DHHS response should be understood in at least three contexts. First, living donors and uncontrolled NHBDs were essentially the only donor types in the early days of transplantation in the United States. The technologies, ethics, and social acceptance of controlling and terminating life support for... (shrink)

Suicide prevention is a National Health Service priority in the United Kingdom. People with mental illness are seen to represent one of the most vulnerable groups for suicide and recent British Government policy has focused on prevention and management of perceived risk. This approach to suicide prevention is constructed under a biomedical model of psychiatry, which maintains that suicidal persons suffer from some form of disease or irrational drive towards self-destruction. Many react to the idea of self-inflicted death with (...) instinctive revulsion, which has prevented serious discussion of the concept of rational suicide, particularly in relation to those with schizophrenia. The idea that there may be circumstances in which suicide can be viewed as rational is discussed within the biomedical approach to ethics and wider literature primarily in relation to physical disease, terminal states and chronic pain. It is not deemed a viable choice for those who are considered ‘non-autonomous’ due to the controlling forces of mental illness. I propose that suicide is not a consequence of mental illness per se, and that it may be seen as a rational response to a realistic perspective on the course and consequences of living with schizophrenia. The denial of dialogue about the validity of suicidal ideation for people with schizophrenia has led to negative consequences for people with serious mental illness in terms of justice and recognition of person-hood. (shrink)

A life-threatening illness such as cancer can bring about much existential suffering and a disconnect to self in spite of surviving cancer. In my recent research project, I interviewed 14 long-term cancer survivors on being post cancer. Contrary to common assumptions about long-term survivorship, my interviewees reported grave existential difficulties in finding a firm footing in their sense of self, fostering a variety of stories of despair. This article examines long-term cancer survivors’ suffering from the vantage point of (...) selfhood and provides a philosophical interpretation of the reintegration of the self by illuminating their stories of despair through the Danish philosopher Søren Kierkegaard’s seminal work The Sickness Unto Death. The participating survivors described how the cancer experience had quaked old perceptions of self, instigating them to question the depth of their self-understanding before the cancer and who they really were. In relating to themselves, they realized the dynamic process of becoming who they are by continuing to balance opposing poles within the self. This act of relating to self revealed the limit of the autonomous self in the creation of selfhood. The article intends to illustrate how a philosophical reading of selfhood and suffering in survivorship can inform medicine and inspire models for follow-up cancer care for long-term survivors. (shrink)

What is the relationship between harm and disease? Discussions of the relationship between harm and disease typically suffer from two shortcomings. First, they offer relatively little analysis of the concept of harm itself, focusing instead on examples of clear cases of harm such as death and dismemberment. This makes it difficult to evaluate such accounts in borderline cases, where the putative harms are less severe. Second, they assume that harm-based accounts of disease must be understood normatively rather than naturalistically, (...) in the sense that they are inherently value based. This makes such accounts vulnerable to more general objections of normative accounts of disease. Here we draw on an influential account of harm from the philosophy of law to develop a harm-based account of disease that overcomes both of these shortcomings. (shrink)

The aim of this study was to gain a deeper understanding of the experience of time when living with severe incurable disease. A phenomenological and philosophical approach of description and deciphering were used. In our modern health care system there is an on-going focus on utilizing and recording the use of time, but less focus on the patient’s experience of time, which highlights the need to explore the patients’ experiences, particularly when life is vulnerable and time is limited. The empirical (...) data consisted of 26 open-ended interviews with 23 participants receiving palliative care at home, in hospital or in a nursing home in Norway. The theoretical frameworks used are mainly based upon K. Martinsens philosophy of care, K. E. Løgstrup phenomenological philosophy, in addition to C. Saunders’ hospice philosophy, L. Feigenberg’s thanatology and U. Qvarnström’s research exploring patient’s reactions to impending death. Experience of time is described as being a movement that moves the individual towards death in the field of opposites, and deciphered to be a universal, but a typical and unique experience emerging through three integrated levels: Sense of time; where time is described as a movement that is proceeding at varying speeds. Relate totime; where the awareness of limited life changes the understanding of time to be more existential. Being in time; where limited time seems to clarify the basic living conditions and phenomena of life. The existence of life when the prospect of death is present is characterized by emotional swings that move within polarizing dimensions which is reflected in the experience of time illustrated as the moves of the pendulum in a grandfather clock. The diversity of the experience of time is oscillating between going fast or slow, being busy or calm, being unpredictable but predictable, safe or unsafe and between being good or bad, depending on the embodied situation of the individual. (shrink)

The thesis of this article is that engagement and suffering are essential aspects of responsible caregiving. The sense of medical responsibility engendered by engaged caregiving is referred to herein as clinical phronesis, i.e. practical wisdom in health care, or, simply, practical health care wisdom. The idea of clinical phronesis calls to mind a relational or communicative sense of medical responsibility which can best be understood as a kind of virtue ethics, yet one that is informed by the exigencies of (...) moral discourse and dialogue, as well as by the technical rigors of formal reasoning. The ideal of clinical phronesis is not (necessarily) contrary to the more common understandings of medical responsibility as either beneficence or patient autonomy — except, of course, when these notions are taken in their disengaged form (reflecting the malaise of modern medicine). Clinical phronesis, which gives rise to a deeper, broader, and richer, yet also to a more complex, sense than these other notions connote, holds the promise both of expanding, correcting, and perhaps completing what it currently means to be a fully responsible health care provider. In engaged caregiving, providers appropriately suffer with the patient, that is, they suffer the exigencies of the patient's affliction (though not his or her actual loss) by consenting to its inescapability. In disengaged caregiving — that ruse Katz has described as the silent world of doctor and patient — provides may deny or refuse any given connection with the patient, especially the inevitability of the patient's affliction and suffering (and, by parody of reasoning, the inevitability of their own. When, however, responsibility is construed qualitatively as an evaluative feature of medical rationality, rather than quantitatively as a form of calculative reasoning only, responsibility can be viewed more broadly as not only a matter of science and will, but of language and communication as well — in particular, as the task of responsibly narrating and interpreting the patient's story of illness. In summary, the question is not whether phronesis can save the life of medical ethics — only responsible humans can do that! Instead, the question should be whether phronesis, as an ethical requirement of health care delivery, can prevent the death of medical ethics. (shrink)

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease (...) as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization. (shrink)

continent. 2.3 (2012): 218–223 Vijay Prashad. Arab Spring, Libyan Winter . Oakland: AK Press. 2012. 271pp, pbk. $14.95 ISBN-13: 978-1849351126. Nearly a decade ago, I sat in a class entitled, quite simply, “Corporations,” taught by Vijay Prashad at Trinity College. Over the course of the semester, I was amazed at the extent of Prashad’s knowledge, and the complexity and erudition of his style. He has since authored a number of classic books that have gained recognition throughout the world. The Darker (...) Nations , a peoples’ history of the Third World, sent defibrillating shockwaves through an academic world that had almost forgotten the epic scope and historic dignity of the non-aligned movement and post-colonial struggles. In his recent, award-winning work, Arab Spring, Libyan Winter , Prashad delves into his capacious knowledge of the Third World to excavate the discourses and narratives surrounding the upheavals of 2011. “Revolutions have no specific timetable,” states Prashad in the opening line of this exciting and provocative look at contemporary events. Instantly, an atmosphere of suspense emerges. The reader is alerted to the problem of history. Does the making of history then involve a suspension of historical time, or is it a continuous narrative structure into which events must eventually be integrated? Arab Spring, Libyan Winter shows that the answer to the question, “How is history made?” lies just as easily in the asking. The first half of the book works through the events that transpired to bring about the explosive popular uprisings of Arab Spring: Tunisia and Egypt, Yemen and Bahrain. But the events are not put together in a cohesive, chronological fashion. Using an uncommonly gripping style more akin to the folk-story motif of the djeli than to traditionally Orientalist academia, Prashad suspends a given situation, points out its components, and traces back the characters and genealogies that define each link before resuming a narrative. Every moment is an end to itself, and an origin of something different. Thus, the making of history becomes the suspension of its own progress, it’s catastrophic 'stability,' in a process of differentiation through inclusion. Empirically, one might suggest that history is a condition of time, and by extension, of the subject, but history is also an eminent producer of the Subject and her concept of time through memory and narrative. Hence, history is often overdetermined by a dominant narrative of the sovereign. The apparently chaotic composition of Prashad’s historicity is, then, an interstitial morphology of resistance. It illustrates that the time to act for the revolutionary lies in the gaps within the dominant historical realities. It points out the sorties of signifiers constituting nothing in the obliterated ruins of history. Through such illuminations, Arab Spring, Libyan Winter breaks through “the surface of history” to elaborate revolution’s snapping synapses, exploding interruptions and breaches, connecting flows. Messianic Politics It is tempting to think, 'History is either singular, or it is diffuse. It is either one coherent factual narrative, or it is comprised of the aletheia of the multitude.' Yet the reader finds Prashad examining the structure of history on multiple levels. For Prashad, world history is shaped by geographically defined political movements, such as communism or national liberation, with historical agents like the working class for the former and the nationalist militant for the latter. Religion, however, is another matter: “Religion has an unshakable eschatology which a post-utopian secular politics lacks.” Within the telos of religion, there appears on the horizon the image of Benjamin’s thoughts on messianic time—time as “a small fissure in the continuous catastrophe,” a break with history, may contain an ultimate redemption of the human beyond the political power struggle. Succoring the split between geo-political and utopian-religious (messianic) time in the context of Arab Spring, Prashad indicates that the base of “the deep desire and commitment to some form of democracy” is forged by the affinity between eschatological Islamist politics with the People. To think about the Subject of messianic time in the context of the lack of a “coherent timetable” for emancipatory politics, it is perhaps best to return to the modern tradition of Martin Luther King, Jr., whose prefigurative blending of liberation theology and emancipatory politics became most important during his works of 1963, the climactic year of “The Letter from a Birmingham Jail,” the March on Washington, and the bombing of the 16th Street Baptist Church. In “The Letter,” King states the point bluntly: Frankly, I have yet to engage in a direct-action campaign that was “well timed” in view of those who have not suffered unduly from the disease of segregation. For years now I have heard the word “wait!” It rings in the ear of every Negro with piercing familiarity. This “Wait” has almost always meant ‘Never.” We must come to see, with one of our distinguished jurists, that “justice too long delayed is justice denied.” The timing of rebellious action must not be a part of history. It must change history. The kairos appears spontaneous and untimely in its convulsive, shocking presence, yet it is, deeper still, a path, a longue durée , forged through diligent and rigorous praxis. King put a finer point on the path of historic liberation in his declaration in his 1963 speech at Western Michigan University: “[T]ime is neutral.... Somewhere along the way we must see that time will never solve the problem alone but that we must help time. Somewhere we must see that human progress never rolls in on the wheels on inevitability. It comes through the tireless efforts and the persistent work of dedicated individuals who are willing to be co-workers with God. Without this hard work, time itself becomes an ally of the insurgent and primitive forces of irrational emotionalism and social stagnation. We must always help time and realize that the time is always right to do right.” Time, then, exists in “the neutral,” while action must turn to the kairos , not only of taking time, but taking the right time. By turning our relation to time into kairos , we move time from its context within history to a duration between histories—the longue dure?e of Messianic time. The implementation of neutrality in this context suggests a broad space of time to extend through the valley of positive and negative. In Roland Barthes’s lectures from 1978, the neutral takes place in this minimal distance of non-conflict that exists outside of two extremes. It is, in the words of Maurice Blanchot, “the non-general, the non-generic, as well as the non-specific.” For Blanchot, the neutrality of time permeates life as death, impassive and beyond control; such is the neutrality of messianic time, which permeates the charge of history, changing the "I" into the "one." The neutrality of time therefore implicates history in a case against extremism, showing that the work of the radical is not to tend to any particular side, but to have the time to navigate through the terrible terrain of history by altering its course, its patterns and rhythms of movement, connection, sociality. Hence, one does not simply “make history,” one alters the course of history in accordance to “the right time.” The historical path toward emerging power is transmitted as a gesture to the outside of history, against history; a gesture as simple as reaching out. Thus a counterhistory, to use Foucault’s term, is brought forward as the guide of time past a point of no return, a Rubicon, the point where the normal path of history falls to the past. The subject, who must be the only true agent of history, facilitates time through helpfulness, and both the Subject and her history become decentered in relation to one another. Yet history negates the neutrality of time. As Barthes discloses, although the neutral is the “thought and practice of the nonconflictual, it is nevertheless bound to assertion, to conflict, in order to make itself heard.” Engaged with history, time is charged with a destiny, and becomes an opposition. As Prashad insists, “For Arab lands, the events of early 2011 were not the inauguration of a new history, but the continuation of an unfinished struggle that is a hundred years old.” The emergence of the Subject during Arab Spring did not conceive of a new history, but changed the path of history toward a different destiny. “Historical grievances combined with inflationary pressures now met with the subjective sense that victory might be at hand—this was not simply a protest to scream into the wind, but a protest to actually remove autocrats from their positions of authority. The facts of resistance had given way to the expectation of revolutionary change.” The negativity of this charge toward “revolutionary destiny” rendered control, as a positive force, seriously lacking. The lack of control lies in the problem that the Subject is not totally detemporalized or timeless, but untimely in her presence. The Subject is untimely, because her work is visionary, and it is only through such visionary work that the Rubicon can be crossed. Still, the crossing of this border is haunted by anxiety over an impending disaster that lays in wait. It is only through the form of what Benjamin calls divine violence, captivated not with the justice of the means, but the ends—the transformation of history—that a revelation of history’s traumatic foundations can be liberated, and patterns and rhythms of time developed throughout obscured traditions awakened. In this situation, the Subject appears to be outside of right, but setting the state to rights. Because her position is correct, in-so-far as the rebelling subject rebels due to a lack of recognition, her representation appears outside of the norm, which is mistaken as right. Therefore, such visionary work must be carried out through obscured traditions, underground, away from the surveillance of empire. Explaining his method from the start along the lines of Marx’s metaphor of the mole, Prashad insists, “It is the burrowing that is essential, not simply the emergence onto the surface of history.” Arab Spring, Libyan Winter is a book on uncharted networks of time, spread out over the 252 pages like an elaborate spider’s web of passages intertwining with and overwhelming the machinery of the state. Although untimely, Arab Spring was not a flash in the pan, or a Facebook or Twitter revolution. Prashad notes that the government’s suspension of these tools led to further radicalism by furthering communications through face-to-face encounters. In existential terms, Arab Spring might be thought of as a revolution of Being over techne , an uprising of the unchartable, infinite potential of the Other. The name of this Other is found in Chance. The faith of the revolution lies in the proper decentering of the subject, its giving to the Other of time, for only with respect to time does history actually appear on the horizon of the subject, rather than as an imposition. This time of historical agency appears as a moment when anything can happen—a revolutionary truth event where everything comes into question while being realized in its Otherness as a community of the people begins anew in the streets amidst discourse, friendship, reconfigurations of hegemony, and a becoming of a constituent power. Throwing a wrench into the gears of the “cobwebbed tradition” of Orientalism, the decentering of history in Arab Spring, Libyan Winter is a defining quality of its impassioned revolutionary cry. But perhaps the most paradigmatic points of the book emerge from the unexpected voices. To make the connection between the particular manifestations of revolutionary demands to the general historic terms of revolution, Prashad quotes an anonymous young Egyptian in Tahrir Square, who reminds us, “[T]he French Revolution took a very long time so the people could eventually get their rights.” Far from timelessness, the historicization of Arab Spring must exist precisely within the most uncanny appearance of time, as something that does not appear to come from the natural state of time as we know it, but in arriving has completely transformed the way that we understand time. Strange Monsters Revolution is never as simple as a revolt from below against a rusting structure of elites trying to remain in power. As with the French Revolution, Arab Spring consisted of complex familial ties, outside interests, and religious factions fighting alongside, often in awkward juxtaposition to, liberals, working class parties, farmers, and students. It is perhaps because of this historically difficult and incongruous composition that the Arabic word for revolution is thawra , referring to the image of the bull, or thawr , which has religious significance as a pagan deity for the Ancient Semitic tribes and Cartheginians. If Daniel Guérin was correct in saying, “Anarchism and Marxism drink from the same spring,” then it is quite a different oasis that drove the thirsty beast of revolution through what Prashad calls, “the Libyan labyrinth.” Recalling Bataille’s Acéphale, the intestinal labyrinth gains significance as the mode of metabolism and rumination in which, “(the Acephale) has lost himself, loses me with him, and in which I discover myself as him, in other words, as a monster.” Unraveling the discourse of the revolution, the flows of power and hegemony—from Qaddafi’s nationalist coup in 1969 to the wars with Chad from 1978 to 1987, the neoliberal reforms of the 1990s to, finally, the War on Terror—we find that the metabolic process of Libyan Winter ends in the production of oil. In a process of what Prashad calls “involution,” Qaddafi’s bellicose policies, along with his attempts to nationalize Islam together with oil, mutated the source of his power, turning his house against itself. Already a divided nation, with its two major cities on opposite geographic sides of the country, Libya became split between two opposed political powers—liberal reformists and staunch nationalists—as Qaddafi’s political disengagement manifested through what can only be described in psychoanalytic terms as a recursive passage a l’act (mysteriously calling Wikipedia “Kleenex,” declaring that opponents drank hallucinogens with their instant coffee, and so on). Prashad declares, “The mercurial style that Qaddafi adopted was not about his personality alone, but also a leader’s natural response to a system that relied upon power brokers whose own loyalty… did not have any ideological commitment to the system.” As in the case of other nations during Arab Spring, the true expression of revolt was an outward exposition of what had inwardly been happening in microcosmic societies throughout the realm—from indigenous tribes to political parties, for a century, the people, partly motivated by (and in resistance to) economic impositions of development, had been changing the traditional social compositions and participating in what Ruth Wilson Gilmore calls, “the relative autonomy of the movement from the leaders.” It was this empowerment of political reconfigurations taking place under the context of new democratic assemblages that shocked the elites and evoked such a powerful response. Unlike Qaddafi’s awkward policy choices and rants, real acts of power from the West were clear and decisive. Prashad sets the stages of war and diplomacy, far removed from the deserts, mountains, and cities that forged the backdrop of popular politics. Taking place under the now-classic architecture of the “four pillars” of US interests—oil, the War on Terror, Israel, and the circumvention of Iranian hegemony—we find elites rubbing elbows in “Heliopolist cocktail parties and hushed conferences in Kasr al-Ittihadiya” as well as the Concorde-Lafayette hotel in Paris, which provides the setting for a meeting of anti-Qaddafi figures consolidating their power. These scenes are buttressed with the careful portraiture of key historical actors. As Prashad brings the stage of history to life, we find the diplomats and liberals like Frank Wisner, whose career has brought him from Enron in the late 1990s to the Obama Administration, under the aegis of which he was meeting with Mubarak about military support during Arab Spring. We spy the provocateurs, for instance, gauche cavalier , Bernard Henri-Levy, who telephones Sarkozy from Benghazi about the need for more NATO air strikes. We follow the rebel military establishment as it suffers mysterious deaths and even more mysterious assents (like that of apparent CIA cohort, Khalifa Hifter). In each of these intriguing characters, we find different representations of the security state biopolitique: an oil-injected reification that drives Arab Spring from the resentment of rising food prices to the brink of implosion in Libyan Winter. Reminiscent of the scenes of Cold War soirées represented in old Bond films, the aristocratic fight for oil against democracy that was Libyan Winter presents a harsh truth that the new global crisis is simply the continuation of the old history: the global exploitation of capitalism waged against the imagination of the people. As Benjamin laments, “The labyrinth is the right path for the person who always arrives early enough at his destination. This destination is the marketplace.” Yet, “(t)he labyrinth is the habitat of… a humanity (a class) which does not want to know where its destiny is taking it.” Thus, the labyrinth leads, like the desert, only further into itself. As Blanchot explains, “The desert is even less certain than the world; it is never anything but the approach to the desert.” Only the visionary can take time out of the involution toward oblivion. It is here, in this approach to and escape from history, that we find ourselves within Benjamin’s Golgotha, Blanchot’s desert: A space of indeterminate uncertainty where we become familiar only with our own exile. Blanchot writes, “For the moderated and moderate man, the room, the desert, and the world are strictly determined places. For the man of the desert and the labyrinth, devoted to the error of a journey necessarily a little longer than his life, the same space will be truly infinite, even if he knows that it is not, all the more so since he knows it.” The desert, as allegory, provides an eschatology, a mortality in the destiny of Arab Spring. But any allegory of nature might lead to a labyrinthine eschatology (for example, in Bachelard, the forest presents "a limitless world"); the prescience of the untimely is always an uncanny acceptance of the infinite within the finite—the outside of what is understood. Transgenerational and occupied with the image of the future, the untimely makes otherness its home as it proceeds toward liberation. In the work of helping time navigate this dangerous passage of history, Prashad illustrates that the more violent break with history may have occurred in the peaceable struggles of Tahrir Square, and not in the military clashes of Qaddafi with his former Generals who defected to the CIA and NATO countries. It might be possible to suggest, then, that in the case of Tunisia and Egypt, the historical subject of the people was drawn together in a Dionysian dance of different rhythms in the marvelous realm of the ancients, while we fear that the case of Libya suggests an Apollonian future where time, itself, may lay dying under the machinic hand of history. The properly Nietzschean inversion would follow: time is dead, for history has killed it. Yet, if time is dead, struck down in Golgotha, exposed in the desert, mauled by the thawra , it is only in the present sense that it is rendered impossible outside of the context into which the untimely has thrown us. Thus, if history becomes an art of revolution, life as being-towards-death (death as the provocation of the neutrality of time) becomes what Benjamin calls “the allegory of resurrection” through the glorious ruins of history. Prashad ends his work with a rousing finale: “The time of the impossible has presented itself. In Egypt, where the appetite for the possibilities of the future are greatest, the people continue to assert themselves into Tahrir Square and other places, pushing to reinvigorate a Revolution that must not die… For them the slogan is simple: Down with the Present. Long live the Future. May it be so.&rdquo. (shrink)

The global reality of suffering and death has always demanded an authentic theological response and impelled debate concerning Gods relationship to suffering, as well as the conceivability of the suffering of God. The scope and impact of this suffering in the last century have driven this debate to an acute pitch, demanding to know how one can speak rightly of God in view of the suffering that is inherent and inflicted in the cosmos. While (...) in former ages, some looked to an omnipotent and impassible deus ex machina in answer to this question, many contemporary theologians have revised their understanding of God in relation to the world. With these theologians, Gloria Schaab proposes that a viable response to cosmic suffering is the recognition that the triune Christian God participates in the very sufferings of the cosmos itself. She sets her argument within theology and science dialogue and specifically within the work of scientist-theologian Arthur Peacocke. Informed by the understandings of evolutionary science, grounded within a panentheistic paradigm of the God-world relationship, and rooted within the Christian theological tradition, this work contends that the understanding of the Triune God as intimately involved with the suffering of the cosmos is viable and efficacious in view of the suffering of the cosmos and its creatures. It develops a female procreative model of the creative suffering of the Triune God, an ecological ethics based on the midwife model of care, and a pastoral model of threefold differentiation of suffering in God as steps toward Christian praxis in response to the mystery of God within the pain, suffering, and death of cosmic existence and human experience. (shrink)

Patients with Wilson’s disease suffer from prospective memory impairment, and some of patients develop cognitive impairment. However, very little is known about how brain structure and function changes effect PM in WD. Here, we employed multimodal neuroimaging data acquired from 22 WD patients and 26 healthy controls who underwent three-dimensional T1-weighted, diffusion tensor imaging, and resting state functional magnetic resonance imaging. We investigated gray matter volumes with voxel-based morphometry, DTI metrics using the fiber tractography method, and RS-fMRI using the seed-based (...) functional connectivity method. Compared with HC, WD patients showed GM volume reductions in the basal ganglia and occipital fusiform gyrus, as well as volume increase in the visual association cortex. Moreover, whiter matter tracks of WD were widely impaired in association and limbic fibers. WM tracks in association fibers are significant related to PM in WD patients. Relative to HC, WD patients showed that the visual association cortex functionally connects to the thalamus and hippocampus, which is associated with global cognitive function in patients with WD. Together, these findings suggested that PM impairment in WD may be modulated by aberrant WM in association fibers, and that GM volume changes in the association cortex has no direct effect on cognitive status, but indirectly affect global cognitive function by its aberrant functional connectivity in patients with WD. Our findings may provide a new window to further study how WD develops into cognitive impairment, and deepen our understanding of the cognitive status and neuropathology of WD. (shrink)

For nearly five years, bioethicists and neurologists debated whether Jahi McMath, an African American teenager, was alive or dead. While Jahi's condition provides a compelling study for analyzing brain death, circumscribing her life status to a question of brain death fails to acknowledge and respond to a chronic, if uncomfortable, bioethics problem in American health care—namely, racial bias and unequal treatment, both real and perceived. Bioethicists should examine the underlying, arguably broader social implications of what Jahi's medical treatment (...) and experience represented. On any given day, disparities in the quality of health care and health outcomes for people of color in comparison to whites are evidenced in American hospitals and clinics. These disparities are not entirely explained by differences in patient education, insurance status, employment, income, expressed preference for treatments, and severity of disease. Instead, research indicates that, even for African Americans able to gain access to health care services and navigate institutional nuances, disparities persist across a broad range of services, including diagnostic screening and general medical care, mental health diagnosis and treatment, pain management, HIV‐related care, and treatments for cancer, heart disease, diabetes, and kidney disease. (shrink)

The ability to convert human somatic cells into induced pluripotent stem cells (iPSCs) is allowing the production of custom‐tailored cells for drug discovery and for the study of disease phenotypes at the cellular and molecular level. IPSCs have been derived from patients suffering from a large variety of disorders with different severities. In many cases, disease related phenotypes have been observed in iPSCs or their lineage‐specific progeny. Several proof of concept studies have demonstrated that these phenotypes can be reversed (...) in vitro using approved drugs. However, several challenges must be overcome to take full advantage of this technology. Here, we highlight recent advances in the field and discuss the main challenges associated with this technology as it applies to disease modelling. (shrink)

Animal production, especially pork production, is facing growing international criticism. The greatest concerns relate to the environment, the animals’ living conditions, and the occupational diseases. But human and animal conditions are rarely considered together. Yet the living conditions at work and the emotional bond that inevitably forms bring the farm workers and the animals to live very close, which leads to shared suffering. Suffering does spread from animals to human beings and can cause workers physical, mental, and also (...) moral suffering, which is all the more harmful due to the fact that it is concealed. The conceptual tools used to conceal suffering ( animal welfare, stress, pain) suggest that the industrial system can be improved, whereas for farmers it is by definition incompatible with animal husbandry. (shrink)

This paper focuses on the set of problems regarding the HIV/AIDS crisis in the specific domain of corporate moral responsibility within a context of the Levinasian notion of proximity (infinite responsibility) and the Third. Against a totalitarian, homogeneous society, Levinas opens the way to a social pluralism, which has its sources in the disquiet provoked by the strangeness of the Other's face. Corporate responsibility, understood from this point of view, would not reduce institutional relations to an anonymous world of neutrality. (...) Corporate responsibility is unconditional in the sense that to be responsible is not a question of choice, but one of deep liberty, the liberty of taking the burden of the infinite responsibility for the Other customers, employees, the public at large and those who suffer in the world. This paper argues that it would then also mean that society (individuals, NGOs and governments) in accordance with the spirit of the Levinasian philosophy of infinite responsibility could exert pressure on corporations, such as pharmaceutical companies. Owing to their power, they could change their present responsibility policies to a more affirmative and engaged responsibility with regard to those who are ill and who suffer death or debilitation from HIV/AIDS and other prevalent diseases in the poorest parts of the world today. (shrink)

The article explores the underlying reasons for patients’ self‐perception of being a burden (SPB) in family settings, including its impact on relationships when wishes to die (WTD) are expressed. In a prospective, interview‐based study of WTD in patients with advanced cancer and non‐cancer disease (organ failure, degenerative neurological disease, and frailty) SPB was an important emerging theme. In a sub‐analysis we examined (a) the facets of SPB, (b) correlations between SPB and WTD, and (c) SPB as a relational phenomenon. We (...) analyzed 248 interviews with 62 patients, their family caregivers, and professionals using grounded theory and interpretive phenomenological analysis. SPB appeared as important empathic concern in care situations. Patients expressed many sorts of concerns for others, but also perceived an altered self‐understanding that did not meet mutual expectations within relationships. In SPB associated with WTD three constellations were found: (a) WTD to unburden others; (b) patients decided against hastening death to prevent being a further burden to others (in these cases, the SPB counteracted the wish to die); and (c) both wishes for and against dying were sustained by SPB. These patients often felt paralyzed and suffered deeply. Family caregivers felt emotionally touched by SPB and tried to unburden patients by caring and compassion. We concluded that the impact of SPB on a WTD and the various meanings the facets of SPB have in balancing relationships need to be worked out individually. An early palliative and narrative approach is warranted. (shrink)

Bioethics should pay more attention to globalization and some of its consequences than it has done so far. The COVID-19 pandemic would not have been possible without globalization, which has also increased some of its negative consequences. Globalization has intensified wildlife trade in the world. One of the main hypotheses about the origin of this pandemic is that it originated in illegal forms of wildlife trade in China. In the last 30 or 40 years, there have been zoonotic outbreaks at (...) a much frequent pace than before, many of those have been related to wildlife trade. Legal and illegal wildlife trade has grown in the shadow of globalization. Second, globalization has had a huge impact on the redistribution of wealth in the world. Since 1990 income inequality has increased in most high- and in many middle- and low-income countries. A country’s level of pre-COVID income inequality is the best predictor of the COVID death rate. These two issues are not unrelated. People living in poverty in LMIC tend to suffer more from infectious diseases and tend to be marginalized from the health sector. Additionally, poverty tends to reproduce the conditions under which zoonotic diseases can more easily spread. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Trauma, Recognition, and the Place of LanguageJuliet Mitchell (bio)Definitions of trauma abound within the psychoanalytic discipline. My own definition is going to be simple. A trauma, whether physical or psychical, must create a breach in a protective covering of such severity that it cannot be coped with by the usual mechanisms by which we deal with pain or loss. The severity of the breach is such that even if (...) the incident is expected, the experience cannot be foretold. We cannot thus make use of anxiety as a preparatory signal. The death of a sick relative, the amputation of a diseased limb may be consciously known about in advance, but if they are to be described as traumatic then the foreknowledge was useless. In trauma we are untimely ripped.Whether it is as childhood seduction, infantile abuse, shell shock, or war violence, or as a preoccupation with the place of neoteny and the trials of human birth, trauma is continually posited as the hypothetical “origin” of psychic states. However, although “trauma” is crucial to psychoanalytic theory, trauma in itself is not really the focus of its analysis. Freud proposed a “biological bedrock” on which psychic states were formed, but this bedrock was not the object of psychoanalytic inquiry. I suggest that what emerges as a motif in the many retheorizings of psychoanalysis time and again, as another “bedrock,” is trauma. One might call it an “experiential bedrock.” As with biology, it is crucial—but as the area of another mode of inquiry. Psychoanalysis is equipped to contribute to the understanding of the reaction to trauma, not to the trauma itself.In a colloquial context we tend to look from the perspective of the observer and label a range of difficult or tragic occurrences “traumatic.” Instead, I want to define trauma from the perspective of the person who experiences it. This means both that the same event will not always be traumatic for different people, and that the experience of different events, if they are experienced as trauma, will be the same whatever the event and whoever the sufferer. It was essentially for this reason that Freud eventually disagreed with the rich findings of Otto Rank, who proposed the trauma of birth as the origin of mankind’s neurosis. Trauma is the great equalizer. What differentiates us, since we were all born? Furthermore, what appears to be the trauma from the observer’s perspective may, from the viewpoint of the psychic response of the recipient, only be the catalyst that brings to the surface an experience which, were it not for this later event, might not in itself have been traumatic (or vice versa). Even so extreme an experience as the Holocaust may not breach the defenses of a particular individual. The catalytic event in the present triggers an earlier occurrence which becomes traumatic only by virtue of its retrospectively endowed meaning.Probably all animate matter can be traumatized; it would seem likely that the response to the breach in the human defensive system takes place at a generalizable psychosocial level. Recognition and language are interactional social processes; without another person neither a psyche nor language is possible. Object relations analysts, notably D. W. Winnicott, whom Max Hernandez addresses in his paper in this issue, have devoted their work to aspects of the psyche, Lacanians to language. To me the fields are interdependent and gain from being looked at together, both in their practice and in the theories that can [End Page 121] be applied to them. When we have a physical trauma it is common for an immediate aftereffect to be some uncertainty about words; even the ability to spell correctly can temporarily disappear. There are undoubtedly physiological explanations for this. But I shall argue that there are psychological parallels. Every patient whom I would regard as having had some relevant form of trauma had a specific relationship to language, and it is this that concerns me. In addition, Max Hernandez describes the breach in the defenses caused by the anal rape of a patient when he was a young boy. But neither the patient’s symptom nor his complaint on coming to a therapist for treatment pertains to... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.1 (2001) 41-44 [Access article in PDF] A Response to Mitchell, Hinshelwood, and Adshead Sarah Richmond Iam grateful to Juliet Mitchell for contributing, in her response to my paper, some interesting further ideas about anorexia. Before commenting on these, I would like to reply to her suggestion that a distinction between symptom and phantasy will provide a necessary corrective to my approach. I think that, (...) in relation to my usage of terms, this suggestion is mistaken.If I have understood her correctly, Mitchell maintains that we need to focus on symptoms rather than on phantasy because the former always indicate the influence of something truly unconscious, a meaning that the subject cannot recognize. On the other hand, phantasy, Mitchell says, involves a "slippage between unconscious and preconscious," between the notions of a meaning that remains disguised and inaccessible to consciousness and one that may be recognized by the subject.I meant, in my paper, to use the term phantasy in the Kleinian sense, that is, to denote mental content that is unconscious. On the Kleinian view, symptoms whose cause is psychological are expressions of (and clues to) an unconscious phantasy that underlies them: To understand symptomatic behavior, the analyst needs to understand its basis in unconscious object-relational phantasy. (Many such cases can be found in Klein's writings. In her seminal paper of 1935, for example, she cites a patient suffering from "hypochondriacal complaints" and carefully "nursing these parts of his body"; in her view, "the different organs he was trying to cure were identified with his internalized brothers and sisters, about whom he felt guilty and whom he had to be perpetually keeping alive" (Klein 275). There is not, therefore, any important distinction, as far as the line of thought pursued in my paper goes, between phantasy and symptom.In introducing the distinction, Mitchell seems to want to emphasize the distinctive, conflict-indicating nature of unconscious material and its heterogeneity with respect to conscious thought. On this, I am in agreement; indeed, my complaint against feminist "literalist" accounts of anorexia is precisely that they overlook the opacity of the unconscious, attributing such "reasonable" and straightforward conflicts to women as to render most of the explanatory resources of psychoanalytical theory redundant.In connection with this issue, it is helpful to be reminded by Mitchell of the "delusion" that often accompanies anorexia, that is, the manifestly false belief, on the sufferer's part, that she is fat. This feature of the subject's outlook must be one of the reasons that anorexia is popularly thought of as [End Page 41] a "slimmer's disease"; equally, it may have helped to encourage the view that anorexia is a response to constructions of female beauty in the media.The "delusional" aspect of the belief, however, discredits this view: Anorexic women do not stop "dieting" when they approximate to a conventional ideal of female slimness. (What about the recent use of anorexically thin fashion models? I don't think this provides a real objection to my claim; so far at least, this practice is quite rare, and I think intended more to shock than to provide an aesthetic ideal.)Anorexic women's continued abstinence from food leads them to acquire an appearance that most people find unattractively thin. Often, they become sufficiently malnourished to endanger their health and sometimes to result in their death. This behavior, surely, cannot be attributed to a desire to conform to fashion, even if that is what the woman says she is trying to do. I agree with Mitchell that the anomaly manifested in some anorexic behavior, the mismatch between what is said and done, suggests the need for explanation in terms of unconscious conflict.Nonetheless, it is plausible that the "media message" and the slimming industry play some role. As I suggested in my article, we might see this role as provocative; the message sounds a note that resonates with or encourages an adolescent's distaste for her body. Further, it may also provide her with a convenient rationalization of her behavior: "I need to diet; I look... (shrink)

The problem of animal suffering is the atheistic argument that an all-knowing, all-powerful, and all-good God would not use millions of years of animal suffering, disease, and death to form a planet for human beings. This argument has not received as much attention in the philosophical literature as other forms of the problem of evil, yet it has been increasingly touted by atheists since the time of Charles Darwin. While several theists have attempted to provide answers to (...) the problem, they disagree with each other as to which answer is correct. Also, some of these theists have given in to the problem and believe it entails that God is limited in certain ways. B. Kyle Keltz seeks to provide a classical answer to the problem of animal suffering inspired by the medieval philosopher/theologian Thomas Aquinas. In doing so, Keltz not only utilizes the wisdom of Aquinas, but also contemporary insights into non-human animal minds from contemporary philosophy and science. Keltz provides a compelling neo-Thomistic answer to the problem of animal suffering and explains why the classical God of theism would create a world that includes animal death. (shrink)

The one thing that is at once most predictable and unpredictable about life is death. Yet, man lives, forgetting death as if he were immortal. Between these two -- a visible manifestation of death and an innate sense of immortality -- hangs the balance of life, a paradox which we do not easily understand. What if death is not an end, but a passage to another life? What if rebirth is not about retribution, but is a (...) form of evolution? What if life and death are not opposites but work towards a common goal? There must be a larger picture, a missing piece of the puzzle to complete the story and make our understanding whole. How should we deal with trauma and loss, suffering and pain and other ethical and existential issues? This is an attempt to find answers to these and many other related issues, theoretically and practically, supported by anecdotes and experiences arising from brushes with death. (shrink)

Schuklenk and van de Vathorst's paper is a very welcome addition to the literature on the assisted dying debate and will be of great interest to clinicians working in the field of mental health.1 Many psychiatrists will have had patients who have asked them to allow them to die, to desist in their efforts to prevent their suicide, and one of us has had personal experience, outside of professional life, of being asked to aid in someone's attempt to end their (...) life in the context of an episode of mood disorder. The person with depression asking professionals, friends and family members to aid them in ending their life is a very real phenomenon. In their discussion, Schuklenk and van de Vathorst's paper uses two principles that we endorse and add weight to their argument: namely, the reality of suffering in depression and the parity of mental and physical illness. Indeed, the case Schuklenk and van de Vathorst make is a strong one and our commentary will focus on the premise of the argument around choosing death and some empirical clarification about competence in depression and the nature of treatment-resistant depression (TRD) and its prognosis. The conceptual concern we wish to discuss in relation to assisted dying, endorsed by the state and legislature, is not linked to any moral or religious concern, or even on grounds related to ‘slippery slope’ or ‘abuse’ arguments. Rather the worry is how one could operationalise decisions around assisted dying as based on competence and capacity and view such decisions as rational. I think this concern is not limited to depressive illness, but to all decisions regarding choosing non-existence. Schuklenk and van de Vathorst offer the following useful criteria to regulate assisted suicide:1. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Death and Dying in JapanRihito Kimura (bio)A majority of Japanese, at present, feel that the modern biomedical and technological innovations pertaining to human life and death have been forcing a change in our common understanding of what, historically, was simply the natural event and process of death and dying. The meaning of death and the dying process in our lives is changing as have the (...) traditional criteria for determining death, namely, cessation of heartbeat and respiration.An individual’s death should be a personal and private matter as well as a familial, communal, and social matter. It has been regarded as such for many thousands of years in our Japanese society and culture. It is well understood that our traditional socio-cultural understanding of human life positively admits the natural process of death as the final event of life. The ideas expressed in Zen-Buddhist phrases such as “accept death as it is” and “life-death as one phenomenon” have been key motifs totally integrated into our traditional understanding of life (Tomomatsu 1939).However, the traditional perception of death as an acceptable process has [End Page 374] been vanishing as the Japanese have applied modern biomedical technologies more frequently in well-equipped hospital settings. Although the involvement of family members in the process of dying and particularly in the death event continues in a variety of ways, the care of dying patients in Japan is becoming much more similar to that delivered in advanced hospital settings in many countries of the world, than it is different. Now, in Japan, a majority of people end their lives in the hospital, surrounded by high-technology machines. Yet, in a survey by the Yomiuri Shimbun of 15 June 1991, half of the respondents said they would prefer to die at home.In addition, there has been a tradition of not explaining to terminally ill people the true nature of their condition, on the ground that this is most appropriate way to proceed (Kashiwagi 1994, pp. 78–85). However, views on this matter are changing. There is a gradual move toward telling patients the truth, and the notion of informed consent has been widely publicized in the clinical setting (Leflar 1996, pp. 96–107). In the 1991 nationwide opinion poll by the Yomiuri Shimbun, 65 percent of the participants said that they would like to be given full diagnostic information about themselves even if they were terminally ill. Nevertheless, only 22 percent of the people questioned said they themselves would definitely be prepared to disclose such information to a family member.The same survey indicated that 78 percent of people considered palliative care desirable, even though it might shorten life, while 16 percent thought life should be sustained as long as possible, irrespective of the pain that patients might be suffering.Challenges of Care for the DyingA special task force on terminal care, set up by the Ministry of Health and Welfare, issued a report in 1989 that encouraged the disclosure of diagnostic information to patients, provided that consideration was given to patients’ life histories, personalities, relationships with family members, and other factors. The report favored the use of drugs for pain control; it also dealt with matters such as spiritual requirements and the care of the family members.Traditionally, the physician-patient relationship in Japan is based on a complete and unquestioning trust of the physician by the patient, such that the physician acts to make health care decisions on behalf of the patient (Kimura 1991). However, increasingly it is believed that people should not have to accept without question the authority of doctors in the treatment of disease. Responsibility for the care of the dying should be shared between family members and all health professionals, not only physicians. Changes are needed in the mentalities of health care providers, patients, and family members, and it must be recognized that the medical system and institutions are not immutable (Annas and Miller 1994, pp. 374–76). [End Page 375]To complicate matters even further, although a patient’s family is informed of the incurable nature of the disease affecting their family member, the patient, as noted above, usually is not told of... (shrink)

Suffering is a ubiquitous yet elusive concept in health care. In a field devoted to the pursuit of objective data, suffering is a phenomenon with deep ties to subjective experience, moral values, and cultural norms. Suffering’s tie to subjective experience makes it challenging to discern and respond to the suffering of others. In particular, the question of whether a child with profound neurocognitive disabilities can suffer has generated a robust discourse, rooted in philosophical conceptualizations of personhood (...) as well as the academic and experiential expertise of practiced health-care professionals. The issue remains unresolved because it is difficult, perhaps impossible, to ever truly know an infant’s lived experience. But what if this is not the best question? What if instead of asking “can this infant suffer?” the discourse is broadened to ask “is there suffering here?” This latter question demands attention to patients’ subjective experiences of suffering, but also to the web of relationships that envelop them. Without losing sight of the importance of patients’ experiences, consideration of their relationships may elucidate the presence of suffering when the patients themselves are unable to provide the same clarity. In this essay, care ethics frames an examination of how suffering manifests in the loving and caring relationships that surround an infant with profound neurocognitive disabilities, changing those relationships and affecting the individuals within them. Exploring suffering through these relationships may offer clarity on the presence and content of suffering for infants with profound cognitive disabilities, in turn offering moral guidance for responding to suffering and supporting flourishing in this context. (shrink)

Ubiquitin is the most phylogenetically conserved protein known. This 8,500 Da polypeptide can be covalently attached to cellular proteins as a posttranslational modification. In most cases, the addition of multiple ubiquitin adducts to a protein targets it for rapid degradation by a multisubunit protease known as the 26S proteasome. While the ubiquitin/26S proteasome pathway is responsible for the degradation of the bulk of cellular proteins during homeostasis, it may also be responsible for the rapid loss of protein during the programmed (...) death of certain cells, such as skeletal muscle during insect metamorphosis. In addition, alterations in the expression and regulation of ubiquitin may play significant roles in pathological disorders. For example, dramatic increases in ubiquitin and ubiquitin‐protein conjugates are observed in a wide variety of neurodegenerative disorders, including Alzheimer's disease. Patients suffering from the autoimmune disease systemic lupus erythematosus generate antibodies reacting with ubiquitin and ubiquitinated histones. At present, it is not known whether these changes in ubiquitin expression and regulation initiate pathological changes in these diseases or if they are altered as a consequence of these disorders. (shrink)

It is not uncommon for patients with advanced disease to express a wish to hasten death. Qualitative studies of the WTHD have found that such a wish may have different meanings, none of which can be understood outside of the patient’s personal and sociocultural background, or which necessarily imply taking concrete steps to ending one’s life. The starting point for the present study was a previous systematic review of qualitative studies of the WTHD in advanced patients. Here we analyse (...) in greater detail the statements made by patients included in that review in order to examine their moral understandings and representations of illness, the dying process and death. We identify and discuss four classes of assumptions: assumptions related to patients’ moral understandings in terms of dignity, autonomy and authenticity; assumptions related to social interactions; assumptions related to the value of life; and assumptions related to medicalisation as an overarching context within which the WTHD is expressed. Our analysis shows how a philosophical perspective can add to an understanding of the WTHD by taking into account cultural and anthropological aspects of the phenomenon. We conclude that the knowledge gained through exploring patients’ experience and moral understandings in the end-of-life context may serve as the basis for care plans and interventions that can help them experience their final days as a meaningful period of life, restoring some sense of personal dignity in those patients who feel this has been lost. (shrink)

COVID-19 pandemic-related perceived risk of infection, illness fears, acute stress, emotional anxiety, exhaustion, and fatigue, psychological trauma and depressive symptoms, and sustained psychological distress can cause smartphone addiction risk and lead to technology-related cognitive, emotional, and behavioral disorders, thus impacting psychological well-being. Behavioral addiction of smartphone users can result in anxiety symptom severity, psychiatric symptoms, and depressive stress. We carried out a quantitative literature review of the Web of Science, Scopus, and ProQuest throughout June 2022, with search terms including “smartphone (...) addiction + COVID-19” + “stress,” “anxiety,” “depression,” “psychological distress,” “screen time,” and “fear.” As we analyzed only articles published between 2020 and 2022, 288 papers met the eligibility criteria. By excluding sources with similar titles, having unclear findings or unsupported by replication, or displaying inconsistent content, we selected 64, mainly empirical, sources. We used layout algorithms and bibliometric mapping as data visualization tools. Assessing the Methodological Quality of Systematic Reviews, a systematic review and literature review software, Mixed Methods Appraisal Tool, and Systematic Review Data Repository were employed as methodological quality assessment tools. As limitations, we analyzed only articles published between 2020 and 2022 in scholarly outlets indexed in the Web of Science, Scopus, and ProQuest databases. The scope of our study also does not advance the inspection of sources covering vulnerable individuals suffering from certain diseases or specific generations. Subsequent analyses should develop on smartphone use and addiction among children and adolescents. Future research should thus investigate problematic smartphone use and addiction across generations Z and Alpha. Attention should be directed to their personality traits and psychopathological symptoms. (shrink)

To comprehend pain, disease, death and suffering as being meaningful - beyond the firing of synapses, the collapse of human abilities, and the mere end of life - requires a context in which to evaluate essential connotations, as well as to place and integrate understandings. If pain and suffering are to have enduring significance, they must be situated within a nest of ontological background assumptions, standards of inquiry, and epistemological foundations. Where secular bioethics fails to give deep (...) meaning to suffering, Christian bioethics succeeds. This essay analyzes the divergent meanings of suffering endorsed by the various Christian religions as conceptualized through the different metaphysical, epistemological, and sociological assumptions of each religion. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Zen and the Art of DeathMaja Milcinski*When reflecting on immortality, longevity, death, and suicide, or taking into consideration some of the central concepts of the Sino-Japanese philosophical tradition, such as impermanence (Chinese: wuchang; Japanese: mujo), we see that the philosophical methods developed in the Graeco-Judeo-Christian tradition might not be very suitable. On the other hand it is instructive to contrast them with the similar themes developed in the (...) Graeco-Judeo-Christian tradition, since these problems present a challenge for a redefinition of philosophy, which has traditionally regarded itself as a European (and in an even less acceptable variation as a Western) phenomenon. As such the very borders of philosophical discourse known in European history as philosophia are today being reconsidered. Although the notion of philosophy (love of wisdom) is distinctly Greek in origin, this does not mean that Asia failed to cultivate activities similar to that. The absence of this notion in China and Japan does not necessarily imply a lack of the cultivation of wisdom within their traditions. Could this mean that, paradoxically, the “philo-“ limits this complex activity primarily to rationally mastered undertakings?By rethinking the history of philosophy as a single narrative, one might come closer to the movements related to the levels of consciousness that were activated in philosophical undertakings in various Asian philosophical schools. In this regard Japanese and Chinese Buddhist philosophical traditions might be instructive since, through the various stages of their development, they have attempted to put the inexpressible into words. The awareness of the insufficiency of words resulted in many original solutions. In the Song dynasty, for instance, China produced a variety of diagrams (tu), by which philosophers and practitioners represented their theories. These formulations, often arose on the basis of meditation techniques and could not therefore be fully transmitted by means of language alone. The illustration of the nine-step process (known in [End Page 385] Japan as kuso) is one such representation, and it is taken here as a point of departure for approaching the concept of impermanence and death in the Japanese philosophical context.One possible means of approaching the discussed topic is to contrast it with the ways in which impermanence, particularly with the phenomenon of death as one of its aspects, has been perceived in the European tradition. It would be naive to generalize and stress the impression that fear of death is much more central and influential in the Euro-American life style than in the Asian one, since it is rooted in human biological and subconscious mechanisms. This paper, however, tries to point at the subtle difference which exists in the spiritual realm.Europe and ImpermanenceThe European Middle Ages developed the so-called ars moriendi, the art of dying. It was this tradition which produced sayings such as “My Lord, it is a great art to die well, and one to be learned by men in health” 1 and the many variations of the dance of death (danse macabre). This awareness of human mortality was also spread by texts, of which the following inspired thought is characteristic: “The one who has not learned how to die, will die against his will. Learn how to die and you will know how to live, since nobody will learn how to live, who has not learned how to die. He shall be y-cleped a wretch that cannot live and dare not die.” 2 These undertakings, however, did not succeed in building any kind of permanent discipline in Europeans connected with the idea of impermanence and death. Rather, it left them caught up in the dizziness of everyday life. The ars moriendi vanished from their consciousness and only became manifest when actual circumstances provoked it, if indeed at all, since often at the moment of impending death people are completely terrified in the light of the prospect of losing their Ego. Although in Christianity there is a tradition of seeing death as a new beginning, some Christians remain skeptical of this “new beginning.” Beginning of what? Is it an illusion of “heaven,” a reflection of this world without suffering and frustrations? In this respect the ars moriendi was cultivating something else: impermanence... (shrink)

The current COVID-19 crisis may have an impact on the mental health of professionals working on the frontline, especially healthcare workers due to the increase of occupational psychosocial risks, such as emotional exhaustion and secondary traumatic stress. This study explored job demands and resources during the COVID-19 crisis in predicting emotional exhaustion and STS among health professionals. The present study is a descriptive and correlational cross-sectional design, conducted in different hospitals and health centers in Spain. The sample consisted of 221 (...) health professionals with direct involvement in treating COVID-19. An online survey was created and distributed nationwide from March 20 to April 15 which assessed: sociodemographic and occupational data, fear of contagion, contact with death/suffering, lack of material and human protection resources, challenge, emotional exhaustion, and STS. Descriptive findings show high levels of workload, contact with death/suffering, lack of MHPR and challenge, and are moderately high for fear of contagion, emotional exhaustion, and STS. We found an indirect significant effect of lack of MHPR on predicting emotional exhaustion through the workload and on STS through fear of contagion, contact with death/suffering, and workload. To conclude, this study examines the immediate consequences of the crisis on health professionals' well-being in Spain, emphasizing the job demands related to COVID-19 that health professionals are facing, and the resources available in these health contexts. These findings may boost follow-up of this crisis among health professionals to prevent them from long-term consequences. (shrink)

The basic challenge that readers of the New Testament face is not only about what Jesus Christ teaches but who he is. Functional Christology has developed at the expense of ontological Christology. This challenge centres on Jesus Christ’s relevance, in terms of his identity, not only for Christians in particular but also for creation as a whole. The question ‘who is Jesus Christ in relation to creation?’ is thus of special interest to this study. Various authors such as Gunton, Gregersen, (...) Peacocke and others have approached this question from different perspectives. The PhD study by Rabie-Boshoff was completed to shed light into the context of dialogue between Christian theology and the science of linguistics in an effort to understand the Genesis 1 creation story. This article refers to part of the study in an effort to make sense of who Jesus Christ is in relation to creation. This provides consolation in a time of worldwide lockdown because of the Coronavirus Disease 2019 virus. The human struggle of making sense of the world is brought into sharp focus in times like these, more so in terms of making sense of their creatureliness and mortality. Although science as a valid knowledge base may provide some answers to this human dilemma, Christians in particular appeal to the Bible and their belief in Jesus Christ. This turn to Jesus, and who he is, provides human beings with enduring and satisfying answers to their suffering and pain.Contribution: This article is an attempt to contribute to the ongoing discussion on creation in terms of how human beings make sense of creation, considering who Jesus Christ is in relation to creation. Human beings have always been engaged in a process of making sense of the world they live in. Ancient cultures provide such a window, allowing a glimpse into how those cultures perceived their world. (shrink)

Rare diseases are a heterogenic group of disorders with a little in common except of their rarity affecting by less than 5 : 10.000 people. In the world is registered about 6000-8000 rare diseases with 6-8% suffering population only in the European Union. In spite of rarity, they represent an important medical and social problem due to their incidence. For many rare diseases have no treatment, but if it exists and if started on time as being available to patients, (...) there is a good prognosis for them to be able for normal life. The problems of patients affected by rare diseases are related to the lack of diagnosis and timely undergoing as well as their treatment or prevention. Orphan drugs are products intended for treatment, diagnosis or prevention of rare diseases, but for their development and marketing the industry has not been interested in yet because of their marketing reasons. Patients suffering from a rare disease although belonging to the vulnerable group for their specific health needs, is becoming invisible in the health care system due to their additional needs un properly recognized. Ethical problems faced by patients, but also health care professionals are related to the allocation of medical diagnostics, unequal approach to health care, inappropriately specialized social services as well as therapy and rare orphan drugs unavailability. Ethical questions related to clinical trails on orphan drugs, population screening and epidemiology testing on rare diseases will also be discussed in this paper. [Projekat Ministarstva nauke Republike Srbije, br. 41004: Rare diseases: Molecular pathophysiology, the diagnostic and therapeutical modalities, social, ethical and legal aspects] Retke bolesti su veoma heterogena grupa poremecaja i imaju malo toga zajednickog osim retkosti, posto pogadjaju manje od pet osoba na 10.000 ljudi. U svetu je evidentirano izmedju 6.000 i 8.000 retkih bolesti koje pogadjaju sest do osam procenata stanovnistva samo u Evropskoj uniji. Dakle, iako retke, one predstavljaju vazan medicinski i socijalni problem s obzirom na broj obolelih. Za mnoge retke bolesti nema terapije, a ukoliko ona postoji i ako se na vreme zapocne i bude dostupna pacijentima, postoje dobri izgledi da ce oboleli moci da zive normalnim zivotom. Problemi s kojima se susrecu pacijenti sa retkim bolestima vezani su za dijagnostikovanje u smislu nemogucnosti ili nepravovremenog postavljanja dijagnoze, kao i same terapije ili prevencije pojave bolesti. Orphan lekovi su proizvodi koji su namenjeni za lecenje, dijagnozu ili prevenciju retkih bolesti, za ciji razvoj i marketing industrija nije zainteresovana iz trzisnih razloga. Pacijenti s retkim bolestima, iako pripadaju osetljivoj grupi, jer imaju specificne zdravstvene potrebe, ostaju nevidljivi u zdravstvenom sistemu, jer se njihove dodatne specificne potrebe ne prepoznaju. Eticki problemi s kojima se susrecu pacijenti, ali i zdravstveni radnici, ticu se alokacije zdravstvene dijagnostike, nejednakog pristupa zdravstvenoj zastiti i nezi, nedostatka specijalizovanih socijalnih usluga, kao i nepostojanja i nedostupnosti terapije orphan lekovima. Eticka pitanja retkih klinickih ispitivanja orphan lekova i populacionih i skrining ispitivanja u vezi sa retkim bolestima takodje su razmatrani u ovom radu. PR Projekat Ministarstva nauke Republike Srbije, br. 41004: Rare diseases: Molecular pathophysiology, the diagnostic and therapeutical modalities, social, ethical and legal aspects. (shrink)

Mass vaccination has been a successful public health strategy for many contagious diseases. The immunity of the vaccinated also protects others who cannot be safely or effectively vaccinated—including infants and the immunosuppressed. When vaccination rates fall, diseases like measles can rapidly resurge in a population. Those who cannot be vaccinated for medical reasons are at the highest risk of severe disease and death. They thus may bear the burden of others' freedom to opt out of vaccination. It is often (...) asked whether it is legitimate for states to adopt and enforce mandatory universal vaccination. Yet this neglects a related question: are those who opt out, where it is permitted, morally responsible when others are harmed or die as a result of their decision? In this article, we argue that individuals who opt out of vaccination are morally responsible for resultant harms to others. Using measles as our main example, we demonstrate the ways in which opting out of vaccination can result in a significant risk of harm and death to others, especially infants and the immunosuppressed. We argue that imposing these risks without good justification is blameworthy and examine ways of reaching a coherent understanding of individual moral responsibility for harms in the context of the collective action required for disease transmission. Finally, we consider several objections to this view, provide counterarguments and suggest morally permissible alternatives to mandatory universal vaccination including controlled infection, self-imposed social isolation and financial penalties for refusal to vaccinate. (shrink)