Cultural competence, a clinical skill to recognise patients' cultural and religious beliefs, is an integral element in patient‐centred medical practice. In the area of death and dying, physicians' understanding of patients' and families' values is essential for the delivery of culturally appropriate care. Dementia is a neurodegenerative condition marked by the decline of cognitive functions. When the condition progresses and deteriorates, patients with advanced dementia often have eating and swallowing problems and are at high risk of developing malnutrition. Enteral (...) tube feeding is a conventional means of providing artificial nutrition and hydration to meet nutritional needs, but its benefits to the frail population are limitedly shown in the clinical evidence. Forgoing tube feeding is ethically challenging when patients are mentally incompetent and in the absence of an advance directive. Unlike some developed countries, like the United States of America, death and dying is a sensitive issue or even a taboo in some cultures in developing countries that forgoing enteral tube feeding is clinically and ethically challenging, such as China and Malaysia. This article in three parts 1) discusses the clinical and ethical issues related to forgoing tube feeding among patients with advanced dementia, 2) describes how Hong Kong Chinese, North American, and Malaysian Islamic cultures respond differently in the decision‐making patterns of forgoing tube feeding for patients with advanced dementia, and 3) reiterates the clinical implications of cultural competence in end‐of‐life care. (shrink)

Disorders of consciousness and the permanent vegetative state -- Legal and political wrangling over Terri's life -- In context--law and ethics -- Terri's wishes -- The limits of evidence -- The implications of surrogacy -- Qualities of life -- Feeding -- The preservation of life -- Respect and care : an alternative framework.

Gathers medical and legal documents, opinions from various perspectives, and a timeline of events in the Terri Shiavo case to provide a resource for examining the moral and ethical issues surrounding end-of-life decisions.

Bioethics has been in existence now for more than twenty years. Much has changed, however, since Van Rensselaer Potter2 first used the term bioethics in 1971. For Potter, bioethics was an applied science with its roots in the biological sciences and its orientation towards the betterment of human life. Today the concept is used in a different context. It has become the name given to the ethical research that has become necessary in light of the new possibilities created by revolutionary (...) developments in medical science. Generally speaking, bioethics is concerned with the beginning and the end of life. In a certain sense, however, this is merely a de facto definition which does not possess a great deal of internal logical consistency.If we attempt to reconstruct the incredibly rapid evolution of bioethics we quickly realize how the times were truly ripe for this new discipline to begin to mature. In a very short space of time bioethics was taken seriously in just about every University and medical centre the world over. There is no part of the world which has not organised a colloquium or developed a study programme or created a Centre for Biomedical Ethics. Yet this advance is hardly surprising if we consider the fact that there have been revolutionary developments in themedical world in the 1960’s which have made it necessary to engage in serious ethical reflection on the borderline questions of human life.From the start, bioethicists have concerned themselves primarily with ethical problems related to reproductive technology such as in vitro fertilization, medically assisted fertilization with donor gametes, pregnancy termination, and the status of the embryo. More recently, however, questions concerning the end of life have entered the bioethicist’s field of interest, e.g. ethical questions related to euthanasia and the problems surrounding the artificial nutrition and hydration of persistently vegetative patients. In the meantime, of course, bioethics has broadened its field of interest beyond questions related to the beginning and end of life. Serious ethical and juridical reflection has resulted from the problems surrounding organ transplantation, transplantation of brain tissue, and the problem of AIDS.With the many recent developments in genetics, the first applications of gene therapy, and the world-wide human genome research project bioethics is assured an exciting future. It is clear that the issues which grab the bioethicist’s attention are rather disparate. Moreover, we are now beginning to realize that a whole gamut of specific questions cannot be addressed unless the broader context of the ethics of health care in general is taken into account. Such a realization has led to something of a new movement within the bioethical sphere which is interested in widening the notion of ‘medical ethics’ or ‘ethics of health’.The purpose of this article is to help familiarize the reader with the world of bioethics. Such a task is both simple and complex; bioethics has become a house with many rooms, a house, furthermore, which is being constantly renovated and rebuilt. By way of introduction, we shall take an investigative and evaluative stroll through the broad landscape bioethics has traced in the first twenty years of its existence. (shrink)

In Emotions, Values & Agency, Christine Tappolet develops a sophisticated, perceptual theory of emotions and their role in wide range of issues in value theory and epistemology. In this paper, we raise three worries about Tappolet's proposal.

In lieu of an abstract, here is a brief excerpt of the content:Comment on Hospice of Washington's PolicyJohn A. Robertson (bio)The recent history of medical ethics may accurately be described as a history of coming to terms with personal autonomy and informed consent across the range of medical practice. Nowhere has this recognition been more important than in decisions to withhold or withdraw life-sustaining medical procedures from terminal and chronically ill patients.Despite the widespread acceptance of autonomy in these decisions, many (...) people—physicians, families, and policymakers—have balked at extending it to the withdrawal of artificially supplied fluids and nutrition. The symbolic connotations of food and water have led some persons to perceive cessation of medically-supplied fluids and nutrition to be a cruel, barbarous act, rather than the merciful respect for the dying patient that such withdrawal usually represents.Two recent events might help resolve the controversy, and ensure that decisions about artificial fluid and nutrition are handled like any other medical intervention—according to patient and family choice and patient welfare. One event is the Supreme Court decision in Cruzan (Cruzan v. Director of Missouri Department of Health, 110 S.Ct. 2841, 1990). Although the Supreme Court upheld Missouri's constitutional power to require artificial nutrition for a patient in a persistent vegetative state, its decision was not based on the symbolic importance of artificial fluids and nutrition. No Supreme Court justice saw a significant difference between medically-supplied nutrition and hydration and other medical interventions, thus allowing them to be discontinued either directly or by advance directive on the same basis as other medical interventions.The second event is the publication of the statement of "Philosophy Regarding Medical Intervention to Supply Fluids and Nutrition" by Hospice of Washington (or similar statements by other organizations). This statement is useful and important because it removes the issue of food and water from its symbolic overlay [End Page 139] and places it in the real context of dying hospice patients. It makes clear that the overriding consideration should be benefit to the patient "in accord with the patient's wishes or those of the appropriate surrogate(s) for the patient." Depending on those wishes and their impact on the patient, this position may or may not involve medically-supplied fluids and nutrition.This statement is also helpful in showing the medical complexity of such decisions in terms of their actual effect on dying patients. Rather than an either/or position, it recognizes that fluids may harm a dying patient by increasing discomfort, and that "persons near death do not ordinarily tolerate substantial volumes of enteral feedings." Thus rather than adhere to a symbolically-based position about the meaning of food and water to a dying patient, the important thing is to look to that patient's needs and give fluids or not, as the patient's wishes and situation demand.Fortunately, the law in most jurisdictions will recognize such a position. In those few jurisdictions that have made a fetish of artificial fluids and nutrition, the law should be changed, for the HOW statement makes clear that such a position may actually end up harming dying patients. Patient welfare should be privileged above all else, and patient welfare may often entail that fluids and nutrition not be medically supplied. Even then, however, caregivers will look to patient comfort and remedy dry mouths and lips with lubricants and ice chips.The HOW statement is, in my view, a very useful guideline not only for hospices but for hospitals, too—for any situation in which a patient is terminally ill and soon to die. A somewhat different set of issues arises, however, when the patient is chronically ill and incompetent, and will survive for long periods with medically-supplied fluids and nutrition. Recognition of patient rights in those situation should also permit cessation of fluids and nutrition on the same basis that respirators, antibiotics, and other life-sustaining measures may be withheld. But the withholding of medically-supplied fluids and nutrition from a patient who no longer has interests in surviving in an extremely debilitated condition raises different issues from withholding fluids that could cause such discomfort and nutrition when the patient is imminently dying. In either case, patient... (shrink)

A wide variety of clinical situations can lead to the implementation of assisted nutrition and hydration (ANH). Both enteral ANH and parenteral assisted nutrition and hydration (PNH) serve to nourish and hydrate those who are incapable of normal eating and drinking. Although PNH via the intravenous (IV) route is comparable to enteral ANH in its intention, IV PNH bypasses the relevant body system—the digestive tract—entirely. Consequently, IV PNH is ethically comparable to mechanical ventilation and thus can (...) be withheld or withdrawn following the ethical criteria that apply to any other extraordinary therapeutic measure. However, other alternatives to oral and enteral hydration that are proportionately less challenging than IV PNH (i.e., hypodermoclysis and proctoclysis) should be further evaluated as potentially ordinary means of keeping patients adequately hydrated at the end of life. National Catholic Bioethics Quarterly 11.4 (Winter 2011): 649–659. (shrink)

One of the basic tenets of paediatric ethics is that competent parents may render healthcare decisions for children who are too young or too incapacitated to make meaningful medical choices for themselves. In the USA, many jurisdictions have expanded this principle to include the right to terminate a child's life support, including nutrition and hydration, when that child enters a persistent vegetative state. However, this approach to the withdrawal of care in the paediatric setting has been put to the (...) test by an increasing number of cases in which one or both parents are themselves accused of causing the child's life-threatening injuries. In such “mixed-motive” situations, parents may express a desire to keep a child on life support for religious or moral reasons; at the same time, forestalling the child's death may also prevent a murder charge against the accused parent. Principles need to be established for handling such tragic cases. (shrink)

The Hebrew phrase tikkun olam means repairing, mending or healing the world. Today, the phrase tikkun olam, particularly in liberal Jewish American circles, has become a slogan for a diverse range of topics such as activism, political participation, call and pursuit of social justice, charities, environmental issues and healthy nutrition. Moreover, the presidents of the United States who attend Jewish religious days and Jewish ceremonies state the tikkun olam in its Hebrew origin, pointing out its origin embedded in the (...) Judaism and a religious rule and/or an obligation that is important in Jewish tradition and thought. Nevertheless, when we look at the context of religious literature in which the phrase is used, it is seen that, although it is difficult to make a clear definition, it does not reflect modern/widespread uses and their meanings. Furthermore, tikkun olam is an ignored and even rejected concept by the Rabbinic Judaism which claims to represent the tradition and its current representative Orthodox Judaism. This fact is also seen in the usage and prevalence of the term in the U.S. and Israel. Thus, in this article, especially with reference to the norms of Mishnah, the religious-juristicial contexts and possible meanings of the phrase of tikkun olam, the notion of tikkun olam in Jewish liturgy and its implied meaning and the Kabbalistic understanding of tikkun will be presented, the development, changing and conversion of the phrase in modern age and its contemporary usage areas and reinterpretations will be demonstrated.Summary: Recently and especially in the U.S., the Hebrew phrase tikkun olam are used as a slogan in a widespread manner such as for activism, political participation, social justice, all kinds of charities, environmental issues, counter terrorism and healthy nutrition. Such a common usage of the phrase is largely the result of its literal meaning and ambiguity. Hence, this article aims to explore the place of the concept of tikkun olam in Jewish religious literature and its variations and semantic changes. Tikkun olam, literally means the repairing, mending or healing the world. However, regarding its religious context, it is difficult to determine what it means accurately. In time, some has used the tikkun olam as a legislative justification for changing specific laws, some has attributed to it an eschatological meaning which indicates to the mesianic age, and some has dicussed it in the context of mystical sense. The first usage of the phrase of tikkun olam in the Jewish religious literature was simply in the form of “because of tikkun olam” in Gittin epistle, a tractate of Mishnah and Talmud. Here, the phrase was used as a reason of a judgment concerning to the subjects of marriage, divorcement, slavery, captivity etc. In the context of these subjects tikkun olam indicates to the similar meanings like “repairing, organizing, healing, changing the world; regulating and improving the society, maintaining the social order, and prioritizing the common good. In fact, the concept of tikkun olam as the reason of the judgements in these matters is likely related to a juridical reason that intends to ensure the personal and public welfare such as clarifying the marital status of woman, to prevent the capture and seizure from Jewish society, and to deal with economy and identification of juridical status of the slaves.The other reference to tikkun olam appears in the second part of the aleinu prayer. However, the notion of tikkun olam in the aleinu prayer refers to a situation that happens in God’s Kingdom if Torah and halakhah are followed carefully. Hence, the aleinu prayer’s tikkun olam points out eschatological expectation which desires a messianic age, but not the socio-political and ecological concerns of the world as in the current fields and meanings.The modern idea of tikkun olam is also associated with the Jewish mystical movement, Kabbalah. Nonetheless, the concept of tikkun in Kabbalah is not a concept related to the socio-political circumstances of the world where we live in, but it is related to the restoring of the divine world. In order to restoring the divine world, human should fulfill the commands by studying Torah and have a spiritual and moral rehabilitation process by engaging in ascetic practices.The use of the phrase of tikkun olam gradually progress in the socio-political life of the U.S. The first use of the expression of tikkun olam in the U.S. was in the 1950’s by Shlomo Bardin, the founder of the Brandeis Camp Institute in California. Bardin asserted that the Aleinu prayer was the most important expression of Jewish values, particularly the expression “le-taken olam be-malchut shaddai” that is typically translated as “when the world shall be perfected under the reign of the God.” Bardin suggested that these words referred to the obligation of Jews to work for a more perfect world. The concept of tikkun olam entered contemporary usage by the way of its being preferred as a name to those such as social justice and charity programmes which was launched by the Reformist and Conservative groups in the second half of the twentieth century. In 1970s, United Synagogue Youth which is the national youth foundation of the conservative movement adopted the expression of tikkun olam and changed the title of its social action programs from “Building Spiritual Bridges” to “Tikkun Olam.” Nowadays, United Synagogue Youth proceeds all of its social activities and tzedakah programs through the tikkun olam project.By the end of 1970’s, New Jewish Agenda, an organization devoted itself to the religious and social values, acknowledged the slogan of “Tikkun Olam” as the spirit of its ideology. In 1986, Michael Lerner entitled a left-oriented liberal publication with the concept of Tikkun by claiming that this concept represented the origin of Judaism, and he take an important role on making the concept have a prevalence.Pittsburgh Platform organized in 1999 by the Reformist Jewish Movement emphasized that people must perform the most significant moral principles in the relationships with all non-Jewish people and all other creatures. This platform also stated that making the world a better place with the help of God would quicken the upcoming the messianic age. The tikkun understanding of the Reformist movement evolved to more universal realm by embracing the non-Jewish people, as well. Over the last two decades, successive presidents of the U.S. who attended in the ceremonies of Jewish religious days and Jewish assemblages have contributed to the prevalence and usefulness of tikkun olam by mentioning the phrase of tikkun olam in Hebrew, expressing that this is an essential principle of Judaism and addressing that this has a central role in Jewish tradition and thought. On the other hand, this concept does not have an important or a central place in Rabbinic Judaism and even in Orthodox Jewish communities which are the current representatives of Rabbinic Judaism. Moreover, Reformist, Conservative, and Reconstructionist American Jews who are considered on the liberal side of the politics has put the concept on the current use and the world’s agenda. Thus, the phrase of the tikkun olam is more popular in non-Judaic milieux in the U.S. than the Jews in Israel. In Israel where the Orthodox doctrine is dominated and shaped the people, tikkun olam is regarded as a western value and is ignored. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:94 Feminist Studies 47, no. 1. © 2021 by Feminist Studies, Inc. Jennifer C. Nash Black Lactation Aesthetics: Remaking the Natural in Lakisha Cohill’s Photographs In her 1992 essay “Selling Hot Pussy,” bell hooks recounts entering a “late night dessert place” with a group of colleagues who all began to laugh at a shelf of “gigantic chocolate breasts complete with nipples— huge edible tits.”1 For hooks, the chocolate Black (...) breasts are mammy imagery, a “displaced longing for a racist past when the bodies of black women were a commodity, available to anyone white who could pay the price.”2 For her white colleagues, the chocolate breasts are simply comical. Her colleagues’ response—their willingness to consume, laugh, and ignore racial, gendered, sexual violence—constitutes the racialized visual marketplace that hooks’s essay seeks to both describe and dismantle. The chocolate breasts become a rhetorical point of entry into hooks’s critical engagement with a visual marketplace where Black female bodies are delectable and disposable objects. hooks’s analysis has become part of a canon of Black feminist work exploring how Black breasts get taken up as signs of pathology, “excess flesh,” sexual deviance, hypersexuality, and alterity.3 From histories of the so-called Hottentot Venus and the preoccupation with her breasts, buttocks, and genitalia—including 1. bell hooks, “Selling Hot Pussy,” Black Looks: Race and Representation (Boston: South End Press, 1992), 61. 2. hooks, 61–62. 3. See Nicole R. Fleetwood, Troubling Vision: Performance, Visuality, and Blackness (Chicago: University of Chicago Press, 2010). Jennifer C. Nash 95 signature works by Zine Magubane, Janell Hobson, Samantha Pinto, and T. Denean Sharpley-Whiting4 —to scholarship on the construction of black women’s imagined corporeality as “social dead weight” by Sabrina Strings, Black feminists have given critical attention to the construction of Black breasts as the location of Black women’s imagined racial and sexual difference.5 If Black breasts have been culturally and scientifically constructed as deviant, excessive, pornographic, and desirous, they have largely been uncoupled from an identification with nutrition—from the capacity to sustain and feed babies—except their connection with wet nursing and their conscription into maternal labor for white children. In this imaginary, Black breasts provide nutrition only when recruited as white property, with their nurturance capacity oriented toward white health and futurity. We might understand the cultural inability to interpret Black breasts as nurturing Black life as part of what Andrea Freeman describes as the “unmothering” of Black women, the unseeing of Black maternity except to elevate it as a symbol of brokenness or pathology.6 But in recent years, as I argue in my forthcoming book Birthing Black Mothers, Black breasts have entered the US cultural imagination anew. Black breasts are increasingly viewed as in need of support through seemingly benign state interventions to encourage Black breastfeeding. Indeed, Black breasts are recruited by an array of actors who often find themselves strangely aligned to champion Black breastfeeding —including NGOs, public health campaigns, and reproductive justice efforts spearheaded by Black feminists—precisely because Black breastfeeding is thought to perform urgent political, emotional, and 4. See Zine Magubane, “Which Bodies Matter? Feminism, Poststructuralism, Race, and the Curious Theoretical Odyssey of the ‘Hottentot Venus,’” Gender & Society 15, no. 6 (2001): 816–834; Janell Hobson, Venus in the Dark: Blackness and Beauty in Popular Culture (New York: Routledge, 2005); Samantha Pinto, Infamous Bodies: Early Black Women’s Celebrity and the Afterlives of Rights (Durham, NC: Duke University Press, 2020); and T. Denean Sharpley-Whiting, Black Venus: Sexualized Savages, Primal Fears, and Primitive Narratives in French (Durham, NC: Duke University Press, 1999). 5. See Sabrina Strings, Fearing the Black Body: The Racial Origins of Fat Phobia (New York: NYU Press, 2019). 6. Andrea Freeman, “Unmothering Black Women: Formula Feeding as an Incident of Slavery,” Hastings Law Journal 69, no 1545 (2018): 1545–1606. 96 Jennifer C. Nash public health work. Black breastmilk is increasingly described as a crucial technology of Black life, one that supports Black infant life and inoculates it physically, psychically, and even spiritually against the array of anti-Black forces that wound and violate. The work that Black breast milk is thought to perform includes its posited... (shrink)

Bioethics has been in existence now for more than twenty years. Much has changed, however, since Van Rensselaer Potter2 first used the term bioethics in 1971. For Potter, bioethics was an applied science with its roots in the biological sciences and its orientation towards the betterment of human life. Today the concept is used in a different context. It has become the name given to the ethical research that has become necessary in light of the new possibilities created by revolutionary (...) developments in medical science. Generally speaking, bioethics is concerned with the beginning and the end of life. In a certain sense, however, this is merely a de facto definition which does not possess a great deal of internal logical consistency.If we attempt to reconstruct the incredibly rapid evolution of bioethics we quickly realize how the times were truly ripe for this new discipline to begin to mature. In a very short space of time bioethics was taken seriously in just about every University and medical centre the world over. There is no part of the world which has not organised a colloquium or developed a study programme or created a Centre for Biomedical Ethics. Yet this advance is hardly surprising if we consider the fact that there have been revolutionary developments in themedical world in the 1960’s which have made it necessary to engage in serious ethical reflection on the borderline questions of human life.From the start, bioethicists have concerned themselves primarily with ethical problems related to reproductive technology such as in vitro fertilization, medically assisted fertilization with donor gametes, pregnancy termination, and the status of the embryo. More recently, however, questions concerning the end of life have entered the bioethicist’s field of interest, e.g. ethical questions related to euthanasia and the problems surrounding the artificial nutrition and hydration of persistently vegetative patients. In the meantime, of course, bioethics has broadened its field of interest beyond questions related to the beginning and end of life. Serious ethical and juridical reflection has resulted from the problems surrounding organ transplantation, transplantation of brain tissue, and the problem of AIDS.With the many recent developments in genetics, the first applications of gene therapy, and the world-wide human genome research project bioethics is assured an exciting future. It is clear that the issues which grab the bioethicist’s attention are rather disparate. Moreover, we are now beginning to realize that a whole gamut of specific questions cannot be addressed unless the broader context of the ethics of health care in general is taken into account. Such a realization has led to something of a new movement within the bioethical sphere which is interested in widening the notion of ‘medical ethics’ or ‘ethics of health’.The purpose of this article is to help familiarize the reader with the world of bioethics. Such a task is both simple and complex; bioethics has become a house with many rooms, a house, furthermore, which is being constantly renovated and rebuilt. By way of introduction, we shall take an investigative and evaluative stroll through the broad landscape bioethics has traced in the first twenty years of its existence. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:FDA Releases Draft Guidance on Regulation of Genetically Engineered AnimalsJohn P. Gluck (bio) and Mark T. Holdsworth (bio)On 18 September 2008, the U.S. Food and Drug Administration (FDA) issued a draft set of guidelines for those involved in developing genetically engineered animals with heritable recombinant DNA (rDNA) constructs and is requesting comment from industry and the public about their content. The document does not impose new regulations but details (...) how existing laws and regulations apply to genetically engineered (GE) animals and offers advice to developers on how to negotiate the laws in the most efficient and productive manner. The draft guidance document is not legally enforceable at this juncture, but the guidelines are recommendations reflecting the FDA's "current thinking on a topic."The modification of GE animals being developed for commercialization, which are the focus of the document, fall into six categories: modifications intended to (1) enhance food quality—e.g., faster growing fish and meats with better nutritional profiles; (2) improve animal health via increased resistance to disease—e.g., mastitis in dairy cattle and Bovine Spongiform Encephalopathy (BSE); (3) create so-called "biopharm" animals capable of producing therapeutic products such as insulin, clotting factors, and tissues for human transplantation; (4) reduce the barriers to human animal interaction—e.g., hypoallergenic pets; (5) develop valid animal models of human disease—e.g., Parkinson's disease, Lesh-Nyhan's syndrome, and cancer; and (6) improve production of industrial or consumer products such as fiber. The timing of the guidelines coincides with the FDA's belief in an expected boon in the number of GE animals approaching the stage of commercialization.The FDA's involvement in the approval process emerges from the new animal drug provisions of the Federal Food Drug and Cosmetic Act and the definition of what constitutes a drug. The Act defines a new animal drug as "an article (other than food) intended to affect the structure or any function of the body of... animals." A rDNA construct intended to affect the structure or function of an animal meets the definition of a new animal drug, regardless of whether the resulting GE animals are intended for human food or the production of pharmaceuticals or any other substances. [End Page 393]Before proceeding to a review of the draft guidelines, it is important briefly to set the controversies around GE animals in historical and ethical context.The Ethical DebateFrom its inception, the intentional genetic modification or genetic engineering of molecules, plants, and animals by the techniques of gene splicing has consistently elicited strong responses from both the scientific community and the public. There are some data to suggest that although the concerns of scientists fall primarily into the category of possible biohazards, those of the public also reflect great concern about the intrinsic moral issues, such as whether there is something fundamentally wrong with this line of work, making it a form of forbidden knowledge (see, e.g., Gaskell 1997). When news of Paul Berg's attempts in 1970 to graft the primate tumor virus (SV 40) onto the intestinal tract bacteria Escherichia coli for the purpose of studying how normal cells may be transformed into cancerous cells was shared with colleagues, he was strongly encouraged to reflect on the potential public health risks if somehow the altered bacteria broke containment and entered the environment. Thanks to Berg's leadership, these concerns soon resulted in conferences held in Asilomar, California, and New Hampton, New Hampshire, where the ethical responsibilities of microbiologists involved in this research were discussed. These initial discussions resulted in what has come to be known as "The Moratorium Letter" (Shattuck 1996) published in the journal Science in 1974. This letter, signed by 11 leaders in the field, actually recommended restrictions on several types of experiments that were considered to be particularly risky and stated "that adherence to our major recommendations will entail postponement or possibly abandonment of certain types of scientifically worthwhile experiments" (Berg 1974). An international conference on the issues came to similar conclusions about the need for a research moratorium for the sake of public safety. Recommendations arising from conference participants led to the formation of the National Institutes... (shrink)

The idea of personalized nutrition is to give tailored dietary advice based on personal health-related data, i.e. phenotoype, genotype, or lifestyle. PN may be seen as part of a general trend towards personalised health care and currently various types of business models are already offering such services in the market. This paper explores ethical issues of PN by examining how PN services within the contextual environment of four future scenarios about health and nutrition in Europe might affect aspects (...) of social justice according to Martha Nussbaum’s capability approach. The scenarios have been created by a mixed group of stakeholders and experts in three consecutive workshops. This resulted in the definition of four future scenarios within a scenario space consisting of two variables: the ‘logic of health care systems’ and ‘conception of health’. Within each scenario, PN is likely to play a more or less important role in improving health by influencing food consumption patterns in society. Nussbaum’s capability approach implies a concept of social justice as a function of a minimum standard of human dignity. This denotes an account for equality in terms of a minimum of entitlements. However, also the ability of achieving individual objectives is essential for social justice. Personalisation advice in health and food consumption patterns, as aimed for by PN, is therefore acceptable provided a minimum of entitlements is guaranteed to all members of a society, and at the same time freedom concerning personal preferences is respected. Potential variation of how different people might benefit from PN should therefore be consistent with the minimum required as defined by the list of capabilities. (shrink)

The purpose of this paper is to assess Profet’s (1992) and others’ hypothesis that nausea and vomiting in pregnancy (NVP) is adaptive. A number of studies have found an association between NVP and a decreased risk for early fetal loss (<20 weeks). It is assumed that the adaptive benefits of improved survivorship associated with NVP outweigh the minimal nutritional consequences. However, in populations that experience marginal levels of nutrition, NVP may have important nutritional consequences. To test these potential consequences, (...) a study on NVP, nutritional status, and pregnancy outcome was conducted among Turkana pastoralists, who experience seasonal and chronic nutritional stress. Interviews and anthropometric assessments were conducted on 68 pregnant Turkana women of Kenya during a 1993–1994 field season. The results from the case study suggest that women who experience NVP do encounter nutritional consequences in the later stages of pregnancy and are more likely to experience poor pregnancy outcomes. These results suggest that NVP may not be adaptive in all environmental settings, particularly among marginally nourished populations. (shrink)

Confusion surrounds Catholic teaching on the use of assisted nutrition and hydration, specifically the question of when, if ever, its refusal or removal is ethical. This paper focuses on two often-neglected considerations: the relationship between means and mechanism, and an assessment of proportionality of the mechanism from the patient’s perspective. The authors draw on two critical principles of Catholic moral teaching: only ordinary means are required, and proportionality is subject to the perspective of the patient, not just that of (...) experts or the culture. The mechanisms that provide food and water have distinct benefits and burdens. Their proportionality is properly subject to analysis by the patient or surrogate, who determines which mechanism is acceptable in the patient’s situation. (shrink)

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

With recent guidance from the BMA and RCP on the withdrawal of nutrition from patients, and how the cause of death is being recorded (1), and the case of Vincent Lambert (2), the debate surrounding withdrawal of care and treatment has been rekindled in Catholic circles. In this article, I wish to highlight some of traditional principles that form the basis of such decision-making. I discuss these within the context of the withdrawal of nutrition and hydration (NaH), as (...) well as ventilation, to elucidate the key points. (shrink)

This collection of essays by some of the most prominent Catholic bioethicists addresses the Pope s statements, the moral issues surrounding artificial feeding and hydration, the refusal of treatment, and the ethics of care for those at the ...

This volume is a detailed study of the concept of the nutritive capacity of the soul and its actual manifestation in living bodies in Aristotle and Aristotelianism. Aristotle’s innovative analysis of the nutritive faculty has laid the intellectual foundation for the increasing appreciation of nutrition as a prerequisite for the maintenance of life and health that can be observed in the history of Greek thought. According to Aristotle, apart from nutrition, the nutritive part of the soul is also (...) responsible for or interacts with many other bodily functions or mechanisms, such as digestion, growth, reproduction, sleep, and the innate heat. After Aristotle, these concepts were used and further developed by a great number of Peripatetic philosophers, commentators on Aristotle and Arabic thinkers until early modern times. This volume is the first of its kind to provide an in-depth survey of the development of this rather philosophical concept from Aristotle to early modern thinkers. It is of key interest to scholars working on classical, medieval and early modern psycho-physiological accounts of living things, historians and philosophers of science, biologists with interests in the history of science, and, generally, students of the history of philosophy and science. (shrink)

Nutrition and hydration are common problems in advanced dementia. There has been growing opposition to the use of tube feeding in these patients both in and out of the Catholic Church. This article takes a critical look at current medical research on the subject and presents a vigorous defense of the use of artificial nutrition and hydration in dementia. A revealing case study is presented and a clear medical and ethical rationale are offered to support the appropriate use (...) of ANH in accord with Church teaching. National Catholic Bioethics Quarterly 9.4 (Winter 2009): 697–710. (shrink)

This article discuses the unexpectedly firm stance professed by John Paul II on the provision of artificial nutrition and hydration to patients who are in a persistent vegetative state, and its implications on previously held standards of judging medical treatments. The traditional ordinary/extraordinary care distinction is assessed in light of complexities of the recent allocution as well as its impact on Catholic individuals and in Catholic health care facilities. Shannon concludes that the papal allocution infers that the average Catholic (...) patient is incapable of making proper judgments about their own care. Shannon sees the preservation of life at all costs as at least highly troubling, if not as a radical move against the Catholic medical ethics tradition. (shrink)

Medical and non-medical experts increasingly argue that individuals, whether they are diagnosed with a specific chronic disease or condition or not (and whether they are judged at minimal risk of these consequences or not), have an obligation to make ‘healthy’ food choices. We argue that this obligation is neither scientifically nor ethically justified at the level of the individual. Our intent in the article is not simply to argue against moralization of the value of prudential uses of food for nutritional (...) health, but to situate nutritional advocacy in the context of Western liberal democracy that values free choice. We have two objectives: (i) to untangle and examine the substance of discourses on ‘healthy’ food choice that simplify nutrition science and place a moral obligation on individuals and (ii) to establish a more comprehensive view of the relationship among food, ethics and health. Although critical of certain features of the liberal political and moral tradition, we argue that John Stuart Mill’s notion of experiments in living provides fertile ground for an improved ethical understanding of individual obligation and of the interconnections among food, health and well-being. (shrink)

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration . This withdrawal is deemed necessary because patients in PDOC (...) can survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession. (shrink)

SummaryThe nutritional status of under-five children is a sensitive sign of a country's health status as well as economic condition. This study investigated the differential impact of some demographic, socioeconomic, environmental and health-related factors on the nutritional status among under-five children in Bangladesh using Bangladesh Demographic and Health Survey 2007 data. Two-level random intercept binary logistic regression models were used to identify the determinants of under-five malnutrition. The analyses revealed that 16% of the children were severely stunted and 25% were (...) moderately stunted. Among the children under five years of age 3% were severely wasted and 14% were moderately wasted. Furthermore, 11% of the children were severely underweight and 28% were moderately underweight. The main contributing factors for under-five malnutrition were found to be child's age, mother's education, father's education, father's occupation, family wealth index, currently breast-feeding, place of delivery and division. Significant community-level variations were found in the analyses. (shrink)

This article focuses on the troubling effects of the secular values of individual freedom and autonomy and their impact on laws regarding suicide and euthanasia. The author argues that in an increasingly secularized culture, death and dying are losing their meaning and are not thought of within a moral framework. The debate regarding the provision of artificial nutrition and hydration is critically considered in light of the history of Catholic morality as well as within the modern healthcare context, and (...) finally with new insight from the recent statements made by the late pope. Drane argues that the pope's insistence on providing artificial nutrition and hydration despite irreversible persistent vegetatitive states is unconvincing. (shrink)

A survey was carried out on 108 Chilean children and a selection of their families. The factors studied were: (1) social, (2) demographic and dietaryto assess the incidence and degree of malnutrition and (4) haematology—to determine the incidence of anaemia.

This cross sectional study was carried out among the workers of British American Tobacco Company, Dhaka with a view to explore their nutritional status, personal hygiene and health seeking behavior as because they are working on a tobacco processing company. The sample size was 179 which were selected purposively. The study showed that out of 179 respondents 89 (49.7%) were in the age groups of 30-39 years and the mean age of the respondents were 31.99 ± 6.01 years. A large (...) number of respondents (55.9%) had monthly family income of Taka 10001-20000 and the mean family income was Taka 12776.54 ± 5230.13. Maximum respondents (73.7%) were Muslim, more than half (54.2%) were shift in charge, 39.1% of the respondents consisted of 4 family members, 43.6% respondents were accustomed to other type of eating habit and 38.5% respondents knew that malnutrition was the effect of lack of proper nutrition, 59.8% of the respondents knew that night blindness was the disease due to malnutrition, most of the respondents (91.6%) performed duties to maintain health, majority (62.0%) respondents used to do nothing to maintain healthcare for their children and 35.9% visited doctor’s single time in a month, 40.2% of the respondents told regular tooth brushing as type of healthy habits. Majority (64.8%) respondents used to brush twice a day, majority (50.8%) respondents used to wash hand after toileting, majority (62.08%) respondents used to bath daily, 43.0% and 31.8% of the respondents told that dysentery and diarrhea was due to eating without proper hand washing respectively. Majority (53.6%) respondents informed that they learned about personal hygiene from television, 45.8% respondents understood that use of safe water in every work as sanitation. Majority (50.84%) came from nuclear family; most (84.92%) had exercise habit and 40.22% had education level of class VIII. Most (75.42%) of the respondents had semi pucca houses and majority (69.83%) of the respondents used only water as materials for hand washing. This study provided some important information which might help the concerned authority to take appropriate measures to improve the health status of the workers. (shrink)

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

Oliver O'Donovan's Ethics as Theology project began withSelf, World, and Time, an "induction" into Christian ethics as ordered reflection on moral thinking within the life of faith. Volume 2, Finding and Seeking, shifted the focus to the movement of moral thought from a first consciousness of agency to the time that determines the moment of decision. In this third and final volume of his magnum opus, O'Donovan turns his attention to the forward horizon with which moral thinking must engage. Moral (...) experience, he argues, is necessarily two-directional, looking both back at responsibility and forward at aims. The Pauline triad of theological virtues (faith, love, and hope) describes a form of responsibility, and its climax in the sovereignty of love opens the way to a definitive teleology. Entering into Restoffers O'Donovan's mature reflections on questions that have engaged him throughout his career and provides a synoptic view of many of his main themes.". (shrink)

New Natural Law Theory and the Catholic medico-moral tradition often lead to similar conclusions in hard cases regarding end-of-life care. Considering the provision of artificial nutrition and hydration to patients suffering from post-coma unresponsive wakefulness, however, brings to light subtle ways in which NNL differs from the centuries-old natural law tradition. In this essay, I formalize the methodology embedded within the casuistry of the medico-moral tradition and show how it differs from NNL with respect to the role played by (...) double-effect reasoning and the perspective for analyzing cases regarding care for those who cannot speak for themselves. Importantly, the ordinary/extraordinary means distinction has never historically been understood as an application of double effect and logically cannot be so understood. Given the outsized role that double effect plays in NNL, the theory leads to conclusions that deviate from the Catholic medico-moral tradition and creates additional burdens and duties for the sick. (shrink)

Nutrition and hydration—including artificially delivered, or assisted, nutrition and hydration (ANH)—are typically considered ordinary or proportionate care in the Roman Catholic moral tradition. They are thus morally obligatory, except when the benefit to the patient does not justify the burden their administration places on the patient or when they no longer prolong life (e.g., in end-stage disease when death is imminent). A review of Church documents and the medical literature provides convincing evidence that there are cases in which (...) ANH provides little hope of benefit and may impose an excessive burden on the patient. This paper closely examines advanced dementia of the Alzheimer’s (DAT) type and shows how ANH can be properly considered extraordinary care and hence is not obligatory in patients with advanced DAT. National Catholic Bioethics Quarterly 8.2 (Summer 2008): 291–305. (shrink)

Objectives To examine the frequency and characteristics of decisions to forgo artificial nutrition and/or hydration at the end of life.Design Postal questionnaire survey regarding end-of-life decisions to physicians certifying a large representative sample of Belgian death certificates in 2007.Setting Flanders, Belgium, 2007.Participants Treating physicians of deceased patients.Results Response rate was 58.4%. A decision to forgo ANH occurred in 6.6% of all deaths . Being female, dying in a care home or hospital and suffering from nervous system diseases or malignancies (...) were the most important patient-related factors positively associated with a decision to forgo ANH. Physicians indicated that the decision to forgo ANH had had some life-shortening effects in 77% of cases. There had been no consultation with the patient in 81%, mostly due to incapacity . The family, colleague physicians and nurses were involved in decision making in 76%, 41% and 62%, respectively.Conclusions A substantial number of deaths are preceded by a decision to forgo ANH in Belgium. These decisions, ethically laden and involving a considerable chance of life shortening, are mostly not preceded by discussion with the patient despite existing patient rights legislation. It is recommended that physicians and patients and their families alike dedicate ample time to the discussion of treatment options and communication about the possibility of forgoing ANH and that this discussion takes place earlier as part of overall end-of-life care planning rather than at the very end of life. (shrink)

This paper argues that focusing on Aristotle’s theory of generation as primarily ‘hylomorphic’ can lead to difficulties. This is especially evident when interpreting the association between the male and sentient soul at GA 2.5. If the focus is on the male’s contribution as form and the female’s as matter, then soul becomes divided into nutritive from female and sentient from male which makes little sense in Aristotle’s biological ontology. In contrast, by seeing Aristotle’s theory as ‘archēkinētic’, a process initiated by (...) the male, the development of nutritive and sentient capacities emerges as intertwined, neither capacity originating in only one sex. (shrink)

Starting with some illustrative examples, I develop a systematic account of a specific type of experimentation--an experimentation which is not, as in the "standard view", driven by specific theories. It is typically practiced in periods in which no theory or--even more fundamentally--no conceptual framework is readily available. I call it exploratory experimentation and I explicate its systematic guidelines. From the historical examples I argue furthermore that exploratory experimentation may have an immense, but hitherto widely neglected, epistemic significance.

As a direct consequence of the sophisticated arrangement of its intrinsic neurons, the gastrointestinal tract is unique among peripheral organs, in its ability to mediate its own reflexes. Neurons of the enteric nervous system are intimately associated with enteric glial cells. These supporting cells do not resemble Schwann cells, the glial cell found in all other parts of the peripheral nervous system, but share many similarities with astrocytes of the central nervous system. Ablation of enteric glial cells in adult transgenic (...) mice has demonstrated that these cells are essential to maintain the integrity of the small intestine. Acute loss of enteric glial cells induces massive pathological changes with similarities to necrotizing enterocolitis (NEC) and early Crohn's disease. These human conditions share some mechanistic similarities. Identification of enteric glial cell dysfunction/loss as sufficient to induce necrotic/inflammatory bowel disease may be important to understand the pathogenesis of both NEC and Crohn's disease. BioEssays 24:130–140, 2002. © 2002 Wiley Periodicals, Inc. (shrink)

Nutrition and hydration—including artificially delivered, or assisted, nutrition and hydration (ANH)—are typically considered ordinary or proportionate care in the Roman Catholic moral tradition. They are thus morally obligatory, except when the benefit to the patient does not justify the burden their administration places on the patient or when they no longer prolong life (e.g., in end-stage disease when death is imminent). A review of Church documents and the medical literature provides convincing evidence that there are cases in which (...) ANH provides little hope of benefit and may impose an excessive burden on the patient. This paper closely examines advanced dementia of the Alzheimer’s (DAT) type and shows how ANH can be properly considered extraordinary care and hence is not obligatory in patients with advanced DAT. National Catholic Bioethics Quarterly 8.2 (Summer 2008): 291–305. (shrink)