Observations with respect to the relationship between symptoms and diseases can seriously be biased by selection phenomena. This selection may occur from the general population, via consultation behavior, diagnostic and therapeutic activities of the general practitioner, and by referral.Relationships may be suggested and reproduced even if they do not exist in unselected populations, as a product of diagnostic routines. Correction for selection bias can only be achieved by choosing proper comparison groups. While this can be done in a general practice (...) setting, this is almost impossible after referral, as is demonstrated in this paper. Surprisingly, the most unbiased estimation of the relationship between symptoms and diseases after referral can be made from patient groups that are referred for reason unrelated to the disease under study. (shrink)

We have compelling extra-philosophical reasons for caring about identity, parthood, and location. For example, we desire ceteris paribus that nothing every part of which is very near to our location be very near to the location of something dangerous, evil, or otherwise unpleasant. This essay argues that such considerations are relevant to certain first-order metaphysical debates, namely, the debates over immanent universals and tropes and endurantism and perdurantism, respectively. As a consequence, even the non-specialist has a reason to (...) class='Hi'>care about the metaphysics of properties and persistence. (shrink)

Law’s processes are likely always to be needed when particularly intractable conflicts arise in relation to the care of a critically ill child like Charlie Gard. Recourse to law has its merits, but it also imposes costs, and the courts’ decisions about the best interests of such children appear to suffer from uncertainty, unpredictability and insufficiency. The insufficiency arises from the courts’ apparent reluctance to enter into the ethical dimensions of such cases. Presuming that such reflection is warranted, this (...) article explores alternatives to the courts, and in particular the merits of specialist ethics support services, which appear to be on the rise in the UK. Such specialist services show promise, as they are less formal and adversarial than the courts and they appear capable of offering expert ethical advice. However, further research is needed into such services – and into generalist ethics support services – in order to gauge whether this is indeed a promising development. (shrink)

The aim of this study was to describe specialist ambulance nurse students’ experiences of ethical conflicts and dilemmas in prehospital emergency care. In the autumn of 2015, after participating in a mandatory lecture on ethics, 24 specialist ambulance nurse students reported experiences and interpretations concerning conflicts and ethical dilemmas from prehospital emergency care. The text consisted of 24 written critical incidents which were interpreted using hermeneutic text interpretation. The text revealed three themes: Not safeguarding a patient’s (...) body and identity; Not agreeing on the care actions; and Not treating the patient with dignity. The SANs experiences ethical dilemmas and conflict of values when they witness how others violate a patient’s dignity. Discussion and reflection is based on ethical conflicts and dilemmas experienced when students see how caregivers do not safeguard the patient’s body or identity. When caregivers have a conflicting will, it results in patients not being treated in an ethical manner. Also, seeing how caregivers put themselves in a power position over patients is described as an ethical dilemma that students experience when they choose not to intervene. (shrink)

Where modern medicine has been criticised for having lost sight of the individual on account of its biomedical focus, the profile of narrative in medicine has gained prominence. Within any medical encounter it is possible to identify the existence of several narratives. The aim of this article is to demonstrate this characteristic within the context of specialist palliative care. The emphasis is to see how an awareness of these narratives might improve upon how we attend to the suffering (...) of dying patients. A narrative approach to this work could also help doctors and other healthcare professionals find meaning and understanding in themselves while working in an environment of death and dying. This can expose many challenging personal dimensions that demand reflection, possibly through narrative. The nature of the narratives identified is such that they can weave together and interlink into a greater whole to achieve a much wider set of meanings and shared understandings. However, they can exist in a fragmented state, in which ambiguity, uncertainty and incoherence are sustained. The effect of this should be to encourage us to engage in a more active process of finding meaning, and certainly to recognise that there could be more than one reading or interpretation. (shrink)

Reasoning and judgement in health care entail complex responses to problems whose demands typically derive from several areas of specialism at once. We argue that current evidence- or value-based models of health care reasoning, despite their virtues, are insufficient to account for responses to such problems exhaustively. At the same time, we offer reasons for contending that health professionals in fact engage in forms of reasoning of a kind described for millennia under the concept of wisdom. Wisdom traditions (...) refer to forms of deliberation which combine knowledge, reflection and life experience with social, emotional and ethical capacities. Wisdom is key in dealing with problems which are vital to human affairs but lack prescribed solutions. Uncertainty and fluidity must be tolerated in seeking to resolve them. We illustrate the application of wisdom using cases in psychiatry, where non-technical aspects of problems are often prominent and require more systematic analysis than conventional approaches offer, but we argue that our thesis applies throughout the health care field. We argue for the relevance of a threefold model of reasoning to modern health care situations in which multifaceted teamwork and complex settings demand wise judgement. A model based on practical wisdom highlights a triadic process with features activating capacities of the self, other and aspects of the problem itself. Such a framework could be used to develop current approaches to health care based on case review and experiential learning. (shrink)

The health care systems are fairly similar in theScandinavian countries. The exact details vary, but inall three countries the system is almost exclusivelypublicly funded through taxation, and most hospitals are also publicly owned and managed. Thecountries also have a fairly strong primary caresector,with family physicians to various degrees acting asgatekeepers to specialist services. In Denmark most ofthe GP services are free. For the patient in Norwayand Sweden there are out-of-pocket co-payments for GPconsultations, with upper limits, but consultations forchildren (...) are free. Hospital treatment is free inDenmark while the other countries use a system without-of-pocket co-payment. There is a very strongpublic commitment to access to high quality healthcare for all. Solidarity and equality form theideological basis for the Scandinavian welfare state.Means testing, for instance, has been widely rejectedin the Scandinavian countries on the grounds thatpublic services should not stigmatise any particulargroup. Solidarity also means devoting specialconsideration to the needs of those who have lesschance than others of making their voices heard orexercising their rights. Issues of limited access arenow, however, challenging the thinking about a healthcare system based on solidarity. (shrink)

Background: Although attention to healthcare ethics in rural areas has increased, specific focus on rural palliative care is still largely under-studied and under-theorized. The purpose of this study was to gain a deeper understanding of the values informing good palliative care from rural individuals' perspectives. Methods: We conducted a qualitative ethnographic study in four rural communities in Western Canada. Each community had a population of 10, 000 or less and was located at least a three hour travelling distance (...) by car from a specialist palliative care treatment centre. Data were collected over a 2-year period and included 95 interviews, 51 days of field work and 74 hours of direct participant observation where the researchers accompanied rural healthcare providers. Data were analyzed inductively to identify the most prevalent thematic values, and then coded using NVivo. Results: This study illuminated the core values of knowing and being known, being present and available, and community and mutuality that provide the foundation for ethically good rural palliative care. These values were congruent across the study communities and across the stakeholders involved in rural palliative care. Although these were highly prized values, each came with a corresponding ethical tension. Being known often resulted in a loss of privacy. Being available and present created a high degree of expectation and potential caregiver strain. The values of community and mutuality created entitlement issues, presenting daunting challenges for coordinated change. Conclusions: The values identified in this study offer the opportunity to better understand common ethical tensions that arise in rural healthcare and key differences between rural and urban palliative care. In particular, these values shed light on problematic health system and health policy changes. When initiatives violate deeply held values and hard won rural capacity to address the needs of their dying members is undermined, there are long lasting negative consequences. The social fabric of rural life is frayed. These findings offer one way to re-conceptualize healthcare decision making through consideration of critical values to support ethically good palliative care in rural settings. (shrink)

This essay describes how longstanding conceptions of professionalism in American medical care came under attack in the decades since the enactment of Medicare in 1965 and how the reform strategy and core provisions of the 2010 Affordable Care Act illustrate the weakening of those ideas and the institutional practices embodying them.The opening identifies the dominant role of physicians in American medical care in the two decades after World War II. By the time Medicare was enacted in 1965, (...) associations of American physicians were almost completely in charge of medical education, specialist certification, and the enforcement of professional norms on their members. Who could be a doctor, what education and training would be required, and what collegial oversight was operative was first a professional matter and only secondly implicated the state through malpractice or major corporations via the employment of physicians. (shrink)

Background: Ethics and dignity in prehospital emergency care are important due to vulnerability and suffering. Patients can lose control of their body and encounter unfamiliar faces in an emergency situation. Objective: To describe what specialist ambulance nurse students experienced as preserved and humiliated dignity in prehospital emergency care. Research design: The study had a qualitative approach. Method: Data were collected by Flanagan’s critical incident technique. The participants were 26 specialist ambulance nurse students who described two critical (...) incidents of preserved and humiliated dignity, from prehospital emergency care. Data consist of 52 critical incidents and were analyzed with interpretive content analysis. Ethical considerations: The study followed the ethical principles in accordance with the Declaration of Helsinki. Findings: The result showed how human dignity in prehospital emergency care can be preserved by the ambulance nurse being there for the patient. The ambulance nurses meet the patient in the patient’s world and make professional decisions. The ambulance nurse respects the patient’s will and protects the patient’s body from the gaze of others. Humiliated dignity was described through the ambulance nurse abandoning the patient and by healthcare professionals failing, disrespecting, and ignoring the patient. Discussion: It is a unique situation when a nurse meets a patient face to face in a critical life or death moment. The discussion describes courage and the ethical vision to see another human. Conclusion: Dignity was preserved when the ambulance nurse showed respect and protected the patient in prehospital emergency care. The ambulance nurse students’ ethical obligation results in the courage to see when a patient’s dignity is in jeopardy of being humiliated. Humiliated dignity occurs when patients are ignored and left unprotected. This ethical dilemma affects the ambulance nurse students badly due to the fact that the morals and attitudes of ambulance nurses are reflected in their actions toward the patient. (shrink)

Eight focus groups were conducted in four public hospitals in Madrid to explore healthcare professionals’ perceptions of advance directives in order to improve the understanding of their lack of success among physicians and patients. A purposive sample of sixty healthcare professionals discussed ADs and reasons for their infrequent use. Three main themes were identified: perceptions about their meaning, appraisals of their use in clinical practice, and decision-making about them. Healthcare professionals perceived a lack of clarity about their definition and implementation. (...) There is insufficient awareness of their efficacy in improving the quality of clinical relationships and decision-making, and they are often perceived only as a bureaucratic procedure. Advance directives are not integrated in the clinical practice of Madrid’s healthcare specialist services because their application is exceedingly complex, because of insufficient education about them, and because of lack of procedural clarity. Consequently, healthcare professionals are not aware of how ADs could improve clinical decision-making, of when and for whom their use is appropriate, and of who has responsibility for providing ADs-related information to patients. These circumstances contribute to patients’ lack of interest in completing these documents and to physicians’ sceptical views about their usefulness. (shrink)

Recent health legislation in Norway significantly increases access to specialist care within a legally binding time frame. The paper describes the contents of the new legislation and introduces some of the challenges with proliferations of rights to health care. The paper describes some of the challenges associated with the proliferation of legal rights to health care. It explains the benefits of assessing the new law in the light of a rights framework. It then analyses the problematic (...) aspects of establishing additional priority rules as solutions to rights conflicts. It then defends adequacy criteria for acceptable priority rules when such rules are unavoidable. It finally defends our proposed method and explores concrete applications. (shrink)

In all systems of health care there are certain essential levels of care and service. These take the form of self-care within the family unit; primary professional care by general medical nursing or social practitioners within a local neighbourhood; general specialist care in a district and super-specialist care in a region. Each of these has its own special roles and responsibilities and each is considered in this paper.

Cultural Consultation is a clinical process that emerged from anthropological critiques of mental healthcare. It includes attention to therapeutic communication, research observations and research methods that capture cultural practices and narratives in mental healthcare. This essay describes the work of a Cultural Consultation Service (ToCCS) that improves service user outcomes by offering cultural consultation to mental health practitioners. The setting is a psychiatric service with complex and challenging work located in an ethnically diverse inner city urban area. Following a period (...) of 18 months of cultural consultation, we gather the dominant narratives that emerged during our evaluation of our service. Results: These narratives highlight how culture is conceptualized and acted upon in the day-to-day practices of individual health and social care professionals, specialist psychiatric teams and in care systems. The findings reveal common narratives and themes about culture, ethnicity, race and their perceived place and meaningfulness in clinical care. These narratives express underlying assumptions and covert rules for managing, and sometimes negating, dilemmas and difficulties when considering “culture” in the presentation and expression of mental distress. The narratives reveal an overall “culture of understanding cultural issues” and specific “cultures of care”. These emerged as necessary foci of intervention to improve service user outcomes. Conclusion: Understanding the cultures of care showed that clinical and managerial over-structuring of care prioritises organisational proficiency, but it leads to inflexibility. Consequently, the care provided is less personalised and less accommodating of cultural issues, therefore, professionals are unable to see or consider cultural influences in recovery. (shrink)

Background: Although attention to healthcare ethics in rural areas has increased, specific focus on rural palliative care is still largely under-studied and under-theorized. The purpose of this study was to gain a deeper understanding of the values informing good palliative care from rural individuals' perspectives. Methods: We conducted a qualitative ethnographic study in four rural communities in Western Canada. Each community had a population of 10, 000 or less and was located at least a three hour travelling distance (...) by car from a specialist palliative care treatment centre. Data were collected over a 2-year period and included 95 interviews, 51 days of field work and 74 hours of direct participant observation where the researchers accompanied rural healthcare providers. Data were analyzed inductively to identify the most prevalent thematic values, and then coded using NVivo. Results: This study illuminated the core values of knowing and being known, being present and available, and community and mutuality that provide the foundation for ethically good rural palliative care. These values were congruent across the study communities and across the stakeholders involved in rural palliative care. Although these were highly prized values, each came with a corresponding ethical tension. Being known often resulted in a loss of privacy. Being available and present created a high degree of expectation and potential caregiver strain. The values of community and mutuality created entitlement issues, presenting daunting challenges for coordinated change. Conclusions: The values identified in this study offer the opportunity to better understand common ethical tensions that arise in rural healthcare and key differences between rural and urban palliative care. In particular, these values shed light on problematic health system and health policy changes. When initiatives violate deeply held values and hard won rural capacity to address the needs of their dying members is undermined, there are long lasting negative consequences. The social fabric of rural life is frayed. These findings offer one way to re-conceptualize healthcare decision making through consideration of critical values to support ethically good palliative care in rural settings. (shrink)

Despite its invasive nature, specific consent for general anaesthesia is rarely sought—rather consent processes for associated procedures include explanation of risk/benefits. In adult intensive care, because no one can consent to treatments provided to incapacitated adults, standardised consent processes have not developed. In paediatric intensive care, despite the ready availability of those who can provide consent, no tradition of seeking it exists, arguably due to the specialty’s evolution from anaesthesia and adult intensive care. With the current Montgomery-related (...) focus on consent, this seems untenable. We undertook a qualitative study in a specialist children’s hospital colocated paediatric/neonatal intensive care in which parental acceptance of admission and entailed procedures is considered implied by virtue of that admission. Semistructured interviews were carried out with both staff and parents to investigate their views about consent, the current system and a proposed blanket consent system, in which parents actively consent at admission to routine procedures. Divergent views emerged: staff were worried that requiring consent at admission might prove a further emotional burden, whereas parents found providing consent a way of coping, feeling empowered and maintaining control. Inconsistencies were found in the way consent is obtained for your routine procedures. Practice does seem inconsistent with contemporary consent standards for medical intervention. Our findings support the introduction of a blanket consent system at admission together with ongoing bedside dialogue to ensure continuing consent. Both parents and staff expressed concern about avoiding possible harmful delays to children due to parental emotional overload and language difficulties. (shrink)

This debate article explores how smart technologies may create a double-edged sword for patient safety and effective therapeutic relationships. Increasing utilization of health monitoring devices by patients will likely become an important aspect of self-care and preventive medicine. It may also help to enhance accurate symptom reports, diagnoses, and prompt referral to specialist care where appropriate. However, the development, marketing, and use of such technology raise significant ethical implications for therapeutic relationships and patient safety. Drawing on lessons (...) learned from other direct-to-consumer health products such as genetic testing, this article explores how smart technology can also pose regulatory challenges and encourage overutilization of healthcare services. In order for smart technology to promote safer care and effective therapeutic encounters, the technology and its utilization must be safe. This article argues for unified regulatory guidelines and better education for both healthcare providers and patients regarding the benefits and risks of these devices. (shrink)

Paediatric cancer care poses ethically difficult situations that can lead to value conflicts about what is best for the child, possibly resulting in moral distress. Research on moral distress is lacking in paediatric cancer care in Sweden and most questionnaires are developed in English. The Moral Distress Scale-Revised is a questionnaire that measures moral distress in specific situations; respondents are asked to indicate both the frequency and the level of disturbance when the situation arises. The aims of this (...) study were to translate and culturally adapt the questionnaire to the context of Swedish paediatric cancer care. In doing so we endeavoured to keep the content in the Swedish version as equivalent to the original as possible but to introduce modifications that improve the functional level and increase respondent satisfaction. The procedure included linguistic translation and cultural adaptation of MDS-R’s paediatric versions for Physicians, Nurses and Other Healthcare Providers to the context of Swedish paediatric cancer care. The process of adjustment included: preparation, translation procedure and respondent validation. The latter included focus group and cognitive interviews with healthcare professionals in paediatric cancer care. To achieve a Swedish version with a good functional level and high trustworthiness, some adjustments were made concerning design, language, cultural matters and content. Cognitive interviews revealed problems with stating the level of disturbance hypothetically and items with negations caused even more problems, after having stated that the situation never happens. Translation and cultural adaptation require the involvement of various types of specialist. It is difficult to combine the intention to keep the content as equivalent to the original as possible with the need for modifications that improve the functional level and increase respondent satisfaction. The translated and culturally adapted Swedish MDS-R seems to have equivalent content as well as improved functional level and respondent satisfaction. The adjustments were made to fit paediatric cancer care but it could be argued that the changes are relevant for most areas of paediatric care of seriously ill patients. (shrink)

Ethical difficulties arise in health-care practices. However, despite extensive research findings that demonstrate that most nurses are involved in recurrent ethical problems, institutions are not always able to effectively support nursing care professionals. The limited availability of ethics consultation services and traditional nursing training fails to meet the frequent and strong requests by health workers to support their ethical dilemmas. A questionnaire was administered to 374 nurses attending a specialist training and a lifetime learning programme in Italy. (...) The respondents reported a high frequency of ethically sensitive situations, and they described the poor development of ethics support and a scarcity of ethics training programmes. The results suggest the importance of promoting ethics services that include consultation and ethics training. A need for systematic ethics educational activities was identified for improving the capacity of nurses to manage ethical issues in patient care. (shrink)

Following the introduction of do-not-resuscitate orders in the 1970s, there was widespread misinterpretation of the term among healthcare professionals. In this brief report, we present findings from a survey of healthcare professionals. Our aim was to examine current understanding of the term do-not-attempt-resuscitate, decision-making surrounding DNAR and awareness of current guidelines. The survey was distributed to doctors and nurses in a university teaching hospital and affiliated primary care physicians in Dublin via email and by hard copy at educational meetings (...) from July to December 2014. A total of 519 completed the survey. The response rate in the hospital doctors group was 35.5%, 19.8% in the nurses group but 68.8% in the specialist nurses group and 40% in the primary care physician group.Alarmingly, our results demonstrate that 26.8% of staff nurses and 30% of primary care physicians surveyed believed that a patient with a DNAR order could not receive any/at least one of a list of simple treatments including antibiotics, physiotherapy, intravenous fluids, pain relief, oxygen, nasogastric feeding or airway suctioning, which were higher percentages compared to the other hospital doctors and experienced nurses groups with statistically significant differences. Furthermore, a higher percentage of staff nurses and primary care physicians believed that a patient with a DNAR order could not be referred to hospital from home/a nursing home, when compared with other healthcare groups. Our findings highlight continued misunderstanding and over-interpretation of DNAR orders. Further collaboration and information is required for meaningful Advance Care Plans. (shrink)

Medical futility, one of the most debated end-of-life issues in medical ethics, has been discussed among physicians and scholars for years but remained an unresolved question. Roger C. Bone (1941–1997), an outstanding pulmonologist and critical care specialist, devoted his last years to ethical issues of terminal care, while facing himself metastatic renal cancer. Criticising the abuse of technology in terminal care and the administrative and financial interference on medical decisions, he bequeathed important points on futility, bringing (...) also patients’ views into attention. He stressed the importance of physician-patient relationship and prompted physicians to remain honest with their patients and stand with them till their very last moments. Roger Bone’s insight of futility, terminal care and physician-patient relationship remains an important legacy for health care professionals and for families and patients facing end-of-life issues. (shrink)

This article considers the development of nurse-led services as a part of a pilot study and explores the therapeutic nature of the role of the nurse. In particular it suggests a need for reconsideration of the fundamental values of nurse-led care in the context of changing organizational culture. Within the UK there has been pressure from policy makers to extend the role of the specialist nurse and create new nursing roles, shifting the boundaries between professional health groups. The (...) philosophy of nurse-led initiatives has therefore been driven mainly from a service redesign and clinical need standpoint rather than necessarily focusing on enhancing patients’ experience and the changes in organizational culture required to achieve this. While several studies have focused on the safety, comparative cost and comparative patient outcomes in nurse-led care in relation to traditional or doctor-led care, little attention has been given to the changing organizational values underlying the nursing role. Exploring this context is essential if new nursing roles are to provide more than relief for bottlenecks in the system and also meet their potential for providing patient centred and innovative models of care. (shrink)

Japan has one of the highest numbers of high-cost medical devices installed relative to its population. While evaluations of the distribution of these devices traditionally involve simple population-based assessments, an indicator that includes the demand of these devices would more accurately reflect the situation. The purpose of this study was to develop an indicator of the supply–demand balance of such devices, using examples of magnetic resonance imaging scanners (MRI) and extracorporeal shockwave lithotripters (ESWL), and to investigate the relationship between this (...) indicator, personnel distribution statuses and operating statuses at the prefectural level. -/- Using data from nation-wide surveys and claims data from 16 hospitals, we developed an indicator based on the ratio of the supplied number of device units to the number of device units in demand for MRI and ESWL. The latter value was based on patient volume and utilization proportion. Correlation analyses were conducted between the supply–demand balances of these devices, personal distribution and operating statuses. -/- Comparisons between our indicator and conventional population-based indicators revealed that 15% and 30% of prefectures were at risk of underestimating the availability of MRI and ESWL, respectively. The numbers of specialist personnel/device units showed significant, negative correlations with our indicators in both devices. -/- Utilization-based analyses of health care resource placement and utilization status provide a more accurate indication than simple population-based assessments, and can assist decision makers in reviewing gaps between health policy and management. Such an indicator therefore has the potential to be a tool in helping to improve the efficiency of the allocation and placement of such devices. (shrink)

Human rights are a central part of a social worker's value base in contemporary practice, but the structures by which social work services are delivered can adversely affect practitioners? abilities to uphold service user rights. This article describes the organizational development of social work services in England and the evolution of a rights focus for the practice of social work. It uses two cases, participation by children and young people looked after by the local authority and parents with learning difficulties, (...) to determine what prevents the delivery of rights at practice level. We argue that the structures which are the product of historical development prevent workers delivering a service that is anti-oppressive and grounded in a rights-based approach to practice. This suggests that the recent changed arrangements for the delivery of social work offer the opportunity to address human rights within practice and reinvigorate the profession. The division of the profession between children's trusts and adult social services within separate local authority departments or care trusts should make dialogue between specialist social workers, which has been suppressed by internal structures, possible. Such a dialogue could contribute to saving the profession from the disintegration that its division threatens, while advancing the human rights agenda. (shrink)

In the absence of a well articulated conceptual framework for nursing ethics, this article argues for a theory of applied ethics - casuistics - used within a clinical reasoning model, to analyse the complicated issues presented in three cases involving adolescents receiving treatment for abuse through a rural alternative learning centre. The clinical nurse specialist, as an independent practitioner within the community, is presented with many ethical challenges arising from cultural diversity. The inherent independent nature of such practice environments (...) combined with the pluralism which exists in today's multicultural society demands that professional nurses working in these circumstances develop and utilize an ethical framework for the analysis of patient care in situations that involve moral conflict. (shrink)

In September 2004 a local authority council commissioned the University of Dundee to undertake a small evaluation of a pilot social work post set up in 2003 and located in the palliative care team of the local Health Trust. The evaluation was to enable decisions to be made regarding the continuation and establishment of this specialist post into the financial year beginning 2005 and beyond. The university was asked to consult clients of the social worker, their relatives and (...) relatives of clients who had died, and the staff in the palliative care team as well as staff in the Adult and Older People's Services of the local authority. The evaluation was eventually completed in March 2006 but the expected date of completion by the local authority had been March 2005. The delay was caused almost entirely by the impact of the National Health Service (NHS) research ethics process. (shrink)

This is a practical introduction to the range of ethical questions which doctors and other health-care professionals may be expected to encounter in practice. The books covers both the traditional "end of life" issues and also deals with medical research and consent issues, confidentiality and AIDS, resource allocation, care of the mentally ill, and the doctor/patient relationship. Each chapter canvasses a range of ethical views, drawing both from traditional philosophical responses and the most recent contemporary responses. Theoretical discussion (...) is extended and enlivened by the use of hypothetical and actual examples, suitable both for private study or group discussion. While the needs of medical students for a non-technical guide to ethics have been kept firmly in mind, the clarity of writing and avoidance of specialist medical and philosophical terminology ensure that it will be of value to students of nursing and related disciplines, and accessible to the lay reader. (shrink)

In few other areas of bioethical inquiry exists as close a connection between bioethical professional advice and policy development as is the case with HIV and AIDS. Historically, the reasons for this have much to do with one of the groups initially affected most severely by HIV and AIDS, namely well-educated middle-class gay men in developed countries. This particular group of people, highly sophisticated and used to political activism in its pursuit of civil rights-related objectives, engaged the medical profession as (...) well as regulatory agencies such as the US Food and Drug Administration, and legislators (more so in the USA than in other countries) in a number of bioethically interesting policy areas. Many of the controversies of the times were framed as civil rights and/or ethical disputes. The initial areas of concern and inquiry focused on: informed consent to HIV testing and trial participation, the confidentiality of HIV test results, access to trials as a means of access to experimental drugs, the length of time it took to get an experimental drug to the market approval stage, and end-of-life decision-making. This line-up of issues explains why AIDS has become such an interesting topic for bioethicists. Bioethicists concerned about the traditional breadand- butter themes of medical ethics themes of the doctor - patient relationship (e.g., Daniels, 1991; Boyd, 1992), as well as bioethicists more concerned about policy and regulatory issues in the drug research and approval process (e.g., Edgar & Rothman, 1990; Salisbury & Schechter, 1990), found research topics worthy of vigorous pursuit. No surprise, then, that HIV/AIDS led to a probably unprecedented number of books and articles in professional journals (Manuel et al., 1990). HIV/AIDS has become a permanent fixture in all major mainstream bioethics textbooks (e.g., Kuhse & Singer, 1998; Arras & Steinbock, 1999). Reference series in medicine, ethics and law provide for dedicated volumes on AIDS.1 Even specialist bioethics textbooks, for instance those directed at dentistry students, carry chapters on HIV/AIDS (Ozar & Sokol, 2002). 128 Udo Schuklenk AIDS, designated by the medical profession a pandemic lives up to its classification. It did not stop at the borders of developed countries. As one would expect of a primarily sexually transmitted illness in the age of globalisation, it spread rapidly across the globe. Indeed, in many countries it has become one of the main causes of death, as in sub- Saharan Africa (Shisana & Simbayi, 2002). Dramatic increases in the number of AIDS cases are predicted for many Eastern European countries as well as for the two most populous nations on earth, India and China. Some of the HIV/AIDS-related bioethical and policy issues of concern to developed countries remain the same for developing countries. However, in ethically important ways they are dwarfed by concerns over drug prices, intellectual property rights, and affordable access to essential AIDS drugs for the impoverished masses of infected people in such countries. Of increasing importance have become ethical issues pertaining to the ever-growing research industry associated with clinical trials undertaken in developing countries. Indeed, major funding initiatives both in the USA and UK have brought clinical research in developing countries into focus. Some have questioned whether this attention is appropriate, considering other bioethical problems of arguably greater importance to developing countries (Chadwick & Schuklenk, 2003). Standards of clinical care in a study, and after a trial has concluded, as well as community benefits and access to the trial regime after the trial’s conclusion remain contentious issues. It is worth noting that more often than not it was an AIDS-related trial or policy decision that led to a great deal of bioethical analysis, yet the issues discussed almost always have ramifications far beyond AIDS. For instance, decisions about the question of what (if any) standards of care failures in preventive trials (of HIV vaccines or microbicides) ought to receive have important implications for non-AIDS prevention trials. (shrink)

Why does Bernard Stiegler speak of “this culture, which I have named, after Epictetus, my melete?” In the first part of this article, I elucidate Stiegler’s claims about both Stoic exercises of reading and writing and their significance for the interpretive questions he has adapted from Michel Foucault and Jacques Derrida. In particular, I address the relations among care for oneself and others, the use of material technologies, and resistance to subjection or “freedom.” In the second part, I consider (...) the merits and limitations of Stiegler’s comments about reading and writing in Stoicism, with particular attention to Epictetus. We will see that Stiegler’s interpretive frame-work casts considerable light on ancient texts and contexts, on the condition that it be combined with close reading of ancient texts and engagement with specialist scholarship. Finally, in the conclusion, I will suggest that the history of technology in Epictetus’s time contributes to a debate about Stiegler’s theories.Bernard Stiegler signale à plusieurs reprises l’importance des exercices stoïciens de lecture et d’écriture. Dans la première partie de cet article, j’essaye de clarifier ces assertions et d’expliquer leur lien aux oeuvres de Michel Foucault et de Jacques Derrida. Il s’agit en particulier des rapports entre le souci de soi et d’autrui, l’usage des techniques et des matériaux et la résistante à la soumission ou à la « liberté ». Dans la deuxième partie, je considère les mérites ainsi que les limites des remarques de Stiegler sur la lecture et l’écriture au sein du stoïcisme, en portant une attention particulière à Épictète. Le point du vue stieglerien donnera de nouvelles significations à quelques passages des oeuvres d’Épictète, à condition qu’il soit conjugué à une lecture attentive d’études spécialisées et de textes anciens. Je conclurai, dans la troisième partie, en proposant que l’histoire des techniques à l’époque d’Épictète pourrait alimenter un débat à l’égard des théories de Stiegler. (shrink)

This book is the outcome of a European Commission-funded project on resource allocation in health care. It is co-authored by a philosopher, an epidemiologist, a public health medicine specialist and a health economist. Its range is broad, covering the historical, economic, methodological and philosophical aspects of healthrelated quality of life and its measurement.

World War II had a profound, but uneven, impact on the delivery of services designed to support the bodies and minds of English children. This article, which is based on a study of a rural local authority located in North-West England, explores the influence of World War II on children's welfare services. Drawing on detailed case files relating to individual children and reports published by local and national policy makers, the article advances three related arguments which together nuance existing understandings (...) of the conflict and its longer-term consequences. First, the article argues that many of the problems associated with evacuees were already familiar to medical and social work professionals. This awareness has important consequences for how we conceptualise the wartime proposals that attracted policy makers’ attention. Second, the article shows that the arrival of evacuees into reception areas initially resulted in an expansion of children’s services. A fuller understanding of Britain's welfare state, however, must acknowledge that local authorities continued to wield significant influence over the delivery of specialist services once the conflict ended. As a result, the priorities of local officials could lead to the needs of looked after children being overlooked despite wartime improvements to children's services. Finally, the article argues that amidst the totality of World War II, the British state remained unwilling to intrude on the rights of parents to influence the care of their children. Closer examination of the implementation of evacuation and the experiences of individuals reveals that important tensions existed between the state appointed experts and the civilians they were tasked with supporting. (shrink)

What decides the outcome of a Homeric battle? This may sound like one of those arcane problems only a devoted Homer-specialist would care to raise, but in fact the question strikes at the root of major issues in archaic Greek history. The orthodox answer is that Homeric battles were decided by single combats between champions, with the rest of the warriors only marginally influencing the fighting. It is added that these champions were aristocrats, ‘knights’. On this interpretation many (...) have argued that the political dominance of archaic Greek aristocrats was largely based on their military dominance, and that their power was seriously impaired when, in the seventh century B.C., military prominence shifted to the mass, the ‘commoners’; this change in the balance of power contributed crucially to the rise of the polis and the emergence of tyrannies. In outline the theory derives from Aristotle and is firmly entrenched in modern works. (shrink)

This medical humanities paper describes our qualitative research into pathways to care and informed consent for 10 children who had cardiac surgery in the Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. Our multidisciplinary team consists of cardiologists, anthropologists, a social scientist and a general practitioner in two sites, South Africa and Australia. This paper builds on our first publication in a specialist cardiology journal on a ‘qualitative snapshot’ of these children’s life stories from 2011 to (...) 2016 but turns to the medical humanities to explore a concept of ‘uncertainty’. Data analysis revealed that for the children’s parents and doctors, ‘uncertainty’ underscored procedures. Indeed, the literature review showed that ‘uncertainty’ is intrinsic to heart surgery and was integral to Barnard’s first heart transplant in Cape Town in 1967. We demonstrate that in meeting the challenges inherent in the ‘uncertainty dimension’, doctors established greater ‘medical certainty’about each operation. This happened as they encountered the difficult clinical and biopsychosocial factors that were fundamental to the diagnosis of children’s cardiac defects. It was doctors’ translation of these decision-making processes that informed parental decisions and described why, despite feelings of uncertainty, parents signed consent. To visually describe heart surgery in this locality we asked the South African photographer, Guy Neveling to record some children undergoing echocardiograms and surgery. These photographs qualitatively demonstrate what medical certainty entails, and parents’ trust in doctors and surgeons, whom they knew had ‘reasonable certainty’ that their child’s ‘heart is worth saving’. (shrink)

continent. 2.1 (2012): 22–28. Jeroen Mettes burst onto the Dutch poetry scene twice. First, in 2005, when he became a strong presence on the nascent Dutch poetry blogosphere overnight as he embarked on his critical project Dichtersalfabet (Poet’s Alphabet). And again in 2011, when to great critical acclaim (and some bafflement) his complete writings were published – almost five years after his far too early death. 2005 was the year in which Dutch poetry blogging exploded. That year saw the foundation (...) of the influential, polemical, and populistically inclined weblog De Contrabas (The Double Bass), which became a strong force for internet poetry in Dutch in the years to follow. In the summer of that year, a lively debate raged in the aftermath of Bas Belleman’s article “ Doet poëzie er nu eindelijk toe ?” (“Does poetry finally matter now?”), on a blog specifically devoted to this question. Up to that point, the poetical debate in the Netherlands had largely been confined to literary reviews (which were often subsidized), having become mostly marginalized in more mainstream media, where poetry could be covered by only a small number of so-called authorities. As a result, literary debate had acquired a rather placid quality. Though a variety of camps with different aesthetics could be discerned, most poetical positions shared a general acceptance of poetry as a form of art somewhat apart from fundamental political concerns. Late modernists would pursue subtlety and density of reference. Others would insist poetry was best understood as a form of entertainment that should ideally be accessible and work well on the stage. Still others would insist that poetry is mostly a play with forms. Linguistically disruptive strategies were valued highly by some, but mostly for their aesthetic effect. Values of disinterested playfulness reigned supreme everywhere. Any idea that poetry could be a field in which one confronts politics and the world was decidedly marginal. This led to a climate in which most attempts at polemics were DOA, often based on far too superficial positioning and analysis. The greatest polemical debates were revolving around the question of whether poetry should be difficult or easy, with both camps defining their ideas of difficulty and accessibility in ways that were so utterly shallow as to make the entire point moot. Debates were performed, rather than engaged with. It was a postmodern hell of underarticulated poetics. Half-consciously, people were yearning for new forms of criticism that could put the oomph back into poetry. Weblogs provided for ways to explore debate directly outside of the clotted older channels of the reviews and the newspapers. Belleman’s essay and the resulting online activity had shown that there was a widespread eagerness to take poetry more seriously as a social art form. It was in this environment that Mettes started his remarkable project Dichtersalfabet . At that moment, Mettes was active mostly in academic circles, having become noted at Leiden University as a particularly gifted student of literary theory. Within the Netherlands, the field of literary theory has a very odd relationship to literature as it is practiced in the country. Academic theory tends to have a mostly international view and engage with international debates of cultural criticism, literary theory, and philosophy, with academics often publishing in English and attending conferences around the world. Literature itself however is much more concerned with domestic traditions. Consequently, in the Netherlands, there exists a language gap between academic theoretical practice (as it is studied in the literary theory departments) and literary practice (which, academically, gets studied in specialized departments of Dutch literature). The Dichtersalfabet can be seen as Mettes’s attempt to close this gap. It is also an attempt to bridge the divide between theory and practice, in which he could apply his theoretical knowledge in a very unorthodox and unacademic critical mode that moreover could reach far beyond the domain of conventional criticism. Mettes’s goal was to trace a diagonal through Dutch poetic culture, to “strangle” what he perceived to be its dominant oppressive traditions of agreeable irrelevance, in order to see whatever might be able to survive his critical assaults. But he could only do so by means of a very serious engagement with poetry itself. To this end, he would go systematically through the poetry bookshelf of the Verwijs bookshop (part of a mainstream chain of booksellers) in The Hague, buying one publication per blog item, starting from A and working his way through the alphabet, reading whatever he might encounter that way in the restaurant of the HEMA store (another big commercial chain in the country). He would subsequently write down his reading experiences, refraining however from trying to write a nuanced book review. Rather, he would write about anything that caught his attention and sparked his critical interest. This way of working would yield vast, at times somewhat rambling, dense, lively, and generally brilliant essays, in which he held no punches. He never hesitated to pull out his entire arsenal of concepts from the international theory traditions, while never degenerating into mere academic exercise and pointless intertextualities. The attempt was rather to live the poetry that he read, and to engage it with the full range of political, academic, cultural, and personal references that he had at his disposal—all that composed the individual named Jeroen Mettes as a reader. Often what he wrote would not be according to the standards of what we usually think of as a critical review of a book of poetry. Sometimes he would even be a little sloppy in his judgments of poets or representations of the books he read, for example by basing an entire essay on the blurb of a book rather than its poetry content. But what he did was always brilliant writing nonetheless—virtuoso riffs on poetic fragments randomly found within capitalist society, exposing an incisive and insistent poetical sensibility. Mettes read poetry for political reasons, to see whether poetry could offer him a way to deal with a political world he detested. The right-wing horrors of the Bush years, the Iraq war, and the turn of Dutch public opinion towards ever more conservative, narrow-minded, and xenophobic views alongside a complete failure of the political left to present any credible alternative, were weighing heavily on the times in which Mettes reported on his reading. Poetry was to measure this world, diagram it, to lay bare its inconsistencies and faults, to indicate where lines of flight might be found. Amid the ruins of a world wrecked by imperialist policies, corporate capitalism, and doctrinal neoliberalism it would have to show the possibility of a new community. And it was, through its rhythmical workings, to release the reading subject from his confinement to ideologically conditioned individuality and lead him into the immanent paradise of reading. The stakes were high. Much higher than anything Dutch poetry had seen for many years. Mettes’s blog was widely read from the start. His posts sparked lively debates. Some of these subsequently led to the publication of extensive essays on a few key poets in some literary journals, particularly Parmentier and the Flemish journal yang , for which Mettes would become a member of the editorial board, a few months after starting the Dichtersalfabet . This could have been the start of a brilliant career, but this was not to be. The initial manic energy that fueled the blog gradually subsided. The Alfabet was updated less and less regularly. Mettes sometimes just disappeared for many weeks, then suddenly returning with a brilliant essay. Until, on September 21, 2006, he posted his final blogpost, consisting of no text whatsoever. That night I learned from his mentor at Leiden University that he had committed suicide. Mettes and I had had some fruitful exchanges on poetry, rhythm, music, and form, mostly on the blogs, but also by email. Three weeks before his death was the last time I heard from him: a very sudden, uncharacteristically curt note saying “My old new sentence epic.” Attached to that message I found a DOC-file of a work so major that I felt intimidated. This was N30 , a text he had been working on for over five years. After his death, it took me a long time before I dared to read it in its entirety. In the meantime, the work of preparing the manuscript for publication was entrusted by his relatives to his colleagues at yang magazine. It took them a few years to brush up the text and to edit the Dichtersalfabet -blog (which, apart from the Alphabet project itself, incorporated many other fragments of political, polemical, and theoretical writing) into book form along with the essays. The result of this labor was finally published in 2011 as a two-book set, and Mettes burst onto the Dutch poetry scene for the second time. The work was widely reviewed, on blogs, in journals, magazines, and newspapers. Many critics who had not followed the blogs in 2005 showed themselves surprised, baffled even, by the intensity of Mettes’s critical writing. But for those who had read the blog, the main surprise was in the poetry. During Mettes’s lifetime, some of his poems had already been published in Parmentier . Although these were strong texts by themselves, in no way did they prepare readers for N30 . Nothing like it had been written in Dutch before. Instead, N30 explicitly follows the American tradition of Language Writing, directly referencing Ron Silliman and his concept of The New Sentence. However, it would seem that much of the poetical thinking around his use of this technique puts him closer to a writer such as Bruce Andrews. For Mettes, using non sequiturs as a unit of poetic construction was not only a way of reinventing formal textual construction, but it was another way of finding the fault lines in the social fabric. From the perspective of the Language tradition, one may put N30 somewhere between Silliman and Andrews. N30 shares an autobiographical element with Silliman’s New Sentence projects, and as in Andrews, there is a concern for mapping out social totality within text—what Mettes refers to as a “textual world civil war.” Again this shows a formal textual strategy for allowing the person “Jeroen Mettes” to be absorbed by the world, which here appears as a whirlwind of demotic and demonic chatter, full of violence, humor, intensity, beauty, disgust, sex, commerce, and strife. Influenced as it may by American precursors, Mettes’s tone and form end up quite different from his American counterparts, consistently referencing a world that is Dutch, all too Dutch, taking on the oppressive orderliness of Dutch society with its endemic penchant for consensus by introducing chaos into its daily life and laying bare its implicit aggressions. The work’s 31 chapters each have a different feel and rhythmical outline, but none of them follow a predetermined pattern. Rather, Mettes would consistently edit and reedit the text, randomly rewriting parts of it, as he explains in his poetical creed Politieke Poëzie (Political Poetry). N30 – referring to the 1999 antiglobalist protest in Seattle – was to be the first text of a trilogy. The work itself was written “in the mode of the present.” A second text was to be written in the mode of the future, and a third one, in the mode of the past, was going to be an epic poem about the Paris Commune, and to form an alternative poetic constitution for the European project. I still deeply regret that Jeroen Mettes never got to complete those projects, just as I would be very keen on knowing what he might have had to say about more recent political developments. Instead, in 2006, he remained stuck in the horrors of the present, that ended up consuming him completely. He left Dutch literature with some of its most piercing criticism and its most profoundly moving, exciting and powerful poetry. Excerpts from N30 Translated by Vincent W.J. van Gerven Oei from Jeroen Mettes. "N30." In N30+ . Amsterdam: De wereldbibliotheek, 2011. Published with permission of Uitgeverij Wereldbibliotheek, Amsterdam. Chapter 1 1999. A day is a space too. And another man, who had chained himself, had his ribs crushed, and a motor has driven over somebody’s legs. Dutch health care system spends ±145 million guilders per year on worriers. A spiderweb vibrates as I pass by. Randstad renovating. She slaps her bag against her ass: “Hurry up!” OPINION IS TRUE FRIENDSHIP Your skin. It doesn’t express anything. “But the use of the sword, that’s what I learned, and you’ll need nothing more for the moment.” Just try to interrogate a guy like that. Gullit in Sierra Leone. Codes silently lying all around. But that’s simply what belongs to “that it’s just allowed”: that sigh of “world” (a word expressing that the trees are now standing along the water like black men with white bags in their hair); that’s nothing else right? And you see how everything has to move, and first of all what cannot do so. Without Elysium and without savings, barbarians lashing out, horny for an enemy, staring across the water, staring into the air—staring to get out of it. “You’ve never showed me more than the mall,” she said. All those “dreams” in the end—and now? It was lying on the stairway, so I picked it up and took it upstairs. Chapter 3 “You know what?” Telecommunication. For love… I don’t really like that cheap cultural pessimism, but… The holy city is on pilgrimage in the earthly bodies of the faithful until the time of the heavenly kingdom has come. The end of an exhausting autumn day behind the computer, my eyes filled with tears of fatigue. KITCHEN / INSTALLATION / SPECIALIST. Network integration. In the sun, stretched out on a sheet. (…) I don’t believe what I’m reading, because I want to believe something else. An illusion? Suits me. There’s a variety of shapes and tastes… “So what?” you may think. 102 dalmatians can’t be wrong. But I want more, dear… A feel good movie. I’m smashing the burned body. So what? We continue to save the European civilization. What’s there to win? Plato with poets = Stalin without gulag? Ball against the crossbar. No wonder. She comes straight to her point. She’s standing in the kitchen eating an apple. (…) The godless Napoleon had used her as a stable and wanted to have her taken down. “Our” Rutger Hauer. Ready or not here I come. Psst… are you also wearing a string? Nobody understands our desire. Cliffs breaking the waves and shattering the sunset. I used to be a real romantic (as a poet). A typical fantasy used to be the one in which I brutally raped mother and daughter Seaver from the sitcom Growing Pains . Nevertheless you only contain bad words. Eyelashes. Automatic or manual? That your skin always in the afternoon. Integration. The air is empty. Too bad! Hand in hand on their lonely way. Alaska! Chapter 12 May 5, 2001 [10:00-10:30] A dust cloud on a hill. Globe. Indian (British) (tie) / pope. Damascus. Rape. We’re carrying the ayatollah’s portrait through the streets. At the moment the girl is mostly suede jacket with white ribbons on her sleeves. A small explosion flares up/impact. Camouflage. Close up. We’re analyzing the situation. He’s dead right? Dead dead. Dead. Everything without, these, and only with the body. Indices signal death. Dollar bills are printed in factories. Holes. Light patch. Globe in a box. Microphone. What’s the situation? Grey impact on a green hill (field?). The water is blue. He has no lips. Interns on the background with skirts that are too long. This is an example of a sonnet. An Islamic woman pushes against the door of an electronics shop. Arrows (percentages (prices)). Is this what awaits the American? Touch screen interface. The word, an island, can only be a sign in that situation. We pull up a chair, join in on the fun. On the shelves only books about computers. One glance in the distance is enough to lighten up a luna park in the distance. She’s really desperate, especially when she laughs. Click. Ah. Next. And now it’s raining, but that’s ok. Yellow stains sliding over the south. Shallow caves light: clothes, boots, electrical equipment. 45. 22:10. Nothing gives you the right to eat more than people starving to death. The Hague. Slam dunk. Traffic light. Two H’s, one L (standing for the L (little prick)). We’re happy to say something. Clouds, small suns, temperatures, cities. The truth is never an excuse. Yellow. Yellow. Green. Yellow. Yellow. Yellow. Yellow. Green. Green. Yellow. Will you email me? Skeleton: “No.” Ex-nerds in brand-new and brightly red sport cars. $$$. I love. Shihab. Hooves in the sand. Skinny senior with over-sized sunglasses; old jockey (cap, trophy) smiling in slow motion. And there I am again, flashback, crying with my head in between my hands. Sometimes I’ve got the feeling that cannibals. Eyes: blue. Cancer. Why would I wait until tomorrow? Golden beams protruding from the lifted/lit earth. May 5, 2001 [11:30-12:45] You’ll remember this for the rest of your life. Graphs, diagrams. Bu$ine$$. Blue shirt, white collar, no neck (porn star). A name lights up. I’m hysteric. Will you join us? Letters falling in their words. Fingers set up a tent and start to dance. Young entrepreneurs from poor neighborhoods (read: black) guided by Microsoft. Kinda makes me happy, that sort of kitsch. A sense of exhaustion/impotence to see anything but the present. (…) Wouldn’t you like to? Orange explosion in an industrial zone. YOU’RE DOING THIS FOR AMNESTY INTERNATIONAL. Would you. A familiar face. Clouds and blossom. Sunflowers. Supermodels. Mountainous area in a rectangle: shades of brown, from dark to beige, more green toward the south. Tents and next to them (it’s all a blur) people. Plane. Stadium. Geometrical block of people. No, I ain’t crying. I don’t speak no more. I just want. Quote + photo. (Positive:) screaming crowd. Three-piece suit, seen from the back, before entering the arena. On the back: “Daddy abused me.” Oh, bummer. State of emergency has been declared and everyone has to cooperate. She’s cut her wrists. What we do know (…) is that there’s never been a unique word, an imperative name, nor will there ever be. [Click here for work that suits you.] Barefooted children are watching it (coherent pieces revelation of what’s lying below). Who knows how she’s changed during those two years. “Everything used to be better” + sigh. And here we are. An empty field of parquet. A city lying behind it. Explosion. Blue. A rain drop falling in my coffee. May 5, 2001 [14:30-15:30] A young Arafat on video speaking with raised finger. “I’m calling from my convertible.” Names on walls, victims, numbers… Tourists. Yellow. Yellow. “Your own child! Really, what kind of human are you?” I don’t want to hear it no more. A woman jumping out of the water in a yellow bikini against a background of fireworks and the Cheops pyramid. Thy sorrow shall become good fortune, thy complaints laudation. All planets will float and wander. Wo die Welt zum Bild wird, kommt das System (…) zur Herrschaft. It is something, but is it? May 5, 2001 [18:30-19:00] Iris. Leaves. NASDAQ. Open / and white and. For the one who’s doing nothing, just waiting. (…) NO DEFEAT is made entirely up of defeat -- since / the world it opens is always a place / formerly / unsuspected. October 2002. “Jeroen, I’m leaving for the cemetery, byeeee.” The rise of the middle class. My entire oeuvre is an ode to the. My entire head is a fight against the. God always demands what you cannot sacrifice. You may take that the easy way, but… “The state hasn’t made us, but we make the state” (Hitler). A stork exits the elevator. Skeletons of. Moscow. Helsinki. Palermo. Paris. Chapter 30 Like your paradises: nothing. United Desire, as only remaining superpower. And even though the sea is now calmer and the wind is blowing pleasantly in my face… Heart! Who determines whether a tradition is “alive”? The yellow leaf or the white branch? Mars. This sentence is a typical example. Most Dutch people are happy. No consolation. When I see a girl sitting at a table with a book, a notepad, a pen, a bottle of mineral water, her hand writing in the light—then I consider that one thing. “Presents,” “poetry,” “classics.” We are what we cannot make from ourselves. “Left”: mendicant orders, missionaries. Saint-Just: “A republic is founded on the destruction of its enemies.” She crosses the street with a banana peel between her fingers. (…) We chose our own wardens, torturers, it was us who called all this insanity upon ourselves, we created this nightmare… But “no”? Girl (just like a beach ball) talking rapid Spanish (Portuguese?) in a mobile phone. Do I have a chance now that her boyfriend is getting bold? CLIO, horny bitch. What else do you want? An old woman, between the doors of the C1000, is suddenly unable to go on; her husband stretches out his hand, speaking a few encouraging words. Selection from. Der Führer schenkt den Jüden ein Stadt. How can it reach us if we haven’t been already reached somehow? It doesn’t “speak.” No problem. Each word she uses is a small miracle, as if she doesn’t belong to it, to language, but wanders around with a pocket light looking for the exit; she’s never desperate (maybe a little nervous), lighting up heavy words from the inside. But indeed, we’re free. But the predicate is not an attribute, but an event, and the subject is not a subject, but a shell. That’s why also samurai, knights, and warriors raised the blossom as emblem: they knew how to die. Locked up in a baby carriage with a McDonald’s balloon. Blue helicopter, the blue sky. Whether you want to refer? The point is. How / Motherfucker can I sing a sad song / When I remember Zion? You’ll feel so miserable and worthless that you think: “If only I were dead!,” or: “Just put an end to it!” “So you’re an economist?” Her card—two little birds building a nest, her handwriting shaking—is still on the mantelpiece. Guevara: “No, a communist.” A straw fire, such was our life: rapidly it flared up, rapidly it passed. I’m fleeing, coming from nowhere. (…) Eazy-E drinking coffee with the American president. If I’d scream, would that be an event? Drown it: the cleaner it will rise up from the depths. No! The night, so fast… As if there’s something opened up in that face. Come on, we may not curse life. He shows me his methadone: “If you drink that all at once, you’ll die instantly.” The last one dictates how we should behave to deserve happiness. One shine / above the earth. “I want to go to Bosnia,” I said bluntly. I don’t even know the name of the current mayor. Let’s despise our success! “There is no future; this is the future. Hope is a weakness that we've overcome. We have found happiness!” Sun. Sushi. Volvo. I feel like a bomb about to explode at any moment. Makes a difference for the reconstruction right? The decor moves forward. Daughter of Nereus, you nymphs of the sea, and you Thetis, you should have kept his tired head above the waves! Alas! This sentence has been written wearing a green cap. I receive my orders from the future. A frog jumps into it. Her husband has turned the Intifada, which he follows daily on CCN, into his hobby, “to forget that he doesn’t have his driver’s license yet." Suddenly the sun slides over the crosswalk. Her (his?) foot is playing with the slipper under the table. Is this how I’m writing this book now? I’m not a fellow man. I hate you and I want to hurt you. These are my people. Their screaming doesn’t rise above the constantly wailing sirens which we've learned to ignore. My whole body became warm and suddenly started to tremble. Unfortunate is he who is standing on the threshold of the most beautiful time, but awaits a better one. Arafat’s “removal” is contrary to American interests. Jeep drives into boy. What you can do alone, you should do alone. A food gift from the people of the United States of America. Two seagulls. [...]. (shrink)

This article presents evidence regarding aspects of the gendered nature of care women with gynaecological cancer receive from their male surgeons and oncologists in Australia. We argue that despite women’s general preference for female gynaecologists, those with a gynaecological cancer develop a strong therapeutic relationship with their male medical specialist, not extended to their female nurses and other allied health professionals. Given the highly sensitive and sexualized nature of gynaecological cancer, this requires explanation. These findings can be partly (...) explained by examining the division of labour between nurses and doctors, specifically issues of control over this process and the development of specializations. The findings also bring into stark relief the way in which power and status differences can be used by medicine to create a positive therapeutic relationship with patients while simultaneously de-eroticizing the intimate procedures necessary in assisting women throughout their cancer treatment. Importantly, this relationship also has relevance for policy makers, particularly those concerned with the highly gendered division of labour of the medical specialty workforce in Australia. (shrink)

In contrast to the introspective doubts of nineteenth century agnosticism comes a synthetic survey of the Age of Faith through the sharp eyes of a candid believer. Professor Warrington translates with care and grace the third of a herculean series of five Church history volumes, which have been widely successful in the original French edition. It is economically understandable but unfortunate that the bibliography of its rich French and German sources is omitted as well as the cross-references to its (...) two predecessors, although a useful twenty-five page index is provided. In an age of specialists who find the humane sharing of discovery increasingly difficult, M. Daniel-Rops is a publicist-prodigy—a practised littérateur with a comprehensive grasp of ideas, events and writings, sacred and profane, which he diffuses widely in works properly described as being de haute vulgarisation. This vivid view of the medieval Church as a whole—spiritually, politically and culturally—is personally rethought as a live unity, and should benefit both the exacting specialist in constant danger of failing to see the wood for his pet trees and the serious beginner trying to recapture the events and mentality of a remote past. Nor should one cavil at the author’s presentation in terms of his own unconcealed belief in its value. A definitive history, in which the observer conceals his own viewpoint and muffles his personal conviction, is an artificial ideal healthily rejected nowadays, as at best producing a stale record of uninspiring fact. This personal testament frankly judges the interaction of Christian belief and institution in the High Middle Ages, which saw the Christianisation of the whole continent, its cultural manifestation in cathedral and university and its militant challenge in the wars of Investiture and crusade. (shrink)

In contrast to the introspective doubts of nineteenth century agnosticism comes a synthetic survey of the Age of Faith through the sharp eyes of a candid believer. Professor Warrington translates with care and grace the third of a herculean series of five Church history volumes, which have been widely successful in the original French edition. It is economically understandable but unfortunate that the bibliography of its rich French and German sources is omitted as well as the cross-references to its (...) two predecessors, although a useful twenty-five page index is provided. In an age of specialists who find the humane sharing of discovery increasingly difficult, M. Daniel-Rops is a publicist-prodigy—a practised littérateur with a comprehensive grasp of ideas, events and writings, sacred and profane, which he diffuses widely in works properly described as being de haute vulgarisation. This vivid view of the medieval Church as a whole—spiritually, politically and culturally—is personally rethought as a live unity, and should benefit both the exacting specialist in constant danger of failing to see the wood for his pet trees and the serious beginner trying to recapture the events and mentality of a remote past. Nor should one cavil at the author’s presentation in terms of his own unconcealed belief in its value. A definitive history, in which the observer conceals his own viewpoint and muffles his personal conviction, is an artificial ideal healthily rejected nowadays, as at best producing a stale record of uninspiring fact. This personal testament frankly judges the interaction of Christian belief and institution in the High Middle Ages, which saw the Christianisation of the whole continent, its cultural manifestation in cathedral and university and its militant challenge in the wars of Investiture and crusade. (shrink)

The UK government intends to regulate mental health care professions by enforcing title protection of the terms “counsellor” and “psychotherapist.” The operational definition they have adopted for “counsellor”— a specialist in psychological therapy—is not recorded in any authoritative source as an exclusive,predominant or fundamental meaning of the term. In fact, there is no evidence that it is an independent sense in its own right, unlike the professional titles “psychotherapist,” “doctor,” and “psychologist.”It is only in recent decades that the (...) term “counsellor” has been interpreted as the title of a psychological profession. It was first used within the context of psychological therapy in 1940 by Carl Rogers to denote a therapist directing a non-programmatic “client-centred” session, and was eventually absorbedinto the occupational dialect of psychology as a descriptor, but did not constitute the title of a separate profession. It also continued to have applications outside the context of psychotherapy. However, various linguistic tropes have contributed to a widespread misconception that it is primarily a professional title for psychological therapists who eschew programmatic therapies. The term was progressively adopted by non-therapists who offered vocational talking-and-listening services.A careful semantic analysis reveals that the PLG’s interpretation of the term rests on a confusion of sense and reference, a widespread but erroneous assumption about the role of counsellors, a failure to acknowledge the limits of an occupational dialect, biased categorical heuristics, and ignorance of modifyingterms. There is a more constructive approach, which accords with the observation that counselling is an activity rather than a profession and is more faithful to the original semantics of the key terms. (shrink)

This magnificent book makes original and unique contributions to the understanding of Aristotle's ethical thought. Sparshott's approach is comprehensive but, unlike S. Broadie's excellent Ethics with Aristotle, it is not systematic: he has written a detailed running commentary on the entire text. However, his "aim is not to argue a thesis about the interpretation of the text as a whole, but to enable the reader to see how it actually goes." This method might seem too modest to the specialist (...) who wants to know Sparshott's views on the perennial topics, but no serious student of the text will read more than a page or two without learning something new. The reasons are simple: Sparshott's ear is uncannily attentive to the least ambiguity in Aristotle's expressions; he meticulously paraphrases, reconstructs, and deciphers every argument and line of thought Aristotle pursues. Lavishing care on such a well-known text might seem overindulgent, but Sparshott shows how many of Aristotle's key terms and concepts are vague or general in scope. In his discussion of book 1, for example, he unpacks the ambiguities in several terms: self-sufficiency does not mean isolation ; ultimacy does not mean termination, but completeness or perfection; and completeness does not mean all-inclusiveness, but concentration on an ideal. Also illuminating is his masterly account of justice, the subject of book 5 of the Ethics. In tracking the broad semantic range of "justice," Sparshott concludes that it is intermediate between a moral and an intellectual virtue, and hence includes both the notions of a fair distribution of things and of the whole of virtue. Sparshott's focus on the genesis of concepts and phrases and his pursuit of the penumbras of meaning that radiate through the text as a whole are the most attractive features of the book. Two additional aspects of this exegesis of terminology are noteworthy. Sparshott reveals more thoroughly than before how deeply rooted in Plato are key Aristotelian concepts and arguments. By extensive reference to the Metaphysics and De anima, Sparshott demonstrates that Aristotle indeed provides a metaphysical foundation for his ethical inquiries. (shrink)

The risks associated with the techniques of medically assisted procreation (MAP) rapidly became well-known, and in such a short space of time that no biomedical domain remained untouched by the great deal of thinking and the expression of a multitude of opinions it provoked. MAP is evolving between two poles: quality/misuse (even violation) and evidence/fantasy. The ethics will be evoked in the clinical reality from which they spring and where their justification lies. The three objects common to these ethics, the (...) oocyte, the embryo and the child, are illustrated in this context. MAP has as its corollary access to the oocyte, the fertilization of which will take place in vitro. Access to the embryo, on the other hand, enables the clinician, for the purposes of diagnosis [preimplantation genetic diagnosis (PGD), predictive medicine], or even soon for therapeutic purposes (gene therapy) to draw close to a boundary, to trespass beyond which may be seen by humanity to threaten its very origins and integrity: the alienation of the human genome. For the infertile couple, the missing child may take on a dimension of which they would have been unaware, had they not been forced to express their desire. The burden of the imaginary child may, in this way, become a heavier load to bear when, after such desire, he comes into being. MAP puts the goal of normalisation within reach and, in doing so, accentuates the risk of the burden of the attributed representation of the child. On the one hand, MAP offers a tremendous diagnostic and therapeutic potential, while on the other it opens the door to excess and delirium. In this melting pot, ethics, catalysed by this new source of problematics, has discovered a favourite area in which to define and redefine itself. We propose the intervention of ethics on three different levels. Before the elaboration of the law: on first reflection, ethics may influence the responsibilities of the legislator, by taking care that the law does not obscure the biomedical and socioeconomic contexts of MAP and, thereby, also include other related and complementary aspects dealing with the same subject. The secondary discussion of ethics should influence the application of legal protection, by taking into account the rapid technological and social development of MAP, there too, by discussing the whole, rather than the details which will obscure the object. The ethical reflection of the clinician, who is aware of these difficulties, is guided by elements that are specific to his position as a doctor. The cohesion of the team around the clinician and the ethics specialist enables us to develop consensual clinical ethics that are transmissible and therefore teachable. This complex role can, in our view, only be acted out directly in the clinical situation, where the constant, direct relationship with the object of the reflection and the treatment allows ethics to take into account the contingencies of medical practice: we invite the ethics specialist to take part in our clinical activity on a daily basis. (shrink)

With more people in the world living into older age, Alzheimer's and other Dementias: The Facts takes a comprehensive look at the spread of dementia, and provides authoritative information and practical advice for sufferers, their families, and the medical professionals who care for them. -/- Written by a consultant in old age psychiatry, the book provides an overview of all the different types of dementia (including younger-onset dementias), from the most-recognized - Alzheimer's - to the less-frequent types, such as (...) those caused by inherited metabolic disorders or HIV. The book guides the reader step-by-step through how the brain works, and explains in clear and simple language the effect of dementias on the brain, and the impact on an individual's cognitive function. -/- A dedicated chapter explains how a diagnosis is reached, including the different modes of assessment, from blood tests carried out by a GP, to specialist scans, highlighting how the brain actually works. Detailed sections cover the latest treatments available, including the controversial use of antipsychotic medication, and the possibility of disease-modifying treatments in the future. -/- The book also explains how the multi-disciplinary team works together to look after the sufferer's social needs, such as bathing and washing, as well as their spiritual and palliative needs. Alzheimer's and other Dementias: The Facts provides all the relevant information and guidance for sufferers, family and their care-givers to choose the right intervention at the right time, to create - as the book advocates - a unique and personalized management plan. (shrink)

Digital communication between a patient and their clinician offers the potential for improved patient care, particularly for young people with long term conditions who are at risk of service disengagement. However, its use raises a number of ethical questions which have not been explored in empirical studies. The objective of this study was to examine, from the patient and clinician perspective, the ethical implications of the use of digital clinical communication in the context of young people living with long-term (...) conditions. A total of 129 semi-structured interviews, 59 with young people and 70 with healthcare professionals, from 20 United Kingdom -based specialist clinics were conducted as part of the LYNC study. Transcripts from five sites were read by a core team to identify explicit and implicit ethical issues and develop descriptive ethical codes. Our subsequent thematic analysis was developed iteratively with reference to professional and ethical norms. Clinician participants saw digital clinical communication as potentially increasing patient empowerment and autonomy; improving trust between patient and healthcare professional; and reducing harm because of rapid access to clinical advice. However, they also described ethical challenges, including: difficulty with defining and maintaining boundaries of confidentiality; uncertainty regarding the level of consent required; and blurring of the limits of a clinician’s duty of care when unlimited access is possible. Paradoxically, the use of digital clinical communication can create dependence rather than promote autonomy in some patients. Patient participants varied in their understanding of, and concern about, confidentiality in the context of digital communication. An overarching theme emerging from the data was a shifting of the boundaries of the patient-clinician relationship and the professional duty of care in the context of use of clinical digital communication. The ethical implications of clinical digital communication are complex and go beyond concerns about confidentiality and consent. Any development of this form of communication should consider its impact on the patient-clinician-relationship, and include appropriate safeguards to ensure that professional ethical obligations are adhered to. (shrink)