The public debate on voluntary termination of life by elderly people, which has been an intensely controversial subject in the Netherlands for some time, has centered around the issue of “completed life” in recent years. In 2016, an ad hoc governmental advisory committee concluded that the already existing Euthanasia Act provided sufficient scope to resolve most of the problems related to the issue. Most of the older adults who feel they no longer have anything to look forward to in their (...) lives and who have developed a wish to die as a result would be able to invoke this Act. Partly for this reason, the committee considered broadening the legal options relating to assisted suicide undesirable. Analysis of the assessment practice of the regional euthanasia review committees reveals that the room for interpretation offered by the Euthanasia Act is indeed considerable. (shrink)

Euthanasia and physician-assisted suicide are controversial issues in medical ethics and medical law. In the debate, several arguments against the moral acceptability and legal feasibility of active involvement of physicians in bringing about a patient’s death can be found.One argument refers back to the Ten Commandments: “Thou shall not kill”. Killing another human being is morally abject. According to the argument, this is certainly so for medical doctors, as can be seen in the Hippocratic Oath, which explicitly forbids abortion and (...) euthanasia. A less apodictic argument refers to the slippery slope: if euthanasia would be permitted, a downhill movement is set in motion. The end of this movement would be, on the one hand, that physicians will feel forced to assist people who ask for termination of life on whatever grounds. On the other hand, it might lead to a situation in which it becomes normal to kill people who are no longer useful for society.In the literature and in the public debate, there are also arguments in favour of euthanasia and physician-assisted suicide. One such argument invokes the right to die. According to this argument, decisions concerning life and death should be up to the individual who is concerned. In many countries, suicide is morally and legally accepted. If people are allowed to kill themselves, why should they be without rights when they are no longer able to perform the act themselves?In medical ethics and medical law, patient autonomy is a central pivot. Patients have the right to refuse treatment even if this leads to their death. Shouldn’t people also have the right to determine the moment of dying, if they are in a situation which is unbearable, and without prospect of improvement? Another argument focuses on the duty of the physician to alleviate pain and suffering. If there is no other option, the doctor, in fulfilling this duty, should be allowed to actively end the patient’s life. This argument is not based on autonomy, but on beneficence.The debate concerning euthanasia involves fundamentally different moral principles. This makes the debate interesting, if not central to medical ethics and medical law. Yet, the principles are normally presented in an abstract way. Discussants stick to very general ideas, which lack reference to specific social and historical conditions, and are not related to concrete experiences. To invoke the Ten Commandments, or plea for a right to die, implies the use of universal standards, which tend to be general and empty.From a philosophical perspective, this type of argumentation can be criticized. Following Aristotle, ethics should be based upon experience. Ethical knowledge requires participation in concrete practices. Central to ethics is a feeling for the concrete situation, which is always contingent and historical. From this perspective, it makes sense to consider how practitioners in specific situations deal with moral issues, for instance concerning euthanasia. What role do they give to notions such as autonomy and beneficence, how do they interpret them and apply them to the concrete situation?In this paper I will present the Dutch experience with euthanasia. I will focus upon the way in which during the past thirty years the arguments in favour of euthanasia have been developed, in interaction with euthanasia practice. I will show that patient autonomy has been a crucial pivot. Yet, the Dutch interpretation of autonomy is not purely liberal. It does not only involve rights, but also obligations. Next, I will make clear that the physician plays a central role, in that the moral and legal basis of euthanasia is a conflict of duties on the side of the physician.This brings in the issue of beneficence. Yet the Dutch interpretation of the duty to help is not simply paternalistic. In Dutch health care, the physician-patient relationship is based upon deliberation and mutual agreement. Therefore, my conclusion will be that the Dutch practice of euthanasia has a moral ground, which goes beyond the traditional opposition between autonomy and beneficence. (shrink)

One of the requirements in the Dutch regulation for euthanasia and assisted suicide is that the doctor must be satisfied ‘that the patient's suffering is unbearable, and that there is no prospect of improvement.’ In the notorious Chabot case, a psychiatrist assisted a 50 year old woman in suicide, although she did not suffer from any somatic disease, nor strictly speaking from any psychiatric condition. In Seduced by Death, Herbert Hendin concluded that apparently the Dutch regulation (...) now allows physicians to assist anyone in suicide simply because he or she is unhappy.In this paper, I reject Hendin's conclusion and in particular his description of Mrs Boomsma as someone who was ‘simply unhappy.’ After a detailed narration of her lifestory, I turn to the American philosopher Harry Frankfurt's account of volitional incapacity and love for a more accurate characterization of her suffering. Having been through what she had, she could only go on living as another person than the one she had been when she was a happy mother. That would have violated her integrity, and that she could not bring herself to do. (shrink)

As in the United States, the Dutch conversation about assisted suicide emerged primarily in the context of cancer. At least in that context, before acceding to a request for assistance in dying, caregivers must be sure that the person has made a voluntary and carefully considered request, and that her suffering is unbearable and without prospect of improvement. The Dutch have recently been trying to use those criteria in the context of Alzheimer's disease. Given the wave (...) of Alzheimer's cases poised to crash onto wealthy countries, along with emerging technology to detect the disease process before symptoms appear, we should be grateful to the Dutch for that attempt. As a newcomer to this discussion, however, I was struck that those criteria may have a somewhat odd result. A patient with Alzheimer's disease can easily meet the conditions in the early stage of the disease, when one usually has the mental capacity to request assistance in dying and to make the case that one's existential suffering is unbearable. If one is in the late stage, though, it can be much harder to get such assistance because one does not have that capacity. (shrink)

IntroductionPalliative care is an emotionally and spiritually high-demanding setting of care. The literature reports on the main issues in order to implement self-care, but there are no models for the organization of the training course. We described the structure of training on self-care and its effects for a Hospital Palliative Care Unit.MethodWe used action-research training experience based mostly on qualitative data. Thematic analysis of data on open-ended questions, researcher’s field notes, oral and written feedback from the trainer and the participants (...) on training outcomes and satisfaction questionnaires were used.ResultsFour major themes emerged: “Professional role and personal feelings”; “Inside and outside the team”; “Do I listen to my emotions in the care relationship?”; “Death: theirs vs. mine.” According to participants’ point of view and researchers’ observations, the training course resulted in ameliorative adjustments of the program; improved skills in self-awareness of own’s emotions and sharing of perceived emotional burden; practicing “compassionate presence” with patients; shared language to address previously uncharted aspects of coping; allowing for continuity of the skills learned; translation of the language learned into daily clinical practices through specific facilitation; a structured staff’s support system for emotional experiences.DiscussionSelf-care is an important enabler for the care of others. The core of our intervention was to encourage a meta-perspective in which the trainees developed greater perspicacity pertaining to their professional role in the working alliance and also recognizing the contribution of their personal emotions to impasse experienced with patients. (shrink)

Although euthanasia and assisted suicide in people with psychiatric disorders is relatively rare, the increasing incidence of EAS requests has given rise to public and political debate. This study aimed to explore support of the public and physicians for euthanasia and assisted suicide in people with psychiatric disorders and examine factors associated with acceptance and conceivability of performing EAS in these patients. A survey was distributed amongst a random sample of Dutch 2641 citizens and 3000 physicians. Acceptance (...) and conceivability of performing EAS, demographics, health status and professional characteristics were measured. Multivariable logistic regression analyses were performed. Of the general public 53% were of the opinion that people with psychiatric disorders should be eligible for EAS, 15% was opposed to this, and 32% remained neutral. Higher educational level, Dutch ethnicity, and higher urbanization level were associated with higher acceptability of EAS whilst a religious life stance and good health were associated with lower acceptability. The percentage of physicians who considered performing EAS in people with psychiatric disorders conceivable ranged between 20% amongst medical specialists and 47% amongst general practitioners. Having received EAS requests from psychiatric patients before was associated with considering performing EAS conceivable. Being female, religious, medical specialist, or psychiatrist were associated with lower conceivability. The majority of the psychiatrists were of the opinion that it is possible to establish whether a psychiatric patient’s suffering is unbearable and without prospect and whether the request is well-considered. The general public shows more support than opposition as to whether patients suffering from a psychiatric disorder should be eligible for EAS, even though one third of the respondents remained neutral. Physicians’ support depends on their specialization; 39% of psychiatrists considered performing EAS in psychiatric patients conceivable. The relatively low conceivability is possibly explained by psychiatric patients often not meeting the eligibility criteria. (shrink)

Performing and creative artists have unique occupational and lifestyle stresses and challenges that can negatively affect self-esteem. Low self-esteem not only has serious implications for their psychological and physical health, it can also affect their performance and creativity. There is a need to establish effective interventions to deal with this issue. To the best of our knowledge, there are no reported studies specific to workshops or interventions on enhancing self- esteem for artists. The Al and Malka Green Artists’ Health (...) Centre at the Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada, is a unique multidisciplinary and integrative clinic serving the special needs of the artist population. We developed a workshop entitled “Building Confidence and Self Esteem Toolbox Workshop” to address this this need. We then designed a single-blind, randomized, prospective, pilot study to evaluate the effectiveness of the workshop on enhancing self-esteem in artists, and to evaluate the long-term effectiveness of using the recommended tools in maintaining a healthy self-esteem, as well as maintaining physical and emotional health. Both quantitative and qualitative data were collected. A validated “Self-Esteem Checkup” questionnaire was administered pre- and immediately post workshop, as well as at 2, 6, and 12 months post workshop. Open-ended questions were posed to study participants via email at 2 and 12 months following the workshop, and at 6 months in in-person interviews. Thirty-five professional artists consented to participate in the study, with 26 completing all study visits. Mean scores for all time points, and the individual questionnaire statement mean scores for the five timepoints increased significantly immediately post-workshop and remained statistically significantly improved by the by the 3rd follow-up 12 months later. (p<0.001). The mean self-esteem rating score increased significantly post-workshop and remained statistically significantly improved by the 3rd follow-up 12 months later. (p<0.01). Qualitative data showed positive feedback on the utilization of the tools learned in the workshop that helped maintain this improvement over a one-year period. This workshop may be an effective means of addressing the issue of self-esteem in artists. Further controlled studies of larger sample size and longer duration are needed to confirm these findings. (shrink)

This article describes two features of technoscience, which are significant for the consideration of the prospects of human improvement projects. The first feature of technoscience is that the object of its research is artificial in origin which means created by person. As an example of new objects, situations and problems are given projects to create «designer children», development of transplantation, creating implantable neural interface. The second feature of technoscience is that the well-established methods can't be applied to determine the (...) results of the implementation of human improvement projects. As an example, the article discussed neo-eugenics projects. The article concludes that today in the social sciences there is no clear position on the grounds of human improvement projects. However, this is not an obstacle for the development of technoscience. (shrink)

This article describes two features of technoscience, which are significant for the consideration of the prospects of human improvement projects. The first feature of technoscience is that the object of its research is artificial in origin which means created by person. As an example of new objects, situations and problems are given projects to create «designer children», development of transplantation, creating implantable neural interface. The second feature of technoscience is that the well-established methods can't be applied to determine the (...) results of the implementation of human improvement projects. As an example, the article discussed neo-eugenics projects. The article concludes that today in the social sciences there is no clear position on the grounds of human improvement projects. However, this is not an obstacle for the development of technoscience. (shrink)

Photo ID 71252867© Stepan Popov| Dreamstime.com Abstract While Medical Assistance in Dying (MAiD) has been legalized in Canada since 2016, it still excludes eligibility for persons who have mental illness as a sole underlying medical condition. This temporary exclusion was set to expire on March 17th, 2024, but was set 3 years further back by the Government of Canada to March 17th, 2027. This paper presents a critical appraisal of the case of MAiD for individuals with mental illness as (...) the sole underlying medical condition through the analysis of three ethical theories: principlism, deontology, and utilitarianism. Through evidence and discussion, it will be demonstrated that MAiD, in this context, may be ethically justifiable on the grounds of upholding human rights, protecting dignity, and minimizing suffering. Introduction In June of 2016, Medical Assistance in Dying (MAiD) was legalized in Canada.[1] Throughout the first six years, a temporary exclusion of eligibility for persons suffering solely from mental illness was extended.[2] The exclusion of mental illness as a sole underlying medical condition was set to expire on March 17, 2024.[3] However, on February 1, 2024, just over a month before the set expiration, the Government of Canada once again extended the exclusion, this time setting it back three years to March 17, 2027. There are currently several countries that allow MAiD for mental illness, including Belgium, the Netherlands, and Luxembourg.[4] Some countries, like Spain,[5] do not give specific guidance, leaving the matter under discussion by ethicists and courts. In these countries, there are specific (although different) requirements for the process; overall, for mental illness, the illness must be verifiable and not simply related to a perception of satisfaction with the length of life. This extension ignited discussion on whether MAiD for persons who have mental illness as a sole underlying medical condition in Canada is ethically acceptable. As a complex, multi-faceted, and interdisciplinary issue, ethicists assessing MAiD must take into account various moral obligations and considerations. This paper analyses MAiD in this context through the application of three ethical theories: principlism, deontology, and utilitarianism. This paper concludes that, based on the current evidence and knowledge of this developing situation, MAiD for persons with mental illness in Canada may be ethically justified on the grounds of upholding human rights, labour obligations, and dignity. Through the exploration of research and discussions, it will be demonstrated that society at large ought to protect liberty and act towards relieving suffering, thereby supporting the potential eligibility of MAiD for persons who have mental illness. Principlism: The Capacity and Ability to Assess and Decide for One’s Own Life Principlism is the application of four principles: autonomy, beneficence, non-maleficence, and justice. Principlism supports permitting MAiD for mental illness due to the importance of autonomy in decision-making, equitable and just practices for MAiD assessors, and reducing suffering for patients and their family member(s) and/or friend(s). Carter v. Canada, the Canadian Supreme Court ruling of 2015—which changed Canadian law to allow for MAiD—held that the prohibition of MAiD infringed on Canadians’ right to “life, liberty, and the security of the person.” In a unanimous decision, the Supreme Court of Canada decided that the criminal prohibition of MAiD violates the Canadian Charter of Rights and Freedoms.[6] The Court concluded that the criminal law prohibiting MAiD interfered with people’s autonomy and dignity, which are protected by the rights of liberty and security of the person.[7] The ruling emphasized that Canada’s constitution reflects the fundamental importance of individual autonomy in personal decision-making. Research provides evidence that MAiD improves autonomy: A study among psychiatric patients found that 8 of 48 psychiatric patients said the mere option of accessing MAiD was enough to assess their future options for living wholly.[8] These findings complement a study entailing interviews with 30 adults who have mental illness, which emphasized that the ability to access MAiD allows individuals to analyze their quality of life, envision their desired future, and make decisions accordingly.[9] Although not all participants agreed that mental illness as the only underlying medical condition was appropriate for MAiD eligibility, many participants agreed that patient autonomy in decision-making was paramount and should be respected. However, autonomy as an ethical principle does not immediately grant all persons with mental illness the option to access MAiD. There are multiple eligibility criteria for those who wish to receive MAiD, which still must be approved and assessed. Currently, eligibility criteria for MAiD states that individuals must “give informed consent to receive MAiD, meaning that the person has consented to receiving MAiD after they have received all information needed to make this decision.”[10] Consent requires capability or capacity, which is the ability to understand relevant information, appreciate its potential consequences, and make an informed decision for oneself.[11] Like for many other diseases, disabilities, and conditions, patient capability is determined on a case-by-case basis.[12] Given the stigma surrounding those struggling with mental health, this thorough case-by-case examination of an individual patient’s capability and capacity without prejudice or partiality should lead to equitable and fair treatment. Without appropriate testing, those with mental illness could be wrongly stripped of their decision-making power. Arguments against MAiD for those with mental illness have raised concerns about the potential for individuals to harm themselves and others. A survey of MAiD providers demonstrated that physicians believed that the bereavement experience following MAiD is challenging and profoundly distinct and that bereavement support for all members involved should be required.[13] However, while watching one die (of MAiD) may cause harm to their families, friends, and support system at large, it is also important to recognize that watching someone suffer and struggle through their mental health journey also poses significant harm. Qualitative studies in Ontario, Canada, have interviewed family members of persons with mental illness as a sole medical condition, and interviewees shared that witnessing the illness and its impacts on their close one's lives was a very difficult experience.[14] As it relates to MAiD, participants emphasized that those living with mental illness are in the best position to understand their own pain and suffering and, in turn, make their own decisions about relief.[15] In an interview, a MAiD provider stated that MAiD may provide less suffering and more peace, and that, although it “depends on the family,... usually the family is more prepared and at peace.”[16] On the contrary, a person who has mental illness may perceive choosing MAiD as beneficial to their family member(s) and/or friend(s). Among those who died by MAiD in 2021, 35.7 percent reported that they perceived themselves as a burden on their family and friends.[17] While some authors report their concerns regarding such social burden as a potential driving factor for MAiD requests, others report that there are other additional burdens associated with requesting MAiD that may be financial, societal, and personal.[18] As such, the extension of MAiD eligibility to those with mental illness will likely only allow a small number of people to be granted MAiD.[19] Many others will be diverted to appropriate services and treatments. Patients’ decision to choose MAID noted their ability to make choices about their own care, reflecting the value of autonomy.[20] Although it is difficult to determine what is good for families in individual cases, MAiD presents an option that is both beneficent and non-maleficent. Therefore, these arguments satisfy the principles which do not necessarily conflict with MAiD. Deontology: The Duty to Recognize Vulnerability and Relieve Suffering The argument here begins with the fundamental focus of deontology—that moral duty lies in an action rather than in its consequences. Further discussion is required to analyze the impact of MAiD on healthcare workers. The Canadian Medical Association (CMA) Code of Ethics and Professionalism requires physicians to abide by virtues, commitments, and responsibilities in delivering health care and service.[21] The code states that “a compassionate physician recognizes suffering and vulnerability, … and alleviate[s] the patient’s suffering.”[22] In the context of MAiD for persons with mental illness as a sole underlying medical condition, vulnerabilities could be wide in range. Many Canadians are concerned with the interaction between mental health and other social determinants of health, such as the lack of medical, disability, financial, housing, and social support and resources.[23] As a result, another layer to the ethical issue arises: Does permitting MAiD for mental illness treat the symptoms of the issue rather than the root problem itself (social, economic, and systemic inequities)? Some argue against MAiD, stating that the nation should first focus on developing better quality care and service.[24] Others support MAiD as a potential harm reduction approach, given that most of these unjust conditions require a higher level of long-term structural and public policy overhaul.[25] The CMA Code also calls upon physicians to recognize and alleviate patients’ suffering. Some argue that while physicians and medical professionals do work to relieve suffering, they are trained to do so through a primary care-based diagnose-and-treat approach.[26] Studies that have captured Canadian physicians’ experiences providing MAiD report that, although physicians stated that the work was rewarding, it came with many challenges, including strained relationships with coworkers, increased workload, and inadequate compensation.[27] Physicians report that a part of the problem is that MAiD rules are written by lawyers and experts who are removed from its reality in medical practice. As a result, there is a lack of clarity surrounding practice norms and a lack of support for physicians.[28] Thus, while healthcare practitioners have a duty to relieve patients’ suffering, they should feel adequately trained and supported in doing so. If physicians and healthcare professionals recognize vulnerability and relieve suffering, then they should act accordingly, regardless of potential associations or outcomes. Making persons with mental illness eligible for MAiD ensures that treatment to relieve their suffering is available. However, it is imperative that there are sufficient resources and support available to healthcare professionals to ensure that they feel prepared and supported to provide MAiD, should they wish to do so. Utilitarianism: Minimizing Intolerable Suffering and Dying with Dignity Overall, utilitarianism is largely concerned with the greatest happiness principle—to increase the amount of happiness for the greatest number of people. So far, this paper has analyzed individual, family, and practitioner-based ethical considerations. But if MAiD were to be extended to those with mental illness as a singular underlying medical condition, what implications would this have for the world and society at large? There is a global drive toward authorizing organized ending of life, with an increasing number of countries legalizing MAiD.[29] The medical system is generally seen as a safe and appropriate system to carry out MAiD, especially when suicide and self-harm are regarded as “alternatives.” Yet despite these worldwide efforts, many argue through the theory of utilitarianism that the inability to see long-term consequences renders MAiD a premature solution, particularly for those who are unable or unwilling to seek other forms of potentially healing treatment or for those who may undergo MAiD only for a technological innovation or biomedical advancement to later come along as a potential cure.[30] While it is true that MAiD does not prevent these “premature deaths,” it is also true that it does not claim to.[31] MAiD provides an option to alleviate intolerable suffering. Some individuals with severe mental illness do describe their condition as intolerable suffering. MAiD is seen as an option to minimize suffering. It can also be seen as a way to die with dignity and relief.[32] While predicting outcomes is difficult, extending MAiD eligibility for persons experiencing mental illness does not undermine its ability to end suffering. It allows eligible individuals to take charge of their health, their life, and their future. Conclusion Based on the current evidence, allowing MAiD for persons with mental illness as their sole underlying medical condition presents as an ethically justifiable action. The right to self-determination and fair accessibility demonstrates that there is more harm done by prohibiting MAiD for mental illness than allowing it. Such liberty is a right, and in the context of relieving suffering, it is a duty that healthcare workers must uphold, although the ability to opt out of providing MAiD is well established. Thus, to recognize vulnerability and relieve suffering means to provide methods, such as MAiD, for those deeply impacted by mental illness. These justifications stand at both the individual level and for society at large. Nevertheless, it remains imperative to take an upstream approach that addresses the social determinants of health and aims to prevent mental illness and promote long-term, beneficial social change for those suffering, struggling, and vulnerable in our communities. - [1] Jaro Kotalik and David W. Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives, 1st ed. 2023., The International Library of Bioethics, 104 (Cham: Springer International Publishing, 2023), https://doi.org/10.1007/978-3-031-30002-8. [2] Department of Justice Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law,” February 21, 2024, https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html. [3] Health Canada, “Final Report of the Expert Panel on MAiD and Mental Illness,” transparency - other, May 13, 2022, https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advi sory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.html. [4] Federal Public Service (FPS) Health Belgium, “Federal Commission for the Control and Evaluation of Euthanasia,” n.d., https://consultativebodies.health.belgium.be/en/advisory-and-consultative-bodies/federal-commission- control-and-evaluation-euthanasia.; Government of Netherlands, “Is Euthanasia Allowed in the Netherlands?,” n.d., https://www.government.nl/topics/euthanasia/is-euthanasia-allowed.; “Information on Requesting Euthanasia or Assisted Suicide,” n.d., https://guichet.public.lu/en/citoyens/sante/fin-vie/euthanasie/euthanasie-assistance-suicide.html. [5] Luis Espericueta, First official report on euthanasia in Spain: A comparison with the Canadian and New Zealand experiences, Medicina Clínica (English Edition), Volume 161, Issue 10, 2023, Pages 445-447, ISSN 2387-0206, https://doi.org/10.1016/j.medcle.2023.06.021. [6] Government of Canada, “The Canadian Charter of Rights and Freedoms,” March 15, 2021, https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/. [7] Supreme Court of Canada, “Carter v. Canada,” Constitutional Law, 2015, https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do.; Kotalik and Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives. [8] Karandeep Sonu Gaind, “What Does ‘Irremediability’ in Mental Illness Mean?,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 65, no. 9 (September 2020): 604–6, https://doi.org/10.1177/0706743720928656; Lieve Thienpont et al., “Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study,” BMJ Open 5, no. 7 (July 27, 2015): e007454, https://doi.org/10.1136/bmjopen-2014-007454. [9] Hamer Bastidas-Bilbao et al., “Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Qualitative Health Research 33 (September 29, 2023), https://doi.org/10.1177/10497323231197365. [10] Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law.” [11] Commission sur les soins de fin de vie, “Les conditions de l’admissibilité à l’aide médicale à mourir au Québec: la constance dans l’évolution de la loi concernant les soins de fin de vie,” June 9, 2023, https://csfv.gouv.qc.ca/ fileadmin/docs/autres_rapports/csfv_lcsfv_conditions_ amm_2023-06-29.pdf.; Trudo Lemmens, “When Death Becomes Therapy: Canada’s Troubling Normalization of Health Care Provider Ending of Life,” The American Journal of Bioethics 23, no. 11 (November 2, 2023): 79–84, https://doi.org/10.1080/15265161.2023.2265265. [12] Justine Dembo, Udo Schuklenk, and Jonathan Reggler, “‘For Their Own Good’: A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) Where Mental Illness Is the Sole Underlying Condition,” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie 63, no. 7 (July 2018): 451–56, https://doi.org/10.1177/0706743718766055. [13] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020). [14] Bastidas-Bilbao et al., “Walking Alongside.” [15] Bastidas-Bilbao et al. [16] Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” 2020. [17] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025; Health Canada, “Third Annual Report on Medical Assistance in Dying in Canada 2021,” report on plans and priorities;transparency - other, July 26, 2022, https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-me dical-assistance-dying-2021.html; Lemmens, “When Death Becomes Therapy.” [18] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023.; Bastidas-Bilbao et al., “Walking Alongside.” [19] Olivia Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News,” Canadian Broadcasting Corporation, January 28, 2024, https://www.cbc.ca/news/politics/special-joint-committee-maid-mental-illness-report-1.7095679; Benjamin Lopez Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News,” Canadian Broadcasting Corporation, October 27, 2023, https://www.cbc.ca/news/politics/maid-canada-report-2022-1.7009704. [20] Hamer Bastidas-Bilbao et al., “Searching for Relief from Suffering: A Patient-Oriented Qualitative Study on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Social Science & Medicine 331 (August 1, 2023): 116075, https://doi.org/10.1016/j.socscimed.2023.116075. [21] Canadian Medical Association, “Canadian Medical Association Code of Ethics and Professionalism” (Canada: Canadian Medical Association, December 8, 2018), https://policybase.cma.ca/link/policy13937. [22] Canadian Medical Association. [23] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News.” [24] John Paul Tasker, “Liberal Government Promoting a ‘culture of Death’ with Medical Assistance in Dying Law, Conservative MP Says | CBC News,” Canadian Broadcasting Corporation, March 6, 2023, https://www.cbc.ca/news/politics/culture-of-death-medical-assistance-in-dying-mental-illness-1.67695 04. [25] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Kayla Wiebe and Amy Mullin, “Choosing Death in Unjust Conditions: Hope, Autonomy and Harm Reduction,” Journal of Medical Ethics, April 26, 2023, https://doi.org/10.1136/jme-2022-108871. [26] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025. [27] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020), https://bcmj.org/articles/attitudes-and-expectations-regarding-bereavement-support-patients-family-m embers-and.; William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 9, 2021): 93–98, https://doi.org/10.7202/1084456ar. [28] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023. [29] Lemmens, “When Death Becomes Therapy.” [30] William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 1, 2021): 93–98, https://doi.org/10.7202/1084456ar. [31] Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News.” [32] A. Plaisance et al., “Quebec Population Highly Supportive of Extending Medical Aid in Dying to Incapacitated Persons and People Suffering Only from a Mental Illness: Content Analysis of Attitudes and Representations,” Ethics, Medicine and Public Health 21 (April 1, 2022): 100759, https://doi.org/10.1016/j.jemep.2022.100759. (shrink)

Background One of the objectives of medicine is to relieve patients' suffering. As a consequence, it is important to understand patients' perspectives of suffering and their ability to cope. However, there is poor insight into what determines their suffering and their ability to bear it. Purpose To explore the constituent elements of suffering of patients who explicitly request euthanasia or physician-assisted suicide (EAS) and to better understand unbearable suffering from the patients' perspective. Patients and (...) methods A qualitative study using in-depth face-to-face interviews was conducted with 31 patients who had requested EAS. The grounded theory approach was used to analyse the data. Results Medical, psycho-emotional, socio-environmental and existential themes contributed to suffering. Especially fatigue, pain, decline, negative feelings, loss of self, fear of future suffering, dependency, loss of autonomy, being worn out, being a burden, loneliness, loss of all that makes life worth living, hopelessness, pointlessness and being tired of living were constituent elements of unbearable suffering. Only patients with a psychiatric (co)diagnosis suffered unbearably all the time. Conclusions Unbearable suffering is the outcome of an intensive process that originates in the symptoms of illness and/or ageing. According to patients, hopelessness is an essential element of unbearable suffering. Medical and social elements may cause suffering, but especially when accompanied by psycho-emotional and existential problems suffering will become ‘unbearable’. Personality characteristics and biographical aspects greatly influence the burden of suffering. Unbearable suffering can only be understood in the continuum of the patients' perspectives of the past, the present and expectations of the future. (shrink)

Playing with correct intonation is one of the major challenges for a string player. A player must learn how to physically reproduce a target pitch, but before that, the player must learn what correct intonation is. This requires audiation- the aural equivalent of visualization- of every note along with self-assessment whether the pitch played matches the target, and if not, what action should be taken to correct it. A challenge for successful learning is that much of it occurs (...) during practice, typically without outside supervision. A student who has not yet learned to hear correct intonation may repeatedly practice out of tune, blithely normalising bad habits and bad intonation. The real-time reflective nature of intonation and its consistent demand on attention make it a ripe target for technological intervention. Using a violin augmented to combine fingerboard sensors with audio analysis for real-time pitch detection, we examine the efficacy of three methods of real-time feedback for improving intonation and pitch learning. The first, aural feedback in the form of an in-tune guide pitch following the student in real-time, is inspired by the tradition of students playing along with teachers. The second is visual feedback on intonation correctness using an algorithm optimised for use throughout normal practice. The third is a combination of the two methods, simultaneously providing aural and visual feedback. Twelve beginning violinists, including children and adults, were given four in-situ 20-30 minute lessons. Each lesson used one of the intonation feedback methods, along with a control lesson using no feedback. We collected data on intonation accuracy and conducted interviews on student experience and preference. The results varied by player, with evidence of some players being helped by the feedback methods but also cases where the feedback was distracting and intonation suffered. However interviews suggested a high level of interest and potential in having such tools to help during practice, and results also suggested that it takes time to learn to use the real-time aural and visual feedback. Both methods of feedback demonstrate potential for assisting self-reflection during individual practice. (shrink)

La Ética es la parte de la filosofía práctica que se ocupa del hecho moral y de los problemas filosóficos que nacen de la conducta humana, la bioética resulta la rama de la ética que se dedica a proveer los principios para la correcta conducta humana; respecto a la vida. En el proceso de atención a los pacientes con enfermedades reumáticas se emplean variados procedimientos. Las nuevas tecnologías han mejorado notablemente su tratamiento integral; estos adelantos científicos deben ser empleados con (...) la intención fundamental de no producir daño y previo consentimiento informado; por lo que resulta necesario argumentar acerca de las implicaciones bioéticas que resultan del empleo de los avances científico-tecnológicos en el tratamiento a los pacientes con enfermedades reumáticas. Ethics is the part of Practical Philosophy that deals with moral facts and philosophical problems that have their roots in human behavior. Bioethics is the branch of Ethics devoted to providing the principles for correct human behavior, with respect to life. Various procedures are used when treating patients with rheumatic diseases. New technologies have considerably improved their integral treatment; these scientific advances must be used with the main purpose of causing no harm and with prior informed consent. Therefore, it is necessary to argue on the bioethical implications that turn out from the use of scientific-technological advances in the treatment of patients with rheumatic diseases. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Eschatology, Sacred and Profane* PHILIP MERLAN LET ME BEGINthis paper with a double motto. The first is from a German poet, C. F. Meyer. It reads in my own translation: "We hosts of the dead ones--more numerous are we--than you who tread the earth and you who sail the sea." The second is a piece of statistical information for the correctness of which, however, I cannot vouchsafe. It (...) reads: "From the time when man first appeared, 77 billion people have been born. Thus, today's population of about 3 billion represents only 4 per cent of all men ever born" (Universitas 6 [1964], p. 423). With these two mottoes in mind let me proceed. Kant is one of the great representatives of the belief both in a goal to history and in progress. As he sees it, this goal is one world-wide society living under one law, which law coincides with the demands of morality, or as we could also say, in which legality and morality at least do not conflict. Kant is convinced that nature will by-and-by compel man to establish this world-wide society characterized, among other things, by eternal peace. Thus, Kant is an optimist with regard to the future. Yet, he is profoundly pessimistic with regard to the past. For him, history is one long chain of sufferings inflicted on man by man; and on the whole he has a very dim view of man's nature. The synthesis of his pessimism with his optimism is contained in a remarkable sentence which we find in one of his last writings--1793, when Kant was 69. The title is On the Adage--This May be Right in Theory, But Is Inapplicable to Practical Purposes, and here he says: When one contemplates the evil which in the course of history man has inflicted on man, one would be inclined to give up in despair. But there is one thought on the thinking of which our mind will cheer up. It is the thought: things will improve in the future. This kind of cheer will be entirely benevolent and unselfish, for this improvement will take place after we * I am indebted for the posthumous edition of this paper of my late husband Philip Merlan to Professor Frederick Sontag of Pomona College. My husband prepared this paper for, and read it to, various philosophical groups. In the course of these readings, he made numerous pencil additions. Thus, what Professor Sontag has done, is to change the tone to suit a printed presentation and to work the additions into the text as the logic of the arguments and notes seemed to dictate. Franciszka Merlan. [193] 194 HISTORY OF PHILOSOPHY have been buried for a long, long time. We ourselves will not be able to harvest what we ourselves have helped to plant. (WW8, 273-13) In whose name did Kant speak? Who are the altruists who feel cheered up by the prospect of a goal which they themselves will not live to reach? No easy answer can be found in Kant's writings. However it would not be surprising if Kant, a Rousseauian in so many respects, retained some of Rousseau's belief in the innate goodness of man (in spite of his pietistic heritage which encourages him to see man as thoroughly corrupt). Thus, he expects everybody to be capable of this altruistic attitude. We all do then cheer up when we think of the prospects for mankind. This means that our altruism permits us in some way to participate in mankind's bright future, to reach the goal, if I may say so, in hope and expectation, though not physically. For Kant the problem of history was never in the center of his own interest, nor would he have admitted that it is of central importance for man. Hegel's attitude is quite different. Man's participation in history is Hegel's main topic. At this point let me remind you briefly of Hegel's fundamental ideas. The enlightenment and romanticism produced two highly characteristic interpretations of religion. According to the former, the kernel of every religion is morality. According to the latter, the... (shrink)

Before Euro-American settlement, many Native American nations intercropped maize (_Zea mays_), beans (_Phaseolus vulgaris_), and squash (_Cucurbita pepo_) in what is colloquially called the “Three Sisters.” Here we review the historic importance and consequences of rejuvenation of Three Sisters intercropping (3SI), outline a framework to engage Native growers in community science with positive feedbacks to university research, and present preliminary findings from ethnography and a randomized, replicated 3SI experiment. We developed mutually beneficial collaborative research agendas with four Midwestern (...) US Native American nations. Ethnographic data highlighted a culturally based respect for 3SI as living beings, the importance it holds for all cultural facets of these Native nations, and the critical impact the practice has on environmental sustainability. One concern expressed by Native growers during ethnographic research was improving soil health—part of the rationale for establishing the 3SI agronomic experiment. To address this, we collaboratively designed a 3SI experiment. After 1 year, 3SI increased short-term soil respiration by 24%, decreased salt-extractable nitrate by 54%, had no effect on soil microbial biomass (but increased its carbon-to-nitrogen ratio by 32%) compared to the average of monoculture crops. The overarching purpose of this collaborative project is to develop a deeper understanding of 3SI, its cultural importance to Native communities, and how reinvigorating the practice—and intercropping in general—can make agroecosystems more sustainable for people and the environment. (shrink)

Individuals with a balanced time perspective, which includes good thoughts about the past, awareness of present constraints and adaptive planning for a positive future, are more likely to report optimal wellbeing. However, people who have had traumas such as adverse childhood experiences (ACEs) are likely to have less balanced time perspectives and lower overall wellbeing when compared to those with fewer or no ACEs. Time perspective can be improved viatime-travel narrativesthat support people in feeling connected to a wise (...) and loving future version of themselves, an approach that has until now only been provided in counseling contexts. Our team used an iterative inclusive design process to shape a scalable time-travel narrative tool – a responsive and progressive web application calledTime Machine.Among other functionalities, Time Machine allowed people to record and listen to messages as if they were from and to their past and future selves. Using pre-planned as well aspost-hocanalyses, we analyzed quantitative and qualitative data from 96 paid design partners (participants) who were taken through a 26-day pilot study of the technology. Among other effects, the results revealed: (1) high engagement throughout the design process, (2) improvements in self-reported time perspective and overall wellbeing scores that were greater for those using Time Machine during an optional-use period, (3) twice as much improvement in overall wellbeing scores for design partners with high ACEs (16%) versus low ACEs (8%), and (4) feelings of unconditional love apparently mediating the relationship between scores on time perspective and overall wellbeing measures. We discuss the limitations of these results as well as implications for the future role of spiritually informed scalable time-travel narrative technologies in healthcare and wellness. (shrink)

Dutch euthanasia legislation states that an act of euthanasia is only permissible if it is based on a voluntary request made in a situation of unbearable suffering to which there are no alternatives.The central question of this article is whether these criteria can be satisfied simultaneously. In an analysis of several (partly overlapping) definitions of voluntariness it is argued that there are circumstances in which this question should be answered negatively.The possible incompatibility of the criteria reveals a tension (...) between different defences of the permissibility of euthanasia. (shrink)

Ng :255–285, 1995. https://doi.org/10.1007/bf00852469) models the evolutionary dynamics underlying the existence of suffering and enjoyment and concludes that there is likely to be more suffering than enjoyment in nature. In this paper, we find an error in Ng’s model that, when fixed, negates the original conclusion. Instead, the model offers only ambiguity as to whether suffering or enjoyment predominates in nature. We illustrate the dynamics around suffering and enjoyment with the most plausible parameters. In our (...) illustration, we find surprising results: the rate of failure to reproduce can improve or worsen average welfare depending on other characteristics of a species. Our illustration suggests that for organisms with more intense conscious experiences, the balance of enjoyment and suffering may lean more toward suffering. We offer some suggestions for empirical study of wild animal welfare. We conclude by noting that recent writings on wild animal welfare should be revised based on this correction to have a somewhat less pessimistic view of nature. (shrink)

Argument-mapping software abounds, and one of the reasons is that using the software has been shown to teach/promote/improve critical thinking skills. These positive results are very encouraging, but they also raise the question of whether the computer tutorial environment is producing these results, or whether learning argument mapping, even with just paper and pencil, is sufficient. Based on the results of two empirical studies, I argue that the basic skill of being able to represent an argument diagrammatically plays an (...) important role in the improvement of critical-thinking skills. While these studies do not offer a direct comparison between the two methods, it is important for anyone wishing to employ argument mapping in the classroom to know that significant results can be obtained even with the most rudimentary of tools. (shrink)

Uterus transplantation is a relatively new intervention. A woman with absolute uterine factor infertility receives, by a surgical procedure, a transplanted uterus, most often by living donation. The uterus recipient may thus become pregnant and conceive her own child. As with any other medical treatment, UTx requires legitimation. The anticipated benefits must outweigh the risks of the medical intervention. The risks and benefits of UTx are by no means unequivocal and cannot be easily determined. The benefits depend on (...) the final evaluation of the suffering to be alleviated by the intervention. In the following, we will analyze the suffering addressed by UTx and discuss its normative value. First, we point out that (a) suffering is generally considered an important normative criterion in medicine as well as in the context of UTx; (b) we then describe the risks and anticipated benefits of UTx for the three persons directly concerned: the child, the donor, and the recipient; (c) we further analyze the suffering addressed by UTx. The intervention addresses a form of existential suffering. We discuss the common notion that existential suffering should be evaluated from the subjective perspective of the sufferer; (d) afterwards, we argue that in a social practice like medicine, a one‐sided evaluation stemming from the sufferer alone is not sufficient; and (e) finally, arguments from a societal perspective lead us to the conclusion that the existential suffering addressed by UTx does not possess a sufficiently strong normative value to legitimize a high‐risk, expensive procedure. (shrink)

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

Jukka Varelius1 ,2 and others3 have advocated that medically assisted dying should be made available on request to competent individuals experiencing ‘existential suffering’. Unlike Cassell and Rich, Varelius believes that existential sufferers do not have to be terminally ill before being helped to die. He does not regard ‘existential suffering’ on its own as sufficient to justify voluntary medically assisted dying, but believes it to be one of a set of jointly sufficient conditions . In ‘Medical expertise, existential (...) suffering and ending life’, however, he aims only to show that if physicians have the expertise required to assess when suffering consequent upon illness or injury is unbearable, that they can equally have that expertise when confronted with ‘existential suffering’. In what follows, I will neither be endeavouring to refute his more general claim , nor his argument in the present paper. Rather, I will offer two reasons for thinking that even if it is sound it is of limited practical significance.First, Varelius outlines his position without reference to relevant political considerations. He distances himself from what he terms the ‘conventional view’, namely, that voluntary medically …. (shrink)

In this article, I assess the position that voluntary euthanasia and physician-assisted suicide ought not to be accepted in the cases of persons who suffer existentially but who have no medical condition, because existential questions do not fall within the domain of physicians’ professional expertise. I maintain that VE and PAS based on suffering arising from medical conditions involves existential issues relevantly similar to those confronted in connection with existential suffering. On that basis I conclude that if (...) VE and PAS based on suffering arising from medical conditions is taken to fall within the domain of medical expertise, it is not consistent to use the view that physicians’ professional expertise does not extend to existential questions as a reason for denying requests for VE and PAS from persons who suffer existentially but have no medical condition. (shrink)

In a recent article, Marilyn Baffoe-Bonnie offers three arguments for conducting CRISPR/Cas9 biotechnology research to cure sickle-cell disease (SCD) based on addressing historical and current injustices in SCD research and care. I show that her second and third arguments suffer from roughly the same defect, which is that they really argue for something else rather than for conducting CRISPR/Cas9 research in particular. For instance, the second argument argues that conducting this gene therapy research would improve the relationship between SCD sufferers (...) (who are mostly of African descent) and health care providers. But really what is essential in improving this relationship is for those providers to genuinely care and be concerned, and this could be lacking even with the CRISPR research being done. Indeed, this relationship could be improved even without that research being done, as long as there is genuine concern. Thus, this argument actually argues for the need for genuine concern. As for the third argument, one (of two) problems arises because it claims that CRISPR research for SCD should be pursued because the benefits would be shared by even non-research-participants, as non-participants would be encouraged. However, this argues for any research for SCD, not for CRISPR research in particular. I conclude that a better justice-based argument will use only Baffoe-Bonnie’s first argument, which is based on historic neglect of an actual cure for SCD (going beyond merely management or transplant therapies). (shrink)

This essay explores the possibility that religiously motivated intolerance and conflict can be reframed and positively utilized for constructive social-political purposes. After reviewing efforts by political philosophers over the past two decades to accommodate religious voices in political discourse, I scrutinize Charles Taylor’s attempt to improve upon the limits of “accommodationist” approaches to religious intolerance and conflict. I argue that both accommodationist and Taylor’s recognition-based approaches to religiously motivated conflict take the gravity of such conflict with insufficient seriousness. I (...) then explore the potential goods of intentional conflict by examining Chantal Mouffe’s account of agonistic pluralism as a proposal for thinking beyond tolerance as an orienting value for resolving intransigent conflict. While I argue that Mouffe’s account finally suffers from certain of the same misgivings as the accommodationist and recognition-based approaches, I conclude that agonistic pluralism’s aim to conceptually reframe (rather than eliminate) intolerance and conflict moves in an important and promising direction. (shrink)

Informed consent has become one of the central problems in medical ehtics. At first sight, it would seem that no argument can be made against a person's right to be fully aware of the extent, course, and implications of his medical condition. It seems equally obvious that it is the patient's right to participate in, influence, or fully and solely assume the decisions of medical actions that should be undertaken or withheld with regard to his disease. Nevertheless, there are (...) circumstances in which these commonly held assumptions about a patient's rights may not apply. It is the purpose of this report to describe a case where informed consent was deliverately not sought, and to discuss the ethical issues involved. (shrink)

Academic writing, even in prestigious journals, is frequently ugly and arduous. The writing in academic philosophy is no exception, especially given philosophers’ tendency to overlook prose and to focus exclusively on philosophical content. This paper argues that good prose matters for moral, prudential, and philosophical reasons. After glossing these reasons, the authors offer advice, born of experience, to academic writers who want to achieve clear, effective prose. Their advice includes how to improve sentence structure (e.g. eliminate undue repetition and forms (...) of “to be,” be careful with comma use, evaluate sentences by reading them aloud), global considerations (e.g. use technical notation cautiously, avoid prose in footnotes, read and report opponents’ views with charity), how to practice reiterating the same point in different words (e.g. play language games likes crossword puzzles, read non-academic prose, aim to communicate one’s point succinctly), and the suggestion to take prose seriously in the evaluation of student work. (shrink)

The case of nonvoluntary euthanasia shows that the current definition of euthanasia must be more accurately determined. Euthanasia refers necessarily to the ending of life due to serious illness which must be expanded to include the lack of any capacity to give sense to life. A person in this latter position would be under lasting and unbearable suffering, perhaps unconscious, and incapable of leading her own life. The ethics of euthanasia must take these considerations into account. The will (...) does not found the ethical decision. This is based instead on the reasonableness of continuing life under these circumstances. Voluntary euthanasia, as well as nonvoluntary, is founded on the right that every person who suffers under these conditions has to put an end to her life. It is understood that this is the only way to escape from such misfortune when life does not make sense any longer. The topic of euthanasia has a political dimension that is associated with the contemporary practice of medicine and the defense of human rights in our society. At the foundational level, euthanasis is unitary; the distinction between voluntary and nonvoluntary establishes only further precision, not a fundamental one. (shrink)

Fyodor Dostoyevsky expressed a strange and surprising sentiment through one of the characters of The Brothers Karamazov. A dying young man named Markel declares: Every one of us has sinned against all men, and I more than others." He later says: "...every one of us is answerable for everyone else and for everything." Markel's absurd claims have engendered many reflections on the nature of suffering and what it means to be responsible for someone else's suffering. The world has (...) no shortage of pain and evil; what exactly is the relationship between suffering and responsibility? Markel's declarations press forward a question that drives this essay collection: how responsible should we consider ourselves for the suffering of the world? This volume is a collection of essays that struggle in various ways to understand and respond to several philosophical, theological and practical problems. In each case the authors grapple with issues surrounding suffering, immorality, evil, exploitation and oppression. The contributors share a clear concern for the ways that philosophers and theologians should respond to the problems of suffering and evil. They also share a conviction that these remain intense and central problems for philosophy and theology. Evil is an obstacle for belief, for morality, for hospitality, and for hope. This book struggles to address the particular and strong sense of responsibility that falls on Christians when it comes to understanding and, more importantly, responding to the problems of suffering and evil in the world. (shrink)

In 2017, Tom Gruber held a TED talk, in which he presented a vision of improving and enhancing humanity with AI technology. Specifically, Gruber suggested that an AI-improved personal memory (APM) would benefit people by improving their “mental gain”, making us more creative, improving our “social grace”, enabling us to do “science on our own data about what makes us feel good and stay healthy”, and, for people suffering from dementia, it “could make a difference between a life (...) of isolation and a life of dignity and connection”. -/- In this paper, Gruber’s idea will be critically assessed. Firstly, it will be argued that most of his pro-arguments for the APM are questionable. Secondly, the APM will also be criticized for other reasons, including the risks and affects to the users’ and other’s privacy and the users’ autonomy. (shrink)

Most people believe that suffering is intrinsically bad. In conjunction with facts about our world and plausible moral principles, this yields a pro tanto obligation to reduce suffering. This is the intuitive starting point for the moral argument in favor of interventions to prevent wild animal suffering. If we accept the moral principle that we ought, pro tanto, to reduce the suffering of all sentient creatures, and we recognize the prevalence of suffering in the (...) wild, then we seem committed to the existence of such a pro tanto obligation. Of course, competing values such as the aesthetic, scientific or moral values of species, biodiversity, naturalness or wildness, might be relevant to the all-things-considered case for or against intervention. Still, many argue that, even if we were to give some weight to such values, no plausible theory could resist the conclusion that WAS is overridingly important. This article is concerned with large-scale interventions to prevent WAS and their tractability and the deep epistemic problem they raise. We concede that suffering gives us a reason to prevent it where it occurs, but we argue that the nature of ecosystems leaves us with no reason to predict that interventions would reduce, rather than exacerbate, suffering. We consider two interventions, based on gene editing technology, proposed as holding promise to prevent WAS; raise epistemic concerns about them; discuss their potential moral costs; and conclude by proposing a way forward: to justify interventions to prevent WAS, we need to develop models that predict the effects of interventions on biodiversity, ecosystem functioning, and animals’ well-being. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Suffering, Victims, and Poetic Inspiration Raymund Schwager University ofInnsbruck Poetic inspiration has something to do with the divine. The Greek tragedies are classic examples of that. The poets regarded themselves as inspired by the divine Muses, and in their works the gods are quite naturally present in the lives of human beings. Sometimes the gods treat them in a friendly way, sometimes they spur on conflicts or (...) even inspire human beings to take revenge upon one another. At the end of some tragedies the gods appear as a deus ex machina who brings everything to resolution, or at least pretends to do so. Nevertheless, it is not these various gods, but rather human beings themselves, suffering human beings more precisely, who are at the center of this dramatic event inspired by the divine Muses. Human beings suffer because they come into conflict with each other and fall victim to the vengeful and violent acts of others. In the Greek tragedies human beings do not act in a calm and sensible way. Rather, they are in bondage to their passions, and through these passions the gods speak to them. While performing a sacrifice of purification and thanksgiving, Heracles flies into a rage inspired by several of the goddesses and slaughters his own children. In a Dionysian frenzy Agaue and her companions tear apart her own son. Orestes, believing himself to be obeying a command of Apollo, kills his mother, who had committed adultery and murdered her own husband. And above all, the great, genocidal war of Troy did not so much originate in the longing of Paris for Helen, as in a dispute between the gods. In every respect human beings seem to be more the victims of the gods than themselves wicked persons who commit evil deeds—and they are above all the ones who suffer the most. Helen, the "cause" of the massive slaughter of the Trojan war, is exclusively depicted by Euripides in the role of one who suffers greatly, indeed even beyond the bounds ofhuman endurance. Even Medea, who goes so far as to kill her own children, is not 64Raymund Schwager depicted by the same poet as a moral monster, but as a woman overwhelmed by boundless grief. The gods thus appear in a somewhat murky light: they are indispensable to the poets' purpose yet at the same time severely criticized. For Euripides they are often much worse than human beings. In his Heracles, he goes so far in his irony as to depict the goddess of vengeance herself criticizing Hera, who makes Heracles suffer in order to quench her thirst for revenge which was caused by the unfaithfulness of her husband Zeus. Euripides considers all these stories of gods to be humanly-contrived fables. Nevertheless, he also believes that there can be no drama without the gods. How could the mysterious depths of human passions be understood without the gods? If the poet had no one to indict except other human beings, his works would quickly become nothing but tepid moral tracts. The gods are indispensable and yet they must be criticized: the poetic inspiration in the Greek tragedies thrives on ambiguity. Suffering humanity is confronted with an incomprehensible fate which only the poet's ambiguous parables and images are able to depict. The great suffering figures in the tragedies of Euripides find their echo in another tradition's suffering figure, whose fate is also depicted in poetic words. A suffering figure who also both listens to and argues with his God: Job. A misfortune has befallen Job, which he simply cannot understand. And while even his alleged friends torment him, he suffers even more from his God. Job feels persecuted by God, tormented and driven to despair. Job would like to argue with God and even take him to court. But he cannot do so. He experiences God as an invisible enemy who is present everywhere. Nevertheless, he turns to this same God in his deepest distress and is confident of finding a savior in him. The God of Job is contradictory: this is a God on whom Job can rely but with whom he must also struggle. However, it is just this contradiction... (shrink)

Quality and service improvement (QSI) research employs a broad range of methods to enhance the efficiency of healthcare delivery. QSI research differs from traditional healthcare research and poses unique ethical questions. Since QSI research aims to generate knowledge to enhance quality improvement efforts, should it be considered research for regulatory purposes? Is review by a research ethics committee required? Should healthcare providers be considered research participants? If participation in QSI research entails no more than minimal risk, is consent (...) required? The lack of consensus on answers to these questions highlights the need for ethical guidance. Three distinct approaches to classifying QSI research in accordance with existing ethical principles and regulations can be found in the literature. In the first approach, QSI research is viewed as distinct from other types of healthcare research and does not require regulation. In the second approach, QSI research falls within regulatory guidelines but is exempt from research ethics committee review. In the third approach, QSI research is deemed to be part of the learning healthcare system and, as such, is subject to a different set of ethical principles entirely. In this paper, we critically assess each of these views. While none of these approaches is entirely satisfactory, we argue that use of the ethical principles governing research provides the best means of addressing the numerous questions posed by QSI research. (shrink)

This paper is a tribute to Rajendra Swaroop Bhatnagar. Bhatnagar Saab was a philosopher of the here and now, of the worldly, of the social, who did not hesitate to look into violence, poverty, pain, and suffering. He was an activist through his writings, and worked to establish social awareness. Metaphysics and the spiritual, considered by many as a central leitmotif of Indian philosophy, he saw as secondary or even marginal. The first part of the paper surveys and contextualizes (...) Bhatnagar Saab’s work as a philosopher and translator of Plato into Hindi. The second part of the paper is a multilingual manifesto, which calls attention to philosophy in Hindi and other modern Indian languages and challenges the over-dominance of English. The third part of the paper is a jugalbandi, a philosophical duet. It includes one of Bhatnagar’s last essays, “No Suffering if Human Beings Were Not Sensitive”, published here for the first time, interwoven with my “commentary,” in which I aim to amplify different points raised by him and to expand the boundaries of the discussion. The main theme to be addressed is suffering. What could be more relevant during the present Covid-19 days? (shrink)

This paper analyses the current organ donor card system in Switzerland and identifies five problems that may be partially responsible for the country’s low deceased organ donation rates. There are two minor issues concerning the process of obtaining a donor card: the Swisstransplant website understates the prospective benefits of donation, and the ease with which donor cards can be obtained raises questions regarding whether any consent to donation provided is truly informed. Furthermore, there are two major practical problems that (...) might affect those who carry an organ donor card: the lack of a central donor registry increases the likelihood that donors’ wishes will be “lost”, and there is a high probability that family members will veto organ donation. The fact that these two practical problems are not mentioned to potential donors by Swisstransplant constitutes the fifth problem. Donation rates would probably improve if more accurate information about the benefits of donation was provided to potential donors, a central donor registry was created, and families were not permitted to veto donation from those on the registry. (shrink)

In 1999 Dean Zimmerman proposed a "falling elevator model" for a bodily resurrection consistent with materialism. Recently, he has defended the model against objections, and a slightly different version has been defended by Timothy O’Connor and Jonathan Jacobs. This article considers both sets of responses, and finds them at best partially successful; a new objection, not previously discussed, is also introduced. It is concluded that the prospects for the falling-elevator model, in either version, are not bright.

As improvements in neuroscience have enabled a better understanding of disorders of consciousness as well as methods to treat them, a hurdle that has become all too prevalent is the denial of coverage for treatment and rehabilitation services. In 2011, a settlement emerged from a Vermont District Court case, Jimmo v. Sebelius, which was brought to stop the use of an “improvement standard” that required tangible progress over an identifiable period of time for Medicare coverage of services. While the (...) use of this standard can have deleterious effects on those with many chronic conditions, it is especially burdensome for those in the minimally conscious state, where improvements are unpredictable and often not manifested through repeatable overt behaviors. Though the focus of this paper is on the challenges of brain injury and the minimally conscious state, which an estimated 100,000 to 200,000 individuals suffer from in the United States, the post-Jimmo arguments presented can and should have a broad impact as envisioned by the plaintiffs who brought the case on behalf of multiple advocacy groups representing patients with a range of chronic care conditions. (shrink)

Maritime services form an integral part of what regulatory agencies requires for the safe navigation and operation of vessels. Therefore, the maritime industry?s compliance with governmental regulations and international protocols has been essential for maritime safety management. As a basis to this aspect, the preparation of maritime students as the forthcoming maritime officers in the future has been a crucial point by the maritime educators in terms of maritime safety. Although English was adopted as the official language of the (...) maritime industries by the International Convention on Standards of Training, Certification and Watchkeeping (STCW Convention) in 1978, many difficulties remain in the teaching and assessing of Maritime English at maritime schools. Some research has examined these difficulties; however, no successful models for improving. Maritime English have been adopted Parallel to the teaching and assessing problems, there have also been many difficulties in reaching a training and testing proficiency in English communication that meets the international standards of the STCW requirements in the maritime industry. This paper concentrates upon the difficulties of teaching and assessing the outcomes of the teaching of Maritime Transportation English at the member schools of the International Association of Maritime Universities (IAMU) from all over the world. As a first step in the methodology of this study, a survey of techniques used at member schools of the IAMU is conducted to solve some difficulties in assessing the teaching of Maritime English. Then a positioning model is developed to identify and measure the positions of the IAMU member schools in comparison to one another by using a multidimensional scaling technique to analyse the multivariate data received through questionnaires. This information provides the foundation upon which the model of this research is built. Consequently, some strategies based upon the results of the analysis are developed to reduce the problems and difficulties in this context. (shrink)

Priority setting (also known as resource allocation or rationing) occurs at every level of every health system and is one of the most significant health care policy questions of the 21st century. Because it is so prevalent and context specific, improving priority setting in a health system entails improving it in the institutions that constitute the system. But, how should this be done? Normative approaches are necessary because they help identify key values that clarify policy choices, but insufficient because different (...) approaches lead to different conclusions and there is no consensus about which ones are correct, and they are too abstract to be directly used in actual decision making. Empirical approaches are necessary because they help to identify what is being done and what can be done, but are insufficient because they cannot identify what should be done. Moreover, to be really helpful, an improvement strategy must utilize rigorous research methods that are able to analyze and capture experience so that past problems are corrected and lessons can be shared with others. Therefore, a constructive, practical and accessible improvement strategy must be research-based and combine both normative and empirical methods. In this paper we propose a research-based improvement strategy that involves combining three linked methods: case study research to describe priority setting; interdisciplinary research to evaluate the description using an ethical framework; and action research to improve priority setting. This describe-evaluate-improve strategy is a generalizable method that can be used in different health care institutions to improve priority setting in that context. (shrink)

In On What Matters, Derek Parfit argues that Nietzsche does not disagree with central normative beliefs that ‘we’ hold. Such disagreement would threaten Parfit’s claim that normative beliefs are known by intuition. However, Nietzsche defends a conception of well-being that challenges Parfit’s normative claim that suffering is bad in itself for the sufferer. Nietzsche recognizes the phenomenon of ‘growth through suffering’ as essential to well-being. Hence, removal of all suffering would lead to diminished well-being. Parfit claims (...) that if Nietzsche understood normative concepts in Parfit’s objectivist sense, he would not disagree with the claim that suffering is bad in itself – that intrinsic facts about suffering count in favour of our not wanting it. I argue that Nietzsche would disagree. Suffering for Nietzsche is not merely instrumentally necessary for psychological growth, nor is it easy to construe it as something bad in itself that contributes value as part of a good whole. Suffering that can be given meaning through growth is something we have reason to want. Suffering that remains brute and uninterpreted is something we have reason not to want. But for Nietzsche, suffering as such has no invariant value across all contexts. (shrink)

Continuing an examination of proposed defeaters for Christian belief, I consider in this chapter the question of whether knowledge of the facts of evil constitutes a defeater for theistic and Christian belief. In the first section of the chapter, I focus on versions of the evidential argument from evil, which claims not that the existence of God and the existence of evil are logically incompatible, but only that the facts of evil offer powerful evidence against the existence of God. I (...) first examine two such arguments due to William Rowe and then turn to one due to Paul Draper; I argue that all three fail. In the second section, I consider what we might call a nonargumentative defeater based on suffering and evil; essentially, the claim at issue here is that one who is properly sensitive and properly aware of the sheer horror of the evil displayed in the world will simply see that no being of the sort God is alleged to be could possibly permit it. After exploring and responding to this claim, I close with a brief look at some relevant themes in the Book of Job. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ecological Suffering:From a Buddhist PerspectiveSulak Sivaraksa“There will be great suffering caused by our human-created climate change, but we may need to go through this process in order to see the ‘light.’”—Nigel Crawhall (IUCN, CEESP representative, South Africa)Ecological suffering is the result of centuries of abuse of our Earth and environment. It is the effects of numerous overlapping developments that are unsustainable for the most part. It (...) results from violent actions, whether in the shape of colonialism, industrial development, wars, economic growth, the arms race, or capitalist competition between states. More importantly, it is a flaw inherent in the global capitalist system—which is nevertheless seen as the best system to organize human life—and will bring down both capitalism and human survival if we act as if we don’t know about it. I explicitly name capitalism because without doing so any critique will be simply abstract, moralistic, and toothless—such as blaming greed in general or on particular greedy individuals, on human nature, on civilization, and so on. No. Ecological suffering is the result of systemic violence rooted in the global political economy. Although our world cherishes diversity and choice, it is increasingly intolerant of any form of living that resists free market fundamentalism. Ecological suffering is happening on a daily level even if we feel that nothing is happening. Ecological suffering sustains the normalcy of our everyday life as we drive to work, eat our lunch, talk on our mobile phones, connect to the Internet, and so on. It is woven into our daily existence. As such, we don’t want our daily life to be disturbed and often act as if we don’t know about ecological suffering. But it is also experienced unevenly: the poor majority more so than the rich minority, who for now could still buy their way out of the problem; developing societies more than developed ones; and so on.One thing is certain: Our ecosystem is crashing. What should be a circle of life, of interconnected life forms, has already started to work as individual parts going in different directions, leading to malfunctions and negative consequences in many parts [End Page 147] of the system. At the Inter-Religious Dialogue on Climate Change and Biodiversity Conservation in September 2012, a conclusion that was arrived at the conference was a simple but profound one: It is all connected; we are all connected. As I mentioned in my latest book, Wisdom of Sustainability,1 our world and nature works in the same way as the wheel of Dhamma. The wheel of Dhamma can be used to countenance the wheels of state and systemic violence. This is why tackling the environmental problem needs a religious or spiritual dimension.Below, I will reflect on the problems and challenges we face in coping with the impending ecological catastrophe. I link the postponement of the crisis and sustainability with the cultivation of spirituality in ourselves—that is, to search for what has been uprooted and what we need to reclaim or retrieve. Bringing in Buddhist ethics, I will tease out how an interfaith approach to problem solving can benefit our environment by pointing to some concrete suggestions.The starting points of this talk are drawn from The Wisdom of Sustainability and the conference overview of the Inter-Religious Dialogue on Climate Change and Biodiversity Conservation, and I will alternate between these two points, which also structure my talk. The dialogue was held in Sri Lanka in September 2012, at the Islander Center. It was organized by the International Network of Engaged Buddhists (INEB), the Sewalanka Foundation, International Union for the Conservation of Nature (IUCN) Sri Lanka National Office, and Commission on Environmental Economic and Social Policy (CEESP). At this conference faith leaders, environmental and climate scientists, conservationists, and social activists from all over the world gathered to collaboratively explore the scientific foundations of climate change and biodiversity loss; its social, political, and economic drivers; the impacts of climate change on human societies and the environment; and the underlying human behaviors that contribute to climate change.2The conference used three levels of engagement to frame the creation of a roadmap for action... (shrink)

Most non-human animals live in the wild and it is probable that suffering predominates in their lives due to natural events. Humans may at some point be able to engage in paradise engineering, or the modification of nature and animal organisms themselves, to improve the well-being of wild animals. We may, in other words, make nature 'red in tooth and claw' no more. We argue that this creates a tension between environmental ethics and animal ethics which is likely insurmountable. (...) First, we argue that concern for the environment can be compatible with helping individual wild animals but should see redesigning nature as morally impermissible. Second, we argue that if we are concerned with animal well-being, we may reject that we have a duty to help wild animals even to the point of redesigning nature, but we must nevertheless concede that it is permissible to do so under certain circumstances. We show how this permissibility can be derived from three animal rights views: Tom Regan's, a novel account inspired by Thomas Pogge and a libertarian approach to animal rights. (shrink)

In 2023, thousands of young Norwegian physicians joined an online movement called #legermåleve (#doctorsmustlive) and shared stories of their own mental and somatic health issues, which they considered to be caused by unacceptable working conditions. This paper discusses this case as an extreme example of physicians’ and healthcare workers’ suffering in late modern societies, using Vosman and Niemeijer’s approach of rethinking care imaginaries by a structured process of thinking along, counter-thinking and rethinking, bringing to bear suffering as a (...) heuristic device. Thinking along, taking the physicians’ stories and arguments literally, reveals an image of an unbearable workload. Counter-thinking resituates their suffering within the broader conditions of late modernity, suggesting that the root cause may lie not in the quantity of the workload itself but in its qualities and in its perceived threat to their integrity as caregivers through epistemic and moral injury and an inability to respond to this threat. In rethinking, the ambiguity of suffering– its dual potential as both a constraint and an opening– becomes central. Following the physicians’ own interpretations and the solutions emerging from this framing, both their suffering and that of their patients could paradoxically be exacerbated by further decentering physicians and reinforcing utilitarian, data-driven approaches. However, staying with their suffering and reinterpreting its causes opens possibilities to leverage critiques of medicalization at large and of their own suffering in particular, challenging the assumption that the weight of care must always grow heavier. From this reframing, I argue, it is possible to reclaim and reimagine care and the clinical space as a nexus of epistemic and moral privilege, recentering response-ability both relationally and socially. (shrink)

Suffering evokes moral and metaphysical reflection, the bioethics of suffering concerns the proper ethos of living with suffering. Because empirical and philosophical explorations of suffering are imprisoned in the world of immanent experience, they cannot reach to a transcendent meaning. Even if religious and other narratives concerning the meaning of suffering have no transcendent import, they can have aesthetic and moral significance. This understanding of narratives of suffering and of their custodians has substantial (...) ecumenical implications: chaplains can function as general custodians of narratives and sustainers of a generic religious meaning. This understanding is contrary to traditional Christianity, which discloses a transcendent significance of human suffering found in a very particular history involving particular persons: Christ as the second Adam through the submission of the second Eve has taken on our nature so that we can be united with God. Human suffering is tied to human sin, not simply as a punishment for sin, much less as an opportunity to discharge a supposed temporal punishment due to sin. Human suffering is the result of our rebellious free choices. It provides an opportunity for humility and submission, so that, united to the cross of Christ, sin can be forgiven and suffering set aside in the Resurrection. Knowledge of this framing context for all human suffering is accessible not through rational argument. It is a knowledge garnered through repentance, purification of the heart, illumination by God's grace, and unification with God. Christian bioethics is embedded in the narrative of suffering, which is part of the history of salvation and which encompasses and places all of medicine in its terms. (shrink)

In recent years, there is an increasingly higher number of people who believe in a prevalence of suffering over welfare in nature. This belief is usually coincident with a sentiocentric axiology according to which what is morally relevant are the mental states of pleasure and pain. This combination leads to the diagnosis that the prevalence of suffering has an enormous moral significance. This paper rejects this traditional line of thought and instead argues that could not be coherent. (...) The claim that there is an ontological prevalence, in the abstract, of suffering in nature is unproblematic. However, the same is not true when considering its moral relevance. A sentiocentrist cannot consider an aggregationist calculation to be morally valuable, strictly speaking, since there is no subject that feels it. Nevertheless, the need for positive intervention in nature with the aim of reducing existing suffering could remain. (shrink)

The problem of suffering crucially focuses on meaninglessness. Meaningful suffering—suffering having some “point” or function—is not as problematic as absurd suffering that cannot be rendered purposeful. This issue is more specific than the problem of the “meaning of life” (or “meaning in life”). Human lives are often full of suffering experienced as serving no purpose whatsoever – indeed, suffering that may threaten to make life itself meaningless. Some philosophers—e.g., D.Z. Phillips and John Cottingham—have persuasively (...) argued that the standard analytic methods of philosophy of religion in particular ought to be enriched by literary reading and interpretation, especially when dealing with issues such as this. The problem of evil and suffering can also be explored from a perspective entangling literary and philosophical approaches (Kivistö & Pihlström, 2016). This double methodology is in this paper applied to the problem of evil and suffering by considering an example drawn from Holocaust literature: Primo Levi’s work is analyzed as developing an essentially ethical argument, with a philosophical-cum-literary structure, against theodicies seeking to render suffering meaningful. By means of such a case study, I hope to shed light on the problem of meaningless suffering, especially regarding the moral critique of “theodicist” attempts to interpret all suffering as meaningful. (shrink)

NED HETTINGER | : This essay explores the tension between concern for the suffering of wild animals and concern about massive human influence on nature. It examines Clare Palmer’s animal ethics and its attempt to balance a commitment to the laissez-faire policy of nonintervention in nature with our obligations to animals. The paper contrasts her approach with an alternative defence of this laissez-faire intuition based on a significant and increasingly important environmental value: Respect for an Independent Nature. (...) The paper articulates and defends naturalness value and explores its implications for the laissez-faire intuition and for concern about wild-animal suffering. | : Le présent essai examine la tension entre la préoccupation pour la souffrance des animaux sauvages et celle concernant l’influence massive des humains sur la nature. Il examine l’éthique animale de Clare Palmer, notamment sa tentative d’atteindre un équilibre entre la politique de non-intervention dans la nature dite du « laissez-faire » et nos engagements envers les animaux. L’article propose une approche alternative à celle de Palmer qui, tout en défendant cette intuition du « laissez-faire », se fonde cette fois sur une valeur environnementale significative de plus en plus importante : le Respect pour une Nature Indépendante. Le texte articule et défend la valeur de naturalité et examine les implications de celle-ci pour l’intuition du « laissez-faire » ainsi que pour le souci envers la souffrance des animaux sauvages. (shrink)