In 2015, the ATS/AACN/ACCP/ESICM/SCCM published an official policy statement about responding to requests for potentially inappropriate treatments in intensive care units. The Multiorganization Statement aims to provide guidance for clinicians to prevent and manage disputes about patients with advanced critical illness. Recommendations 2 and 3 focus on terminology and suggest an alternative set of words to define and to help manage medical futility. Recommendations 1 and 4 focus on conflict resolution strategies and the development of new policies or legislation about (...) when life-prolonging technologies should not be used. Schneiderman and colleagues have written an... (shrink)

In The Netherlands, neonatal euthanasia has become a legal option and the Groningen Protocol contains an approach to identify situations in which neonatal euthanasia might be appropriate. In the 5 years following the publication of the protocol, neither the prediction that this would be the first step on a slippery slope, nor the prediction of complete transparency and legal control became true. Instead, we experienced a transformation of the healthcare system after antenatal screening policy became a part of antenatal care. (...) This resulted in increased terminations of pregnancy and less euthanasia. (shrink)

For a minority of children managed in the NICU, there is a need for more complex technologic assistance in order to sustain life, mitigate a more chronic debilitation from a pervasive life-limiting condition, or provide a bridge from life-sustaining therapy to a more semi-permanent treatment such as organ transplantation. This chapter will address two major types of technology assistance for infants and children—tracheostomy and assisted home ventilation, and dialysis—and the myriad complications and considerations that they raise. Some attention to why (...) clinicians may be so inclined to impose technology as a solution to life-limiting conditions will be noted, as well as why some parents may seem to insist on pursuing technology. (shrink)

Given the lack of knowledge about safety and efficacy of many treatments for children, pediatric clinical trials are important, but recruitment for pediatric research is difficult. Little is known about children's perspective on participating in trials. The purpose of this study was to understand the experiences and motivations of young people who took part in clinical trials. This is a qualitative interview study of 25 young people aged 10–23 who were invited to take part in clinical trials. Interviews were audio (...) or video recorded and analyzed using framework analysis. Young peoples' motivations were both personal benefit and helping others. Both incentives appeared to be more complex than expected. We introduce the terms “network of exchange” and “intergenerational solidarity” to describe these motivations. To improve recruitment, professionals should be more open about research opportunities, provide better information, and give young people feedback after the trial has ended. (shrink)

When talking about decisionmaking for children with a life-threatening condition, the death of children with brain tumors deserves special attention. The last days of the lives of these children can be particularly harsh for bystanders, and raise questions about the suffering of these children themselves. In the Netherlands, these children are part of the group for whom a wide range of end-of-life decisions are discussed, and questions raised. What does the end-of-life for these children look like, and what motivates physicians (...) and parents to make decisions that may affect the life and death of these children? This article highlights the story of the parents of the sisters Roos and Noor. When both their daughters were diagnosed with a hereditary brain tumor, they had to make similar decisions twice. Their story sheds light on the suffering of children in the terminal phase, and how this suffering may motivate parents and physicians to make decisions that influence the end of life of these children’s lives.We argue that complete knowledge about suffering in the terminal phase of children with brain tumors is impossible. However, by collecting experiences like those of Roos and Noor, we can move toward an experienced-based understanding and better guide parents and physicians through these hardest of decisions. (shrink)

BackgroundThe Dutch Euthanasia Act applies to patients 12 years and older, which makes euthanasia for minors younger than 12 legally impossible. The issue under discussion specifically regards the capacity of minors to request euthanasia.ObjectiveGain insight in paediatric experts’ views about which criteria are important to assess capacity, from what age minors can meet those criteria, what an assessment procedure should look like and what role parents should have.MethodsA Delphi study with 16 experts (paediatricians, paediatric nurses and paediatric psychologists) who work (...) in Children Comfort Teams in Dutch academic hospitals. The questionnaire contained statements concerning criteria for capacity and procedural criteria. Consensus was defined as ≥80% agreement.ResultsThe experts agreed that five criteria for capacity, found in a previous literature study, are all important. They agreed that some children between ages 9 and 11 could meet all the criteria. Consensus was reached for the statements that the entire medical team should be involved in the decision making and that a second independent expert must assess the case. Experts agreed that the parents’ opinion is relevant and should always be taken into account, but it need not be decisive.ConclusionThis study shows that the age limit of 12 years in the Dutch Euthanasia Act is too strong according to paediatric experts. Letting go of the age limit or lowering the age limit combined with adequate capacity assessment for minors younger than 12 are options that should be discussed further. (shrink)

This article examines the ethical validity of using viability as the cutoff point for abortion in the Netherlands, in view of potential changes to the Dutch perinatal care guideline. According to the Dutch Penal Code, abortion is permitted until viability: the point at which a fetus can survive outside the womb with technological assistance. Since the law was enacted in 1984, viability has been set at 24 weeks gestational age. Currently, in the Netherlands, the treatment limit for extreme prematurity is (...) also set at 24 weeks. The potential revision of the guideline could lower this threshold. Such a change could have implications for abortion in the Netherlands. We critically evaluate the use of viability within the Dutch context and offer recommendations for modifying the legal framework concerning abortion. We conclude that relying on any interpretation of viability is morally problematic for abortion regulation, as it is too indeterminate a concept to establish a threshold in a morally relevant way. (shrink)

This collection presents the English-language reader for the first time with essays that are representative of Bernstein's much-neglected revisionist period, 1901-1921. Bernstein himself suggested that this later work included significant new elements, indicating further progress in his liberal-socialist theory. Bernstein's later work acquires additional significance in light of the events of 1989, which have discredited not only Marxism-Leninism, but revolutionary Marxist theory in general, thus making the reevaluation of Bernstein's revisionism a worthwhile experience.

Constructions of Intersubjectivity shows that the meaning of grammatical constructions often has more to do with the human cognitive capacity for taking other peoples' points of view than with describing the world. Treating pragmatics, semantics, and syntax in parallel and integrating insights from linguistics, psychology, and animal communication, Arie Verhagen develops a new understanding of linguistic communication. In doing so he shows the continuity between language and animal communication and reveals the nature of human linguistic specialization. Professor Verhagen (...) uses Dutch and English data from a wide variety of sources and considers the contributions of grammar to the coherence of discourse. He argues that important problems in semantics and syntax may be resolved if language is understood as an instrument for exerting influence and coordinating different perspectives. The grammatical phenomena he discusses include negative expressions, the let alone construction, complementation constructions, and discourse connectives.This powerfully argued and original explanation of the nature and operation of communication will interest a wide range of scholars and advanced students in linguistics, cognitive science, and human evolution. (shrink)

The purpose of this article is to contribute to the dialogue on spirituality in mental health care. Spirituality is still an uncomfortable theme in mental health care despite a burgeoning literature and research. We will introduce a conceptual model on spiritual and interpersonal relationships based on love in relatedness. The model will enable the therapist to assess the interconnectedness of spiritual and interpersonal relationships, to analyse positive or negative effects of spirituality on interpersonal functioning and vice versa, and to look (...) for possibilities for spiritual and therapeutic change. Based on the model, the next step is to reflect on the relationship between psychiatry and spirituality with a view to dialogue instead of unfruitful discussion and controversy. We will propose a dialogue about the alternative DSM-5™ model for personality disorders. Although preliminary, we will show the usefulness of such an interdisciplinary dialogue. (shrink)

A provocative Target Article in this issue of AJOB proposes a new approach to decision-making for babies born in the “gray-zone” at the margins of viability. Titled “Postponed Withholding: balanced...

Here we discuss the hypothesis that the RNA components of the Ro ribonucleoproteins (RNPs), the Y RNAs, can be processed into microRNAs (miRNAs). Although Ro RNPs, whose main protein components Ro60 and La are targeted by the immune system in several autoimmune diseases, were discovered many years ago, their function is still poorly understood. Indeed, recent data show that miRNA-sized small RNAs can be generated from Y RNAs. This hypothesis leads also to a model in which Ro60 acts as a (...) modulator in the Y RNA-derived miRNA biogenesis pathway. The implications of these Y RNA-derived miRNAs, which may be specifically produced under pathological circumstances such as in autoimmunity or during viral infections, for the enigmatic function of Ro RNPs are discussed. (shrink)

In 2006, Two Dutch psychiatric residents and their residency training director reported on a small qualitative survey among 13 psychiatrists working in their mental health institution. The psychiatrists were interviewed about their attitude toward religion and spirituality. The interviewers were especially interested in the role religion plays according to the psychiatrists in the relationship between psychiatrists and patient (Fiselier et al. 2006). The theme is not new, and it still evokes a lot of controversy, considering the turmoil the well-known authority (...) and opinion leader in this field of inquiry Koenig recently provoked with his editorial in Psychiatric Bulletin (Koenig 2008; Correspondence 2008). .. (shrink)

The 2002 Dutch Euthanasia law applies to patients aged 12 years and older. Developments in end-of-life care and decision-making in the last decade have sparked the debate about usefulness and necessity to extend euthanasia to include children under 12 years of age. This paper describes two opposite positions: the affirmative position of a pediatrician and expert in pediatric palliative care and the negative position of a jurist and specialist in health law.

In this paper I develop an account of member obligation: the obligations that fall on the members of an obligated collective in virtue of that collective obligation. I use this account to argue that unorganized collections of individuals can constitute obligated agents. I argue first that, to know when a collective obligation entails obligations on that collective’s members, we have to know not just what it would take for each member to do their part in satisfying the collective obligation, but (...) also what they should do if they cannot do their part because others will not do theirs. I go on to argue (contra recent proposals) that it is not good enough for members in this situation to reasonably believe that others will not do their part. Rather, for a member of an obligated collective to permissibly escape doing her part in a collective obligation, she must both reasonably doubt that others will do their part and stand ready to act in case others do as well. -/- This necessary condition for collective obligation points the way to plausible sufficient conditions – conditions that, I argue, allow unstructured collectives to bear obligations. For (a) if a collective’s members are individually obligated to be ready to do their part, in a given collective action, and (b) if that individual readiness makes it sufficiently likely that the collective will in fact act, then it is hard to see what could block an attribution of collective obligation. In particular, in that case there ought to be no additional objection that there is no existing, organized “agent” on which the obligation might fall. For agents are, simply, things that can act. To be able to act is just to be able to succeed by trying. Unstructured collectives try to do something, I argue, when each member acts on their willingness to do their part in that thing if others do theirs; sometimes they succeed, producing a collective action. Some unstructured collectives, therefore, can succeed by trying; therefore, they can act; therefore they are agents. (shrink)

The social model of disability claims that disadvantage from disability is primarily a result of the social response to bodily difference. Social modellers typically draw two normative conclusions: first, that society has a responsibility to address disability disadvantage as a matter of justice, not charity; second, that the appropriate way of addressing this disadvantage is to change social institutions themselves, to better fit for bodily difference, rather than to normalize bodies to fit existing institutions. This paper offers a qualified defense (...) of both inferences. Social institutions have reasons of justice to fix disability disadvantage, because the choice of institutions that contingently favor those whose bodies are statistically typical incurs responsibilities to compensate those who disfavored, in that choice. Among other things, this responsibility implies that societies should not simultaneously materially disadvantage disabled people, and also withhold symbolic resources, by demanding a presumption in favor of personal transformation – thereby, undermining the social conditions for disability pride. (shrink)

This paper argues that disabled people can be healthy. I argue, first, following the well-known ‘social model of disability’, that we should prefer a usage of ‘disabled’ which does not imply any kind of impairment that is essentially inconsistent with health. This is because one can be disabled only because limited by false social perception of impairment and one can be, if impaired, disabled not because of the impairment but rather only because of the social response to it. Second, I (...) argue that it is often wrong to use the term ‘healthy’ in a way that makes health inconsistent with any degree whatsoever of health-relevant bodily dysfunction. Whether someone is ‘healthy’ properly-so-called depends on standards of health presupposed in conversational context. Sometimes, I argue, these standards are or ought to be lax enough to allow some people with some health deficits still to count as ‘healthy’ per se. Taking inspiration from David Lewis and Mary Kate Mcgowan, I go on to argue that denying that someone is ‘healthy’ in a context typically succeeds in shifting going presuppositions to require standards strict enough to make that denial acceptable. And this, I conclude by arguing, often constitutes an abuse of conversational power. (shrink)

This article asks whether personal ventilators should be redistributed to maximize lives saved in emergency condition, like the COVID-19 pandemic. It begins by examining extant claims that items like ventilators are literally parts of their user’s bodies. Arguments in favor of incorporation for ventilators fail to show that they meet valid sufficient conditions to be body parts, but arguments against incorporation also fail to show that they fail to meet clearly valid necessary conditions. Further progress on this issue awaits clarification (...) of difficult normative, conceptual, and metaphysical questions about the possible boundaries of a person’s body. Rather than relying solely on incorporation arguments, we propose an argument against reallocation from widely accepted anti-discrimination principles. Possession of a personal ventilator is an obvious marker of disability identity; thus, reallocating ventilators from those that already possess them discriminates on the basis of a stigmatized trait – a paradigm case of presumptively wrongful discrimination. This discrimination claim, taken together with uncertainty about the bodily status of ventilators, yields a strong presumption against personal ventilator reallocation. (shrink)

"Allerdings, das ist eine grosse Frage, der ich zu sehr ausgewichen bin, die Evidenz des Ich als ein Identisches, das also doch nicht in dem Bündel bestehen kann." (Husserl, 1907) Bekanntlich verwirft Husserl in den Logischen Untersuchungen die Auffassung, "dass die Beziehung auf das Ich etwas zum we sentlichen Bestande des intentionalen Erlebnisses selbst Gehöriges sei'',! und bildet um 1907, nach Einführung der phänomenolo gischen Reduktion, "die Beziehung auf das Ich zu unterlassen, oder von ihr zu abstrahieren" geradezu die Bedingung, (...) ein "reines Phänomen im Sinne der Phänomenologie" 2 zu gewinnen. Und bekanntlich heisst es demgegenüber in den Ideen von 1913: "Unter den allgemeinen Wesenseigentümlichkeiten des tran szendental gereinigten Erlebnisgebietes gebührt eigentlich die erste Stelle der Beziehung auf das,reine' Ich",3 und revidiert Husserl in der zweiten Auflage der Logischen Untersuchungen von 4 1913 seine Stellungnahme zur Frage des reinen Ich. Weniger bekannt ist bisher, wie Husserl auf seinem Denkweg von der einen zur anderen Stellungnahme zum Problem des Ich gekommen ist. Was bewegte ihn, das "Ich" in die phänomeno logische Problematik einzubeziehen? Zu vermuten war, dem Wandel in der Stellung zum Problem des Ich liege ein Wandel im Verständnis der Phänomenologie selbst zugrunde. Welche Phänomene motivierten, auf dem phänomenologischen Boden selbst, die Einbeziehung des Ich? Vor allem dieser Frage gehen wir, unter Berücksichtigung des Nachlassmaterials des Husserl Archivs (Leuven), in unserer Studie nach. (shrink)

What makes something a part of my body, for moral purposes? Is the body defined naturalistically: by biological relations, or psychological relations, or some combination of the two? This paper approaches this question by considering a borderline case: the status of prostheses. I argue that extant accounts of the body fail to capture prostheses as genuine body parts. Nor, however, do they provide plausible grounds for excluding prostheses, without excluding some paradigm organic parts in the process. I conclude by suggesting (...) that embodiment is moralized all the way down: to be a body part is to be the sort of thing that ought to be protected, in a certain way, by social practices. (shrink)