Felsefe tarihi, Heidegger’e göre, varlık sorusu etrafında inşa edilmiştir. Büyük filozofların neredeyse tamamı yüzeydeki tüm farklılıklara rağmen esasında bu ontolojik soruyla ilgilenmişlerdir. Bununla birlikte özellikle özgün düşünce geleneğinde bir kırılmanın yaşandığı Platon’la birlikte “varlık sorusu”, gitgide sahihliğinden uzaklaşmış ve Descartes’ın modern felsefenin de başlangıcı olmak bakımından tepe noktasını oluşturduğu bir çizgide, özne ile nesnenin karşılıklı konumlandırılarak yorumlandığı bir epistemolojik soru haline dönüşmüştür. Epistemolojik yaklaşımın öne çıkan özelliği, özne-nesne ilişkisinde bilginin koşullarını belirleyerek öznenin bilme sınırlarını saptamaya çalışmaktır. Bu yaklaşımda nesne özneye (...) aşkındır; dolayısıyla öznenin nesneyi bilmesi ancak kendinden yola çıkmasıyla olanaklıdır; çünkü öznenin kendisine ilişkin bilgisi doğrudan gerçekleşen, içkin bir bilgidir. Dolayısıyla bu yaklaşımdaki temel varsayım, özne ile nesnenin birbirini dışladığı, nesnenin özneye tâbi kılındığı ikili bir dünya varsayımıdır ve bu varsayımda ortaya çıkan karakteristik sorun, dış dünyanın varlığının kanıtlanması/bilinmesi sorunudur. Sonuç olarak bu makalede Heidegger’in bu problemi “varlık sorusu” bağlamında nasıl bir çözüme kavuşturduğu gösterilmeye çalışılacaktır. (shrink)

Results of a comprehensive simulation study are reported investigating the effects of sample size, test length, number of attributes and base rate of mastery on item parameter recovery and classification accuracy of four DCMs. Effects were evaluated using bias and RMSE computed between true parameters and estimated parameters. Effects of simulated factors on attribute assignment were also evaluated using the percentage of classification accuracy. More precise estimates of item parameters were obtained with larger sample size and longer test length. Recovery (...) of item parameters decreased as the number of attributes increased from three to five but base rate of mastery had a varying effect on the item recovery. Item parameter and classification accuracy were higher for DINA and DINO models. (shrink)

Kant’s general taxonomy of duties includes substantial claims that normatively and theoretically differentiates it from other moral theories. Basing his moral theory on a conception of Right, he also made a general classification of several duties with their corresponding moral worth. The general aim of this study is to identify the basic principles and criteria that determine Kant’s classification of duties. Another aim is to trace some implications and effects of Kant’s conception of duties in the contemporary discussion of social (...) and economic rights. We argue that the normative basis of the argument against social and economic rights is very similar to that of the principles Kant uses in his classification of duties. However, from the responsibility of the state, Kant imposes legitimate obligations over individuals, albeit indirectly. (shrink)

Bu kitap değerlendirmesinde, Orna Donath’ın annelikten pişman olma durumunu nasıl ele aldığına değinilecek, kitabın güçlü ve zayıf yönleri üzerinde durulacaktır.

Roland Barthes, çağdaş mitlere göstergebilimsel bir çözümleme uygulayarak bu mitlerin esasen ideolojik bir mesaj ya da bildiri içerdiğini ortaya koyar. Modern mitler, gösterdiğinden başka bir şey kast eder; onların gerçek anlamının dışında her zaman ikincil bir anlamı vardır. Bu da mitlerin muğlaklıklar, aldatmacalar, belirsizlikler ve çok anlamlılık içerdiği manasına gelir. Göstergebilimsel analiz, söz konusu aldatmacaların ardında gizlenen amacı görünür hale getirir. Bu amaç da, burjuva sınıfının politik, kültürel, ekonomik ve toplumsal egemenliğini korumak ve devam ettirmektir. Mitlerde ‘doğal’ olarak sunulan aslında (...) belirli bir ideolojik dünya görüşü tarafından inşa edilir. Bu ideoloji de burjuva ideolojisidir. Çağdaş mitler, burjuva dünya görüşünü ebedi bir doğaya dönüştürür. Barthes’ın çözümlemesi, mitler tarafından doğallaştırılan ve evrenselleştirilen göstergelerin esasen burjuva ideolojisinin amacına hizmet ettiğini gösterir. Bu çalışmada, Barthes’ın göstergebilim yoluyla anlam incelemesine nasıl politik bir önem kazandırdığı ve burjuva kültürünü eleştirme amacını nasıl bilimsel bir temele dayandırdığı gösterilecektir. (shrink)

Bu çalışmanın amacı, söz verme örneği üzerinden olgudan değerin nasıl türetildiğini göstererek bu türetmenin etik ile ilişkisini ortaya koymaktır. Bu amaç, temelde John Searle ve Paul Ricoeur’ün olgu-değer sorununa getirdiği yanıtlar üzerinden gerçekleştirilecektir. Olgudan değerin türetilip türetilemeyeceği problemini dil felsefesinin sınırları içinde kalarak çözmeye çalışan Searle ile bu türetme sağlandığı taktirde problemin bir ahlak felsefesi problemi olduğunu düşünen Ricoeur’ün görüşleri ortaya konarak dil felsefesi ve etik arasında bir köprü kurulmaya çalışılacaktır. Bu köprü kurma çabası felsefenin iki temel disiplini arasındaki sınır (...) ve ayrımları bir anlamda ihlal etme niyeti taşımaktadır. (shrink)

İdrak ve niteliği felsefenin en önemli problemlerinden biridir. İbn Sînâ hissî, hayalî, vehmî ve aklî olmak üzere dört farklı idrak mertebesi dillendirir. Buna göre insan nefsi nesnelerin suretlerini duyu yetileriyle algılar. Daha sonra bu suretleri hayal yetisine teslim eder. Akabinde akıl bu sureti barındırdığı maddî eklentilerden arındırarak aklî suretlerin oluşumu için gerekli zeminleri hazırlar. Daha sonra faal akıl insan nefsine aklî suretleri verir. İnsan zihninde duyularla algılanan bu kavramlardan başka kavramlar da vardır. Bu küllî kavramların yeri nesnel âlem değil öznel (...) âlemdir. İslam felsefesi geleneğinde Fârâbî ilk defa bu ayırımı yapar ve ma‘kūlleri birinci ve ikinci ma‘kūller diye iki kısma ayırır. İbn Sînâ da bu sınıflandırmayı benimser ve konu hakkında yeni açıklamalar getirir. İbn Sînâ, ikinci ma‘kūllerin sonraki dönemlerde yapılan felsefî ve mantıkî ayırımını her ne kadar dillendirmese de eserlerinden bu iki ma‘kūl türünün farklılığına teveccüh eder. Bu çalışmada İbn Sînâ felsefesinde idrak olgusunun gerçekleşme niteliği ele alınacak ve daha sonraki dönemlerde dillendirilen ikinci felsefî ma‘kūl anlamların İbn Sînâ felsefesindeki yeri açıklanacaktır. (shrink)

After a review of terminology, I identify—in addition to Margaret Battin’s list of five primary arguments for and against aid-in-dying—the argument from functional equivalence as another primary argument. I introduce a novel way to approach this argument based on Bernard Lonergan’s generalized empirical method. Then I proceed on the basis of GEM to distinguish palliative sedation, palliative sedation to unconsciousness when prognosis is less than two weeks, and foregoing life-sustaining treatment from aid-in-dying. I conclude that aid-in-dying must be justified on (...) its own merits and not on the basis of these well-established palliative care practices; and that societies must decide, in weighing the merits of aid-in-dying, whether or not to make the judgment that no life is better than life-like-this part of their operative value structure. (shrink)

Continuous sedation until death is an increasingly common practice in end-of-life care. However, it raises numerous medical, ethical, emotional and legal concerns, such as the reducing or removing of consciousness, the withholding of artificial nutrition and hydration, the proportionality of the sedation to the symptoms, its adequacy in actually relieving symptoms rather than simply giving onlookers the impression that the patient is undergoing a painless 'natural' death, and the perception that it may be functionally equivalent to euthanasia. This book brings (...) together contributions from clinicians, ethicists, lawyers and social scientists, and discusses guidelines as well as clinical, emotional and legal aspects of the practice. The chapters shine a critical spotlight on areas of concern and on the validity of the justifications given for the practice, including in particular the doctrine of double effect. (shrink)

Slow euthanasia or a good palliative intervention?There are many ways in which doctors influence the circumstances and/or the timing of a patient’s death. Some of these are accepted as normal medical practice—for instance, when a disproportional treatment is forgone, others are considered tolerable only under strict conditions or even intolerable, such as non-voluntary active euthanasia. A relatively new phenomenon in the ethical discussion on end-of-life decisions is terminal sedation. Terminal sedation is used in patients with terminal illnesses where normal medical (...) treatments cannot relieve severe symptoms such as pain and agitation, and no option is left but to take away the perception of these symptoms. Often, the decision to start terminal sedation is accompanied by the decision to forgo the provision of artificial nutrition and hydration in these patients. In The Netherlands, terminal sedation was estimated to be applied in 4–10% of all deaths in 2001.1 The combination of these two decisions have made the moral status of terminal sedation the subject of fierce ethical debates. Is it slow euthanasia2,3 or is it a good palliative intervention that should be sharply distinguished from euthanasia?4,5 One of the characteristics of this debate is that it is a very confused one: people disagree about the meaning of the term, the appropriateness of it and, of course, about the conditions under which it would be morally justified. As a matter of fact, these three discussions are deeply connected: as is often the case, a discussion about terms is a discussion about norms in disguise.The first observation to be made is that many seemingly descriptive definitions of terminal sedation contain normative claims. Examples of this are definitions of terminal sedation in which only …. (shrink)

“Terminal sedation” refers to the use of sedation as palliation in dying patients with a terminal diagnosis. Although terminal sedation has received widespread legal and ethical justification, the practice remains ethically contentious, particularly as some hold that it foreseeably hastens death. It has been proposed that empirical studies show that terminal sedation does not hasten death, or that even if it may hasten death it does not do so in a foreseeable way. Nonetheless, it is clear that providing terminal sedation (...) in combination with the withholding or withdrawing of life-prolonging treatments such as fluid and nutrition can foreseeably hasten death significantly—what is here called early terminal sedation . There are ethical justifications for the use of sedation in palliative care and thus it would seem that ETS is an ethically and legally acceptable practice. However, what emerges from the literature is the repeated assertion that terminal sedation must be restricted to use in imminently dying patients—the “imminence condition”—and that therefore ETS is unacceptable. This restriction has taken on greater significance with the trend of palliative care to include the care of patients who are not imminently dying. This paper proposes to show that although there is widespread intuitive support for the imminence condition, it does not follow from the justifications for sedation as palliation, and that explicit arguments for the imminence condition are needed. (shrink)

This paper addresses sedation at the end of life. The use of sedation is often seen as a last resort for patients whose death is imminent and whose symptoms cannot be treated in any other way. This paper asks how to assess constellations, where patients want to hasten their death by refusing (further) life-sustaining treatment, or by voluntarily stopping eating and drinking (VSED), and wish this to be accompanied by sedation. We argue that sedation is ethically and legally permissible not (...) only as a last resort, but in principle. Furthermore, we see a clear obligation to sedate in cases of acute suffering of any kind, while in some other constellations individual physicians’ objections to supposedly premature or unnecessary sedation must be respected. Such possible reservations should, however, be reconsidered in light of the fundamental ethical and legal right to a self-determined death. In general, sedation practices should be less restrictive, and existing guidelines should be revised accordingly. -/- ----- Dieser Beitrag befasst sich mit Sedierungen von Patienten am Lebensende. In der Regel werden Sedierungen nur als ultima ratio vorgenommen, wenn die Betroffenen dem Tod bereits nahe sind und Leidenssymptome aufweisen, die anders nicht zu lindern sind. Doch wie sind Fälle zu beurteilen, in denen Patienten sich selbstbestimmt für einen Behandlungs- oder einen Flüssigkeits‑/Nahrungsverzicht entscheiden, um zu sterben, und dafür eine „Begleitsedierung“ erbitten oder erwarten – auch wenn dies aus medizinischer Sicht über eine Anwendung von Sedierung als letztes Mittel hinausgeht? Wir argumentieren hier dafür, dass Zusage wie Anwendung einer Begleitsedierung ethisch und rechtlich nicht nur als ultima ratio, sondern grundsätzlich zulässig sind. Eine klare Verpflichtung zu sedieren sehen wir darüber hinaus bei akutem Leiden jeder Art, während in einigen anderen Konstellationen Vorbehalte individueller Ärzte gegenüber vermeintlich verfrühten oder unnötigen Sedierungen respektiert werden müssen. Vor dem Hintergrund des ethischen und juridischen Grundrechts auf ein selbstbestimmtes Sterben plädieren wir allerdings dafür, auch solche Vorbehalte zu überdenken. Die medizinischen Leitlinien sollten entsprechend überarbeitet werden. (shrink)

Continuous sedation until death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, often provokes medical-ethical discussions in the opinion sections of medical and nursing journals. A content analysis of opinion pieces in medical and nursing literature was conducted to examine how clinicians define and describe CSD, and how they justify this practice morally. Most publications were written by physicians and published in palliative or general medicine journals. Terminal Sedation and Palliative Sedation are (...) the most frequently used terms to describe CSD. Seventeen definitions with varying content were identified. CSD was found to be morally justified in 73 % of the publications using justifications such as Last Resort, Doctrine of Double Effect, Sanctity of Life, Autonomy, and Proportionality. The debate over CSD in the opinion sections of medical and nursing journals lacks uniform terms and definitions, and is profoundly marked by ‘charged language’, aiming at realizing agreement in attitude towards CSD. Not all of the moral justifications found are equally straightforward. To enable a more effective debate, the terms, definitions and justifications for CSD need to be further clarified. (shrink)

A distinction is commonly drawn between continuous sedation until death and physician-assisted suicide/euthanasia. Only the latter is found to involve killing, whereas the former eludes such characterization. I argue that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia in that both involve killing. This is established by first defining and clarifying palliative sedation therapies in general and continuous sedation until death in particular. A case study analysis and a look at current practices are provided. This is followed by a (...) defense of arguments in favor of definitions of death centering on higher brain (neocortical) functioning rather than on whole brain or cardiopulmonary functioning. It is then shown that continuous sedation until death simulates higher brain definitions of death by eliminating consciousness. Appeals to reversibility and double effect fail to establish any distinguishing characteristics between the simulation of death that occurs in continuous sedation until death and the death that occurs as a result of physician-assisted suicide/euthanasia. Concluding remarks clarify the moral ramifications of these findings. (shrink)

Medical assistance in dying (MAiD) and palliative sedation (PS) are both legal options in Canada that may be considered by patients experiencing intolerable and unmanageable suffering. A contentious, lively debate has been ongoing in the literature regarding the similarities and differences between MAiD and PS. The aim of this paper is to explore the propositions that MAiD and PS are essentially similar and conversely that MAiD and PS are distinctly different. The relevance of such a debate is apparent for clinicians (...) and patients alike. Understanding the complex and multi‐faceted nuances between PS and MAiD allows patients and caregivers to make more informed decisions pertaining to end‐of‐life care. It is hoped that this paper will also serve to foster further debate and consideration of the issues associated with PS and MAiD with a view to improve patient care and the quality of both living and dying in Canada. (shrink)

This paper is concerned with the moral justification for palliative sedation until death. Palliative sedation involves the intentional lowering of consciousness for the relief of untreatable symptoms. The paper focuses on the moral problems surrounding the intentional lowering of consciousness until death itself, rather than possible adjacent life-shortening effects. Starting from a Kantian perspective on virtue, it is shown that continuous deep sedation until death (CDS) does not conflict with the perfect duty of moral self-preservation because CDS does not destroy (...) capacities for agency. In addition, it is argued that CDS can frustrate the imperfect duty of self-cultivation by reducing consciousness permanently. Nevertheless, there are cases where CDS is morally acceptable, namely, cases where the agent has already permanently lost the possibility for free action in advance of sedation—for example, due to excruciating and ongoing pain. Because the latter can be difficult to diagnose properly, safeguards may be needed in order to prevent the application of CDS for the wrong reasons. (shrink)

The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny the ethical distinctions between euthanasia and palliative sedation, we will critically analyse the guideline's argumentation strategy with which euthanasia is demarcated from palliative sedation. First, we will analyse the guideline's main premise, which entails that palliative sedation is normal medical treatment. After this, we will critically discuss three crucial propositions of (...) the guideline that are used to support this premise: (1) the patient's life expectancy should not exceed 2 weeks; (2) the aim of the physician should be to relieve suffering and (3) expert consultation is optional. We will conclude that, if inherent problematic aspects of palliative sedation are taken seriously, palliative sedation is less normal than it is now depicted in the guideline. (shrink)

A patient with end-stage motor neurone disease was admitted for hospice care with worsening bulbar symptoms. Although he initially walked onto the ward he became very distressed and asked for sedation. After much discussion, this man was deeply sedated, and after some harrowing days, died. Was it right to provide terminal sedation? What should the threshold be for such treatment? How should our personal reservations affect how we approach the distressed patient in an end-of-life situation?

This article discusses the place of sedation in the care of the terminally ill, as used in the practice of palliative care using case studies, clinical pragmatism forms the theoretical framework from which to elucidate the varying part that sedation plays in the overall management of a person facing the end of life. We contend that when used appropriately, sedation is an ethical and legitimate intervention that enhances comfort at the end of life and ought not sedate the person onto (...) “oblivion”. (shrink)

ABSTRACT There has been much discussion regarding the acceptable use of sedation for palliation. A particularly contentious practice concerns deep, continuous sedation given to patients who are not imminently dying and given without provision of hydration or nutrition, with the end result that death is hastened. This has been called ‘early terminal sedation’. Early terminal sedation is a practice composed of two legally and ethically accepted treatment options. Under certain conditions, patients have the right to reject hydration and nutrition, even (...) if these are life‐sustaining. Patients are also entitled to sedation as palliation for intolerable, intractable suffering. Though early terminal sedation is thought to be rare at present, the changing nature of palliative medicine suggests its use will increase. Arguments regarding early terminal sedation have failed to recognize early terminal sedation as a distinct legal and ethical entity. It can be seen as both the simple sum of treatment refusal and sedation for palliation, analogous to terminal sedation. It can also be seen as an indivisible palliative treatment, more analogous to assisted suicide or euthanasia. But ultimately, it is wholly analogous neither to terminal sedation given when death is imminent, nor to assisted suicide or euthanasia. This paper contends that early terminal sedation should be considered as a distinct entity. Such a reconception promises to provide a way forward in the debate, practice and policy regarding this contentious area of palliative medicine. (shrink)

In a substantial number of cases, dying patients are brought into a state of lowered consciousness and kept in it until they die in order to prevent or stop severe suffering. Many guidelines and position statements have been published in recent years on sedation until death, as I will call this policy. Some have been published by professional organisations and are meant to be binding for their members, others are the work of task forces and merely aim at providing medical, (...) moral, and legal guidance.1 These guidelines all take the following positions: the patient’s consciousness should not be lowered more than is necessary for preventing her from suffering; it must be impossible to alleviate the suffering in any... (shrink)

Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress.

Background: In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research design: We (...) reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation. (shrink)

Despite advances in palliative care, some patients still suffer significantly at the end of life. Terminal Sedation (TS) refers to the use of sedatives in dying patients until the point of death. The following limits are commonly applied: (1) symptoms should be refractory, (2) sedatives should be administered proportionally to symptoms and (3) the patient should be imminently dying. The term ‘Expanded TS’ (ETS) can be used to describe the use of sedation at the end of life outside one or (...) more of these limits.In this paper, we explore and defend ETS, focusing on jurisdictions where assisted dying is lawful. We argue that ETS is morally permissible: (1) in cases of non-refractory suffering where earlier treatments are likely to fail, (2) where gradual sedation is likely to be ineffective or where unconsciousness is a clinically desirable outcome, (3) where the patient meets all criteria for assisted dying or (4) where the patient has greater than 2 weeks to live, is suffering intolerably, and sedation is considered to be the next best treatment option for their suffering.While remaining two distinct practices, there is scope for some convergence between the criteria for assisted dying and the criteria for ETS. Dying patients who are currently ineligible for TS, or even assisted dying, should not be left to suffer. ETS provides one means to bridge this gap. (shrink)