Daryl Pullman provides a valuable comparison between the Medical Assistance in Dying (MAiD) rates in Canada and California, illuminating the factors that appear to be pushing Canada down a slippery...

In lieu of an abstract, here is a brief excerpt of the content:Marcia Muelder Eaton ANTHONY POWELL AND THE AESTHETIC LIFE Anthony POWELL'S work has been looked at carefully by relatively few critical scholars, in spite of the fact that he has been called "the most elegant writer presently working in the English language." ' I am surprised at how little he is read — at least in the United States. He is a splendid writer, often entertaining, always a (...) skilled craftsman. His earlier novels {Afternoon Men, 1931; Venusberg, 1932; From a View to a Death, 1933; Agents and Patients, 1936; and What's Become of Waring, 1939) are short satiric and ironic comedies dealing mainly with London bohemia in the 1920s. His later fictional work is a twelve volume tour de force (A Question of Upbringing, 1951; A Buyer's Market, 1952; The Acceptance World, 1955; At Lady Molly's, 1957; Casanova's Chinese Restaurant, 1960; The Kindly Ones, 1962; The Valley of Bones, 1964; The Soldier's Art, 1966; The Military Philosophers, 1968; Books Do Furnish a Room, 1971; Temporary Kings, 1973; Hearing Secret Harmonies, 1975) 2 in which the narrator, NicholasJenkins, attempts, with varying degrees of success, to make sense of life as A Dance to the Music of Time. Both the early and later works are populated by many characters. Manageable in the short, independent novels, they become so numerous in the interdependent volumes of Dance that several critics are dubious about anyone's keeping them straight; had I read them as they were published — with months, sometimes years and the novels of others between appearances — I am sure it would have been impossible to keep track of the minor characters. In 1960, Time and Tide published a cast ofcharacters for "readers who find it difficult to remember from book to book details of family and other more tenuous relationships between characters who have a habit of popping up surprisingly in the most unexpected places."3 The entries provide the following kinds of information: "McReith, Lady (Gwen): friend of Babs Templer and Jimmy Stripling; goes to bed with 166 Marcia Muelder Eaton167 Peter Templer when staying in the Templer (senior) house.... Tolland, George: son of Lord Warminster: was in Coldstream for some years then went into city. Very correct." More recently Hilary Spurling has compiled a book-length guide to the plots and characters ofDance. It also includes an index of books, paintings, and places referred to.4 Even with these guides there are loose ends, and it is not always clear what functions certain minor characters serve. Nonetheless, the popping-up in unexpected places is, as I hope to show, essential to the theme of the work. Powell is by no means universally acclaimed; his novels have been described as "contrived,"5 and "pseudo-Proustian" and "blandly snobbish."6 The early novels have been said to "tell about 'twentyish emancipation, silly parties at which drunks behave stupidly, ambitious young men on the make for the daughters of fox-hunting families, all with an air of slightness and couldn't-care less." 7 And Dance has likewise been scorned: To begin with, each character is introduced as he first appears to the narrator, who immediately speculates for three or four pages on the probable nature of a character who is blond, has small ears, and wears a black overcoat. The overcoat then says a few desultory words, whereupon the narrator takes several pages of pain to modify his original opinion in the light of this additional evidence.8 Like all parodies, these have some truth in them. But it is simplistic to describe his work in these terms — it amounts to painting in colors far too crude what is an enormously subtle picture of life. Powell's "easy modulations," as John Russell has called his novels,9 capture intricacies of human behavior and interaction in a profound and original way. And Powell's focus on ritual and the attempts of people to play chosen roles, ultimately provides a genuinely metaphysical, epistemological, ethical, and aesthetic interpretation of life. It is hopeless to try to provide a synopsis of the twelve volumes. The novels follow Nicholas Jenkins from his school days to late middle age. Friends such as Peter Templer, Charles... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Echoes of Grief:Tales from an Emergency Medicine and Critical Care NurseMarcia KingWell, I have 42 years of stories from working in ICU and Emergency Medicine as a registered nurse. The first situation that comes to mind on the subject of grieving on the job in healthcare happened about 37 years ago. I had a nice lady in ICU for several days in a row as a patient. She had (...) a bad myocardial infarction (MI) and was critical. We tried all the medications and pain meds, and nothing took her chest pain away. Meanwhile, her husband stayed with her all day, and all night. He doted after her 24/7. He slept in a chair and never went home for about three days, even though they lived just a few blocks from the hospital. I was amazed at what an awesome husband he was.Finally, after about three days, she fell asleep for more than 10 minutes. She had said her pain was gone. Her husband didn't want to leave her, but he asked me "if it would be okay" to go home and take a shower, eat a sandwich, and get the mail. He explained that he would be right back.I said, "Sure, now is a good time since her pain is gone and she's sleeping. You must take care of yourself too."The husband ran out in a hurry. About 10 minutes after he left, his wife suddenly had pain again and a run of ventricular tachycardia, (V-tach), which is a type of abnormal heart rhythm, or arrhythmia. Even though the V-tach stopped on its own, I called the husband and told him to come back because he wanted to be there if anything happened. A few minutes later, she had another run of V-tach, but this time, she coded and died. About two minutes after she died, the husband came running into the room—panicked and crying and talking to her dead body.He was saying, "I'm so sorry I left you! I shouldn't have left you!" I felt awful because I was the one who told him it was okay to go. Then I was crying with him and for the poor man.He then left for home, and their doctor (who was a well-known grouch-ass) appeared and saw that I was upset, and he asked me what my problem was. Why was I so sad about it? I thought, "Jerk, you are in the wrong career."Thinking about that doctor's reaction at the time, I wondered, "WTF is wrong with him!" I had known the doctor for several years because his mom was the head nurse of the surgical floor. I thought for a moment and then said to him, "How could you be a decent doctor if that death didn't bother you?" I was [End Page 74] in my 20s at the time—a fairly new nurse—and was just starting to be able to feel comfortable speaking up and being assertive.I just felt so bad for that poor man. I felt terrible that I told him it was okay to run home. He really wanted to be there if something happened to her, and from what I saw, he was an amazing husband to her. Looking back, she probably was waiting for the minute he stepped out to go.Another time, while working in the emergency department, a trauma alert was called on a patient who came in by ambulance. We were told the woman had fallen off a hayloft while pushing hay onto the floor in her barn. She hit her head bad in the fall. She wasn't my patient, but I ran into the room to help when she arrived. There was a bunch of staff around blocking my view. Without even looking at her, I grabbed her arm to put in an IV as I had done thousands of times before. Suddenly, I noticed it was weirdly quiet. I looked up, and the ER Doc and tech were looking at me funny. Then the Doc said, "Marcia, you know who this is, don't... (shrink)

Public health ethics is emerging as a new field of inquiry, distinct not only from public health law, but also from traditional medical ethics and research ethics. Public health professional and scholarly attention is focusing on ways that ethical analysis and a new public health code of ethics can be a resource for health professionals working in the field. This article provides a preliminary exploration of the ethical issues faced by public health professionals in day-to-day practice and of the type (...) of ethics education and support they believe may be helpful. (shrink)

In the heady days of 2011–2012, when Barack Obama was in his first term and the Patient Protection and Affordable Care Act heralded a golden future, medical anthropologists and activists had reason to be excited. Their country was about to take—so they believed—the greatest single step in the right direction since LBJ’s “Great Society” welfare spending program. It was in this climate that Inhorn and Wentzell’s collection of essays was published, and the optimism of the times shines through many of (...) the essays.The harsh reality is that at the end of 2012 Obama was re-elected, and after a painful deadlock the health insurance legislation known as “Obamacare” was pushed through. What followed has not turned out quite the way anyone expected and has driven an initial and unprecedented tidal wave of disapproval of the Obama presidency. Reading Medical Anthropology at the Intersections is therefore a sobering lesson in how a week can be a very long time in politics and a year a positive etern. (shrink)

Respect for Autonomy has been a mainstay of medical ethics since its enshrinement as one of the four principles of biomedical ethics by Beauchamp and Childress’ in the late 1970s. This paper traces the development of this modern concept from Antiquity to the present day, paying attention to its Enlightenment origins in Kant and Rousseau. The rapid C20th developments of bioethics and RFA are then considered in the context of the post-war period and American socio-political thought. The validity and (...) utility of the RFA are discussed in light of this philosophical-historical account. It is concluded that it is not necessary to embrace an ethic of autonomy in order to guard patients from coercion or paternalism, and that, on the contrary, the dominance of autonomy threatens to undermine those very things which have helped doctors come to view and respect their patients as persons. (shrink)

Medical ethics enjoyed a remarkable degree of continuity from the days of Hippocrates until its long-standing traditions began to be supplanted, or at least supplemented, around the middle of the twentieth century. Scientific, technological, and social developments during that time produced rapid changes in the biological sciences and in health care. These developments challenged many prevalent conceptions of the moral obligations of health professionals and society in meeting the needs of the sick and injured .The Anglo-American textbook of Beauchamp and (...) Childress became the referential work for the discipline of `bio-ethics'. The authors are convinced that a long history of ancient, medieval and modern health care reflection remains very disappointing from the perspective of contemporary biomedical ethics: “It shows how inadequately, and with what measure of insularity, problems of truthfulness, privacy, justice, communal responsibility and the like were framed in past centuries ”. They defend the four principles approach to biomedical ethics, an approach which somewhat disparagingly has been called principlism.The influence of their work has been so strong that bio-ethics seemed to become overwhelmed by the importance of their contribution. It even created a large separation between Anglo-American approaches in bio-ethics and the European-Continental approach . In any case, contemporary biomedical ethics incorporates theoretical conflicts of considerable complexity, and the diverse theories make it no easier.The personalist approach to biomedical ethics presents itself as a typical European reaction to the rapid changes in medicine and health care. Some call it, however, a kind of renewal of the old Thomistic approach, whereby the concept of `nature' has been replaced by the more dynamic concept of `person'. In that way personalism has been situated by many observers as a `person' centred natural law tradition which focuses on the rational nature of the human person as the moral norm of nature. This gives the impression that personalism is only a very `static' variant of the natural law approach.I would, however, defend the opinion that personalism offers a very dynamic and creative approach to the complexities of recent developments in biomedicine. In what follows, I will illustrate this by clarifying two basic dimensions of the integration of personalism in biomedical ethics: the personalist approach offers a relational foundation for medicine as a healing profession and it presents an ethical framework for the integration of new developments in medicine. First, however, I would like to situate the importance of this theoretical reflection for medical ethics. (shrink)

Green Mass is a meditation on—and with—twelfth-century Christian mystic and polymath Saint Hildegard of Bingen. Attending to Hildegard's vegetal vision, which greens theological tradition and imbues plant life with spirit, philosopher Michael Marder uncovers a verdant mode of thinking. The book stages a fresh encounter between present-day and premodern concerns, ecology and theology, philosophy and mysticism, the material and the spiritual, in word and sound. Hildegard's lush notion of viriditas, the vegetal power of creation, is emblematic of her deeply entwined (...) understanding of physical reality and spiritual elevation. From blossoming flora to burning desert, Marder plays with the symphonic multiplicity of meanings in her thought, listening to the resonances between the ardency of holy fire and the aridity of a world aflame. Across Hildegard's cosmos, we hear the anarchic proliferation of her ecological theology, in which both God and greening are circular, without beginning or end. Introduced with a foreword by philosopher Marcia Sá Cavalcante Schuback and accompanied by cellist Peter Schuback's musical movements, which echo both Hildegard's own compositions and key themes in each chapter of the book, this multifaceted work creates a resonance chamber, in which to discover the living world anew. The original compositions accompanying each chapter are available free for streaming and for download at www.sup.org/greenmass. (shrink)

The principles of medical ethics, common as they are in the world at the present time, have been formed in the context of Western secular communities; consequently, secular principles and values are inevitably manifested in all corners of medical ethics. Medical ethics is at its infancy in Iran. In order to incorporate medical ethics into the country's health system, either the same thoughts, principles, rules, and codes of Western communities should be translated and taught across the country, or else, if (...) the principles and values and consequently the prominent moral rules and codes of Western medical ethics are not consistent with the culture, customs, and religion of our country, then new principles and values should be formulated that are more in harmony with our society. According to the available literature in Iran, the four principles proposed by Beauchamp and Childress do not contradict the Islamic-Iranian culture and can thus be generally applied in the mentioned context. However, the application of these four principles and their derivatives requires careful examination and adaptation to Islamic ethics. A comparison of the ontological, anthropological and epistemological foundations of secular and Islamic attitudes shows the differences between these two attitudes to be deep-rooted. “Rationalism,” “scientism,” and “humanism” are the main foundations of secularism, whereas “Godcentrism,” “pure human servitude to God,” the belief in “returning of humans to God,” “resurrection day,” and also human's accountability to God are all fundamental beliefs and principles of religion for Muslims of all cults and sects. It can thus be concluded that the principles of secularist thought are different from and to some extent inconsistent with the principles of Islam. Instructions derived from secular thought can therefore not be implemented in an Islamic community; rather, these communities should adopt Islamic foundations as the source for the norms and standards of their medical ethics. The capacities of religious thought make possible the formation of an ethical system consistent with Islamic Ummah. (shrink)

Photo ID 222412412 © US Navy Medicine | Dreamstime.com ABSTRACT In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. INTRODUCTION Medical resources in an austere environment without quick recourse for resupply or casualty evacuation are often (...) limited. The shortage extends not only to supplies like blood products and drugs, but physicians and other medical personnel. In the midst of a mass casualty scenario, such as a battle that includes intense ground fighting, the medical staff will stretch scarce resources and triage casualties according to specific criteria. Typically, they proceed by providing care for the most severely wounded first, referred to here as conventional triage. At times, though, the staff may reverse the triage so that soldiers with minor wounds can return to the fight. In a mass casualty situation, when medical personnel apply conventional triage and treat casualties from opposing forces, a dilemma may arise. We argue that it can be permissible for military physicians to prioritize their own soldiers over enemy combatants in a mass casualty triage, where reverse triage does not apply. The case we will focus on is as follows: Battlefield Triage: During combat operations on a remote island in the Pacific Ocean, a compatriot soldier and an enemy combatant arrive at the compatriot soldier country’s medical treatment facility. Both have similar gunshot wounds to the abdomen, and they arrive with similar conditions. Both have low oxygen saturation and excessive blood loss. The sole physician only has enough time to stabilize one person. The scenario is brief, and we are aware that medical rules of eligibility will most often dictate how the physician proceeds,[1] but this scenario is useful in setting up the question we focus on in this paper: would it be wrong to favor the stabilization of a soldier just because the soldier is the physician’s compatriot? In other words, can nationality serve as an ethically justified tiebreaker in a situation such as Battlefield Triage?[2] In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. The AMA’s Code of Medical Ethics asserts that physicians have “ethical obligations to place patients’ welfare above their self-interest and above obligations to other groups.”[3] The World Medical Association’s Declaration of Tokyo affirms that “no motive, whether personal, collective or political, shall prevail against this higher purpose” of alleviating distress.[4] Physicians are taught early on that triage decisions must be medically indicated and made without consideration of factors such as race, ethnicity, religion, social status, and nationality. They are taught that public trust and obligations of justice grounded in equality demand that only medical indications be considered. But military physicians in a military setting are beholden to obligations, duties, and responsibilities as members of the military, and when these obligations, duties, and responsibilities conflict, as they do in Battlefield Triage, which loyalties win out and why?[5] Critics of partiality on national grounds argue that partiality undermines public trust in medicine and justice because everyone should be treated equally regardless of nationality.[6] Proponents of partiality argue that military obligations supersede equality and that justice requires partiality in such cases.[7] Despite the critics’ disagreement, both agree that there is a morally right, perhaps even blameless, course of action. Drawing on insights from virtue ethics, we argue that Battlefield Triage is a moral tragedy in which justice is unattainable and there is no action without moral cost. The assumption that there is a morally right choice is flawed. We argue that while no decision in this scenario is free from moral blame, there are reasons to favor treating one’s soldiers over enemy combatants. I. The Case Against Partiality There is a common assumption that there is a morally right or just decision in Battlefield Triage. A number of organizations and scholars claim that it is wrong for military physicians to favor their own soldiers on the grounds of nationality or some form of ‘group membership.’ (In a conflict involving service members from multiple nations working as a coalition, a soldier from an allied country may receive the same priority as the US service member due to ‘group membership.’) The World Medical Association’s WMA Declaration of Lisbon on the Rights of the Patient, which was reaffirmed in 2015, posits that, “[i]n circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.”[8] This echoes what was set forth in Article 12 of the Geneva Conventions, which states that “[o]nly urgent medical reasons will authorize priority in the order of treatment to be administered.”[9] The argument for impartiality in Battlefield Triage is that every person is morally equal, and equality entails that medical distribution is, “based on a combination of medical need and urgency.”[10] This is in keeping with the bioethical principles that are generally applied.[11] II. The Case for Partiality On the other side, there are arguments that favoritism is the ethically right decision in Battlefield Triage.[12] The argument asserts that members of the military form a morally significant community of friends and participation in these relationships demands partiality. Just as parents have strong ethical duties to their children and not just any children, military personnel have ethical duties to their group, a group that involves an affirmation of mutual aid and support. Some have termed these ‘associative duties. According to Michael Gross, obligations of friendship, care, and solidarity “leave very little room for generally applicable principles of justice that would obligate a medic to treat enemy or non-compatriot wounded ahead of their compatriots.”[13] This is true in Battlefield Triage, but it may also be true even if the enemy’s soldier were more seriously wounded: “the ethics of small group cohesion, largely an ethics of care, mostly replaces the demands of impartial justice.”[14] In a more recent article, Gross explains that preferential treatment is ethically justified based on fighting capability and “the special obligations people owe friends, family, and, no less, comrades-in-arms.”[15] To not show partiality to the US soldier would be morally wrong on the grounds of friendship and mutual care.[16] III. The Moral Tragedy of Battlefield Triage Defenders and critics of Battlefield Triage favoritism based on nationality both frame their position as just or fair. For example, Justin List argues that physicians are “bound to practice medical neutrality,”[17] Marcus Adams denies that physicians “possess special ethical obligations” to enemy combatants because of their profession.[18] These perspectives assume that there is a morally right decision and that justice is attainable. The assumption that there is or can be a morally right Battlefield Triage decision, and we need to put our heads together to figure it out, remains strongly entrenched. However, the facts of the situation should give us pause; there are too many people and too few resources, and this demands a decision-making process that determines who will receive scarce resources. By its very nature, a battlefield triage decision has to be made based on some characteristic or value, a characteristic or value that will inevitably favor some at the expense of others. This is precisely why competing analyses “in the military context struggle to resolve these conflicts satisfactorily.”[19] Drawing on the insights of virtue ethics, we suggest that Battlefield Triage is a moral tragedy. Virtue ethics suggests that morality is about acting virtuously, which is to say that we should do what a virtuous person would do in the situation. Ethics is about figuring out how a just, wise, compassionate, loving, and fair person would act, and then doing that, as one grows in virtue. But life is not always clear cut, and it is possible that virtuous people may find themselves in a moral tragedy, a situation in which, through no fault of one’s own, a person must make a morally objectionable decision. After the action the virtuous person “emerges having done a terrible thing, the very sort of thing that the callous, dishonest, unjust, or in general vicious agent would characteristically do.”[20] Stated differently, a moral tragedy presents a virtuous person with two or more courses of action, all of which have a moral cost.[21] In Battlefield Triage, no matter how the physician goes about deciding, there is going to be defensible concern from those not saved. The fact that there are more people than can be helped fosters competing values in battlefield triage: maximize lives saved, treat people equally, treat the worse off, and support the war effort. Treating people equally may create tension between treating the worse off, maximizing lives saved, and supporting the war effort. Reverse triage is a case in point, as supporting the war effort conflicts with treating the worse off first, as is a fair lottery system since deploying a lottery may not maximize lives saved or support the war effort. There can be reasons why one person is selected over another, to be sure. Yet, there are reasons for making a decision, and that the decision is subject to legitimate moral concern is another. To recognize the moral tragedy of Battlefield Triage is to recognize the impossibility of acting blamelessly in the situation. In this situation, the virtuous military physician is going to have to sacrifice important values such as justice, compassion, and respect for others, even with a defensible criterion in hand. The physician will grieve this sacrifice accordingly. The physician may find her decision difficult or stressful, and rightly so, because of what her circumstances require of her. This kind of moral tragedy results “in actions which betray and violate the rights of persons to whom there may be a strong duty of care. When this happens, it properly triggers an appropriate moral emotion since our moral integrity has been violated and this affects how we think of ourselves and what we have become.”[22] Rather than view her triage decision as the morally superior choice, the virtuous military physician will view her decisions in these circumstances in a different light: it is the least bad option in a terrible situation, and she did something ethically problematic, something that is contrary to her moral character. She deeply regrets the circumstances in which she had to act. IV. Virtue Ethics A virtue ethicist has insight into how one should go about deciding what to do in a moral tragedy, although virtue ethics may not be as helpful as one may hope. The goal of the virtuous military physician in Battlefield Triage is to adopt the best course of action or the action that she feels she ought to do, all things considered. This does not make her choice devoid of serious wrongdoing—a decision must be made, but that does not make it just. The virtuous military physician will approach the situation with courage, responsibility, and insight. She will think about the decision carefully, wisely, and conscientiously; she will weigh the goods and harms of the choices before her, in conjunction with a proper conception of the good life, human worth, and understanding of her obligations to others—including chain of command, fellow soldiers, and the medical community. She is attuned to the value of human life and has a reasonable idea of the various ways her decisions will affect others. She recognizes that she is in this non-ideal situation through no fault of her own: she is not the one fighting in battles; she is serving her country as a physician, whose job it is to save lives, treat everyone justly, and promote military objectives. She regrets the decision she is forced to make in battlefield triage, acting “with immense regret and pain,” Hursthouse explains, “instead of indifferently or gladly.”[23] This is because, no matter what decision is made, the virtuous military physician “does something terrible or horrible,” something she otherwise would not do and is contrary to her values.[24] V. A Resolvable Moral Tragedy Instead of asking whether there is a morally right decision, in which a decision is morally blameless and above reproach, the virtue ethicist asks whether there is a decision with a convincing rationale, knowing that a decision can have a clear rationale but still be morally tragic. It is perfectly reasonable to think that different virtuous persons will arrive at different courses of action: “two virtuous agents, in the same situation,” Hursthouse writes, “may act differently” in irresolvable moral tragedies, in cases in which there is no clear course of action.[25] Because a person must act in a moral tragedy, one goal is to identify reasons for choosing the chosen action. Some decisions are clearly indefensible—treating neither the compatriot soldier nor the enemy combatant in Battlefield Triage would be wrong—and some decisions are more problematic than others. If the military physician selects to treat the soldier because she does not like the enemy combatant’s skin color, such a reason would be deeply problematic. But much of the debate over how to act in a moral tragedy is not over clearly indefensible or problematic criteria. Instead, the literature is largely about different standards or implementations of justice. Some scholars defend nation-impartial triage as right, while others defend nation-aware triage as right, and each argues that the other side is promoting an unjust or otherwise wrong solution to Battlefield Triage. We suggest that Battlefield Triage is a resolvable moral tragedy and that virtue ethics offers convincing reasons to prefer the treatment of the compatriot soldier rather than the enemy combatant on the grounds of national identity. Virtues are integral to living a good life, a flourishing life, but as Aristotle observed long ago, human beings are inherently social, interdependent and interconnected in profound ways.[26] This goes beyond the obvious fact that we need each other to survive day to day (one person makes clothes, another farms, and another makes tools); the claim is that a good or flourishing life depends in large part on one’s social network or community. This is why many of Aristotle’s moral virtues are other facing: justice, friendship, generosity, and magnanimity, to name a few. Courage, a typically self-facing virtue, is understood by Aristotle to be the virtue that regards one’s fear of death in battle, a battle fought on behalf of one’s city.[27] All of this remains true today. Namely, there is an important sense in which our community matters to our lives: it is easier to live a good, flourishing life if one is part of a good, flourishing community. Our community is made up of smaller groups, and it is more accurate to say that we are simultaneous members of different groups within a broader community. A person may be part of a family, friend group, research team, large state university, city, state, and nation. Groups can function well or not, as we all have experienced, and this suggests that there are virtues or excellences that groups can instantiate. Good groups are unified in purpose, with each member doing their duty alongside others for the attainment of that purpose. Good groups manifest solidarity among their members. Although Aristotle does not list solidarity as a virtue, a number of modern-day virtue ethicists have begun examining how group solidarity can be a virtue that contributes to a good or flourishing life.[28] Solidarity is not conceptualized as an individual virtue, a virtue possessed by a person in isolation of others; instead, it is a collective virtue, a virtue that is shared among members of a defined group with particular ends.[29] “A group has solidarity to the extent that its members are disposed to: (1) share values, aims, or goals; (2) care about those values, aims, or goals; (3) act in accordance with those values, aims, or goals; (4) trust the testimony of other group members with respect to those values, aims, and goals; and (5) feel a sense of belonging to the group.”[30] The virtue of collective or group solidarity involves individuals having special concern for each other, shared aims and values, trust, loyalty, and a sense of belonging with these specific others. There is a oneness to the group in the pursuit of a definite goal or purpose, involving mutual support and affirmation of each member. As such, the group has ends and goods above and beyond the good of each individual person. Sometimes solidarity requires personal sacrifice for the collective (for example, a father sacrificing food so his child can eat). The virtue of collective or group solidarity is important to the military and medical community at every level, and for clear reasons. In the military, there is a clear hierarchy of command, unity of purpose and end, mutual trust and support in complex settings, and so on. Soldiers need to know they can count on one another, and solidarity grounds a soldier’s ability to trust others and be assured of mutual aid. In medicine, solidarity maintains self-regulation of the profession, shared values and goals, as well as public support, not to mention that day-to-day operations require physician trust, engagement, and effort toward the ends of clinical care. Physicians need to work together, along with others, in pursuit of health, and disunity is sowed when there is mistrust, selfishness, or disengagement among the healthcare team and organization. Importantly, just as we are all members of various groups and hence may manifest group solidarity in different settings, the virtuous military physician instantiates collective solidarity with both the medical profession and the military. Her dual loyalty contributes to the moral difficulty of acting in Battlefield Triage. The military physician has competing obligations to distinct groups and cannot satisfy all obligations in Battlefield Triage. Solidarity with the military supports the consideration of favoring the soldier for reasons of national identity, whereas solidarity with the medical community does not. Something has to give, which is why it is a moral tragedy. The virtuous military physician, therefore, must weigh the costs of each course of action. To fulfill her obligations to the medical community would require that she does not use nationality and other non-medical considerations in Battlefield Triage. Since the soldier and enemy combatant are equally injured, justice would demand a random process, perhaps a flip of the coin. Although this may satisfy obligations the military physician has to the medical community, this would be costly to the physician’s military group. If word gets out that the physician decides who to treat based on a coin toss, soldiers, families, and citizens may become frustrated and angry. Soldier morale may go down if it becomes known that a coin flip led to the preventable death of a soldier and the saving of an enemy combatant who had killed (or attempted to kill) other soldiers. As Gross highlights, military solidarity involves a mutual aid promise that military personnel promise to help one another.[31] A military physician is part of the military and, as such, is part of the mutual aid promise, which would appear to be violated if the physician flips a coin. Treating a member of one’s own team may be psychologically more beneficial than treating an enemy combatant and may lead to less moral distress.[32] Finally, treating soldiers rather than enemy combatants promotes broader military and social aims, including returning soldiers to health, maintaining unity of purpose, and minimizing community suffering from a soldier’s death. Favoring members of one’s group, that is, triage based on nationality in Battlefield Triage, would fulfill obligations of military group loyalty, which is contrary to the values and duties of medicine. It does not seem as though showing favoritism in this particular situation is very costly to the medical community or general public, but this is because there is recognition that the physician is in the military. Medicine is impartial to non-medical indications partly because of fairness and to promote public trust in medicine. However, Battlefield Triage is unique, as medicine is being practiced in a non-public, wartime setting. In ordinary circumstances, a patient’s identity is irrelevant, and physicians ought not play favorites. Since Battlefield Triage is not an ordinary circumstance, decisions based on patient identity may not undermine public trust in medicine. In addition, it is contestable that fairness in Battlefield Triage requires that no consideration be paid to one’s nationality. Fairness is about giving each person their due, what is owed to them, and the case can be made that soldiers who place themselves in danger for the sake of the common good or a just cause are owed special attention when they suffer harm in the line of duty. In other words, soldiers voluntarily undergo risk to themselves for the greater good, and society owes them for this sacrifice. This plausibly includes preferential treatment in a situation such as Battlefield Triage. So, while the medical community affirms justice demands non-preferential treatment, the military community can affirm the opposite. The demands of fairness are unclear at best or in conflict in this situation: demands of physician justice decry favoritism, while demands of military justice support favoritism. Triage not based on nationality is arguably unfair and triage based on nationality may not undermine public trust, after all. All things considered, there is a clear rationale for favoring nationality-based preferential treatment in Battlefield Triage. Adopting a nationality-based preference in this situation is more defensible than not. This does not make such a decision ethically right or just. Preference based on nationality is the least bad decision, but it is not morally blameless. It involves one in a serious moral wrong, a wrong otherwise avoided and contrary to one’s character. The virtuous military physician is in a situation in which obligations conflict, and we disagree with Gross, who posits that care of fellow soldiers “is important to the near exclusion of all else.”[33] Gross fails to appreciate the collective virtue of solidarity as applied to those in medicine. The military physician has duties to fellow soldiers but also to fellow physicians, to the medical community, and humanity. To favor a soldier on grounds of nationality violates her duties and responsibilities to this latter group. She is involved in a moral tragedy and can only seek the most just action given the circumstances, yet, at least in virtue ethics, the action remains far from blameless. CONCLUSION We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. As such, the virtuous military physician incurs a moral cost to acting as she does—there is a moral residue. However, despite being a moral tragedy, there are clear reasons to act in favor of treating one’s own, considering group solidarity. As such, these kinds of tragedies are resolvable: virtuous military physicians should favor treatment of their own, although they would do so with sorrow. - [1] Militaries set forth medical rules of eligibility or guidelines used to determine whether a person qualifies for specific medical interventions or treatments in certain circumstances, and these guidelines are binding for a military physician. For example, despite opposition from medical organizations, militaries have adopted reverse triage guidelines for military physicians to follow. For ethical discussion, see Falzone, Elisabeth, P. Pasquier, C. Hoffmann, O. Barbier, M. Boutonnet, A. Salvadori, A. Jarrassier, J. Renner, B. Malgras, and S. Mérat. "Triage in military settings." Anaesthesia Critical Care & Pain Medicine 36, no. 1 (2017): 43-51. https://doi.org/10.1016/j.accpm.2016.05.004 [2] There are issues that are related to this, including the triage of civilians and allied soldiers. We set related issues aside for purposes of this paper [3] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [4] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [5] This is termed the “dual loyalty” dilemma in military medicine and has been described at length elsewhere: Institute of Medicine (US) Board on Health Sciences Policy. Military Medical Ethics: Issues regarding Dual Loyalties: Workshop Summary. Washington (DC): National Academies Press (US); 2008. Toward a Framework for Resolving Dual Loyalties. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214853/ [6] See Kenneth G. Swan and K.G. Swan, Jr., “Triage: The Past Revisited,” Military Medicine 161:8 (1996): 448–452. https://doi.org/10.1093/milmed/161.8.448; Jerome A. Singh, “American Physicians and dual loyalty obligations in the ‘war on terror,’” BMC Medical Ethics 4.4 (2003): 1–10. https://doi.org/10.1186/1472-6939-4-4; Beam, Thomas E. "Medical Ethics on the Battlefield." Military Medical Ethics: Sect. IV. Medical ethics in the military. Medical ethics on the battlefield: the crucible of military medical ethics 2 (2003): 369-402; Hereth, Blake. "Health justice for unjust combatants." Journal of Military Ethics 20, no. 1 (2021): 67-81. https://doi.org/10.1080/15027570.2021.1949782. [7] See Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. Gross, Michael L. "Comradery, community, and care in military medical ethics." Theoretical medicine and bioethics 32 (2011): 337-350. https://doi.org/10.1007/s11017-011-9189-6. Gross, Michael L. "The limits of impartial medical treatment during armed conflict." In Military medical ethics for the 21st century, pp. 71-84. Routledge, 2016. [8] World Medical Association, WMA Declaration of Lisbon on the Rights of the Patient. 5 December 2022, https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ [9] Geneva Convention for the Amelioration of the Condition of Wounded, Sick in Armed Forces in the Field. 12 August 1949. https://www.un.org/en/genocideprevention/documents/atrocity-crimes/Doc.30_GC-I-EN.pdf. [10] List, Justin M. "Medical neutrality and political activism: physicians' roles in conflict situations." In Physicians at war: The dual-loyalties challenge, pp. 237-253. Dordrecht: Springer Netherlands, 2008. 240 [11] Beauchamp, T., and J. Childress. 2013. Principles of Biomedical Ethics, 7th ed. Oxford, United Kingdom: Oxford University Press. [12] Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. [13] Gross, "Comradery, community, and care in military medical ethics," 347. [14] Gross, “Comradery, community, and care in military medical ethics,” 349. [15] Gross, Michael L. "When medical ethics and military ethics collide." Narrative inquiry in bioethics 13, no. 3 (2023): 199-204. 202 https://dx.doi.org/10.1353/nib.2023.a924191 [16] Our argument draws on virtue ethics, from which care ethics derives, and it is worth clarifying how our argument relates to Gross’s. We do not think that the virtue of friendship grounds triage decisions, for we think it is unlikely that the physician and wounded soldier are friends. Instead, as explained below, we think the collective virtue of group solidarity better captures the moral significance of group loyalty and that Gross would agree with us. But since military physicians are part of distinct groups, with competing obligations, the military physician will be forced to sacrifice a value in battlefield triage cases. In other words, we think Gross downplays the dual group membership of a military physician. [17] List,”Medical neutrality and political activism,” 250. [18] Adams,”Triage priorities and military physicians,” 235. [19] London, Leslie, Leonard S. Rubenstein, Laurel Baldwin-Ragaven, and Adriaan Van Es. "Dual loyalty among military health professionals: human rights and ethics in times of armed conflict." Cambridge Quarterly of Healthcare Ethics 15, no. 4 (2006): 381-391. 383. [20] Hursthouse, R. On Virtue Ethics. OUP 1999. 74 [21] Nussbaum, Martha C. "The costs of tragedy: Some moral limits of cost-benefit analysis." The Journal of Legal Studies 29, no. S2 (2000): 1005-1036, 1007. [22] De Wijze, S. (2005). Tragic-remorse–the anguish of dirty hands. Ethical theory and moral practice, 7(5), 453-471, 457. https://doi.org/10.1007/s10677-005-6836-x [23] Hursthouse, 73 [24] Hursthouse, 81 [25] Hursthouse, 72 [26] Aristotle, Politics 1253a8. Reeve, C. D. C., Indianapolis: Hackett Publishing Co., 2017 [27] Aristotle, Nicomachean Ethics. III.6.114a, 34-35. 2002, Nicomachean Ethics, Christopher Rowe (trans.), Oxford: Oxford University Press [28] Byerly, T. Ryan, and Meghan Byerly. "Collective virtue." The Journal of Value Inquiry 50, no. 1 (2016): 33-50. https://doi.org/10.1007/s10790-015-9484-y; Federico, Veronica. "Conclusion: solidarity as a public virtue." Solidarity as a Public Virtue (2018): 495-542. https://doi.org/10.5771/9783845290058. Rehg, William. "Solidarity and the common good: An analytic framework." Journal of Social Philosophy 38, no. 1 (2007): 7-21. https://doi.org/10.1111/j.1467-9833.2007.00363.x [29] Byerly and Byerly. "Collective virtue." 43 [30] Battaly, Heather. "Solidarity: Virtue or vice?." In Social virtue epistemology, pp. 303-324. Routledge, 2022. 304 [31] Ibid., 2011: 341 [32] It might be thought that displaying altruism by helping an enemy combatant at the expense of one’s fellow soldier may be psychologically satisfiying. For evidence that military physicians find it difficult to treat enemy combatants, see Lundberg, Kristina, Sofia Kjellström, Anders Jonsson, and Lars Sandman. "Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties." Military medicine 179, no. 8 (2014): 821-826. https://doi.org/10.7205/MILMED-D-14-00038. Lamblin, Antoine, Clément Derkenne, Marion Trousselard, and Marie-Ange Einaudi. "Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study." BMC Medical Ethics 22 (2021): 1-13. https://doi.org/10.1186/s12910-021-00723-2 [33] Ibid., 2011: 344. (shrink)

Bioethics introduces students to the most relevant historical, epistemological, methodological, and practical aspects of bioethics. The book presents readers with some of the most thought-provoking writing in the field, along with an original introduction to each reading. Selections range from the work of great philosophers like Aristotle, Immanuel Kant, and John Stuart Mill, to contemporary writings and reports. Readers explore various ideologies and philosophies including the seminal work of Tom Beauchamp and James Childress on principles of biomedical ethics and (...) the dialogical approach to bioethics. They also consider controversial topics straight from the headlines of the day, such as the collision between paternalism and autonomy, futility, human research, genetic manipulation, and active and passive euthanasia. Bioethics encourages students to think objectively and impartially in order to resolve the ethical dilemmas that stem from biotechnological empowerment and biomedical techniques. The book is suitable for courses in biomedical, research, and practical ethics, as well as those that discuss moral philosophy. It can be used as a stand-alone text, or as a supplement to standard textbooks. Erick Valdes earned a Ph.D. in philosophy from the University of Chile as well as a Ph.D. in political philosophy from Paris-Sorbonne University in France. He is an adjunct research scholar at the Kennedy Institute of Ethics, Georgetown University, where he conducts advanced research on bioethics and biolaw. In addition, Dr. Valdes teaches bioethics, research ethics, theories of democracy and international human rights at George Mason University and American University. He is the author of nine books on bioethics and political philosophy and has published in both English and Spanish. He has written extensively on bioethics and biolaw for international journals, and served as a visiting professor at universities in England, France, Spain, Russia, Mexico, Colombia, Argentina, and Chile. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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"Peter Iver Kaufman is admirably and ideally qualified to undertake this project of reading More on politics in the light of Augustine on politics. In vigorous, well-paced prose, he tackles an important and original subject." —_Marcia L. Colish, Frederick B. Artz Professor of History, emerita, Oberlin College_ _“Incorrectly Political_ will attract readers not only because it is written with the author's characteristic flair and liveliness, but also because of his established capacity to bridge centuries of Western thought and history. Written (...) at the dawn of the new century, this book acquires deep resonance from the events unfolding around the world, circumstances to which Augustine’s and More's complex thoughts on political possibility still speak. If ever a study of such hoary figures from the Christian past deserved the label 'timely,' it is surely this one.” —_Kevin Madigan, Harvard University Divinity School_ Augustine in the fourth and fifth centuries and Thomas More in the sixteenth were familiar with the deceits and illusions that enabled even the most vile rulers to shore up their dignity and that gave repressive regimes an inviolability of sorts. Both men knew the politics of their times, both were involved in politics, and both were at one time politically ambitious. Augustine needed and made good use of government's powers of coercion and damage control in his struggle against the Donatists. The clear advantages of political protection and correction preoccupied More in his battle against Martin Luther. Both later changed their minds and believed, finally, the political imagination, based as it is on a desire for power, always and inevitably leads to devastation and suffering. Peter Iver Kaufman explains how and why we have failed to appreciate Augustine's and More's profound political pessimism, reintroducing readers to two of the Christian tradition's most enigmatic yet influential figures. Each had been disturbed by the reach of his own political ambitions—as by those of contemporaries. Each knew that government was useful—yet always deceitful. And each wrote a classic—widely read to this day, Augustine's _City of God_ and More's _Utopia,_as well as abundant correspondence and polemical tracts to explain why government on earth might be used, though never meaningfully improved. (shrink)

Experimental philosophers advocate expansion of philosophical methods to include empirical investigation into the concepts used by ordinary people in reasoning and action. We propose also including methods of qualitative social science, which we argue serve both moral and epistemic goals. Philosophical analytical tools applied to interdisciplinary research designs can provide ways to extract rich contextual information from subjects. We argue that this approach has important implications for bioethics; it provides both epistemic and moral reasons to use the experiences and perspectives (...) of diverse populations to better identify underlying concepts as well as to develop effective interventions within particular communities. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:American Journal of Philology 124.4 (2003) 621-624 [Access article in PDF] HARRY B. EVANS. Aqueduct Hunting in the Seventeenth Century: Raffaello Fabretti's De aquis et aquaeductibus veteris Romae. Ann Arbor: The University of Michigan Press, 2002. xvi + 309 pp. 38 black-and-white figures. Cloth, $55. Stretching across the Roman Campagna, the tall arches of ancient aqueducts, even in their present ruined condition, are vivid reminders of the powerful state (...) and skilled engineers that built them. Scholarly interest in the geography and topography of the Campagna, with its natural and manmade wonders, had its genesis in such ancient commentators as Pliny the Elder and Strabo, but perhaps no scholars were more energetic than the early modern. Antiquarians and archaeologists perused the ruins of Rome and its countryside, among them the talented epigrapher and hunter of aqueducts, Raffaello Fabretti. A prominent figure in the learned world of seventeenth-century Rome, Fabretti published a study of the city's ancient aqueducts in 1680. It was the earliest modern topographical work to take the water system as its subject and among the most influential studies of its kind. Until now, Fabretti's treatise, titled De aquis et aquaeductibus veteris Romae, was available only in the original Latin (reprinted in The Printed Sources of Western Art series); its language quirky, ornate, and difficult, the treatise was not readily accessible to most readers.In the volume under review, Harry Evans, a veteran scholar of the Roman countryside and its water system, provides a complete English translation of and commentary on Fabretti's Deaquis. In the original text, Fabretti takes his readers on an exhaustive tour of the Roman Campagna that includes not only the aqueducts—whose water sources, conduit routes, and distribution systems he details—but also the ancient road system and city gates; he even assesses the size of the ancient city itself. His discussion encompasses literary, epigraphic, and archaeological evidence and is invaluable for its description of physical remains long since lost. Focusing primarily on the topographical issues addressed by Fabretti, Evans assesses his methods, contributions, and errors; at the same time, Evans offers a glimpse into the lively, often deeply contentious world of early modern scholarship.Fabretti's treatise was initially written as three separate "dissertations," published together in 1680. The first addresses the route and purpose of the Aqua Alexandrina, a third-century imperial conduit; the second explores the sources of the Aqua Marcia and Aqua Claudia in the upper Anio valley east of Tivoli; the third investigates a discrepancy between the number of aqueducts cited by Procopius (14) and the number of water sources listed in the fourth-century regionary catalogues (20). In two introductory chapters, Evans reviews Fabretti's biography and provides historical context for the treatise. Each of the following three chapters addresses one of the dissertations, with Evans' commentary following a full translation of the text. In a brief conclusion, Evan reflects upon Fabretti's contribution to later archaeological and topographical scholarship down to the twentieth century. Evans provides a readable translation of Fabretti's Latin text (while remaining faithful to the original), a text that will amuse [End Page 621] readers with its frequent barbs aimed at rivals in the field. Amply illustrated, including reproductions of the topographical maps that accompany each dissertation, this volume is a significant resource not only for philologists but also for historians of Rome more generally.Like many polymaths of his day, Fabretti had a career in the Church but made his name as a scholar of the ancients. His knowledge of Rome and the Campagna was not simply literary, though his command of the written sources was unquestionable, for as superintendent of the catacombs and custodian of antiquities, Fabretti had ample opportunity to excavate and examine Roman remains firsthand. He formed his own collection of inscriptions and published a number of ambitious archaeological tomes, including one on the column of Trajan. Intimate with the most learned persons of his day, Bernard Montfaucon and Giovanni Ciampini among them, Fabretti moved in the scholarly... (shrink)

This paper discusses ways in which empirical research investigating sexual networks can further understanding of the transmission of HIV in London, using information from a 24-month period of participant observation and 53 open-ended, in-depth interviews with eighteen men and one woman who have direct and indirect sexual links with each other. These interviews enabled the identification of a wider sexual network between 154 participants and contacts during the year August 1994-July 1995. The linked network data help to identify pathways of (...) transmission between individuals who are HIV+ and those who are HIVolderyounger’ men, and with male prostitutes. There appears to be considerable on-going transmission of HIV in London. The majority of participants reported having had unprotected anal and/or vaginal sex within a variety of relationships. The implications of these findings for policies designed to prevent the transmission of HIV are discussed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Full Collection of Personal NarrativesJake Beery, Neethi Pinto, Marcia King, Laura Wachsmuth, Alisha, Katie L. Gholson, T.S. Moran, Calvin R. Gross, Joanne Alfred, Cindy Bitter, Jenna Bennett, Nadia Khan, Clarice Douille, Kristen Carey Rock, Adrienne Feller Novick, Andrea Eisenberg, Japmehr Sandhu, Katherine Bakke, Heer Hendry, Karan K. Mirpuri, and Katerina V. Liong• Being the Difference• Grieving One More Time• Echoes of Grief: Tales from an Emergency Medicine and (...) Critical Care Nurse• Searching for Peace in Death• “I’d Love to go Off the Grid and Never Come Back”• “A Mother’s Love”• Tiny Person, Big Impact• Night Shift• Cracked Armor• Who Tells the Story• Navigating Hard Situations that Medical School Cannot Prepare You For• The Wish• Break• Five More Minutes• I Saw My Reflection• The Aftermath• Where the Journey Begins• Lessons Learned in Room 208• Joint and Grief Aches• My First Loss: Carrying His Legacy• Grieving the Loss of What Medicine Was Supposed to BeCopyright © 2024 Johns Hopkins University Press... (shrink)

We question the usefulness of Pylyshyn's dichotomy between cognitively penetrable and cognitively impenetrable mechanisms as the basis for his distinction between cognition and early vision. This dichotomy is comparable to others that have been proposed in psychology prompting disputes that by their very nature could not be resolved. This fate is inevitable for Pylyshyn's thesis because of its reliance on internal representations and their interpretation. What is more fruitful in relation to this issue is not a difficult dichotomy, but a (...) different look at perception such as proposed by Gibson (1979). (shrink)

I take up the question of how models of extended cognition might redirect the academic study of religion. Entering into a conversation of sorts with Emile Durkheim and Bruno Latour regarding the "overtakenness" of social agency, I argue that a robust portrait of extended cognition must redirect our interest in explaining religion in two key ways. First, religious studies should take up the methodological principle of symmetry that informs contemporary histories of science and begin theorizing the efficacy of gods as (...) social actors. Second, theorists of religion should begin noting how the work required to construct spaces in which the gods appear depends on the construction of disciplined and capable subjects. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Death in the Greek World: From Homer to the Classical Age by Maria Serena MirtoJoseph W. DayMaria Serena Mirto. Death in the Greek World: From Homer to the Classical Age. Trans. by A. M. Osborne. Oklahoma Series in Classical Culture 44 Norman: University of Oklahoma Press, 2012. x + 197 pp. 10 black-and-white figs. Paper, $19.95.Mirto (with Osborne) has given us a readable book on a topic of (...) perennial interest, full of learning but unencumbered by the development of a comprehensive argument with full scholarly apparatus (there are no footnotes or endnotes). I devoured it on a couple of airplane rides, during which its intelligent presentation thoroughly distracted me from my physical discomfort. The book provided a clear and concise review of important topics which I have not studied intensely for years, and it initiated me into recent trends and made me thirsty to approach its suggestions for further reading—while avoiding the spring by the white cypress, of course.The volume is an expansion and updating, as well as a translation, of the Italian original, La morte nel mondo greco (Rome 2007). Much scholarship from 2007 and later is cited, especially in discussions of Dionysian and “Orphic” material (chap. 2). Important additions are a useful section on the confusing (to the uninitiated) topic of hero cults and “an appendix outlining fundamental developments in modern studies of death in the Greek world” (x). The latter traces an interesting journey through the history of mentalities from R. Hertz (Durkheim’s student), through E. de Martino and P. Ariès, on to C. Sourvinou-Inwood’s disagreement with I. Morris about change and stability in early Greek attitudes toward death.Mirto articulates her goal in the preface as “a general synthesis of people’s relationships with death in the Greek world... [a] survey of the ways in which archaic and classical Greek culture dealt with the trauma of death” (ix). One does not judge such a book on its original interpretations and scholarly arguments; other criteria apply. For example, how comprehensive (or representative) is the selection of topics, approaches, and examples? How useful (or user-friendly) is the selection, especially for the audience to which it is addressed?At the level of overall structure, Mirto scores high for comprehensiveness. Any treatment of Greek death must devote major attention to the three topics she announces : (1) “beliefs about the afterlife, on the boundary between literary imagination and religious faith”; (2) “funerary rituals and material evidence of the cult of the dead”; (3) “ideologies... that construct an ideal model of death, making it an acceptable, perhaps even desirable, event” (ix). Chapter 1 on traditional views, mostly derived from Homer (also treated in chap. 5.1), commences Mirto’s discussion of the first topic, which is continued in chapter 2 on more [End Page 337] optimistic eschatologies, especially those associated with Dionysus and Orpheus. The second topic is treated in chapters 3 (on death, mourning, and last rites) and 4 (on markers, epitaphs, and tomb and hero cult). Chapter 5 is devoted to the third topic, with particular attention to the development of the polis and Athens’ patrios nomos and funerary legislation. R. Garland’s widely used survey (The Greek Way of Death [Ithaca 1985], 2d ed. 2001) covers much the same ground, though that book’s feel is quite different. Garland provides a richness of source and scholarly citations that Mirto eschews; for example, Garland devotes twenty-three pages (chap. 7 and its dense endnotes) to visits to the grave, while Mirto barely touches on the matter.At the level of specifics, Mirto’s comprehensiveness is uneven. Reflecting her expertise in archaic and classical poetry, as well as her engagement with the history of mentalities, discussions of literature and some sub-literary textual material are excellent, while she is less full but still useful on iconography (especially that of white-ground lekythoi and sculpture) and polis regulations. Perceptions of comprehensiveness, of course, will vary among readers. Because of gaps in my knowledge, I learned most from Mirto’s presentation of Dionysian and “Orphic” material: the gold lamellae, the Olbia bones, the Derveni papyrus (chap. 2, with the... (shrink)

Into every life a little Zen must fall. A Christian philosopher looks to Alan Watts and the East. Alan Keightley. Wisdom Publications, London 1986. 194 pp. £6.95.

This is an abridged, paperback edition of Peter le Huray and James Day's invaluable anthology of writings concerned with the role of music in eighteenth- and early-nineteenth-century aesthetics. This volume retains all the most important and significant items from the original hardcover edition. Over fifty writers are represented here, including such major figures as Rousseau, Kant, Schlegel, Schopenhauer and Hegel, and the useful introductions and biographical details of the original are also retained. The aesthetic literature of the period is profuse (...) but this carefully edited volume offers a balanced selection which illuminates the ways people experienced music and how they came to an understanding in particular of the new music of their day. (shrink)

Gideon Rosen (2014) has drawn our attention to cases of duress of a particularly interesting sort: the person's ‘mind is not flooded with pain or fear’, she knows exactly what she is doing, and she makes a clear-headed choice to act in, as Rosen says, ‘awful ways’. The explanation of why we excuse such actions cannot be that the action was not voluntary. In addition, although some duress cases could also be viewed as necessity cases and thus as justified, Rosen (...) wisely sets aside that complicating factor by zeroing in on those cases where the action clearly is not justified. So why do we excuse in these cases, where the action is not justified and the agent acted voluntarily?Rosen thinks the key lies in the ‘ill will’ condition, ‘the idea that an act is blameworthy only if it manifests insufficient concern or regard for those affected’. He says this is relatively uncontroversial; much of my paper is taken up with calling the ‘ill will’ condition into question. I also take issue with Rosen on just how justifications and excuses differ. I argue in favour of understanding justifications (in a context where we are asking how justifications and excuses differ) as not requiring truth, but only reasonable belief. (shrink)

Books Received Kantian Review, FirstView Article.