When can or should citizenship be granted to prospective members of states? When can or should states withdraw citizenship from their existing members? In recent decades, political philosophers have paid considerable attention to the first question, but have generally neglected the second. There are of course good practical reasons for prioritizing the question of when citizenship should be granted—many individuals have a strong interest in acquiring citizenship in particular political communities, while many fewer are at risk of denationalization. Still, loss (...) of membership in a political community is a practice with a long history that continues to take place today. -/- Concerns about national security have recently led several liberal democratic states to pass, strengthen or consider legislation that would empower their governments to denationalize certain persons.] At the international level, formal norms governing denationalization are vague and generally toothless, and there are no international legal norms that restrict denationalization to citizens who hold another citizenship or wish to take up citizenship elsewhere (Worster, 2009). So it is important to determine whether there are conditions under which denationalization can be morally justified and, if so, what those conditions are. We shall argue that while denationalization is ordinarily impermissible, there is a class of crime committed by citizens that may render it not only permissible, but a fitting response on the part of the state. (shrink)

Religion is an important element of end-of-life care on the paediatric intensive care unit with religious belief providing support for many families and for some staff. However, religious claims used by families to challenge cessation of aggressive therapies considered futile and burdensome by a wide range of medical and lay people can cause considerable problems and be very difficult to resolve. While it is vital to support families in such difficult times, we are increasingly concerned that deeply held belief in (...) religion can lead to children being potentially subjected to burdensome care in expectation of ‘miraculous’ intervention. We reviewed cases involving end-of-life decisions over a 3-year period. In 186 of 203 cases in which withdrawal or limitation of invasive therapy was recommended, agreement was achieved. However, in the 17 remaining cases extended discussions with medical teams and local support mechanisms did not lead to resolution. Of these cases, 11 (65%) involved explicit religious claims that intensive care should not be stopped due to expectation of divine intervention and complete cure together with conviction that overly pessimistic medical predictions were wrong. The distribution of the religions included Protestant, Muslim, Jewish and Roman Catholic groups. Five of the 11 cases were resolved after meeting religious community leaders; one child had intensive care withdrawn following a High Court order, and in the remaining five, all Christian, no resolution was possible due to expressed expectations that a ‘miracle’ would happen. (shrink)

The right to withdraw from participation in research is recognized in virtually all national and international guidelines for research on human subjects. It is therefore surprising that there has been little justification for that right in the literature. We argue that the right to withdraw should protect research participants from information imbalance, inability to hedge, inherent uncertainty, and untoward bodily invasion, and it serves to bolster public trust in the research enterprise. Although this argument is not radical, it provides a (...) useful way to determine how the right should be applied in various cases. (shrink)

If a doctor is trying to decide whether or not to provide a medical treatment, does it matter ethically whether that treatment has already been started? Health professionals sometimes find it harder to stop a treatment (withdraw) than to refrain from starting the treatment (withhold). But does that feeling correspond to an ethical difference? In this article, we defend equivalence—the view that withholding and withdrawal of treatment are ethically equivalent when all other factors are equal. We argue that preference (...) for withholding over withdrawal could represent a form of cognitive bias—withdrawal aversion. Nevertheless, we consider whether there could be circumstances in which there is a moral difference. We identify four examples of conditional nonequivalence. Finally, we reflect on the moral significance of diverging intuitions and the implications for policy. We propose a set of practical strategies for helping to reduce bias in end-of-life decision making, including the equivalence test. (shrink)

The Zhuangzi, a 4th century BCE Daoist text, is sceptical about the political culture of its time. Those who debated conceptions of a good life were hostile to the views of others. They were intolerant and at times contemptuous of others who did not embody their values. In contrast to such negativity, the Zhuangzi promotes equanimity. The equanimity of the sagely person is grounded in a balance she maintains between engagement and withdrawal. Engaging critically, she problematises the lack of (...) diversity in their options for a good life. By withdrawing, she refuses to be party to the squabbles that perpetuate intolerance. The paper aims to show how equanimity is possible, thereby articulating a new angle on emotions in the Zhuangzi. (shrink)

There is a concern that as a result of COVID-19 there will be a shortage of ventilators for patients requiring respiratory support. This concern has resulted in significant debate about whether it is appropriate to withdraw ventilation from one patient in order to provide it to another patient who may benefit more. The current advice available to doctors appears to be inconsistent, with some suggesting withdrawal of treatment is more serious than withholding, while others suggest that this distinction should (...) not be made. We argue that there is no ethically relevant difference between withdrawing and withholding treatment and that suggesting otherwise may have problematic consequences. If doctors are discouraged from withdrawing treatment, concern about a future shortage may make them reluctant to provide ventilation to patients who are unlikely to have a successful outcome. This may result in underutilisation of available resources. A national policy is urgently required to provide doctors with guidance about how patients should be prioritised to ensure the maximum benefit is derived from limited resources. (shrink)

The problem of how to remove information from an agent's stock of beliefs is of paramount concern in the belief change literature. An inquiring agent may remove beliefs for a variety of reasons: a belief may be called into doubt or the agent may simply wish to entertain other possibilities. In the prominent AGM framework for belief change, upon which the work here is based, one of the three central operations, contraction, addresses this concern (the other two deal with the (...) incorporation of new information). Makinson has generalised this work by introducing the notion of a withdrawal operation. Underlying the account proffered by AGM is the idea of rational belief change. A belief change operation should be guided by certain principles or integrity constraints in order to characterise change by a rational agent. One of the most noted principles within the context of AGM is the Principle of Informational Economy. However, adoption of this principle in its purest form has been rejected by AGM leading to a more relaxed interpretation. In this paper, we argue that this weakening of the Principle of Informational Economy suggests that it is only one of a number of principles which should be taken into account. Furthermore, this weakening points toward a Principle of Indifference. This motivates the introduction of a belief removal operation that we call severe withdrawal. We provide rationality postulates for severe withdrawal and explore its relationship with AGM contraction. Moreover, we furnish possible worlds and epistemic entrenchment semantics for severe withdrawals. (shrink)

In 2011 the English Court of Protection ruled that it would be unlawful to withdraw artificial nutrition and hydration from a woman, M, who had been in a minimally conscious state for 8 years. It was reported as the first English legal case concerning withdrawal of artificial nutrition and hydration from a patient in a minimally conscious state who was otherwise stable. In the absence of a valid and applicable advance decision refusing treatment, of other life-limiting pathology or excessively (...) burdensome suffering, the judgement makes it clear that the obligation on health professionals falls strongly in favour of preserving life. Although the Court sought to limit the judgement as closely as possible to the facts of the case, it is likely to have a significant impact on life-sustaining treatment decisions for people in states of low awareness. This paper outlines the main legal features of the judgement. (shrink)

I reject the traditional picture of philosophical withdrawal in the Hellenistic Age by showing how both Epicureans and Stoics oppose, in different ways, the Platonic and Aristotelian assumption that contemplative activity is the greatest good for a human being. Chrysippus the Stoic agrees with Plato and Aristotle that the greatest good for a human being is virtuous activity, but he denies that contemplation exercises virtue. Epicurus more thoroughly rejects the assumption that the greatest good for a human (...) being is virtuous activity. He maintains that the greatest good for a human being is the tranquility that virtuous activity always and contemplative activity sometimes brings about. (shrink)

BackgroundWhen rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a ‘grandfather clause’ when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians’ and patient organization representatives’ experiences- and perceptions of withdrawing and withholding treatments in rationing situations of (...) relative scarcity.MethodsFourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used.ResultsParticipants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients’ need for treatment withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers.ConclusionsWe conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment’s effect, and to provide guidelines on a national level. (shrink)

Although AGM theory contraction (Alchourrón et al., 1985; Alchourrón and Makinson, 1985) occupies a central position in the literature on belief change, there is one aspect about it that has created a fair amount of controversy. It involves the inclusion of the postulate known as Recovery. As a result, a number of alternatives to AGM theory contraction have been proposed that do not always satisfy the Recovery postulate (Levi, 1991, 1998; Hansson and Olsson, 1995; Fermé, 1998; Fermé and Rodriguez, 1998; (...) Rott and Pagnucco, 1999). In this paper we present a new addition, systematic withdrawal, to the family of withdrawal operations, as they have become known. We define systematic withdrawal semantically, in terms of a set of preorders, and show that it can be characterised by a set of postulates. In a comparison of withdrawal operations we show that AGM contraction, systematic withdrawal and the severe withdrawal of Rott and Pagnucco (1999) are intimately connected by virtue of their definition in terms of sets of preorders. In a future paper it will be shown that this connection can be extended to include the epistemic entrenchment orderings of Gärdenfors (1988) and Gärdenfors and Makinson (1988) and the refined entrenchment orderings of Meyer et al. (2000). (shrink)

This study aimed to elucidate the withdrawal behaviors syndrome (lateness, absence, and intent to leave work) among nurses by examining interrelations between these behaviors and the mediating effect of organizational commitment upon ethical perceptions (caring climate, formal climate, and distributive justice) and withdrawal behaviors. Two-hundred and one nurses from one hospital in northern Israel participated. Data collection was based on questionnaires and hospital records using a two-phase design. The analyses are based on Hierarchical Multiple Regressions and on Structural (...) Equation Modeling with AMOS. Affective commitment was found to mediate the relationship between different dimensions of nurses’ ethical perceptions (caring climate, formal climate, and distributive justice) and their intent to leave work. Lateness was found to be positively related to absence frequency which was found negatively related to intent to leave. Males were late more frequently than females, while seniority was related only to absence frequency. The findings indicated that each withdrawal behavior exhibits unique relationships. The results may help policy makers to focus on improving the ethical environment in order to increase nurses’ commitment and reduce their intent to leave. Improving the ethical environment may be achieved through ethical education for nurses which may promote ethical considerations becoming an integral part of nurses’ work. (shrink)

The right to withdraw from research without penalty is well established around the world. However, it has been challenged in some corners of bioethics based on concerns about various harms—to participants, to scientific integrity, and to research bystanders—that may stem from withdrawal. These concerns have become particularly salient in emerging debates about the ethics of controlled human infection (CHI) studies in which participants are intentionally infected with pathogens, often in inpatient settings with extensive follow‐up. In this article, I provide (...) support for preserving the right to withdraw from research without penalty and demonstrate that it is also typically justified in the specific context of CHI studies. The right is well aligned with individual freedoms outside the research setting, where autonomous individuals are permitted to engage in behaviors that will foreseeably cause them harm; where they cannot be compelled to satisfy contracts for their services, nor penalized for failure to do so; and where their behavior is not constrained by public health authorities except in extreme circumstances. These freedoms are supported by U.S. law, as well as by ethical analysis that is more globally relevant. The problems associated with the right to withdraw, however, remain. The best approach to addressing them is not to restrict the right but rather to avoid initiating research when withdrawal would be especially problematic. If research proceeds, steps can still be taken to minimize participant withdrawal without infringing the right. Investigators can avoid participant surprise through informed consent focused on a study’s most burdensome aspects and promote study completion through financial incentives. Should participants nonetheless seek to withdraw, investigators may attempt to persuade them not to do so by encouraging consideration of the range of potential harms that may result. Researchers conducting CHI studies and other research from which withdrawal might be especially problematic should prepare for the possibility of participant withdrawal, respect participant requests to withdraw without penalty, and incorporate various measures to avoid such requests. (shrink)

The advent of COVID-19 has been the occasion for a renewed interest in the principles governing triage when the number of critically ill patients exceeds the healthcare infrastructure’s capacity in a given location. Some scholars advocate that it would be morally acceptable in a crisis to withdraw resources like life support and ICU beds from one patient in favor of another, if, in the judgment of medical personnel, the other patient has a significantly better prognosis. The paper examines the arguments (...) for and against this approach from the point of view of natural law theory, especially using the principle of double effect. We conclude that it is inadmissible to withdraw life-saving medical interventions from patients who are still benefiting from them, on the sole grounds that other patients might benefit more. Those who are currently using such technology should only interrupt their treatment if, in the judgment of medical personnel and, if possible, taking into account the wishes and needs of the patient and his family, the treatment is deemed futile, burdensome, or disproportionate. (shrink)

Confucius lived in a society he found morally wanting. The rituals were distorted, the government was corrupt, and the rulers lacked a Heavenly mandate. Our limited historical knowledge makes it difficult today to imagine Confucius' situation in all its rich context and detail; however, we may be able to imagine something like it, at least something like it in certain ways. We can probably imagine living in a state led by officials of questionable integrity, and many of us may feel (...) that we in fact do live in a society that suffers some kind of serious moral deficiency.What should a person do when she finds herself in a morally compromised society? Should she try to avoid moral contamination by withdrawing into .. (shrink)

In healthcare priority settings, early access to treatment before reimbursement decisions gives rise to problems of whether negative decisions for cost‐effectiveness reasons should result in withdrawing treatment, already accessed by patients. Among professionals there seems to be a strong attitude to distinguish between withdrawing and withholding treatment, viewing the former as ethically worse. In this article the distinction between withdrawing and withholding treatment for reasons of cost effectiveness is explored by analysing the doing/allowing distinction, different theories of justice, consequentialist and (...) virtue perspectives. The authors do not find any strong reasons for an intrinsic difference, but do find some reasons for a consequentialist difference, given present attitudes. However, overall, such a difference does not, all things considered, provide a convincing reason against withdrawal, given the greater consequentialist gain of using cost‐effective treatment. As a result, patients should be properly informed when given early access to treatment, that such treatment can be later withdrawn following a negative reimbursement decision. (shrink)

Withholding and withdrawing treatment are widely regarded as ethically equivalent in medical guidelines and ethics literature. Health care personnel, however, widely perceive moral differences between withholding and withdrawing. The proponents of equivalence argue that any perceived difference can be explained in terms of cognitive biases and flawed reasoning. Thus, policymakers should clear away any resistance to accept the equivalence stance by moral education. To embark on such a campaign of changing attitudes, we need to be convinced that the ethical analysis (...) is correct. Is it? In this article, I take a closer look at the moral relation between withholding and withdrawing. My conclusion is that withholding and withdrawing are not in general ethically equivalent. Thus, medical guidelines should be rewritten, and rather than being “educated” away from their sound judgments, medical professionals and patients should have nuanced medico-ethical discussions regarding withholding and withdrawing treatment. (shrink)

Ethical guidelines commonly state that research subjects should have a right to withdraw consent to participate. According to the guidelines we have studied, this right applies also to research on biological samples. However, research conducted on human subjects themselves differs in important respects from research on biological samples. It is therefore not obvious that the same rights should be granted research participants in the two cases. This paper investigates arguments for and against granting a right to withdraw consent to research (...) on biobank samples. We conclude that (1) there are no explicit arguments for such a right in the guidelines we have studied, (2) the arguments against such a right are inconclusive, (3) considerations of autonomy, privacy, personal integrity, and trust in medical research provide sufficient reasons for granting a right to withdraw consent to research on biobank samples, (4) in certain cases, research participants should be allowed to waive this right. (shrink)

Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only relatively (...) weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. (shrink)

Many medical ethicists accept the thesis that there is no moral difference between withholding and withdrawing life-sustaining therapy. In this paper, we offer an interesting counterexample which shows that this thesis is not always true. Withholding is distinguished from withdrawing by the simple fact that therapy must have already been initiated in order to speak coherently about withdrawal. Provided that there is a genuine need and that therapy is biomedically effective, the historical fact that therapy has been initiated entails (...) a claim to continue therapy that cannot be attributed to patients who have not yet received therapy. This intrinsic difference between withholding and withdrawing therapy is of moral importance. In many instances, patients will waive this claim. But when one considers withdrawing therapy from one patient to help another in a setting of scarce resources, this intrinsic moral difference comes into sharp focus. In an era of shrinking medical resources, this difference cannot be ignored. (shrink)

As is well known, sense-bestowal (_Sinngebung_) is a fundamental concept in Husserl’s transcendental phenomenology. Husserl considers that everything, including nonsense or absurdity, is a result of consciousness’ production of sense. In the following article, I will argue against this thesis. More precisely, I claim that there are experiences that are not characterised by sense-bestowal. These experiences, which, in my view, are directly related to Husserl’s concept of limit-phenomena, can be called sense-withdrawal experiences. In order to show this, the paper (...) has the following structure: First, I will analyse the highly nuanced concept of sense-bestowal, drawing connections to the notion of constitution. Second, I will introduce the concept of limit-phenomena, which I will interpret in terms of sense-refusing experiences. This, in turn, will enable me to delve into the concept of sense-withdrawal, which will serve as the focal point of the final segment of the paper. (shrink)

Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating (...) suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed. (shrink)

Philosophical discussion about citizenship has traditionally focused on the questions of what citizenship is, its relationship to civic virtue and political participation, and whether or not it can be meaningfully exercised at the supra-national level. In recent years, however, philosophers have turned their attention to the legal status attached to citizenship, and have questioned existing principles of citizenship allocation and withdrawal. With regard to the question of who is morally entitled to citizenship, philosophers have argued for principles of citizenship (...) allocation that go beyond birth and lineage, and have focused instead on the value of political attachment and located life plans. These principles have several advantages over existing legal principles, but they suffer from being under-specified, as well as being over and under-inclusive. With regard to loss of citizenship, philosophers have primarily denounced citizenship withdrawal as a form of punishment by appealing to principles of fair and equal treatment. However, theories purporting to show that denationalization is always wrong have trouble explaining why loss of citizenship is so problematic for persons who have committed the most horrendous crimes against their fellow citizens, and who, in so doing, have in effect self-excluded from the political community. (shrink)

RD, a 32-year-old male, was admitted to the hospital with hypoxic COVID pneumonia–a potentially life-threatening condition characterized by dangerously low levels of oxygen in the body- during one of the pandemic’s surges. While RD’s age gave the clinical team hope for his prognosis, his ability to recover was complicated by his being unvaccinated and having multiple comorbidities, including diabetes and obesity. His condition worsened to the point that he required extracorporeal membrane oxygenation (ECMO), a machine that maintains the functioning (...) of a person’s heart and lungs. -/- Given its scarcity–only 264 of the over 6,000 hospitals in the United States offer ECMO, according to the Extracorporeal Life Support Organization–as well as its high cost and the inadequate supply of staff required to maintain it, ECMO primarily serves as a bridge to support critically ill patients until they can receive an organ transplant or implanted medical device. For RD, ECMO was started to support him until he could be evaluated for, and possibly receive, a bilateral lung transplant. Despite its intended use as a treatment of last resort, some patients can remain on ECMO for weeks or months. And some are awake, alert, and capable of medical decision-making. -/- RD was one such patient. However, the transplant evaluation committee ruled out RD’s candidacy for bilateral lung transplantation, based on his poor potential for recovery and a lack of family and friends to provide post-transplant support. This determination raised the prospect of continued ECMO treatment being a bridge to nowhere. But RD was comfortable on ECMO and wanted to remain in the ICU. The ICU intensivist contacted the ethics consult service with questions about whether continued ECMO support was medically and ethically inappropriate. (shrink)

Consent forms given to potential subjects in research protocols typically contain a sentence like this: “You have a right to withdraw from this study at any time without penalty.” If you have ever served on an institutional review board or a research ethics committee, you have no doubt read such a sentence often. Moreover, codes of ethics governing medical research endorse such a right. For example, paragraph 24 of the Declaration of Helsinki says, “The subject should be informed of the (...) right… to withdraw consent to participate at any time without reprisal.” Similarly, section C of the Belmont Report says that subjects must be informed that they have the right “to withdraw at any time from the research.” And in section 46.116 of the Common Rule, it says that one of the elements of informed consent must include a statement that “the subject may discontinue participation at any time without penalty or loss of benefit to which the subject is otherwise entitled.”. (shrink)

There has been little research into the weak kindsof negating hypotheses. Hypotheses may be unfalsifiable. In this case it is impossible tofind a contradiction in some area of the conceptualsystems in which they are incorporated.Notwithstanding this fact, it is sometimes necessaryto construct ways of rejecting the unfalsifiablehypothesis at hand by resorting to some external forms of negation, external because wewant to avoid any arbitrary and subjectiveelimination, which would be rationally orepistemologically unjustified. I will consider akind of ``weak'''' (unfalsifiable) hypotheses that (...) arehard to negate and the ways for making it easy. Inthese cases the subject can ``rationally'''' decide towithdraw his hypotheses even in contexts where it is``impossible'''' to find ``explicit'''' contradictions: theuse of negation as failure (an interestingtechnique for negating hypotheses and accessing newones suggested by artificial intelligence) isilluminating. I plan to explore whether this kind ofnegation can be employed to model hypothesiswithdrawal in Poincaré''s conventionalism of theprinciples of physics and in Freudian analyticreasoning. (shrink)

By comparing Object-Oriented Ontology (OOO) and Baudrillard through the lens of a study of the notion of withdrawal in Heidegger’s tool analysis and “The Question Concerning Technology”, this article explores the extent to which an Object-Oriented Baudrillard is possible, or even necessary. Considering an OOO understanding of Mauss’s gift-exchange, a possible critique of duomining in Baudrillard and a revision of Baudrillard’s understanding of art, the prospects of a new reading of Baudrillard and interpretation of OOO’s genealogy are established. These (...) lines of comparison qualify the role of withdrawal in Baudrillard and symbolic exchange for OOO, and lead towards the conclusion that an Object-Oriented Baudrillard is possible, but may not, conversely, be considered necessary. (shrink)

In this paper I argue, against the current consensus, that the right to withdraw from research is sometimes alienable. In other words, research subjects are sometimes morally permitted to waive their right to withdraw. The argument proceeds in three major steps. In the first step, I argue that rights typically should be presumed alienable, both because that is not illegitimately coercive and because the general paternalistic motivation for keeping them inalienable is untenable. In the second step of the argument, I (...) consider three special characteristics of the right to withdraw, first that its waiver might be exploitative, second that research involves intimate bodily access, and third that it is irreversible. I argue that none of these characteristics justify an inalienable right to withdraw. In the third step, I examine four considerations often taken to justify various other allegedly inalienable rights: concerns about treating yourself merely as a means as might be the case in suicide, concerns about revoking all your future freedoms in slavery contracts, the resolution of coordination problems, and public interest. I argue that the motivations involved in these four types of situations do not apply to the right to withdraw from research. (shrink)

Care workers frequently withdraw from elderly people in their care; this has resulted in a number of scandals in the media. Here I analyze an empirical scene observed at an old people’s home in Denmark, which contains behavioral patterns among the care workers which could be seen as withdrawal. At the same time it illustrates the care workers' commitment to the elderly. A paradoxical "empathy at a distance" is characteristic of the scene. When analyzing my written observations in an (...) interpretation group, my use of language was a point of discussion. What did it mean when I described the interactions between care workers and elderly residents in words commonly used to describe mother-child interactions? My use of language became a "hermeneutical key" which enabled a psychoanalytically inspired interpretation. This focuses on the care relationship as activating our earliest memories of our own care relations, independently of whether we are in the role of care providers or care receivers. Through collusion theory, the interpretation accepts both the anxiety which the helpless elderly people arouse in the care workers and their motivation for care work as two sides of a subjectively important theme. The article illustrates how working consciously with the researcher's subjectivity makes it possible to understand apparently irrational patterns. The insights thus gained may be used to prevent withdrawals in care work as an argument for care workers’ need for emotional supervision. (shrink)

This study was conducted with the purpose of analyzing the combined and mediating effect of actor’s withdrawal–partner’s demand conflict resolution strategies between avoidance attachment dimension and relationship satisfaction. We conducted a dyadic study with 175 heterosexual couples who filled in the questionnaires. Six hypotheses were tested using the actor–partner interdependence model with mediation analysis. Results showed that the avoidance dimension of attachment was more strongly associated with actor’s withdrawal strategy than with demand/aggression strategy. Furthermore, avoidance attachment was negatively (...) associated with both actor’s and partner’s relationship satisfaction, the actor effect being higher. Withdrawal strategy was a mediator between actor’s avoidance and actor’s relationship satisfaction, but it was not a mediator for partner’s relationship satisfaction. The interactive pattern of actor’s withdrawal–partner’s demand/aggression was associated with low levels of both actor’s and partner’s relationship satisfaction. These results point out to the need of discerning the interactive pattern of conflict-solving strategies as well as their intertwined effect on relationship satisfaction. (shrink)

A fundamental property of emotional responses is a change in action tendencies that allow the individual to cope with the situation. Most basically, there are two types of behaviour one can switch to when responding emotionally: approach or withdrawal. The present study examined whether the ability to switch to approach or withdrawal depends on the type of behaviour shown before. Using familiar (Experiment 1) and unfamiliar (Experiment 2) neutral stimuli, we first show that switching from approach to (...) class='Hi'>withdrawal is generally easier than vice versa. In Experiment 3, we demonstrate that this holds true even when participants respond to emotional stimuli that typically elicit strong approach or withdrawal tendencies. These results indicate that there is a fundamental asymmetry in the ability to switch from approach to withdrawal or vice versa. As shown in Experiment 3, this asymmetry may represent a serious confound in many previous studies examining the link between stimulus valence and associated action tendencies, suggesting that the link between positive stimuli and approach tendencies may be stronger, and the link between negative stimuli and withdrawal tendencies weaker, than previously believed. (shrink)

PurposeScarce evidence exists regarding end-of-life decision (EOLD) in neurocritically ill patients. We investigated the factors associated with EOLD making, including the group and individual characteristics of involved healthcare professionals, in a multiprofessional neurointensive care unit (NICU) setting.Materials and methodsA prospective, observational pilot study was conducted between 2013 and 2014 in a 10-bed NICU. Factors associated with EOLD in long-term neurocritically ill patients were evaluated using an anonymised survey based on a standardised questionnaire.Results8 (25%) physicians and 24 (75%) nurses participated in (...) the study by providing their ‘treatment decisions’ for 14 patients at several time points. EOLD was ‘made’ 44 (31%) times, while maintenance of life support 98 (69%) times. EOLD patterns were not significantly different between professional groups. The individual characteristics of the professionals (age, gender, religion, personal experience with death of family member and NICU experience) had no significant impact on decisions to forgo or maintain life-sustaining therapy. EOLD was patient-specific (intraclass correlation coefficient: 0.861), with the presence of acute life-threatening disease (OR (95% CI): 18.199 (1.721 to 192.405), p=0.038) and low expected patient quality of life (OR (95% CI): 9.276 (1.131 to 76.099), p=0.016) being significant and independent determinants for withholding or withdrawing life-sustaining treatment.ConclusionsOur findings suggest that EOLD in NICU relies mainly on patient prognosis and not on the characteristics of the healthcare professionals. (shrink)

This paper introduces an epistemological model of scientific reasoning which can be described in terms of abduction, deduction and induction. The aim is to emphasize the significance of abduction in order to illustrate the problem-solving process and to propose a unified epistemological model of scientific discovery. The model first describes the different meanings of the word abduction in order to clarify their significance for epistemology and artificial intelligence. In different theoretical changes in theoretical systems we witness different kinds of discovery (...) processes operating. Discovery methods are "data-driven," "explanation-driven", and "coherence-driven". Sometimes there is a mixture of such methods: for example, an hypothesis devoted to overcome a contradiction is found by abduction. Contradiction, far from damaging a system, help to indicate regions in which it can be changed and improved. I will also consider a kind of "weak" hypothesis that is hard to negate and the ways for making it easy. In these cases the subject can "rationally" decide to withdraw his or her hypotheses even in contexts where it is "impossible" to find "explicit" contradictions and anomalies. Here, the use of negation as failure is illuminating. (shrink)

Best known for his two-year sojourn at Walden Pond in Massachusetts, Henry David Thoreau is often considered a recluse who emerged from solitude only occasionally to take a stand on the issues of his day. In _Thoreau’s Democratic Withdrawal_, Shannon L. Mariotti explores Thoreau’s nature writings to offer a new way of understanding the unique politics of the so-called hermit of Walden Pond. Drawing imaginatively from the twentieth-century German social theorist Theodor W. Adorno, she shows how withdrawal from the (...) public sphere can paradoxically be a valuable part of democratic politics. Separated by time, space, and context, Thoreau and Adorno share a common belief that critical inquiry is essential to democracy but threatened by modern society. While walking, huckleberrying, and picking wild apples, Thoreau tries to recover the capacities for independent perception and thought that are blunted by “Main Street,” conventional society, and the rapidly industrializing world that surrounded him. Adorno’s thoughts on particularity and the microscopic gaze he employs to work against the alienated experience of modernity help us better understand the value of Thoreau’s excursions into nature. Reading Thoreau with Adorno, we see how periodic withdrawals from public spaces are not necessarily apolitical or apathetic but can revitalize our capacity for the critical thought that truly defines democracy. In graceful, readable prose, Mariotti reintroduces us to a celebrated American thinker, offers new insights on Adorno, and highlights the striking common ground they share. Their provocative and challenging ideas, she shows, still hold lessons on how we can be responsible citizens in a society that often discourages original, critical analysis of public issues. (shrink)

Dr. Brown, a hospitalist, admits Mark, a patient transferred from a local jail for management of cellulitis. The patient, who was taken into custody two days prior to hospital admission, has a history of intravenous heroin use. Mark explains that he had been prescribed buprenorphine-naloxone maintenance therapy for opioid use disorder for several years prior to being arrested and had not used other opioids during that time. As a policy, the jail where Mark is detained does not prescribe opioid (...) agonists, and his maintenance therapy was stopped upon his arrival there. Dr. Brown discovers that Mark is diaphoretic and appears distressed. Mark's symptoms suggest to Dr. Brown that, in addition to having cellulitis, Mark is actively withdrawing from opioids. Mark tells Dr. Brown that he has felt “horrible” since his buprenorphine-naloxone therapy was stopped and that he now has intense cravings for opioids. He asks Dr. Brown to help alleviate the withdrawal symptoms. Dr. Brown, who is accustomed to treating opioid withdrawal with opioid replacement therapy, wonders if she should initiate ORT for Mark while he is in the hospital. (shrink)

Based on the power basis theory, this study examined the relationship between high-level talents’ perceived overqualification and withdrawal behavior and the mediating role of sense of power. We also analyze the boundary effects of protected values and being trusted. The hypotheses of this study were tested through questionnaires gathered across three phases over 3 months from 371 high-level talents from 6 enterprises, 5 governments, and 13 universities in China. Hierarchical regression analyses and bootstrapping appraisals showed that: POQ has (...) a positive relationship with withdrawal behavior; sense of power mediates the relationship between overqualification and withdrawal behavior, with high POQ resulting in low perceived power, which then reinforces withdrawal behavior; the negative relationship between POQ and sense of power is stronger for high-level talents with high protected value ; the negative relationship between sense of power and withdrawal behavior is stronger for high-level talents with highly being trusted ; moderated-mediation analyses reveal that the mediating effects of sense of power are stronger for employees with high protected values or being trusted. At the end of this study, the theoretical and practical implications are discussed. (shrink)

Despite much research now being published on Environmental, Social, and Governance (ESG) investments and Initial Public Offerings (IPOs) withdrawal risk, there appears to be a lack of evidence on the prospective IPO withdrawal risk associated with voluntary disclosure of ESG policies. This paper investigates the influence of ESG disclosure on IPO withdrawal by comparing voluntary ESG disclosure to conventional IPOs in the international market. A large data set is employed here, containing 33,535 failed and successful IPOs (...) from 1995 to 2019 from several nations with their own legal systems, cultural norms, and economic systems. The findings reveal that voluntary disclosure of ESG practices does significantly reduce the likelihood of an IPO withdrawal, by as much as 48%. These findings strongly suggest that organizations engaged in ESG activities perceive voluntary disclosure as an incentive, to adhere to social expectations. Consequently, reducing the asymmetry of information between IPO participants minimizes the withdrawal risk these companies face, hence diminishing doubts about their legitimacy. The results have consequences for IPO businesses, investors, researchers, and regulators. (shrink)

This paper takes up the problem of correlationism from a phenomenological perspective. Speculative realists, such as Quentin Meillassoux and Graham Harman, seek to establish new forms of Continental realism largely because, in their view, phenomenology cannot adequately account for the real. To counter these claims, I will use what I call a “critical phenomenological approach”, which critically delimits the real from the intentional relation, and thus makes possible a phenomenological theory of the real. This approach to realism establishes not only (...) that the real is independent from the intentional relation but also that the intentional relation itself is contingent with regard to the real. Furthermore, it also shows that the human being is exposed to the real in an originary way that calls into question the adequacy of Meillassoux’s and Harman’s forms of realism. (shrink)

Most ethics committees which review research protocols insist that potential research participants reserve unconditional or absolute ‘right’ of withdrawal at any time and without giving any reason. In this paper, I examine what consent means for research participation and a sense of commitment in relation to this right to withdraw. I suggest that, once consent has been given (and here I am excluding incompetent minors and adults), participants should not necessarily have unconditional or absolute rights to withdraw.This does not (...) imply that that there should be a complete absence of rights, or, indeed, an abandonment of the right to withdraw. The point of this paper is to show that the supposed unconditional or absolute nature of these rights may be self‐defeating and so fail to respect the autonomy of participants. In addition, and on a more positive note, I suggest that, attaching certain conditions on the right to withdraw, may better respect the autonomy of these participants by underlining the idea that autonomy is more than mere whim or indifference to the fate of others. On the contrary, research staff are currently unable to ‘push’ participants, who may merely have logistical difficulties unrelated to the research itself, but who really want to stay the course, for fear of coercing them. Furthermore, researchers now try to ‘screen out’ people they think may be unreliable to protect the science of the study and so groups at risk of dropping out may be unfairly denied access to research treatments. I conclude that on‐going negotiation between the relevant parties could be on balance the only truly acceptable way forward but concede certain important limitations to take into account. (shrink)

Unfortunately, there is broad confusion regarding the justification for healthcare professionals unilaterally limiting or withdrawing life-prolonging interventions. Many mistakenly believe that suc...

_ Source: _Volume 48, Issue 2, pp 233 - 243 This article focuses on two Platonic concepts, δύναµις and χώρα, and Heidegger’s interpretation of them in his lecture courses on Greek philosophy. I try to demonstrate that these two concepts offer us insights into the dynamic movement of Being between self-showing and withdrawal. The aim of the article is to show that Being, as one of the greatest kinds in the _Sophist_, and the elusive χώρα in the (...) _Timaeus_ can open up new perspectives on the Heideggerian question of Being. (shrink)

BackgroundThere has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. MethodsA cross-sectional study was conducted on a three-stage random sample of adult citizens of (...) the Republic of Croatia, stratified by regions, counties, and locations within those counties. In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis, correlation analysis and multiple regression analysis for data analysis.Results38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person’s autonomous decisions regarding end-of-life procedures.ConclusionsThe study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people’s views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia. (shrink)

Why do we persist in the relentless pursuit of artificial nourishment and other treatments to maintain a permanently unconscious existence? In facing the future, if not the present world-wide reality of a huge number of persistent vegetative state (PVS) patients, will they be treated because of our ethical commitment to their humanity, or because of an ethical paralysis in the face of biotechnical progress? The PVS patient is cut off from the normal patterns of human connection and communication, with a (...) life unlike other forms of human existence. Why the struggle to justify ending a life which, it is said, has suffered an irreversible loss of the content of consciousness? Elsewhere, the authors have addressed the ethical controversies and confusion engendered by ambiguous terminology, misuse of medical facts and the differing interpretations of what constitutes 'effective' treatment: in particular, the issue of whether in fact artificial nutrition and hydration is a medical treatment, or simply part of the obligatory care owed to all patients, permanently unconscious or not. In this paper, we intend to argue that recent analyses of medical futility, its meaning and ethical implications, despite an absence of public consensus, permit some tentative re-evaluation of our ethical obligations to the PVS patient. (shrink)

Clinical trials of xenotransplantation (XTx) may begin early in the next decade, with kidneys from genetically modified pigs transplanted into adult humans. If successful, transplanting pig hearts into children with advanced heart failure may be the next step. Typically, clinical trials have a specified end date, and participants are aware of the amount of time they will be in the study. This is not so with XTx. The current ethical consensus is that XTx recipients must consent to lifelong monitoring. While (...) this presents challenges to the right to withdraw in the adult population, additional and unanswered questions also linger in the paediatric population. In paediatric XTx, parents or guardians consent not only to the initial treatment of the child but also to lifelong monitoring, thus making a decision whose consequences will remain present as the child develops the capacity for assent, and finally the capacity for informed consent or refusal. This article presents and evaluates unanswered paediatric ethical questions in regard to the right to withdraw from XTx follow-up in the paediatric population. (shrink)

Preclinical xenotransplantation research using genetically engineered pigs has begun to show some promising results and could one day offer a scalable means of addressing organ shortage. While it is a fundamental tenet of ethical human subject research that participants have a right to withdraw from research once enrolled, several scholars have argued that the right to withdraw from xenotransplant research should be suspended because of the public health risks posed by xenozoonotic transmission. Here, we present a comprehensive critical evaluation of (...) the claim that xenotransplant recipients should be required to waive their right to withdraw from lifelong biosurveillance. We conclude that if xenotransplantation requires participants to waive their right to withdraw, then clinical trials may not be justifiable, given the ethical and legal obstacles involved with doing so. Consequently, if clinical trials are permitted with a right to withdraw, then they may pose a significant public health risk. (shrink)

The valence–arousal conflict theory assumes that both valence and arousal will trigger approaching or withdrawing tendencies. It also predicts that the speed of processing emotional stimuli will depend on whether valence and arousal trigger conflicting or congruent motivational tendencies. However, most previous studies have provided evidence of the interaction between valence and arousal only, and have not provided direct proof of the interactive links between valence, arousal and motivational tendencies. The present study provides direct evidence for the relationship between approach– (...) class='Hi'>withdrawal tendencies and the valence–arousal conflict. In an empirical test, participants were instructed to judge the valence of emotional words after visual–spatial cues that appeared to be either approaching or withdrawing from participants. A three-way interaction was observed such that the response time was shorter if participants responded to a negative high-arousal stimulus after a withdrawing cue, or to a positive low-arousal stimulus after an approaching cue. These findings suggest that the approach–withdrawal tendency indeed plays a crucial role in valence–arousal conflict, and that the effect depends on the congruency of valence, arousal and tendency at an early stage of processing. (shrink)

A request to admit a hospital inpatient with motor neurone disease to the hospice generated unusual unease. Significantly, withdrawal of ventilation had already been planned. The presumption that ventilation would be withdrawn after transfer presented a dilemma. Should the hospice accept the admission? If so, should the hospice staff stop the ventilation, and then when and how? Debate centred on the continuity of best interests and the logistics of withdrawing ventilation. The factors making the request contentious identified competing interests (...) within hospice admission decision making that could detrimentally impact on patient care. (shrink)

Conscious but incapacitated patients need protection from both undertreatment and overtreatment, for they are exceptionally vulnerable, and dependent on others to act in their interests. In the United States, the law prioritizes autonomy over best interests in decision making. Yet U.S. courts, using both substituted judgment and best interests decision making standards, frequently prohibit the withdrawal of life-sustaining treatment from conscious but incapacitated patients, such as those in the minimally conscious state, even when ostensibly seeking to determine what patients (...) would have wanted. In the United Kingdom, under the Mental Capacity Act of 2005, courts decide on the best interests of incapacitated patients by, in part, taking into account the past wishes and values of the patient. This paper examines and compares those ethicolegal approaches to decision making on behalf of conscious but incapacitated patients. We argue for a limited interpretation of best interests such that the standard is properly used only when the preferences of a conscious, but incapacitated patient are unknown and unknowable. When patient preferences and values are known or can be reasonably inferred, using a holistic, all-things-considered substituted judgment standard respects patient autonomy. (shrink)

Where a decision has been made to stop futile treatment of critically ill patients on an intensive care unit – what is termed withdrawal of treatment in the UK – yet no doctor is available to perform the actions of withdrawal, nurses may be called upon to perform key tasks. In this paper I present two moral justifications for this activity by offering answers to two major questions. One is to ask if it can be in patients' best (...) interests for nurses to be the key actors in withdrawal of life‐sustaining treatment. The other is to ask if there is any reason that the nursing profession should not undertake such tasks if this is so. Both these questions require the resolution of weighty moral and philosophical issues. Thus, while offering a serious attempt to provide moral justifications for nurses undertaking withdrawal, this paper also invites debate over both the aim of task division between nurses and doctors, and how we might decide what is in the best interests of patients. (shrink)